The number of patients with pulmonary arterial hypertension related to congenital heart disease ( PAH ‐ CHD ) seen in specialist centers continues to increase. The extreme end of the spectrum, namely Eisenmenger's syndrome, is further compromised with chronic cyanosis and multiorgan disease, In this review we present the current knowledge on definition, prevalence, pathophysiology, classification, diagnosis, and treatment of this entity that has great impact on CHD patients’ life.
AbstractAbdominal aortic aneurysm (AAA) is a frequent cause of death. Management of AAA includes different strategies: open surgery repair, endovascular repair and, for small AAA, medical therapy and careful follow‐up. Endovascular repair is a valid alternative to surgical repair, especially in patients whit high procedural risk.
Myocardial perfusion imaging with single-photon emission computed tomography (SPECT) is an important and widely used non-invasive imaging test for the diagnosis and semiquantification of myocardial ischemia. SPECT data, acquired after a stress test and at rest on a gamma camera, shows left ventricular tracer uptake during stress and at rest. The tracer distributions are proportionate to the relative, regional coronary-flow distributions, respectively. A stress-induced perfusion defect reflects myocardial ischemia, while a permanent defect, unchanged from stress to rest, indicates myocardial infarction. By ECG-gating global and regional left ventricular function can also be assessed. The three most important indications for SPECT in the setting of interventional cardiology include (1) the diagnosis of coronary artery disease in intermediate-risk patients, (2) the assessment of ischemia in patients with prior successful revascularization and recurrence of symptoms, and (3) the diagnosis of acute coronary syndrome in the emergency department. The amount of ischemia is related to the outcome of patients undergoing revascularization. It was observed that patients with an ischemic area of <10% of the left ventricle demonstrated by SPECT benefit from staying on optimal medical therapy, whereas patients with more ischemia on SPECT benefit from revascularization. Guidelines and appropriate use criteria for the indications of SPECT in relation to interventional cardiology have been published by the European Society and American College of Cardiology.
AbstractPulmonary hypertension is a fatal disease of multiple etiologies that is estimated to affect over 100 million people worldwide. The disease is defined hemodynamically as a mean pulmonary artery pressure ≥ 25 mmHg at rest. Despite important advances in our understanding of the pathobiology of this disease and improvements in patient management, outcomes are still poor and no curative treatments are currently available. The complex nature of this disease requires detailed clinical evaluation for accurate diagnosis and treatment. Recent advances in clinical recognition, classification, and understanding of the underlying pathological processes in pulmonary hypertension have led to improved diagnostic testing and therapeutic options for patients. A hallmark of pulmonary hypertension is an increased pulmonary vascular resistance which leads to progressive elevations in pulmonary artery pressure, resulting in compensatory right ventricular hypertrophy and, ultimately, heart failure. Clinically, these pulmonary vascular changes initially present as nonspecific symptoms, including unexplained dyspnea on exertion, fatigue, chest pain, and syncope. Signs of right ventricular dysfunction are also frequently present. Common pathogenic features of pulmonary hypertension include sustained pulmonary vasoconstriction, vascular remodeling of the small pulmonary arteries, in situ thrombosis, and increased vascular wall stiffness, resulting in increased pulmonary arterial pressure due to increased pulmonary vascular resistance. Despite improvements in clinical classification and understanding of the underlying pathogenic mechanisms of pulmonary hypertension, current therapies are limited to supportive care and targeting pulmonary vasoconstriction. There remains a need to identify novel therapeutic targets in this disease. This review provides a succinct overview of the clinical classification and pathophysiology of PH that can be used as a reference by physicians and physician‐scientists.
Pulmonary hypertension (PH) is a disorder with sometimes a challenging diagnosis, which can be made only by right heart catheterization. The role of echocardiography in the work-up of these patients is manifold. Its main contribution is in the assessment of the presence of PH in the setting of a clinical suspicion and thus it serves as a gatekeeper to avoid unnecessary invasive catheterizations. In this regard, estimation of pulmonary artery pressure is a central but not the only component that should be pursued, since there are many other additional echocardiographic features that can help the clinician to estimate the probability of the presence of PH more accurately and to fully assess its pathophysiological consequences. In addition, echocardiography can offer invaluable insight into right ventricular size and function, which is the cardiac chamber that is mainly affected by the disease and finally, it can provide important clues about the cause of PH and mainly help identify patients with pulmonary venous hypertension, in which treatment is entirely different from patients with precapillary hypertension. This review summarizes the echocardiographic findings commonly observed in patients with PH and focuses on important features that allow the clinician to exploit the full potential of this modality when assessing these patients.
AbstractVery late stent thrombosis (VLST) represents a rare, but potentially lethal complication, in the era of percutaneous coronary intervention. Its etiology, pathogenesis, and predictive factors have not yet been established due to its relatively low prevalence and multifactorial nature. In this review article, after presenting the current definitions on stent thrombosis, we focus on the contemporary data on VLST, for both bare‐metal stents and drug‐eluting stents. Possible pathophysiological mechanisms and predictive factors are also illustrated, with data drawn from several multicenter studies. Factors such as younger patients, smokers at the time of initial DES implantation, STEMI or the presence of thrombus at the time of initial DES implantation, overlapping stents, seem to represent independent predictors of VLST. Finally, there is a special reference on cases of VLST, studied with optical coherence tomography (OCT). OCT managed to identify the cause of VLST in over 97% of the cases in these studies, whereas some of the most common mechanisms of VLST in these patients were stent malapposition, neoatherosclerosis rupture, uncovered struts, and stent underexpansion.
Acute heart failure (AHF) is defined as the rapid development or change in symptoms and signs of heart failure that requires urgent medical attention and usually hospitalization. AHF is the first reason for hospital admission in individuals aged 65 or more. Despite therapeutic advances, it remains a syndrome with particularly ominous prognosis, with an in-hospital mortality rate of 4–7%, a 2- to 3-month postdischarge mortality of 7–11% and a 2- to 3-month readmission rate of 25–30%. In addition, AHF is the single most important determinant of the huge healthcare expenditure related to heart failure, as it accounts for nearly 70% of the total heart failure-related cost. Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/5608946/Activity.aspx
Acute heart failure (AHF) encompasses a wide range of clinical presentations, from acute hypertensive heart failure (HF) to low cardiac output hypoperfusion syndromes with cardiogenic shock at the extreme end of this side. Inotropes are pharmacologic agents that enhance cardiac contractility, thereby augmenting cardiac output. Currently, there are three classes of inotropes available in clinical practice with distinct mechanisms of action: beta‐adrenergic agonists, phosphodiesterase III inhibitors, and the calcium‐sensitizer levosimendan. Inotropes are indicated as short‐term therapy in low cardiac output AHF and cardiogenic shock (usually with coadministration of a vasoconstrictor) to increase cardiac output, restore peripheral perfusion, and prevent end‐organ dysfunction. Inotropes can cause serious cardiovascular adverse effects, most commonly tachyarrhythmias and myocardial ischemia and are associated with increased medium‐ and long‐term mortality in HF. Therefore, intense monitoring is necessary during their administration, while long‐term infusion is contraindicated with the exception of advanced HF patients in whom inotropes may be used as a bridge to a definitive therapy (transplantation or ventricular assist device implantation) or as palliative treatment. Emerging inotropes acting through novel pathways independent of those targeted by conventional agents may overcome safety limitations of currently available agents.
Evidence supporting the use of exercise echocardiography to identify the true hemodynamic consequences of valvular heart disease ( VHD ) is progressively accumulating. From a clinical standpoint, the evaluation of VHD limited to resting conditions often underestimates the full clinical impact of the lesion. Exercise echocardiography has proved to be an important clinical tool in the risk stratification and the decision making of patients with VHD . It is very useful in case of discrepancy between symptoms and severity of valve lesion. Moreover, the evaluation of dynamic components of VHD , ventricular function, and exercise capacity provides clinician additive prognostic value that can be really helpful in the management planning of these patients.
Heart failure (HF) is the common sequela of many cardiovascular diseases. Although device‐based treatments and pharmacotherapies have improved patient survival, current standard therapies are far from optimal, and do not address the molecular mechanisms underlying HF pathogenesis. In the last decade, cardiac gene therapy has emerged as an innovative experimental therapeutic strategy for the treatment of advanced HF. Increasing insights into the molecular pathophysiology and improvements in gene targeting approaches provide novel therapeutic modalities. In this review we focus on the recent developments in cardiac gene therapy strategies targeting advanced HF. We emphasize ongoing clinical trials, and discuss the limitations and future evolution of the field.
Cardiovascular magnetic resonance imaging ( CMR ) offers a broader assessment of cardiac structure and function than any other single imaging modality. In patients with known or suspected ischemic heart disease ( IHD ), a comprehensive CMR protocol provides an assessment of left ventricular function, myocardial perfusion, edema, and viability in a single sitting. There are applications for this technology in both the acute and chronic IHD settings. CMR is also a valuable tool in the assessment of patients presenting with chest pain, raised troponin levels, and unobstructed coronaries. Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/5430068/Activity.aspx
AbstractCardiogenic shock (CS) is the most severe form of acute heart failure, characterized by low cardiac output, hypotension, and systemic hypoperfusion. CS is the leading cause of death in acute coronary syndrome (ACS) that accounts for about 80% of CS cases. In addition to acute cardiac cause, the diagnostic criteria for CS include persistent hypotension (systolic blood pressure < 90 mmHg) and clinical signs of hypoperfusion. Mortality rates in CS remain as high as 35–50%. Severe left ventricular dysfunction usually triggers the shock and leads to the activation of systemic inflammatory response and hypothalamic‐pituitary‐adrenal axis. Immediately after detection of the shock, electrocardiography and echocardiography should be performed to determine the etiology of CS and to rule out mechanical complications. Urgent revascularization by percutaneous coronary intervention, or less often by coronary artery bypass graft, is the most important treatment in CS caused by ACS. In the case of mechanical complication, immediate surgical treatment is essential. Regardless of the etiology, the basic treatment strategy includes fluid challenge that aims at obtaining euvolemia and relieving tissue hypoperfusion. Inotropes and vasopressors are often needed to improve cardiac performance and to maintain sufficient blood pressure. Ventilation is often supported mechanically and CS patients are best treated in intensive cardiac care unit. Continuous invasive blood pressure monitoring, electrocardiography, and repeated echocardiography are required. In CS refractory to other treatments, mechanical circulatory support may be considered to maintain adequate perfusion pressure and to prevent multiorgan failure.Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/5608947/Activity.aspx
Cardiomyopathies are a heterogeneous group of diseases recognized by specific patterns of myocardial morphology and function. Myocardial deformation imaging, using strain and strain rate as main parameters, is a novel echocardiographic method for the evaluation of global and regional myocardial function. Speckle tracking imaging is currently the best technique for the evaluation of myocardial deformation in the longitudinal, radial, and circumferential axis. The aim of the following review was to analyze the potential role of the deformation imaging in the evaluation of cardiomyopathies, focusing on the recent developments regarding the differential and early diagnosis as well as the prognosis of the disease.
Volume 4 of Continuing Cardiology Education focuses on the treatment of patients with coronary artery disease, CAD. All European cardiologists need to have a thorough knowledge of the issues that are discussed, since despite advances in our understanding of the prevention of CAD, patients suffering from its consequences increasingly seek help from cardiologists across all European countries and across all the subspecialty areas of cardiology. The authors of the articles are all practising clinicians working in an area with a particularly high prevalence of coronary artery disease, the North East of England. The regional cardiothoracic centre at The James Cook University Hospital in Middlesbrough serves a population of around 1.5 million people across Teesside, County Durham, North Yorkshire and Cumbria. The authors have drawn on their day to day experience of treating patients alongside the published literature to provide, for both the trainee in cardiology and the established specialist, a review and update of the essential knowledge needed to understand contemporary clinical practice. Where appropriate, the authors have referred to existing ESC guidelines. It must be remembered that not all the guideline recommendations can be based on firm evidence from randomized control trials or high quality observational research and there are unfortunately still a large number of recommendations based on only “expert opinion”. Where possible, we must work harder to reduce these sources of uncertainty with more research. It is also critical for us to be aware that when applying guidelines to individual cases, we need to know the strengths and weaknesses of the underlying evidence so that that guideline recommendations can be appropriately applied to a plan of care for an individual patient and not just follow a “one size fits all” approach. For trainees in cardiology, the knowledge required across this area of cardiology is set out in the ESC Core Curriculum for General Cardiology (see particularly chapters 2.8 and 2.9) and how the acquisition and application of this knowledge fits into overall training is set out in the Training Requirements for the Specialty of Cardiology from the UEMS 1, 2.Readers will be able to confirm their understanding of the material and gain EBAC CME credits by completion of the series of formative MCQs that have been prepared in conjunction with each of the articles. These MCQs have been modeled on the style of question used in the European Examination of General Cardiology, that is, there is a clinical stem, a single question followed by five possible answers with the need to select the single best answer. Further details about the EEGC are available at the UEMS-Cardiac Section website 3. Completion of the formative MCQs can be used as evidence of successful knowledge acquisition, for example, for ongoing specialist revalidation or for the European Diploma of General Cardiology 4. Coronary artery disease, CAD, is a common contributor to or bystander of cardiac arrhythmias. Dr Ruairidh Martin and Dr Matt Bates have provided a practical guide to the management of atrial fibrillation, AF, in patients with concomitant CAD, including an update on the rapidly evolving area of appropriate antithrombotic therapy in the context of AF and CAD. Dr Dewi Thomas and Dr Andrew Thornley have looked at the basic mechanisms underlying ventricular arrhythmia in the different presentations of CAD and given us and some practical guidance for treatments. Coronary artery disease can present to the practicing cardiologist in the stable phase or as an acute coronary syndrome. Dr Thandar Aye and Dr Richard Graham outline their approach to the assessment of prognosis in the patient with stable disease. They have provided insights into the evidence relating to the pros and cons of the commonly available imaging modalities used every day in our clinics. Dr Alex Brown and Dr David Austin have looked at the question of which antiplatelet therapy to use in CAD patients presenting with an acute coronary syndrome. This is a relatively evidence-rich area of clinical practice but nevertheless still throws up practical questions for day to day practice. In order to make balanced judgments of the best advice for individual patients, we need a thorough understanding of the strengths and weaknesses of the evidence base. Their comprehensive review of this important topic contains messages that we can take away and apply to our patients. Heart failure is an increasing problem with an increasingly aged population and CAD is a common cause. Dr Pamela Brown and Dr Jeet Thambyrajah have provided an evidence-based approach to the management of patients with both acute and chronic heart failure. Cardiology is a rapidly developing area for the established clinician and the developments have often been driven by quantum leaps in technology. Cardiac magnetic resonance imaging is underpinned by complex theories of subatomic physics and has the potential to redefine our traditional approaches to investigation and monitoring of cardiovascular disease. Dr Alexandra Thompson and Dr Neil Maredia have provided an up-to-date guide to what they call the “comprehensive IHD assessment” with a basic outline of their approach using the techniques of LV cine stacks, edema imaging, stress myocardial perfusion, rest myocardial perfusion, early and late Gadolinium enhancement. How and when to use these techniques and how to interpret the results will be a key part of the knowledge and skills of all practising cardiologists, not just cardiac imaging subspecialists. Another new development driven by improved technology in material science is transarterial aortic valve implantation, TAVI, where the engineering of the implant devices has permitted safe and effective percutaneous delivery. Dr Muzaffar Mahmood and Dr Douglas Muir have reviewed the vexing issue of how best to manage concomitant CAD when a patient undergoes TAVI. This is currently the best example of highly individualized decision-making based upon clinical judgment rather than an extensive evidence base and the most convincing need for a well-functioning local multidisciplinary team. Also venturing into the world of materials science is the consideration of stent design by Dr Mohammed Awan and Dr Paul Williams—what stents to use and when and why, and how to more critically appraise potential pitfalls in stent design. We hope that trainees and specialists find these reviews and updates valuable. We hope that the formative MCQs will be used to confirm the assimilation of the information presented. We have attempted in this issue to emphasize the importance to all cardiologists of knowledge across the spectrum of “sub-specialty areas”. In our experience, it is usually the case that patients do not confine their needs to a single area of cardiology and so the knowledge, skills, and behaviors needed for success in general cardiology will remain a basic requirement for all cardiologists well into the 21st century. Educational activities such as CCE will hopefully prosper and be widely available to help trainees and all practising cardiologists maintain their grounding in general cardiology. Dr Hall and Dr Wright have nothing to disclose.
Coronary artery disease ( CAD ) and aortic stenosis ( AS ) frequently coexist. The advent of transcatheter aortic valve implantation ( TAVI ) and its increased use over the last decade has brought a paradigm shift in the management of patients with severe AS who are considered inoperable or high risk for sAVR . The most appropriate management of coexistent CAD in patients undergoing TAVI is yet to be defined. In this article, we present a review of the issues arising in the management of CAD in patients with severe AS —with particular reference to those who are undergoing TAVI . Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/5222680/Activity.aspx
AbstractPercutaneous coronary intervention (PCI) with stent deployment is the dominant form of myocardial revascularization, with millions of procedures performed worldwide each year. Stent design has evolved substantially over time and there are now a wide range of options available to the interventional cardiologist. This review will cover the development of intracoronary stents and the patient and vessel factors which are important in stent selection.Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/5430072/Activity.aspx
AbstractAcute heart failure (AHF) represents a potentially fatal disease that needs immediate hospital care. In‐hospital management can be divided into three consecutive phases: an early phase of intensive management of symptoms, an intermediate phase of stabilization and transition from intravenous to oral medication, and a late phase of discharge and outpatient management. However, despite its life‐threatening features (increased mortality and readmission rates), many treatment decisions are opinion based and only few are evidence based. The present paper describes in‐hospital treating modalities and attempts to provide clinical and laboratory criteria for patient evaluation that will help doctors determine readiness and safety of discharge. In addition, it highlights some unresolved issues that need to be addressed by future research.Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/5608938/Activity.aspx
Cardiac injury and loss of functional cardiomyocytes result in cardiac pump failure, the leading cause of morbidity and mortality in the world. Endogenous regeneration of the injured heart holds great promise but is very limited in the human heart. Various strategies have been developed to boost replacement of the lost cardiomyocytes including stem cells and cellular reprogramming. In this review we will discuss the progress in cardiac regeneration field, the advantages and disadvantages of each cell type and how a combinatorial approach with regards to current drug treatment could enhance cardiac regeneration.
Liver involvement in chronic heart failure has long been recognized and reflects the systemic hemodynamic changes that occur during the evolution of heart failure syndrome. Apart from venous congestion and backward failure, other fundamental mechanisms also exist such as decreased hepatic blood flow, decreased arterial saturation, and sinusoidal thrombosis. In the acute setting, the decrease in cardiac output, accompanied by severe and profound hypotension is the main cause of acute liver injury, whereas increased venous pressure also plays an important role. The biochemical dominance of a cholestatic profile is rather related to congestion and increased systemic venous pressures, whereas the hepatotoxic profile is rather related to hypoperfusion. Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/5608949/Activity.aspx
Regular exercise training induces several cardiac physiological adaptations commonly referred as “athlete's heart.” These changes can overlap pathological findings present in several cardiac diseases, mainly cardiomyopathies, associated with sudden cardiac death. The differentiation between physiological and pathological findings is often challenging and clinical decision making in such cases can be difficult: missing a condition associated with an increased risk of life‐threatening events has significant clinical impact, whereas the disqualification of a healthy athlete from competition can lead to severe psychological and socioeconomic burden. Echocardiography assumes a central role to evaluate cardiac remodeling in athletes. This paper provides an up‐to‐date and practical review of the role of echocardiography in differentiation non‐ischemic cardiomyopathies from “athlete's heart.”
