Acute pulmonary embolism in a patient with hepatitis C virus infection and hepatocellular carcinoma: a case report.

BACKGROUND: Cardiac metastases in hepatocellular carcinoma patients are infrequently encountered and usually associated with a very poor prognosis. CASE PRESENTATION: Hereby, we report a case of an acute pulmonary embolism (PE) on top of HCC with direct cardiac invasion to the right atrium (RA) through the inferior vena cava with another metastasis to the right ventricular apex in the form of highly mobile cauliflower mass protruding through the tricuspid valve into RA and nearly obliterating right ventricular outflow tract in a multi-centric hepatocellular carcinoma patient. CONCLUSION: Acute dyspnea in a patient with a long history of hepatitis C virus infection raises the suspicion of acute PE due to either hypercoagulable state induced by malignancy or by cardiac extension of the tumor which usually carries high mortality rates. To the best of our knowledge, this case is the first case in the literature to show cardiac metastases in HCC with two different pathological mechanisms.

Comprehensive Assessment of Heart Failure with Preserved Ejection Fraction Using Cardiac MRI.

Heart failure with preserved ejection fraction (HFpEF) burden is increasing. Its diagnostic process is challenging and imprecise due to absence of a single diagnostic marker, and the multiparametric echocardiography evaluation needed. Left ventricular (LV) ejection fraction (LVEF) is a limited marker of LV function; thus, allocating HF phenotypes based on LVEF can be misleading. HFpEF encompasses a broad spectrum of causes, and its diagnostic criteria give a central role to echocardiography, a first-line technique with inherent limitations related to ultrasound capabilities. Conversely, cardiac magnetic resonance provides superior anatomic and functional assessment, enabling tissue characterization, offering unprecedented diagnostic precision.

An indirect effect of covid-19 on the heart: A case report.

Covid-19 virus has been recognized to develop major cardiac complications. The indirect effect of the virus though, in terms of fear for hospital admissions, constitutes a greater threat. In this case we present a 69-year old male patient who suffered from a myocardial infarction that has not been given the proper attention due to the fear of in-hospital contact with covid patients. The result was the delayed revascularization and eventually the development of heart failure. This case presents the full range of covid-19 affection to the heart and raises the public awareness for not underestimating symptoms suggesting life-threatening conditions.

A real-life correlation between clinical SYNTAX score II and carotid intima-media thickness in patients with stable coronary artery disease.

BACKGROUND: SYNTAX score II (SSII) is an update of the established SYNTAX score (SS) that uses clinical variables such as age, sex, creatinine clearance, left ventricular ejection fraction, chronic obstructive pulmonary disease, and peripheral arterial disease. Furthermore, SSII has been proven to be a more powerful predictive tool than SS in patients with complex coronary artery disease (CAD). Carotid õntima-media thickness (CIMT) is a widely used noninvasive evidence for subclinical or early atherosclerosis, and it was proved to be an independent predictor for cardiovascular events. Most of the previously published articles studied the association between the CIMT with old cardiovascular scoring systems such as SSI and Gensini score with debatable data about their correlation. AIM: To study the correlation between SSII and CIMT in stable CAD patients undergoing elective coronary angiography (CA). METHOD AND PATIENTS: A prospective study including 155 patients undergoing elective CA for stable CAD excluding patients with history of acute coronary syndrome, previous coronary revascularization either by percutaneous coronary intervention or coronary artery bypass grafting, and previous cerebrovascular stroke. RESULTS: The mean age of patients was 58.25 ± 16.46 years, and 79 patients (50.96%) were men. The mean SSII score was 10.23 ± 11.36 and mean CIMT was 0.85 ± 0.24. The correlation between SSII and CIMT using Spearman correlation showed a strong correlation between SSII score and CIMT with correlation coefficient r = 0.752. CONCLUSION: The study showed a strong positive correlation between SSII and CIMT in stable CAD patients undergoing elective CA.

Association of abnormal coronary sinus reflux with coronary slow flow and importance of the Thebesian valve.

BACKGROUND: The relationship between coronary slow flow (CSF) and coronary sinus (CS) reflux has not been previously studied. This study aimed to investigate the relationship between CSF and CS reflux and Thebesian valve presence as well as the relationship between CS reflux and serum annexin-V and ICAM-1 levels. METHODS: In this case-control study, patients were divided into two groups: CSF (n = 13) and control (n = 7) groups. CS flow parameters and Thebesian valve presence were evaluated by cardiac magnetic resonance (CMR). Moreover, serum ICAM-1 and annexin-V levels were measured. RESULTS: Regurgitation volume and regurgitation fraction, indicators of reflux flow in CS, were higher in the CSF group than in the control group (p = 0.039 and p = 0.019). Fewer Thebesian valves were observed in the CSF group than in the control group (p = 0.022). Furthermore, a positive correlation was found between regurgitation volume and regurgitation fraction and serum annexin-V and ICAM-1 levels (r = 0.813, p < 0.001 and r = 0.996, p < 0.001; r = 0.817, p < 0.001 and r = 0.993, p < 0.001, respectively). CONCLUSIONS: This study revealed the significant relationship between CSF and reflux flow in CS. The fact that the patients in the CSF group have fewer Thebesian valves suggests the importance of the valve in preventing backward flow from the coronary vein. A positive correlation between serum ICAM-1 and annexin-V levels with regurgitation volume and regurgitation fraction indicates that after a certain threshold, CS reflux should be considered an abnormal condition.

Adherence to guideline-directed medical and device Therapy in outpAtients with heart failure with reduced ejection fraction: The ATA study.

OBJECTIVE: Despite recommendations from heart failure guidelines on the use of pharmacologic and device therapy in patients with heart failure with reduced ejection fraction (HFrEF), important inconsistencies in guideline adherence persist in practice. The aim of this study was to assess adherence to guideline-directed medical and device therapy for the treatment of patients with chronic HFrEF (left ventricular ejection fraction ≤40%). METHODS: The Adherence to guideline-directed medical and device Therapy in outpAtients with HFrEF (ATA) study is a prospective, multicenter, observational study conducted in 24 centers from January 2019 to June 2019. RESULTS: The study included 1462 outpatients (male: 70.1%, mean age: 67±11 years, mean LVEF: 30%±6%) with chronic HFrEF. Renin-angiotensin system (RAS) inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and ivabradin were used in 78.2%, 90.2%, 55.4%, and 12.1% of patients, respectively. The proportion of patients receiving target doses of medical treatments was 24.6% for RAS inhibitors, 9.9% for beta-blockers, and 10.5% for MRAs. Among patients who met the criteria for implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT), only 16.9% of patients received an ICD (167 of 983) and 34% (95 of 279) of patients underwent CRT (95 of 279). CONCLUSION: The ATA study shows that most HFrEF outpatients receive RAS inhibitors and beta-blockers but not MRAs or ivabradin when the medical reasons for nonuse, such as drug intolerance or contraindications, are taken into account. In addition, most eligible patients with HFrEF do not receive target doses of pharmacological treatments or guideline-recommended device therapy.

Peripheral blood mononuclear cell microRNAs in coronary artery disease.

The accuracy of risk prediction for coronary artery disease can be improved with the use of novel molecular or genetic biomarkers. In this study, we investigated the difference of five selected microRNAs (miR or miRNA) in patients with coronary artery disease (CAD) and controls, assessed by coronary angiography. The study population consisted of 85 subjects, aged between 18 and 75 years and underwent invasive coronary angiography. Subjects with more than 30% stenosis in at least one coronary artery, patients with a history of prior percutaneous coronary intervention or coronary by-pass surgery were allocated to the patient group; whereas the subjects without at least 30% stenosis consisted the control group. Groups were similar in age, presence of hypertension, and smoking status. However, the proportion of males and subjects taking angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta blockers, nitrates, and statins were higher in the patient group. miR-221 and miR-155 were downregulated (P = .02 and .001, respectively), while miR-21 levels were significantly increased (P = .003) in the patient group compared to controls. Changes in miR-145 and miR-126 did not reach statistical significance (P > .05). miRNA- 21, miR-155, and miR-221 were differentially expressed between the patients and controls. miRNAs are promising biomarkers for CAD diagnosis, however, this requires further research with larger groups.

The role of GRACE score in the prediction of high-risk coronary anatomy in patients with non-ST elevation acute coronary syndrome.

BACKGROUND: In patients with non-ST elevation acute coronary syndrome (NSTE-ACS), identification of the patients with high-risk coronary anatomy (HRCA) who are most likely to require coronary artery bypass grafting (CABG) is crucial. The SYNTAX score (SXscore) is an angiographic grading tool designed to determine the complexity of coronary artery disease. It appears that CABG offers significantly better outcomes in patients with SXscore ≥ 33, which shows severe HRCA. AIM: We sought to assess the accuracy of the GRACE score in predicting HRCA in terms of SXscore in patients with NSTE-ACS. METHODS: Patients admitted to our coronary unit with a diagnosis of NSTE-ACS and undergoing coronary angiography during hospitalisation were recruited to this study. Patients were categorised into two groups based on SXscore: HRCA (SXscore ≥ 33) and low-risk coronary anatomy (LRCA, SXscore < 33). The cut-off level of GRACE score for HRCA was established by receiver operator characteristic (ROC) analysis. RESULTS: We studied 207 consecutive patients (mean age: 59 ± 11 years, 27.5% female). The GRACE score was 139 ± 34 in the HRCA group and 114 ± 33 in the LRCA group (p = 0.001). There was a significant positive correlation between SXscore and GRACE score (r = 0.338, p < 0.001). The area under ROC curve for GRACE score was 0.71 (95% CI 0.60-0.81, p = 0.001). A GRACE score of 123 was identified as the optimal cut-off to predict HRCA with a sensitivity of 71% and a specificity of 60%. In multivariate regression analysis, GRACE score ≥ 123 was the only variable that identified HRCA (OR 2.8, 95% CI 1.18-6.6, p = 0.019).Conclusions: Our study demonstrates that, in the setting of NSTE-ACS, patients with HRCA, who are most likely to require CABG, have higher GRACE scores at presentation. However, the ability of GRACE score to predict HRCA was modest.