[Update on endocarditis 2024]

Infective endocarditis (IE) is a life-threatening disease with an increasing incidence despite improved preventive measures. The revision of the European Society of Cardiology (ESC) guidelines on infective endocarditis in 2023 brings significant innovations in prevention, diagnostics, and treatment. Many measures for prophylaxis and prevention have been more clearly defined and given higher recommendation levels. In the diagnostics of IE the use of other imaging modalities besides echocardiography, such as cardiac computed tomography (CT), positron emission tomography (PET)/CT or single photon emission computed tomography (SPECT)/CT with radioactively labeled leukocytes was more strongly emphasized. The diagnostics and treatment of IE associated with a cardiac implantable electronic device (CIED) were also revised. An essential innovation is also the possibility of an outpatient antibiotic treatment for certain patients after initial treatment in hospital. The indications for surgery have also been revised and, in particular, the timing of surgery has been more clearly defined. This article provides an overview of the most important changes.

A report on a survey among Portuguese Association of Interventional Cardiology associates regarding ionizing radiation protection practices in national interventional cath-labs

INTRODUCTION AND OBJECTIVES

Concerns surrounding the consequences of ionizing radiation (IR) have increased in interventional cardiology (IC). Despite this, the ever-growing complexity of diseases as well as procedures can lead to greater exposure to radiation. The aim of this survey, led by Portuguese Association of Interventional Cardiology (APIC), was to evaluate the level of awareness and current practices on IR protection among its members.

METHODS

An online survey was emailed to all APIC members, between August and November 2021. The questionnaire consisted of 50 questions focusing on knowledge and measures of IR protection in the catheterization laboratory. Results were analyzed using descriptive statistics.

RESULTS

From a response rate of 46.9%, the study obtained a total sample of 159 responses (156 selected for analysis). Most survey respondents (66.0%) were unaware of the radiation exposure category, and only 60.4% reported systematically using a dosimeter. A large majority (90.4%) employed techniques to minimize exposure to radiation. All participants used personal protective equipment, despite eyewear protection only being used frequently by 49.2% of main operators. Ceiling suspended shields and table protectors were often used. Only two-thirds were familiar with the legally established limit on radiation doses for workers or the dose that should trigger patient follow-up. Most of the survey respondents had a non-certified training in IR procedures and only 32.0% had attended their yearly occupational health consultation.

CONCLUSIONS

Safety methods and protective equipment are largely adopted among interventional cardiologists, who have shown some IR awareness. Despite this, there is room for improvement, especially concerning the use of eyewear protection, monitoring, and certification.

Unlocking the potential of artificial intelligence in sports cardiology: does it have a role in evaluating athlete's heart?

The integration of artificial intelligence (AI) technologies is evolving in different fields of cardiology and in particular in sports cardiology. Artificial intelligence offers significant opportunities to enhance risk assessment, diagnosis, treatment planning, and monitoring of athletes. This article explores the application of AI in various aspects of sports cardiology, including imaging techniques, genetic testing, and wearable devices. The use of machine learning and deep neural networks enables improved analysis and interpretation of complex datasets. However, ethical and legal dilemmas must be addressed, including informed consent, algorithmic fairness, data privacy, and intellectual property issues. The integration of AI technologies should complement the expertise of physicians, allowing for a balanced approach that optimizes patient care and outcomes. Ongoing research and collaborations are vital to harness the full potential of AI in sports cardiology and advance our management of cardiovascular health in athletes.

[Precision medicine enhances personalized medicine in cardiology]

Personalized medicine and precision medicine, frequently used synonymously, shall be clearly differentiated. Accordingly, personalization in cardiac medicine is based on the clinical presentation of a patient, as well as his/her cardiovascular risk factors and comorbidities, electrocardiography, imaging, and biomarkers for myocardial load and ischemia. Personalization is based on large clinical trials with detailed subgroup analyses and is practiced on the basis of guidelines. Further in depth personalization is achieved by precision medicine, which is based on innovative imaging for myocardial structure, coronary morphology, and electrophysiology. From the clinical perspective, genome analyses are relevant for comparatively rare monogenetic cardiovascular diseases. While these as well as transcriptome and metabolome analyses play a significant role in cardiovascular research with great translation potential, they have not yet been broadly introduced in the diagnosis, prevention, and treatment of complex cardiovascular diseases. Furthermore, digital technologies have considerable potential in cardiovascular precision medicine. On the one hand, this is based on the frequency of the diseases with the availability of Big Data and, on the other hand, on the availability of bio-signals and sensors of those signals in cardiovascular diseases.

Principles of artificial intelligence and its application in cardiovascular medicine

Artificial intelligence (AI) represents a rapidly developing field. Its use can improve diagnosis and therapy in many areas of medicine. Despite this enormous progress, many physicians perceive it as a black box and are skeptical about it. This review will present the basics of machine learning. Different classifications of artificial intelligence, such as supervised versus unsupervised and discriminative versus generative AI, are given. Analogies to human intelligence are discussed as far as algorithms are oriented toward it. In the second step, the most common models like random forest, k-means clustering, convolutional neural network, and transformers will be presented in a way that the underlying idea can be understood. Corresponding medical applications in cardiovascular medicine will be named for all models, respectively. The overview is intended to show that the term artificial intelligence covers a wide range of different concepts. It should help physicians understand the principles of AI to make up one's minds about its application in cardiology. It should also enable them to evaluate results obtained with AI's help critically.

2022 Artificial intelligence primer for the nuclear cardiologist

Driven by advances in computing power, the past decade has seen rapid developments in artificial intelligence (AI) which now offers potential enhancements to every aspect of nuclear cardiology workflow including acquisition, reconstruction, segmentation, direct image analysis, and interpretation; as well as facilitating clinical and imaging big-data integration for superior personalized risk stratification. To understand the relevance and potential of AI in their field, this review provides a primer for nuclear cardiologists in 2022. The aim is to explain terminology and provide a summary of key current implementations, challenges, and future aspirations of AI-based enhancements to nuclear cardiology.

Radiation exposure in interventional cardiology: extremities doses

X-rays are widely used in interventional cardiology (IC). Medical staff is exposed to ionising radiations with difficulties to accurately estimate the absorbed dose, on the other hand, it is well known that eye lens and extremities are the most exposed. In most IC units, radiological monitoring is performed by measuring the personal dose equivalent with a dosemeter worn under the operator's apron. The ambient dose equivalent is, usually, also measured. Furthermore, doses to the lens and extremities are often not measured because of the absence or difficulty of wearing the appropriate dosemeters. The main aim of our study is to estimate the extremities doses, of the interventional cardiologists, from the personal dose equivalent, the patient's received doses or to the ambient dose equivalent. For this purpose, we use a radiological monitoring, of four (04) interventional cardiologists, carried out at Algiers hospital. A Monte Carlo calculation is performed for comparison. This paper reports the preliminary results of this study.

Coordinating Cardiology clinics randomized trial of interventions to improve outcomes (COORDINATE) - Diabetes: rationale and design

Several medications that are proven to reduce cardiovascular events exist for individuals with type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease, however they are substantially underused in clinical practice. Clinician, patient, and system-level barriers all contribute to these gaps in care; yet, there is a paucity of high quality, rigorous studies evaluating the role of interventions to increase utilization. The COORDINATE-Diabetes trial randomized 42 cardiology clinics across the United States to either a multifaceted, site-specific intervention focused on evidence-based care for patients with T2DM or standard of care. The multifaceted intervention comprised the development of an interdisciplinary care pathway for each clinic, audit-and-feedback tools and educational outreach, in addition to patient-facing tools. The primary outcome is the proportion of individuals with T2DM prescribed three key classes of evidence-based medications (high-intensity statin, angiotensin converting enzyme inhibitor or angiotensin receptor blocker, and either a sodium/glucose cotransporter-2 inhibitor (SGLT-2i) inhibitor or glucagon-like peptide 1 receptor agonist (GLP-1RA) and will be assessed at least 6 months after participant enrollment. COORDINATE-Diabetes aims to identify strategies that improve the implementation and adoption of evidence-based therapies.

[Computed tomography and magnetic resonance imaging in cardiac diagnostics-how to choose the right modality : A guide based on the new guidelines of the European Society of Cardiology (ESC)]

In the guideline updates of the European Society of Cardiology (ESC), noninvasive radiological cross-sectional imaging is taking an increasingly prominent role, while at the same time invasive diagnostic approaches are becoming less important. Especially for the diagnosis and treatment of chronic and acute coronary syndromes, there are fundamental changes in clinical routine. In addition, cross-sectional imaging also offers an alternative to diagnostic algorithms for other cardiac pathologies, especially echocardiography, which is increasingly used in the differential diagnosis of cardiac diseases. The radiologist should be aware of the recommendations of the current guidelines and encourage their establishment in clinical practice. This paper summarizes the indications of cross-sectional cardiac imaging with focus on new recommendations in the ESC guidelines and addresses specific strengths and weaknesses of each modality.

Setting up regional diagnostic reference levels for pediatric interventional cardiology in Latin America and the Caribbean countries: preliminary results and identified challenges

The goal of the present study was to propose a set of preliminary regional diagnostic reference levels (DRLs) for pediatric interventional cardiology (IC) procedures in Latin America and the Caribbean countries, classified by age and weight groups. The study was conducted in the framework of the Optimization of Protection in Pediatric Interventional Radiology in Latin America and the Caribbean program coordinated by the World Health Organization and the Pan American Health Organization in cooperation with the International Atomic Energy Agency. The first step of the program was focused on pediatric IC. Dose data from diagnostic and therapeutic procedures were collected between December 2020 and December 2021. Regional DRLs were set as the third quartile of patient dose data (kerma area product) collected in 18 hospitals from 10 countries in an initial sample of 968 procedures. DRLs were set for four age bands and five weight ranges. The values obtained for the four age bands (<1 yr, 1 to <5 yr, 5 to <10 yr and 10 to <16 yr) were 2.9, 6.1, 8.8 and 14.4 Gy cm²for diagnostic procedures, and 4.0, 5.0, 10.0 and 38.1 Gy cm²for therapeutic procedures, respectively. The values obtained for the five weight bands (<5 kg, 5 to <15 kg, 15 to <30 kg, 30 to <50 kg and 50 to <80 kg) were 3.0, 4.5, 8.1, 9.2 and 26.8 Gy cm²for diagnostic procedures and 3.7, 4,3, 7.3, 16.1 and 53.4 Gy cm²for therapeutic procedures, respectively. While initial data were collected manually as patient dose management systems (DMSs) were not available in most of the hospitals involved in the program, a centralized automatic DMS for the collection and management of patient dose indicators has now been introduced and is envisaged to increase the sample size. The possibility of alerting on high dose values and introducing corrective actions will help in optimization.

COMPARISON OF TWO TYPES EYE LENS DOSEMETERS USED IN INTERVENTIONAL CARDIOLOGY AND RADIOLOGY

The aim of this contribution is to provide an overview of comparison of two types of eye lens dosemeter systems. The comparison was performed at the Department of Intravenous Cardiology using patient and physician phantoms and supplemented by dose simulation using the Monte Carlo method. The tests were performed in several specific geometries and in addition to eye lens dosemeters the value of a personal dosemeter located at the reference point was also monitored. The value of Hp(3) and Hp(10) was monitored. It is clear from the results that film dosemeters achieve more correct results in most cases. It is probably due to a better correction for the angle of exposure. This assumption must be verified by more detailed measurements in laboratory conditions.

[e-Health, telemedicine and applications in cardiology: state of the art in Italy and experience of the cardiology unit of the G.B. Grassi Hospital of Rome]

e-Health (electronic health) refers to the use of information and communication technologies (ICT) to promote organizational change and facilitate new healthcare skills. In the last few years, several telemedicine services using ICT have been launched and the updating of related regulations has started, also for the increase in demand for services, their complexity and the need to offer adequate care to the patient. In cardiology, the experiences concern mainly patients suffering from heart failure or the carriers of cardiac implantable electronic devices (CIEDs), and few experiences are described in ischemic heart disease. In this article we present the design, the implementation and the results of the telemedicine service at the Cardiology Unit of the G.B. Grassi Hospital in Rome, concerning follow-up televisits for patients with heart failure, ischemic heart disease and for management of treatment plans, telemonitoring and telecontrol of CIEDs carriers and teleconsultation in ischemic heart disease. The considerations of this review, the experiences reported and the speed of digital evolution make the implementation of existing practices and the redesign of new pathways necessary.

Shining Damaged Hearts: Immunotherapy-Related Cardiotoxicity in the Spotlight of Nuclear Cardiology

The emerging use of immunotherapies in cancer treatment increases the risk of immunotherapy-related cardiotoxicity. In contrast to conventional chemotherapy, these novel therapies have expanded the forms and presentations of cardiovascular damage to a broad spectrum from asymptomatic changes to fulminant short- and long-term complications in terms of cardiomyopathy, arrythmia, and vascular disease. In cancer patients and, particularly, cancer patients undergoing (immune-)therapy, cardio-oncological monitoring is a complex interplay between pretherapeutic risk assessment, identification of impending cardiotoxicity, and post-therapeutic surveillance. For these purposes, the cardio-oncologist can revert to a broad spectrum of nuclear cardiological diagnostic workup. The most promising commonly used nuclear medicine imaging techniques in relation to immunotherapy will be discussed in this review article with a special focus on the continuous development of highly specific molecular markers and steadily improving methods of image generation. The review closes with an outlook on possible new developments of molecular imaging and advanced image evaluation techniques in this exciting and increasingly growing field of immunotherapy-related cardiotoxicity.

PATIENT AND STAFF DOSES FOR VARIOUS INTERVENTIONAL RADIOLOGY AND CARDIOLOGY EXAMINATIONS IN TURKEY

This study aims to determine the radiation doses of patients and staff during different interventional radiology and cardiology examinations. Dose measurements for interventional radiology examinations were performed in Ibn-i Sina Hospital of Ankara University using Siemens Artis-Zee medical imaging system. Patient dose measurement was carried out for interventional cardiology examinations in Cardiology Department of TOBB-ETU University, Medical Faculty Hospital using Philips Allura Centron interventional X-ray system. Patient doses were obtained in terms of kerma area product (KAP) and cumulative air kerma (CAK) from KAP meter attached to the angiography system. Performance tests of the angiography system were performed before patient dose measurements. Staff dose measurements were carried out with thermoluminescence dosimeters (TLD-100) placed in certain areas on the staff. Patient dose measurements were performed for 15 different interventional radiology examinations on a total of 431 patients and for four different cardiology examinations on a total of 299 patients. Monte Carlo based PCXMC 2.0 program was used to calculate patient effective doses. Lower extremity arteriography was the most common examination with a mean KAP value of 30 Gy cm2 and mean effective dose value of 1.2 mSv for total number of 194 patients. Mean KAP values calculated for coronary angiography, percutaneous coronary intervention, electrophysiological procedures and radiofrequency cardiac ablation examinations were 62.8, 162.8, 16.7 and 70.6 Gy cm2, respectively. Radiologist, nurse and technician effective dose normalised to the unit KAP of patient dose were 0.15, 0.11 and 0.14 μSv Gy-1 cm-2. Similarly, cardiologist, nurse and technician effective dose normalised to the unit KAP of patient dose were 0.22, 0.15 and 0.09 μSv Gy-1 cm-2. Measured KAP and CAK values vary depending on the type and complexity of the examination. The measured staff doses during cardiac examinations were higher when compared with that measured for interventional radiology as expected.

Novel tech throws knock-out punch to ECG improving GP referral decisions to cardiology

Purpose

In a comparator study, designed with assistance from the Food and Drug Administration, a State-of-the-Art (SOTA) ECG device augmented with automated analysis, the comparator, was compared with a breakthrough technology, Cardio-HART (CHART).

Methods

The referral decision defined by physician reading biosignal-based ECG or CHART report were compared for 550 patients, where its performance is calculated against the ground truth referral decision. The ground truth was established by cardiologist consensus based on all the available measurements and findings including echocardiography (ECHO).

Results

The results confirmed that CHART analysis was far more effective than ECG only analysis: CHART reduced false negative rates 15.8% and false positive (FP) rates by 5%, when compared with SOTA ECG devices. General physicians (GP’s) using CHART saw their positive diagnosis rate significantly increased, from ~10% to ~26% (260% increase), and the uncertainty rate significantly decreased, from ~31% to ~1.9% (94% decrease). For cardiology, the study showed that in 98% of the cases, the CHART report was found to be a good indicator as to what kind of heart problems can be expected (the ‘start-point’) in the ECHO examination.

Conclusions

The study revealed that GP use of CHART resulted in more accurate referrals for cardiology, resulting in fewer true negative or FP—healthy or mildly abnormal patients not in need of ECHO confirmation. The indirect benefit is the reduction in wait-times and in unnecessary and costly testing in secondary care. Moreover, when used as a start-point, CHART can shorten the echocardiograph examination time.

Exercise intensity assessment and prescription in cardiovascular rehabilitation and beyond: why and how: a position statement from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology

A proper determination of the exercise intensity is important for the rehabilitation of patients with cardiovascular disease (CVD) since it affects the effectiveness and medical safety of exercise training. In 2013, the European Association of Preventive Cardiology (EAPC), together with the American Association of Cardiovascular and Pulmonary Rehabilitation and the Canadian Association of Cardiac Rehabilitation, published a position statement on aerobic exercise intensity assessment and prescription in cardiovascular rehabilitation (CR). Since this publication, many subsequent papers were published concerning the determination of the exercise intensity in CR, in which some controversies were revealed and some of the commonly applied concepts were further refined. Moreover, how to determine the exercise intensity during resistance training was not covered in this position paper. In light of these new findings, an update on how to determine the exercise intensity for patients with CVD is mandatory, both for aerobic and resistance exercises. In this EAPC position paper, it will be explained in detail which objective and subjective methods for CR exercise intensity determination exist for aerobic and resistance training, together with their (dis)advantages and practical applications.

Diagnostic reasoning in cardiovascular medicine

Research in cognitive psychology shows that expert clinicians make a medical diagnosis through a two step process of hypothesis generation and hypothesis testing. Experts generate a list of possible diagnoses quickly and intuitively, drawing on previous experience. Experts remember specific examples of various disease categories as exemplars, which enables rapid access to diagnostic possibilities and gives them an intuitive sense of the base rates of various diagnoses. After generating diagnostic hypotheses, clinicians then test the hypotheses and subjectively estimate the probability of each diagnostic possibility by using a heuristic called anchoring and adjusting. Although both novices and experts use this two step diagnostic process, experts distinguish themselves as better diagnosticians through their ability to mobilize experiential knowledge in a manner that is content specific. Experience is clearly the best teacher, but some educational strategies have been shown to modestly improve diagnostic accuracy. Increased knowledge about the cognitive psychology of the diagnostic process and the pitfalls inherent in the process may inform clinical teachers and help learners and clinicians to improve the accuracy of diagnostic reasoning. This article reviews the literature on the cognitive psychology of diagnostic reasoning in the context of cardiovascular disease.

Artificial intelligence and cardiology: Current status and perspective: Artificial Intelligence and Cardiology

The development of artificial intelligence (AI) began in the mid-20th century but has been rapidly accelerating in the past decade. Reflecting the development of digital health over the past few years, this trend is also seen in medicine. The field of cardiovascular medicine uses a wide variety and a large amount of biosignals, so there are many situations where AI can contribute. The development of AI is in progress for all aspects of the healthcare system, including the prevention, screening, and treatment of diseases and the prediction of the prognosis. AI is expected to be used to provide specialist-level medical care, even in a situation where medical resources are scarce. However, like other medical devices, the concept and mechanism of AI must be fully understood when used; otherwise, it may be used inappropriately, resulting in detriment to the patient. Therefore, it is important to understand what we need to know as a cardiologist handling AI. This review introduces the basics and principles of AI, then shows how far the current development of AI has come, and finally gives a brief introduction of how to start the AI development for those who want to develop their own AI.

Italian Cardiological Guidelines (COCIS) for Competitive Sport Eligibility in athletes with heart disease: update 2020

Since 1989, SIC Sport and a FMSI, in partnership with leading Italian Cardiological Scientific Associations (ANCE, ANMCO and SIC) have produced Cardiological Guidelines for Completive Sports Eligibility for athletes with heart disease (COCIS -- 1989, 1995, 2003, 2009 and 2017). The English version of the Italian Cardiological Guidelines for Competitive Sports Eligibility for athletes with heart disease was published in 2013 in this Journal. This publication is an update with respect to the document previously published in English in 2013. It includes the principal innovations that have emerged over recent years, and is divided into five main chapters: arrhythmias, ion channel disorders, congenital heart diseases, acquired valve diseases, cardiomyopathies, myocarditis and pericarditis and ischemic heart disease. Wherever no new data have been introduced with respect to the 2013 publication, please refer to the previous version. This document is intended to complement recent European and American guidelines but an important difference should be noted. The European and American guidelines indicate good practice for people engaging in physical activity at various levels, not only at the competitive level. In contrast, the COCIS guidelines refer specifically to competitive athletes in various sports including those with high cardiovascular stress. This explains why Italian guidelines are more restrictive than European and USA ones. COCIS guidelines address 'sports doctors' who, in Italy, must certify fitness to participate in competitive sports. In Italy, this certificate is essential for participating in any competition.

Beyond wellness monitoring: Continuous multiparameter remote automated monitoring of patients

The pursuit of more efficient patient-friendly health systems and reductions in tertiary health services use has seen enormous growth in the application and study of remote patient monitoring systems for cardiovascular patient care. While there are many consumer-grade products available to monitor patient wellness, the regulation of these technologies varies considerably, with most products having little to no evaluation data. As the science and practice of virtual care continues to evolve, clinicians and researchers can benefit from an understanding of more comprehensive solutions, capable of monitoring three or more biophysical parameters (e.g., oxygen saturation, heart rate) continuously and simultaneously. These devices, herein referred to as continuous multiparameter remote automated monitoring (CM-RAM) devices, have the potential to revolutionize virtual patient care. Through seamless integration of multiple biophysical signals, CM-RAM technologies can allow for the acquisition of high-volume big data for the development of algorithms to facilitate early detection of negative changes in patient health status and timely clinician response. In this article, we review key principles, architecture, and components of CM-RAM technologies. Work to date in this field and related implications are also presented, including strategic priorities for advancing the science and practice of CM-RAM.

How did COVID-19 affect medical and cardiology journals? A pandemic in literature

BACKGROUND AND AIMS

The spreading speed of the COVID-19 pandemic forced the medical community to produce efforts in updating and sharing the evidence about this new disease, trying to preserve the accuracy of the data but at the same time avoiding the potentially harmful delay from discovery to implementation. The aim of our analysis was to assess the impact of the COVID-19 pandemic on medical literature in terms of proportion of COVID-19-related published papers and temporal patterns of publications within a sample of general/internal medicine and cardiology journals.

METHODS

We searched through PubMed scientific papers published from 1 January 2020 to 31 January 2021 about COVID-19 in ten major medical journals, of which five were in general/internal medicine and five in the cardiology field. We analyzed the proportion of COVID-19-related papers, and we examined temporal trends in the number of published papers.

RESULTS

Overall, the proportion of COVID-19-related papers was 18.5% (1986/10 756). This proportion was higher among the five selected general/internal medicine journals, compared with cardiology journals (23.8% vs 9.5%). The vast majority of papers were not original articles; in particular, in cardiology journals, there were 28% 'original articles', 17% 'review articles' and 55.1% 'miscellaneous', compared with 20.2%, 5.1% and 74.7% in general/internal medicine journals, respectively.

CONCLUSIONS

Our analysis highlights the big impact of the COVID-19 pandemic on international scientific literature. General and internal medicine journals were mainly involved, with cardiology journals only at a later time.

Niveles de referencia de dosis para adultos en procedimientos de cardiología intervencionista en Ecuador

Antecedents and objective

The knowledge of the reference levels for diagnoses and therapeutic studies is important, because it contributes to the optimization of the radiological protection of the patients, avoiding them to be exposed to unnecessarily high doses. However, there was no evidence of these levels in interventionist cardiology procedures in Ecuador, so the objective of this study was to estimate the diagnostic reference levels of dose at the entrance surface in adult patients undergoing interventional cardiology procedures (cinecoronariography, catheterization and coronary percutaneous interventionism) in the Unit of Hemodynamic of the Hospital of Specialties Carlos Andrade Marín in Ecuador.

Materials and methods

The measurements of product dose-area, dose in input surface, number of images and the time of fluoroscopy performed using the Axiom Artis angiographer, and the obtained data was tabulated and processed with the Excel computer program. For this study, 145 patients older than 18 years were selected, and the values obtained from diagnostic reference dose levels were compared with others reported in previous investigations and with the permissible limits for the appearance of deterministic effects on the skin.

Results

This study made it possible to establish reference levels for diagnosis in interventional cardiology procedures (coronary angiography, catheterization and percutaneous coronary intervention) in the Hemodynamics Unit of the Carlos Andrade Marín Specialty Hospital in Ecuador.

Conclusions

The results showed that the intake surface doses obtained were lower than the maximum levels recommended by the International Atomic Energy Agency.

Optimising cardiovascular care of patients with multiple myeloma

Multiple myeloma (MM) is the third most common haematological malignancy, with increasing prevalence over recent years. Advances in therapy have improved survival, changing the clinical course of MM into a chronic condition and meaning that management of comorbidities is fundamental to improve clinical outcomes. Cardiovascular (CV) events affect up to 7.5% of individuals with MM, due to a combination of patient, disease and treatment-related factors and adversely impact survival. MM typically affects older people, many with pre-existing CV risk factors or established CV disease, and the disease itself can cause renal impairment, anaemia and hyperviscosity, which exacerabate these further. Up to 15% of patients with MM develop systemic amyloidosis, with prognosis determined by the extent of cardiac involvement. Management of MM generally involves administration of multiple treatment lines over several years as disease progresses, with many drug classes associated with adverse CV effects including high rates of venous and arterial thrombosis alongside heart failure. Recommendations for holistic management of patients with MM now include routine baseline risk stratification including ECG and echocardiography and administration of thromboprophylaxis drugs for patients treated with immunomodulatory drugs. Close surveillance of high-risk patients with collaboration between haematology and cardiology is required, with prompt investigation in the event of CV symptoms, in order to identify and treat complications early. Decisions regarding discontinuation of cardiotoxic therapies should be made in a multidisciplinary setting, taking into account the severity of the complication, prognosis, expected benefits and the availability of effective alternatives.

Prenatal diagnosis and planned peripartum care improve perinatal outcome of fetuses with transposition of the great arteries and intact ventricular septum in low-resource settings

OBJECTIVE

To report on the feasibility of establishing a regional prenatal referral network for critical congenital heart defects (CHDs) and its impact on perinatal outcome of fetuses with transposition of the great arteries and intact ventricular septum (TGA-IVS) in low-resource settings.

METHODS

This was a retrospective study of consecutive fetuses with a diagnosis of TGA-IVS between January 2011 and December 2019 in Kochi, Kerala, India. A regional network for prenatal diagnosis and referral of patients with critical CHDs was initiated in 2011. Pregnancy and early neonatal outcomes were reported. The impact of the timing of diagnosis (prenatal or after birth) on age at surgery, perinatal mortality and postoperative recovery was evaluated.

RESULTS

A total of 82 fetuses with TGA-IVS were included. Diagnosis typically occurred later on in gestation, at a median of 25 (interquartile range (IQR), 21-32) weeks. The majority (78.0%) of affected pregnancies resulted in live birth, most (84.4%) of which occurred in a specialist pediatric cardiac centers. Delivery in a specialist center, compared with delivery in a local maternity center, was associated with a significantly higher rate of surgical correction (98.1% vs 70.0%; P = 0.01) and overall lower neonatal mortality (3.7% vs 50%; P = 0.001). The proportion of cases undergoing arterial switch operation after prenatal diagnosis of TGA-IVS increased significantly, along with the prenatal detection rate, over the study period (2011-2015, 11.1% vs 2016-2019, 29.4%; P = 0.001). Median age at surgery was significantly lower in the prenatally diagnosed group than that in the postnatally diagnosed group (4 days (IQR, 1-23 days) vs 10 days (IQR, 1-91 days); P < 0.001). There was no significant difference in postoperative mortality (2.0% vs 3.6%; P = 0.49) between the two groups.

CONCLUSIONS

This study demonstrates the feasibility of creating a network for prenatal diagnosis and referral of patients with critical CHDs, such as TGA, in low-resource settings, that enables planned peripartum care in specialist pediatric cardiac centers and improved neonatal survival. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Appropriate use criteria for cardiovascular MRI: SIC - SIRM position paper Part 2 (myocarditis, pericardial disease, cardiomyopathies and valvular heart disease)

Cardiovascular magnetic resonance (CMR) has emerged as an accurate diagnostic technique for the evaluation of patients with cardiac disease in the majority of clinical settings, thanks to an established additional diagnostic and prognostic value. This document has been developed by a joined group of experts of the Italian Society of Cardiology (SIC) and Italian Society of Radiology (SIRM) to provide a summary about the current state of technology and clinical applications of CMR, to improve the clinical diagnostic pathways and to promote its inclusion in clinical practice. The writing committee consisted of members and experts of both societies in order to develop a more integrated approach in the field of cardiac imaging. This section 2 will cover myocarditis, pericardial disease, cardiomyopathies and valvular heart disease.

Patient Use and Clinical Practice Patterns of Remote Cardiology Clinic Visits in the Era of COVID-19

IMPORTANCE

The COVID-19 pandemic has led to an unprecedented shift in ambulatory cardiovascular care from in-person to remote visits.

OBJECTIVE

To understand whether the transition to remote visits is associated with disparities in patient use of care, diagnostic test ordering, and medication prescribing.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used electronic health records data for all ambulatory cardiology visits at an urban, multisite health system in Los Angeles County, California, during 2 periods: April 1, 2019, to December 31, 2019 (pre-COVID) and April 1 to December 31, 2020 (COVID-era). Statistical analysis was performed from January to February 2021.

EXPOSURE

In-person or remote ambulatory cardiology clinic visit at one of 31 during the pre-COVID period or COVID-era period.

MAIN OUTCOMES AND MEASURES

Comparison of patient characteristics and frequencies of medication ordering and cardiology-specific testing across 4 visit types (pre-COVID in-person (reference), COVID-era in-person, COVID-era video, COVID-era telephone).

RESULTS

This study analyzed data from 87 182 pre-COVID in-person, 74 498 COVID-era in-person, 4720 COVID-era video, and 10 381 COVID-era telephone visits. Across visits, 79 572 patients were female (45.0%), 127 080 patients were non-Hispanic White (71.9%), and the mean (SD) age was 68.1 (17.0) years. Patients accessing COVID-era remote visits were more likely to be Asian, Black, or Hispanic individuals (24 934 pre-COVID in-person visits [28.6%] vs 19 742 COVID-era in-person visits [26.5%] vs 3633 COVID-era video visits [30.4%] vs 1435 COVID-era telephone visits [35.0%]; P < .001 for all comparisons), have private insurance (34 063 pre-COVID in-person visits [39.1%] vs 25 474 COVID-era in-person visits [34.2%] vs 2562 COVID-era video visits [54.3%] vs 4264 COVID-era telephone visits [41.1%]; P < .001 for COVID-era in-person vs video and COVID-era in-person vs telephone), and have cardiovascular comorbidities (eg, hypertension: 37 166 pre-COVID in-person visits [42.6%] vs 31 359 COVID-era in-person visits [42.1%] vs 2006 COVID-era video visits [42.5%] vs 5181 COVID-era telephone visits [49.9%]; P < .001 for COVID-era in-person vs telephone; and heart failure: 14 319 pre-COVID in-person visits [16.4%] vs 10 488 COVID-era in-person visits [14.1%] vs 1172 COVID-era video visits [24.8%] vs 2674 COVID-era telephone visits [25.8%]; P < .001 for COVID-era in-person vs video and COVID-era in-person vs telephone). After adjusting for patient and visit characteristics and in comparison with pre-COVID in-person visits, during video and telephone visits, clinicians had lower odds of ordering any medication (COVID-era in-person: odds ratio [OR], 0.62 [95% CI, 0.60-0.64], COVID-era video: OR, 0.22 [95% CI, 0.20-0.24]; COVID-era telephone: OR, 0.14 [95% CI, 0.13-0.15]) or tests, such as electrocardiograms (COVID-era in-person: OR, 0.60 [95% CI, 0.58-0.62]; COVID-era video: OR, 0.03 [95% CI, 0.02-0.04]; COVID-era telephone: OR, 0.02 [95% CI, 0.01-0.03]) or echocardiograms (COVID-era in-person: OR, 1.21 [95% CI, 1.18-1.24]; COVID-era video: OR, 0.47 [95% CI, 0.42-0.52]; COVID-era telephone: OR, 0.28 [95% CI, 0.25-0.31]).

CONCLUSIONS AND RELEVANCE

Patients who were Asian, Black, or Hispanic, had private insurance, and had at least one of several cardiovascular comorbidities used remote cardiovascular care more frequently in the COVID-era period. Clinician ordering of diagnostic testing and medications consistently decreased when comparing pre-COVID vs COVID-era and in-person vs remote visits. Further studies are needed to clarify whether these decreases represent a reduction in the overuse of tests and medications vs an underuse of indicated testing and prescribing.

2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the hypertrophic cardiomyopathy clinical practice guideline provides recommendations and algorithms for clinicians to diagnose and manage hypertrophic cardiomyopathy in adult and pediatric patients as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to April 30, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases.

STRUCTURE

Many recommendations from the earlier hypertrophic cardiomyopathy guidelines have been updated with new evidence or a better understanding of earlier evidence. This summary operationalizes the recommendations from the full guideline and presents a combination of diagnostic work-up, genetic and family screening, risk stratification approaches, lifestyle modifications, surgical and catheter interventions, and medications that constitute components of guideline directed medical therapy. For both guideline-directed medical therapy and other recommended drug treatment regimens, the reader is advised to follow dosing, contraindications and drug-drug interactions based on product insert materials.

Molecular imaging in nuclear cardiology: Pathways to individual precision medicine

Growth of molecular imaging bears potential to transform nuclear cardiology from a primarily diagnostic method to a precision medicine tool. Molecular targets amenable for imaging and therapeutic intervention are particularly promising to facilitate risk stratification, patient selection and exquisite guidance of novel therapies, and interrogation of systems-based interorgan communication. Non-invasive visualization of pathobiology provides valuable insights into the progression of disease and response to treatment. Specifically, inflammation, fibrosis, and neurohormonal signaling, central to the progression of cardiovascular disease and emerging therapeutic strategies, have been investigated by molecular imaging. As the number of radioligands grows, careful investigation of the binding properties and added-value of imaging should be prioritized to identify high-potential probes and facilitate translation to clinical applications. In this review, we discuss the current state of molecular imaging in cardiovascular medicine, and the challenges and opportunities ahead for cardiovascular molecular imaging to navigate the path from diagnosis to prognosis to personalized medicine.

A quick glance at selected topics in this issue

"A quick glance at selected topics in this issue" aims to highlight contents of the Journal and provide a quick review to the readers.

The Vicious Circle of Left Ventricular Dysfunction and Diabetes: From Pathophysiology to Emerging Treatments

CONTEXT

Diabetes and heart failure (HF) are 2 deadly and strictly related epidemic disorders. The aim of this review is to present an updated discussion of the epidemiology, pathophysiology, clinical presentation and treatment options for HF in diabetes.

EVIDENCE ACQUISITION

Relevant references published up to February 2020 were identified through searches in PubMed. Quality was graded using the Newcastle-Ottawa score in observational studies and the Cochrane Collaboration tool in randomized studies.

EVIDENCE SYNTHESIS

Metabolic and neurohumoral derangements, oxidative stress, inflammation, micro- and macroangiopathy all contribute through complex molecular and cellular mechanisms to cardiac dysfunction in diabetes, which in turn, results as one the most frequent underlying conditions affecting up to 42% of patients with HF and causing a 34% increased risk of cardiovascular death. On top of traditional guideline-based HF medical and device therapies, equally effective in patients with and without diabetes, a new class of glucose-lowering agents acting through the sodium-glucose cotransporter 2 (SGLT2) inhibition showed impressive results in reducing HF outcomes in individuals with diabetes and represents an active area of investigation.

CONCLUSIONS

Diabetes and HF are strictly linked in a bidirectional and deadly vicious circle difficult to break. Therefore, preventive strategies and a timely diagnosis are crucial to improve outcomes in such patients. SGLT2 inhibitors represent a major breakthrough with remarkably consistent findings. However, it is still not clear whether their benefits may be definitely extended to patients with HF with preserved ejection fraction, to those without diabetes and in the acute setting.

Contemporary Management of Severe Acute Kidney Injury and Refractory Cardiorenal Syndrome: JACC Council Perspectives

Acute kidney injury (AKI) and cardiorenal syndrome (CRS) are increasingly prevalent in hospitalized patients with cardiovascular disease and remain associated with poor short- and long-term outcomes. There are no specific therapies to reduce mortality related to either AKI or CRS, apart from supportive care and volume status management. Acute renal replacement therapies (RRTs), including ultrafiltration, intermittent hemodialysis, and continuous RRT are used to manage complications of medically refractory AKI and CRS and may restore normal electrolyte, acid-base, and fluid balance before renal recovery. Patients who require acute RRT have a significant risk of mortality and long-term dialysis dependence, emphasizing the importance of appropriate patient selection. Despite the growing use of RRT in the cardiac intensive care unit, there are few resources for the cardiovascular specialist that integrate the epidemiology, diagnostic workup, and medical management of AKI and CRS with an overview of indications, multidisciplinary team management, and transition off of RRT.