Exercise and cardiac rehabilitation in hypertensive patients with heart failure with preserved ejection fraction: A position statement on behalf of the Working Group of Arterial Hypertension of the Hellenic Society of Cardiology.

Arterial hypertension is a major cause of cardiovascular morbidity and mortality and the most common cause of comorbidity in heart failure (HF) with preserved ejection fraction (HFpEF). As an adjunct to medication, healthy lifestyle modifications with emphasis on regular exercise are strongly recommended by both the hypertension and the HF guidelines of the European Society of Cardiology. Several long-term studies have shown that exercise is associated with a reduction in all-cause mortality, a favorable cardiac and metabolic risk profile, mental health, and other non-cardiovascular benefits, as well as an improvement in overall quality of life. However, the instructions for the prescriptive or recommended exercise in hypertensive patients and, more specifically, in those with HFpEF are not well defined. Moreover, the evidence is based on observational or small randomized studies, while well-designed clinical trials are lacking. Despite the proven benefit and the guidelines' recommendations, exercise programs and cardiac rehabilitation in patients with hypertensive heart disease and HFpEF are grossly underutilized. This position statement provides a general framework for exercise and exercise-based rehabilitation in patients with hypertension and HFpEF, guides clinicians' rehabilitation strategies, and facilitates clinical practice. It has been endorsed by the Working Group of Arterial Hypertension of the Hellenic Society of Cardiology and is focused on the Health Care System in Greece.

Psychological Distress and Concerns of In-Home Older People Living with Cancer and Their Impact on Supportive Care Needs: An Observational Survey.

(1) Background: Cancer patients are experiencing psychological problems after diagnosis, such as emotional distress and social anxiety, which may increase their demands for emotional and supportive care. This study aimed to assess the influence of both emotional distress and concerns on the supportive care needs of cancer patients receiving home-based healthcare. (2) Methods: In this door-to-door screening program, 97 cancer patients were approached, with a mean age of 73 years old (mean = 73.43; SD = 6.60). (3) Results: As expected, 42.3% of patients highlighted their treatment as their main psychological priority, with 20.6% identifying concerns about the future of their family in this regard. No significant associations with respect to sex were identified in terms of focus, though females reported the need for more frequent psychological support (58.7% vs. 37.3%, respectively, p = 0.035) compared to males. Patients who had experienced an increased number of concerns during the last weeks (IRR = 1.02; 95% CI: 1.00-1.03, p = 0.007) had a significantly greater risk of presenting an increased rate of supportive care needs. Notably, male patients with bone cancer presented a significantly greater number of supportive care needs (mean rank 45.5 vs. 9.0, p = 0.031) respectively, in comparison to those with other types of cancer. (4) Conclusions: Supportive care needs arise from a greater concern and specific type of cancer, highlighting the need for supportive care, such as psychosocial and psychological support. This may have significant implications for treatment and patient outcomes in home care settings.

Cardiac magnetic resonance imaging of pericardial diseases: a comprehensive guide.

Cardiac magnetic resonance (CMR) imaging has been established as a valuable diagnostic tool in the assessment of pericardial diseases by providing information on cardiac anatomy and function, surrounding extra-cardiac structures, pericardial thickening and effusion, characterization of pericardial effusion, and the presence of active pericardial inflammation from the same scan. In addition, CMR imaging has excellent diagnostic accuracy for the non-invasive detection of constrictive physiology evading the need for invasive catheterization in most instances. Growing evidence in the field suggests that pericardial enhancement on CMR is not only diagnostic of pericarditis but also has prognostic value for pericarditis recurrence, although such evidence is derived from small patient cohorts. CMR findings could also be used to guide treatment de-escalation or up-titration in recurrent pericarditis and selecting patients most likely to benefit from novel treatments such as anakinra and rilonacept. This article is an overview of the CMR applications in pericardial syndromes as a primer for reporting physicians. We sought to provide a summary of the clinical protocols used and an interpretation of the major CMR findings in the setting of pericardial diseases. We also discuss points that are less well clear and delineate the strengths and weak points of CMR in pericardial diseases.

Heterogeneity in meta-analysis: a comprehensive overview.

In recent years, meta-analysis has evolved to a critically important field of Statistics, and has significant applications in Medicine and Health Sciences. In this work we briefly present existing methodologies to conduct meta-analysis along with any discussion and recent developments accompanying them. Undoubtedly, studies brought together in a systematic review will differ in one way or another. This yields a considerable amount of variability, any kind of which may be termed heterogeneity. To this end, reports of meta-analyses commonly present a statistical test of heterogeneity when attempting to establish whether the included studies are indeed similar in terms of the reported output or not. We intend to provide an overview of the topic, discuss the potential sources of heterogeneity commonly met in the literature and provide useful guidelines on how to address this issue and to detect heterogeneity. Moreover, we review the recent developments in the Bayesian approach along with the various graphical tools and statistical software that are currently available to the analyst. In addition, we discuss sensitivity analysis issues and other approaches of understanding the causes of heterogeneity. Finally, we explore heterogeneity in meta-analysis for time to event data in a nutshell, pointing out its unique characteristics.

Strengths and weaknesses of alternative noninvasive imaging approaches for microvascular ischemia.

Structural and functional abnormalities of coronary microvasculature are highly prevalent in several clinical settings and often associated with worse clinical outcomes. Therefore, there is a growing interest in the detection and treatment of this, often overlooked, disease. Coronary angiography allows the assessment of the Coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR). However, the measurement of these parameters is not always feasible because of limited technical availability and the need for a cardiac catheterization with a small but real risk of potential complications. Recent advances in non-invasive imaging techniques allow the assessment of coronary microvascular function with good accuracy and reproducibility. The objective of this review is to discuss the strengths and weaknesses of alternative non-invasive approaches used in the diagnosis of coronary microvascular dysfunction (CMD), highlighting the most recent advances for each imaging modality.

Non-LGE Cardiac Magnetic Resonance Imaging in Patients with Cardiac Amyloidosis.

Cardiac involvement is the leading cause of death in patients with cardiac amyloidosis. Early recognition is crucial as it can significantly change the course of the disease. Until now, the imaging modality of choice for diagnosing cardiac amyloidosis has been cardiac magnetic resonance imaging (CMR) with late gadolinium enhancement (LGE). LGE-CMR in patients with cardiac amyloidosis reveals characteristic LGE patterns that lead to a diagnosis while also correlating well with disease prognosis. However, LGE-CMR has numerous drawbacks that the newer CMR modality, T1 mapping, aims to improve. T1 mapping can be further subdivided into native T1 mapping, which does not require the use of contrast, and ECV measurement, which requires the use of contrast. Numerous T1 mapping techniques have been developed, each one with its own advantages and disadvantages when it comes to procedure difficulty and image quality. A literature review to identify relevant published articles was performed by two authors. This review aimed to present the value of T1 mapping in diagnosing cardiac amyloidosis, quantifying the amyloid burden, and evaluating the prognosis of patients with amyloidosis with cardiac involvement.

The Impact of Socioeconomic Factors and Geriatric Syndromes on Frailty among Elderly People Receiving Home-Based Healthcare: A Cross-Sectional Study.

Purpose: To evaluate frailty and its relationship with geriatric syndromes in the context of socioeconomic variables. Patients and Methods: In this cross-sectional study, elderly people aged 65 years old and over who received homecare in the reference region of Crete, Greece, were enrolled. Geriatric syndromes such as frailty, dementia, and depression were evaluated using the SHARE-Frailty Index (SHARE-Fi), the Montreal Cognitive Assessment (MoCA), and the Geriatric Depression Scale (GDS), respectively. Level of education, annual individual income, disability in Activities of Daily Living (ADL) and homebound status were also assessed as 'socioeconomic factors.' Results: The mean age of 301 participants was 78.45 (±7.87) years old. A proportion of 38.5% was identified as frail. A multiple logistic regression model revealed that elderly people with cognitive dysfunction were more likely to be frail (OR = 1.65; 95% CI: 0.55−4.98, p = 0.469) compared to those with normal cognition, but this association was not significant. Although elderly people with mild depression were significantly more likely to be frail (OR = 2.62; CI: 1.33−5.17, p = 0.005) compared to those with normal depression, the association for elderly people with severe depression (OR = 2.05, CI: 0.80−5.24, p = 0.134) was not significant. Additionally, comorbidity (OR = 1.06, CI: 0.49−2.27, p = 0.876) was not associated with frailty, suggesting that comorbidity is not a risk factor for frailty. In addition, patients with mild depression were significantly more likely to report frailty (OR = 2.62, CI:1.33−5.17, p = 0.005) compared to those with normal depression, whereas elders with an annual individual income (>EUR 4500) were less likely to be frail (OR = 0.45, CI: 0.25−0.83, p = 0.011) compared to those with

Reflux-Qual-Short-Form Questionnaire: Translation and Validation of the Greek Version.

The aim of this study was the translation and validation of the Reflux-Qual Short-Form (RQS), a quality of life questionnaire in a Greek sample of 148 individuals with gastroesophageal reflux disease (GERD). This tool through eight items explores the effects of GERD in five dimensions of quality of life: daily activity, well-being, psychological impact, sleep, and eating. Exploratory factor analysis yielded a one-factor scale for the Greek-translated version. Internal consistency reliability of the questionnaire was deemed very satisfactory based on Cronbach's alpha coefficient, which was equal to 0.816. Split-half reliability was evaluated as an additional measure of internal consistency. The test-retest reliability analysis revealed a good stability after a 1-month interval. Construct validity was measured by the correlation level between each item and the adjusted global score, resulting in an acceptable level of convergence between the items. Concurrent validity was confirmed using the 36-Item Short Form Health Survey (SF-36) as a reference scale. This study indicates that RQS Questionnaire is a short, simple, reliable, and valid tool that can be used to assess quality of life in Greek individuals with GERD.

Utility of echocardiographic right ventricular subcostal strain in critical care.

AIMS: Right ventricular (RV) strain is a known predictor of outcomes in various heart and lung pathologies but has been considered too technically challenging for routine use in critical care. We examined whether RV strain acquired from the subcostal view, frequently more accessible in the critically ill, is an alternative to conventionally derived RV strain in intensive care. METHODS AND RESULTS: RV strain data were acquired from apical and subcostal views on transthoracic echocardiography (TTE) in 94 patients (35% female), mean age 50.5 ± 15.2 years, venovenous extracorporeal membrane oxygenation (VVECMO) (44%). RV strain values from the apical (mean ± standard deviation; -20.4 ± 6.7) and subcostal views (-21.1 ± 7) were highly correlated (Pearson's r -0.89, P < 0.001). RV subcostal strain correlated moderately well with other echocardiography parameters including tricuspid annular plane systolic excursion (r -0.44, P < 0.001), RV systolic velocity (rho = -0.51, P < 0.001), fractional area change (r -0.66, P < 0.01), and RV outflow tract velocity time integral (r -0.49, P < 0.001). VVECMO was associated with higher RV subcostal strain (non-VVECMO -19.6 ± 6.7 vs. VVECMO -23.2 ± 7, P = 0.01) but not apical RV strain. On univariate analysis, RV subcostal strain was weakly associated with survival at 30 days (R2 = 0.04, P = 0.05, odds ratio =1.08) while apical RV was not (P = 0.16). CONCLUSION: RV subcostal deformation imaging is a reliable surrogate for conventionally derived strain in critical care and may in time prove to be a useful diagnostic marker in this cohort.

The Impact of Frailty and Geriatric Syndromes on the Quality of Life of Older Adults Receiving Home-Based Healthcare: A Cross-Sectional Survey.

Purpose: To identify the effect of frailty and geriatric syndromes on the quality of life (QoL), of older adults receiving home care, taking into consideration their socioeconomic and homebound status, including multi-comorbidities. Patients and Methods: This cross-sectional study enrolled elders aged (≥65) years old, registered members of "Help at Home" programs in the Reference Region of Crete, from March to May 2019. Participants were screened using the WHOQOL-BREF for Quality of Life, geriatric syndromes such as frailty using the SHARE-Frailty Index (SHARE-Fi), the Montreal Cognitive Assessment (MoCA), for cognitive function and the Geriatric Depression Scale (GDS), for the assessment of depression. Results: The mean age of the 301 participants was 78.45 (±7.87) years old. The prevalence of frailty was 38.5%, severe depression 13.6%, cognitive dysfunction 87.8% and severe comorbidity 70.6%. Intriguingly, none of the participants (0%) was identified as free of comorbidity (CCI = 0−1). The overall QoL (ranging from 4−20) of the study participants was 13.24 (±4.09). The bivariate analysis showed that overall QoL significantly differed among older adults with frailty (15.91 vs. 11.56, p < 0.001), cognitive dysfunction (15.42 vs. 12.90, p < 0.001), depression (14.90 vs. 9.31, p < 0.001), and disability in Activities of Daily Living (13.67 vs. 10.67, p = 0.002), compared to non-frail, normal cognition and depression, and independent elders, respectively. Multiple linear regression models revealed that frail and depressive elders reported significantly lower QoL (ß = −2.65, p < 0.001 and (ß = −5.71, p < 0.001), compared to non-frail and older adults with no depressive symptoms, respectively, despite the fact that this association was not significant for older adults with dementia (ß = −2.25, p = 0.159), even after adjusting for potential confounding effects (age, gender, comorbidity, homebound status, etc.). Conclusion: frailty and geriatric syndromes including comorbidities are important risk factors for "poor" QoL among older adults receiving home-based healthcare.

Right ventricular dysfunction in critically ill COVID-19 ARDS.

AIMS: Comprehensive echocardiography assessment of right ventricular (RV) impairment has not been reported in critically ill patients with COVID-19. We detail the specific phenotype and clinical associations of RV impairment in COVID-19 acute respiratory distress syndrome (ARDS). METHODS: Transthoracic echocardiography (TTE) measures of RV function were collected in critically unwell patients for associations with clinical, ventilatory and laboratory data. RESULTS: Ninety patients (25.6% female), mean age 52.0 ± 10.8 years, veno-venous extracorporeal membrane oxygenation (VVECMO) (42.2%) were studied. A significantly higher proportion of patients were identified as having RV dysfunction by RV fractional area change (FAC) (72.0%,95% confidence interval (CI) 61.0-81.0) and RV velocity time integral (VTI) (86.4%, 95 CI 77.3-93.2) than by tricuspid annular plane systolic excursion (TAPSE) (23.8%, 95 CI 16.0-33.9), RVS' (11.9%, 95% CI 6.6-20.5) or RV free wall strain (FWS) (35.3%, 95% CI 23.6-49.0). RV VTI correlated strongly with RV FAC (p ≤ 0.01). Multivariate regression demonstrated independent associations of RV FAC with NTpro-BNP and PVR. RV-PA coupling correlated with PVR (univariate p < 0.01), as well as RVEDAi (p < 0.01), and RVESAi (p < 0.01), and was associated with P/F ratio (p 0.026), PEEP (p 0.025), and ALT (p 0.028). CONCLUSIONS: Severe COVID-19 ARDS is associated with a specific phenotype of RV radial impairment with sparing of longitudinal function. Clinicians should avoid interpretation of RV health purely on long-axis parameters in these patients. RV-PA coupling potentially provides important additional information above standard measures of RV performance in this cohort.

Associations of Bullying and Cyberbullying With Substance Use and Sexual Risk Taking in Young Adults.

PURPOSE: This study aims at identifying the sex-stratified associations of involvement in traditional bullying during middle and high school years and in cyberbullying during college years with multiple health risk behaviors in undergraduate students. DESIGN: This cross-sectional analysis draws on the data of the second wave of the LATO study (Lifestyle & Attitudes in a Student Population) in Greece. METHODS: During November and December 2013, 812 second-year undergraduate students (mean age = 19.3 years; girls = 66.1%) provided data on substance use (smoking, alcohol abuse or drunkenness, illegal drug use including marijuana, hashish, and cannabis) and sexual risk taking (paying for sex and not using condoms) and completed the Cyberbullying and its Effects and the Retrospective Bullying Questionnaires. Logistic regression models performed were adjusted for potential confounders. FINDINGS: Both male and female late adolescents who were victims of bullying during middle and high school were less likely to use condoms during college years when compared to uninvolved students. Among males, being a bully or victim at school doubled the odds for past month drunkenness and tripled the odds of paying for sex. Greater likelihood to pay for sex was also evident in bullying victims. Cyberbully or cybervictim male students were more likely to report smoking. In female bullying victims, alcohol abuse associations were somewhat conflicting, with decreased lifetime but increased past month likelihood for drunkenness. CONCLUSIONS: Engagement in bullying and cyberbullying is associated with the manifestation of gender-specific health risk behaviors for the different involvement groups in college students. CLINICAL RELEVANCE: Involvement in bullying and cyberbullying is a major public health concern due to the associations with multiple health risk behaviors. Nurses and healthcare professionals should adopt multifaceted prevention interventions tailored according to bullying status and gender that extend through all educational levels.

The Effect of Sodium-Glucose Co-transporter-2 (SGLT-2) Inhibitors on Cardiometabolic Profile; Beyond the Hypoglycaemic Action.

Type 2 diabetes mellitus (T2DM) has growing prevalence worldwide and major clinical implications, chiefly cardiovascular (CV) and renal disease burden. Sodium-glucose co-transporter (SGLT)-2 inhibitors are a new drug class in the management of T2DM with a mechanism of action independent of insulin. In addition to their hypoglycaemic effect, SGLT-2 inhibitors appear to have haemodynamic and nephroprotective effects. Studies have consistently showed a modest but significant blood pressure (BP) reduction. Metabolic benefits are also attributed to SGLT-2 inhibitors with a modest but consistent body weight decrease recorded along with improvements in lipid profile and uric acid levels. Remarkable findings of significant cardioprotective effects came from the recent EMPA-REG study with a particular focus on heart failure. In the kidney, SGLT-2 inhibitors reduce hyperfiltration, a precipitant of diabetic nephropathy.

Novel therapeutic strategies targeting vascular endothelium in essential hypertension.

IMPORTANCE OF THE FIELD: Several studies have demonstrated the high prevalence of hypertension and the crucial role of the association between endothelial function and hypertension. Thus, in depth investigation of the pathophysiological mechanisms linking endothelial dysfunction and hypertension, as well as evaluation of the efficacy of therapeutic approaches targeting vascular endothelium in states of essential hypertension seems to be of great interest. AREAS COVERED IN THIS REVIEW: The association of essential hypertension and endothelial function are discussed in depth. In addition to the classical anti-hypertensive agents, agents such as statins, tetrahydrobiopterin, l-arginine, antioxidants, sildenafil, third generation beta blockers and NO-release related agents have been found to be beneficial by improving endothelial dysfunction in essential hypertension. WHAT THE READER WILL GAIN: Important aspects regarding the association of hypertension and endothelial dysfunction will be highlighted. In addition, classical and novel agents especially, will be reported thoroughly according to their effects on endothelial function in hypertension. TAKE HOME MESSAGE: There is a strong bidirectional association between essential hypertension and endothelial dysfunction. Moreover, novel agents appear to be beneficial and promising in improving endothelial function in states of hypertension. However, more studies are required to evaluate their role, as the literature lacks large scale studies.

A 31 year old woman with essential hypertension grade III and branch retinal vein occlusion with homozygous C677T MTHFR hyperhomocysteinemia and high Lp(a) levels.

We report a 31-year old woman with essential hypertension grade III and history of branch retinal vein occlusion in the setting of hyperhomocysteinemia due to homozygous MTHFR gene mutation and elevated Lp(a). The patient was treated successfully with antihypertensive treatment, acetylsalicylic acid and multivitamin complex supplementation.