A rare case of upper septal fascicular ventricular tachycardia presented in a case report.

CASE SUMMARY: A 71-year-old presented at the outpatient clinic with palpitations and NYHA II functional class. 12-lead ECG exhibited Upper septal idiopathic left ventricular tachycardia (US-ILVT). Ventricular tachycardia (VT) was interrupted with Verapamil administration, no further recurrences were documented after beta-blockers therapy was started. No coronary artery stenosis were detected. The US-ILVT was successfully treated by ablating the proximal site of the left anterior fascicle (LAF), where diastolic potential (P1) and pre-systolic potential (P2) with inverted sequence were detected during the electrophysiology study (EP) study. Cardiac magnetic resonance imaging (CMR) was performed with demonstration of intramyocardial late gadolinium enhancement (LGE) at the level of middle-basal portions of interventricular septum and basal portion of infero-lateral wall and no edema detection. A single catheter implantable cardioverter defibrillator (ICD) was implanted as secondary prevention. VT has never recurred during 3 months of follow-up with remote control of ICD. DISCUSSION: To the best of our knowledge, this is the first report in which US-ILVT was associated with ventricular septal LGE, suggestive of previous myocarditis, as substrate of re-entrant circuit. Scar-related ventricular tachycardia circuit is also suggested by the evidence of a premature ventricular complex (PVC) as trigger of recurrent VT in our case.

Colchicine for cardiovascular medicine: a systematic review and meta-analysis.

Aim: Colchicine, a microtubule-disassembling (antitubulin) agent used for centuries for the treatment of gout and autoimmune diseases, is a drug of growing interest in the cardiovascular field. While in the last decades it has become cornerstone of pericarditis treatment, it has also emerged in the last few years as a promising drug in the management of coronary artery disease, atrial fibrillation and heart failure. This systematic review and meta-analysis aimed to assess the efficacy of colchicine in patients with cardiovascular diseases. Methods: Systematic search in electronic databases (MEDLINE/PubMed, Scopus, BioMed Central, the Cochrane Collaboration Database of Randomized Trials, ClinicalTrials.gov, EMBASE, Google Scholar) was performed to identify randomized controlled trials (RCTs) up to February 2021. Random-effects meta-analysis was performed to assess the risk of cardiovascular events, defined according to clinical setting. Results: Among 15,569 pooled patients from 21 RCTs, colchicine was superior to placebo in the reduction of cardiovascular events. In the setting of pericardial diseases, it was associated with a lower risk of recurrent pericarditis (17 vs 34%, RR = 0.50, 95% CI: 0.42-0.60, I2 = 10%). In other studies assessing coronary artery disease patients, colchicine was associated with a reduced risk of major adverse cardiovascular events (MACE) such as myocardial infarction, stroke, cardiovascular death, coronary revascularisation and hospitalization (6.3 vs 9%, RR = 0.67, 95% CI: 0.54-0.84, I2 = 55). Among patients with atrial fibrillation, it was associated with lower rates of recurrence (20 vs 30%, RR = 0.68, 95% CI: 0.58-0.81, I2 = 0). In the single RCT on heart failure, colchicine was not associated with improved NYHA class. Conclusion: Colchicine is a valuable anti-inflammatory agent for the prevention of cardiovascular events in patients with inflammatory cardiac conditions such as pericardial diseases, coronary artery disease and atrial fibrillation.

Colchicine is an ancient drug with anti-inflammatory properties, classically used for gout and autoimmune diseases. While in the last decades it has become cornerstone for the treatment of pericarditis, in the last few years is emerging as a promising drug in the setting of coronary artery disease, heart failure and arrhythmias. Due to promising findings, almost ten trials are currently ongoing to investigate novel applications, which will be discussed throughout the paper. The aim of this systematic review and meta-analysis is to provide an overview of the latest evidence on colchicine, a microtubule-disassembling (antitubulin) agent, for the treatment and prevention of cardiovascular diseases and to discuss possible future applications.

Efficacy and safety of colchicine for the prevention of major cardiovascular and cerebrovascular events in patients with coronary artery disease: a systematic review and meta-analysis on 12 869 patients.

AIMS: The key role of inflammation in the pathogenesis of coronary artery disease (CAD) is an urgent call for innovative treatments. Several trials have proposed colchicine as a therapeutic option for secondary prevention in CAD patients but its utilization is hampered by fears about drug-related adverse events (DAEs) and conflicting evidences. The aim of this meta-analysis was to consolidate evidence on the efficacy and safety of colchicine for secondary prevention in patients with CAD. METHODS AND RESULTS: A systematic search in electronic bibliographic databases of Medline, Scopus, Embase, and the Cochrane Library was performed to identify randomized controlled trials (RCTs) assessing the cardiovascular effects of colchicine in CAD patients, compared with placebo. Outcomes of interest were the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) and DAEs. Estimates were pooled using inverse-variance random-effects model. A total of 11 RCTs, including 12 869 patients, were identified as eligible. A total of 6501 patients received colchicine, while 6368 received placebo. After a median follow-up of 6 months (interquartile range, 1-16), patients receiving colchicine had a lower risk of MACCE [6% vs. 8.8%, relative risk (RR) = 0.67, 95% confidence interval (CI) 0.56-0.80, I2 = 19%], myocardial infarction (3.3% vs. 4.3%, RR = 0.76, 95% CI 0.61-0.96, I2 = 17%), coronary revascularization (2.9% vs. 4.2%, RR = 0.61, 95% CI 0.42-0.89, I2 = 40%), stroke (0.4% vs. 0.9%, RR = 0.48, 95% CI 0.30-0.77, I2 = 0%), hospitalization for cardiovascular cause (0.9% vs. 2.9%, RR = 0.32, 95% CI 0.12-0.87, I2 = 0%). Colchicine was associated with an increased risk of gastrointestinal DAEs (11% vs. 9.2%, RR = 1.67, 95% CI 1.20-2.34, I2 = 76%), myalgia (18% vs. 16%, RR = 1.16, 95% CI 1.02-1.32, I2 = 0%) and DAEs-related discontinuation (4.1% vs. 3%, RR = 1.54, 95% CI 1.02-2.32, I2 = 65%). However, gastrointestinal DAEs and discontinuation may be prevented with a lower daily dose. Colchicine did not increase the risk of cardiovascular death (0.7% vs. 1%, RR = 0.73, 95% CI 0.45-1.21, I2 = 14%), all-cause death (2% vs. 1.9%, RR = 1.01, 95% CI 0.71-1.43, I2 = 16%), or other DAEs. CONCLUSIONS: The use of colchicine in patients with CAD is safe and efficacious for MACCE prevention.

Post cardiac injury syndromes: diagnosis and management.

Post cardiac injury syndromes (PCIS) are becoming increasingly common, due to the growing number of cardiovascular procedures (cardiac surgery, percutaneous interventions) and the high burden of cardiovascular diseases such as acute coronary syndromes. This review aims to provide an overview of the main clinical characteristics of PCIS, along with their management in clinical practice.

Pharmacologic treatment of acute and recurrent pericarditis: a systematic review and meta-analysis of controlled clinical trials.

INTRODUCTION: Recurrence is the most frequent complication following acute pericarditis and may occur in 30% patients, rising to 50% in case of multiple recurrences, lack of colchicine treatment or use of glucocorticoids. Available treatments include aspirin or non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, glucocorticoids, immunosuppressive agents, immunoglobulins, anti-interleukin-1 (IL-1) agents. EVIDENCE ACQUISITION: This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to assess the efficacy of pharmacological treatments for acute and recurrent pericarditis. Bibliographic databases were searched (PubMed, MEDLINE, Embase, Scopus, and the Cochrane Library) using the terms "acute pericarditis" or "recurrent pericarditis" and "colchicine" or "NSAIDs" or "glucocorticoids" or "immunosuppressive agents" or "immunoglobulins" or "anti-IL1 agents." Random-effects meta-analysis was used to assess the risk of recurrent pericarditis. Publication bias was assessed using the Egger test, and meta-regression was performed to assess sources of heterogeneity. EVIDENCE SYNTHESIS: Eleven RCTs assessed the efficacy of pharmacological treatments for acute and recurrent pericarditis (colchicine and anti-interleukin-1 agents). Colchicine, assessed in nine RCTs, was effective in the reduction of recurrent pericarditis, compared with standard treatment (17% vs .34%, RR=0.50; 95% CI 0.42-0.60, P<0.001), without any differences according to clinical setting (i.e. acute pericarditis, recurrent pericarditis, post-pericardiotomy syndrome; P=0.58). Anti-interleukin-1 agents (anakinra, rilonacept), assessed in two RCT, were effective in the reduction of recurrences, compared with placebo (10% vs.78%, RR=0.14; 95% CI 0.05-0.35, P<0.001). CONCLUSIONS: A correct pharmacological management of pericarditis is key to prevent recurrences. Colchicine is the mainstay of treatment in acute and recurrent pericarditis, while anti-IL1 agents are a valuable option in case of recurrent pericarditis refractory to conventional drugs.

Colchicine efficacy and safety for the treatment of cardiovascular diseases.

The emerging role of colchicine in the treatment of cardiovascular diseases is a strong demand for a comprehensive understanding of its efficacy and safety. This meta-analysis and systematic review aimed to study the efficacy in the reduction of adverse cardiovascular outcomes (CO), and the risk of colchicine-related adverse events (CRAEs). Fourteen thousand and nine eighty three patients from 22 randomized controlled trials (RCTs) were included, 9 in patients with coronary artery disease-CAD, 9 in patients with pericarditis, 4 in patients with atrial fibrillation-AF or heart failure. Colchicine was efficacious in the reduction of adverse CO across different settings: pericardial diseases (reduced risk of recurrent pericarditis, 17.6% vs. 35%, RR 0.50, 95% CI 0.41-0.61), CAD (reduced risk of cardiac death, myocardial infarction, stroke,coronary revascularization or hospitalization, 6.1% vs. 8.5%, RR 0.73, 95% CI 0.64-0.83), AF (reduced risk of arrhythmia recurrence, 14.2% vs. 22.7%, RR 0.62, 95% CI 0.44-0.88). Colchicine was associated with increased risk of gastrointestinal CRAEs (11.2% vs. 8.8%, RR 1.87, 95% CI 1.41-2.47) and drug discontinuation (5.4% vs. 3.7%, RR 1.58, 95% CI 1.25-1.99). In both cases, the risk was proportional to the daily dose or duration of treatment, possibly due to early drug discontinuation or tolerance. Other CRAEs (muscle-related, liver,hematologic,cutaneous, infections) were not increased by colchicine, as long as all-cause death (2.2% vs. 1.9%, RR 1.11, 95% CI 0.79-1.54) or non-cardiovascular death (1.5% vs. 1%, RR 1.43, 95% CI 0.93-2.19). Colchicine is efficacious and safe for the treatment of cardiovascular diseases. The risk of gastrointestinal CRAEs and drug discontinuation is not significant if colchicine is used at lower doses (0.5 mg daily) or for longer periods of time (> 6 months).

Usefulness of Beta-Blockers to Control Symptoms in Patients With Pericarditis.

Exercise restriction is a nonpharmacological treatment of pericarditis that could reduce symptoms by slowing heart rate (HR). Beta-blockers allow pharmacological control of HR. Aim of this paper is to explore the possible efficacy of beta-blockers to improve control of symptoms in patients with pericarditis. We analyzed consecutive cases with pericarditis referred to our center. Beta-blockers were prescribed on top of standard anti-inflammatory therapy in symptomatic patients (chest pain and palpitations) with rest HR>75 beats/min. The primary end point was the persistence of pericardial pain at 3 weeks. The secondary end point was the occurrence of recurrent pericarditis at 18 months. Propensity score matching was used to generate 2 cohorts of 101 patients with and without beta-blockers with balanced baseline features. A clinical and echocardiographic follow-up was performed at 3 weeks, 1, 3, 6 months and then every 12 months. A total of 347 patients (mean age 53 years, 58% females, 48% with a recurrence, 81% with idiopathic/viral etiology) were included. Among them, 128 patients (36.9%) were treated with beta-blockers. Peak C-reactive protein values were correlated with heart rate on first observation (r=0.48, p<0.001). Using propensity-score matched cohorts, patients treated with beta-blockers had a lower frequency of symptoms persistence at 3 weeks (respectively 4% vs. 14%; p = 0.024) and a trend towards a reduction of recurrences at 18 months (p = 0.069). In conclusion the use of beta-blockers on top of standard anti-inflammatory therapies was associated with improved symptom control.

Recurrent pericarditis: an update on diagnosis and management.

Recurrent pericarditis is a true challenge for clinicians, especially when the patient becomes unresponsive or not tolerant to conventional treatments. An accurate diagnosis of recurrent pericarditis, possibly supported by advanced imaging tools, is critical to provide timely and appropriate treatment of symptoms and prevention of further episodes. The incessant research on the inflammatory pathways underlying cardiovascular diseases, led recently to the assessment of anti interleukin-1 agents in the setting of recurrent pericarditis. This review will focus on the diagnostic assessment of recurrent pericarditis, along with the most modern therapeutic advances in this field. Bibliographic databases were searched (MEDLINE/PubMed, BioMed Central, the Cochrane Collaboration Database of Randomized Trials, Scopus, ClinicalTrials.gov, EMBASE, Google Scholar) using the terms "recurrent pericarditis" AND "diagnosis" OR "treatment" OR "IL-1" OR "inflammation".

Adverse events of colchicine for cardiovascular diseases: a comprehensive meta-analysis of 14 188 patients from 21 randomized controlled trials.

AIMS: Colchicine has an emerging role in the cardiovascular field, although, concerns for side effects, especially gastrointestinal, limit its prescription. We aimed at evaluating reported side effects of colchicine for cardiovascular indications. METHODS: We performed a meta-analysis of published randomized controlled trials on colchicine for the treatment of cardiovascular diseases. Random-effects meta-analysis was used to assess the risk of adverse events and drug withdrawal. Publication bias was assessed using the Egger test, and meta-regression was performed to assess sources of heterogeneity. RESULTS: Among 14 188 patients, 7136 patients received colchicine while the other 7052 received placebo. The occurrence of any adverse event with colchicine was reported in 15.3 vs. 13.9% patients [relative risk (RR) 1.26, 95% confidence interval (CI) 0.96-1.64, P = 0.09]. Gastrointestinal events were reported in 16.1 vs. 12.2% (RR 2.16, 95% CI 1.50-3.12, P < 0.001), while diarrhea was reported in 12.5 vs. 8.1% (RR 2.77, 95% CI 1.55-4.94, P < 0.001). The risk of gastrointestinal events increased with daily dose and shorter treatment duration. Myalgias were observed in 21 vs. 18% patients (RR 1.16, 95% CI 1.02-1.32, P = 0.03). Other adverse events such as myotoxicity, hepatic adverse events, hematologic adverse events, cutaneous adverse events, infection or death were not increased by colchicine treatment. Colchicine discontinuation was reported in 4.8 vs. 3.4% patients (RR 1.54, 95% CI 1.20-1.99, P < 0.001). CONCLUSION: Colchicine is associated with increased risk of gastrointestinal events and myalgias, but not of other adverse events. The risk of gastrointestinal events may be avoided with lower dose (0.5 mg/daily) and is inversely related to treatment duration, possibly due to early drug discontinuation or drug tolerance.

Update on diagnosis and management of neoplastic pericardial disease.

INTRODUCTION: Pericardial neoplasms are uncommon, mostly due to secondary involvement of the pericardium by extracardiac tumors. Clinical presentation is nonspecific, frequently leading to a delayed diagnosis. Moreover, both benign and malignant pericardial tumors may be associated with myocardial infiltration and mechanical compression of cardiac chambers, possibly precipitating clinical conditions. Pericardial tumors are indeed a diagnostic and therapeutic clinical challenge. AREAS COVERED: This review aims to provide an overview of the main clinical characteristics of pericardial tumors, along with their management in clinical practice. EXPERT COMMENTARY: Multimodality imaging (echocardiography, chest X-ray, CT, CMR, and PET) enable full characterization of pericardial neoplasms. An individualized strategy should be developed by a multidisciplinary team including cardiologists, oncologists, radiologists, and cardiac surgeons.