Bicuspid aortic valve with associated aortopathy, significant left ventricular hypertrophy or concomitant hypertrophic cardiomyopathy: A diagnostic and therapeutic challenge.

Due to its prevalence of 0.5% to 2% in the general population, with a 75% predominance among men, bicuspid aortic valve is the most common congenital heart defect. It is frequently accompanied by other cardiac congenital anomalies, and clinical presentation can vary significantly, with stenosis being the most common manifestation, often resulting in mild to moderate concentric hypertrophy of the left ventricle. Echocardiography is the primary diagnostic modality utilized for establishing the diagnosis, and it is often the sole diagnostic tool relied upon by clinicians. However, due to the heterogeneous clinical presentation and possible associated anomalies (which are often overlooked in clinical practice), it is necessary to employ various diagnostic methods and persist in finding the accurate diagnosis if multiple inconsistencies exist. By employing this approach, we can effectively manage these patients and provide them with appropriate treatment. Through a clinical case from our practice, we provide an overview of the literature on bicuspid aortic valve with aortophaty and the possible association with hypertrophic cardiomyopathy, diagnostic methods, and treatment options. This review article highlights the critical significance of achieving an accurate diagnosis in patients with bicuspid aortic valve and significant left ventricular hypertrophy. It is crucial to exclude other possible causes of left ventricular outflow tract obstruction, such as sub- or supra-aortic obstructions, and hypertrophic cardiomyopathy.

Prevalence of posttraumatic stress disorder following acute coronary syndrome and clinical characteristics of patients referred to cardiac rehabilitation.

BACKGROUND: Studies have demonstrated that patients who have experienced acute coronary syndrome (ACS) have an increased risk of developing posttraumatic stress disorder (PTSD) and experiencing worse survival outcomes than those who do not develop PTSD. Nevertheless, the prevalence rates of PTSD following ACS vary widely across studies, and it is noteworthy that in most cases, the diagnosis of PTSD was based on self-report symptom questionnaires, rather than being established by psychiatrists. Additionally, the individual characteristics of patients who develop PTSD after ACS can differ widely, making it difficult to identify any consistent patterns or predictors of the disorder. AIM: To investigate the prevalence of PTSD among a large sample of patients undergoing cardiac rehabilitation (CR) after ACS, as well as their characteristics in comparison to a control group. METHODS: The participants of this study are patients who have experienced ACS with or without undergoing percutaneous coronary intervention and are enrolled in a 3-wk CR program at the largest CR center in Croatia, the Special Hospital for Medical Rehabilitation Krapinske Toplice. Patient recruitment for the study took place over the course of one year, from January 1, 2022, to December 31, 2022, with a total of 504 participants. The expected average follow-up period for patients included in the study is about 18 mo, and currently ongoing. Using self-assessment questionnaire for PTSD criteria and clinical psychiatric interview, a group of patients with a PTSD diagnosis was identified. From the participants who do not have a PTSD diagnosis, patients who would match those with a PTSD diagnosis in terms of relevant clinical and medical stratification variables and during the same rehabilitation period were selected to enable comparability of the two groups. RESULTS: A total of 507 patients who were enrolled in the CR program were approached to participate in the study. Three patients declined to participate in the study. The screening PTSD Checklist-Civilian Version questionnaire was completed by 504 patients. Out of the total sample of 504 patients, 74.2% were men (n = 374) and 25.8% were women (n = 130). The mean age of all participants was 56.7 years (55.8 for men and 59.1 for women). Among the 504 participants who completed the screening questionnaire, 80 met the cutoff criteria for the PTSD and qualified for further evaluation (15.9%). All 80 patients agreed to a psychiatric interview. Among them, 51 patients (10.1%) were diagnosed with clinical PTSD by a psychiatrist according to Diagnostic and Statistical Manual of Mental Disorders criteria. Among the variables analyzed, there was a noticeable difference in the percentage of theoretical maximum achieved on exercise testing between the PTSD and non-PTSD groups. Non-PTSD group achieved a significantly higher percentage of their maximum compared to the PTSD group (P = 0.035). CONCLUSION: The preliminary results of the study indicate that a significant proportion of patients with PTSD induced by ACS are not receiving adequate treatment. Furthermore, the data suggest that these patients may exhibit reduced physical activity levels, which could be one of the possible underlying mechanisms in observed poor cardiovascular outcomes in this population. Identifying cardiac biomarkers is crucial for identifying patients at risk of developing PTSD and may derive benefits from personalized interventions based on the principles of precision medicine in multidisciplinary CR programs.

Quo vadis cardiac rehabilitation; the role of comprehensive cardiac rehabilitation in modern cardiology.

In accordance with the guidelines established by prominent European and global cardiology associations, comprehensive cardiac rehabilitation (CR) stands as an officially endorsed and highly recommended therapeutic approach (class I recommendations; level of evidence A) for a diverse spectrum of cardiac patients. Nevertheless, it is a cause for concern to observe that fewer than 50% of eligible patients are being effectively referred for CR, whether in an outpatient or inpatient setting. Concurrently, studies reveal that a substantial proportion of individuals with atherosclerotic cardiovascular disease maintain unhealthy lifestyles and exhibit suboptimal management of modifiable cardiovascular risk factors, including hypertension, lipid levels, and diabetes. Beyond the conventional patient profile encompassing those recovering from acute coronary syndrome with or without percutaneous coronary intervention, as well as patients who have undergone coronary or valvular surgery, contemporary CR now emphasizes specialized subgroups of patients. These include frail elderly patients, the female population with its unique considerations, individuals burdened by multiple cardiovascular comorbidities, those who have developed psychological consequences due to a cardiac illness and particularly those grappling with chronic heart failure. This editorial seeks to offer a state-of-the-art assessment of the significance and role of comprehensive CR within modern cardiology.

Euglycemic diabetic ketoacidosis: A rare but serious side effect of sodium-glucose co-transporter 2 inhibitors.

Sodium-glucose co-transporter 2 (SGLT2) inhibitors are an insulin-independent class of oral antihyperglycemic medication and from recently established therapy in chronic heart failure patients. A rare, but potentially life-threatening complication of SGLT2 inhibitor use is euglycemic diabetic ketoacidosis. We described a case of a middle-aged male patient with type 2 diabetes who developed metabolic ketoacidosis after a few days of empagliflozin administration. SGLT2 inhibitor related ketoacidosis presents with euglycemia or only modestly elevated glucose blood concentrations, which causes delayed detection and treatment of ketoacidosis. There are multiple possible risk factors and mechanism that might contribute to the pathogenesis of ketoacidosis. It is implied that SGLT2 inhibitor use and prescription by non-diabetologists (cardiologists, nephrologists, family physicians, etc.) will continue to grow in the future. It is important to inform the general cardiac public about this rare but serious side effect of SGLT2 inhibitors.

Comment on von Känel et al. Early Trauma-Focused Counseling for the Prevention of Acute Coronary Syndrome-Induced Posttraumatic Stress: Social and Health Care Resources Matter. J. Clin. Med. 2022, 11, 1993.

Posttraumatic stress disorder (PTSD) is a debilitating disorder, and it is known that it can be triggered by acute coronary syndrome (ACS). Patients with ACS-induced PTSD have an increased risk of recurrent adverse cardiovascular events and mortality. This is still an insufficiently recognized subgroup of patients among clinicians that could benefit from specific therapeutic and rehabilitation approaches.

Quadricuspid aortic valve and right ventricular type of myocardial bridging in an asymptomatic middle-aged woman: A case report.

BACKGROUND: Quadricuspid aortic valve (QAV) is a very rare congenital cardiac defect with the incidence of 0.0125%-0.033% (< 0.05%) predominantly causing aortic regurgitation. A certain number of patients (nearly one-half) have abnormal function and often require surgery, commonly in their fifth or sixth decade. QAV usually appears as an isolated anomaly but may also be associated with other cardiac congenital defects. Echocardiography is considered the main diagnostic method although more and more importance is given to computed tomography (CT) and magnetic resonance imaging (MRI) as complementary methods. CASE SUMMARY: A 60-year-old female patient was referred for transthoracic ultrasound of the heart as part of a routine examination in the treatment of arterial hypertension. She did not have any significant symptoms. QAV was confirmed and there were no elements of valve stenosis with moderate aortic regurgitation. At first, it seemed that in the projection of the presumed left coronary cusp, there were two smaller and equally large cusps along with two larger and normally developed cusps. Cardiac CT imaging was performed to obtain an even more precise valve morphology and it showed that the location of the supernumerary cusp is between the right and left coronary cusp, with visible central malcoaptation of the cusps. Also, coronary computed angiography confirmed the right-type of myocardial bridging at the distal segment of the left anterior descending coronary artery. Significant valve dysfunction often occurs in middle-aged patients and results in surgical treatment, therefore, a 1-year transthoracic echocardiogram control examination and follow-up was recommended to our patient. CONCLUSION: This case highlights the importance of diagnosing QAV since it leads to progressive valve dysfunction and can be associated with other congenital heart defects which is important to detect, emphasizing the role of cardiac CT and MRI.

ANTIPLATELET THERAPY AFTER CORONARY ARTERY BYPASS GRAFT SURGERY - UNEVENNESS OF DAILY CLINICAL PRACTICE.

Antiplatelet therapy is an integral part of optimal medicamentous therapy in patients with coronary artery disease. The strategy of antiplatelet/anticoagulant therapy is adjusted (combination of drugs, dosing and duration of therapy) depending on the stage of the disease (acute coronary syndrome with percutaneous coronary intervention, chronic coronary syndrome, or coronary surgical revascularization) and comorbidity of each patient (e.g., atrial fibrillation, left ventricular thrombus, etc.). Guidelines and clinical practice in particular are not uniform and specific regarding dual antiplatelet therapy in patients undergoing coronary artery bypass grafting, especially in the setting of chronic coronary syndrome.

Current concept in the diagnosis, treatment and rehabilitation of patients with congestive heart failure.

Heart failure (HF) is a major public health problem with a prevalence of 1%-2% in developed countries. The underlying pathophysiology of HF is complex and as a clinical syndrome is characterized by various symptoms and signs. HF is classified according to left ventricular ejection fraction (LVEF) and falls into three groups: LVEF ≥ 50% - HF with preserved ejection fraction (HFpEF), LVEF < 40% - HF with reduced ejection fraction (HFrEF), LVEF 40%-49% - HF with mid-range ejection fraction. Diagnosing HF is primarily a clinical approach and it is based on anamnesis, physical examination, echocardiogram, radiological findings of the heart and lungs and laboratory tests, including a specific markers of HF - brain natriuretic peptide or N-terminal pro-B-type natriuretic peptide as well as other diagnostic tests in order to elucidate possible etiologies. Updated diagnostic algorithms for HFpEF have been recommended (H2FPEF, HFA-PEFF). New therapeutic options improve clinical outcomes as well as functional status in patients with HFrEF (e.g., sodium-glucose cotransporter-2 - SGLT2 inhibitors) and such progress in treatment of HFrEF patients resulted in new working definition of the term "HF with recovered left ventricular ejection fraction". In line with rapid development of HF treatment, cardiac rehabilitation becomes an increasingly important part of overall approach to patients with chronic HF for it has been proven that exercise training can relieve symptoms, improve exercise capacity and quality of life as well as reduce disability and hospitalization rates. We gave an overview of latest insights in HF diagnosis and treatment with special emphasize on the important role of cardiac rehabilitation in such patients.

Heterophile antibodies, false-positive troponin, and acute coronary syndrome: a case report indicating a pitfall in clinical practice.

BACKGROUND: Heterophile antibodies are one of the most common causes of false-positive troponin. CASE SUMMARY: We report a case of a 53-year-old woman with false-positive troponin elevation and a clinical presentation understood and treated as non-ST-elevation acute coronary syndrome. Because of chronic basal elevation of troponin (at a 'plateau' level) and chest pain, the patient underwent several invasive coronary angiograms until false-positive increase of troponin due to heterophile antibodies was suspected. Borderline stenosis of a left circumflex coronary artery found on first coronary angiogram was a coincidental finding and heterophile antibodies in the patient's serum were confirmed. DISCUSSION: This interesting case report aims to remind the clinicians about the possibility of false-positive troponin level due to laboratory analytical interference caused by heterophile antibodies. In this case, it is important to suspect false-positive troponin elevation, even when coronary artery disease is found. This rare and less mentioned and/or recognized cause of troponin elevation may lead to unnecessary invasive diagnostics and aggressive treatment of patients.

TORSADES DE POINTES IN ELDERLY PATIENT WITH PAROXYSMAL ATRIAL FIBRILLATION TREATED BY SHORT-TERM PARENTERAL AMIODARONE THERAPY.

One of the drugs that are widely used in the treatment of atrial fibrillation is amiodarone. Despite considerable prolongation of the corrected QT interval and a substantial degree of bradycardia, amiodarone exhibits a remarkably low frequency of pro-arrhythmic events and <1.0% incidence of torsades de pointes, mostly after long-term usage. We present a case of an 80-year-old female with paroxysmal atrial fibrillation accompanied by acute heart failure treated by short-term parenteral amiodarone therapy and development of torsades de pointes.

Does heart rate variability correlate with long-term prognosis in myocardial infarction patients treated by early revascularization?

AIM: To assess the prevalence of depressed heart rate variability (HRV) after an acute myocardial infarction (MI), and to evaluate its prognostic significance in the present era of immediate reperfusion. METHODS: Time-domain HRV (obtained from 24-h Holter recordings) was assessed in 326 patients (63.5 ± 12.1 years old; 80% males), two weeks after a complicated MI treated by early reperfusion: 208 ST-elevation myocardial infarction (STEMI) patients (in which reperfusion was successfully obtained within 6 h of symptoms in 94% of cases) and 118 non-ST-elevation myocardial infarction (NSTEMI) patients (percutaneous coronary intervention was performed within 24 h and successful in 73% of cases). Follow-up of the patients was performed via telephone interviews a median of 25 mo after the index event (95%CI of the mean 23.3-28.0). Primary end-point was occurrence of all-cause or cardiac death; secondary end-point was occurrence of major clinical events (MCE, defined as mortality or readmission for new MI, new revascularization, episodes of heart failure or stroke). Possible correlations between HRV parameters (mainly the standard deviation of all normal RR intervals, SDNN), clinical features (age, sex, type of MI, history of diabetes, left ventricle ejection fraction), angiographic characteristics (number of coronary arteries with critical stenoses, success and completeness of revascularization) and long-term outcomes were analysed. RESULTS: Markedly depressed HRV parameters were present in a relatively small percentage of patients: SDNN < 70 ms was found in 16% and SDNN < 50 ms in 4% of cases. No significant differences were present between STEMI and NSTEMI cases as regards to their distribution among quartiles of SDNN (χ2 =1.536, P = 0.674). Female sex and history of diabetes maintained a significant correlation with lower values of SDNN at multivariate Cox regression analysis (respectively: P = 0.008 and P = 0.008), while no correlation was found between depressed SDNN and history of previous MI (P = 0.999) or number of diseased coronary arteries (P = 0.428) or unsuccessful percutaneous coronary intervention (PCI) (P = 0.691). Patients with left ventricle ejection fraction (LVEF) < 40% presented more often SDNN values in the lowest quartile (P < 0.001). After > 2 years from infarction, a total of 10 patients (3.1%) were lost to follow-up. Overall incidence of MCE at follow-up was similar between STEMI and NSTEMI (P = 0.141), although all-cause and cardiac mortality were higher among NSTEMI cases (respectively: 14% vs 2%, P = 0.001; and 10% vs 1.5%, P = 0.001). The Kaplan-Meier survival curves for all-cause mortality and for cardiac deaths did not reveal significant differences between patients with SDNN in the lowest quartile and other quartiles of SDNN (respectively: P = 0.137 and P = 0.527). Also the MCE-free survival curves were similar between the group of patients with SDNN in the lowest quartile vs the patients of the other SDNN quartiles (P = 0.540), with no difference for STEMI (P = 0.180) or NSTEMI patients (P = 0.541). By the contrary, events-free survival was worse if patients presented with LVEF < 40% (P = 0.001). CONCLUSION: In our group of patients with a recent complicated MI, abnormal autonomic parameters have been found with a prevalence that was similar for STEMI and NSTEMI cases, and substantially unchanged in comparison to what reported in the pre-primary-PCI era. Long-term outcomes did not correlate with level of depression of HRV parameters recorded in the subacute phase of the disease, both in STEMI and in NSTEMI patients. These results support lack of prognostic significance of traditional HRV parameters when immediate coronary reperfusion is utilised.

Functional parameters but not heart rate variability correlate with long-term outcomes in St-elevation myocardial infarction patients treated by primary angioplasty.

BACKGROUND: Depressed heart rate variability (HRV) is usually considered a negative long-term prognostic factor after acute myocardial infarction. Anyway, most of the supporting research was conducted before the era of immediate reperfusion by percutaneous coronary intervention (PCI). Main aim of this study was to evaluate if HRV still retains prognostic significance in our era of immediate PCI. METHODS AND RESULTS: Two weeks after STEMI treated by primary PCI, time-domain HRV was assessed from 24-h Holter recordings in 186 patients: markedly depressed HRV (SDNN <70ms or <50ms) was present in 16% and in 5% of cases, respectively; patients with left ventricle ejection fraction (LVEF) <40% presented more often SDNN values in the lowest quartile. Physical performance was also assessed, by 6-minute walk tests (6MWT) and by cardiopulmonary exercise test (CPET). After >2years from infarction, occurrence of major clinical events (MCE) was investigated. Cases with or without MCE did not differ by initial HRV parameters; Kaplan-Meier events-free survival curves were similar between patients with lowest quartile SDNN and the remaining ones (χ2 0.981, p=0.322). By the contrary, events-free survival was worse if patients walked shorter distances at 6MWT (χ2 6.435, p=0.011), developed poorer ventilatory efficiency at CPET (χ2 10.060, p=0.002), or presented LVEF <40% (χ2 7.085, p=0.008). CONCLUSIONS: In primary-PCI STEMI patients, markedly abnormal HRV was found in a small percentage of cases. HRV seems to have lost its prognostic significance, while parameters indicating LV function (LVEF and physical performance) could allow better prognostication in primary-PCI STEMI patients.

The monitoring of antiaggregation effect of acetylsalicylic acid therapy by measuring serum thromboxane B2 in patients with coronary artery bypass grafting.

Cardiovascular patients take acetylsalicylic acid (ASA) for preventing myocardial infarction and other thromboembolic complications. It is already known that in some patients this therapy is not effective. The aim of this study was to assess the percentage of ASA resistance on the sample of patients with coronary artery bypass grafting. Our study included 105 patients with coronary artery bypass grafting treated with ASA 150 mg/day or lesser. Platelet aggregation was measured by serum thromboxane B2 level as well as impedance aggregometry from whole blood to determine ASA antiaggregation effect. The percentage of ASA resistance was 41.9% with impedance aggregometry, and after determining the serum thromboxane B2 level this percentage was only 8.6%. The correlation between these two methods was weak (r = 0.443; P < 0.0001). Thromboembolic complications still occur in ASA-treated patients because some patients are resistant to ASA therapy. It would be useful to monitor the effectiveness of ASA therapy and give another antiaggregation drug to these patients to reduce adverse events. The problem is which test is ideal because different tests show different percentages of ASA resistance.

Changes in Heart Rate Variability after Coronary Artery Bypass Grafting and Clinical Importance of These Findings.

Heart rate variability is a physiological feature indicating the influence of the autonomic nervous system on the heart rate. Association of the reduced heart rate variability due to myocardial infarction and the increased postinfarction mortality was first described more than thirty years ago. Many studies have unequivocally demonstrated that coronary artery bypass grafting surgery generally leads to significant reduction in heart rate variability, which is even more pronounced than after myocardial infarction. Pathophysiologically, however, the mechanisms of heart rate variability reduction associated with acute myocardial infarction and coronary artery bypass grafting are different. Generally, heart rate variability gradually recovers to the preoperative values within six months of the procedure. Unlike the reduced heart rate variability in patients having sustained myocardial infarction, a finding of reduced heart rate variability after coronary artery bypass surgery is not considered relevant in predicting mortality. Current knowledge about changes in heart rate variability in coronary patients and clinical relevance of such a finding in patients undergoing coronary artery bypass grafting are presented.

Left ventricular diastolic function in diabetes mellitus type 2 patients: correlation with heart rate and its variability.

AIMS: To assess the prevalence of left ventricular diastolic dysfunction in a population of patients with type 2 diabetes mellitus; to determine correlation of diastolic dysfunction with heart rate and its variability. METHODS: The study included 202 patients with type 2 diabetes mellitus. Echocardiography was performed with special reference to diastolic function, and heart rate variability was analysed using standard deviation of normal RR intervals, root mean square of successive differences and percentage of successive R-R intervals greater than 50 ms (pNN 50 %) in a 24-h electrocardiogram recording. RESULTS: Diastolic dysfunction is present in 79 % of type 2 diabetes mellitus patients: grade 1 in 52 %, grade 2 in 26 % and grade 3 in 1 % of patients. The subjects with grade 1 diastolic dysfunction had a statistically significantly higher heart rate variability compared with those with grade 2 diastolic dysfunction (LSD, post hoc test, p = 0.001). In the group with diastolic dysfunction, grade 2 reduced heart rate variability was recorded in 83 % of patients (37 and 7 % for grade 1 and normal diastolic function). An increase in the severity of diastolic dysfunction was associated with decreased heart rate variability and increased heart rate. CONCLUSION: Progression of diastolic dysfunction is associated with a significantly greater prevalence of reduced heart rate variability, which is accompanied by increased heart rate.