Diagnosis and treatment of myocarditis and inflammatory cardiomyopathy. Consensus document of the SEC-Working Group on Myocarditis.

Myocarditis is defined as myocardial inflammation and its etiology is highly diverse, including infectious agents, drugs, and autoimmune diseases. The clinical presentation also varies widely, extending beyond the classic clinical picture of acute chest pain, and includes cases of cardiomyopathy of unknown cause whose etiology may be inflammatory. Because certain patients may benefit from targeted treatments, the search for the etiology should begin when myocarditis is first suspected. There remain several areas of uncertainty in the diagnosis and treatment of this disease. Consequently, this consensus document aims to provide clear recommendations for its diagnosis and treatment. Hence, a diagnostic algorithm is proposed, specifying when non-invasive diagnosis with cardiac MR is appropriate vs a noninvasive approach with endomyocardial biopsy. In addition, more novel aspects are discussed, such as when to suspect an underlying genetic etiology. The recommendations cover the management of myocarditis and inflammatory cardiomyopathy, both for general complications and specific clinical entities.

Vaccine-carditis study: Spanish multicenter registry of inflammatory heart disease after COVID-19 vaccination.

INTRODUCTION AND OBJECTIVES: Vaccines against SARS-CoV-2 have been a major scientific and medical achievement in the control of the COVID-19 pandemic. However, very infrequent cases of inflammatory heart disease have been described as adverse events, leading to uncertainty in the scientific community and in the general population. METHODS: The Vaccine-Carditis Registry has included all cases of myocarditis and pericarditis diagnosed within 30 days after COVID-19 vaccination since August 1, 2021 in 29 centers throughout the Spanish territory. The definitions of myocarditis (probable or confirmed) and pericarditis followed the consensus of the Centers for Disease Control and the Clinical Practice Guidelines of the European Society of Cardiology. A comprehensive analysis of clinical characteristics and 3-month evolution is presented. RESULTS: From August 1, 2021, to March 10, 2022, 139 cases of myocarditis or pericarditis were recorded (81.3% male, median age 28 years). Most cases were detected in the 1st week after administration of an mRNA vaccine, the majority after the second dose. The most common presentation was mixed inflammatory disease (myocarditis and pericarditis). 11% had left ventricular systolic dysfunction, 4% had right ventricular systolic dysfunction, and 21% had pericardial effusion. In cardiac magnetic resonance studies, left ventricular inferolateral involvement was the most frequent pattern (58%). More than 90% of cases had a benign clinical course. After a 3-month follow-up, the incidence of adverse events was 12.78% (1.44% mortality). CONCLUSIONS: In our setting, inflammatory heart disease after vaccination against SARS-CoV-2 predominantly affects young men in the 1st week after the second dose of RNA-m vaccine and presents a favorable clinical course in most cases.

Consenso de expertos sobre el diagnóstico y el tratamiento de la miocarditis asociada con infección o vacunación contra el SARS-CoV-2 / Myocarditis related SARS-CoV-2 infection or vaccination: an expert consensus statement on its diagnosis and management

La pandemia causada por el coronavirus del síndrome respiratorio agudo grave de tipo 2 (SARS-CoV-2) ha puesto de manifiesto una serie de complicaciones cardiovasculares, entre las que destaca la miocarditis ocasionada tanto por la propia infección por SARS-CoV-2 (COVID-19) como por la administración de vacunas de ARN mensajero. La elevada prevalencia de primoinfección, la difusión universal de los programas de vacunación y la constante aparición de nueva información sobre la miocarditis en estos contextos, hace necesario condensar el conocimiento adquirido desde el inicio de la pandemia. Con este objetivo, el Grupo de Trabajo Miocarditis de la Asociación de Insuficiencia Cardiaca de la Sociedad Española de Cardiología, con la colaboración de la Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), ha elaborado el presente documento que pretende abordar el diagnóstico y el tratamiento de los casos de miocarditis asociados con la infección por SARS-CoV-2 o la vacuna de ARN mensajero. (AU)

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has revealed several cardiovascular complications, including myocarditis caused by SARS-CoV-2 infection (COVID-19) or after messenger RNA vaccine administration. Because of the high prevalence of COVID-19, the expansion of vaccination programs, and the appearance of new information on myocarditis in these contexts, there is a need to condense the knowledge acquired since the start of the pandemic. To meet this need, this document was drafted by the Myocarditis Working Group of the Heart Failure Association of the Spanish Society of Cardiology, with the collaboration of the Spanish Agency for Medicines and Health Products (AEMPS). The document aims to address the diagnosis and treatment of cases of myocarditis associated with SARS-CoV-2 infection or messenger RNA vaccine administration. (AU)

Myocarditis related SARS-CoV-2 infection or vaccination: an expert consensus statement on its diagnosis and management.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has revealed several cardiovascular complications, including myocarditis caused by SARS-CoV-2 infection (COVID-19) or after messenger RNA vaccine administration. Because of the high prevalence of COVID-19, the expansion of vaccination programs, and the appearance of new information on myocarditis in these contexts, there is a need to condense the knowledge acquired since the start of the pandemic. To meet this need, this document was drafted by the Myocarditis Working Group of the Heart Failure Association of the Spanish Society of Cardiology, with the collaboration of the Spanish Agency for Medicines and Health Products (AEMPS). The document aims to address the diagnosis and treatment of cases of myocarditis associated with SARS-CoV-2 infection or messenger RNA vaccine administration.

[Myocarditis related SARS-CoV-2 infection or vaccination: an expert consensus statement on its diagnosis and management]. / Consenso de expertos sobre el diagnóstico y el tratamiento de la miocarditis asociada con infección o vacunación contra el SARS-CoV-2.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has revealed several cardiovascular complications, including myocarditis caused by SARS-CoV-2 infection (COVID-19) or after messenger RNA vaccine administration. Because of the high prevalence of COVID-19, the expansion of vaccination programs, and the appearance of new information on myocarditis in these contexts, there is a need to condense the knowledge acquired since the start of the pandemic. To meet this need, this document was drafted by the Myocarditis Working Group of the Heart Failure Association of the Spanish Society of Cardiology, with the collaboration of the Spanish Agency for Medicines and Health Products (AEMPS). The document aims to address the diagnosis and treatment of cases of myocarditis associated with SARS-CoV-2 infection or messenger RNA vaccine administration.

Smartwatch ECG Tracing and Ischemic Heart Disease: ACS Watch Study.

BACKGROUND: Smartwatches have become a widely used tool for health self-care. Its role in ischemic heart disease (IHD) has not been assessed. Objetcive: The aim of this study was to evaluate the usefulness of smartwatch ECG registry in IHD. METHODS: We present an observational study of 25 consecutive patients with acute IHD. Conventional ECG and smartwatch tracing were obtained simultaneously at admission. Waves of conventional and smartwatch ECGs were objectively compared. A survey on medical attitude was conducted among 12 physicians (3 cardiologists, 3 intensivists, 3 emergency physicians, and 3 general practitioners) and a score (1-5) of concordance between the records was requested. RESULTS: There were no differences in Q-wave, R-wave, ST segment, or T-wave. There was a very strong correlation between ST segments, a strong correlation in Q-waves and R-waves, and a moderate correlation in T-wave measurements. All specialists obtained a high level of agreement (4.45 ± 0.45). Smartwatch tracings would lead to similar management compared to conventional ECG. There were only 6 (2%) discrepant cases due to differences in inferior repolarization, showing an almost perfect agreement (kappa = 0.96). CONCLUSIONS: In most patients with acute IHD, smartwatch ECG tracing is a reliable tool to make the diagnosis and guide appropriate medical care. However, due to their intrinsic limitations, inferior myocardial infarctions may be missed and require a conventional 12-lead ECG to rule them out.

Una vegetación de infarto / Myocardial infarction and culprit vegetation

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The Role of Frailty in Acute Coronary Syndromes in the Elderly.

BACKGROUND: Myocardial infarction (MI) patients are increasingly older, and common risk scores include chronological age, but do not consider chronic comorbidity or biological age. Frailty status reflects these variables and may be independently correlated with prognosis in this setting. OBJECTIVE: This study investigated the impact of frailty on the prognosis of elderly patients admitted due to MI. METHODS: This prospective and observational study included patients ≥75 years admitted to three tertiary hospitals in Spain due to MI. Frailty assessment was performed at admission using the Survey of Health, Ageing and Retirement in Europe Frailty Index (SHARE-FI) tool. The primary endpoint was the composite of death or non-fatal reinfarction during a follow-up of 1 year. Overall mortality, reinfarction, the composite of death, reinfarction and stroke, major bleeding, and readmission rates were also explored. RESULTS: A total of 285 patients were enrolled. Frail patients (109, 38.2%) were older, with a higher score in the Charlson Comorbidity Index and with a higher risk score addressed in the GRACE and CRUSADE indexes. On multivariate analysis including GRACE, CRUSADE, maximum creatinine level, culprit lesion revascularization, complete revascularization, and dual antiplatelet therapy at discharge, frailty was an independent predictor of the composite of death and reinfarction (2.81, 95% CI 1.16-6.78) and overall mortality (3.07, 95% CI 1.35-6.98). CONCLUSION: Frailty is an independent prognostic marker of the composite of mortality and reinfarction and of overall mortality in patients aged ≥75 years admitted due to MI.

Frailty is an independent prognostic marker in elderly patients with myocardial infarction.

BACKGROUND: Acute coronary syndrome (ACS) patients are increasingly older. Conventional prognostic scales include chronological age but do not consider vulnerability. In elderly patients, a frail phenotype represents a better reflection of biological age. HYPOTHESIS: This study aims to determine the prevalence of frailty and its influence on patients age ≥75 years with ACS. METHODS: Patients age ≥75 years admitted due to type 1 myocardial infarction were included in 2 tertiary hospitals, and clinical data were collected prospectively. Frailty was defined at admission using the previously validated Survey of Health Ageing and Retirement in Europe Frailty Index (SHARE-FI) tool. The primary endpoint was the combination of death or nonfatal myocardial reinfarction during a follow-up of 6 months. Major bleeding (hemoglobin decrease ≥3 g/dL or transfusion needed) and readmission rates were also explored. RESULTS: A total of 234 consecutive patients were included. Frail patients (40.2%) had a higher-risk profile, based on higher age and comorbidities. On multivariate analysis, frailty was an independent predictor of the combination of death or nonfatal myocardial reinfarction (adjusted hazard ratio [aHR]: 2.54, 95% confidence interval [CI]: 1.12-5.79), an independent predictor of the combination of death, nonfatal myocardial reinfarction, or major bleeding (aHR: 2.14, 95% CI: 1.13-4.04), and an independent predictor of readmission (aHR: 1.80, 95% CI: 1.00-3.22). CONCLUSIONS: Frailty phenotype at admission is common among elderly patients with ACS and is an independent predictor for severe adverse events. It should be considered in future risk-stratification models.

Frailty predicts major bleeding within 30days in elderly patients with Acute Coronary Syndrome.

OBJECTIVE: Bleeding in ACS patients is an independent marker of adverse outcomes. Its prognostic impact is even worse in elderly population. Current bleeding risk scores include chronological age but do not consider biologic vulnerability. No studies have assessed the effect of frailty on major bleeding. The aim of this study is to determine whether frailty status increases bleeding risk in patients with ACS. METHODS: This prospective and observational study included patients aged ≥75years admitted due to type 1 myocardial infarction. Exclusion criteria were severe cognitive impairment, impossibility to measure handgrip strength, cardiogenic shock and limited life expectancy due to oncologic diseases. The primary endpoint was 30-day major bleeding defined as a decrease of ≥3g/dl of haemoglobin or need of transfusion. RESULTS: A total of 190 patients were included. Frail patients (72, 37.9%) were older, with higher comorbidity features and with a higher CRUSADE score at admission. On univariate analysis, frailty predicted major bleeding during 30-day follow-up despite less frequent use of a P2Y12 inhibitor (66.2% vs 83.6%, p=0.007) and decreased catheterisation rate (69.4% vs 94.1%, p<0.001). Major bleeding was associated with increased all-cause mortality at day 30 (18.2% vs 2.5%, p<0.001). On multivariate analysis, frailty was an independent predictor for major bleeding. CONCLUSION: Frailty phenotype, as a marker of biological vulnerability, is an independent predictor of major bleeding in elderly patients with ACS. Frailty can play an important role in bleeding risk stratification and objective indices should be integrated into routine initial evaluation of these patients.

Ventricular septal rupture in a case of myocardial infarction with normal coronary arteries: Case report.

Ventricular wall rupture has become an infrequent complication of myocardial infarction due to widespread use of prompt reperfusion strategies. Patients suffering myocardial infarction with normal coronary arteries seldom develop severe mechanical complications. We present the case of a patient who developed a ventricular septal rupture following an anteroseptal myocardial infarction and who presented normal coronary arteries at the time of coronary angiography.

Efficacy and safety of rivaroxaban in real-life patients with atrial fibrillation.

Rivaroxaban is a once-daily oral anticoagulant currently marketed for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation. This indication is largely based on the results of the ROCKET-AF trial. Although these results are robust, studies performed in clinical practice are necessary to confirm these data in real-life patients. These studies have shown rates of stroke and bleeding similar to that found in ROCKET-AF. As an anticoagulant, attention should be paid to making a correct prescription of rivaroxaban, particularly in fragile patients, to reduce the risk of bleeding. In addition, a number of studies have shown that rivaroxaban is cost-effective in clinical practice. Moreover, rivaroxaban is a good alternative to warfarin in patients undergoing elective cardioversion or atrial fibrillation ablation.