Cardiovascular-kidney-metabolic (CKM) syndrome is a complex clinical entity that encompasses health conditions whose prevalence has markedly increased in recent years, such as atherosclerotic cardiovascular disease, diabetes mellitus, and obesity, which are closely interconnected through shared pathophysiological mechanisms. The need to recognize CKM syndrome arises from its substantial burden on public health, as it is associated with increased morbidity and mortality, particularly in the advanced stages of the disease.Its multifactorial pathophysiology and heterogeneous clinical presentation necessitate a multidisciplinary and holistic approach, including comprehensive diagnostic evaluation and coordinated therapeutic management. involving multiple medical specialties.This expert consensus document, developed under the auspices of the Hellenic Society of Cardiology, represents the first official, national initiative to highlight CKM syndrome as a clinical entity. Its aim is to raise awareness among cardiologists as well as other involved medical specialties, promoting early recognition, appropriate diagnostic approach, and effective therapeutic management of the syndrome.
OBJECTIVE:This study investigates the association of statin therapy and prognosis in heart failure with mildly reduced ejection fraction (HFmrEF). While statins are routinely prescribed in patients with cardiovascular disease, their prognostic impact in HFmrEF remains unclear. METHODS:Consecutive HFmrEF patients hospitalized at the University Medical Centre Mannheim between 2016 and 2022 were retrospectively included. Endpoints were assessed based on the prescription of statin therapy at discharge in all patients with an indication for statin treatment, as well as stratified by ischemic vs. non-ischemic cardiomyopathy and in the setting of primary vs. secondary prevention. The primary endpoint was all-cause mortality at 30 months (median follow-up), key secondary endpoint was HF-related rehospitalization. RESULTS:Among 1885 HFmrEF patients with an indication for statin treatment, 74% were discharged on a statin (atorvastatin: 64%). Statin use was associated with lower 30-month all-cause mortality (24.3% vs. 41.6%; log-rank p = 0.001), even after multivariable adjustment (adjusted hazard ratio (aHR) = 0.704; 95% confidence interval (CI) 0.563-0.879; p = 0.002) and propensity score matching. Subgroup analyses showed significantly lower long-term mortality with statin use in ischemic cardiomyopathy (aHR = 0.596; 95% CI 0.438-0.811; p = 0.001) and in primary (aHR = 0.279; 95% CI 0.131-0.593; p = 0.001) or secondary prevention settings (aHR = 0.752; 95% CI 0.583-0.969; p = 0.027), but not in non-ischemic cardiomyopathy (aHR = 0.908; 95% CI 0.576-1.430; p = 0.676). There was no association with the risk of HF-related rehospitalization (13.2% vs. 15.5%; log-rank p = 0.202). CONCLUSION:Statin therapy was associated with a significantly decreased risk of long-term all-cause mortality in patients with HFmrEF.
AIMS:Long-standing type 2 diabetes mellitus (DM) increases the risk of chronic coronary syndrome (CCS). We estimated the prevalence of undiagnosed CCS during routine outpatient care and described diagnostic testing strategies. METHODS:This multicenter observational study was conducted in eight diabetes and cardiology outpatient clinics in Greece. Adults with DM ≥10 years and suspected ischemia [angina equivalents and/or ischemic electrocardiographic (ECG) abnormalities] without known CCS underwent joint diabetologist-cardiologist evaluation and appropriate non-invasive and/or invasive testing at physician discretion. RESULTS:Overall, 110 people with type 2 DM (mean age 65.4 years; 47.3% women; mean DM duration 21.3 years) were evaluated. CCS was diagnosed in 15 individuals (13.6%). No patient with CCS reported typical or atypical angina; presentations were mainly angina equivalents, most commonly fatigue (66.7%) and dyspnea (58.3%). Ischemic ECG abnormalities were present in 6/15 (40.0%), including repolarization or conduction changes. Initial tests varied: exercise ECG (33.6%), SPECT/PET (32.7%), and stress echocardiography (28.2%). CONCLUSIONS:This study highlights the diagnostic complexity of detecting CCS in individuals with type 2 DM, particularly due to the prevalence of non-classical symptoms. The findings underscore the importance of a personalized diagnostic approach and multidisciplinary collaboration between diabetologists and cardiologists, to improve cardiovascular risk stratification.
Cardiovascular disease is the leading cause of death in Greece, despite substantial reductions in age-standardized mortality over recent decades. These improvements have been largely confined to older populations, while the burden of cardiometabolic risk remains high. The Greek cardiovascular landscape has also evolved under the combined influence of population aging, the COVID-19 pandemic, persistent socioeconomic pressures, and increasingly stringent European Society of Cardiology targets for lipid and blood pressure control. Traditional determinants, particularly dyslipidemia, hypertension, diabetes, obesity, unhealthy dietary patterns, smoking, and physical inactivity, remain prevalent and frequently suboptimally controlled. Against this background, residual risk and emerging determinants of disease are increasingly recognized as clinically relevant contributors to cardiovascular burden. This narrative review summarizes recent evidence on the role of non-traditional risk factors in the Greek population, including lipoprotein(a), inflammation, metabolic dysfunction-associated steatotic liver disease, chronic kidney disease, chronic obstructive pulmonary disease, sleep disturbances, infections and vaccination, environmental exposures, mental health, and social determinants of health. Overall, the available evidence supports a broader cardiovascular prevention framework that extends beyond conventional risk-factor assessment. Integrating selected non-traditional determinants into clinical practice and prevention policy may improve risk stratification, support individualized care, and help address the evolving cardiovascular burden in Greece.
The principle of complete vessel restoration in percutaneous coronary intervention (PCI) has highlighted the significance of drug-coated balloons (DCBs) as a crucial alternative to permanent metallic stents, which are associated with potential risks such as neoatherosclerosis and delayed stent thrombosis. Although paclitaxel-coated balloons (PCBs) are widely accepted as the preferred option for managing in-stent restenosis (ISR) due to their lipophilic and cytotoxic characteristics, sirolimus-coated balloons (SCBs) have emerged as a potentially less risky alternative, using a cytostatic mode of action. This review synthesizes clinical evidence from 10 randomized controlled trials (RCTs) and 7 meta-analyses published between 2020 and 2025. The analysis focuses on comparative safety and efficacy across major indications: in-stent restenosis (ISR), de novo small vessel disease (SVD), and bifurcation lesions. In-Stent Restenosis (ISR): Multiple trials (such as Scheller et al., 2022, BIO ASCEND ISR) demonstrated the non-inferiority of limus-based platforms compared to PCBs. For instance, late lumen loss (LLL) was nearly identical between groups (0.25 mm for the PCB group vs. 0.26 mm for the SCB group). However, the REFORM trial failed to show non-inferiority for a biolimus-coated balloon, highlighting that outcomes often reflect device-specific effects rather than a class effect. De Novo Small Vessel Disease: Outcomes in this category were more heterogeneous. In the TRANSFORM I trial, the MagicTouch SCB failed to meet non-inferiority for net lumen gain compared to the SeQuent Please Neo PCB. Conversely, other studies observed comparable LLL between the two platforms. Safety Profile: Across most indications, Major Adverse Cardiovascular Events (MACE) and Target Lesion Failure (TL F) rates were comparable between paclitaxel and sirolimus platforms at 12-month follow-up. PCBs demonstrated a higher frequency of "late lumen enlargement" compared to SCBs. Both paclitaxel and sirolimus-based DCBs are effective for treating in-stent restenosis. However, in de novo lesions, PCBs currently maintain a more consistent evidence base. Clinical performance appears heavily dependent on device-specific factors, such as coating technology and excipient formulation, rather than a general class effect. Extended follow-up data of 3-5 years are still required to fully evaluate long-term safety and the risk of very late thrombosis.
OBJECTIVE:Current European guidelines for primary atherosclerotic cardiovascular disease (ASCVD) prevention recommend using Systematic COronary Risk Evaluation 2 (SCORE2) algorithms for risk classification and decision-making. For the Greek population, an updated model, HellenicSCORE II+, has been developed. This cross-sectional study compared SCORE2 with HellenicSCORE II+ in detecting preclinical carotid atherosclerosis. METHODS:Middle-aged (40-69 years) individuals from the general population without ASCVD were invited to participate voluntarily in screening programs in 3 municipalities of Attica, Greece (2023-2025). Handheld carotid ultrasonography was performed and carotid plaque score (CPS) was calculated by summing points allocated to the number/height of plaques. RESULTS:A total of 965 individuals were analyzed [mean age 57.1 ± 8.0 (SD) years, men 43.2%, body mass index 27.6 ± 4.7 kg/m2, smokers 27.8%, diabetes 7%, antihypertensive/lipid-lowering drug treatment 41.6%/46.5%, respectively, SCORE2 5.2 ± 3.4%, HellenicSCORE II+ 3.7 ± 2.4%]. Participants classified as low-moderate/high/very-high ASCVD risk were 50.9%/43.3%/5.8% according to SCORE2, 74.4%/23%/2.6% with HellenicSCORE II+ and 55.6%/36.4%/8% with CPS. The agreement between SCORE2 and HellenicSCORE II+ was 67.2% (kappa 0.37, P < 0.01), whereas agreement between CPS and SCORE2/HellenicSCORE II+ was 57.6%/56.2% (kappa 0.24/0.13, P < 0.01 for each, P < 0.01 for comparison). Receiver operating characteristic curve analysis demonstrated similar discrimination of SCORE2/HellenicSCORE II+ for detecting carotid atherosclerosis (AUC, 0.74; 95% confidence interval, 0.71-0.78, and AUC, 0.71; 95% confidence interval, 0.68-0.74, respectively; P = NS for comparison). CONCLUSION:SCORE2 classified a higher proportion of participants as high/very-high ASCVD risk compared with HellenicSCORE II+. Both models demonstrated moderate discrimination for detecting carotid plaque burden, highlighting the need for carotid imaging to refine ASCVD risk.
OBJECTIVE:Cardiac intensive care units (CICUs) have evolved to manage increasingly complex cardiovascular illnesses, yet national-level data on infrastructure, staffing, and advanced support in Greece are limited. The aim of this nationwide survey was to map CICUs in Greece. METHODS:The survey questionnaire was distributed to hospitals in the national health system across the country. RESULTS:Of 81 hospitals, 74% reported the presence of a general intensive care unit, 25% an intermediate care unit, and 70% had a dedicated CICU. Among 57 CICUs, 53% operated with 6-10 beds; hospital bed number and tertiary hospital type were independent predictors of CICU bed number. Nursing coverage in most CICUs was at least 1 nurse per 3 patients (1:3) during the morning shift (72%), with declining percentages of the 1:3 ratio during the afternoon (47%) and night (44%) shifts. A nurse-to-patient ratio of less than 1:4 was frequent during the afternoon (32%) and night (37%) shifts, even in CICUs in tertiary centers. Staffing with a cardiologist-intensivist was observed in only 21% of all CICUs (24% in tertiary centers). Respiratory support (non-invasive/invasive: 95%/89%) was widely available. Availability of continuous renal replacement therapy (odds ratio [OR]:3.9; p = 0.019), Swan-Ganz use (OR:11.2; p = 0.010), intra-aortic balloon pump (OR:14.2; p < 0.001) and tracheotomy (OR:3.6; p = 0.043) was more frequent in CICUs in tertiary centers. CONCLUSION:The survey identified potential actionable items for improvement, including an increase in nurse-to-patient ratios and cardiovascular intensivists in CICUs in Greek public hospitals. Aligning the operation/staffing of CICUs with international standards could be considered to advance acute/critical cardiac care at a national level.
BACKGROUND:This systematic review and meta-analysis aimed to determine the prevalence and clinical relevance of main coronary artery (CA) origin and course anomalies (class A variations) in healthy populations. METHODS:This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 and Evidence-based Anatomy guidelines. A literature search was conducted across PubMed, Google Scholar, Scopus, and Web of Science. Statistical analysis was performed in R using random-effects models, with pooled prevalence calculated through the Freeman-Tukey transformation. Subgroup, meta-regression, and leave-one-out analyses were performed to explain the source of heterogeneity. RESULTS:A total of 58 studies with 503,171 subjects were included. The pooled prevalence of typical CA anatomy was 97.89% (95% CI: 97.51-98.25), whereas main CA anomalies had a prevalence of 2.11% (95% CI: 1.82-2.70). Subgroup analysis retrieved statistically significant differences for nationality and study type, and meta-regression revealed an increasing trend of CA variants with later publication years. The most common variation was the anomalous origin of the right CA from the left sinus (0.30%), followed by a high take-off of the right CA (0.14%). Left CA anomalies were less frequent, with anomalous origin from the right sinus recorded in 0.05% of cases. Subgroup analyses revealed a higher prevalence in American populations and computed tomography-based studies. CONCLUSIONS:Main CA anomalies (class A variations) are rare but clinically significant owing to their association with ischemic events and sudden cardiac death, particularly variants with interarterial or intramural courses. Early identification through modern imaging is critical for risk stratification and clinical decision-making.
Naxos disease and related cardiocutaneous syndromes are rare inherited desmosomal disorders in which characteristic cutaneous features, most notably, woolly hair and palmoplantar keratoderma, precede myocardial involvement, providing a unique opportunity for early cardiac detection. Mostly caused by pathogenic variants in JUP and DSP, these conditions progress to arrhythmogenic cardiomyopathy with heterogeneous right, left, or biventricular phenotypes and a recognized contribution of myocardial inflammation. Accurate phenotypic definition, early identification of cardiac involvement, and longitudinal risk stratificationtherefore depend on an integrated, multimodality imaging strategy. This review presents a clinically oriented, stepwise imaging pathway for patients and families with Naxos disease and related cardiocutaneous syndromes, developed within the framework of the NAXCARE clinical outcome registry. Transthoracic echocardiography serves as the first-line modality for baseline evaluation and family screening, particularly in heterozygous carriers, but has limited sensitivity for early, left-dominant, or inflammatory disease. Cardiovascular magnetic resonance is central to comprehensive biventricular assessment and tissue characterization, enabling detection of high-risk late gadolinium enhancement patterns and myocarditis-like inflammatory "hot phases." Cardiac computed tomography and 18F-fluorodeoxyglucose positron emission tomography provide complementary, problem-solving information in selected clinical scenarios.
OBJECTIVE:Fluoroscopy-guided transseptal puncture (TSP) remains essential for left atrial access; however, it carries rare but serious risks, including cardiac tamponade. We report outcomes from one of the largest single-center registries assessing a modified needle-free technique for TSP. METHODS:A total of 4100 procedures requiring TSP were analyzed. RESULTS:Subjects with patent foramen ovale (PFO) (n = 322, 7.8%) were excluded from the analysis. The modified needle-free rotational probing of the fossa ovalis with the assembly technique was applied in 1335 patients under fluoroscopic guidance. Successful left atrial catheterization was achieved in 960 patients (72%), while conventional needle puncture was required in the remaining 375 (28%) patients. There were no major complications, including pericardial effusion, related to the non-puncture technique. The traditional needle approach was attempted in total in 2818 patients. Successful left atrial catheterization was achieved in 2813 patients (99.8%). Pericardial effusion without cardiac tamponade developed in four out of 2818 patients (0.14%) who underwent the traditional approach. In 12 out of 4100 patients (0.29%), a false impression of PFO led to interatrial septum dissection. No pericardial effusion was noted in these cases. Transient ST-segment elevation during TSP was observed in four cases (0.1%). CONCLUSION:This large-scale registry derived from a high-volume center suggests that the modified needle-free technique may represent a safe alternative to conventional TSP and could serve as a useful adjunct or an intermediate step in the TSP learning curve.
OBJECTIVE:Transthyretin cardiac amyloidosis (ATTR) is prevalent among patients undergoing transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS). We aimed to develop and validate a risk score for predicting ATTR in this context. METHODS:In the prospective multicenter GRECA-TAVI registry, 500 patients with severe AS scheduled for TAVI were screened for ATTR using technetium-99m-labeled 3,3-diphosphono-1,2-propanodicarboxylic acid or pyrophosphate bone scintigraphy in 12 tertiary hospitals, from January 1 to December 31, 2024. Clinical, echocardiographic, and electrocardiographic variables were recorded. A logistic regression-derived integer-based risk score was developed in a training cohort (n = 350) and validated in a validation cohort (n = 150). Model performance was evaluated using discrimination, calibration, and decision curve analyses. RESULTS:ATTR was diagnosed in 38 (7.6%) patients. Five variables (age, sex, MWT, left ventricular ejection fraction, and intracardiac device presence) formed the basis of an 8-point risk score. The score demonstrated good discrimination (AUC = 0.75 training, 0.76 validation) and calibration (slope = 1.15). A score ≥4 identified patients with an ∼16% ATTR prevalence compared with 2.4% in those with a score <4. This threshold captured most of the ATTR cases (73%) while recommending screening for only 36% of the cohort. The decision curve analysis showed net clinical benefit across clinically relevant thresholds (5-20%) over and above a guideline-recommended approach (based on MWT ≥12 mm) or a screen-all strategy. CONCLUSION:ATTR is common in patients with severe AS undergoing TAVI. A simple bedside score using routinely available variables effectively identifies those patients at risk for ATTR. Selective screening using this tool could improve diagnostic yield and resource allocation.
