Potential for optimizing management of obesity in the secondary prevention of coronary heart disease

AIMS

Prevention guidelines have identified the management of obese patients as an important priority to reduce the burden of incident and recurrent cardiovascular disease. Still, studies have demonstrated that over 80% of patients with coronary heart disease (CHD) fail to achieve their weight target. Here, we describe advice received and actions reported by overweight CHD patients since being discharged from hospital and how weight changes relate to their risk profile.

METHODS AND RESULTS

Based on data from 10 507 CHD patients participating in the EUROASPIRE IV and V studies, we analysed weight changes from hospital admission to the time of a study visit ≥6 and <24 months later. At hospitalization, 34.9% were obese and another 46.0% were overweight. Obesity was more frequent in women and associated with more comorbidities. By the time of the study visit, 19.5% of obese patients had lost ≥5% of weight. However, in 16.4% weight had increased ≥5%. Weight gain in those overweight was associated with physical inactivity, non-adherence to dietary recommendations, smoking cessation, raised blood pressure, dyslipidaemia, dysglycaemia, and lower levels of quality of life. Less than half of obese patients was considering weight loss in the coming month.

CONCLUSIONS

The management of obesity remains a challenge in the secondary prevention of CHD despite a beneficial effect of weight loss on risk factor prevalences and quality of life. Cardiac rehabilitation programmes should include weight loss interventions as a specific component and the incremental value of telehealth intervention as well as recently described pharmacological interventions need full consideration.

Thromboembolic risk is potentially reduced in mitral stenosis shortly after percutaneous mitral valvotomy

Background

Rheumatic mitral stenosis (MS) is a problem in the developing countries. Left atrium (LA) and appendage (LAA) dysfunction are considered determinant factors for thrombus formation even in patients with sinus rhythm (SR). Percutaneous mitral valvotomy (PMV) is a well accepted therapeutic option. However, no available data considers patients with SR as a low risk group for the development of thrombus.

Purpose

Studying short term impact of PMV on P wave morphology, NT-pro BNP as well as LAA properties in patients with MS and SR.

Methods

A prospective study was conducted in a tertiary University hospital including 41 patients with symptomatic uncomplicated MS having favorable morphology with sinus Rhythm. P wave duration, amplitude and dispersion, NT-pro BNP, transthoracic and transesophageal echocardiography were carried out directly before and 1 month following PMV. Student t-test was used to compare the variables before and after PMV. Correlation was calculated using Pearson's correlation and multivariate regression analysis was used for prediction of unfavorable outcomes.

Results

After PMV, 36 (87.8%) patients had a favorable outcome manifested with improvement of NYHA class, valve area, estimated systolic pulmonary artery pressure (sPAP) as well as grade of spontaneous echo contrast (SEC). P wave duration, P wave amplitude and P wave dispersion decreased after PMV (14.97±2.65 vs. 13.21±2.36 ms, 4.01±1.01 vs. 2.51±0.71 ms and 4.01±1.01 vs. 2.51±0.71mv; P&lt;0.001 respectively). NT pro-BNP also reduced (2.90±2.19 vs. 2.01±1.31 Pg/L; P&lt;0.001). TEE PW of LAA showed increase of early (E LAA) and late (A LAA) emptying velocities after PMV (41.70±19.50 vs. 48.82±20.18 and 31.31±21.99 vs. 38.48±19.86 cm/s; P&lt;0.001 respectively). By TDI, late wall motion (LAA A) velocity increased (7.41±2.50 vs. 8.23±3.01 cm/s; P&lt;0.001) with an improvement of LAA ejection fraction post procedural (50.80±13.11 vs. 55.75±10.12%; P&lt;0.001). Negative correlation between LAA EF and P wave amplitude (r=−0.40; P&lt;0.001) as well as a correlation between reduction in NT pro-BNP and the improvement of both LAA A velocity and E LAA wave were noticed (r=0.55; P=0.02 and 0.01 respectively). The grade of SEC was negatively correlated with E LAA (r=−0.55, P=0.02). Only 5 patients (12.2%) had an unfavorable outcome. Four patients had severe mitral regurge (7.8%), only one patient (2.4%) was indicated for surgery. AF developed in one patient (2.4%). The grade of SEC remains the same in 3 patients (7.3%). Both baseline estimated sPAP and Wilkins score were predictors for unfavorable outcome; sPAP (odd's ratio= 4.08; 95% CI=1.01- 7.17; P=0.04); Wilkins score (odd's ratio= 1.59; 95% CI=1.22- 5.98; P=0.01).

Conclusion

PMV has a favorable rapid impact on LA and LAA properties in patients with MS and SR. Our data suggests that PMV could potentially contribute to lowering the risk of future thromboembolic events in those patients.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Assiut University Hospital

RV function by cardiac magnetic resonance and its relationship with neutrophil/lymphocyte ratio in patients with acute inferior STEMI undergoing PPCI

Funding Acknowledgements

Type of funding sources: None.

Background

Although acute inferior myocardial infarction (MI) is usually regarded as being lower risk compared with acute anterior MI, right ventricular (RV) myocardial involvement (RVMI) carries an increased risk of cardiovascular (CV) morbidity and mortality in patients with inferior MI.Cardiac Magnetic resonance (CMR) is ideal for assessing the RV because it allows a comprehensive assessment of cardiovascular morphology and physiology without most of the limitations that hinder alternative imaging modalities.

Objectives

To evaluate the sensitivity of other parameters;the neutrophil/ lymphocyte ratio (NLR) and RV function using 2D speckle tracking echo compared to (CMR) among patients with inferior STEMI undergoing primary percutaneous coronary intervention (PPCI).

Methodology

 40 Patients with inferior MI who had PPCI were included in the study; two groups were highlighted according to the CMR derived RVEF RV dysfunction (RVD and non-RVD). NLR  and 2D speckle tracking echo were done in comparison to RVEF.

Results

out of the 40 patients, 18 (45%) patients had RVD. ST segment elevation in the right leads was significantly higher (P-value =0.03) in patients with RV dysfunction (55.6%) in comparison with patients (22.7%) who had no RV dysfunction.When comparing groups according to the complications, heart block was significantly higher in patients with RV dysfunction (P-value= 0.008) as it occurred in 5 (27.8%) patients.Echocardiography was done for all patients, and it was found that fractional area change (FAC) in the RV dysfunction group appeared to be significantly reduced compared to the group without RV dysfunction (P-value =0.03). RV longitudinal strain (LS) by speckle tracking echo was reduced with an average of -19.5 ±3.9 % in the RV dysfunction group P value 0.008.Both CMR- derived RV SV, and EF were lower among the RV dysfunction group, (26.8 ± 15.8) ml and (35.4 ± 6.9) % respectively, with large RV systolic volume, with the highly statistically significant difference in comparison to the other group (p value = 0.000). Mean N/L ratio was higher (7.3 ± 5.2 (10^3/uL)) in the group with RV dysfunction compared to (6.4 ± 4.1(10^3/uL)) in the group with non RV dysfunction group. N/L ratio for predicting RV dysfunction by CMR had a cutoff value of &gt;7.7 with low sensitivity (38.89%) and high specificity (77.27 %), while LS for predicting RV dysfunction by CMR had both high sensitivity (83.33%) and high specificity (63.64%) with P-value =0.005.

Conclusion

Our results showed that RV dysfunction in inferior MI is better detected using cardiac magnetic resonance imaging. In inferior STEMI patients who underwent primary PCI, NLR has low sensitivity but high specificity for predicting  RVD when measured by cardiac MRI.

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

Antiapoptotic and antioxidant effects of carvedilol and vitamin E protect against diabetic nephropathy and cardiomyopathy in diabetic Wistar albino rats

Carvedilol is a novel β-adrenoreceptor blocker, with antioxidant properties inhibiting lipid peroxidation and preventing the depletion of endogenous antioxidants. Moreover, carvedilol was reported to enhance the expression of Bcl-2 gene, which has antioxidant and antiapoptotic effects. There are few researches testing the protective effect of carvedilol on the development of diabetic cardiomyopathy and nephropathy. In this study, we induced diabetes mellitus in male Wistar albino rats. We investigated carvedilol, as well as vitamin E, administrated in healthy and diabetic rats for 6 weeks to compare their effects on biochemical parameters and the expression of Bcl-2 protein in both myocardial and renal tissues by immunohistochemistry. The study showed that the diabetic rats not only had renal dysfunction and more myocardial damage, but also showed lower expression of Bcl-2 protein. Carvedilol and vitamin E treatments were associated with better renal function and less myocardial damage, lower blood glucose, and lipid peroxidation, higher antioxidant capacity, better serum lipids, and higher expression of Bcl-2 protein in diabetic rats. These results indicate that carvedilol and vitamin E treatments partly protect against myocardial and renal damage probably via their antioxidant and antiapoptotic properties in diabetic rats.

Corrected QT dispersion improves diagnostic performance of exercise testing in diagnosing coronary artery disease

To determine the best combination of parameters that would improve the diagnostic performance of exercise testing, coronary angiography plus exercise testing were done on 112 patients with angina pectoris and normal electrocardiogram. The univariate predictors of coronary artery disease included: age > or = 40 years, male sex, hypertension, smoking, development of exertional chest pain, decrease in systolic blood pressure (BP) > or = 10 mmHg or systolic BP 3 min post-exercise > 90% of peak, heart rate drop < 12 beats/min 1 min postexercise, exercise-induced ST-segment depression > or = 1 mm. Multivariate logistic regression analysis showed that using either ST depression > or = 1 mm or peak exercise QTDc > 70 ms significantly improved sensitivity and negative predictive value of the test without a significant decrease in specificity.

Pattern and possible contributing factors to dialysis-associated arrhythmia in young patients

We studied dialysis-associated arrhythmia in 48 uraemic patients < 35 years on chronic haemodialysis (HD) (> 3 months). Holter findings showed only minor arrhythmia; atrial in 42% of patients and ventricular in 38%. ST-segment depression > 1 mm was observed in 58% of patients; 80% had arrhythmia, and 36% experienced anginal pain. HD caused a significant increase in QTc, QTdc and Ca2+ level, while K+ level was significantly decreased. Patients who experienced arrhythmia during HD had higher left ventricular mass and left ventricular mass index, lower post-dialysis K+ level, higher QTc and QTdc both before and after HD. They were more frequently hypertensive. ST-segment depression was significantly related to ventricular arrhythmia.