Pub Date : 2022-05-25DOI: 10.1136/heartjnl-2022-321087
A. Barton, M. Dweck
Aortic stenosis (AS) is characterised both by progressive valve narrowing and the remodelling response of the left ventricle (LV) that occurs secondary to an increased afterload. The latter is of particular importance when considering the development of patient symptoms, adverse clinical events and the need for aortic valve replacement (AVR). The hypertrophic response of the left ventricle is protective for many years, even decades, yet with time it decompensates and patients transition to heart failure. Current wisdom is that valve replacement should be performed in patients with severe stenosis just as that decompensation is starting to occur. Most commonly we use symptom development as our barometer of developing myocardial ill health, however there is increasing interest in more objective markers of LV dysfunction with which to optimise the timing of AVR. These include imaging markers of myocardial fibrosis and early systolic dysfunction as well as serum biomarkers such as highsensitivity troponin and Nterminalprobeta natriuretic peptide (NTproBNP)). 6 It is on this background that Dr Tan and colleagues report a multibiomarker study in 173 patients (55% male, age 69±11 years) with moderatetosevere AS, preserved LV function and New York Heart Association (NYHA) class III symptoms. A range of widely used (highsensitivity troponin T, NTproBNP) and novel (growth differentiation factor, suppression of tumorigenicity2, midregional proadrenomedullin (MRproADM), and MRproatrial natriuretic peptide) biomarkers were obtained from each participant, who were then followed up for a median of 2.7 years. The primary outcome was a composite of allcause mortality, progression to NYHA class IIIIV, and heart failure hospitalisation with the secondary outcome also incorporating syncope and acute coronary syndromes. Impressively, all but one participant had followup data available until either (1) aortic valve replacement was performed, (2) the first outcome of interest was reached, or (3) the date of final followup in those without events. Fiftynine participants fulfilled criteria for the primary outcome (34%) and 66 the secondary outcome (38%). Thirtyfour patients died (20%) with causes being cardiovascular (n=18), respiratory (n=4), sepsis (n=1) and unknown (n=15). There were additionally 28 (16%) heart failure hospitalisations, 10 (6%) syncopal events, 22 (13%) episodes of the acute coronary syndrome and 37 (21%) episodes of symtom progression to NYHA class IIIIV. Across all outcomes, MRproADM emerged as the biomarker with the best prognostic potential, being associated with HRs of 11 and 13 for the primary and secondary outcomes, respectively. The authors also looked at combining multiple biomarkers. Although the strongest dualbiomarker combination was NTproBNP combined with MRproADM, MRproADM remained stronger alone than in any combination. Receiver operating characteristic curve analysis suggested a cutoff level of 0.645 nmol/L was optimal for prediction o
{"title":"Mid-regional pro-adrenomedullin: a new tool in prognosticating asymptomatic severe aortic stenosis?","authors":"A. Barton, M. Dweck","doi":"10.1136/heartjnl-2022-321087","DOIUrl":"https://doi.org/10.1136/heartjnl-2022-321087","url":null,"abstract":"Aortic stenosis (AS) is characterised both by progressive valve narrowing and the remodelling response of the left ventricle (LV) that occurs secondary to an increased afterload. The latter is of particular importance when considering the development of patient symptoms, adverse clinical events and the need for aortic valve replacement (AVR). The hypertrophic response of the left ventricle is protective for many years, even decades, yet with time it decompensates and patients transition to heart failure. Current wisdom is that valve replacement should be performed in patients with severe stenosis just as that decompensation is starting to occur. Most commonly we use symptom development as our barometer of developing myocardial ill health, however there is increasing interest in more objective markers of LV dysfunction with which to optimise the timing of AVR. These include imaging markers of myocardial fibrosis and early systolic dysfunction as well as serum biomarkers such as highsensitivity troponin and Nterminalprobeta natriuretic peptide (NTproBNP)). 6 It is on this background that Dr Tan and colleagues report a multibiomarker study in 173 patients (55% male, age 69±11 years) with moderatetosevere AS, preserved LV function and New York Heart Association (NYHA) class III symptoms. A range of widely used (highsensitivity troponin T, NTproBNP) and novel (growth differentiation factor, suppression of tumorigenicity2, midregional proadrenomedullin (MRproADM), and MRproatrial natriuretic peptide) biomarkers were obtained from each participant, who were then followed up for a median of 2.7 years. The primary outcome was a composite of allcause mortality, progression to NYHA class IIIIV, and heart failure hospitalisation with the secondary outcome also incorporating syncope and acute coronary syndromes. Impressively, all but one participant had followup data available until either (1) aortic valve replacement was performed, (2) the first outcome of interest was reached, or (3) the date of final followup in those without events. Fiftynine participants fulfilled criteria for the primary outcome (34%) and 66 the secondary outcome (38%). Thirtyfour patients died (20%) with causes being cardiovascular (n=18), respiratory (n=4), sepsis (n=1) and unknown (n=15). There were additionally 28 (16%) heart failure hospitalisations, 10 (6%) syncopal events, 22 (13%) episodes of the acute coronary syndrome and 37 (21%) episodes of symtom progression to NYHA class IIIIV. Across all outcomes, MRproADM emerged as the biomarker with the best prognostic potential, being associated with HRs of 11 and 13 for the primary and secondary outcomes, respectively. The authors also looked at combining multiple biomarkers. Although the strongest dualbiomarker combination was NTproBNP combined with MRproADM, MRproADM remained stronger alone than in any combination. Receiver operating characteristic curve analysis suggested a cutoff level of 0.645 nmol/L was optimal for prediction o","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":"1255 - 1256"},"PeriodicalIF":0.0,"publicationDate":"2022-05-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45445268","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-05-25DOI: 10.1136/heartjnl-2022-320799
T. Treibel, A. Kelion, Tom E Ingram, R. Archbold, S. Myerson, L. Menezes, G. Morgan-Hughes, R. Schofield, N. Keenan, S. Clarke, Alan Keys, Bruce Keogh, N. Masani, S. Ray, M. Westwood, K. Pearce, C. Colebourn, R. Bull, J. Greenwood, G. Roditi, G. Lloyd
Heart and circulatory diseases affect more than seven million people in the UK. Non-invasive cardiac imaging is a critical element of contemporary cardiology practice. Progressive improvements in technology over the last 20 years have increased diagnostic accuracy in all modalities and led to the incorporation of non-invasive imaging into many standard cardiac clinical care pathways. Cardiac imaging tests are requested by a variety of healthcare practitioners and performed in a range of settings from the most advanced hospitals to local health centres. Imaging is used to detect the presence and consequences of cardiovascular disease, as well as to monitor the response to therapies. The previous UK national imaging strategy statement which brought together all of the non-invasive imaging modalities was published in 2010. The purpose of this document is to collate contemporary standards developed by the modality-specific professional organisations which make up the British Cardiovascular Society Imaging Council, bringing together common and essential recommendations. The development process has been inclusive and iterative. Imaging societies (representing both cardiology and radiology) reviewed and agreed on the initial structure. The final document therefore represents a position, which has been generated inclusively, presents rigorous standards, is applicable to clinical practice and deliverable. This document will be of value to a variety of healthcare professionals including imaging departments, the National Health Service or other organisations, regulatory bodies, commissioners and other purchasers of services, and service users, i.e., patients, and their relatives.
{"title":"United Kingdom standards for non-invasive cardiac imaging: recommendations from the Imaging Council of the British Cardiovascular Society","authors":"T. Treibel, A. Kelion, Tom E Ingram, R. Archbold, S. Myerson, L. Menezes, G. Morgan-Hughes, R. Schofield, N. Keenan, S. Clarke, Alan Keys, Bruce Keogh, N. Masani, S. Ray, M. Westwood, K. Pearce, C. Colebourn, R. Bull, J. Greenwood, G. Roditi, G. Lloyd","doi":"10.1136/heartjnl-2022-320799","DOIUrl":"https://doi.org/10.1136/heartjnl-2022-320799","url":null,"abstract":"Heart and circulatory diseases affect more than seven million people in the UK. Non-invasive cardiac imaging is a critical element of contemporary cardiology practice. Progressive improvements in technology over the last 20 years have increased diagnostic accuracy in all modalities and led to the incorporation of non-invasive imaging into many standard cardiac clinical care pathways. Cardiac imaging tests are requested by a variety of healthcare practitioners and performed in a range of settings from the most advanced hospitals to local health centres. Imaging is used to detect the presence and consequences of cardiovascular disease, as well as to monitor the response to therapies. The previous UK national imaging strategy statement which brought together all of the non-invasive imaging modalities was published in 2010. The purpose of this document is to collate contemporary standards developed by the modality-specific professional organisations which make up the British Cardiovascular Society Imaging Council, bringing together common and essential recommendations. The development process has been inclusive and iterative. Imaging societies (representing both cardiology and radiology) reviewed and agreed on the initial structure. The final document therefore represents a position, which has been generated inclusively, presents rigorous standards, is applicable to clinical practice and deliverable. This document will be of value to a variety of healthcare professionals including imaging departments, the National Health Service or other organisations, regulatory bodies, commissioners and other purchasers of services, and service users, i.e., patients, and their relatives.","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":"e7 - e7"},"PeriodicalIF":0.0,"publicationDate":"2022-05-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42190423","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-05-25DOI: 10.1136/heartjnl-2021-320716
Ana-Catarina Pinho-Gomes, Sanne Ae Peters, Nata Nambatingué, Cheryl Carcel, Mark Woodward, Amy Vassallo
{"title":"Did the 'Digital Experience' improve women's representation at the European Society of Cardiology congress?","authors":"Ana-Catarina Pinho-Gomes, Sanne Ae Peters, Nata Nambatingué, Cheryl Carcel, Mark Woodward, Amy Vassallo","doi":"10.1136/heartjnl-2021-320716","DOIUrl":"10.1136/heartjnl-2021-320716","url":null,"abstract":"","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":"982-985"},"PeriodicalIF":0.0,"publicationDate":"2022-05-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9132847/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48633980","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-05-24DOI: 10.1136/heartjnl-2022-321262
A. Chang, Arooj R. Khan, Kan Liu
To the Editor We have read the article by Silverio et al regarding betablockers reducing allcause mortality in patients with Takotsubo syndrome (TTS). The beneficial effect of betablockers particularly applies to TTS patients with hypertension or cardiogenic shock. While this exciting finding validates an important risk reduction strategy in TTS survivors at longterm followup, Silverio et al’s results also bring up a seemingly paradoxical therapeutic dilemma in TTS patients with cardiogenic shock. Dynamic left ventricular outflow tract (LVOT) obstruction and worsening mitral regurgitation (MR) play important roles in TTSassociated cardiogenic shock. 3 Preceding myocardial structural abnormalities (hypertensive heart disease and basal septal hypertrophy, etc) may exacerbate LVOT obstruction on top of hyperdynamic motion of basal ventricular walls. There is a growing body of evidence that preexisting myocardial pathologies not only increase adverse haemodynamic events during TTS episodes but also are associated with persistent postTTS diastolic dysfunction and adverse outcomes. 4 5 This signifies the presence of certain specific conditions in some patients with TTS that warrants particular therapeutic strategies for longterm management and secondary prevention. A recent subset analysis of the DOREMI trial showed an outcome improvement in patients with cardiogenic shock who presented with betablockers on admission. Silverio et al’s results further highlight the possible prognostic benefits of early betablockade in TTS patients with cardiogenic shock. Betablockers are traditionally contraindicated in cardiogenic shock. Paradoxically, patients with TTS expected to benefit the most from early β-blockade are not expected to ‘tolerate’ this medication due to concern for worsening haemodynamic instability. In realworld practice, this may also result in an extended medication gap from the immediate hospitalisation period until outpatient followup visits, potentially depriving patients with TTS of the prognostic benefit from appropriate pharmacotherapy in the critical therapeutic window. Uncovering the unique pathophysiology underlying TTS may help solidify timely and effective therapeutic strategies. Brain natriuretic peptide (BNP) release in patients with TTS is usually more prominent than that in patients with acute myocardial infarction. Other than being a prognostic parameter, BNP release also causes natriuresis, vasodilatation and inhibition of the reninaldosterone system, which decreases mean arterial pressure and pulmonary capillary wedge pressure. Natriuresis, when combined with diuresis, may cause patients with TTS to become preload sensitive, precipitating hypotension and reflex tachycardia, resulting in ‘cardiogenic’ shock. In addition, a significant ventricular dilation during TTS episode easily leads to an assumption of pump failure and volume overload. Strict volume restriction or overdiuresis can cause inappropriately low ventricular preload
{"title":"Correspondence on 'Beta-blockers are associated with better long-term survival in patients with Takotsubo syndrome’ by Silverio et al","authors":"A. Chang, Arooj R. Khan, Kan Liu","doi":"10.1136/heartjnl-2022-321262","DOIUrl":"https://doi.org/10.1136/heartjnl-2022-321262","url":null,"abstract":"To the Editor We have read the article by Silverio et al regarding betablockers reducing allcause mortality in patients with Takotsubo syndrome (TTS). The beneficial effect of betablockers particularly applies to TTS patients with hypertension or cardiogenic shock. While this exciting finding validates an important risk reduction strategy in TTS survivors at longterm followup, Silverio et al’s results also bring up a seemingly paradoxical therapeutic dilemma in TTS patients with cardiogenic shock. Dynamic left ventricular outflow tract (LVOT) obstruction and worsening mitral regurgitation (MR) play important roles in TTSassociated cardiogenic shock. 3 Preceding myocardial structural abnormalities (hypertensive heart disease and basal septal hypertrophy, etc) may exacerbate LVOT obstruction on top of hyperdynamic motion of basal ventricular walls. There is a growing body of evidence that preexisting myocardial pathologies not only increase adverse haemodynamic events during TTS episodes but also are associated with persistent postTTS diastolic dysfunction and adverse outcomes. 4 5 This signifies the presence of certain specific conditions in some patients with TTS that warrants particular therapeutic strategies for longterm management and secondary prevention. A recent subset analysis of the DOREMI trial showed an outcome improvement in patients with cardiogenic shock who presented with betablockers on admission. Silverio et al’s results further highlight the possible prognostic benefits of early betablockade in TTS patients with cardiogenic shock. Betablockers are traditionally contraindicated in cardiogenic shock. Paradoxically, patients with TTS expected to benefit the most from early β-blockade are not expected to ‘tolerate’ this medication due to concern for worsening haemodynamic instability. In realworld practice, this may also result in an extended medication gap from the immediate hospitalisation period until outpatient followup visits, potentially depriving patients with TTS of the prognostic benefit from appropriate pharmacotherapy in the critical therapeutic window. Uncovering the unique pathophysiology underlying TTS may help solidify timely and effective therapeutic strategies. Brain natriuretic peptide (BNP) release in patients with TTS is usually more prominent than that in patients with acute myocardial infarction. Other than being a prognostic parameter, BNP release also causes natriuresis, vasodilatation and inhibition of the reninaldosterone system, which decreases mean arterial pressure and pulmonary capillary wedge pressure. Natriuresis, when combined with diuresis, may cause patients with TTS to become preload sensitive, precipitating hypotension and reflex tachycardia, resulting in ‘cardiogenic’ shock. In addition, a significant ventricular dilation during TTS episode easily leads to an assumption of pump failure and volume overload. Strict volume restriction or overdiuresis can cause inappropriately low ventricular preload","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":"1243 - 1244"},"PeriodicalIF":0.0,"publicationDate":"2022-05-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44185443","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-05-24DOI: 10.1136/heartjnl-2022-321263
A. Silverio, M. Bellino, G. Galasso, E. Bossone, R. Citro
The Authors’ reply We appreciate the interest of Dr Chang and Dr Liu in our study. Cardiogenic shock (CS) complicates the inhospital course of patients with takotsubo syndrome (TTS) in 6%–20% of cases and is the main cause of inhospital mortality. Treatment of CS in TTS is a clinical challenge and, due to the complexity of investigating this subject in dedicated randomised controlled trials, current evidence is limited to case reports or retrospective observational studies. The use of catecholamines in TTS complicated by CS is still debated since the administration of exogenous catecholamines might reexacerbate the acute phase and increase the risk of inhospital adverse events. In this scenario, previous case series have suggested the use of the Ca sensitiser levosimendan as a safe and feasible nonadrenergic alternative to common inotropic agents in TTS. Owing to the key role of catecholamine overstimulation in TTS pathophysiology, the use of betablockers has been proposed to mitigate the sympathetic drive and the effects of further catecholamine surges during the acute phase. In a monkey model of epinephrineinduced TTS, metoprolol improved left ventricular dysfunction, diminished the catecholamineinduced cardiomyocytolysis and modified the expression of heart failurerelated genes. However, in a recent propensity score matching analysis including 2110 Japanese patients with TTS, the early use of betablockers (started on hospitalisation day 1 or 2) did not influence patient 30day mortality. One interpretation of these conflicting results may be that the expected benefit of betablockers during the acute phase depends on the correct identification of the patient most likely to benefit. In TTS scenario, the early identification of patients at high risk of developing CS or with initial signs of haemodynamic instability constitutes the first step of an individualised patienttailored therapy. In a study from the INTERTAK Registry including 2078 patients with TTS, 198 (9.5%) developed CS. Some parameters easily detectable on admission including apical TTS, physical stress, lower left ventricular ejection fraction, diabetes mellitus and atrial fibrillation were associated with the risk of CS, hence emphasising their early detection for the identification of patients more prone to develop CS. We concur with Dr Chang and Dr Liu that betablockers should be considered in all patients after clinical stabilisation and before discharge, even in those who did not tolerate their early use. This certainly includes patients who developed CS during the acute phase, who have a significantly higher risk of developing adverse events compared with those without CS over the long term. 7 In our study, the prescription of betablockers at discharge was associated with a lower risk of mortality at longterm followup, particularly in patients with TTS who developed CS during the hospitalisation. This finding suggests that these patients may constitute a particular TTS phenotype
{"title":"Response to: Correspondence on ‘Beta-blockers are associated with better long-term survival in patients with Takotsubo syndrome’ by Chang et al","authors":"A. Silverio, M. Bellino, G. Galasso, E. Bossone, R. Citro","doi":"10.1136/heartjnl-2022-321263","DOIUrl":"https://doi.org/10.1136/heartjnl-2022-321263","url":null,"abstract":"The Authors’ reply We appreciate the interest of Dr Chang and Dr Liu in our study. Cardiogenic shock (CS) complicates the inhospital course of patients with takotsubo syndrome (TTS) in 6%–20% of cases and is the main cause of inhospital mortality. Treatment of CS in TTS is a clinical challenge and, due to the complexity of investigating this subject in dedicated randomised controlled trials, current evidence is limited to case reports or retrospective observational studies. The use of catecholamines in TTS complicated by CS is still debated since the administration of exogenous catecholamines might reexacerbate the acute phase and increase the risk of inhospital adverse events. In this scenario, previous case series have suggested the use of the Ca sensitiser levosimendan as a safe and feasible nonadrenergic alternative to common inotropic agents in TTS. Owing to the key role of catecholamine overstimulation in TTS pathophysiology, the use of betablockers has been proposed to mitigate the sympathetic drive and the effects of further catecholamine surges during the acute phase. In a monkey model of epinephrineinduced TTS, metoprolol improved left ventricular dysfunction, diminished the catecholamineinduced cardiomyocytolysis and modified the expression of heart failurerelated genes. However, in a recent propensity score matching analysis including 2110 Japanese patients with TTS, the early use of betablockers (started on hospitalisation day 1 or 2) did not influence patient 30day mortality. One interpretation of these conflicting results may be that the expected benefit of betablockers during the acute phase depends on the correct identification of the patient most likely to benefit. In TTS scenario, the early identification of patients at high risk of developing CS or with initial signs of haemodynamic instability constitutes the first step of an individualised patienttailored therapy. In a study from the INTERTAK Registry including 2078 patients with TTS, 198 (9.5%) developed CS. Some parameters easily detectable on admission including apical TTS, physical stress, lower left ventricular ejection fraction, diabetes mellitus and atrial fibrillation were associated with the risk of CS, hence emphasising their early detection for the identification of patients more prone to develop CS. We concur with Dr Chang and Dr Liu that betablockers should be considered in all patients after clinical stabilisation and before discharge, even in those who did not tolerate their early use. This certainly includes patients who developed CS during the acute phase, who have a significantly higher risk of developing adverse events compared with those without CS over the long term. 7 In our study, the prescription of betablockers at discharge was associated with a lower risk of mortality at longterm followup, particularly in patients with TTS who developed CS during the hospitalisation. This finding suggests that these patients may constitute a particular TTS phenotype","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":"1244 - 1245"},"PeriodicalIF":0.0,"publicationDate":"2022-05-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43713689","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-05-24DOI: 10.1136/heartjnl-2022-321223
Matthew C Langston, Chad. J. Zack, E. Fender
Sterile vegetations of the cardiac valves were first identified in 1888 by Zeigler, with case reports described eponymously in 1924 by Libman and Sacks. 2 These and subsequent early accounts identified an association between noninfectious endocarditis and a variety of diseases, specifically malignancy and rheumatological conditions such as systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (AAS). Autopsy cases predominated the early literature; however, after the advent of echocardiography, many case series relied on noninvasive diagnosis (table 1). 4 These studies found a strong association with cancers, with a higher prevalence and greater mortality in patients with metastatic disease. Up to 31 per cent of cases are in fact culturenegative endocarditis rather than nonbacterial thrombotic endocarditis (NBTE). Therefore, a diagnosis of NBTE requires obtaining extended blood cultures to ensure infection is fully excluded. Currently, the diagnosis remains challenging as there are no pathognomonic echocardiographic or clinical features, and because the disease is associated with a variety of concomitant disorders. In Heart, QuinteroMartinez and colleagues provide an update on the epidemiology and conditions associated with NBTE. This singlecentre retrospective analysis included 48 patients defined by specialist consensus as having NBTE following an extensive echocardiographic and microbiological investigation. The study population was predominantly female (75%) with a median age of 60 years. Transoesophageal echocardiography (TOE) was the preferred initial imaging technique and was completed in 91.7% of the study population, with 54.2% of patients also undergoing transthoracic echocardiographic (TTE) imaging. Associated clinical conditions including connective tissue diseases (37.5%) and malignancies (52.1%) were defined. The authors observed many patients had echocardiographic evidence of a vegetation (85.4%) and/or valve thickening (89.6%) resulting in moderate to severe regurgitation in 54.2%. The mitral valve was most frequently affected (mitral vegetation in 54.2% and thickening in 70.8%), followed by the aortic valve (aortic vegetation in 41.7% and thickening in 56.3%). Twenty seven per cent of patients had evidence of multivalvular involvement. Based on their observation that TOE had superior diagnostic sensitivity when compared with TTE, the authors propose a diagnostic pathway which emphasises the role of TOE. The authors found that 79% of subjects suffered an embolic event (ischaemic stroke, peripheral ischaemic event, transient ischaemic attack or any combination thereof). This is in line with, if not increased, from similar postmortem reports. Anticoagulation was initiated in 91.7% of the study population, most commonly with low molecular weight heparin (45.8%) or warfarin (39.6%). Overall mortality was 33% at 1 year, which is unsurprising considering the strong association of NBTE with malignancy, particularly lun
{"title":"Non-bacterial thrombotic endocarditis: manifestations and diagnosis in the age of echocardiography","authors":"Matthew C Langston, Chad. J. Zack, E. Fender","doi":"10.1136/heartjnl-2022-321223","DOIUrl":"https://doi.org/10.1136/heartjnl-2022-321223","url":null,"abstract":"Sterile vegetations of the cardiac valves were first identified in 1888 by Zeigler, with case reports described eponymously in 1924 by Libman and Sacks. 2 These and subsequent early accounts identified an association between noninfectious endocarditis and a variety of diseases, specifically malignancy and rheumatological conditions such as systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (AAS). Autopsy cases predominated the early literature; however, after the advent of echocardiography, many case series relied on noninvasive diagnosis (table 1). 4 These studies found a strong association with cancers, with a higher prevalence and greater mortality in patients with metastatic disease. Up to 31 per cent of cases are in fact culturenegative endocarditis rather than nonbacterial thrombotic endocarditis (NBTE). Therefore, a diagnosis of NBTE requires obtaining extended blood cultures to ensure infection is fully excluded. Currently, the diagnosis remains challenging as there are no pathognomonic echocardiographic or clinical features, and because the disease is associated with a variety of concomitant disorders. In Heart, QuinteroMartinez and colleagues provide an update on the epidemiology and conditions associated with NBTE. This singlecentre retrospective analysis included 48 patients defined by specialist consensus as having NBTE following an extensive echocardiographic and microbiological investigation. The study population was predominantly female (75%) with a median age of 60 years. Transoesophageal echocardiography (TOE) was the preferred initial imaging technique and was completed in 91.7% of the study population, with 54.2% of patients also undergoing transthoracic echocardiographic (TTE) imaging. Associated clinical conditions including connective tissue diseases (37.5%) and malignancies (52.1%) were defined. The authors observed many patients had echocardiographic evidence of a vegetation (85.4%) and/or valve thickening (89.6%) resulting in moderate to severe regurgitation in 54.2%. The mitral valve was most frequently affected (mitral vegetation in 54.2% and thickening in 70.8%), followed by the aortic valve (aortic vegetation in 41.7% and thickening in 56.3%). Twenty seven per cent of patients had evidence of multivalvular involvement. Based on their observation that TOE had superior diagnostic sensitivity when compared with TTE, the authors propose a diagnostic pathway which emphasises the role of TOE. The authors found that 79% of subjects suffered an embolic event (ischaemic stroke, peripheral ischaemic event, transient ischaemic attack or any combination thereof). This is in line with, if not increased, from similar postmortem reports. Anticoagulation was initiated in 91.7% of the study population, most commonly with low molecular weight heparin (45.8%) or warfarin (39.6%). Overall mortality was 33% at 1 year, which is unsurprising considering the strong association of NBTE with malignancy, particularly lun","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":"1590 - 1591"},"PeriodicalIF":0.0,"publicationDate":"2022-05-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44476671","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-05-23DOI: 10.1136/heartjnl-2021-320686
J. Devgun, Tharwat Nasser, James Lee
16 Elze MC, Gregson J, Baber U, et al. Comparison of propensity score methods and covariate adjustment: evaluation in 4 cardiovascular studies. J Am Coll Cardiol 2017;69:345–57. 17 Cases in the UK | coronavirus in the UK. Available: https://coronavirus.data.gov.uk/ details/cases [Accessed 30 Jun 2021]. 18 Dofferhoff ASM, Piscaer I, Schurgers LJ. Reduced vitamin K status as a potentially modifiable risk factor of severe coronavirus disease 2019. Clin Infect Dis 2020. 19 NICE. Atrial fibrillation: management | guidance | NICE, 2014. Available: https://www. nice.org.uk/guidance/cg180 [Accessed 22 Jun 2021]. 20 NHS Digital. QOF 201920 | NHS digital. Available: https://qof.digital.nhs.uk/ [Accessed 30 Jun 2021]. 21 Curtis HJ, MacKenna B, Walker AJ. OpenSAFELY: impact of national guidance on switching from warfarin to direct oral anticoagulants (DOACs) in early phase of COVID19 pandemic in England. medRxiv 2020:2020.12.03.20243535. 22 NHS England. Specialty guides for patient management during the coronavirus pandemic Clinical guide for the management of anticoagulant services during the coronavirus pandemic, 2020. Available: https://www.england.nhs.uk/coronavirus/ publication/specialty-guides/%0Ahttps://www.england.nhs.uk/coronavirus/wpcontent/uploads/sites/52/2020/03/C0077-Specialty-guide_Anticoagulant-servicesand-coronavirus-v1-31-March.pdf [Accessed 30 Jun 2021]. 23 Dalgaard F, Mulder H, Wojdyla DM, et al. Patients with atrial fibrillation taking nonsteroidal antiinflammatory drugs and oral anticoagulants in the ARISTOTLE trial. Circulation 2020;141:10–20. 24 Søgaard KK, HorváthPuhó E, Grønbaek H, et al. Risk of venous thromboembolism in patients with liver disease: a nationwide populationbased casecontrol study. Am J Gastroenterol 2009;104:96–101. 25 Qamar A, Vaduganathan M, Greenberger NJ, et al. Oral anticoagulation in patients with liver disease. J Am Coll Cardiol 2018;71:2162–75. 26 Lee SR, Lee HJ, Choi EK, et al. Direct oral anticoagulants in patients with atrial fibrillation and liver disease. J Am Coll Cardiol 2019;73:3295–308. 27 Donzé J, Clair C, Hug B, et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med 2012;125:773–8. 28 Williamson EJ, Walker AJ, Bhaskaran K, et al. Factors associated with COVID19related death using OpenSAFELY. Nature 2020;584:430–6. 29 Marmot M, Bell R. Fair society, healthy lives. Public Health 2012;126 Suppl 1:S4. 30 Fauvel C, Weizman O, Trimaille A, et al. Pulmonary embolism in COVID19 patients: a French multicentre cohort study. Eur Heart J 2020;41:3058–68.
{"title":"Pulmonary vein Doppler flow in a patient with fatigue and dyspnoea","authors":"J. Devgun, Tharwat Nasser, James Lee","doi":"10.1136/heartjnl-2021-320686","DOIUrl":"https://doi.org/10.1136/heartjnl-2021-320686","url":null,"abstract":"16 Elze MC, Gregson J, Baber U, et al. Comparison of propensity score methods and covariate adjustment: evaluation in 4 cardiovascular studies. J Am Coll Cardiol 2017;69:345–57. 17 Cases in the UK | coronavirus in the UK. Available: https://coronavirus.data.gov.uk/ details/cases [Accessed 30 Jun 2021]. 18 Dofferhoff ASM, Piscaer I, Schurgers LJ. Reduced vitamin K status as a potentially modifiable risk factor of severe coronavirus disease 2019. Clin Infect Dis 2020. 19 NICE. Atrial fibrillation: management | guidance | NICE, 2014. Available: https://www. nice.org.uk/guidance/cg180 [Accessed 22 Jun 2021]. 20 NHS Digital. QOF 201920 | NHS digital. Available: https://qof.digital.nhs.uk/ [Accessed 30 Jun 2021]. 21 Curtis HJ, MacKenna B, Walker AJ. OpenSAFELY: impact of national guidance on switching from warfarin to direct oral anticoagulants (DOACs) in early phase of COVID19 pandemic in England. medRxiv 2020:2020.12.03.20243535. 22 NHS England. Specialty guides for patient management during the coronavirus pandemic Clinical guide for the management of anticoagulant services during the coronavirus pandemic, 2020. Available: https://www.england.nhs.uk/coronavirus/ publication/specialty-guides/%0Ahttps://www.england.nhs.uk/coronavirus/wpcontent/uploads/sites/52/2020/03/C0077-Specialty-guide_Anticoagulant-servicesand-coronavirus-v1-31-March.pdf [Accessed 30 Jun 2021]. 23 Dalgaard F, Mulder H, Wojdyla DM, et al. Patients with atrial fibrillation taking nonsteroidal antiinflammatory drugs and oral anticoagulants in the ARISTOTLE trial. Circulation 2020;141:10–20. 24 Søgaard KK, HorváthPuhó E, Grønbaek H, et al. Risk of venous thromboembolism in patients with liver disease: a nationwide populationbased casecontrol study. Am J Gastroenterol 2009;104:96–101. 25 Qamar A, Vaduganathan M, Greenberger NJ, et al. Oral anticoagulation in patients with liver disease. J Am Coll Cardiol 2018;71:2162–75. 26 Lee SR, Lee HJ, Choi EK, et al. Direct oral anticoagulants in patients with atrial fibrillation and liver disease. J Am Coll Cardiol 2019;73:3295–308. 27 Donzé J, Clair C, Hug B, et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med 2012;125:773–8. 28 Williamson EJ, Walker AJ, Bhaskaran K, et al. Factors associated with COVID19related death using OpenSAFELY. Nature 2020;584:430–6. 29 Marmot M, Bell R. Fair society, healthy lives. Public Health 2012;126 Suppl 1:S4. 30 Fauvel C, Weizman O, Trimaille A, et al. Pulmonary embolism in COVID19 patients: a French multicentre cohort study. Eur Heart J 2020;41:3058–68.","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":"931 - 988"},"PeriodicalIF":0.0,"publicationDate":"2022-05-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41731229","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-05-23DOI: 10.1136/heartjnl-2022-321278
R. Citro, A. Silverio, M. Bellino, G. Parodi, E. Bossone
To the Editor I enjoyed reading the article by Silverio et al, pertaining to the longterm (median followup of 24.0 months) effects of β-blocker therapy in patients with takotsubo syndrome (TTS). The authors employed a consecutive patient database of 825, studied over a 12year period, mostly female in their early 60s to late 70s from the Takotsubo Italian Network (TIN) registry, about 60% of whom were discharged on β-blockers, while the balance of patients did not receive such therapy, focusing on allcause mortality, TTS recurrence, and cardiac and noncardiac mortality as outcomes. While β-blockers did not influence TTS recurrence or cardiac mortality, they led to a reduction of allcause mortality, particularly for patients with hypertension and those who developed cardiogenic shock during the acute phase of TTS. The results reinforce the current belief that β-blockers do not have a specific effect in patients who have suffered TTS, in terms of prevention of its recurrence; also, it is not surprising that there was a beneficial effect of β-blockers in patients with hypertension and cardiogenic shock, considering the established indications for β-blocker therapy for patients with history of hypertension, coronary artery disease and heart failure. Considering the interest among Italian and other investigators on the effect of ACE inhibitors/ angiotensin receptor blockers, alone or in combination with β-blockers, on mortality and the recurrence of TTS, I would like to ask the authors if they have any information on the above for the patients in the TIN registry, and whether they recommend the use of ACE inhibitors/angiotensin receptor blockers, with or without β-blockers, for patients discharged after an index admission with TTS, as done by others. Also, since the TIN registry constitutes a multicentre (16 Italian hospitals) study of consecutive patients with TTS prospectively collected, fairly representative of the Italian population, it would be of interest to compare the observed prevalence of diabetes mellitus (DM) (11.9%) noted in the TIN registry with the prevalence of DM in the general Italian population, particularly in women in their early 60s to late 70s, considering previous work showing a low prevalence of DM in patients with TTS.
{"title":"Response to: Correspondence on ‘Beta-blockers are associated with better long-term survival in patients with Takotsubo syndrome’ by John E Madias","authors":"R. Citro, A. Silverio, M. Bellino, G. Parodi, E. Bossone","doi":"10.1136/heartjnl-2022-321278","DOIUrl":"https://doi.org/10.1136/heartjnl-2022-321278","url":null,"abstract":"To the Editor I enjoyed reading the article by Silverio et al, pertaining to the longterm (median followup of 24.0 months) effects of β-blocker therapy in patients with takotsubo syndrome (TTS). The authors employed a consecutive patient database of 825, studied over a 12year period, mostly female in their early 60s to late 70s from the Takotsubo Italian Network (TIN) registry, about 60% of whom were discharged on β-blockers, while the balance of patients did not receive such therapy, focusing on allcause mortality, TTS recurrence, and cardiac and noncardiac mortality as outcomes. While β-blockers did not influence TTS recurrence or cardiac mortality, they led to a reduction of allcause mortality, particularly for patients with hypertension and those who developed cardiogenic shock during the acute phase of TTS. The results reinforce the current belief that β-blockers do not have a specific effect in patients who have suffered TTS, in terms of prevention of its recurrence; also, it is not surprising that there was a beneficial effect of β-blockers in patients with hypertension and cardiogenic shock, considering the established indications for β-blocker therapy for patients with history of hypertension, coronary artery disease and heart failure. Considering the interest among Italian and other investigators on the effect of ACE inhibitors/ angiotensin receptor blockers, alone or in combination with β-blockers, on mortality and the recurrence of TTS, I would like to ask the authors if they have any information on the above for the patients in the TIN registry, and whether they recommend the use of ACE inhibitors/angiotensin receptor blockers, with or without β-blockers, for patients discharged after an index admission with TTS, as done by others. Also, since the TIN registry constitutes a multicentre (16 Italian hospitals) study of consecutive patients with TTS prospectively collected, fairly representative of the Italian population, it would be of interest to compare the observed prevalence of diabetes mellitus (DM) (11.9%) noted in the TIN registry with the prevalence of DM in the general Italian population, particularly in women in their early 60s to late 70s, considering previous work showing a low prevalence of DM in patients with TTS.","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":"1242 - 1243"},"PeriodicalIF":0.0,"publicationDate":"2022-05-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44164136","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-05-23DOI: 10.1136/heartjnl-2022-321203
J. Madias
To the Editor I enjoyed reading the article by Silverio et al, pertaining to the longterm (median followup of 24.0 months) effects of β-blocker therapy in patients with takotsubo syndrome (TTS). The authors employed a consecutive patient database of 825, studied over a 12year period, mostly female in their early 60s to late 70s from the Takotsubo Italian Network (TIN) registry, about 60% of whom were discharged on β-blockers, while the balance of patients did not receive such therapy, focusing on allcause mortality, TTS recurrence, and cardiac and noncardiac mortality as outcomes. While β-blockers did not influence TTS recurrence or cardiac mortality, they led to a reduction of allcause mortality, particularly for patients with hypertension and those who developed cardiogenic shock during the acute phase of TTS. The results reinforce the current belief that β-blockers do not have a specific effect in patients who have suffered TTS, in terms of prevention of its recurrence; also, it is not surprising that there was a beneficial effect of β-blockers in patients with hypertension and cardiogenic shock, considering the established indications for β-blocker therapy for patients with history of hypertension, coronary artery disease and heart failure. Considering the interest among Italian and other investigators on the effect of ACE inhibitors/ angiotensin receptor blockers, alone or in combination with β-blockers, on mortality and the recurrence of TTS, I would like to ask the authors if they have any information on the above for the patients in the TIN registry, and whether they recommend the use of ACE inhibitors/angiotensin receptor blockers, with or without β-blockers, for patients discharged after an index admission with TTS, as done by others. Also, since the TIN registry constitutes a multicentre (16 Italian hospitals) study of consecutive patients with TTS prospectively collected, fairly representative of the Italian population, it would be of interest to compare the observed prevalence of diabetes mellitus (DM) (11.9%) noted in the TIN registry with the prevalence of DM in the general Italian population, particularly in women in their early 60s to late 70s, considering previous work showing a low prevalence of DM in patients with TTS.
{"title":"Correspondence on ‘Beta-blockers are associated with better long-term survival in patients with Takotsubo syndrome’ by Silverio et al","authors":"J. Madias","doi":"10.1136/heartjnl-2022-321203","DOIUrl":"https://doi.org/10.1136/heartjnl-2022-321203","url":null,"abstract":"To the Editor I enjoyed reading the article by Silverio et al, pertaining to the longterm (median followup of 24.0 months) effects of β-blocker therapy in patients with takotsubo syndrome (TTS). The authors employed a consecutive patient database of 825, studied over a 12year period, mostly female in their early 60s to late 70s from the Takotsubo Italian Network (TIN) registry, about 60% of whom were discharged on β-blockers, while the balance of patients did not receive such therapy, focusing on allcause mortality, TTS recurrence, and cardiac and noncardiac mortality as outcomes. While β-blockers did not influence TTS recurrence or cardiac mortality, they led to a reduction of allcause mortality, particularly for patients with hypertension and those who developed cardiogenic shock during the acute phase of TTS. The results reinforce the current belief that β-blockers do not have a specific effect in patients who have suffered TTS, in terms of prevention of its recurrence; also, it is not surprising that there was a beneficial effect of β-blockers in patients with hypertension and cardiogenic shock, considering the established indications for β-blocker therapy for patients with history of hypertension, coronary artery disease and heart failure. Considering the interest among Italian and other investigators on the effect of ACE inhibitors/ angiotensin receptor blockers, alone or in combination with β-blockers, on mortality and the recurrence of TTS, I would like to ask the authors if they have any information on the above for the patients in the TIN registry, and whether they recommend the use of ACE inhibitors/angiotensin receptor blockers, with or without β-blockers, for patients discharged after an index admission with TTS, as done by others. Also, since the TIN registry constitutes a multicentre (16 Italian hospitals) study of consecutive patients with TTS prospectively collected, fairly representative of the Italian population, it would be of interest to compare the observed prevalence of diabetes mellitus (DM) (11.9%) noted in the TIN registry with the prevalence of DM in the general Italian population, particularly in women in their early 60s to late 70s, considering previous work showing a low prevalence of DM in patients with TTS.","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":"1242 - 1242"},"PeriodicalIF":0.0,"publicationDate":"2022-05-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47517497","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-05-23DOI: 10.1136/heartjnl-2022-320823
A. Zaidi
{"title":"Response to: Correspondence on “Tetralogy of Fallot: management of residual hemodynamic and electrophysiological abnormalities” by Yalta et al","authors":"A. Zaidi","doi":"10.1136/heartjnl-2022-320823","DOIUrl":"https://doi.org/10.1136/heartjnl-2022-320823","url":null,"abstract":"","PeriodicalId":9311,"journal":{"name":"British Heart Journal","volume":"108 1","pages":"1157 - 1158"},"PeriodicalIF":0.0,"publicationDate":"2022-05-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46522147","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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