Perioperative adverse cardiac events in maxillofacial surgery: A systematic review and meta-analysis

Background and Aims

Maxillofacial surgeries, including procedures to the face, oral cavity, jaw, and head and neck, are common in adults. However, they impose a risk of adverse cardiac events (ACEs). While ACEs are well understood for other non-cardiac surgeries, there is a paucity of data about maxillofacial surgeries. This systematic review and meta-analysis report the incidence and presentation of perioperative ACEs during maxillofacial surgery.

Methods

We included primary studies that reported on perioperative ACEs in adults. To standardise reporting, ACEs were categorised as 1. heart rate and rhythm disturbances, 2. blood pressure disturbances, 3. ischaemic heart disease and 4. heart failure and other complications. The primary outcome was ACE presentation and incidence during the perioperative period. Secondary outcomes included the surgical outcome according to the Clavien-Dindo classification and trigeminocardiac reflex involvement. STATA version 17.0 and MetaProp were used to delineate proportion as effect size with a 95% confidence interval (CI).

Results

Twelve studies (34,227 patients) were included. The incidence of perioperative ACEs was 2.58% (95% CI 1.70, 3.45, I2 = 96.17%, P = 0.001). Heart rate and rhythm disturbances resulted in the greatest incidence at 3.84% among the four categories. Most commonly, these ACEs resulted in intensive care unit admission (i.e. Clavien-Dindo score of 4).

Conclusion

Despite an incidence of 2.58%, ACEs can disproportionately impact surgical outcomes. Future research should include large-scale prospective studies that may provide a better understanding of the contributory factors and long-term effects of ACEs in patients during maxillofacial surgery.

Left ventricular global longitudinal strain and acute myocardial injury in patients with sickle cell disease admitted to the intensive care unit for vaso-occlusive crisis

In patients with sickle cell disease (SCD), SCD-related cardiomyopathy may be partly due to repeated ischaemic events related to sickling during vaso-occlusive crises, but few clinical studies support this hypothesis. We evaluated the incidence of acute myocardial ischaemia during vaso-occlusive crises as assessed by the left ventricular global longitudinal strain (LVGLS) and high-sensitive cardiac troponin T (hs-cTnT). We included adult patients with SCD admitted to the intensive care unit (ICU) for vaso-occlusive crisis. We collected hs-cTnT and measured LVGLS with echocardiography at admission (day 1), day 2, day 3 and ICU discharge. Among 55 patients included, considering only the first hospitalization of patients admitted several times, 3 (5%) had elevated hs-cTnT at ≥1 time point of the ICU stay. It was ≤2 times the upper limit of normal in two of these patients. LVGLS was altered at ≥1 time point of the ICU stay in 13 (24%) patients. Both hs-cTnT and LVGLS were abnormal at ≥1 time point of the hospital stay in 2 (4%) patients. Acute myocardial injury as assessed by troponin elevation and LVGLS impairment was a rare event during vaso-occlusive crises.

Association of postsystolic shortening on stress echocardiography and significant coronary artery stenosis: A single-centre retrospective cohort study

BACKGROUND

Postsystolic shortening (PSS) is one of the proposed quantitative measures to predict myocardial ischaemia in the stress echocardiographic (SE) evaluation. It is previously known that hypo-/akinesia (HA) correlates well with coronary stenosis. However, some patients undergoing SE only present with PSS, and their risk of significant coronary stenosis is less clear. This study aimed to evaluate the association between PSS and significant coronary stenosis compared with HA.

METHODS

This was a retrospective cohort study at the hospital of S:t Görans, Stockholm, Sweden. All patients who underwent SE to investigate inducible ischaemia between 1 January 2018 and 15 October 2021 were eligible for inclusion. Exclusion criteria were normal SE and inconclusive test. Pathological SE were divided into two groups, patients with HA and those with PSS. Outcome was significant coronary artery stenosis visualized by invasive coronary angiography.

RESULTS

The final study population consisted of 108 patients (73 PSS, 35 HA). The presence of HA was associated with a higher risk of significant stenosis compared to those with PSS (63% vs. 23%, p < 0.001). This relationship was observed among males (p < 0.001), but not among females (p = 0.133). Nonsignificant stenosis trended to be more common among patients with PSS (21% vs. 6%, p = 0.053) CONCLUSIONS: The finding of PSS without HA was associated with a lower risk of significant coronary stenosis than HA. However, patients with PSS still often had nonsignificant coronary stenosis and PSS in the evaluation for nonobstructive coronary artery disease (CAD) should be further investigated.

Screening of silent myocardial ischaemia using a stress test in rheumatoid arthritis patients: Association with traditional risk factors and disease activity

INTRODUCTION

We aimed to screen the presence of silent myocardial ischaemia, in established rheumatoid arthritis (RA) patients, using a stress test then to evaluate its association with the disease activity and the cardiovascular (CV) risk factors and Heartscore.

METHODS

It is a transversal study in a rheumatologic centre in Tunisia. One hundred three RA patients, asymptomatic for CV diseases, were submitted to a stress test. Demographic data, CV risk factors and disease characteristics were assessed and risk factors of silent myocardial ischaemia in RA patients were identified.

RESULTS

There were 103 patients (sex-ratio = 0.3) with a mean age of 53 ± 10 years. The evaluation of the disease activity showed that the mean Disease Activity Score in 28 joints C-reactive protein, Clinical Disease Activity Index and Simplified Disease Activity Index were 3.9 ± 1.38, 17.17 ± 11.4 and 33.39 ± 26, respectively. The ischaemic ratio (CT/HDL) revealed that 42% of patients had a moderate to high myocardial ischaemic risk. HeartSCORE was high in 35% of cases. A silent myocardial ischaemia in the stress test was found in 11 patients (10.6%) and was associated with male sex (p = 0.03), advanced age (p = 0.04), erosive character (p = 0.05), the advanced age of the RA diagnosis (p = 0.01) and the ischaemic ratio (p = 0.05). No relationship was found with the majority of traditional CV risk factors nor with disease activity variables.

CONCLUSION

Our results corroborated the hypothesis that the stress test could reveal subclinical CV dysfunction and supported the utility of the Heartscore as a screening tool.

Glutamate infusion associated with reduced rises of p-Copeptin after coronary surgery: Substudy of GLUTAMICS II

BACKGROUND

Glutamate plays a key role for post-ischaemic recovery of myocardial metabolism. According to post hoc analyses of the two GLUTAMICS trials, patients without diabetes benefit from glutamate with less myocardial dysfunction after coronary artery bypass surgery (CABG). Copeptin reflects activation of the Arginine Vasopressin system and is a reliable marker of heart failure but available studies in cardiac surgery are limited. We investigated whether glutamate infusion is associated with reduced postoperative rises of plasma Copeptin (p-Copeptin) after CABG.

METHODS

A prespecified randomised double-blind substudy of GLUTAMICS II. Patients had left ventricular ejection fraction ≤0.30 or EuroSCORE II ≥3.0 and underwent CABG ± valve procedure. Intravenous infusion of 0.125 M L-glutamic acid or saline at 1.65 mL/kg/h was commenced 10-20 min before the release of the aortic cross-clamp and then continued for another 150 min P-Copeptin was measured preoperatively and postoperatively on day one (POD1) and day three. The primary endpoint was an increase in p-Copeptin from the preoperative level to POD1. Postoperative stroke ≤24 h and mortality ≤30 days were safety outcomes.

RESULTS

We included 181 patients of whom 48% had diabetes. The incidence of postoperative mortality ≤30 days (0% vs. 2.1%; p = .50) and stroke ≤24 h (0% vs. 3.2%; p = .25) did not differ between the glutamate group and controls. P-Copeptin increased postoperatively with the highest values recorded on POD1 without significant inter-group differences. Among patients without diabetes, p-Copeptin did not differ preoperatively but postoperative rise from preoperative level to POD1 was significantly reduced in the glutamate group (73 ± 66 vs. 115 ± 102 pmol/L; p = .02). P-Copeptin was significantly lower in the Glutamate group on POD1 (p = .02) and POD 3 (p = .02).

CONCLUSIONS

Glutamate did not reduce rises of p-Copeptin significantly after moderate to high-risk CABG. However, glutamate was associated with reduced rises of p-Copeptin among patients without diabetes. These results agree with previous observations suggesting that glutamate mitigates myocardial dysfunction after CABG in patients without diabetes. Given the exploratory nature of these findings, they need to be confirmed in future studies.

Role of Preoperative Oral Rehydration Solution on Myocardial Ischaemia During Orthopaedic Surgery under Spinal Anaesthesia: A Prospective Randomised Study

Objective

Preoperative oral rehydration solution (ORS) supplementation offers wide postoperative benefits, but its role in reducing post-spinal myocardial ischaemia is uncertain. We evaluated this aspect in elective lower limb orthopaedic surgeries and compared it to conventional preoperative fasting.

Methods

Prospectively, we randomised 126 patients aged >60 years into two groups: (A) received reconstituted ORS (1000 mL) during the overnight preoperative fasting, continued up to 2 hrs prior to spinal anaesthesia (SA) induction; (B) kept on conventional overnight preoperative fasting. This study evaluated electrocardiographic ischaemic changes at 2, 5, 10, 15, and 30 minutes after SA induction.

Results

In total, 27 patients (group A: 7; group B: 20) developed transient electrocardiographic ischaemic changes. On intergroup comparison, group B had a significantly higher incidence at all time points, with highest statistical levels at 5- and 10-minutes ((P < 0.001). The receiver operating characteristic curve at a threshold fasting duration (fluids) of >3 hours, had an area-under-curve of 0.74 to predict such changes within 30 minutes of SA induction (sensitivity 96.30%, specificity 55.56%, accuracy 64.29%, odds ratio 32.50, relative risk 20.80, (P < 0.001). Post-spinal hemodynamic changes were higher in group B than in A; hypotension and tachycardia were statistically significant ((P=0.020). The pleth variability index was significantly higher ((P < 0.001), while perfusion index was significantly lower (P < 0.001) in group B at all time points.

Conclusion

Preoperative ORS supplementation significantly reduced post-spinal transient ischaemic electrocardiographic changes in elderly patients than conventional overnight fasting.

Echocardiographic multiparameter assessment for patients with heart failure with preserved ejection fraction and atrial fibrillation

We aimed to assess the echocardiographic parameters of cardiac structure and function in patients with heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF). Thirty-seven HFpEF patients with AF were selected, while 38 patients with simple HFpEF in the same period were selected as controls. Three-dimensional speckle-tracking echocardiography was performed on both groups and the parameters were compared. The early diastolic longitudinal peak strain rates [early diastolic longitudinal strain rate (LSRE), early diastolic circumferential strain rate (CSRE), early diastolic radial strain rate (RSRE) and early diastolic rotational strain rate (RotRE)], late diastolic longitudinal peak strain rates (LSRA, CSRA, RSRA and RotRA) and untwisting parameters [untwisting rate during isovolumic relaxation time (UTRIVR) and early peak untwisting rate (UTRE)] were all negatively correlated with the ratio of early diastolic transmitral velocity to early diastolic mitral annular velocity ( E/E') (p < 0.01). The cardiac event-free survival rate of the simple HFpEF group (92.11%) was significantly higher than that of the HFpEF + AF group (81.08%) (p < 0.0001). UTRIVR had a more significant correlation with E/E' ratio than the other indicators and could serve as a sensitive indicator for evaluating the diastolic function of patients with HFpEF + AF.

The cardioprotective effect of S. africana caerulea/Blue Sage in ischaemia and reperfusion induced oxidative stress

Background: Since antiquity, alternative herbal remedies, such as S. africana caerulea/Blue Sage (BLS) water infusion extract (WIE) has been used by traditional healers, for the effective treatment of various chronic inflammatory disorders associated with reduced cellular antioxidant defense mechanisms and free radical cellular damage. In the heart, ischaemia-reperfusion (I/R) induced oxidative stress becomes an early crucial event in the pathogenesis of ischaemia-reperfusion injury (I/RI) and subsequent heart failure. Purpose/Aim: To investigate whether BLS WIE treatment during ischaemia and/or reperfusion may be cardioprotective. Study design: Isolated perfused rat hearts were exposed to 35 min regional ischaemia (RI) and 60 min reperfusion. The BLS WIE was applied: i) for the last 10 min of RI (PerT) or ii) from onset of reperfusion (PostT) or iii) both (PerT) + (PostT). Methods: Endpoints were functional recovery and infarct size (IS). In another set of experiments, left ventricles were freeze-clamped after RI and 10 min reperfusion for detection of total and phosphorylated p-ERK p44/p42, p-Akt, p-p38-MAPK, p-JNK, Nrf-2, NF-kB, Bax, Bcl-2, Caspase-3, and PGC-1α by Western blot analysis. Results: BLS (PostT) significantly increased ERK p44, p-Akt, Nrf-2, and Bcl-2 levels; significantly decreased p-p38-MAPK as well as p-JNK p46 phosphorylation; did not affect Bax levels and significantly decreased Bax/Bcl-2 ratios. This was associated with significantly reduced Caspase-3 levels and increased PGC-1α phosphorylation, particlarly when BLS WIE was administered as PostT. Conclusion: The administration of polyphenol-rich BLS WIE at different stages of ischaemia and/or reperfusion, activate/inhibit several signaling events simultaneously and mediate cardioprotection in a multitarget manner.

Surgical repair of the anomalous aortic origin of the coronary arteries: a single-center experience

OBJECTIVE

Anomalous aortic origin of the coronary artery is a rare congenital cardiac anomaly. The aim of this study was to present our experience with patients who underwent surgery for the anomalous aortic origin of the coronary artery.

METHODS

This was a retrospective review of our experience with patients who had anomalous aortic origin of the coronary artery from 2019 to 2022.

RESULTS

Seven patients were managed for anomalous aortic origin of the coronary artery, including five males and two females. The median age of the patients were 16 years (IQR, 14.5-26 years). Five patients had anomalous aortic origin of the right coronary artery and two patients had anomalous aortic origin of the left coronary artery. Five patients were treated surgically, one patient refused surgical treatment despite myocardial ischaemia symptoms, and the other one was not operated because she had no symptoms. Two patients underwent pulmonary root anterior translocation and left main coronary artery unroofing procedure, one patient underwent right coronary artery unroofing procedure, one patient underwent pulmonary artery lateral translocation procedure, and the last patient underwent right coronary artery osteal translocation procedure. The post-operative mortality or myocardial infarction was not observed in any patient. Patients were followed for a median of 10 months (IQR, 6.75-20.5 months) after repair.

CONCLUSION

The data suggest that surgical repair of anomalous aortic origin of the coronary artery can be performed confidently and can be very effective for relieving myocardial ischaemia symptoms. Different surgical techniques can be used in anomalous aortic origin of the coronary artery according to the course and origin of the coronary arteries. To the our knowledge, pulmonary root anterior translocation and coronary artery unroofing procedure were performed for the first time in the literature.

Is N-methylacetazolamide a possible new therapy against ischemia-reperfusion injury?

The increase of intracellular Ca2+ concentration, produced principally by its influx through the L-type Ca2+ channels, is one of the major contributors to the ischemia-reperfusion injury. The inhibition of those channels in different experimental models was effective to ameliorate the post-ischemic damage. However, at a clinical level, the results were contradictory. Recent results of our group obtained in an ¨ex vivo¨ heart model demonstrated that a chemical derived from acetazolamide, the N-methylacetazolamide (NMA) protected the heart against ischemia-reperfusion injury, diminishing the infarct size and improving the post-ischemic recovery of myocardial function and mitochondrial dynamic. A significant inhibitory action on L-type Ca2+ channels was also detected after NMA treatment, suggesting this action as responsible for the beneficial effects on myocardium exerted by this compound. Although these results were promising, the effectiveness of NMA in the treatment of ischemic heart disease in humans as well as the advantages or disadvantages in comparison to the classic calcium antagonists needs to be investigated.

Difficulty Weaning From Cardiopulmonary Bypass Following an Aortic Valve Replacement

Aortic valve replacement (AVR) remains the treatment of choice for severe aortic stenosis. Despite the growing number of transcatheter AVR (TAVR) in younger and intermediate-to-low-risk patients, surgical AVR (SAVR) is widely used and retains low operative mortality, low rate of complications, and predictable long-term valve durability. Although it is a straightforward procedure, on some occasions, a surgeon could face challenging situations, such as compromised coronary flow and an inability to wean the patient from cardiopulmonary bypass (CPB). Our patient required concomitant coronary artery bypass grafting to overcome biventricular failure and facilitate successful weaning from CPB.

FOXO6 transcription inhibition of CTRP3 promotes OGD/R-triggered cardiac microvascular endothelial barrier disruption via SIRT1/Nrf2 signalling

BACKGROUND

C1q/TNF-related protein 3 (CTRP3) has been clarified to display its protective roles in cardiac function. The current study is concentrated on exploring the impacts of CTRP3 on myocardial ischaemia.

MATERIALS AND METHODS

Oxygen and glucose hypoxia/reoxygenation (OGD/R) model was constructed in human cardiac microvascular endothelial cells (HCMECs). Reverse transcription-quantitative polymerase chain reaction and western blot analysis of CTRP3 expression were conducted. CCK-8 assay was to estimate cell activity and lactate dehydrogenase (LDH) assay kit was to test LDH release. TUNEL assay and western blot were to judge apoptosis. Endothelial barrier function was detected by in vitro vascular permeability assay kit. Zonula occludens-1 (ZO-1) expression was evaluated by immunofluorescence assay. The interaction between CTRP3 promoter and Forkhead Box O6 (FOXO6) was predicted by JASPAR database and verified by chromatin immunoprecipitation and luciferase reporter assays. After OGD/R-induced HCMECs were co-transfected with CTRP3 overexpression and FOXO6 overexpression plasmids, the above functional experiments above were conducted again. Lastly, the expression of sirtuin 1 (SIRT1)/nuclear factor erythroid 2-related factor 2 (Nrf2) signalling-related proteins was examined by western blot.

RESULTS

CTRP3 was down-regulated in OGD/R-induced HCMECs. CTRP3 enhanced the viability and barrier integrity while reduced the apoptosis and permeability of OGD/R-insulted HCMECs. This process may be regulated by FOXO6 transcription. Also, FOXO6 inhibition-mediated CTRP3 up-regulation activated the SIRT1/Nrf2 signalling.

CONCLUSIONS

FOXO6 transcription inhibition of CTRP3 promotes OGD/R-triggered cardiac microvascular endothelial barrier disruption via SIRT1/Nrf2 signalling.

Importance of plaque volume and composition for the prediction of myocardial ischaemia using sequential coronary computed tomography angiography/positron emission tomography imaging

AIMS

Coronary atherosclerosis with a large necrotic core has been postulated to reduce the vasodilatory capacity of vascular tissue. In the present analysis, we explored whether total plaque volume and necrotic core volume on coronary computed tomography angiography (CCTA) are independently associated with myocardial ischaemia on positron emission tomography (PET).

METHODS AND RESULTS

From a registry of symptomatic patients with suspected coronary artery disease and clinically indicated CCTA with sequential [15O]H2O PET myocardial perfusion imaging, we quantitatively measured diameter stenosis, total and compositional plaque volumes on CCTA. Primary endpoint was myocardial ischaemia on PET, defined as an absolute stress myocardial blood flow ≤2.4 mL/g/min in ≥1 segment. Multivariable prediction models for myocardial ischaemia were consecutively created using logistic regression analysis (stenosis model: diameter stenosis ≥50%; plaque volume model: +total plaque volume; plaque composition model: +necrotic core volume). A total of 493 patients (mean age 63 ± 8 years, 54% men) underwent sequential CCTA/PET imaging. In 153 (31%) patients, myocardial ischaemia was detected on PET. Diameter stenosis ≥50% (P < 0.001) and necrotic core volume (P = 0.029) were independently associated with myocardial ischaemia, while total plaque volume showed borderline significance (P = 0.052). The plaque composition model (χ2 = 169) provided incremental value for the prediction of ischaemia when compared with the stenosis model (χ2 = 138, P < 0.001) and plaque volume model (χ2 = 164, P = 0.021).

CONCLUSION

The volume of necrotic core on CCTA independently and incrementally predicts myocardial ischaemia on PET, beyond diameter stenosis alone.

Clinical applications of cardiac computed tomography: a consensus paper of the European Association of Cardiovascular Imaging-part II

Cardiac computed tomography (CT) was initially developed as a non-invasive diagnostic tool to detect and quantify coronary stenosis. Thanks to the rapid technological development, cardiac CT has become a comprehensive imaging modality which offers anatomical and functional information to guide patient management. This is the second of two complementary documents endorsed by the European Association of Cardiovascular Imaging aiming to give updated indications on the appropriate use of cardiac CT in different clinical scenarios. In this article, emerging CT technologies and biomarkers, such as CT-derived fractional flow reserve, perfusion imaging, and pericoronary adipose tissue attenuation, are described. In addition, the role of cardiac CT in the evaluation of atherosclerotic plaque, cardiomyopathies, structural heart disease, and congenital heart disease is revised.

2021 Asian Pacific Society of Cardiology Consensus Recommendations on the Use of P2Y12 Receptor Antagonists in the Asia-Pacific Region: Special Populations

Advanced age, diabetes, and chronic kidney disease not only increase the risk for ischaemic events in chronic coronary syndromes (CCS) but also confer a high bleeding risk during antiplatelet therapy. These special populations may warrant modification of therapy, especially among Asians, who have displayed characteristics that are clinically distinct from Western patients. Previous guidance has been provided regarding the classification of high-risk CCS and the use of newer-generation P2Y₁₂ inhibitors (i.e. ticagrelor and prasugrel) after acute coronary syndromes (ACS) in Asia. The authors summarise evidence on the use of these P2Y₁₂ inhibitors during the transition from ACS to CCS and among special populations. Specifically, they present recommendations on the roles of standard dual antiplatelet therapy, shortened dual antiplatelet therapy and single antiplatelet therapy among patients with coronary artery disease, who are either transitioning from ACS to CCS; elderly; or with chronic kidney disease, diabetes, multivessel coronary artery disease and bleeding events during therapy.

Single photon emission computed tomography myocardial perfusion imaging in patients with moderate to severe psoriosissis

BACKGROUND

Psoriasis is a chronic inflammatory disorder with an increased risk for coronary artery disease (CAD). This retrospective study aimed to evaluate the rate of myocardial ischaemia in patients with psoriasis subjected to myocardial perfusion imaging (MPI).

MATERIAL AND METHODS

Twelve patients with moderate to severe psoriasis that had MPI were compared to 395 MPIs randomly retrieved from our MPIs pool data. All patients had a [99mTc]tetrofosmin stress - rest single-photon emission computer tomography ([99mTc]SPECT). Summed difference scores (SDS) were calculated for stress (SSS), rest (SRS) and their difference (SDS = SSS - SRS).

RESULTS

There was no significant difference in the frequency of abnormal MPI SPECT outcomes between patients with vs. without psoriasis (6/12 vs 214/395 respectively; p = 0.778). From the evaluation of SSS, SRS and SDS, only the SDS scores of inadequately compensated resting perfusion defects were significantly lower in patients with psoriasis (p = 0.012).

CONCLUSIONS

Patients with moderate-to-severe psoriasis had a similar rate of abnormal SSS scans compared to control patients. However, the SDS scans were significantly lower in patients with psoriasis indicating compromised reversibility of resting perfusion defects. Larger controlled studies are needed to verify these observations.

Patterns of [18F]FDG myocardial uptake in oncology patients as a predictor of myocardial ischaemia on stress myocardial perfusion imaging

BACKGROUND

There is variable cardiac uptake observed on oncological ¹⁸F-fludeoxyglucose ([¹⁸F]FDG) positron emission/computed tomography (PET/CT). The main purpose of this study is to evaluate patterns of overnight fasting myocardial [¹⁸F]FDG uptake in oncological PET/CT and analyse the relationship between myocardial [¹⁸F]FDG uptake and myocardial ischaemia on stress single-photon emission CT (SPECT) myocardial perfusion imaging (MPI).

MATERIAL AND METHODS

A total of 362 subjects underwent both oncological PET/CT and stress SPECT MPI within 3 months of each other. Subjects with focal-mass-like [¹⁸F]FDG myocardial uptake raising the suspicion of cardiac metastasis and subjects with coronary artery disease (CAD) were excluded. The myocardial [18F]FDG uptake was classified into four patterns.

RESULTS

Abnormal SPECT MPI was noted in 91 (25%) patients; 220 (61%) patients had completely absent [18F]FDG uptake, 80 (22%) had diffuse [¹⁸F]FDG uptake, 39 (11%) had focal on diffuse [¹⁸F]FDG uptake, and 23 (6%) had focal or regional myocardial [¹⁸F]FDG uptake, the regional [¹⁸F]FDG myocardial uptake was the most predictive of myocardial ischaemia on SPECT MPI, and there were positive associations between age, sex, hypertension, tobacco smoking, hypercholesterolemia, and left ventricular ejection, a fair agreement was noted between the focal or regional FDG uptake and presence of ischaemia on SPECT, K = 0.394 (95% CI 0.164 to 0.189).

CONCLUSIONS

Based on the presented findings, the physiological myocardial [¹⁸F]FDG uptake in fasting oncology patients is variable. The regional myocardial [¹⁸F]FDG uptake pattern is the most frequent pattern associated with myocardial ischaemia on stress SPECT MPI, however, the agreement between regional FDG uptake and presence of ischaemia on SPECT is fair.

Non-invasive CMR-Based Quantification of Myocardial Power and Efficiency Under Stress and Ischemic Conditions in Landrace Pigs

Background: Myocardial efficiency should be maintained stable under light-to-moderate stress conditions, but ischemia puts the myocardium at risk for impaired functionality. Additionally, the measurement of such efficiency typically requires invasive heart catheterization and exposure to ionizing radiation. In this work, we aimed to non-invasively assess myocardial power and the resulting efficiency during pharmacological stress testing and ischemia induction. Methods: In a cohort of n = 10 healthy Landrace pigs, dobutamine stress testing was performed, followed by verapamil-induced ischemia alongside cardiac magnetic resonance (CMR) imaging. External myocardial power, internal myocardial power, and myocardial efficiency were assessed non-invasively using geometrical and functional parameters from CMR volumetric as well as blood flow and pressure measurements. Results: External myocardial power significantly increased under dobutamine stress [2.3 (1.6-3.1) W/m² vs. 1.3 (1.1-1.6) W/m², p = 0.005] and significantly decreased under verapamil-induced ischemia [0.8 (0.5-0.9) W/m², p = 0.005]. Internal myocardial power [baseline: 5.9 (4.6-8.5) W/m²] was not affected by dobutamine [7.5 (6.9-9.0) W/m², p = 0.241] nor verapamil [5.8 (4.7-8.8) W/m², p = 0.878]. Myocardial efficiency did not change from baseline to dobutamine [21% (15-27) vs. 31% (20-44), p = 0.059] but decreased significantly during verapamil-induced ischemia [10% (8-13), p = 0.005]. Conclusion: In healthy Landrace pigs, dobutamine stress increased external myocardial power, whereas myocardial efficiency was maintained stable. On the contrary, verapamil-induced ischemia substantially decreased external myocardial power and myocardial efficiency. Non-invasive CMR was able to quantify these efficiency losses and might be useful for future clinical studies evaluating the effects of therapeutic interventions on myocardial energetics.

Effect of hypoglycaemia on measures of myocardial blood flow and myocardial injury in adults with and without type 1 diabetes: A prospective, randomised, open-label, blinded endpoint, cross-over study

AIMS

This study examined the effect of experimentally-induced hypoglycaemia on measures of myocardial blood flow and myocardial injury in adults with, and without, type 1 diabetes.

METHODS

In a prospective, randomised, open-label, blinded, endpoint cross-over study, 17 young adults with type 1 diabetes with no cardiovascular risk factors, and 10 healthy non-diabetic volunteers, underwent hyperinsulinaemic-euglycaemic (blood glucose 4.5-5.5 mmol/L) and hypoglycaemic (2.2-2.5 mmol/L) clamps. Myocardial blood flow was assessed using transthoracic echocardiography Doppler coronary flow reserve (CFR) and myocardial injury using plasma high-sensitivity cardiac troponin I (hs-cTnI) concentration.

RESULTS

During hypoglycaemia, coronary flow reserve trended non-significantly lower in those with type 1 diabetes than in the non-diabetic participants (3.54 ± 0.47 vs. 3.89 ± 0.89). A generalised linear mixed-model analysis examined diabetes status and euglycaemia or hypoglycaemia as factors affecting CFR. No statistically significant difference in CFR was observed for diabetes status (p = .23) or between euglycaemia and hypoglycaemia (p = .31). No changes in hs-cTnI occurred during hypoglycaemia or in the recovery period (p = .86).

CONCLUSIONS

A small change in CFR was not statistically significant in this study, implying hypoglycaemia may require more than coronary vasomotor dysfunction to cause harm. Further larger studies are required to investigate this putative problem.

Aortic valve calcium is associated with left ventricular diastolic function in patients without evidence of ischaemic heart disease: assessment by gated single-photon emission computed tomography

BACKGROUND

Several studies have shown that aortic valve calcium (AVC) is associated with cardiovascular events. Furthermore, the extent of AVC is associated with adverse prognosis even in patients without significant aortic stenosis. We investigated the relationship between AVC and left ventricular (LV) diastolic parameters determined by gated single-photon emission computed tomography (SPECT) in patients with no evidence of ischaemic heart disease.

METHODS

This study included 157 patients with no evidence of ischaemic heart disease who underwent both coronary computed tomography and gated SPECT. The AVC scores were calculated by the Agatston method, and peak filling rate (PFR) and one-third mean filling rate (1/3 MFR) were determined as LV diastolic parameters.

RESULTS

There were 93 (59%) and 64 (41%) patients with and without AVC, respectively, and the AVC scores ranged from 0 to 1251. There was no significant difference in LV end-diastolic volume (EDV) (60 ± 18 vs 62 ± 25 mL, p = 0.52) or LV ejection fraction (67% ± 10% vs 66% ± 8%, p = 0.60) between the two groups. Patients with AVC had lower PFR (2.2 ± 0.5 vs 2.4 ± 0.5 EDV/s, p = 0.002) and 1/3 MFR (1.3 ± 0.3 vs 1.5 ± 0.4 EDV/s, p = 0.003) than those without AVC. Multivariate linear regression analysis showed that ln(AVC score + 1) was significantly associated with PFR and 1/3 MFR.

CONCLUSION

In patients without evidence of ischaemic heart disease, the extent of AVC was inversely correlated with gated SPECT-derived parameters of LV diastolic function.

Comparison between cardiac magnetic resonance stress T1 mapping and [15O]H2O positron emission tomography in patients with suspected obstructive coronary artery disease

AIMS

To compare cardiac magnetic resonance (CMR) measurement of T1 reactivity (ΔT1) with [15O]H2O positron emission tomography (PET) measurements of quantitative myocardial perfusion.

METHODS AND RESULTS

Forty-three patients with suspected obstructed coronary artery disease underwent [15O]H2O PET and CMR at 1.5-T, including rest and adenosine stress T1 mapping (ShMOLLI) and late gadolinium enhancement to rule out presence of scar tissue. ΔT1 was determined for the three main vascular territories and compared with [15O]H2O PET-derived regional stress myocardial blood flow (MBF) and myocardial flow reserve (MFR). ΔT1 showed a significant but poor correlation with stress MBF (R2 = 0.04, P = 0.03) and MFR (R2 = 0.07, P = 0.004). Vascular territories with impaired stress MBF (i.e. ≤2.30 mL/min/g) demonstrated attenuated ΔT1 compared with vascular territories with preserved stress MBF (2.9 ± 2.2% vs. 4.1 ± 2.2%, P = 0.008). In contrast, ΔT1 did not differ between vascular territories with impaired (i.e. <2.50) and preserved MFR (3.2 ± 2.6% vs. 4.0 ± 2.1%, P = 0.25). Receiver operating curve analysis of ΔT1 resulted in an area under the curve of 0.66 [95% confidence interval (CI): 0.57-0.75, P = 0.009] for diagnosing impaired stress MBF and 0.62 (95% CI: 0.53-0.71, P = 0.07) for diagnosing impaired MFR.

CONCLUSIONS

CMR stress T1 mapping has poor agreement with [15O]H2O PET measurements of absolute myocardial perfusion. Stress T1 and ΔT1 are lower in vascular territories with reduced stress MBF but have poor accuracy for detecting impaired myocardial perfusion.

Role of Anaesthetic Choice in Improving Outcome after Cardiac Surgery

Clinical background

Volatile anaesthetics (VAs) have been shown to protect cardiomyocytes against ischaemia and reperfusion injury in cardiac surgery.

Clinical problems

VAs have been shown in multiple trials and meta-analyses to be associated with better outcomes when compared to intravenous anaesthesia in cardiac surgery. However, recent data from a large randomised controlled trial do not confirm the superiority of VA as compared to total intravenous anaesthesia in this population.

Review objectives

This mini review presents the VA cardioprotective effects, their clinical use in cardiac surgery and the most recent evidence that compares VA to intravenous anaesthesia for reducing perioperative morbidity. At present, there is no clear superiority of VA over intravenous anaesthesia in improving the outcome after cardiac surgery.

Electrophysiological and anatomical factors determine arrhythmic risk in acute myocardial ischaemia and its modulation by sodium current availability

Acute myocardial ischaemia caused by coronary artery disease is one of the main causes of sudden cardiac death. Even though sodium current blockers are used as anti-arrhythmic drugs, decreased sodium current availability, also caused by mutations, has been shown to increase arrhythmic risk in ischaemic patients. The mechanisms are still unclear. Our goal is to exploit perfect control and data transparency of over 300 high-performance computing simulations to investigate arrhythmia mechanisms in acute myocardial ischaemia with variable sodium current availability. The human anatomically based torso-biventricular electrophysiological model used includes representation of realistic ventricular anatomy and fibre architecture, as well as ionic to electrocardiographic properties. Simulations show that reduced sodium current availability increased arrhythmic risk in acute regional ischaemia due to both electrophysiological (increased dispersion of refractoriness across the ischaemic border zone) and anatomical factors (conduction block from the thin right ventricle to thick left ventricle). The asymmetric ventricular anatomy caused high arrhythmic risk specifically for ectopic stimuli originating from the right ventricle and ventricular base. Increased sodium current availability was ineffective in reducing arrhythmic risk for septo-basal ectopic excitation. Human-based multiscale modelling and simulations reveal key electrophysiological and anatomical factors determining arrhythmic risk in acute ischaemia with variable sodium current availability.

Diosmetin exerts cardioprotective effect on myocardial ischaemia injury in neonatal rats by decreasing oxidative stress and myocardial apoptosis

Myocardial injury caused by the myocardial ischaemia (MI) is still a troublesome condition in the clinic, including apoptosis, oxidative stress and inflammation. Diosmetin inhibits the cellular apoptosis and inflammatory response and enhances antioxidant activity. So, this study was designed to investigate the cardioprotective effects of diosmetin on MI model neonatal rats. Forty Sprague Dawley (SD) rats 7 days old were randomly divided into five groups. Four groups of rats received diosmetin (50, 100, and 200 mg/kg) or vehicle (MI group) after ischaemia. Another group received vehicle without ischaemia to serve as a control group. Rats were pretreated with diosmetin intraperitoneally for 7 days and intoxicated with isoproterenol (ISO, 85 mg/kg, sc) on the last 2 days. The expression of apoptotic molecules, myocardial systolic function index, antioxidant enzymes and myocardial enzyme was analyzed. Compared with the control group, the proliferation marker proteins of Ki67 were increased significantly (P < .05), the MI group significantly increased the cardiac apoptosis, oxidative stress and myocardial enzymes, and weakened myocardial contractility. The levels of p‐P65/P65 were increased significantly (P < .05) with decreased p‐AKT/AKT and p‐Nrf2/Nrf2 (P < .05). Nevertheless, pretreatment with diosmetin reversed these changes, especially high‐dose group. In summary, diosmetin has significant potential as a therapeutic intervention to ameliorate myocardial injury after MI and provides the rationale for further clinical studies.

Myocardial ischaemia and valve insufficiency caused by a dysplastic aortic valve cusp: a previously unreported unique morphologic anomaly

Isolated aortic regurgitation and myocardial infarction are a rare congenital defect among neonatal patients. We present a case of a neonate with an unusual aortic valve morphology causing both regurgitation and obstruction of the left coronary artery ostium. Despite both non-invasive and invasive imaging modalities, accurate diagnosis of the valve morphology was only determined by direct visualisation at the time of surgical repair. To the knowledge of authors, this particular aortic valve morphology in neonatal population has not been previously reported in the literature.

Exercise-induced myocardial dysfunction detected by cardiopulmonary exercise testing is associated with increased risk of mortality in major oncological colorectal surgery

BACKGROUND

Cardiopulmonary exercise testing (CPET) identifies high-risk patients before major surgery. In addition to using oxygen uptake and ventilatory efficiency to assess functional capacity, CPET can be used to identify underlying myocardial dysfunction through the assessment of the oxygen uptake to heart rate response (oxygen pulse response). We examined the relationship of oxygen pulse response, in combination with other CPET variables and known cardiac risk factors, with mortality after colorectal cancer surgery.

METHODS

This work focused on a retrospective cohort study of patients who had CPET and underwent colorectal cancer surgery. The primary outcome was a composite of in-hospital and 30-day mortality. Ventilatory inefficiency (Ve/Vco2>34) and exercise-induced myocardial dysfunction (abnormal oxygen pulse response) were investigated for an association with mortality using bivariable analysis and multivariable Cox regression.

RESULTS

A total of 1214 patients who underwent colorectal cancer surgery were included, and the primary outcome occurred in 26 patients (2.1%). Multivariable Cox regression showed abnormal oxygen pulse response was independently associated with the primary outcome (odds ratio [OR]=2.75; 95% confidence interval [CI], 1.17-6.47). Bivariable analysis showed that Ve/Vco2 >34 was associated with the primary outcome (OR=3.43; 95% CI, 1.47-8.01). Combining Ve/Vco2 >34 and abnormal oxygen pulse response conferred an increased risk for the primary outcome (OR=4.47; 95% CI, 1.62-12.34), compared with Ve/Vco2 >34 and normal oxygen pulse response.

CONCLUSION

Ventilatory inefficiency and an abnormal oxygen pulse response were independently associated with short- (30-day) and long-term (2-yr) mortality. Oxygen pulse response may provide additional information when considering perioperative risk stratification.

Added value of subjective assessed functional capacity before non-cardiac surgery in predicting postoperative myocardial injury

BACKGROUND

Functional capacity is used as an indicator for cardiac testing before non-cardiac surgery and is often performed subjectively. However, the value of subjectively estimated functional capacity in predicting cardiac complications is under debate. We determined the predictive value of subjectively assessed functional capacity on postoperative cardiac complications and mortality.

DESIGN

An observational cohort study in patients aged 60 years and over undergoing elective inpatient non-cardiac surgery in a tertiary referral hospital.

METHODS

Subjective functional capacity was determined by anaesthesiologists. The primary outcome was postoperative myocardial injury. Secondary outcomes were postoperative inhospital myocardial infarction and one year mortality. Logistic regression analysis and area under the receiver operating curves were used to determine the added value of functional capacity.

RESULTS

A total of 4879 patients was included; 824 (17%) patients had a poor subjective functional capacity. Postoperative myocardial injury occurred in 718 patients (15%). Poor functional capacity was associated with myocardial injury (relative risk (RR) 1.7, 95% confidence interval (CI) 1.5-2.0; P < 0.001), postoperative myocardial infarction (RR 2.9, 95% CI 1.9-4.2; P < 0.001) and one year mortality (RR 1.7, 95% CI 1.4-2.0; P < 0.001). After adjustment for other predictors, functional capacity was still a significant predictor for myocardial injury (odds ratio (OR) 1.3, 95% CI 1.0-1.7; P = 0.023), postoperative myocardial infarction (OR 2.0, 95% CI 1.3-3.0; P = 0.002) and one year mortality (OR 1.4, 95% CI 1.1-1.8; P = 0.003), but had no added value on top of other predictors.

CONCLUSIONS

Subjectively assessed functional capacity is a predictor of postoperative myocardial injury and death, but had no added value on top of other preoperative predictors.

Diagnostic value of peak filling rate derived from ECG-gated myocardial perfusion SPECT for detecting myocardial ischaemia in patients with non-obstructive coronary artery disease

Background: Left ventricular (LV) diastolic dysfunction represents an earlier step of the ischaemic cascade. We tested the hypothesis that the index of LV diastolic function from electrocardiogram (ECG)-gated single photon emission computed tomography (SPECT) is useful in detecting myocardial ischaemia in patients with non-obstructive coronary artery disease (CAD).Methods: One-hundred-ten patients with non-obstructive CAD and summed redistribution score of zero were enrolled. Summed difference score (SDS) of ≥2 was considered as the presence of myocardial ischaemia. Peak filling rate (PFR) defined as the maximum dV/dt divided by LV end-diastolic volume was obtained as the index of LV diastolic function.Results: Of 110 patients with non-obstructive CAD, 51 patients had myocardial ischaemia. SDSs in patients with myocardial ischaemia and those without were 3.5 ± 1.8 and 0.4 ± 0.5, respectively (p < 0.001). PFRs after stress (r = -0.22, p = 0.02) and at redistribution (r = -0.24, p = 0.01) were inversely correlated with SDS. Multivariate logistic regression analysis showed that PFR at redistribution was an independent predictor of the presence of myocardial ischaemia in patients with non-obstructive CAD (odds ratio: 0.15, 95% confidence interval: 0.04-0.51, p = 0.002).Conclusion: Our data suggest that PFR, the index of LV diastolic function from ECG-gated SPECT, helps to find myocardial ischaemia in patients with non-obstructive CAD.

Current approach to the diagnosis of atherosclerotic coronary artery disease: more questions than answers

Despite its commonality in routine clinical practice, the approach to a diagnosis of atherosclerotic coronary artery disease remains complex and, in part, contentious. The traditional dogma linking ischaemia to hard clinical outcomes has been questioned and reframed over the years; rather than being a predictor of hard clinical outcomes, the degree of ischaemia may simply be a marker of atherosclerotic disease burden. A renewed interest in the imaging of plaque burden has spawned the contemporary role of CT imaging for not only diagnosis and prognosis, but also for dictating downstream management. As the technology develops and evidence expands, decisions on investigative modalities remain centred around patient factors, local availability, test performance and cost. This review summarizes the available methods for diagnosis in the symptomatic patient and provides an overview of the current evidence behind functional and anatomical approaches.

Preoperative coronary angiography in vascular surgery patients with asymptomatic elevated high-sensitivity troponin T: a case series

This case series presents 10 patients undergoing vascular surgery with asymptomatic elevated high-sensitivity troponin T concentrations, measured at outpatient clinic before surgery. Patients were included in the RAVE (Rotterdam Antiplatelet therapy in Vascular patiEnts) pilot study. All included patients underwent coronary angiography before surgery to identify significant obstructive coronary artery disease. We identified five out of 10 patients with high-grade stenosis and high-risk angiographic features of left main and/or proximal left anterior descending coronary artery disease. The study was terminated prematurely before any subject reached the study endpoint of 1 yr follow-up. This case series provides more insight into the meaning of preoperative troponin elevation and coronary angiographic features in vascular surgery patients. TRIAL REGISTRY NUMBER: NL5803.

FOXC1 up-regulates the expression of toll-like receptors in myocardial ischaemia

Myocardial ischaemia (MI) remains a major cause of death and disability worldwide. Accumulating evidence suggests a significant role for innate immunity, in which the family of toll‐like receptors (TLRs) acts as an essential player. We previously reported and reviewed the changes of Tlr expression in models of MI. However, the underlying mechanisms regulating Tlr expression in MI remain unclear. The present study first screened transcription factors (TFs) that potentially regulate Tlr gene transcription based on in silico analyses followed by experimental verification, using both in vivo and in vitro models. Forkhead box C1 (FOXC1) was identified as a putative TF, which was highly responsive to MI. Next, by focusing on two representative TLR subtypes, an intracellular subtype TLR3 and a cell‐surface subtype TLR4, the regulation of FOXC1 on Tlr expression was investigated. The overexpression or knockdown of FoxC1 was observed to up‐ or down‐regulate Tlr3/4 mRNA and protein levels, respectively. A dual‐luciferase assay showed that FOXC1 trans‐activated Tlr3/4 promoter, and a ChIP assay showed direct binding of FOXC1 to Tlr3/4 promoter. Last, a functional study of FOXC1 was performed, which revealed the pro‐inflammatory effects of FOXC1 and its destructive effects on infarct size and heart function in a mouse model of MI. The present study for the first time identified FOXC1 as a novel regulator of Tlr expression and described its function in MI.

Testosterone and the Heart

The development of a subnormal level of testosterone (T) is not universal in ageing men, with 75% of men retaining normal levels. However, a substantial number of men do develop T deficiency (TD), with many of them carrying a portfolio of cardiovascular (CV) risk factors, including type 2 diabetes (T2D) and the metabolic syndrome. TD increases the risk of CV disease (CVD) and the risk of developing T2D and the metabolic syndrome. The key symptoms suggesting low T are sexual in nature, including erectile dysfunction (ED), loss of night-time erections and reduced libido. Many men with heart disease, if asked, admit to ED being present; a problem that is often compounded by drugs used to treat CVD. A large number of studies and meta-analyses have provided evidence of the link between TD and an increase in CVD and total mortality. Patients with chronic heart failure (CHF) who have TD have a poor prognosis and this is associated with more frequent admissions and increased mortality compared with those who do not have TD. Conversely, in men with symptoms and documented TD, T therapy has been shown to have beneficial effects, namely improvement in exercise capacity in patients with CHF, improvement of myocardial ischaemia and coronary artery disease. Reductions in BMI and waist circumference, and improvements in glycaemic control and lipid profiles, are observed in T-deficient men receiving T therapy. These effects might be expected to translate into benefits and there are more than 100 studies showing CV benefit or improved CV risk factors with T therapy. There are flawed retrospective and prescribing data studies that have suggested increased mortality in treated men, which has led to regulatory warnings, and one placebo-controlled study demonstrating an increase in coronary artery non-calcified and total plaque volumes in men treated with T, which is open for debate. Men with ED and TD who fail to respond to phosphodiesterase type 5 (PDE5) inhibitors can be salvaged by treating the TD. There are data to suggest that T and PDE5 inhibitors may act synergistically to reduce CV risk.

Thromboembolic and haemorrhagic events in patients with atrial fibrillation: a prospective cohort study in UK primary and secondary care

BACKGROUND

Strong evidence on the long-term safety and efficacy of different types of anticoagulants would help clinicians to prevent thromboembolic events among patients with atrial fibrillation (AF) while minimising the risk of haemorrhages.

AIM

To estimate the risk of thromboembolic and haemorrhagic events for patients with AF on antiplatelets or anticoagulants.

DESIGN AND SETTING

This was a cohort study using routinely collected UK primary and secondary care clinical data from patients with AF, aged ≥18 years, and with an indication to receive anticoagulation before April 2012.

METHOD

The risk of ischaemic stroke or transient ischaemic attack (TIA), coronary heart disease (CHD), peripheral artery disease (PAD), or gastrointestinal (GI) haemorrhage, between 1 April 2012 and 1 April 2017, was estimated using multivariate Cox regression models for patients on antiplatelets only, a combination of antiplatelets and vitamin K antagonists (VKAs), or novel oral anticoagulants (NOACs), and compared with those on VKAs only.

RESULTS

Compared with VKAs, antiplatelets were associated with a higher risk of stroke or TIA, hazard ratio (HR) 1.51, 95% confidence interval (CI) = 1.09 to 2.09, and GI haemorrhage, HR 1.79, 95% CI = 1.01 to 3.18. The risk of thromboembolic and haemorrhagic events was similar for those on a combination of antiplatelets and VKAs, or those on VKAs only. The risk was also similar for those on NOACs or VKAs, except for CHD, where it was higher for patients on NOACs, HR 2.07, 95% CI = 1.35 to 3.19.

CONCLUSION

Anticoagulants are associated with lower risk of thromboembolic and haemorrhagic events among patients with AF than antiplatelets. More research is required on the risk associated with VKAs or NOACs.

ST-elevation myocardial infarction in a migrant population: a registry-based study of patient treatment and outcomes

BACKGROUND

Internationally, a growing number of studies has identified race-related disparities in the presentation, treatment and outcomes of patients with ST-elevation myocardial infarction (STEMI). With a large migrant population, Australia presents a unique microcosm in which to study the impact of migrant status and ethnicity in STEMI patients.

AIM

To investigate if first-generation migrants differed in presentation, treatment or outcomes following STEMI compared with the Australian-born population.

METHODS

We conducted a retrospective observational study using data from a clinician-initiated registry. The study involved 2154 patients who presented to 12 hospitals between 2004 and 2012. Our main outcome measures included time to reperfusion, 30-day mortality and complications.

RESULTS

Migrants (n = 1035, 48.8%) were more likely to be older (61 vs 58 years, P < 0.001), diabetic (29.3 vs 21.5%, P < 0.001) and have a prolonged symptom to door time (102 vs 91 min, P = 0.04). Despite lower rates of previous known ischaemic heart disease (22.5 vs 26.6%, P = 0.03), migrants had more diffuse disease (triple vessel or left main (3VD/LM): 29.8 vs 22.0%, P < 0.001) and higher troponin values (3.77 vs 3.22 μg/L, P = 0.01). We found no significant differences in hospital treatment times, intervention types or rates. Multivariate regression identified age, diabetes, female gender and multi-vessel disease as predictors of complications and death at 30 days.

CONCLUSIONS

Migrants had longer pre-hospital delays and exhibited different cardiovascular risk profiles than Australian-born patients but received comparable treatment in the acute hospital setting. Higher rates of diabetes and multi-vessel coronary artery disease were seen among migrant patients, indicating a relatively higher risk population.

Efficacy and safety of intravenous esmolol for cardiac protection in non-cardiac surgery. A systematic review and meta-analysis

Haemodynamic instability predisposes patients to cardiac complications in non-cardiac surgery. Esmolol, a short-acting cardioselective beta-adrenergic blocker might be efficient in perioperative cardiac protection, but could affect other vital organs, such as the kidneys, and post-discharge survival. We performed a systematic review on the use of esmolol for perioperative cardiac protection. We searched PubMed, Ovid Medline and Cochrane Central Register for Controlled trials. Eligible randomized controlled studies (RCTs) reported a perioperative esmolol intervention with at least one of the primary (major cardiac or renal complications during the first 30 postoperative days) or secondary (postoperative adverse effects and all-cause mortality) outcomes. We included 196 adult patients from three RCTs. Esmolol significantly reduced postoperative myocardial ischaemia, RR =0.43 [95% confidence interval, CI: 0.21-0.88], p = .02. No association with clinically significant bradycardia and hypotension compared to patients receiving control treatment could be confirmed (RR =7.4 [95% CI: 0.29-139.81], p = .18 and RR =2.21 [95% CI: 0.34-14.36], p = .41, respectively). No differences regarding other outcomes were observed. No study reported postoperative renal outcomes. Esmolol seems promising for the prevention of perioperative myocardial ischaemia. However, the association with bradycardia and hypotension remains unclear. Randomized trials investigating the effect of β1-selective blockade on clinically relevant outcomes and non-cardiac vital organs are warranted. Key messages Short-acting cardioselective esmolol seems efficient in the prevention of perioperative myocardial ischaemia. The possibly increased risk of bradycardia and hypotension with short-acting intravenous beta blockade could not be confirmed or refuted by available data. Future adequately powered trials investigating the effect of β1-selective blockade on clinically relevant outcomes and non-cardiac vital organs are warranted.

Non-alcoholic steatohepatitis aggravates nitric oxide synthase inhibition-induced arteriosclerosis in SHRSP5/Dmcr rat model

Non-alcoholic steatohepatitis (NASH) is linked to increased cardiovascular risk, independent of the broad spectrum of metabolic syndrome risk factors. Stroke-prone (SP) spontaneously hypertensive rats (SHRSP5/Dmcr) fed a high-fat and high-cholesterol (HFC) diet developed hepatic lesions similar to those in human NASH pathology. These rats simultaneously developed lipid deposits in the mesenteric arteries, cardiac fibrosis, endothelial dysfunction and left ventricle (LV) diastolic dysfunction. However, the intermediary factors between NASH and cardiovascular disease are still unknown. We investigated whether NASH aggravates nitric oxide (NO) synthase inhibition-induced arteriosclerosis in SHRSP5/Dmcr rats. Wistar Kyoto and SHRSP5/Dmcr rats were divided into 4 groups of 5 and fed the stroke-prone (SP) or HFC diets for 8 weeks. To induce NO synthase inhibition, N^ω -nitro-L-arginine methyl ester hydrochloride (L-NAME) mixed with drinking water was administered in the final 2 weeks. The NASH+L-NAME group demonstrated the following characteristics related to arteriosclerosis and myocardial ischaemia: (a) LV systolic dysfunction with asynergy, (b) replacement fibrosis caused by the shedding of cardiomyocytes and (c) arterial lipid deposition and coronary occlusion secondary to endothelial dysfunction. These characteristics were not observed in the NASH or non-NASH+L-NAME groups. The SHRSP5/Dmcr rat model demonstrates that NASH significantly aggravates cardiovascular risk.

The effect of pegylated granulocyte colony-stimulating factor on collateral function and myocardial ischaemia in chronic coronary artery disease: A randomized controlled trial

OBJECTIVE

To test the effect of long-term pegfilgrastim on collateral function and myocardial ischaemia in patients with chronic stable coronary artery disease (CAD).

METHODS

This was a prospective clinical trial with randomized 2:1 allocation to pegfilgrastim or placebo for 6 months. The primary study endpoint was collateral flow index (CFI) as obtained during a 1-minute ostial coronary artery balloon occlusion. CFI is the ratio of mean coronary occlusive divided by mean aortic pressure both subtracted by central venous pressure (mm Hg/mm Hg). Secondary endpoints were signs of myocardial ischaemia determined during the same coronary occlusion, that is quantitative intracoronary (i.c.) ECG ST-segment shift (mV) and the occurrence of angina pectoris. Endpoints were obtained at baseline before and at follow-up after three subcutaneous study drug injections.

RESULTS

Collateral flow index in the pegfilgrastim group changed from 0.096 ± 0.076 at baseline to 0.126 ± 0.070 at follow-up (P = 0.0039), while in the placebo group CFI changed from 0.157 ± 0.146 to 0.122 ± 0.043, respectively (P = 0.29); the CFI increment at follow-up was +0.030 ± 0.075 in the pegfilgrastim group and -0.034 ± 0.148 in the placebo group (P = 0.0172). In the pegfilgrastim group, i.c. ECG ST-segment shift changed from +1.23 ± 1.01 mV at baseline to +0.93 ± 0.97 mV at follow-up (P = 0.0049), and in the placebo group, it changed from +0.98 ± 1.02 mV to +1.43 ± 1.09 mV, respectively (P = 0.05). At follow-up, the fraction of patients free from angina pectoris during coronary occlusion had increased in the pegfilgrastim but not in the placebo group.

CONCLUSION

Pegfilgrastim given over the course of 6 months improves collateral function in chronic stable CAD, which is reflected by reduced myocardial ischaemia during a controlled coronary occlusion.

Duration of myocardial early systolic lengthening for diagnosis of coronary artery disease

Objective

Myocardial early systolic lengthening (ESL) duration is prolonged in patients with coronary artery disease (CAD). However, the relationship between the fractional flow reserve (FFR), the current gold standard for evaluating physiological myocardial ischaemia, and ESL has not been studied. The aims of this study were to investigate whether left ventricular (LV) ESL duration could identify patients with CAD, and to examine the relationship between FFR and LV ESL duration.

Methods

In this single-centre, cross-sectional, prospective study of 75 patients with suspected or known CAD, we performed two-dimensional speckle tracking echocardiography at rest on the day before coronary angiography or percutaneous coronary intervention. Apical 3 views were used to examine ESL duration, defined as time from onset of the Q wave to maximum myocardial systolic lengthening.

Results

Thirty-five patients had non-significant stenosis. Forty patients with CAD underwent FFR testing: 17 had an FFR≥0.8 and 23 had an FFR<0.8. Global ESL duration was 20.9±22.2 ms in patients with non-significant stenosis, 36.4±23.2 ms in patients with FFR≥0.8 and 39.6±29.5 ms in patients with FFR<0.8 (p=0.020). However, global and regional ESL durations were not significantly correlated with FFR and demonstrated poor reproducibility.

Conclusion

Although myocardial ESL duration was significantly prolonged in patients with CAD compared with patients without CAD, ESL at rest showed poor reproducibility, and this new parameter did not predict FFR in patients with suspected CAD.

Isolated cardiac hydatid cyst mimicking myocardial ischaemia in a female patient

Hydatid disease is a zoonotic parasitic infection endemic in livestock-raising countries. Isolated cardiac hydatid cyst is a very rare disease, and chest pain, palpitations, cough, and dyspnoea are the most common presenting symptoms. Here a case of isolated cardiac hydatid cyst in a female patient with chest pain and electrocardiographic changes mimicking myocardial ischaemia is presented.

Causes and prevention of postoperative myocardial injury

Over the past few years non-cardiac surgery has been recognised as a serious circulatory stress test which may trigger cardiovascular events such as myocardial infarction, in particular in patients at high risk. Detection of these postoperative cardiovascular events is difficult as clinical symptoms often go unnoticed. To improve detection, guidelines advise to perform routine postoperative assessment of cardiac troponin. Troponin elevation - or postoperative myocardial injury - can be caused by myocardial infarction. However, also non-coronary causes, such as cardiac arrhythmias, sepsis and pulmonary embolism, may play a role in a considerable number of patients with postoperative myocardial injury. It is crucial to acquire more knowledge about the underlying mechanisms of postoperative myocardial injury because effective prevention and treatment options are lacking. Preoperative administration of beta-blockers, aspirin, statins, clonidine, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, and preoperative revascularisation have all been investigated as preventive options. Of these, only statins should be considered as the initiation or reload of statins may reduce the risk of postoperative myocardial injury. There is also not enough evidence for intraoperative measures such blood pressure optimisation or intensified medical therapy once patients have developed postoperative myocardial injury. Given the impact, better preoperative identification of patients at risk of postoperative myocardial injury, for example using preoperatively measured biomarkers, would be helpful to improve cardiac optimisation.

'Primary' Microvascular Angina: Clinical Characteristics, Pathogenesis and Management

Microvascular angina (MVA), i.e. angina caused by abnormalities of the coronary microcirculation, is increasingly recognised in clinical practice. The pathogenetic mechanisms of MVA are heterogeneous and may involve both structural and functional alterations of coronary microcirculation, and functional abnormalities may variably involve an impairment of coronary microvascular dilatation and an increased microvascular constrictor activity. Both invasive and non-invasive diagnostic tools exist to identify patients with MVA in clinical practice. Prognosis has been reported to be good in primary MVA patients, although the prognostic implications of coronary microvascular dysfunction (CMVD) in more heterogeneous populations of angina patients need further assessment. Management of primary MVA can be challenging, but pharmacological and non-pharmacological treatments exist that allow satisfactory control of symptoms in most patients.

Troponin elevations after non-cardiac, non-vascular surgery are predictive of major adverse cardiac events and mortality: a systematic review and meta-analysis

BACKGROUND

Patients undergoing non-cardiac, non-vascular surgery are at risk of major cardiovascular complications. In non-cardiac surgery, troponin elevation has previously been shown to be an independent predictor of major adverse cardiac events and postoperative mortality; however, a majority of studies have focused on vascular surgery patients. The aim of this meta-analysis was to determine whether troponin elevation is a predictor of major adverse cardiac events and mortality within 30 days and 1 yr after non-cardiac, non-vascular surgery.

METHODS

A systematic review and meta-analysis was conducted in January 2016 according to the Meta-analysis Of Observational Studies in Epidemiology guidelines. Both interventional and observational studies measuring troponin within the first 4 days after surgery were eligible. A systematic search was performed in PubMed, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials.

RESULTS

Eleven eligible clinical studies (n=2193) were identified. A postoperative troponin elevation was a predictor of 30 day mortality, odds ratio (OR) 3.52 [95% confidence interval (CI) 2.21-5.62; I²=0%], and an independent predictor of 1 yr mortality, adjusted OR 2.53 (95% CI 1.20-5.36; I²=26%). A postoperative troponin elevation was associated with major adverse cardiac events at 30 days, OR 5.92 (95% CI 1.67-20.96; I²=86%), and 1 yr after surgery, adjusted OR 3.00 (95% CI 1.43-6.29; I²=21%).

CONCLUSIONS

Postoperative myocardial injury is an independent predictor of major adverse cardiac events and mortality within 30 days and 1 yr after non-cardiac, non-vascular surgery. The meta-analysis provides evidence that supports troponin monitoring as a cardiovascular risk stratification tool.

New Advances in the Management of Refractory Angina Pectoris

Refractory angina is a significant clinical problem and its successful management is often extremely challenging. Defined as chronic angina-type chest pain in the presence of myocardial ischaemia that persists despite optimal medical, interventional and surgical treatment, current therapies are limited and new approaches to treatment are needed. With an ageing population and increased survival from coronary artery disease, clinicians will increasingly encounter this complex condition in routine clinical practice. Novel therapies to target myocardial ischaemia in patients with refractory angina are at the forefront of research and in this review we discuss those in clinical translation and assess the evidence behind their efficacy.

Symptomatic myocardial bridging: a frequently occurring coronary variation can cause severe myocardial ischaemia in affected children with underlying cardiac conditions

Myocardial bridging is a congenital coronary artery anomaly in which the coronary artery has a partly "tunnelled" intramyocardial course. This tunnelling leads to compression of the affected vessel segment during ventricular systole. It is considered to be a benign variation of the norm in about 25% of the population caused by an aberrancy of embryologic coronary development. The bridging is also thought to cause severe cardiac conditions in a few of those affected. The series of six young patients presented here is the largest series so far to report on symptomatic myocardial bridging in children with different underlying heart diseases. All patients recently presented to our centre with signs of myocardial ischaemia. They subsequently underwent coronary angiography, which revealed myocardial bridging of the ramus interventricularis anterior. In all patients, therapy with β blockers was started to reduce heart rate and myocardial contractility. β Blocker treatment was also given in order to prolong diastole and improve coronary artery blood flow. Two patients underwent surgical exposure of the involved coronary segment: a 2-year-old boy because of recurrent, severe myocardial ischaemia in combination with a reduction of general health, changes in ST-segments, and the presence of a dilative cardiomyopathy; and a 13-year-old girl because of evidence of myocardial ischaemia during exercise testing after surviving sudden cardiac death. Surgery was successful and recovery was complete and uneventful. The presented series shows that myocardial bridging can be symptomatic and may require urgent treatment and even surgical intervention in early childhood in rare cases.