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IntroductionA novel handheld dual-electrode stick is a portable atrial fibrillation (AF) screening device (AFSD). We evaluated AFSD performance in primary care patients referred for echocardiogram (echo).MethodsThe AFSD has a light indication of irregular rhythm and single-lead ECG recording. Patients were instructed to hold the device for 1 min, and AF indication was recorded. A 12-lead ECG was performed for all AFSD-positive patients and 250 patients with negative AFSD screen. Echos were performed based on a clinical risk score: all high-risk patients and a sampling of low-risk patients underwent complete echo. Intermediate risk patients first had a screening echocardiogram, with a follow-up complete study if abnormality was suspected.ResultsIn 5 days, 1518 patients underwent clinical evaluation and cardiovascular risk stratification: mean age 58±16 years, 66% women. The AFSD was positive in 6.4%: 12.6% high risk, 6.1% intermediate risk and 2.2% low risk. Older age was a risk factor (9.3% vs 4.8% in those more than and less than 65 years, p=0.001). AFSD positive was independently associated with heart disease in echo (OR=3.9, 95% CI 2.1 to 7.2, pConclusionAFSD demonstrated high sensitivity for AF detection in primary care patients referred for echo. AF prevalence was substantial and independently associated with structural or functional heart disease, suggesting that AFSD screening could be a useful primary care tool to stratify risk and prioritise echo.

Since the inception of the COVID-19 pandemic, the identification of factors associated with unfavourable outcomes has been a topic of intense investigation. With limited disease-specific therapies, early stratification of those at highest risk of complications can guide who needs intensive clinical monitoring and supportive management. The large body of evidence in the early phases of the pandemic strongly suggested that cardiac involvement could potentially be one of these prognostic factors, and several hypotheses have been raised for the cardiovascular abnormalities observed, especially in severely ill patients. Markers of acute myocardial injury have been reported in up to one-fifth of patients with COVID-19,1 and several mechanisms have been implicated: (a) direct myocardial injury due to viral invasion of cardiomyocytes; (b) systemic inflammatory response and cytokine storm; (c) increased cardiometabolic demand associated with acute hypoxic respiratory failure; (d) increased vascular shear stress precipitating plaque rupture in the setting of a prothrombotic state; (e) deleterious cardiovascular effects of empirical drug regimens; (f) critical electrolyte disturbances. These disease-related mechanisms may be exacerbated by underlying cardiac disease and increase risk of adverse outcomes.1 The present study by Singh et al 2 brings a significant contribution to this growing body of evidence. Fifty-two patients recovered from COVID-19 (one-third with intensive care admission and one-fifth requiring mechanical ventilation) underwent a comprehensive imaging protocol with gadolinium and manganese-enhanced MRI, with 23 additionally undergoing CT coronary angiography for evaluation of underlying coronary artery disease. They were compared with 10 healthy controls and 26 volunteers propensity matched for cardiovascular morbidity. COVID-19-recovered patients demonstrated impaired left (LV) and right (RV) ventricular systolic function, elevated myocardial T1 values and extracellular volume fraction, and reduced myocardial manganese uptake compared with healthy controls. In contrast, when comparing with comorbidity-matched volunteers, patients with COVID-19 had preserved LV function but reduced RV systolic function …

Objectives Rheumatic mitral stenosis (MS) is a progressive disease, and risk of death may persist despite relief of the obstruction. Net atrioventricular compliance (C n ) modulates the overall haemodynamic burden of the MS and may be useful in predicting cardiovascular death after percutaneous mitral valvuloplasty (PMV). Methods A total of 427 patients (mean age 50±16 years, 84% female) with severe MS undergoing PMV were enrolled. Doppler-derived C n was estimated at baseline using a previously validated equation. The primary endpoint was late cardiovascular death, and the secondary endpoint was a composite of all-cause mortality, mitral valve (MV) replacement or repeat PMV over a median follow-up of 31 months (IQR: 7.8–49.2 months). Results At baseline, 209 patients (49%) were in New York Heart Association (NYHA) functional class III or IV. During follow-up, 49 patients died (41 cardiovascular deaths), 50 underwent MV replacement and 12 required repeat PMV, with an overall incidence of cardiac mortality and adverse events of 4.1 deaths and 11.1 events per 100 patient-years, respectively. Low baseline C n was a strong predictor of both cardiac death (adjusted HR 0.70, 95% CI 0.49 to 0.86) and composite endpoint (adjusted HR 0.81, 95% CI 0.67 to 0.91) after adjusting for clinical factors, baseline pulmonary artery pressure, tricuspid regurgitation severity, right ventricular function and immediate procedural haemodynamic data. The inclusion of C n in a model with conventional parameters resulted in improvement in 5-year cardiovascular mortality risk prediction. Conclusions Baseline C n is a strong predictor of cardiovascular death in patients with MS undergoing PMV, independent of other prognostic markers of decreased survival in MS, including baseline patient characteristics and postprocedural data. C n assessment therefore has potential value in evaluation of cardiovascular mortality risk in the setting of MS.

Percutaneous mitral commissurotomy (PMC) is the first-line therapy for managing rheumatic mitral stenosis. Over the past two decades, the indications of the procedure have expanded to include patients with unfavourable valve anatomy as a consequence of epidemiological changes in patient population. The procedure is increasingly being performed in patients with increased age, more deformed valves and associated comorbidities. Echocardiography plays a crucial role in patient selection and to guide a more efficient procedure. The main echocardiographic predictors of immediate results after PMC are mitral valve area, subvalvular thickening and valve calcification, especially at the commissural level. However, procedural success rate is not only dependent on valve anatomy, but a number of other factors including patient characteristics, interventional management strategies and operator expertise. Severe mitral regurgitation continues to be the most common immediate procedural complication with unchanged incidence rates over time. The long-term outcome after PMC is mainly determined by the immediate procedural results. Postprocedural parameters associated with late adverse events include mitral valve area, mitral regurgitation severity, mean gradient and pulmonary artery pressure. Mitral restenosis is an important predictor of event-free survival rates after successful PMC, and repeat procedure can be considered in cases with commissural refusion. PMC can be performed in special situations, which include high-risk patients, during pregnancy and in the presence of left atrial thrombus, especially in centres with specialised expertise. Therefore, procedural decision-making should take into account the several determinant factors of PMC outcomes. This paper provides an overview and update of PMC techniques, complications, immediate and long-term results over time, and assessment of suitability for the procedure.

Rheumatic heart disease (RHD) is the late sequelae of inadequately treated group A streptococcal pharyngeal infections, leading to acute rheumatic fever, a multisystem immune response that often culminates in valvular damage and ultimately heart failure (HF).1 While advanced rheumatic valvular disease is ideally treated with interventional procedures (surgical or percutaneous), the reality is that access to these procedures is severely constrained in many RHD-endemic areas, limiting patients to medical management for symptom control.2 There are very limited data on the best practices for medical management of RHD, with most recommendations drawn from what is known from the general literature on HF, supraventricular arrhythmias and valvular heart disease. This is problematic because the population of patients with RHD is both younger and less likely to have secondary cardiac risk (such as coronary artery disease and hypertension) as compared with the general HF and valvular heart disease communities. In addition, cardiac involvement by RHD has some particularities that impact mortality, such as the frequent association with atrial fibrillation (AF) and flutter, which may influence therapeutic response and change outcomes.2 Newly, a large, multinational Global Rheumatic Heart Disease Registry (REMEDY) has provided the power to study therapeutics specifically in patients with RHD. The registry contains data on over 3300 patients with RHD, the majority living in low-income and middle-income countries, and half (51%) with advanced valvular heart disease at enrolment. While the data are exclusively observational—no therapeutics were guided by or changed by registry participation—REMEDY provides some of the first data on therapeutic practices and response among a large RHD-affected population.3 In Heart , we get the chance to review the first therapeutics paper to emerge from the REMEDY study; the use and effectiveness of digoxin.3 While digoxin (digitalis) is one of the oldest known cardiovascular drugs, its contemporary risk:benefit ratio …