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The Hellenic Heart Failure Association has undertaken the initiative to develop a national network of heart failure clinics (HFCs) and cardio‐oncology clinics (COCs). We conducted two questionnaire surveys among these clinics within 17 months and another during the coronavirus disease 2019 outbreak to assess adjustments of the developing network to the pandemic. Out of 68 HFCs comprising the network, 52 participated in the first survey and 55 in the second survey. The median number of patients assessed per week is 10. Changes in engaged personnel were encountered between the two surveys, along with increasing use of advanced echocardiographic techniques (23.1% in 2018 vs. 34.5% in 2020). Drawbacks were encountered, concerning magnetic resonance imaging and ergospirometry use (being available in 14.6% and 29% of HFCs, respectively), exercise rehabilitation programmes (applied only in 5.5%), and telemedicine applications (used in 16.4%). There are 13 COCs in the country with nine of them in the capital region; the median number of patients being assessed per week is 10. Platforms for virtual consultations and video calls are used in 38.5%. Coronavirus disease 2019 outbreak affected provision of HFC services dramatically as only 18.5% continued to function regularly, imposing hurdles that need to be addressed, at least temporarily, possibly by alternative methods of follow‐up such as remote consultation. The function of COCs, in contrast, seemed to be much less affected during the pandemic (77% of them continued to follow up their patients). This staged, survey‐based procedure may serve as a blueprint to help building national HFC/COC networks and provides the means to address changes during healthcare crises.

Current data indicate that in the community, approximately 50% of patients with heart failure (HF) have preserved left ventricular (LV) ejection fraction (LVEF)—the so-called HFpEF. Treatment of HFpEF has been considered an unmet need for decades. We believe that the main underlying reasons have been (a) the ever-changing LVEF cut-offs used for HF classification; (b) controversies regarding the definition of the LVEF normal range; (c) the fact that HFpEF does not represent a phenotype, but a category of diseases with entirely different characteristics (hypertensive heart disease, valvular heart disease (VHD), hypertrophic cardiomyopathy (HCM) etc.); (d) the lack of recognition that hypertensive HFpEF is the most common and important HFpEF phenotype; (e) the assumption that neurohormonal overactivity is absent in HF patients with a LVEF > 45–50% which has been proven to be wrong. Current HFpEF trials, in which the vast majority of the participants suffered from hypertension (HTN), whereas VHD and HCM were absent, demonstrated that neurohormonal and sodium-glucose cotransporter 2 (SGLT2) inhibitors are effective in HF patients over a wide LVEF range. Thus, restricting these lifesaving treatments to HF patients with reduced LVEF is not justified anymore and it should be additionally considered for HFpEF patients suffering from HTN.

Colorectal cancer (CRC) is the third most common malignancy in men and the second in women and the fourth cause of cancer death. Survival rates decrease greatly according to the stage of the disease at the time of diagnosis. Approximately 50% of CRC patients will develop metastatic disease (mCRC) with survival and prognosis depending on the timing of metastatic development, and the localization and number of metastatic sites. The overall survival of patients with mCRC has been significantly improved over the last years from approximately 12 to more than 30 months with the integration of multiple cytotoxic agents and targeted therapies. The optimal therapeutic strategy depends on the general condition and performance status of the patient, the resectability or not of metastases and the mutational status of the tumor in terms of BRAF and RAS. Cardiovascular (CV) complications of mCRC treatment may develop peri-operatively and mostly during chemotherapy. During first-line treatment, 90% of patients experience more than one adverse event (AE) and 39% of them are CV. Angina, hypertension, arrhythmias, arterial and venous thrombotic events (VTEs), heart failure (HF) and death are the main CV events resulting from the applied chemotherapy regimens. Cardio-oncology consultation for identification of high-risk patients, proper monitoring during and after therapy and timely intervention would allow the successful prevention and the efficient management of cardiotoxicity, rendering the patient able to receive the indicated cancer therapy and improving the overall outcome.

Chronic inflammation and increased oxidative stress are contributing factors to many non-communicable diseases. A growing body of evidence indicates that dietary nutrients can activate the immune system and may lead to the overproduction of pro-inflammatory cytokines. Fatty acids as macronutrients are key players for immunomodulation, with n-3 polyunsaturated fatty acids having the most beneficial effect, while polyphenols and carotenoids seem to be the most promising antioxidants. Psoriasis is a chronic, immune-mediated inflammatory disease with multifactorial etiology. Obesity is a major risk factor for psoriasis, which leads to worse clinical outcomes. Weight loss interventions and, generally, dietary regimens such as gluten-free and Mediterranean diet or supplement use may potentially improve psoriasis’ natural course and response to therapy. However, data about more sophisticated nutritional patterns, such as ketogenic, very low-carb or specific macro- and micro-nutrient substitution, are scarce. This review aims to present the effect of strictly structured dietary nutrients, that are known to affect glucose/lipid metabolism and insulin responses, on chronic inflammation and immunity, and to discuss the utility of nutritional regimens as possible therapeutic tools for psoriasis and psoriatic arthritis.

Background: Conventional echocardiographic parameters, such as rest ejection fraction, perform poorly in the prediction of exercise tolerance in heart failure. The aim of the present study was to evaluate the contribution of hemodynamic instability in the observed lower functional capacity and investigate the role of left ventricular strain for the prediction of stress test duration in obese hypertensive patients with reduced ejection fraction. Methods: Sixty-one patients with reduced ejection fraction underwent treadmill exercise echocardiography. Systolic and diastolic echocardiographic parameters were recorded. Moreover, the presence of hemodynamic instability was assessed through N-terminal pro B-type natriuretic peptide (NT-proBNP) measurements at baseline and peak exercise. Results: Rest and peak NT-proBNP levels, and their difference, were significantly correlated with mean global strain at peak, which was the only parameter associated with changes in NT-proBNP levels. Rest and peak mean global strain were found to be predictive for the duration of treadmill stress test. In particular, mean global strain, but not left ventricular ejection fraction, was independently correlated with exercise ability. Conclusions: Stress echocardiography may provide important information regarding exercise tolerance in obese hypertensive patients with reduced ejection fraction, mainly through the evaluation of left ventricular strain. The obtained evidence may also have prognostic value, particularly in the early stages of the syndrome. Keywords: echocardiography, ejection fraction, exercise capacity, heart failure, NT-proBNP, strain analysis

The effects of medically-aided smoking cessation on vascular function and oxidative stress are not fully clarified.One hundred eighty-eight current smokers were randomized to varenicline or nicotine replacement treatment (NRT) for a 3-month period. We assessed: (a) augmentation index (Aix) and pulse wave velocity (PWV); (b) perfusion boundary region (PBR) of sublingual microvasculature (range:5-25 μm), an index of the endothelial glycocalyx thickness, using Sideview, Darkfield imaging; (c) the exhaled CO; and (d) the malondialdehyde (MDA) and protein carbonyls (PC) plasma levels, as markers of oxidative stress, at baseline and after 3 and 12 months.After 3 months of treatment, CO, MDA, PC and Aix were decreased in all subjects (median CO: 25 vs. 6 ppm, MDA: 0.81 vs. 0.63 nmol/L, PC: 0.102, vs. 0.093 nmol/mg protein, Aix: 13% vs. 9%, p 0.05) while PWV remained unchanged. Endothelial glycocalyx integrity showed a greater improvement in the varenicline than the NRT treatment (PBR range 5-9 μm: 1.07 ± 0.02 vs. 1.17 ± 0.02 μm, p = 0.03) in parallel with the greater CO reduction (5 vs. 7 ppm, p = 0.02). At 1-year follow-up, MDA, PC, Aix and PBR at 5-25 μm range were further improved in subjects who abstained from smoking (n = 84 out of 188), while the above markers and PWV deteriorated in relapsed smokers (p 0.05).A smoking cessation program using varenicline or NRT for 3 months resulted in a decrease of CO, oxidative stress, arterial stiffness and restored endothelial glycocalyx. These effects were more evident after varenicline treatment, likely because of a greater CO reduction, and were maintained after 1 year only in subjects who abstained from smoking.

Heart failure (HF) is rapidly growing, conferring considerable mortality, morbidity, and costs. Dedicated HF clinics improve patient outcomes, and the development of a national HF clinics network aims at addressing this need at national level. Such a network should respect the existing health care infrastructures, and according to the capacities of hosting facilities, it can be organized into three levels. Establishing the continuous communication and interaction among the components of the network is crucial, while supportive actions that can enhance its efficiency include involvement of multidisciplinary health care professionals, use of structured HF‐specific documents, such as discharge notes, patient information leaflets, and patient booklets, and implementation of an HF‐specific electronic health care record and database platform.

Atrial fibrillation (AF) and heart failure are often coexisting major public health burdens. Although several studies have reported partial restoration of systolic left ventricular (LV) function after catheter ablation for AF, the method is not widely applied in patients with LV dysfunction. We reviewed the results of AF ablation in patients with systolic LV dysfunction.PubMed was searched for studies published after 2000 reporting original data on AF catheter ablation in adult patients with systolic LV dysfunction. Primary end point was the change of LV ejection fraction (LVEF) after catheter ablation; secondary endpoints were the changes of exercise capacity and quality of life after the procedure. We calculated mean difference (MD) of LVEF and 95% confidence interval (95% CI) using random-effects models. Heterogeneity was investigated by I(2) statistic, publication bias with Egger's test. The impact of covariates on LVEF improvement was evaluated with meta-regression analyses. Nine studies with a total of 354 patients with systolic LV dysfunction were analyzed. Study patients were mainly male with mean age 49 to 62 years, LVEF was moderately impaired and ranged in all but 1 study from 35% to 43%. LVEF improved after ablation with a MD of 11.1% (95% CI: 7.1-15.2, P.001). Heterogeneity among analyzed studies was significant (I(2) = 92.9, P.001). No potential publication bias was found. In meta-regression analyses, the proportion of patients with coronary artery disease was inversely related with LVEF improvement (P.0001) whereas there was no association between the LVEF change and the proportion of patients with nonparoxysmal AF or the proportion of patients without AF recurrences during follow-up.AF ablation in patients with systolic LV dysfunction results in significant improvement of LV function, but the extent of this improvement is heterogeneous. Patients with coronary artery disease seem to benefit less than patients with other underlying diseases. These results may be explained by patient selection.

OBJECTIVES Ischemia affects the left ventricular (LV) diastolic function earlier than the systolic function. The ratio of the early diastolic transmitral velocity to the early diastolic tissue velocity (E/E') measured by tissue Doppler echocardiography allows a reliable assessment of the diastolic function. We investigated whether exercise-induced changes in E/E' ratio may help in the detection of coronary artery disease (CAD). METHODS The study population consisted of 114 patients undergoing coronary angiography. Patients with impaired LV ejection fraction, earlier myocardial infarction, arterial hypertension greater than stage I, or LV hypertrophy were excluded. Patients underwent a treadmill exercise test combined with an echocardiogram at baseline and within the first minute after exercise. RESULTS Coronary angiography showed a stenosis more than 70% in 72 (63%) patients (CAD group), the remaining 42 formed the non-CAD group. The two groups did not differ regarding age, sex, LV dimensions, and function. At baseline, the E/E' lateral and septal ratios and their average did not differ between the two groups. The exercise-induced changes of the E/E' ratios were higher in the CAD group (change of E/E' average: 1.9+/-3.3 vs. -1.1+/-2.3, P

AIMS Left atrial (LA) stunning, the transient impairment of LA function, is responsible for an increased thrombo-embolic risk after cardioversion of atrial fibrillation (AF). Angiotensin receptor blockers (ARBs) attenuate atrial remodelling in AF and could theoretically influence LA stunning. We studied the effect of Irbesartan on LA stunning. METHODS AND RESULTS We prospectively assigned 50 patients from the outpatient clinic undergoing electrical cardioversion for AF with duration of >4 weeks, into two matched groups: 25 patients were treated with Irbesartan (228+/-93 mg/day) for at least 2 weeks prior to cardioversion (Irbesartan group); 25 patients did not receive ARBs (control group). The groups did not differ concerning age (64+/-13 vs. 63+/-13 years, respectively), AF duration (20+/-18 vs. 20+/-19 weeks), underlying disease, LA diameter (46+/-7 vs. 47+/-9 mm), left ventricular dimensions, and ejection fraction (47.7+/-11.6 vs. 49.7+/-14.5%). We assessed LA appendage emptying velocities (LAAEV) and LA spontaneous echo contrast (LASEC) by transoesophageal echocardiography before and after cardioversion and at 2 weeks, and the A-wave by transthoracic echocardiography after cardioversion, at 2 and at 4 weeks. LA stunning was significantly attenuated in the Irbesartan group. The reduction of LAAEV immediately after cardioversion was significantly less in the Irbesartan group (LAAEV reduction of 9+/-49% from 28+/-9 cm/s before cardioversion to 25+/-13 cm/s immediately afterwards) than in the control group (reduction of 48+/-20% from 34+/-15 cm/s before cardioversion to 16+/-6 cm/s afterwards) (P = 0.048). New or increased LASEC occurred in eight patients (32%) in the Irbesartan vs. 16 patients (64%) in the control group (P = 0.046). CONCLUSION Irbesartan significantly attenuates LA stunning after electrical cardioversion of AF. Therefore, ARBs may represent an important pharmacological supplementation in patients being prepared for cardioversion.

Differentiation between left- and right-sided inferoseptal accessory pathways by existing ECG algorithms is unsatisfactory. We reviewed the 12-lead ECGs of 113 consecutive patients undergoing successful ablation of a single manifest inferoseptal pathway (40% at the mitral, 60% at the tricuspid annulus). For prediction of a right-sided location, the most useful criteria were a) a negative QRS polarity in all three inferior leads and in V1 (positive predictive value (PPV) 0.90, negative predictive value (NPV) 0.51) and b) a negative QRS polarity in > or =2 inferior leads and in V1 (PPV 0.80, NPV 0.56). A positive QRS polarity in > or =1 inferior lead predicted a left-sided location (PPV 0.54, NPV 0.80). A new algorithm had an accuracy of 76%.

To investigate whether exercise-induced changes of the E/E’ average ratio can detect high-burden coronary artery disease (CAD) in patients with chest pain and normal left ventricular (LV) systolic function. The study population consisted of 359 patients admitted for chest pain (59.8 ± 9.8 years, 75% male). Patients underwent exercise echocardiography, scintigraphy and coronary angiography. The average of the lateral and septal ratios of early diastolic transmitral velocity to early diastolic tissue velocity (E/E’) at baseline and immediately after exercise was calculated. Exercise induced wall motion abnormalities were also calculated. Coronary angiography showed flow limiting CAD in 238 patients (66%). The exercise-induced changes of E/E’ average ratio had a sensitivity of 87.3% and a specificity of 75.2% for detection of flow limiting CAD, whereas myocardial scintigraphy showed 79.2% sensitivity and 80.1% specificity and exercise induced wall motion abnormalities had a sensitivity of 74.3% and a specificity of 66.9%. Likelihood ratio chi square showed an incremental value of the exercise-induced changes of E/E’ average ratio over regional perfusion technique (from 121.37 to 194.15, P

AIM The diagnostic and prognostic utility of B-type natriuretic peptide (BNP) has been shown in patients either with heart failure or with known coronary artery disease (CAD). We aimed to investigate the utility of the exercise-induced changes of BNP in patients with chest pain, unknown CAD, and normal left ventricular systolic function. METHODS We evaluated 100 consecutive patients (mean age 58.7 ± 9 years) (80% male) with left ventricular ejection fraction of more than 50%. Blood samples were collected and BNP was measured before exercise stress testing, at peak, and 20 min after it. All patients underwent coronary artery angiography. We used univariate and multivariate logistic regression analysis. RESULTS An increment in BNP values of 1.3 fold (from before to peak exercise BNP values) have 11 times greater odds of having CAD [odds ratio (OR): 11.45 with 95% confidence interval (CI): 3.48–37.66, P

OBJECTIVES: Diabetes mellitus is considered as an equivalent of coronary artery disease (CAD). Aim of the study was to investigate whether in asymptomatic patients with type II diabetes, diastolic stress echocardiography may represent an alternative tool for the detection of CAD. METHODS: The study population consisted of 105 patients with diabetes mellitus (age 61+/-9 years, 26% female, duration of diabetes 37+/-14 months). We performed an exercise stress test, followed by an echo-study and a single-positron emission tomography. Coronary angiography was performed within 1 month. RESULTS: Coronary angiography revealed a coronary artery stenosis of at least 70% in 72 patients (69%, CAD group), while the remaining formed the non-CAD group. Exercise induced an increase of both E/E' lateral and septal ratios as well as their average in the CAD group and on the contrary a decrease of these ratios in the non-CAD group. Receiver operating curve analysis for discrimination between patients with and without obstructive CAD showed an optimal cut-off value of -0.0708 for the exercise-induced change of E/E' average (area under curve 0.892, P

Introduction Nonrandomized studies suggest a survival benefit for patients with atrial fibrillation (AF) undergoing catheter ablation compared with antiarrhythmic drug (AAD) therapy. Data from randomized trials are lacking. We performed a meta-analysis on mortality in randomized controlled trials comparing AF ablation with AADs. Methods Pubmed, the Cochrane Central Register of Controlled Trials, and abstracts of major conferences were searched for randomized trials comparing AF catheter ablation with AADs. Eight trials with a total of 930 patients were analyzed. Trial quality was assessed by a modified Jadad scale. Follow-up was 1 year in most trials. We assessed fixed effect risk differences (RDs) with the Mantel-Haenzel method, heterogeneity with I 2 statistic, and publication bias with Begg's funnel plot and with Egger's test. Results A total of 7 deaths were reported: 3 in the ablation and 4 in the AAD arm. There was no difference in mortality between AF ablation and AAD therapy. The RD of mortality in all trials between patients randomized to ablation and those randomized to AADs was −0.003 (95% CI −0.018 to 0.013, P = .74) without evidence for heterogeneity ( I 2 = 0%, P = .907). No potential publication bias was found. There was also no difference in rates of stroke or transient ischemic attack between ablation and antiarrhythmic therapy for AF (RD = 0.004, 95% CI −0.010 to 0.018, P = .54). Conclusion This meta-analysis of randomized controlled trials showed similar survival of patients undergoing catheter ablation for AF compared with patients treated with AADs after 12 months of follow-up. There was also no difference in the rates of stroke or transient ischemic attack. These findings can be probably explained by the low-risk young populations who were included in the trials and the relatively short 12-month follow-up.

Background There is considerable research interest about the platelet GPIIb/IIIa receptor polymorphisms in CAD. Methods We investigated differences in the frequency of the polymorphism in the GPIIb subunit of the receptor HPA-3 (a and b allele) between patients with more extensive coronary thrombosis such as patients with ST segment elevation (STEMI) and those with less extensive coronary thrombosis such as those with non-ST elevation myocardial infarction (NSTEMI), unstable angina (UA) or chronic CAD. We studied 118 CAD patients, of which 38 suffered from STEMI, 62 from NSTEMI or UA and 18 from chronic CAD and 15 healthy individuals. Patients were followed-up for 21±6 months for occurrence of death, myocardial infarction and revascularization. Results Seventeen out of 38 (45%) patients with STEMI were homozygous for the HPA-3 b allele compared to 6 out 62 (10%) with NSTEMI-UA , 4 out of 18 (22%) with chronic CAD and 2 out of 15 (13%) healthy controls ( χ 2 =16,4, p =0.03.) Homozygous patients for the HPA-3b exhibited a 5-fold higher risk for STEMI compared to heterozygous patients for HPA-3b or homozygous for HPA-3a allele (OR: 5.90, 95% CI: 2.15–16.54, p =0.01) after adjustment for age, sex and risk factors. The HPA-3 genotypes were not related with cardiovascular events during follow-up. Conclusions Among patients with an acute coronary syndrome those being HPA-3b homozygous have a tendency to develop ST segment elevation myocardial infarction instead of non-ST segment elevation infarction or unstable angina. There is no association between the HPA-3 genotypes and future cardiovascular events.