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Background: Cardiovascular (CV) disease (CVD) remains the leading cause of death globally. Besides lack of exercise, obesity, smoking, and other risk factors, poor nutrition and unhealthy/ unbalanced diets play an important role in CVD.... more
Background: Cardiovascular (CV) disease (CVD) remains the leading cause of death globally. Besides lack of exercise, obesity, smoking, and other risk factors, poor nutrition and unhealthy/ unbalanced diets play an important role in CVD. Objective: This review examined data on all issues of the CV-health benefits of a balanced diet, with tabulation of nutritional data and health-authority recommendations and pictorial illustration of the main features of a CV-healthy diet. Methods: PubMed and Google Scholar were searched for relevant studies and reviews on diet and CV health. Results: For a long time, there has been evidence, corroborated by recent findings, that pro-vegetarian diets have a beneficial influence on serum lipid levels, markers of inflammation and endothelial function, prooxidant-antioxidant balance, and gut microbiome, all probably contributing to reduced CV risk. Worries about the nutritional adequacy of vegetarian diets are circumvented by obtaining certain nutrients lacking or found in lower amounts in plants than in animal foods, by consuming a wide variety of healthy plant foods and through intake of oral supplements or fortified foods. Well-balanced diets, such as the Mediterranean or the Dietary-Approaches-to-Stop-Hypertension diets, provide CV-health benefits. Nevertheless, a broad variety of plant-based diets with low/minimal animal food intake may allow for a personalized and culturally adjusted application of dietary recommendations contributing to the maintenance of CV health. Conclusion: Universal adoption of a balanced CV-healthy diet can reduce global, CV and other mortality by ~20%. This requires world-wide programs of information for and education of the public, starting with school children and expanding to all groups, sectors, and levels.
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Growing evidence suggests that atrial fibrillation (AF), in addition to its thromboembolic risk, is a risk factor for cognitive impairment (CI) via several pathways and mechanisms, further contributing to morbidity/mortality. Prior stroke... more
Growing evidence suggests that atrial fibrillation (AF), in addition to its thromboembolic risk, is a risk factor for cognitive impairment (CI) via several pathways and mechanisms, further contributing to morbidity/mortality. Prior stroke is a contributor to CI, but AF is also associated with CI independently from prior stroke. Silent brain infarctions, microemboli and microbleeds, brain atrophy, cerebral hypoperfusion from widely fluctuating ventricular rates, altered hemostatic function, vascular oxidative stress, and inflammation may all exacerbate CI, particularly in patients with persistent/permanent rather than paroxysmal AF and with increased duration/burden of the arrhythmia. Brain magnetic resonance imaging is an important screening tool in eliciting and monitoring vascular and nonvascular lesions contributing to CI. Evidence is also emerging about the role of genetics in CI development. Anticoagulation and rhythm/rate control strategies may protect against CI preventing or slowing its progression or conversion to dementia, particularly at the early stages when CI may still be a treatable condition. Importantly, AF and CI share many common risk factors. Thus, screening for these 2 conditions and searching for and managing modifiable risk factors and potentially reversible causes for both AF and CI remains an important step toward prevention or amelioration of the impact incurred by these 2 conditions.
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Purpose of review The new pandemic of coronavirus disease-2019 (COVID-19) has produced a global tumult and has overburdened national health systems. We herein discuss the cardiovascular implications and complications of this pandemic... more
Purpose of review The new pandemic of coronavirus disease-2019 (COVID-19) has produced a global tumult and has overburdened national health systems. We herein discuss the cardiovascular implications and complications of this pandemic analyzing the most recent data clustered over the last several months. Recent findings COVID-19 afflicts the cardiovascular system producing acute cardiac injury in 10–20% of cases with mild disease but in greater than 50–60% in severe cases, contributing to patients’ demise. Other cardiovascular complications include arrhythmias, heart failure, pulmonary embolism and shock. Off-label therapies are being trialed with their own inherent cardiovascular risks, while supportive therapies currently dominate, until more specific and effective antiviral therapies and vaccinations become available. A controversial issue relates to the safety of drugs blocking the renin--angiotensin system as an angiotensin-converting enzyme (ACE) homologue, ACE2, serves as the receptor for viral entry into host cells. However, to-date, no harm has been proven for these drugs. Summary In the cardiovascular system, COVID-19 can induce acute cardiac injury, arrhythmias, heart failure, pulmonary embolism, shock and death, whereas anti-COVID therapies also confer serious cardiovascular side-effects. Ongoing extensive efforts focus on specific vaccines and antivirals. Meanwhile, cardiovascular risk factors and diseases should be jointly controlled according to current evidence-based guidelines.
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Takotsubo syndrome (TTS), triggered by intense emotional or physical stress, occurring most commonly in post-menopausal women, presents as an ST-elevation myocardial infarction (MI). Cardiovascular complications occur in almost half the... more
Takotsubo syndrome (TTS), triggered by intense emotional or physical stress, occurring most commonly in post-menopausal women, presents as an ST-elevation myocardial infarction (MI). Cardiovascular complications occur in almost half the patients with TTS, and the inpatient mortality is comparable to MI (4–5%) owing to cardiogenic shock, myocardial rupture, or life-threatening arrhythmias. Thus, its prognosis is not as benign as previously thought, as it may cause mechanical complications (cardiac rupture) and potentially lethal arrhythmias and sudden cardiac death (SCD). Similar to MI, some patients may perish before reaching the hospital due to out-of-hospital cardiac arrest; this may lead to underestimation of the actual SCD risk. Furthermore, after discharge, some patients may develop late SCD and/or TTS recurrence that may result in SCD. There are risk factors for SCD in TTS patients, such as severe/persistent QT-interval prolongation inciting torsade-de-pointes, other ECG abnormalities (diffuse giant negative T-waves, widened QRS-complex), bradyarrhythmias, comorbidities, concurrent obstructive coronary artery disease or vasospasm, male gender, older age, severe left ventricular dysfunction, and use of sympathomimetic drugs. All these issues are herein reviewed, case reports/series and data from large cohort studies and meta-analyses are analyzed, risk factors are tabulated, and proarrhythmic effects and management strategies are discussed and pictorially illustrated.
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: Caffeinated beverages are the most widely consumed beverages globally with coffee and tea as the two most prominent sources of caffeine. Caffeine content varies across different types of beverages. In addition to caffeine, coffee and... more
: Caffeinated beverages are the most widely consumed beverages globally with coffee and tea as the two most prominent sources of caffeine. Caffeine content varies across different types of beverages. In addition to caffeine, coffee and tea have other biologically active compounds, and all may affect general and cardiovascular (CV) health. Moderate caffeine consumption (<300-400 mg/day), regardless of the source, is considered safe by both European and US Health Authorities, as it is not associated with adverse health and CV effects, while it may confer certain health benefits. There is a nonlinear association between coffee ingestion and CV risk; moderate coffee drinking is inversely significantly associated with CV risk, with the highest benefit at 2-4 cups per day, while heavy coffee drinking might confer increased risk. With regards to tea, due to a lower caffeine content per serving, its consumption is only limited by the total caffeine daily intake. Both these caffeinated beverages, coffee and tea, have additional phenolic compounds, with anti-oxidant and anti-inflammatory activities, which confer cardioprotective benefits. Of the several coffee compounds, chloroacetic acids and melanoidins offer such beneficial effects, while diterpenes may have unfavorable effects on lipids. Most of the tea ingredients (polyphenols) are cardioprotective. A major concern relates to energy drinks with their much higher caffeine content which puts individuals, especially adolescents and young adults, at high health and CV risk. All these issues are herein discussed, including pertinent studies and meta-analyses, pathogenetic mechanisms involved and relevant recommendations from health authorities.
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The arrhythmogenic potential of alcohol consumption that leads to cardiac arrhythmia development includes the induction of both atrial and ventricular arrhythmias, with atrial fibrillation (AF) being the commonest alcohol-related... more
The arrhythmogenic potential of alcohol consumption that leads to cardiac arrhythmia development includes the induction of both atrial and ventricular arrhythmias, with atrial fibrillation (AF) being the commonest alcohol-related arrhythmia, even with low/moderate alcohol consumption. Arrhythmias occur both with acute and chronic alcohol use. The "Holiday Heart Syndrome" relates to the occurrence of AF, most commonly following weekend or public holiday binge drinking; however, other arrhythmias may also occur, including other supraventricular arrhythmias, and occasionally even frequent ventricular premature beats and a rare occurrence of ventricular tachycardia. Arrhythmias in individuals with alcohol use disorder, in addition to AF, may comprise ventricular arrhythmias (VAs) that may be potentially fatal leading to cardiac arrest. The effects of alcohol on triggering VAs appear to be dose-dependent, observed more commonly in heavy drinkers, both in healthy individuals and patients with underlying structural heart disease, including ischemic heart disease and alcoholic cardiomyopathy. Men appear to be affected at higher dosages of alcohol, while women can suffer from arrhythmias at lower dosages. On the other hand, low to moderate consumption of alcohol may confer some protection from serious VAs and cardiac arrest (J- or U-curve phenomenon); however, abstinence is the optimal strategy. These issues as they relate to alcohol-induced proarrhythmia are herein reviewed, with the large studies and meta-analyses tabulated and the arrhythmogenic mechanisms pictorially illustrated.
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: In addition to the association of dietary patterns, specific foods and nutrients with several diseases, including cardiovascular disease and mortality, there is also strong emerging evidence of an association of dietary patterns with... more
: In addition to the association of dietary patterns, specific foods and nutrients with several diseases, including cardiovascular disease and mortality, there is also strong emerging evidence of an association of dietary patterns with the risk of sudden cardiac death (SCD). In this comprehensive review, data are presented and analyzed about foods and diets that mitigate the risk of ventricular arrhythmias (VAs) and SCD, but also about arrhythmogenic nutritional elements and patterns that seem to enhance or facilitate potentially malignant VAs and SCD. The antiarrhythmic or protective group comprises fish, nuts and other foods enriched in omega-3 polyunsaturated fatty acids, the Mediterranean and other healthy diets, vitamins E, A and D and certain minerals (magnesium, potassium, selenium). The arrhythmogenic-food group includes saturated fat, trans fats, ketogenic and liquid protein diets, the Southern and other unhealthy diets, energy drinks and excessive caffeine intake, as well as heavy alcohol drinking. Relevant antiarrhythmic mechanisms include modification of cell membrane structure by n-3 polyunsaturated fatty acids, their direct effect on calcium channels and cardiomyocytes and their important role in eicosanoid metabolism, enhancing myocyte electric stability, reducing vulnerability to VAs, lowering heart rate, and improving heart rate variability, each of which is a risk factor for SCD. Contrarily, saturated fat causes calcium handling abnormalities and calcium overload in cardiomyocytes, while a high-fat diet causes mitochondrial dysfunction that dysregulates a variety of ion channels promoting VAs and SCD. Free fatty acids have been considered proarrhythmic and implicated in facilitating SCD; thus, diets increasing free fatty acids, e.g., ketogenic diets, should be discouraged and replaced with diets enriched with polyunsaturated fatty acids, which can also reduce free fatty acids. All available relevant data on this important topic are herein reviewed, large studies and meta-analyses and pertinent advisories are tabulated, while protective (antiarrhythmic) and arrhythmogenic specific diet constituents are pictorially illustrated.
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As a potentially life-threatening disease with no definitive treatment and without fully implemented population-wide vaccination, COVID-19 has created unprecedented turmoil in socioeconomic life worldwide. In addition to physical signs... more
As a potentially life-threatening disease with no definitive treatment and without fully implemented population-wide vaccination, COVID-19 has created unprecedented turmoil in socioeconomic life worldwide. In addition to physical signs from the respiratory and many other systems, the SARS-CoV-2 virus produces a broad range of neurological and neuropsychiatric problems, including olfactory and gustatory impairments, encephalopathy and delirium, stroke and neuromuscular complications, stress reactions, and psychoses. Moreover, the psychosocial impact of the pandemic and its indirect effects on neuropsychiatric health in noninfected individuals in the general public and among health care workers are similarly far-ranging. In addition to acute neuropsychiatric manifestations, COVID-19 may also produce late neuropsychiatric sequelae as a function of the psychoneuroimmunological cascade that it provokes. The present article presents a state-of-the-science review of these issues through an integrative review and synthesis of case series, large-cohort studies, and relevant meta-analyses. Heuristics for evaluation and further study of the neuropsychiatric manifestations of SARS-CoV-2 infection are offered.
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The autonomic nervous system (ANS) with its two limbs, the sympathetic (SNS) and parasympathetic nervous system (PSNS), plays a critical role in the modulation of cardiac arrhythmogenesis. It can be both pro- and/or anti-arrhythmic at... more
The autonomic nervous system (ANS) with its two limbs, the sympathetic (SNS) and parasympathetic nervous system (PSNS), plays a critical role in the modulation of cardiac arrhythmogenesis. It can be both pro- and/or anti-arrhythmic at both the atrial and ventricular level of the myocardium. Intricate mechanisms, different for specific cardiac arrhythmias, are involved in this modulatory process. More data are available for the arrhythmogenic effects of the SNS, which, when overactive, can trigger atrial and/or ventricular "adrenergic" arrhythmias in susceptible individuals (e.g. in patients with paroxysmal atrial fibrillation-PAF, ventricular pre-excitation, specific channelopathies, ischemic heart disease or cardiomyopathies), while it can also negate the protective anti-arrhythmic drug effects. However, there is also evidence that PSNS overactivity may be responsible for triggering "vagotonic" arrhythmias (e.g. PAF, Brugada syndrome, idiopathic ventricular fibrillation). Thus, a fine balance is necessary to attain in these two limbs of the ANS in order to maintain eurhythmia, which is a difficult task to accomplish. Over the years, in addition to classical drug therapies, where beta-blockers prevail, several ANS-modulating interventions have been developed aiming at prevention and management of arrhythmias. Among them, techniques of cardiac sympathetic denervation, renal denervation, vagal stimulation, ganglionated plexi ablation and the newer experimental method of optogenetics have been employed. However, in many arrhythmogenic diseases, ANS modulation is still an investigative tool. Initial data are encouraging; however, further studies are needed to explore the efficacy of such interventions. These issues are herein reviewed and old and recent literature data are discussed, tabulated and pictorially illustrated.
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The changes introduced with the new (2018) compared with the previous (2013) European Hypertension Guidelines are herein highlighted together with some notable differences from current (2017) American Guidelines. Rhythmos 2018;13(4):71-74.
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The ongoing COVID-19 pandemic has produced serious turmoil world-wide. Lung injury causing acute respiratory distress syndrome (ARDS) appears to be a most dreaded complication occurring in ∼30%. Older patients with cardiovascular (CV)... more
The ongoing COVID-19 pandemic has produced serious turmoil world-wide. Lung injury causing acute respiratory distress syndrome (ARDS) appears to be a most dreaded complication occurring in ∼30%. Older patients with cardiovascular (CV) comorbidities and ARDS have an increased mortality. Although the precise mechanisms involved in the development of lung injury have not been fully elucidated, the role of the extended renin-angiotensin system (RAS) appears to be pivotal. In this context, angiotensin-converting enzyme 2 (ACE2), an ACE homologue, has been recognized as a facilitator of viral entry into the host, albeit its involvement in other counter-regulatory effects, such as converting angiotensin (Ang) II into Ang 1-7 with its known protective actions. Thus, concern was raised that the use of RAS inhibitors by increasing ACE2 expression may enhance patient susceptibility to the COVID virus. However, current data have appeased such concerns as there has been no clinical evidence of a harmful effect of these agents as based on observational studies. However, properly designed future studies will be needed to further confirm or refute current evidence. Furthermore, other pathways may also play important roles in COVID-19 transmission and pathogenesis; spike (S) protein proteases facilitate viral transmission by cleaving S protein that promotes viral entry into the host; neprilysin (NEP), a neutral endopeptidase known to cleave natriuretic peptides, degrades Ang I into Ang 1-7; NEP can also catabolize bradykinin and thus mitigate bradykinin's role in inflammation, while, in the same context, specific bradykinin inhibitors might also negate bradykinin's harmful effects. Based on these intricate mechanisms, various preventive and therapeutic strategies may be devised, such as upregulating ACE2 and/or using recombinant ACE2, and exploiting the NEP, bradykinin and serine protease pathways, in addition to anti-inflammatory and antiviral therapies. These issues are herein reviewed, available studies are tabulated and pathogenetic mechanisms are pictorially illustrated.
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The increased metabolic activity of the heart as a pump involves a high demand of mitochondrial adenosine triphosphate (ATP) production for its mechanical and electrical activities accomplished mainly via oxidative phosphorylation,... more
The increased metabolic activity of the heart as a pump involves a high demand of mitochondrial adenosine triphosphate (ATP) production for its mechanical and electrical activities accomplished mainly via oxidative phosphorylation, supplying up to 95% of the necessary ATP production, with the rest attained by substrate-level phosphorylation in glycolysis. In the normal human heart, fatty acids provide the principal fuel (40–70%) for ATP generation, followed mainly by glucose (20–30%), and to a lesser degree (<5%) by other substrates (lactate, ketones, pyruvate and amino acids). Although ketones contribute 4–15% under normal situations, the rate of glucose use is drastically diminished in the hypertrophied and failing heart which switches to ketone bodies as an alternate fuel which are oxidized in lieu of glucose, and if adequately abundant, they reduce myocardial fat delivery and usage. Increasing cardiac ketone body oxidation appears beneficial in the context of heart failure (H...
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ABSTRACT Lipoprotein(a) or lipoprotein "little a" is an under-recognized causal risk factor for cardiovascular (CV) disease (CVD), including coronary atherosclerosis, aortic valvular stenosis, ischemic stroke, heart failure and... more
ABSTRACT Lipoprotein(a) or lipoprotein "little a" is an under-recognized causal risk factor for cardiovascular (CV) disease (CVD), including coronary atherosclerosis, aortic valvular stenosis, ischemic stroke, heart failure and peripheral arterial disease. Elevated plasma Lp(a) (≥50 mg/dL or ≥100 nmol/L) is commonly encountered in almost 1 in 5 individuals and confers a higher CV risk compared to those with normal Lp(a) levels, although such normal levels have not been generally agreed upon. Elevated Lp(a) is considered a cause of premature and accelerated atherosclerotic CVD. Thus, in patients with a positive family or personal history of premature coronary artery disease (CAD), Lp(a) should be measured. However, elevated Lp(a) may confer increased risk for incident CAD even in the absence of a family history of CAD, and even in those who have guideline-lowered LDL-cholesterol (<70 mg/dl) and continue to have a persisting CV residual risk. Thus, measurement of Lp(a) will have a significant clinical impact on the assessment of atherosclerotic CVD risk, and will assume a more important role in managing patients with CVD with the advent and clinical application of specific Lp(a)-lowering therapies. Conventional therapeutic approaches like lifestyle modification and statin therapy remain ineffective at lowering Lp(a). Newer treatment modalities, such as gene silencing via RNA interference with use of antisense oligonucleotide(s) or small interfering RNA molecules targeting Lp(a) seem very promising. These issues are herein reviewed, accumulated data are scrutinized, meta-analyses and current guidelines are tabulated and Lp(a)-related CVDs and newer therapeutic modalities are pictorially illustrated.
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Foramen ovale plays a very important role in fetal circulation by bypassing the lungs and diverting circulation from the right to the left heart. With birth it is usually sealed; however, probe patent or incompletely sealed foramen ovale... more
Foramen ovale plays a very important role in fetal circulation by bypassing the lungs and diverting circulation from the right to the left heart. With birth it is usually sealed; however, probe patent or incompletely sealed foramen ovale remains in approximately 25% of adults. Patent ...
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In Part 1 of this Thematic Issue entitled “Systemic Autoimmune Rheumatic Diseases and Cardiology”, a panel of specialists and experts in cardiology, rheumatology, immunology and related fields discussed the cardiovascular complications of... more
In Part 1 of this Thematic Issue entitled “Systemic Autoimmune Rheumatic Diseases and Cardiology”, a panel of specialists and experts in cardiology, rheumatology, immunology and related fields discussed the cardiovascular complications of spondyloarthritides, rheumatoid arthritis, Sjogren’s syndrome and vasculitides, as well as relevant cardiovascular issues related to non-biologic and biologic disease-modifying anti-rheumatic drugs (DMARDs), and provided their recommendations for prevention and management of these complications. In part 2 of this Thematic Issue, experts discuss the enhanced cardiovascular risk conferred by additional autoimmune rheumatic diseases (ARDs), including systemic lupus erythematosus, the antiphospholipid syndrome, psoriasis and psoriatic arthritis and juvenile idiopathic arthritis. These, and the previous articles, place inflammation as the key common link to explain the enhanced risk of cardiovascular complications in patients with ARDs. It follows that ...
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Ensuing the recent approval of novel oral anticoagulant agents (NOACs) in Greece and many other countries for stoke prevention in patients with non-valvular atrial fibrillation (AF), an overview is herein attempted of some practical... more
Ensuing the recent approval of novel oral anticoagulant agents (NOACs) in Greece and many other countries for stoke prevention in patients with non-valvular atrial fibrillation (AF), an overview is herein attempted of some practical points concerning their use with regards to agent selection and patient monitoring. There are currently 3 NOACs, dabigatran (a direct thrombin inhibitor), rivaroxaban and apixaban (direct factor Xa inhibitors), among which physicians are called upon to choose if they decide to use these more expensive agents in lieu of the much cheaper classic vitamin K antagonists (VKA), either to initiate or switch anticoagulant therapy in patients with AF. All three NOACs were evaluated in large randomized trials and found to be effective anticoagulants in patients with non-valvular AF, with comparable to or improved efficacy over warfarin, and a significant reduction in intracranial hemorrhage compared to warfarin. There was even a significant (apixaban) or strong tr...
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positions in the right ventricular outflow tract for ventricular pacing. Methods and Results: During our participation in an international multicenter study, we randomized 30 patients with standard indications for permanent dual-chamber... more
positions in the right ventricular outflow tract for ventricular pacing. Methods and Results: During our participation in an international multicenter study, we randomized 30 patients with standard indications for permanent dual-chamber pacing to alternate site pacing with the use of a new, thin and compact, active fixation and steroid-eluting pacing lead and a steerable guiding catheter system. The study group comprised 18 men and 12 women, with a mean age of 70±12 years, afflicted by sick sinus syndrome (n=6), Mobitz II or complete atrioventricular block (n=22) or both (n=2). The randomized pacing sites included the interatrial septum/high anterior right ventricular outflow tract (n=15) and the coronary sinus ostium/low septal right ventricular outflow tract (n=15). Implantation of the pacing system with the use of novel technology leads assisted by a steerable catheter system was successful in 28 patients (93%). There was one complication (pneumothorax) not related to the pacing ...
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In the current Thematic Issue of Current Vascular Pharmacology (CVP), entitled “Systemic Autoimmune Rheumatic Diseases and Cardiology”, presented in two parts, Part 1 and Part 2, review articles are included from specialists in... more
In the current Thematic Issue of Current Vascular Pharmacology (CVP), entitled “Systemic Autoimmune Rheumatic Diseases and Cardiology”, presented in two parts, Part 1 and Part 2, review articles are included from specialists in cardiology, rheumatology, immunology and related fields. These reviews discuss the cardiovascular complications of the main systemic Autoimmune Rheumatic Diseases (ARDs). For example, the underlying pathogenetic mechanisms, the role of cardiovascular imaging and recommendations for prevention and management. These articles place inflammation as the key process, linking cardiovascular complications with ARDs. From all these reviews, the conclusion is the need for collaboration between the disciplines of Rheumatology and Cardiology to establish the emerging field of Cardio- Rheumatology. This will aid to fine-tune risk stratification and optimize preventive strategies and pharmacological therapies for patients with ARDs.
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An 18-year-old gentleman with a 5-year-long history of palpitations was referred for radiofrequency ablation of a wide-QRS complex tachycardia. He admitted having 2-3 tachycardia episodes per year, which had recently increased in... more
An 18-year-old gentleman with a 5-year-long history of palpitations was referred for radiofrequency ablation of a wide-QRS complex tachycardia. He admitted having 2-3 tachycardia episodes per year, which had recently increased in frequency despite therapy with a beta blocker, recently combined with the antiarrhythmic medication flecainide (100 mg bid). The morphology of the tachycardia on the 12-lead electrocardiogram indicated a right bundle branch block with a left axis deviation at a cycle length of 290 ms (207 bpm) ( Fig . 1A). Cardiac work-up revealed a normal heart anatomy by echocardiography, while a treadmill test was normal with no provokable arrhythmia... (excerpt)
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A 37-year old male came to the emergency room complaining of atypical chest pain of a few hours duration. Initial ECG displayed atrial flutter with 3:1 atrioventricular (AV) conduction with mostly pronounced inferior-wall but also diffuse... more
A 37-year old male came to the emergency room complaining of atypical chest pain of a few hours duration. Initial ECG displayed atrial flutter with 3:1 atrioventricular (AV) conduction with mostly pronounced inferior-wall but also diffuse ST-T changes suspect of acute ST elevation myocardial infarction (STEMI) ( Figure, panel A ) with already established inferior Q waves. However, due to non-convincing clinical history, further investigation was undertaken, which showed a normal bedside echocardiogram, while determination of cardiac enzymes confirmed normal values which remained normal at subsequent measurements... (excerpt)
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Classical risk factors for the development of atherosclerosis include hypercholesterolemia, hypertension, smoking, and diabetes. When the atheromatous plaque erodes or ruptures, local thrombosis develops which leads to partial or complete... more
Classical risk factors for the development of atherosclerosis include hypercholesterolemia, hypertension, smoking, and diabetes. When the atheromatous plaque erodes or ruptures, local thrombosis develops which leads to partial or complete vessel occlusion with its attendant potentially catastrophic consequences. Thus, the term athero-thrombotic disease has been adopted. However, inflammation is also a major contributor to the initiation and evolution of this process and has not been adequately addressed. The concept that atherosclerosis is an inflammatory disease has caused a paradigm shift in our understanding of its pathogenesis. Recent convincing evidence has accumulated that inflammation plays a fundamental role in atherothrombosis and the associated risk may be equal to that of hyperlipidemia. Based on this concept, new biomarkers and novel anti-inflammatory and immune therapies are being currently tested for managing atherosclerotic cardiovascular disease.
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The new Dietary Guidelines for Americans 2015-2020 focus on healthy eating patterns and exercise. They recommend 3 different healthy eating patterns: the Healthy US Style, the Healthy Mediterranean Style, and the Healthy Vegetarian Style... more
The new Dietary Guidelines for Americans 2015-2020 focus on healthy eating patterns and exercise. They recommend 3 different healthy eating patterns: the Healthy US Style, the Healthy Mediterranean Style, and the Healthy Vegetarian Style eating pattern, accommodating a variety of cultural and individual preferences, but sharing many common food based features. A healthy eating pattern includes a variety of vegetables, fruits, grains, low-fat dairy products, protein foods, and oils. Specific recommendations have been made for particular dietary components to reduce: saturated fat (< 10% of calories); sodium (< 2.3 g/day); and added sugars (< 10% of calories). Interestingly, these guidelines do not make a recommendation for a quantitative limit for dietary cholesterol indicating the lack of adequate evidence for such recommendation. However, they state that there is evidence showing that eating patterns that include lower intake of dietary cholesterol (~100 - 300 mg/d) are as...
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A case of complex and arduous percutaneous cardiac implantable electronic device (CIED) lead extraction is presented that illustrates several aspects of technical challenges that may emerge during the procedure requiring a change of... more
A case of complex and arduous percutaneous cardiac implantable electronic device (CIED) lead extraction is presented that illustrates several aspects of technical challenges that may emerge during the procedure requiring a change of strategy, appropriate tool selection, and operator and patient endurance. Rhythmos 2018;13(4):78-80 .
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Consumption of added sugar is associated with weight gain and metabolic syndrome, but most importantly with cardiovascular disease (CVD) morbidity and mortality. Sugar-sweetened beverages (SSBs) in the form of soft drinks or sodas... more
Consumption of added sugar is associated with weight gain and metabolic syndrome, but most importantly with cardiovascular disease (CVD) morbidity and mortality. Sugar-sweetened beverages (SSBs) in the form of soft drinks or sodas constitute a major source of added sugar with its attendant ill effects on health. Of particular concern is the rising consumption of soft drinks among young people. The World Health Organization (WHO) recommends the reduction of free sugars to <10% of total energy intake due to their potential implications in dental caries, weight gain and CVD consequences, however, adherence to this recommendation is generally very low. Non-caloric drinks in the form of artificially sweetened beverages (ASBs) (diet sodas) are popular as alternatives to SSBs. However, these sweeteners may also have various negative, albeit at a lesser degree, health outcomes, including weight gain, obesity, metabolic syndrome, type II diabetes, and CV events. Finally, substantially low...
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Digoxin is one of the oldest of cardiovascular drugs which is still frequently used, both in patients with atrial fibrillation (AF) and patients with heart failure with or without AF. The use of digoxin preceded the era of evidence based... more
Digoxin is one of the oldest of cardiovascular drugs which is still frequently used, both in patients with atrial fibrillation (AF) and patients with heart failure with or without AF. The use of digoxin preceded the era of evidence based medicine. However, over the recent past, there has been growing evidence disputing and challenging the safety and efficacy of digoxin, while evidence has accumulated that a plethora of other therapies for both heart failure and atrial tachyarrhythmias has proven more effective and safe. Nevertheless, digoxin still retains its role, albeit limited, in the current era, but most recent evidence has cast significant doubts about its safety. Thus, its role remains controversial and the drug should be reserved for specific patients and clinical scenarios, with careful monitoring of its serum concentration due to its narrow therapeutic and toxic ranges, maintaining it <0.8 ng/mL, with additional monitoring of serum electrolytes and renal function to avo...
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An 84-year-old lady, admitted with acute inferior wall myocardial infarction (STEMI), was subjected to emergent coronary angiography and percutaneous coronary intervention (PCI) of a totally occluded right coronary artery (RCA). When the... more
An 84-year-old lady, admitted with acute inferior wall myocardial infarction (STEMI), was subjected to emergent coronary angiography and percutaneous coronary intervention (PCI) of a totally occluded right coronary artery (RCA). When the occlusion was crossed with an angioplasty wire and dilated with a small balloon, it became apparent that the artery had markedly reduced flow as it was filled with thrombi, which were successfully removed with use of a thromboaspiration catheter. Thromboaspiration, subsequent stenting and a IIB/IIIA antiplatlet agent led to full mechanical recanalization and complete restoration of TIMI 3 blood flow to the artery. This interventional strategy prevented distal embolization of the intracoronary thrombi and thus the noreflow phenomenon, which would have otherwise developed in this complex PCI case with such a heavy thrombotic load.
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A 14-year-old was diagnosed with recurrent bouts of narrow-QRS complex tachycardia displaying the phenomenon of “warm-up” and “cool-down” that aided in the differential diagnosis. Rhythmos 2017;12(3):52.
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A sizeable proportion of individuals contracting the corona virus disease 2019 (COVID-19) infection remains asymptomatic, while some patients develop mild symptoms and others exhibit severe symptomatology becoming critically ill... more
A sizeable proportion of individuals contracting the corona virus disease 2019 (COVID-19) infection remains asymptomatic, while some patients develop mild symptoms and others exhibit severe symptomatology becoming critically ill necessitating admission to intensive care unit exposed to a high mortality risk The pathophysiological mechanisms underlying this diversity in the clinical picture of COVID-19 are poorly understood A variety of reasons have been postulated, among which, viral load, age, gender, immune response, blood type, genotypes, polymorphisms, comorbidities and pre-existing immunity are actively explored Thus, there is a dire need to further elucidate this phenomenon and find ways to identify and discern susceptible from resistant individuals with the ultimate goal to find a cure for the disease These issues are herein discussed and pertinent recent literature is reviewed [ABSTRACT FROM AUTHOR] Copyright of Rhythmos is the property of Evagelismos General Hospital of Ath...
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Over the recent years, new oral anticoagulant agents have been developed and entered the clinical arena, the direct or non-vitamin K oral anticoagulants (NOACs). Although more expensive, these agents have been proven as equivalent or... more
Over the recent years, new oral anticoagulant agents have been developed and entered the clinical arena, the direct or non-vitamin K oral anticoagulants (NOACs). Although more expensive, these agents have been proven as equivalent or superior to vitamin K antagonists in the treatment of non-valvular atrial fibrillation (AF) and venous thrombo-embolism with a lower incidence of intracerebral hemorrhage. Nevertheless, occurrence of major or life-threatening bleeding events is still quite possible. Thus, there is a major concern regarding the lack of a specific antidote and rapid reversal agent in such disastrous situations. Fortunately, the development of effective specific NOAC antidotes has recently made great advances, which are herein briefly reviewed.
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Contemporary technology using mapping tools and algorithms in animal and computer models has suggested discrete atrial fibrillation (AF)-sustaining mechanisms in the form of electric rotors as focal areas of AF perpetuation. When these... more
Contemporary technology using mapping tools and algorithms in animal and computer models has suggested discrete atrial fibrillation (AF)-sustaining mechanisms in the form of electric rotors as focal areas of AF perpetuation. When these focal sites were targeted, ablation initially appeared promising in reducing the recurrence rates of AF. However, many other investigators have been unable to reproduce this kind of success with focal impulse and rotor modulation (FIRM)-guided ablation, and have cast doubts on the effectiveness of this novel technique that could have led to a paradigm-shift in our approach to AF ablation. A single randomized trial that was recently published in a high-impact cardiology journal indicating poor results of rotor ablation was subsequently retracted amidst a cloud of controversy and doubt about the flaws and conflicts of current medical publishing. Thus, until further evidence from ongoing and future randomized studies becomes available, the target of foca...
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A case of a patient with Brugada pattern on ECG is presented with dubious symptoms whose management was guided by an electrophysiology (EP) study where programmed ventricular stimulation easily induced ventricular fibrillation with only... more
A case of a patient with Brugada pattern on ECG is presented with dubious symptoms whose management was guided by an electrophysiology (EP) study where programmed ventricular stimulation easily induced ventricular fibrillation with only two ventricular extrastimuli and facilitated a decision to implant a defibrillator for sudden death protection. Images of the EP tracings are provided that illustrate the findings and the pros and cons of such an approach are herein discussed. Rhythmos 2019;14(3):55-57 .
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Bicuspid aortic valve (BAV) disease is the most common congenital cardiac malformation with a prevalence of 0.4% to 2%. For a long time, a BAV has not been considered an indication for transcatheter aortic valve implantation (TAVI) due to... more
Bicuspid aortic valve (BAV) disease is the most common congenital cardiac malformation with a prevalence of 0.4% to 2%. For a long time, a BAV has not been considered an indication for transcatheter aortic valve implantation (TAVI) due to insufficient technology and poor procedural results conferred by a challenging valvular anatomy leading to poor stability of the prosthetic valve and/or paravalvular regurgitation due to distorted native valve leaflets. Large randomized controlled TAVI trials typically excluded bicuspid aortic stenosis (AS) because of its unique anatomic features. However, current technological advancements are apparently changing this landscape, and over the last few years, TAVI appears technically feasible, albeit a demanding procedure, and has been used to treat severe bicuspid AoV stenosis with promising results, as shown, apart from earlier case reports and patient series, in several recent observational studies and comparative trials between patients with tri...
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A case of a 72-year-old gentleman with very late non-target lesion revascularization is presented illustrating late atherosclerosis progression despite long-term statin therapy, while at the same time long-lasting patency of drug-eluting... more
A case of a 72-year-old gentleman with very late non-target lesion revascularization is presented illustrating late atherosclerosis progression despite long-term statin therapy, while at the same time long-lasting patency of drug-eluting stents implanted 12 years earlier is pictorially exemplified. Rhythmos 2019;14(4):77-79.
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A permanent pacemaker is commonly required in patients undergoing transcatheter aortic valve implantation (TAVI) at ranges up to 30-50%. In general, the incidence is higher with the self- vs balloon-expandable valves. Several risk factors... more
A permanent pacemaker is commonly required in patients undergoing transcatheter aortic valve implantation (TAVI) at ranges up to 30-50%. In general, the incidence is higher with the self- vs balloon-expandable valves. Several risk factors have been identified. Importantly, pacemaker implantation does not seem to improve prognosis and this needs to be further explored. Finally, new generation valves appear to increase the complication of AV block and need for permanent pacing. These issues are herein briefly reviewed. Rhythmos 2016;11(4):87-89.