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Physical activity (PA) has been demonstrated to have a powerful role in reducing cardiovascular risk and is therefore universally recommended by international guidelines. Although there is a dose-dependent risk reduction with increasing levels of PA, there is some concern that extreme levels of PA can result in adverse cardiovascular outcomes. It is important to adapt PA advice to each individual, and in particular to note that there are conditions that are not compatible with competitive sport because of increased cardiovascular risk. Exercise also has an key role in the assessment of patients presenting with symptoms that could potentially result from cardiovascular disease, both as a measure of the impact of the disease and as a diagnostic tool.

Global circumferential strain (GCS) and global radial strain (GRS) are reduced with cytotoxic chemotherapy. There are limited data on the effect of immune checkpoint inhibitor (ICI) myocarditis on GCS and GRS.This study aimed to detail the role of GCS and GRS in ICI myocarditis.In this retrospective study, GCS and GRS from 75 cases of patients with ICI myocarditis and 50 ICI-treated patients without myocarditis (controls) were compared. Pre-ICI GCS and GRS were available for 12 cases and 50 controls. Measurements were performed in a core laboratory blinded to group and time. Major adverse cardiovascular events (MACEs) were defined as a composite of cardiogenic shock, cardiac arrest, complete heart block, and cardiac death.Cases and controls were similar in age (66 ± 15 years vs 63 ± 12 years; P = 0.20), sex (male: 73% vs 61%; P = 0.20) and cancer type (P = 0.08). Pre-ICI GCS and GRS were also similar (GCS: 22.6% ± 3.4% vs 23.5% ± 3.8%; P = 0.14; GRS: 45.5% ± 6.2% vs 43.6% ± 8.8%; P = 0.24). Overall, 56% (n=42) of patients with myocarditis presented with preserved left ventricular ejection fraction (LVEF). GCS and GRS were lower in myocarditis compared with on-ICI controls (GCS: 17.5% ± 4.2% vs 23.6% ± 3.0%; P< 0.001; GRS: 28.6% ± 6.7% vs 47.0% ± 7.4%; P< 0.001). Over a median follow-up of 30days, 28 cardiovascular events occurred. A GCS (HR: 4.9 [95%CI: 1.6-15.0]; P = 0.005) and GRS (HR: 3.9 [95%CI: 1.4-10.8]; P = 0.008) below the median was associated with an increased event rate. In receiver-operating characteristic (ROC) curves, GCS (AUC: 0.80 [95%CI: 0.70-0.91]) and GRS (AUC: 0.76 [95%CI: 0.64-0.88]) showed better performance than cardiac troponin T (cTnT) (AUC: 0.70 [95%CI: 0.58-0.82]), LVEF (AUC: 0.69 [95%CI: 0.56-0.81]), and age (AUC: 0.54 [95%CI: 0.40-0.68]). Net reclassification index and integrated discrimination improvement demonstrated incremental prognostic utility of GRS over LVEF (P = 0.04) and GCS over cTnT (P = 0.002).GCS and GRS are lower in ICI myocarditis, and the magnitude of reduction has prognostic significance.

Approximately 50% of patients presenting with an acute ST-segment elevation myocardial infarction (STEMI) have multivessel coronary artery disease (CAD). A number of randomized studies ( Table 1 ) have all shown that complete revascularization (CR), either at the time of primary percutaneous coronary revascularization (PPCI) or within 45 days of the index admission, is safe and reduces the risk of repeat coronary revascularization and myocardial infarction (MI), particularly in the non-infarct related artery (NIRA). Despite consistently showing clinical benefit for CR, the results from the trials show variations in what drives this effect. Specifically, no study to date has provided a mechanistic insight as to how complete revascularization of chronic bystander disease may lead to the observed clinical benefit. Indeed, the randomized studies, through the variable nature of their results (reduction in MI versus revascularization etc.), have suggested the possibility that there are differing mechanisms for the observed benefit. In this review, we summarize the evidence base, highlight the limitations, and make the case that we need to understand the mechanism(s) underpinning the advantage of revascularization of NIRA in order to establish which patients are most likely to benefit. Without this insight, the current “one size fits all” approach may lead us in the wrong direction.