Search

The aims of the current review were to compare the efficacy of monotherapy with bendroflumethiazide vs. indapamide on mortality, cardiovascular outcomes, blood pressure, need for intensification of treatment and treatment withdrawal. Two authors independently screened the results of a literature search, assessed the risk of bias and extracted relevant data. Randomized clinical trials of hypertensive patients of at least a 1‐year duration were included. When there was disagreement, a third reviewer was consulted. Risk ratio (RR) and mean differences were used as measures of effect. Two trials comparing bendroflumethiazide against placebo, one comparing indapamide with placebo and three of short duration directly comparing indapamide and Bendroflumethiazide, were included. No statistically significant difference was found between indapamide and bendroflumethiazide for all deaths [RR 0.82; 95% confidence interval (CI) 0.57, 1.18], cardiovascular deaths (RR 0.82; 95% CI 0.55, 1.20), noncardiovascular deaths (0.81; 95% CI 0.54, 1.22), coronary events (RR 0.73; 95% CI 0.30, 1.79) or all cardiovascular events (RR 0.89; 95% CI 0.67, 1.18). Indapamide performed worse for stroke (RR 2.21; 95% CI 1.19, 4.11), even though a reduction in RR compared with placebo was observed in both groups. There was no statistically or clinically significant difference between indapamide and bendroflumethiazide in blood pressure reduction (mean absolute difference

This paper presents an analysis of risk mitigation measures taken by countries around the world facing the current COVID-19 outbreak. In light of the current pandemic the authors collated and clustered (using harmonised terminology) the risk mitigation measures taken around the globe in the combat to contain, and since March 11, 2020, to limit the spread of the SARS-CoV-2 virus known to cause the Coronavirus disease 2019 (COVID-19). This overview gathers lessons learnt, providing an update on the current knowledge for authorities, sectors and first responders on the effectiveness of said measures, and may allow enhanced prevention, preparedness and response for future outbreaks. Various measures such as mobility restrictions, physical distancing, hygienic measures, socio-economic restrictions, communication and international support mechanisms have been clustered and are reviewed in terms of the nature of the actions taken and their qualitative early-perceived impact. At the time of writing, it is still too premature to express the quantitative effectiveness of each risk mitigation cluster, but it seems that the best mitigation results are reported when applying a combination of voluntary and enforceable measures.

Background Although clopidogrel is still frequently used in patients with acute coronary syndromes (ACS), its efficacy is hampered by interpatient response variability caused by genetic polymorphisms associated with clopidogrel’s metabolism. Objectives The goal of this study was to evaluate whether selecting antiplatelet therapy (clopidogrel, prasugrel, or ticagrelor) on the basis of a patient’s genetic and clinical characteristics leads to better clinical outcomes compared with the standard of care, which bases the selection on clinical characteristics alone. Methods Patients hospitalized for ACS were randomly assigned to standard of care or the pharmacogenomic arm, which included the genotyping of ABCB1, CYP2C19*2, and CYP2C19*17 using an ST Q3 system that provides data within 70 min at each patient’s bedside. The patients were followed up for 12 ± 1 month for the primary composite endpoint of cardiovascular death and the first occurrence of nonfatal myocardial infarction, nonfatal stroke, and major bleeding defined according to Bleeding Academic Research Consortium type 3 to 5 criteria. Results After enrolling 888 patients, the study was prematurely stopped. Clopidogrel was used more frequently in the standard-of-care arm (50.7% vs. 43.3%), ticagrelor in the pharmacogenomic arm (42.6% vs. 32.7%; p = 0.02), and prasugrel was equally used in both arms. The primary endpoint occurred in 71 patients (15.9%) in the pharmacogenomic arm and in 114 (25.9%) in the standard-of-care arm (hazard ratio: 0.58; 95% confidence interval: 0.43 to 0.78; p Conclusions A personalized approach to selecting antiplatelet therapy for patients with ACS may reduce ischemic and bleeding events. (Pharmacogenetics of Clopidogrel in Patients With Acute Coronary Syndromes [PHARMCLO]; NCT03347435)

Objectives This study sought to assess an echocardiographic approach (scar imaging echocardiography with ultrasound multipulse scheme [eSCAR]), based on existing multipulse ultrasound scheme, as a marker of myocardial scar in humans, compared with cardiac magnetic resonance assessing late gadolinium enhancement (CMR-LGE). Background The detection of myocardial scar impacts patient prognosis and management in coronary artery disease and other types of cardiac disease. The clinical experience with echocardiography suggests that the reflected ultrasound signal is often significantly enhanced in infarcted myocardial segments. Methods Twenty patients with a recent ST-segment elevation myocardial infarction (STEMI) (cases) and 15 patients with absent CMR-LGE (negative controls) were imaged with both the eSCAR pulse-cancellation echocardiography and CMR-LGE to assess their potential association. Results Scar was detectable at CMR-LGE in 19 of 20 STEMI patients (91%), whereas all (100%) demonstrated eSCAR at echocardiography. In the 19 STEMI patients in whom CMR-LGE was detected, regional matching between eSCAR and CMR-LGE was total, although the segmental extent of detected scar was not always superimposable, particularly in the most apical segments, a region in which eSCAR demonstrated undersensitivity for the true extent of scar. Conclusions A 2-dimensional multipulse echocardiography allows detection of myocardial scar, reliably matching the presence and site of CMR-LGE at 30 days after STEMI, or its absence in negative controls.

Non-steroidal anti-inflammatory drugs are associated with a dose and duration-dependent coronary risk. There is little information concerning analgesic-dose ibuprofen, among the most widely used drugs worldwide.Our objective was to measure the risks of acute coronary syndrome (ACS) after dispensing of ibuprofen, versus paracetamol.Propensity score 1:2-matched cohorts of ibuprofen or paracetamol treatment episodes (TEs) in Echantillon Généraliste de Bénéficiaires (EGB), the 1/97 sample of Système National des Données de Santé (SNDS), the French nationwide claims database, from 2009 to 2014, were compared. Outcomes were hospital admissions for ACS during the 3 months after the dispensing of ibuprofen or paracetamol. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated overall and stratified on low-dose aspirin dispensing.A total of 315,269 ibuprofen TEs in 168,400 persons were matched to 630,457 paracetamol TEs in 395,952 patients. Event rates were 50-100 times higher in low-dose aspirin users (27 vs 0.28 per 1000 patient years). Overall there was no difference in risk of ACS at 3 months (HR 0.94, 95% CI 0.74-1.20) despite a transient increase in the first 2 weeks in ibuprofen users (HR 1.70, 95% CI 1.11-2.59). In the stratified analysis, this short-term risk was only found in aspirin users (5% of population, HR 1.84, 95% CI 1.24-3.24), but not in non-aspirin users (HR 1.09, 95% CI 0.40-2.94).There was no evidence for an increased risk of ACS in patients dispensed ibuprofen compared to paracetamol.

Background The benefits associated with leisure time physical activity (LTPA) in primary and secondary cardiovascular prevention has been known for decades. Although several studies demonstrated that exercise-based cardiac rehabilitation (CR) programs reduce mortality, the long-term prognostic value of adherence to LTPA presciption after exercise-based CR has not been well estrablished. Purpose Evaluate the long-term prognostic value of adherence to LTPA presciption after exercise-based CR in patients undergoing myocardial revascularization and/or cardiac valve surgery. Methods A prospective registry of 2.340 consecutive patients, admitted to the Cardiovascular Prevention and Rehabilitation Unit was created. All patients completed a standard in-hospital CR program. Data regarding LTPA and outcomes were collected. End points were: overall and cardiovascular (CV) mortality and major adverse cardiovascular and cerebrovascular events (MACCEs). The population has been classified into: 1) Physical inactivity: almost completely sedentary or occasional physical activity; 2) Physical activity: regular aerobic LTPA. The amount of LTPA was further collected according to minutes per week. Results A total of 1.892 patients with available data on LTPA and outcomes were included in the study; mean follow-up was 50±23 months. One-thousand and twenty-two (54%) patients underwent myocardial revascularization (CABG), 662 (35%) cardiac valve surgery, 208 (11%) combined valve and CABG surgery. Adherence to a regular LTPA was found in the 42% (792 participants) of the population, while 58% (1.100 patients) reported occasional LTPA or a complete physical inactivity. Kaplan-Meier survival curve showed a lower overall mortality (p Central figure Conclusion Adherence to leisure time physical activity prescription is independently associated with significant reduction of overall mortality, CV mortality and MACCEs on top of exercise-based CR program after myocardial revascularization and/or cardiac valve surgery. Acknowledgement/Funding None

Acute myocardial infarction is primarily due to coronary atherosclerotic plaque rupture and subsequent thrombus formation. Platelets play a key role in the genesis and progression of both atherosclerosis and thrombosis. Since platelets are anuclear cells that inherit their mRNA from megakaryocyte precursors and maintain it unchanged during their life span, gene expression profiling at the time of an acute myocardial infarction provides information concerning the platelet gene expression preceding the coronary event. In ST-segment elevation myocardial infarction (STEMI), a gene-by-gene analysis of the platelet gene expression identified five differentially expressed genes: FKBP5, S100P, SAMSN1, CLEC4E and S100A12. The logistic regression model used to combine the gene expression in a STEMI vs healthy donors score showed an AUC of 0.95. The same five differentially expressed genes were externally validated using platelet gene expression data from patients with coronary atherosclerosis but without thrombosis. Platelet gene expression profile highlights five genes able to identify STEMI patients and to discriminate them in the background of atherosclerosis. Consequently, early signals of an imminent acute myocardial infarction are likely to be found by platelet gene expression profiling before the infarction occurs.

Myocardium subtended by obstructive coronary artery disease (CAD) may show reduced left ventricle (LV) global longitudinal strain (GLS), as well as early systolic lengthening (ESL) before shortening; these can be measured at rest and may predict obstructive CAD. This study investigated whether baseline resting LV longitudinal strain measurements may be able to detect significant CAD in patients undergoing stress echocardiography (SE) and coronary angiography, who have normal resting wall motion. We selected patients with a clinical indication of coronary angiography who were previously referred for SE. Patients with known CAD, rest wall-motion (WM) abnormalities, or rhythm/conduction abnormalities were excluded. Speckle tracking strain analyses were retrospectively performed on digitally archived 2D video-loops, using vendor independent software. Peak GLS and duration of ESL were recorded. Diagnostic accuracy of each parameter to predict obstructive (≥50%) CAD was assessed and multivariate logistic regression models fitted and compared. Eighty-two patients were enrolled and 49 had significant CAD by quantitative angiography. Patients with CAD were more often male (P=0.01) and more frequently presented with typical angina (P

Background Dual antiplatelet therapy with aspirin and a platelet P2Y12 receptor inhibitors (clopidogrel, prasugrel, ticagrelor) is a cornerstone of antithrombotic treatment in patients with acute coronary syndromes (ACS). Clopidogrel has been the standard of care for nearly a decade; however, its clinical efficacy is influenced by a considerable inter-patient variability in response, clearly associated to cytochrome P (CYP) enzyme genetic variations. We used a novel point-of-care lab-on-chip instrument to genotype ACS patients in order to identify carriers of the ATB-binding cassette ABCB1 3435, CYP2C19*2 and CYPC2C19*17 alleles and adjust the pharmacological approach accordingly. Methods and results Between October 2012 and January 2013, 160 ACS patients were enrolled at the Cardiology Unit of the Ospedale Niguarda Ca Granda and genotyped at the patients' point-of-care using the newly developed Q3 portable real-time PCR instrument, which remarkably scored the CYP2C19*2, CYP2C19*17, and ABCB1 3435 alleles in a time of 70 min from DNA extraction to final genotype calls; concordance with the other gold-standard genotyping techniques was 100%. Conclusions The Q3 instrument proved to be as reliable as the current conventional techniques. As genotyping in the ACS setting cannot be delegated to centralised clinical laboratories for reasons of time, genotyping at the patients' bedside provides an opportunity to conduct large-scale randomised trials in order to assess whether adding genotype data to clinical variables improves clinical outcomes.

Methods One hundred forty six consecutive pts (age 61 ± 14, 83 [57%]) females) with suspected AMI and normal coronary arteries or nonobstructive coronary artery disease at coronary angiography were enrolled. Suspected AMI was defined as typical chest pain lasting >20’, electrocardiographic (EKG) changes and increased cardiac enzymes (troponin I>99th percentile and creatine kinase MB levels more than twice the upper normal limit). All pts underwent CMR 6.2 ± 5.7 days after admission using a 1.5T MRI system with cine imaging with breath-hold steadystate free-precession sequences, T2 imaging and late enhancement imaging after gadolinium injection (LGE). The image analysis included: presence of myocardial edema on T2 images; presence, localization and pattern of distribution of LGE.

SUMMARY What is known and Objective: The major clinical complication of statins is a variety of muscle complaints ranging from myalgia to rhabdomyolysis. There is growing evidence that carriers of genetic polymorphisms in the enzymes and transporters implicated in statin disposition, particularly the SLCO1B1 gene, are at increased risk of myotoxicity. Our objective is to report on two cases of statin-induced myopathy occurring in a family with two patients who are carriers of the loss of function SLCO1B1 genetic variant and to briefly review the related literature. Case summary: Patient 1, a 48-year-old man with history of coronary artery disease, experienced rapidly evolving muscle pain and weakness of the extremities during treatment with atorvastatin 40 mg. Patient 2, a 65-year-old man, father of patient 1, had symptoms similar to those of his son after 2 weeks’ treatment with the same statin. Atorvastatin was stopped in both cases, and symptoms resolved. On the basis of family relationship between the two patients, it was possible to hypothesize a genetic basis for the myopathy. Genotyping showed the patients to be carriers of the rs4363657 polymorphism of SLCO1B1 gene. What is new and Conclusion: The two cases reported here and the brief literature review emphasize the impact of genetic factors on the risk of myopathy with statins. Although genotyping all patients before initiating therapy is not recommended at present, pharmacogenetic testing may be useful for new patients who have a family history of statin-induced myopathy.

Background To test the hypothesis that a semi-quantitative echocardiographic calcium score (eCS) significantly correlates with cardiac calcium measured by coronary computed tomography angiography (CCTA) and, secondarily, severe coronary artery calcifications and stenosis. Methods This is a retrospective, observational study, conducted in a tertiary centre. eCS was compared with CCTA scores of non-coronary cardiac calcium (nCACS), coronary cardiac calcium (CACS) and number of diseased coronary vessels, in 141 subjects without known coronary artery disease (CAD), who underwent both echocardiography and CCTA for clinical reasons. Results Age, prevalence of hypertension and all measures of calcium (eCS, nCACS and CACS) differed significantly between the no-CAD and CAD subgroups. eCS was positively correlated with nCACS (Spearman rho = 0.64, p 400), a known predictor of cardiovascular morbidity and mortality. The eCS also predicts obstructive CAD, incrementally to age and clinical variables, although for this purpose CACS remains the most accurate score.

A 26-year-old West-African woman presented at the emergency room with dyspnoea and atypical chest pain. The electrocardiogram showed atrial fibrillation with average ventricular rate of 105 b.p.m. Chest radiogram ( Panel A ) showed marked cardiomegaly with a cardiothoracic ratio of 0.88. Transthoracic echocardiography revealed a giant left atrium associated with …