Arrhythmic syncope: From diagnosis to management

Syncope is a concerning symptom that affects a large proportion of patients.It can be related to a heterogeneous group of pathologies ranging from trivial causes to diseases with a high risk of sudden death.However,benign causes are the most frequent,and identifying high-risk patients with potentially severe etiologies is crucial to establish an accurate diagnosis,initiate effective therapy,and alter the prognosis.The term cardiac syncope refers to those episodes where the cause of the cerebral hypoperfusion is directly related to a cardiac disorder,while arrhythmic syncope is cardiac syncope specifically due to rhythm disorders.Indeed,arrhythmias are the most common cause of cardiac syncope.Both bradyarrhythmia and tachyarrhythmia can cause a sudden decrease in cardiac output and produce syncope.In this review,we summarized the main guidelines in the management of patients with syncope of presumed arrhythmic origin.Therefore,we presented a thorough approach to syncope work-up through different tests depending on the clinical characteristics of the patients,risk stratification,and the management of syncope in different scenarios such as structural heart disease and channelopathies.

Value of cardiac magnetic resonance on the risk stratification of cardiomyopathies

Cardiomyopathies represent a diverse group of heart muscle diseases with varying etiologies,presenting a diagnostic challenge due to their heterogeneous manifestations.Regular evaluation using cardiac imaging techniques is impera-tive as symptoms can evolve over time.These imaging approaches are pivotal for accurate diagnosis,treatment planning,and optimizing prognostic outcomes.Among these,cardiovascular magnetic resonance(CMR)stands out for its ability to provide precise anatomical and functional assessments.This manuscript ex-plores the significant contributions of CMR in the diagnosis and management of patients with cardiomyopathies,with special attention to risk stratification.CMR’s high spatial resolution and tissue characterization capabilities enable early detec-tion and differentiation of various cardiomyopathy subtypes.Additionally,it offers valuable insights into myocardial fibrosis,tissue viability,and left ven-tricular function,crucial parameters for risk stratification and predicting adverse cardiac events.By integrating CMR into clinical practice,clinicians can tailor patient-specific treatment plans,implement timely interventions,and optimize long-term prognosis.The non-invasive nature of CMR reduces the need for invasive procedures,minimizing patient discomfort.This review highlights the vital role of CMR in monitoring disease progression,guiding treatment decisions,and identifying potential complications in patients with cardiomyopathies.The utilization of CMR has significantly advanced our understanding and management of these complex cardiac conditions,leading to improved patient outcomes and a more personalized approach to care.

Management of portopulmonary hypertension:New perspectives

Portopulmonary hypertension(PPHTN)is a known complication of cirrhosis.Moderate-to-severe PPHTN implies an extremely poor prognosis.It occurs in 5%-10%of patients referred for liver transplantation(LT),and probably with an higher incidence in patients with large portosystemic shunts.Patients with moderate-tosevere pulmonary hypertension have been previously excluded from LT because of the extremely high surgical risk and since the post-transplant outcome reported was poor.Recently,new perspectives in the management of patients with portopulmonary hypertension are emerging.In fact,some pulmonary vasoactive drugs have become routine in the treatment of patients with idiopathic pulmonary hypertension.These drugs,particularly epoprostenol,have been recently introduced in the treatment of patients with PPHTN,and have been shown to be effective in reducing pulmonary artery pressure as well as pulmonary vascular resistances.Furthermore,recent studies seem to demonstrate that treatment with pulmonary vasoactive drugs could allow liver transplantation with acceptable surgical risks and excellent survival.Although there are not large series nor prospective studies addressing this topic,the clinical scenario of patients with PPHTN seems to be positively changing.

Serum uric acid as a prognostic marker in the setting of advanced vascular disease： a prospective study in the elderly

Background Many epidemiological studies analyze the relationship between hyperuricemia and cardiovascular outcomes. This observational prospective study investigates the association of serum uric acid （SUA） levels with adverse cardiovascular events and deaths in an elderly population affected by advanced atherosclerosis. Methods Two hundred and seventy six elderly patients affected by advanced atherosclerosis （217 males and 59 females; aged 71.2 ±7.8 years） were included. All patients were assessed for history of cardiovascular disease, cancer, obesity and traditional risk factors. Patients were followed for approximately 31 ±11 months. Major events were recorded during follow-up, defined as myocardial infarction, cerebral isehemia, myocardial and/or peripheral revascularization and death. Results Mean SUA level was 5.47 ±1.43 mg/dL; then we further divided the population in two groups, according to the median value （5.36 mg/dL）. During a median follow up of 31 months （5 to 49 months）, 66 cardiovascular events, 9 fatal cardiovascular events and 14 cancer-related deaths have occurred. The patients with increased SUA level presented a higher significant incidence of total cardiovascular events （HR： 1.867, P = 0.014, 95% CI： 1.134-3.074）, The same patients showed a significant increased risk of cancer-related death （HR： 4.335, P = 0.025, 95% CI： 1.204-15.606）. Conclusions Increased SUA levels are independently and significantly associated with risk of cardiovascular events and cancer related death in a population of mainly elderly patients affected by peripheral vasculopathy.

Frailty and acute coronary syndrome: does gender matter?

There are important sex-related differences in elderly patients with acute coronary syndrome(ACS).Women are older,more frequently frail,and present more comorbidities than men.Atypical symptoms at presentation are also more common in female patients,they are leaded to a delayed diagnosis and treatment.Coronary angiography and subsequent revascularization are frequently underused in elderly women and they tend to receive less guidelines-recommended therapies.The prognosis in elderly frail women with ACS is poor,and it is with high mortality and readmissions rates.Bleeding is recurrent ischemic events in which it is more frequent in women than in men.Recovery time might be long,and a multidisciplinary approach is desirable to improve prognosis and quality of life.Further studies are needed in order to clarify the benefit of the different therapies in the group of frail women,and this is particularly true for revascularization,as scientific evidence in this group is very scarce.

Invasive strategy in elderly patients with acute coronary syndrome in 2018: close to the truth?

Elderly population constitutes an increasingly larger proportion of patients admitted for acute coronary syndromes(ACS).The optimal management of ACS in these patients is still a challenge due to their clinical peculiarities and the paucity of specific data,and they have been traditionally managed more conservatively mainly based on subjective criteria.In ST^segment elevation acute myocardial infarction urgent reperfusion is the standard of care and there is no upper age limit.In non-ST segment elevation acute myocardial infarction evidence is controversial,incomplete and mainly focused on chronological age.While a strict conservative strategy should be avoided,routine invasive strategy may reduce the occurrence of myocardial infarction and need for revascularization at follow-up with no established benefit in terms of mortality.Clinical characteristics associated with aging,such as comorbidities and frailty,further discriminate patient's risk beyond age.Evidence is scarce,but it suggests that these features may modulate the benefit of invasive strategy in this population.Ongoing trials should clarify the optimal management of ACS based on these parameters.

Optimal dual antiplatelet therapy strategy in elderly patients with acute coronary syndrome

One out of three hospitalizations for acute coronary syndrome(ACS)involve nowadays elderly patients,carrying together a significant burden of comorbidities and a higher risk of complications.In particular,both ischemic and haemorrhagic risk are markedly enhanced in advanced age,and strictly interconnected,challenging the management of dual antiplatelet therapy(DAPT)in these patients.The recent development of several therapeutic options in terms of duration and combination of antiplatelet agents have offered a wider spectrum of opportunities for a more individualized approach in the management of DAPT after an ACS,although the criteria for the selection of the most appropriate strategy in each patient still lack validation.In particular,dose-adjustment,early aspirin discontinuation,laboratory-driven tailoring and shorter or extended DAPT have been addressed with promising safety and efficacy results.The present review provides an updated overview on the emerging evidencefrom randomized clinical trials and subanalyses dedicated to the management of DAPT in elderly patients presenting with ACS.

Cardiovascular autonomic neuropathy in diabetes:Pathophysiology,clinical assessment and implications

Cardiovascular autonomic neuropathy(CAN)is a debilitating condition that mainly occurs in long-standing type 2 diabetes patients but can manifest earlier,even before diabetes is diagnosed.CAN is a microvascular complication that results from lesions of the sympathetic and parasympathetic nerve fibers,which innervate the heart and blood vessels and promote alterations in cardiovascular autonomic control.The entire mechanism is still not elucidated,but several aspects of the pathophysiology of CAN have already been described,such as the production of advanced glycation end products,reactive oxygen species,nuclear factor kappa B,and pro-inflammatory cytokines.This microvascular complication is an important risk factor for silent myocardial ischemia,chronic kidney disease,myocardial dysfunction,major cardiovascular events,cardiac arrhythmias,and sudden death.It has also been suggested that,compared to other traditional cardiovascular risk factors,CAN progression may have a greater impact on cardiovascular disease development.However,CAN might be subclinical for several years,and a late diagnosis increases the mortality risk.The duration of the transition period from the subclinical to clinical stage remains unknown,but the progression of CAN is associated with a poor prognosis.Several tests can be used for CAN diagnosis,such as heart rate variability(HRV),cardiovascular autonomic reflex tests,and myocardial scintigraphy.Currently,it has already been described that CAN could be detected even during the subclinical stage through a reduction in HRV,which is a non-invasive test with a lower operating cost.Therefore,considering that diabetes mellitus is a global epidemic and that diabetic neuropathy is the most common chronic complication of diabetes,the early identification and treatment of CAN could be a key point to mitigate the morbidity and mortality associated with this long-lasting condition.

Congenital Cardiac Defects, Such as Eustachian Valve, May Increase the Risk of Cryptogenic Stroke: A Case Report

Eustachian valve is an embryonic endocardial heart structure;after birth it becomes an embryogenic residue and its persistance in adult life is unusual. The literature reports some cases of association between Eustachian valve and PFO and is known that the prominent Eustachian valve can represent a way facilitating systemic embolism.Several studies also investigated the role of Eustachian valve in the pathophysiology of both migraine and cerebral embolism. In addiction is known how Eustachian valve may increase the risk of endocarditis, which mostly affects intravenous drug abusers or those with implanted medical devices or central venous catheters. The most commonly identified organism is Staphylococcus aureus (approximately 53% of cases). We present a case of a 46-year-old woman with known migraine. She was hospitalized in Stroke Unit for a cryptogenic stroke with a right-to-left shunt detected with transcranial doppler ultrasound with “bubble test” and a patent foramen ovale with right-to-left shunt with a fenestration of atrial septum and a voluminous Eustachian valve detected with transesophageal echocardiography;she developed fever with a blood cultures positive for methicillin-resis- tant Staphylococcus aureus (MRSA), even if without evidence of endocarditis vegetations. In summary, the objective of our paper is to present an example of a correlation between the persistence of the Eustachian valve with bothcryptogenetic stroke, possible valve infection and migraine.

A caval homograft for Budd-Chiari syndrome due to inferior vena cava obstruction

Transjugular intrahepatic portosystemic shunt (TIPS) is the standard treatment of Budd-Chiari syndrome (BCS) non responsive to medical therapy. However, patients with inferior vena cava (IVC) obstruction proximal to the atrium do not benefit from TIPS and a surgical approach is mandatory. We report the case of BCS due to intrapericardial IVC obstruction. We describe a novel surgical approach using a fresh caval homograft. An attempt to balloon dilatation of the IVC obstruction was complicated by right atrial disruption with tamponade and ventricular fibrillation. Lately, the patient successfully underwent a reconstruction of the cavo-atrial continuity by the interposition of a fresh caval homograft, a novel surgical approach never described before for BCS. Further follow-up revealed progressive reduction and resolution of ascites, and overall clinical improvement. IVC obstruction near to the atrium can be surgically approached with a new technique consisting in inferior vena cava resection and replacement with a caval homograft.

Anticoagulation in elderly patients at high risk of atrial fibrillation without documented arrhythmias

Recent studies have suggested that patients with high CHA2DS2VASc-score [Congestive Heart failure, hyperten- sion, Age ≥ 75 years （doubled）, Diabetes, Stroke （doubled）, Vascular disease, Age 65-74 years, Sex category （female sex）] thromboembolic complications occurred irrespective of the presence of atrial fibrillation （AF） and anticoagulant therapy may be initiated irrespective of documented AF.

Avocado and Cardiovascular Health

Avocado is a fruit which had a caloric density of 1.7 kcal per gram and a half unit (~70 g) is composed by 114 kcal, 4.6 g of fibers, 345 mg of potassium, 19.5 mg of magnesium, 1.3 mg of vitamin E and 57 mg of phytosterols. Approximately 75% of fiber’s avocado contents are considered insoluble and 25% are soluble. The avocado contains lipids that consist of 71% from monounsaturated fatty acids (MUFA), 13% from polyunsaturated (PUFA) and 16% from saturated fatty acids (SFA). Recent researches have shown that avocado may improve hypercholesterolemia and may be useful in the treatment of hypertension and type 2 diabetes mellitus (T2DM). This way, avocado plays an important role in the cardiovascular health. This review summarizes the potential benefits of avocado consumption in the prevention of cardiovascular risk factors and metabolic diseases.

Endothelial dysfunction as a predictor of cardiovascular disease in type 1 diabetes

Macro and microvascular disease are the main cause of morbi-mortality in type 1 diabetes(T1DM).Although there is a clear association between endothelial dysfunction and atherosclerosis in type 2 diabetes,a cause-effect relationship is less clear in T1 DM.Although endothelial dysfunction(ED) precedes atherosclerosis,it is not clear weather,in recent onset T1 DM,it may progress to clinical macrovascular disease.Moreover,endothelial dysfunction may either be reversed spontaneously or in response to intensive glycemic control,long-term exercise training and use of statins.Acute,long-term and post-prandial hyperglycemia as well as duration of diabetes and microalbuminuria are all conditions associated with ED in T1 DM.The pathogenesis of endothelial dysfunction is closely related to oxidative-stress.NAD(P)H oxidase over activity induces excessive superoxide production inside the mitochondrial oxidative chain of endothelial cells,thus reducing nitric oxide bioavailability and resulting in peroxynitrite formation,a potent oxidant agent.Moreover,oxidative stress also uncouples endothelial nitric oxide synthase,which becomes dysfunctional,inducing formation of superoxide.Other important mechanisms are the activation of both the polyol and protein kinase C pathways as well as the presence of advanced glycation end-products.Future studies are needed to evaluate the potential clinical applicability of endothelial dysfunction as a marker for early vascular complications in T1 DM.

Thrombosis in ST-elevation myocardial infarction:Insights from thrombi retrieved by aspiration thrombectomy

In patients with ST-elevation myocardial infarction, recurrent cardiovascular events still remain the main cause of morbidity and mortality, despite significant improvements in antithrombotic therapy. We sought to review data regarding coronary thrombus analysis provided by studies using manual aspiration thrombectomy(AT), andto discuss how insights from this line of investigation could further improve management of acute coronary disease. Several studies investigated the fresh specimens retrieved by AT using techniques such as traditional morphological evaluation, optical microscopy, scanning electron microscopy, magnetic resonance imaging, and immunohistochemistry. These approaches have provided a better understanding of the composition and dynamics of the human coronary thrombosis process, as well as its relationship with some clinical outcomes. Recent data signaling to new antithrombotic therapeutic targets are still emerging.

The Impact of the Essential Fatty Acids (EFA) in Human Health

Linoleic (LA) and α-linolenic acids (ALA) are considered essential fatty acids (EFA) because they are not produced by the human body. This way, EFAs sources must come from the diet. The primary dietary source of n-3 fatty acids is ALA, found in seeds and seed oils. Other important sources are fish oils such as tuna, salmon and herring. Currently, numerous studies suggest possible benefits of essential fatty acids in human health, such as in cardiovascular, cognitive and eye health, and also during pregnancy and childhood. This paper also discusses the impact of fatty acids in human metabolism, and the available evidence regarding its risks. It addresses the relevant debate regarding a general ban of trans fatty acids (TFA) from the world food market, because of the cardiovascular risks associated with its consumption.

Compression of Left Main Coronary Artery in Patients with Pulmonary Artery Aneurysm and Pulmonary Hypertension

Background: Pulmonary artery aneurysm (PAA) is an unusual finding and its association with left main coronary (LMCA) compression is even more infrequent. Cardiac CT evaluates of presence and size of PAA and the degree of LMCA compression. The aim of this study is to describe two cases of adults with compression of LMCA with PAA associated with PDA and pulmonary hypertension. Case presentation: The first case is a 27-year-old man with PAA (78 mm diameter) and LMCA compression of 70% between the aortic sinus and the PAA. He presented angina as a manifestation of the LMCA compression. During follow-up the patient died. The second case is a 28-year-old man with PAA (110 mm diameter) that compresses LMCA in 55%, he rejected surgical treatment, but he is in close follow-up with medical treatment. Conclusion: Cardiac computed tomography played an important role both in the diagnosis and identification of high-risk PAA patients.

脊髓刺激对心脏X综合征患者自发性或应激诱发的心绞痛及“缺血样”ST段压低的影响

A significant number of patients with cardiac syndrome X(CSX) present frequent episodes of severe chest pain, refractory to maximal multi-drug therapy. A few, small, uncontrolled data suggested that spinal cord stimulation(SCS) may have favourable clinical benefits in these patients. Methods and results: We studied 10 CSX patients who were being treated by SCS for refractory angina pectoris for 17± 16 months(median 8). Patients were randomized to either continue or withdraw SCS for a period of 3 weeks and were then crossed over to the other condition for a further 3- week period. During each 3- week period patients kept a detailed diary of angina episodes occurring in the last 2 weeks of each phase. Furthermore, at the end of each 3- week period, angina status was also assessed by Seattle Angina Questionnaire(SAQ), a 0- 100 visual analogue scale(VAS), and patients underwent 24- h Holter monitoring(HM) and echocardiographic dobutamine stress test(DST). Compared with the withdrawal phase, SCS reduced the number(P=0.01), duration(P=0.022), and severity(P=0.011) of angina episodes, and nitrate consumption(P=0.042). SAQ scores(P≤ 0.013 for all) and VAS(P< 0.001) were also improved, the number of episodes of ST-segment depression on HM was decreased(P=0.014), and time to angina(P=0.045) and to 1 mm ST-segment depression(P=0.04) during DST were both prolonged by SCS. Conclusions: Our data point out that SCS may be an effective form of treatment in patients with CSX suffering from frequent angina episodes significantly impairing quality of life(QOL) and refractory to maximally tolerated drug therapy.

经电话心电图监测对房颤患者射频消融术后短期心律失常复发的监测作用

OBJECTIVES: The aim of our study was to determine the incidence of asymptomatic recurrences of atrial fibrillation(AF) by daily transtelephonic(TT) electrocardiographic(ECG) monitoring, as compared with standard ECG and 24-h Holter recording, in patients who underwent radiofrequency catheter ablation(RCA) of AF. BACKGROUND: The efficacy of RCA of AF is usually evaluated by means of patients’symptoms. METHODS: Seventy-two patients with paroxysmal(n=37) or persistent(n=35) drug-refractory AF underwent circumferential RCA of the pulmonary vein(PV) ostia. Left isthmus ablation was performed in 57 patients, and cavotricuspid isthmus ablation was done in 69 patients. Patients were scheduled to obtain an ECG and Holter recordings one and four months after ablation, as well as a daily TT ECG, from 30 to 120 days after ablation or in the event of symptoms. RESULTS:A total of 5,585 TT ECGs were obtained(mean 77.5 per patient). In 20 patients(27.8%), AF recurrences were recorded during TT ECG, whereas ECG and Holter monitoring revealed AF recurrences in 10 patients(13.9%, p=0.001). Ten patients had at least one asymptomatic AF recurrence, and eight were completely asymptomatic. The ECG recorded in the event of symptoms always showed AF. CONCLUSIONS: Transtelephonic ECG is better than standard ECG and 24-h Holter recordings in evaluating AF relapses after RCA, thus decreasing the short-term success of ablation from 86%to 72%. The absence of symptoms should not be interpreted as absence of AF, as 50%of patients were asymptomatic during at least one AF episode.

MicroRNAs as possible biomarkers for diagnosis and prognosis of hepatitis b- and c-related-hepatocellularcarcinoma

Aim of the present review is to summarize the current knowledge about the potential relationship between mi RNAs and hepatitis B virus(HBV)-hepatitis C virus(HCV) related liver diseases. A systematic computerbased search of published articles, according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis Statement, was performed to identify relevant studies on usefulness of serum/plasma/urine mi RNAs, as noninvasive biomarkers for early detection of HBV and HCV-induced hepatocellular carcinoma(HCC) development, as well as for its prognostic evaluation. The used Medical Subject Headings terms and keywords were: "HBV", "HCV", "hepatocellular carcinoma", "micro RNAs", "mi RNAs", "diagnosis", "prognosis", "therapy", "treatment". Some serum/plasma mi RNAs, including mi R-21, mi R-122, mi-125a/b, mi R-199a/b, mi R-221, mi R-222, mi R-223, mi R-224 might serve as biomarkers for early diagnosis/prognosis of HCC, but, to date, not definitive results or well-defined panels of mi RNAs have been obtained. More well-designed studies, focusing on populations of different geographical areas and involving larger series of patients, should be carried out to improve our knowledge on the potential role of mi RNAs for HCC early detection and prognosis.

Role of the HLA-DQ locus in the development of chronic gastritis and gastric carcinoma in Mexican patients

AIM： To determine the HLA-DQ locus in Mexican patients with Chronic gastritis and gastric adenocarcinoma.METHODS： Oligotyping for HLA-DQ locus was performed in 45 Mexican patients with chronic gastritis and 13 Mexican patients with diffuse-type gastric adenocarcinoma, and was then compared with 99 clinically healthy unrelated individuals. H pylori infection and CagA status were assessed in patients by enzyme-linked immunosorbent assay （EUSA） method. RESULTS： We found a significant increased frequency of HLA-DQBI＊0401 allele in Hpylori-positive patients with chronic gastritis when compared with healthy subjects [19 vs 0%, P = 1 × 10^-7, odds ratio （OR） = 4.96; 95% confidence interval （95% CI）, 3.87-6.35]. We also found a significant increased frequency of HLA-DQBI＊0501 in patients with diffuse-type gastric carcinoma in comparison with healthy individuals （P = 1 × 10^4, OR = 13.07; 95% CI, 2.82-85.14）.CONCLUSION： HLA-DQ locus may play a different role in the development of H pylori-related chronic gastritis and difffuse-type gastric adenocarcinoma in the Mexican Mestizo population.