QTc Interval: A Frequently Unrecognized Electrocardiographic Interval.

The QT interval, an electrocardiographic temporal representation of the ventricular depolarization and repolarization, is an integral parameter that must be carefully evaluated to gather critical information regarding electrical instability that may cause malignant ventricular dysrhythmias or sudden cardiac death. The QT interval is affected by several inheritable and acquired factors, such as genetic mutations, electrolyte disturbances, and medication interactions. We strongly believe that prompt and accurate recognition of any QT interval abnormalities is critical in many clinical settings. This concise review article highlights the importance of accurate measurement of the QT interval, enhances understanding of the most prevalent factors yielding abnormalities within the QT interval and the prognostic value of the QT interval, as well as provides several key practical reminders for healthcare professionals to strengthen our clinical practice.

Nonobstructive epicardial coronary artery disease: an evolving concept in need of diagnostic and therapeutic guidance.

For decades, we have been treating patients presenting with angina and concerning electrocardiographic changes indicative of ischemia or injury, in whom no culprit epicardial coronary stenosis was found during diagnostic coronary angiography. Unfortunately, the clinical outcomes of these patients were not better than those with recognized obstructive coronary disease. Improvements in technology have allowed us to better characterize these patients. Consequently, an increasing number of patients with ischemia and no obstructive coronary artery disease (INOCA) or myocardial infarction in the absence of coronary artery disease (MINOCA) have now gained formal recognition and are more commonly encountered in clinical practice. Although both entities might share functional similarities at their core, they pose significant diagnostic and therapeutic challenges. Unless we become more proficient in identifying these patients, particularly those at higher risk, morbidity and mortality outcomes will not improve. Though this field remains in constant flux, data continue to become available. Therefore, we thought it would be useful to highlight important milestones that have been recognized so we can all learn about these clinical entities. Despite all the progress made regarding INOCA and MINOCA, many important knowledge gaps continue to exist. For the time being, prompt identification and early diagnosis remain crucial in managing these patients. Even though we are still not clear whether intensive medical therapy alters clinical outcomes, we remain vigilant and wait for more data.

Heart Failure with Preserved Left Ventricular Ejection Fraction: A Complex Conundrum Simply Not Limited to Diastolic Dysfunction.

Over the last two decades, the changing paradigm of heart failure with preserved ejection fraction (HFpEF) has transformed our understanding not only of the pathophysiology of this clinical entity but also the diagnostic and therapeutic approaches aimed at treating this complex patient population. No longer HFpEF should be seen as simply left ventricular diastolic dysfunction but as a group of that in addition of having small and thick left ventricles with abnormal diastolic filling patterns as their main pathophysiologic abnormality; they also have whole host of different abnormalities. In fact, this heterogeneous clinical entity embodies numerous mechanisms and is linked to multiorgan dysfunction, with hypertension and obesity playing a major role. Although we have gained an enormous amount of understanding not only on the causes but also the downstream effects of HFpEF, there is still much to be learned before we can fully comprehend this complex clinical entity. It is the main intention of this review to synthesize the most recent attributes, mechanism, diagnostic tools, and most useful therapeutic alternatives to be considered when evaluating patients either complaining of dyspnea on exertion as well as exercise intolerance or those recently admitted with HF symptoms but with normal LVEF in the absence of any other valvular abnormalities.

Profiling Cardiometabolic Health in Jordan: A Call to Action to Improve Cardiovascular Health.

Over the past decades, Jordan has witnessed unprecedented growth in the prevalence of cardiometabolic diseases, with a crude prevalence of 48.2% in 2020, up from 38% in 2009. This is slightly higher than the reported prevalence of 40% in the US population. According to the latest World Health Organization report published in 2020, Jordan's leading cause of mortality is cardiovascular diseases with a cause-specific mortality rate of 18.6%. Since the advancement of the healthcare system in Jordan took place in the early 2000s, Jordan has witnessed a major epidemiologic transition where the burden of infectious disease has decreased, but on the other hand, the burden of cardiometabolic disease has increased as well. For such a country with limited resources and healthcare infrastructure where two-thirds of its population is below the age of 30, this is alarming. This growth can be attributed to a complex interplay between genetic and lifestyle factors. Smoking, physical inactivity, obesity, and unhealthy diet are considered major public health problems in Jordan, as reported in 2007 by the Jordanian Behavioral Risk Factor Surveillance. We attempt to raise awareness through this review article, so healthcare providers in Jordan understand the magnitude of the issue, and appropriate steps are taken to reestablish screening and management guidelines pertaining to cardiometabolic diseases in Jordan.

Growth Differentiation Factor 15 (GDF-15), a New Biomarker in Heart Failure Management.

The emergence of biomarkers across medicine's subspecialties continues to evolve. In essence, a biomarker is a biological observation that clearly substitutes a clinical endpoint or intermediate outcome not only are more difficult to observe but also, biomarkers are easier, less expensive and could be measured over shorter periods. In general, biomarkers are versatile and not only used for disease screening and diagnosis but, most importantly, for disease characterization, monitoring, and determination of prognosis as well as individualized therapeutic responses. Obviously, heart failure (HF) is no exception to the use of biomarkers. Currently, natriuretic peptides are the most used biomarkers for both diagnosis and prognostication, while their role in the monitoring of treatment is still debatable. Although several other new biomarkers are currently under investigation regarding diagnosis and determination of prognosis, none of them are specific for HF, and none are recommended for routine clinical use at present. However, among these emerging biomarkers, we would like to highlight the potential for growth differentiation factor (GDF)-15 as a plausible new biomarker that could be helpful in providing prognostic information regarding HF morbidity and mortality.

True relationship between tricuspid annular motion and velocity displacement components: Potential role in assessing right ventricular decoupling.

BACKGROUND: Although measures of longitudinal displacement of the tricuspid annulus measured by M-mode as tricuspid annular systolic plane excursion (TAPSE) and systolic velocity by tissue Doppler imaging (TA TDI s) are routinely used for assessment of right ventricular (RV) systolic function; these measures describe different phenomena and should not be used interchangeably. METHODS: Previously published data was used to determine the individual relationship between TAPSE and TA TDI s with increasing pulmonary artery systolic pressures (PASP). RESULTS: In this retrospective analysis, 488 patients were divided into 2 groups based on TAPSE (Group 1: <1.8 cm and Group 2: ≥1.8 cm). A robust correlation (R = .79) between TAPSE and TA TDI s noted for the entire population. However, a statistically lower correlation (R = .43) was seen between Group 1 and Group 2 (R = .65; p < .0047). With increasing pulmonary pressures, only PASP (p < .0001) and TA TDI s (p < .0001) discriminated between low and normal TAPSE/PASP values. Suggesting that a TA TDI s/PASP ratio would be most useful than TAPSE/PASP with a specificity of 80%. CONCLUSIONS: Significant differences exist between TAPSE and TA TDI s, particularly at low TAPSE values with increased PASP, were uncoupling occurs. Our data seems to suggest that TA TDI s/PASP would be most useful than TAPSE/PASP ratio. Future studies should address, if abnormalities in the material properties along the RV free wall account for these differences seen between TAPSE and TA TDI s.

Epigenetic Regulation and its Effects on Aging and Cardiovascular Disease.

Cardiovascular disease (CVD), specifically coronary atherosclerosis, is regulated by an interplay between genetic and lifestyle factors. Most recently, a factor getting much attention is the role epigenetics play in atherosclerosis; particularly the development of coronary artery disease. Furthermore, it is important to understand the intricate interaction between the environment and each individual genetic material and how this interaction affects gene expression and consequently influences the development of atherosclerosis. Our main goal is to discuss epigenetic regulations; particularly, the factors contributing to coronary atherosclerosis and their role in aging and longevity. We reviewed the current literature and provided a simplified yet structured and reasonable appraisal of this topic. This role has also been recently linked to longevity and aging. Epigenetic regulations (modifications) whether through histone modifications or DNA or RNA methylation have been shown to be regulated by environmental factors such as social stress, smoking, chemical contaminants, and diet. These sensitive interactions are further aggravated by racial health disparities that ultimately impact cardiovascular disease outcomes through epigenetic interactions. Certainly, limiting our exposure to such causative events at younger ages seems our "golden opportunity" to tackle the incidence of coronary atherosclerosis and probably the answer to longevity.

Early repolarization: Electrocardiographic cues to distinguish benign from malignant variants.

Historically, early repolarization (ER) has been considered a marker of good health as it is more prevalent in athletes, younger persons, and at slower heart rates. However, contemporary reports, largely based on data from resuscitated sudden cardiac arrest patients, suggest an association between ER and an increased risk for sudden cardiac death and the development of malignant ventricular arrhythmias. Therefore, after we present a brief-case presentation, we intend to review a challenging topic in recognition of malignant variants and propose a four-step comprehensive approach to simplify ECG discrimination when assessing ER changes.

Vasospastic Angina With ST-Segment Elevation Seen During Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring.

A 54-year-old man presented with significant ST-segment elevations noted on both channels displayed on the mobile cardiac outpatient telemetry (MCOT). Pertinent cardiac history was remarkable for syncope and episodes of atypical chest pain. The latter were described as infrequent and not associated with exercise intolerance. His syncopal episodes were described as occurring mostly in the mornings after the use of the restroom. Episodes happen 1 or 2 times a year since 2015. Patient had undergone thorough investigation with no significant findings. An MCOT was prescribed since frequency of symptoms has recently increased. Significant ST-segment elevations were noted. The patient described atypical chest pain and a sensation of presyncope during these recordings. He was urgently admitted, and a coronary angiogram revealed no epicardial luminal stenosis. However, the presence of sluggish coronary flow was suggestive of possible vasospastic angina. No ST-segment changes were noted during his coronary angiogram. The remarkable element portrayed by this case hinges in showing the unique utility of MCOT, as the most uncharacteristic diagnostic tool, in identifying transient ST-segment elevations that finally led to the diagnosis.

Improving diagnostic assessments in the ever-changing landscape of atherosclerosis.

As our understanding of atherosclerotic vascular injury continues to evolve, so should our diagnostic approaches. Emerging data have recently challenged our basic understanding in linking ischemia to its adverse outcomes as well as the need for invasive testing for both diagnosis and treatment. The advent of coronary computed tomography in providing improved visualization of coronary arteries has led to the identification of both subclinical atherosclerosis and high-risk coronary lesions. Recognition of asymptomatic coronary artery disease (CAD) with objective localization of subclinical coronary atherosclerosis improves atherosclerotic cardiovascular risk assessment and allows healthcare providers to take effective primary prevention measures. Therefore, reshaping the diagnostic landscape in proposing new testing modalities would be highly dependent on local resource availability and the reading expertise of each clinical practice and medical institution. The main objective of this Review is to propose a potentially new diagnostic approach of simply using noninvasive stress testing or coronary angiography in the routine assessment of CAD.

Abnormal Resting Myocardial Contrast Echocardiographic Uptake: Clue of an Ongoing Acute Coronary Artery Event.

Acute coronary syndromes (ACSs) present most frequently with chest pain, but angina equivalents such as dyspnea, diaphoresis, and fatigue are not uncommon. Atypical presentations are especially seen in women, the elderly, and diabetics. Cardiac evaluation using a transthoracic echocardiogram is almost always done before or immediately after someone undergoes left heart catheterization for ACS. It provides information valuable information regarding wall motion, left ventricular systolic function, diastolic function, right ventricular involvement, pulmonary pressures, incidental valvular disease, pericardial fluid, or any other unsuspected abnormality. We describe a novel case where an atypical presentation of ACS was suspected based on the lack of intravenous contrast administered, to enhance endocardial border resolution. The use of contrast during echocardiography has been used during stress protocols to assess microcirculation during perfusion assessment studies. However, we described a reduced uptake during the acquisition of resting myocardial echocardiogram images and it was very useful to direct therapy.

Echo-Doppler measures of right ventricular systolic function are affected by reduced left ventricular systolic function.

BACKGROUND: Objective right ventricular (RV) systolic function assessment is attained using a series of well-described and validated echo-Doppler measurements. However, how left ventricular (LV) systolic function influences these RV functional measurements has not been previously studied. Consequently, we conducted a retrospective proof-of-concept analysis to answer this important question. METHODS: A total of 100 echocardiographic studies were included and patients were divided into two groups according to their LV ejection fraction (LVEF). The following RV variables were acquired including, tricuspid annular systolic plane excursion (TAPSE), velocity of the systolic motion (TA TDI s'), RV outflow tract velocity time integral (VTI), pulmonary vascular resistance (PVR), and the TAPSE to pulmonary artery systolic pressure (PASP) ratio. RESULTS: Not only TAPSE, TA DI s', RVOT VTI, PVR, and TAPSE/PASP were all significantly different between patients with normal versus abnormal LVEF; but most importantly, RVOT VTI (p < .0001) was the best discriminatory variable in assessing normal versus abnormal LVEF followed by TAPSE (p = .0001). Using receiver operating characteristic curve analysis, an RVOT VTI value > 11 identified patients with a normal LVEF with a sensitivity of 90% and specificity of 76%. CONCLUSION: Based on our results, reduced LVEF affects the RV, likely mediated by mechanisms of interventricular dependence. Therefore, RV analysis cannot be performed in isolation as it not only reflects intrinsic RV systolic function but also, is dependent on LV systolic function. In cases of reduced LVEF, additional measures of RV assessment should be used to provide better objective assessments.

Utility of the tricuspid annular tissue doppler systolic velocity and pulmonary artery systolic pressure relationship in right ventricular systolic function assessment: A pilot study.

BACKGROUND: Tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) ratio has been validated as a valuable noninvasive measure of right ventricular (RV) elastance and systolic function. However, the more reliable TA systolic (s') velocity measure of RV systolic function compared to TAPSE has not been previously studied. METHODS: We conducted a pilot study using several variables of RV function in 50 patients with the main aim to determine which numerical expression between TA TDI s'/PASP and TAPSE/PASP ratio was most useful. RESULTS: In a stepwise multiple regression analysis, TA TDI s'/PASP ratio (p < .0002); LVOT VTI/RVOT VTI ratio (p < .0002); RVOT VTI (p < .0047); TAPSE/PASP ratio (p < .0259) and TA TDI e' (p < .0292) were best in discriminating normal versus abnormal RV systolic function. Using receiver operator curve analysis, cut-off values for both TA TDI s'/PASP (>3.9 mm/c/mmHg) had 82.1% sensitivity and 77.3% specificity while the TAPSE/PASP (>.61 mm/mmHg) had 89.3% sensitivity and 68.2% specificity in identifying normal RV function in our studied population. CONCLUSION: Our results indicate that TA TDI s'/PASP is a better mathematical expression when examining the relationship between RV contractility and RV resistance relationship. Furthermore, we also found that inclusion of RVOT VTI, RV diastolic properties, and left ventricular systolic function are important determinants of RV systolic function assessments and should be routinely included. Additional prospective studies are now needed to confirm these results using hemodynamic data.

Obstructive Sleep Apnea and Cardiovascular Diseases: Sad Realities and Untold Truths regarding Care of Patients in 2022.

Obstructive sleep apnea (OSA) is one of the most common and serious sleep-related breathing disorders with a high prevalence among patients with cardiovascular (CV) diseases. Despite its widespread presence, OSA remains severely undiagnosed and untreated. CV mortality and morbidity are significantly increased in the presence of OSA as it is associated with an increased risk of resistant hypertension, heart failure, arrhythmias, and coronary artery disease. Evaluation and treatment of OSA should focus on recognizing patients at risk of developing OSA. The use of screening questionnaires should be routine, but a formal polysomnography sleep study is fundamental in establishing and classifying OSA. Recognition of OSA patients will allow for the institution of appropriate therapy that should alleviate OSA-related symptoms with the intent of decreasing adverse CV risk. In this review, we focus on the impact OSA has on CV disease and evaluate contemporary OSA treatments. Our goal is to heighten awareness among CV practitioners.