Risk Stratification in People with Diabetes for Fasting During Ramadan: Consensus from Arabic Association for the Study of Diabetes and Metabolism.

BACKGROUND: Current international guidelines recommend a pre-Ramadan risk assessment for people with diabetes (PwDM) who plan on fasting during the Holy month. However, a comprehensive risk assessment-based recommendation for the management of PwDM intending to fast is still controversial. Therefore, the Arabic Association for the Study of Diabetes and Metabolism (AASD) developed this consensus to provide further insights into risk stratification in PwDM intending to fast during Ramadan. METHODS: The present consensus was based on the three-step modified Delphi method. The modified Delphi method is based on a series of voting rounds and in-between meetings of the expert panel to reach agreements on the statements that did not reach the consensus level during voting. The panel group comprised professors and consultants in endocrinology (both adult and pediatric). Other members included experts in the fields of cardiovascular medicine, nephrology, ophthalmology, and vascular surgery, affiliated with academic institutions in Egypt. RESULT: In PwDM who intend to fast during Ramadan, risk stratification is crucial to optimize patient outcomes and prevent serious complications. The present consensus provides risk assessment of those living with diabetes according to several factors, including the type of diabetes, presence, and severity of complications, number of fasting hours, and other socioeconomic factors. According to their risk factors, patients were classified into four categories (very high, high, moderate, and low risk). CONCLUSION: Future research is warranted due to the controversial literature regarding the impact of fasting on certain comorbidities.

Transcatheter Mitral Valve Repair via MitraClip in Patients Aged <65 Years: Multicentre 2-year Outcomes.

Background: Transcatheter mitral valve repair (TMVR) using the MitraClip has become a well-established interventional therapy and is usually performed in elderly patients. The objective of this study was to assess 2-year clinical outcomes of TMVR in patients aged <65 years at three heart centres with severe mitral regurgitation (MR) and no surgical options. Methods: A retrospective study analysed data of 36 patients aged <65 years treated with TMVR . All patients were refused surgery by Heart Team decision. Baseline MR was assessed by biplane vena contracta width in two perpendicular views (mean 8.35 ± 1.87 mm). Degenerative MR was detected in 11 patients (30.6%); functional MR was detected in 25 patients (69.4%). Results: Acute procedural success was accomplished in 88.9% of patients. No procedure-related mortality during the first 30 days was detected. Over an average of 2 years of follow-up, all-cause mortality was 19.4% and cardiovascular death was 11.1% owing to advanced heart failure. The average follow-up period was 25.8 months (median was 20 months). Statistically significant difference (p-value <0.01) was detected for N-terminal prohormone of brain natriuretic peptide (pg/ml) at baseline (mean 9,870 ± 10,819; median 7,748) compared to follow-up visits (mean 7,645 ± 11,292; median 3,263). New York Heart Association functional class improvement was achieved in 69% of patients. A second intervention (reclipping) was required in two patients to correct recurrent significant MR. Conclusion: TMVR in patients aged <65 years refused surgical repair provides satisfactory clinical outcomes at 2 years. Future studies should evaluate the outcomes of MitraClip in this population in a larger cohort.

Acute Coronary Syndrome and Ischemic Heart Disease in Pregnancy: Data From the EURObservational Research Programme-European Society of Cardiology Registry of Pregnancy and Cardiac Disease.

Background The prevalence of ischemic heart disease (IHD) in women of child-bearing age is rising. Data on pregnancies however are scarce. The objective is to describe the pregnancy outcomes in these women. Methods and Results The European Society of Cardiology-EURObservational Research Programme ROPAC (Registry of Pregnancy and Cardiac Disease) is a prospective registry in which data on pregnancies in women with heart disease were collected from 138 centers in 53 countries. Pregnant women with preexistent and pregnancy-onset IHD were included. Primary end point were maternal cardiac events. Secondary end points were obstetric and fetal complications. There were 117 women with IHD, of which 104 had preexisting IHD. Median age was 35.5 years and 17.1% of women were smoking. There was no maternal mortality, heart failure occurred in 5 pregnancies (4.8%). Of the 104 women with preexisting IHD, 11 women suffered from acute coronary syndrome during pregnancy. ST-segment‒elevation myocardial infarction were more common than non‒ST-segment‒elevation myocardial infarction, and atherosclerosis was the most common etiology. Women who had undergone revascularization before pregnancy did not have less events than women who had not. There were 13 women with pregnancy-onset IHD, in whom non‒ST-segment‒elevation myocardial infarction was the most common. Smoking during pregnancy was associated with acute coronary syndrome. Caesarean section was the primary mode of delivery (55.8% in preexisting IHD, 84.6% in pregnancy-onset IHD) and there were high rates of preterm births (20.2% and 38.5%, respectively). Conclusions Women with IHD tolerate pregnancy relatively well, however there is a high rate of ischemic events and these women should therefore be considered moderate- to high-risk. Ongoing cigarette smoking is associated with acute coronary syndrome during pregnancy.

Short-term prognostic value of TAPSE, RVFAC and Tricuspid S' wave peak systolic velocity after first acute myocardial infarction.

OBJECTIVES: Right ventricular dysfunction impacts the prognosis of various heart diseases. We set-out to examine which right ventricular functional parameters after STEMI and NSTEMI have prognostic value. Of 297 eligible participants, 266 (149 STEMI and 117 NSTEMI) completed follow-up. All patients underwent Grace score and 2D-echocardiography within 24 h. Outcome was defined as occurrence of Major Adverse Cardiovascular events (MACE), such as death, recurrent ischaemia, arrhythmia, reinfarction, stroke or heart failure, within 30 days. Patients were categorized into patients with MACE and patients without MACE. RESULTS: In STEMI-patients, compared to those without MACE, patients with MACE experienced higher grace score, left ventricle (LV) end-systolic volume, LV end-systolic dimension and wall motion score index values, but lower tricuspid annular plane systolic excursion, right ventricle (RV) fractional area change, Tricuspid S' wave peak systolic velocity and LV ejection fraction. Nevertheless, in NSTEMI-patients, those with MACE exhibited higher left atrial volume index values, but lower tricuspid annular plane systolic excursion, RV fractional area change, S' wave peak systolic velocity and LVEF. Right ventricular fractional area change < 37.5%, tricuspid annular plane systolic excursion < 15.8 mm and Tricuspid S' peak systolic velocity < 9.67 cm/s are independent predictors of MACE within first 30 days after STEMI and NSTEMI.

PTEN gene & TNF-alpha in acute myocardial infarction.

BACKGROUND: PTEN gene triggers cells to undergo apoptosis and promotes myocardial dysfunction. Several TNF family cytokines are elevated during acute myocardial infarction (AMI). Their role in predicting subsequent prognosis in these setting remains poorly understood. We assessed serum levels of PTEN gene activity & TNF-α in acute ST elevation myocardial infarction and determined the impact of their levels on both left ventricular function and the clinical outcome in these patients. METHODS AND RESULTS: Seventy patients with AMI and seventy persons as control group were subjected to: ECG, echocardiography, serum TNF-α and PTEN gene assessment. Patients were classified into: Group I (n = 32): All had left ventricular systolic failure. Group II (n = 38): without left ventricular systolic failure. Group I had a statistically significant higher serum levels of both TNF-α & PTEN gene activity as compared to group II. EF% at presentation was weakly correlated with serum levels of both markers in both groups. However at follow up, EF% in group I showed a significant negative correlations with both serum levels of TNF-α and PTEN gene activity (r = 0.77 & r = 0.67, respectively). During one year follow, 5 patients died of cardiovascular causes and 6 patients had recurrent hospitalization with heart failure. These patients had statistically significant increased serum levels of TNF-α & PTEN gene activity levels as compared by other patients. CONCLUSIONS: Patients with acute myocardial infarction had statistically significant increased serum levels of PTEN & TNF-α gene activity. Both markers predict worsening of left ventricular systolic functions, development of heart failure and death.

Clinical and procedural predictors of suboptimal myocardial reperfusion in primary percutaneous coronary intervention.

BACKGROUND: Suboptimal myocardial perfusion in primary PCI is associated with increased infarct size, left ventricular (LV) dysfunction and higher mortality rates as compared as those with optimal myocardial perfusion. We identified clinical and procedural predictors of suboptimal myocardial reperfusion as judged by myocardial plush grade (MBG) in primary PCI. METHODS AND RESULTS: 100 patients with acute STEMI who underwent primary PCI were prospectively subjected to clinical, ECG, laboratory and angiographic evaluation. Patients were classified into: Optimal myocardial reperfusion group: (n=73) who had final MBG=3. Suboptimal myocardial reperfusion group: (n=27) who had persistent final MBG ≤ 2. Suboptimal myocardial reperfusion group had statistically significant little history of angina prior to MI 5 (18.5%) vs 44 (60.3%), little current aspirin intake 6(22%) vs 38 (52% ), increased blood sugar on admission (240 ±â€¯101 mg/dl vs 171 ±â€¯72 mg/dl), increased total leucocytic count on admission (12.1 ±â€¯3.6 vs 10.2 ±â€¯3.3) 103/mm3, longer reperfusion time (6.1 ±â€¯2.8 vs 4.3 ±â€¯2.1 h ), higher thrombus burden 12 (44.4 % ) vs 13 (17.8 %), higher predilatation pressure (16 ±â€¯2.3 vs 14 ±â€¯1.8 ATM), repeated balloon inflation during predilatation 24 (92.3 % ) vs 46 (69.7%) as compared optimal myocardial reperfusion group, (P < 0.05 for all). CONCLUSION: Longer reperfusion time, repeated balloon inflations, high predilatation pressure> 15 ATM , high thrombus burden, neither history of angina nor aspirin intake prior to AMI, high total leucocytic count > 10103/mm3 and high blood glucose level > 160mg/dl were predictors for persistent suboptimal myocardial reperfusion in primary PCI.

Retinal fluorescein angiography: A sensitive and specific tool to predict coronary slow flow.

BACKGROUND: Obstructive coronary artery disease (OCAD) and coronary slow flow (CSF) are frequent angiographic findings for patients that have chest pain and require frequent hospital admission. The retina provides a window for detecting changes in microvasculature relating to the development of cardiovascular diseases such as arterial hypertension or coronary heart disease. OBJECTIVES: To assess the coronary and ocular circulations in patients with CSF and those with obstructive coronary artery disease. METHODS: A prospective study was conducted over 3.5 years, included a total of 105 subjects classified to 4 groups: Group I (OCAD): Included 30 patients with obstructive coronary artery disease, group II (CSF): Included 30 patients with coronary slow-flow, group III (Control 1): Included 30 healthy control persons and group IV (Control 2): Included 15 patients indicated for coronary angiography that proved normal. All participants were subjected to coronary angiography (except control group 1), ophthalmic artery Doppler for measuring Pulsatility index (PI) and resistivity index (RI) and Fluorescence angiography of retinal vessels. RESULTS: Patients with CSF showed slow flow retinal circulation (microcirculation) evidenced by prolonged fluorescein angiography (Arm-retina time [ART] & Arterio-venous Transit time [AVTT]). Ophthalmic artery Doppler measurements (RI & PI) were significantly delayed in OCAD and CSF patients. There was significant positive correlation between TIMI frame count in all subjects and ART, AVTT, PI, RI and Body Mass Index. Using ART cutoff value of >16 s predicted CSF with sensitivity and specificity of 100%, meanwhile AVTT of >2 s predicted CSF with a sensitivity 96.7% and specificity of 93.3. CONCLUSION: Both delayed arm-retina time and retinal arterio-venous transit times can accurately predict coronary slow-flow.

Pregnancy Outcomes in Women With Rheumatic Mitral Valve Disease: Results From the Registry of Pregnancy and Cardiac Disease.

BACKGROUND: Cardiac disease is 1 of the major causes of maternal mortality. We studied pregnancy outcomes in women with rheumatic mitral valve disease. METHODS: The Registry of Pregnancy and Cardiac Disease is an international prospective registry, and consecutive pregnant women with cardiac disease were included. Pregnancy outcomes in all women with rheumatic mitral valve disease and no prepregnancy valve replacement is described in the present study (n=390). A maternal cardiac event was defined as cardiac death, arrhythmia requiring treatment, heart failure, thromboembolic event, aortic dissection, endocarditis, acute coronary syndrome, and hospitalization for other cardiac reasons or cardiac intervention. Associations between patient characteristics and cardiac outcomes were checked in a 3-level model (patient-center-country). RESULTS: Most patients came from emerging countries (75%). Mitral stenosis (MS) with or without mitral regurgitation (MR) was present in 273 women, isolated MR in 117. The degree of MS was mild in 20.9%, moderate in 39.2%, severe in 19.8%, and severity not classified in the remainder. Maternal death during pregnancy occurred in 1 patient with severe MS. Hospital admission occurred in 23.1% of the women with MS, and the main reason was heart failure (mild MS 15.8%, moderate 23.4%, severe 48.1%; P<0.001). Heart failure occurred in 23.1% of patients with moderate or severe MR. An intervention during pregnancy was performed in 16 patients, 14 had percutaneous balloon mitral commissurotomy, and 2 had surgical valve replacement (1 for MS, 1 for MR). In multivariable modeling, prepregnancy New York Heart Association class >1 was an independent predictor of maternal cardiac events. Follow-up at 6 months postpartum was available for 53%, and 3 more patients died (1 with severe MS, 1 with moderate MS, 1 with moderate to severe MR). CONCLUSIONS: Although mortality was only 1.9% during pregnancy, ≈50% of the patients with severe rheumatic MS and 23% of those with significant MR developed heart failure during pregnancy. Prepregnancy counseling and considering mitral valve interventions in selected patients are important to prevent these complications.

Influence of socioeconomic factors on pregnancy outcome in women with structural heart disease.

OBJECTIVE: Cardiac disease is the leading cause of indirect maternal mortality. The aim of this study was to analyse to what extent socioeconomic factors influence the outcome of pregnancy in women with heart disease. METHODS: The Registry of Pregnancy and Cardiac disease is a global prospective registry. For this analysis, countries that enrolled ≥10 patients were included. A combined cardiac endpoint included maternal cardiac death, arrhythmia requiring treatment, heart failure, thromboembolic event, aortic dissection, endocarditis, acute coronary syndrome, hospitalisation for cardiac reason or intervention. Associations between patient characteristics, country characteristics (income inequality expressed as Gini coefficient, health expenditure, schooling, gross domestic product, birth rate and hospital beds) and cardiac endpoints were checked in a three-level model (patient-centre-country). RESULTS: A total of 30 countries enrolled 2924 patients from 89 centres. At least one endpoint occurred in 645 women (22.1%). Maternal age, New York Heart Association classification and modified WHO risk classification were associated with the combined endpoint and explained 37% of variance in outcome. Gini coefficient and country-specific birth rate explained an additional 4%. There were large differences between the individual countries, but the need for multilevel modelling to account for these differences disappeared after adjustment for patient characteristics, Gini and country-specific birth rate. CONCLUSION: While there are definite interregional differences in pregnancy outcome in women with cardiac disease, these differences seem to be mainly driven by individual patient characteristics. Adjustment for country characteristics refined the results to a limited extent, but maternal condition seems to be the main determinant of outcome.

Global cardiac risk assessment in the Registry Of Pregnancy And Cardiac disease: results of a registry from the European Society of Cardiology.

AIMS: To validate the modified World Health Organization (mWHO) risk classification in advanced and emerging countries, and to identify additional risk factors for cardiac events during pregnancy. METHODS AND RESULTS: The ongoing prospective worldwide Registry Of Pregnancy And Cardiac disease (ROPAC) included 2742 pregnant women (mean age ± standard deviation, 29.2 ± 5.5 years) with established cardiac disease: 1827 from advanced countries and 915 from emerging countries. In patients from advanced countries, congenital heart disease was the most prevalent diagnosis (70%) while in emerging countries valvular heart disease was more common (55%). A cardiac event occurred in 566 patients (20.6%) during pregnancy: 234 (12.8%) in advanced countries and 332 (36.3%) in emerging countries. The mWHO classification had a moderate performance to discriminate between women with and without cardiac events (c-statistic 0.711 and 95% confidence interval (CI) 0.686-0.735). However, its performance in advanced countries (0.726) was better than in emerging countries (0.633). The best performance was found in patients with acquired heart disease from developed countries (0.712). Pre-pregnancy signs of heart failure and, in advanced countries, atrial fibrillation and no previous cardiac intervention added prognostic value to the mWHO classification, with a c-statistic of 0.751 (95% CI 0.715-0.786) in advanced countries and of 0.724 (95% CI 0.691-0.758) in emerging countries. CONCLUSION: The mWHO risk classification is a useful tool for predicting cardiac events during pregnancy in women with established cardiac disease in advanced countries, but seems less effective in emerging countries. Data on pre-pregnancy cardiac condition including signs of heart failure and atrial fibrillation, may help to improve preconception counselling in advanced and emerging countries.

Arterial stiffness changes in patients with cardiovascular risk factors but normal carotid intima-media thickness.

AIMS: We aimed to evaluate, through an Echotracking system, the functional changes of carotid arteries with relation to the amount of cardiovascular risk factors in patients without structural atherosclerotic damage. METHODS: From a series of 260 asymptomatic consecutive patients we selected 75 patients (mean age: 47 ±â€Š8 years) with normal intima-media thickness (IMT) and without atherosclerotic plaques. In these patients, local arterial stiffness parameters were evaluated using a simple Echotracking system. Patients were divided in three groups: group 1 (n = 25 patients without risk factors), group 2 (n = 23 patients with one risk factor) and group 3 (n = 27 patients with two or more risk factors). RESULTS: Carotid IMT was similar in all groups (P = ns). On the contrary, stiffness parameters progressively increased according to the number of risk factors [pulse wave velocity (PWV) = 5.8 ±â€Š1.1 m/s, 6.4 ±â€Š1.2 m/s and 6.7 ±â€Š1.4 m/s in Group 1, 2 and 3, respectively, P = 0.002; ß-index = 7.5 ±â€Š3.4, 8.5 ±â€Š3.2 and 9.5 ±â€Š4.7 in Group 1, 2 and 3, respectively, P = 0.047]. Furthermore, on multivariate linear regression analysis, PWV and ß-index significantly correlated (P = 0.002 and P = 0.048, respectively) with the number of risk factors even when adjusted for age, gender and current therapy. CONCLUSION: In a population with normal carotid IMT and without plaques, changes in arterial stiffness are significantly related to the number of risk factors. This information could be relevant for a more tailored primary prevention in patients with risk factors even in absence of structural atherosclerotic abnormalities.

Outcome of pregnancy in patients with structural or ischaemic heart disease: results of a registry of the European Society of Cardiology.

AIMS: To describe the outcome of pregnancy in patients with structural or ischaemic heart disease. METHODS AND RESULTS: In 2007, the European Registry on Pregnancy and Heart disease was initiated by the European Society of Cardiology. Consecutive patients with valvular heart disease, congenital heart disease, ischaemic heart disease (IHD), or cardiomyopathy (CMP) presenting with pregnancy were enrolled. Data for the normal population were derived from the literature. Sixty hospitals in 28 countries enrolled 1321 pregnant women between 2007 and 2011. Median maternal age was 30 years (range 16-53). Most patients were in NYHA class I (72%). Congenital heart disease (66%) was most prevalent, followed by valvular heart disease 25%, CMP 7%, and IHD in 2%. Maternal death occurred in 1%, compared with 0.007% in the normal population. Highest maternal mortality was found in patients with CMP. During pregnancy, 338 patients (26%) were hospitalized, 133 for heart failure. Caesarean section was performed in 41%. Foetal mortality occurred in 1.7% and neonatal mortality in 0.6%, both higher than in the normal population. Median duration of pregnancy was 38 weeks (range 24-42) and median birth weight 3010 g (range 300-4850). In centres of developing countries, maternal and foetal mortality was higher than in centres of developed countries (3.9 vs. 0.6%, P < 0.001 and 6.5 vs. 0.9% P < 0.001) CONCLUSION: The vast majority of patients can go safely through pregnancy and delivery as long as adequate pre-pregnancy evaluation and specialized high-quality care during pregnancy and delivery are available. Pregnancy outcomes were markedly worse in patients with CMP and in developing countries.