Publications by authors named "Adam Ioannou"

36 Publications

A standardised pathway increases clinicians' confidence and ability to manage implantable cardioverter defibrillator shocks.

Am J Emerg Med 2021 Mar 5. Epub 2021 Mar 5.

Royal Free NHS Foundation Trust, United Kingdom.

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http://dx.doi.org/10.1016/j.ajem.2021.02.069DOI Listing
March 2021

Drug-related bradycardia precipitating hospital admission in older adults: an ongoing problem.

Eur J Hosp Pharm 2021 Feb 24. Epub 2021 Feb 24.

Cardiology/Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK.

Background: Drug-related bradycardia (DRB) is a common clinical conundrum and can result in multiple hospital admissions as a result of the increased prescription of rate-limiting medications that can predispose to presyncopal or syncopal episodes.

Aim: To evaluate the incidence of DRB in elderly hospital inpatients.

Methods: We conducted a retrospective analysis of all patients admitted to our acute medical unit between November 2018 and February 2019 and identified patients over the age of 70 with more than one diurnal bradycardic episode during their admission. We extracted patient demographics, presenting complaint, admission 12-lead ECG and medications from the hospital electronic database.

Results: We screened 2312 adults and identified 100 patients over the age of 70 years with two or more episodes of diurnal bradycardia during their hospital admission. This constituted 4.32% of total admissions. Beta blockers were the most commonly prescribed rate-limiting medication (n=54, 87.1%), of which bisoprolol was the most frequently prescribed (n=41) and sinus bradycardia was the most commonly identified rhythm disturbance in our cohort of patients (n=41, 41%). Syncope was the most common presenting symptom and occurred in 23 patients, 14 (60.9%) of which were diagnosed with a DRB. Atrial fibrillation was more common in those with DRB compared with those with bradycardia not caused by medications (35.5% vs 10.5%, p=0.006), and atrial fibrillation was a significant predictor of DRB (OR=10.2, 95% CI 3.3 to 31.6, p<0.001).

Conclusion: Bradycardia is a significant cause of hospital admissions in older adults and can be avoided with pharmacovigilance. Caution should be exercised when initiating or changing the dose of rate-limiting agents in these patients; while those with atrial fibrillation should undergo regular review of their heart rate followed by appropriate medication dose adjustments.
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http://dx.doi.org/10.1136/ejhpharm-2020-002603DOI Listing
February 2021

Could the QTc prolongation seen in diabetic ketoacidosis be due to more than just a raised anion gap?

J Pediatr 2021 Apr 14;231:295. Epub 2020 Dec 14.

Department of Cardiology, Hammersmith Hospital, London, United Kingdom.

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http://dx.doi.org/10.1016/j.jpeds.2020.12.027DOI Listing
April 2021

Donepezil induces ventricular arrhythmias by delayed repolarisation.

Naunyn Schmiedebergs Arch Pharmacol 2021 03 24;394(3):559-560. Epub 2020 Nov 24.

Department of Cardiology and Internal Medicine, Frimley Health NHS Foundation Trust, Wexham Park Hospital, Wexham Street, Slough, UK.

Acetylcholinesterase inhibitors such as donepezil delay the progression of Alzheimer's dementia by increasing acetylcholine concentrations in the central nervous system. However, it is becoming apparent that cholinesterase inhibition by donepezil is not confined to the brain. This is supported by previous case reports of peripheral cholinergic side effects and adverse cardiac arrhythmias such as Torsades de Pointes which are reversible upon cessation of donepezil. The augmented acetylcholine concentrations and I inhibition in cardiomyocytes caused by donepezil are believed to mediate this effect.
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http://dx.doi.org/10.1007/s00210-020-02028-4DOI Listing
March 2021

In situ immune-mediated pulmonary artery thrombosis and Covid-19 pneumonitis.

Thromb Res 2021 01 11;197:112-113. Epub 2020 Nov 11.

Wexham Park Hospital, Frimley Health NHS Foundation Trust, UK; University of Cyprus Medical School, Nicosia, Cyprus. Electronic address:

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http://dx.doi.org/10.1016/j.thromres.2020.11.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7657098PMC
January 2021

Covid-19 and in situ pulmonary artery thrombosis.

Respir Med 2021 01 2;176:106176. Epub 2020 Oct 2.

Wexham Park Hospital, Frimley Health NHS Foundation Trust, UK; University of Cyprus Medical School, Nicosia, Cyprus. Electronic address:

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http://dx.doi.org/10.1016/j.rmed.2020.106176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7529605PMC
January 2021

Pulmonary embolism in COVID-19: Clinical characteristics and cardiac implications.

Am J Emerg Med 2020 Oct 24;38(10):2142-2146. Epub 2020 Jul 24.

Wexham Park Hospital, Frimley Health NHS Foundation Trust, UK; University of Cyprus Medical School, Nicosia, Cyprus. Electronic address:

Background: The thrombogenic potential of Covid-19 is increasingly recognised. We aim to assess the characteristics of COVID-19 patients diagnosed with pulmonary embolism (PE).

Methods: We conducted a single centre, retrospective observational cohort study of COVID-19 patients admitted between 1st March and 30th April 2020 subsequently diagnosed with PE following computed tomography pulmonary angiogram (CTPA). Patient demographics, comorbidities, presenting complaints and inpatient investigations were recorded.

Results: We identified 15 COVID-19 patients diagnosed with PE (median age = 58 years [IQR = 23], 87% male). 2 died (13%), both male patients >70 years. Most common symptoms were dyspnoea (N = 10, 67%) and fever (N = 7, 47%). 12 (80%) reported 7 days or more of non-resolving symptoms prior to admission. 7 (47%) required continuous positive airway pressure (CPAP), 2 (13%) of which were subsequently intubated. All patients had significantly raised D-dimer levels, lactate dehydrogenase (LDH), C-reactive protein (CRP), ferritin and prothrombin times. The distribution of PEs correlated with the pattern of consolidation observed on CTPA in 9 (60%) patients; the majority being peripheral or subsegmental (N = 14, 93%) and only 1 central PE. 10 (67%) had an abnormal resting electrocardiogram (ECG), the commonest finding being sinus tachycardia. 6 (40%) who underwent transthoracic echocardiography (TTE) had structurally and functionally normal right hearts.

Conclusion: Our study suggests that patients who demonstrate acute deterioration, a protracted course of illness with non-resolving symptoms, worsening dyspnoea, persistent oxygen requirements or significantly raised D-dimer levels should be investigated for PE, particularly in the context of COVID-19 infection. TTE and to a lesser degree the ECG are unreliable predictors of PE within this context.
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http://dx.doi.org/10.1016/j.ajem.2020.07.054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7378013PMC
October 2020

Efficacy and safety of ablation index-guided catheter ablation for atrial fibrillation: an updated meta-analysis.

Europace 2020 11;22(11):1659-1671

Electrophysiology Department, Barts Heart Centre, St. Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK.

Aims: Despite recent advances in catheter ablation for atrial fibrillation (AF), pulmonary vein reconnection (PVR), and AF recurrence remain significantly high. Ablation index (AI) is a new method incorporating contact force, time, and power that should optimize procedural outcomes. We aimed to evaluate the efficacy and safety of AI-guided catheter ablation compared to a non-AI-guided approach.

Methods And Results: A systematic search was performed on MEDLINE (via PubMED), EMBASE, COCHRANE, and European Society of Cardiology (ESC) databases (from inception to 1 July 2019). We included only studies that compared AI-guided with non-AI-guided catheter ablation of AF. Eleven studies reporting on 2306 patients were identified. Median follow-up period was 12 months. Ablation index-guided ablation had a significant shorter procedural time (141.0 vs. 152.8 min, P = 0.01; I2 = 90%), ablation time (21.8 vs. 32.0 min, P < 0.00001; I2 = 0%), achieved first-pass isolation more frequently [odds ratio (OR) = 0.09, 95%CI 0.04-0.21; 93.4% vs. 62.9%, P < 0.001; I2 = 58%] and was less frequently associated with acute PVR (OR = 0.37, 95%CI 0.18-0.75; 18.0% vs 35.0%; P = 0.006; I2 = 0%). Importantly, atrial arrhythmia relapse post-blanking was significantly lower in AI compared to non-AI catheter ablation (OR = 0.41, 95%CI 0.25-0.66; 11.8% vs. 24.9%, P = 0.0003; I2 = 35%). Finally, there was no difference in complication rate between AI and non-AI ablation, with the number of cardiac tamponade events in the AI group less being numerically lower (OR = 0.69, 95%CI 0.30-1.60, 1.6% vs. 2.5%, P = 0.39; I2 = 0%).

Conclusions: These data suggest that AI-guided catheter ablation is associated with increased efficacy of AF ablation, while preserving a comparable safety profile to non-AI catheter ablation.
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http://dx.doi.org/10.1093/europace/euaa224DOI Listing
November 2020

Letter to the Editor - New Pharmacotherapy for Heart Failure with Reduced Ejection Fraction.

Expert Rev Cardiovasc Ther 2020 09 1;18(9):651-652. Epub 2020 Aug 1.

Department of Cardiology, Wrexham Park Hospital, Frimley Health NHS Foundation Trust , Slough, UK.

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http://dx.doi.org/10.1080/14779072.2020.1799562DOI Listing
September 2020

Comparison of the Effect of Sacubitril/Valsartan on Left Ventricular Systolic Function in Patients with Non-ischaemic and Ischaemic Cardiomyopathy.

Cardiovasc Drugs Ther 2020 12 9;34(6):755-762. Epub 2020 Jul 9.

Department of Cardiology, Wexham Park Hospital, Wexham Street, Slough, UK.

Purpose: Sacubitril/valsartan has been demonstrated to improve prognosis and outcomes in heart failure with reduced ejection fraction (HFrEF) patients. We sought to compare the improvement in cardiac function between non-ischaemic and ischaemic cardiomyopathy for patients receiving sacubitril/valsartan.

Methods: We conducted a single centre prospective cohort survey of patients reviewed in the Heart Function Clinic between February 2017 and January 2018. Functional evaluation and measurement of biochemical and echocardiographic parameters occurred before the initiation of sacubitril/valsartan, and after 3 months of treatment.

Results: We identified 52 patients (26 non-ischaemic and 26 ischaemic cardiomyopathy) suitable for treatment with sacubitril/valsartan. Treatment was followed by a significant decrease in a New York Heart Association (NYHA) class in both patients with non-ischaemic (2.3 ± 0.6 vs. 1.6 ± 0.7, P < 0.001) and ischaemic cardiomyopathy (2.3 ± 0.5 vs. 1.5 ± 0.6, P < 0.001), along with an increase in ejection fraction in both patients with non-ischaemic (26.2% ± 6.5% vs. 37.2% ± 13.8%, P < 0.001) and ischaemic cardiomyopathy (28.1% ± 5.7% vs. 31.5% ± 8.4%, P = 0.007). The improvement in ejection fraction was significantly greater in the patients with non-ischaemic cardiomyopathy compared to those with ischaemic cardiomyopathy (10.7% ± 13.0% vs. 3.9% ± 6.0%, P = 0.023).

Conclusion: Our study suggests that treatment with sacubitril/valsartan in patients with non-ischaemic cardiomyopathy is followed by a greater improvement in ejection fraction than in patients with ischaemic cardiomyopathy.
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http://dx.doi.org/10.1007/s10557-020-07036-3DOI Listing
December 2020

Long term use of donepezil and QTc prolongation.

Clin Toxicol (Phila) 2021 Mar 1;59(3):208-214. Epub 2020 Jul 1.

Department of Cardiology and Internal Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK.

Background: The neurocognitive benefits of donepezil are well recognised, but the potential side effects on cardiac conduction remain unclear.

Objective: To investigate whether long-term donepezil therapy is associated with electrocardiographic (ECG) changes and in particular to assess its effects on the QT interval.

Methods: We conducted a single centre retrospective analysis of patients admitted to our trust on donepezil therapy over a 12-month period. An admission resting 12-lead ECG was obtained and compared to their ECG prior to commencement of donepezil therapy to assess for any significant difference in ECG parameters.

Results: We identified 59 patients suitable for analysis. PR (177.0 ± 29.0 ms vs. 186.1 ± 34.2 ms,  = 0.04), QRS (101.7 ± 20.3 ms vs. 104.7 ± 22.3 ms,  = 0.04) and QT (393.3 ± 35.6 ms vs. 411.9 ± 44.6 ms,  = 0.002) interval prolongation were all associated with donepezil use. The increase in QT intervals remained significant on correction for heart rate; resulting in 8 (13.6%) patients developing high arrhythmogenic risk based on assessment using QT nomogram plots. Concomitant use of tricyclic antidepressants was associated with significant QT prolongation (QTcB: = 0.344,  = 0.008, QTcFred: = 0.382,  = 0.003, QTcFram: = 0.379,  = 0.003, QTcH: = 0.352,  = 0.006), while the use of rate-limiting calcium channel blockers was associated with significant PR prolongation ( = 0.314,  = 0.030), and beta-blockers with a reduction in heart rate ( = 0.256,  = 0.050).

Conclusion: Our results clearly demonstrate that long-term use of donepezil is associated with prolongation of the QT interval. We suggest ECG evaluation should take place before and after donepezil initiation, and clinicians should be even more vigilant in those prescribed tricyclic antidepressants.
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http://dx.doi.org/10.1080/15563650.2020.1788054DOI Listing
March 2021

Permanent pacemaker implantation rates following cardiac surgery in the modern era.

Ir J Med Sci 2020 Nov 22;189(4):1289-1294. Epub 2020 May 22.

Royal Victoria Hospital, Belfast Health and Social Care Trust, 274 Grosvenor Road, Belfast, BT12 6BA, UK.

Aims: The aim of this study was to evaluate the incidence of permanent pacemaker (PPM) implantation after cardiac surgery in our institution and investigate risk factors for PPM dependency to provide patients with accurate incidence figures at the time of consent for surgery.

Methods: Data was collected retrospectively from a single tertiary institution from October 2018 to April 2019 inclusive of 403 patients. Incidence of PPM implantation after various cardiac operations was evaluated. A univariate analysis was carried out to identify the independent risk factors related to PPM implantation.

Results: Ten patients required a PPM (2.48%). The most common indication for PPM implantation post-cardiac surgery was complete heart block (N = 7, 70%) followed by bradycardia/pauses (N = 2, 20%) and sick sinus syndrome (N = 1, 10%). PPM implantation after coronary artery bypass graft (CABG) surgery was the lowest (0.63%), while combined CABG and valve operations had the highest incidence (5.97%). Independent risk predictors for PPM implantation included female gender (p = 0.03), rheumatic heart disease (p = 0.008), pulmonary hypertension (p = 0.01), redo operations (p = 0.002), mitral valve procedures (p = 0.001), tricuspid valve procedures (p = 0.0003) and combined mitral and tricuspid valve procedures (p = 0.0001). Average length of intensive care unit (ICU)/high-dependency unit (HDU) stay was significantly prolonged for patients who required a PPM post-cardiac surgery.

Conclusion: As clinicians, it can be challenging to provide our patients with accurate information on the risk of PPM implantation relative to their operation. A unit-specific data may be a more accurate method of informing our patients on this risk.
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http://dx.doi.org/10.1007/s11845-020-02254-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7554001PMC
November 2020

Antithrombotic Therapy in Patients with Recent Stroke and Atrial Fibrillation.

Curr Pharm Des 2020 ;26(23):2715-2724

Electrophysiology Department, Barts Heart Centre, St. Bartholomew's Hospital, London EC1A 7BE, United Kingdom.

Atrial fibrillation (AF) is a common arrhythmia which carries a significant risk of stroke. Secondary prevention, particularly in the acute phase of stroke with anti-thrombotic therapy, has not been validated. The aim of this review is to evaluate the available evidence on the use of antithrombotic therapy in patients with recent stroke who have AF, and suggest a treatment algorithm for the various time points, taking into account both the bleeding and thrombosis risks posed at each stage.
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http://dx.doi.org/10.2174/1381612826666200407150307DOI Listing
January 2021

Audit of the prevalence and investigation of iron deficiency anaemia in patients with heart failure in hospital practice.

Postgrad Med J 2020 Apr 15;96(1134):206-211. Epub 2019 Nov 15.

Department of Cardiology, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, Berkshire, United Kingdom

Purpose Of The Study: Iron deficiency anaemia (IDA) is associated with increased morbidity and mortality in heart failure patients. The aim of our audit was to evaluate the current practice in diagnosis and assessment of IDA in patients admitted with heart failure.

Study Design: We conducted a retrospective audit of patients admitted to our hospital between January 2017 and June 2017 with a diagnosis of heart failure, and obtained data regarding each patient's demographics and anaemic status. We also conducted a qualitative survey to assess healthcare professionals' ability to diagnose IDA, and their knowledge of iron replacement in heart failure patients.

Results: Our audit identified 218 heart failure patients, nearly two-thirds (n=138, 63.3%) of which were anaemic. Of the 138 anaemic patients, only 40 had a full haematinic screen compared with 98 who had incomplete investigations (29% vs 71%, p=0.007). Iron studies were the most commonly performed haematinic investigation (n=87, 63%), and over half of these patients were iron deficient (n=49, 56.3%). Only 12 (24.5%) iron deficient patients were prescribed oral iron therapy, while 37 (75.5%) were left without iron replacement (X=12.8, p=0.0003). Our survey demonstrated a lack of awareness among healthcare professionals with only 19.7% of participants being able to correctly define anaemia and 9.1% being aware of guidelines regarding treatment of IDA.

Conclusion: Many patients admitted to hospital with heart failure also have a concomitant diagnosis of anaemia. The aetiology of the underlying anaemia is often poorly investigated, and where IDA is identified it is poorly treated.
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http://dx.doi.org/10.1136/postgradmedj-2019-136867DOI Listing
April 2020

Full blood count as potential predictor of outcomes in patients undergoing cardiac resynchronization therapy.

Sci Rep 2019 09 10;9(1):13016. Epub 2019 Sep 10.

Electrophysiology Department, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom.

Almost a third of patients fulfilling current guidelines criteria have suboptimal responses following cardiac resynchronization therapy (CRT). Circulating biomarkers may help identify these patients. We aimed to assess the predictive role of full blood count (FBC) parameters in prognosis of heart failure (HF) patients undergoing CRT device implantation. We enrolled 612 consecutive CRT patients and FBC was measured within 24 hours prior to implantation. The follow-up period was a median of 1652 days (IQR: 837-2612). The study endpoints were i) composite of all-cause mortality or transplant, and ii) reverse left ventricular (LV) remodeling. On multivariate analysis [hazard ratio (HR), 95% confidence interval (CI)] only red cell count (RCC) (p = 0.004), red cell distribution width (RDW) (p < 0.001), percentage of lymphocytes (p = 0.03) and platelet count (p < 0.001) predicted all-cause mortality. Interestingly, RDW (p = 0.004) and platelet count (p = 0.008) were independent predictors of reverse LV remodeling. This is the first powered single-centre study to demonstrate that RDW and platelet count are independent predictors of long-term all-cause mortality and/or heart transplant in CRT patients. Further studies, on the role of these parameters in enhancing patient selection for CRT implantation should be conducted to confirm our findings.
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http://dx.doi.org/10.1038/s41598-019-49659-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6736835PMC
September 2019

Interrupted versus uninterrupted novel oral anticoagulant peri-implantation of cardiac device: A single-center randomized prospective pilot trial.

Pacing Clin Electrophysiol 2018 11 19;41(11):1476-1480. Epub 2018 Sep 19.

Campus Bio-Medico, Unit of Cardiology, University of Rome, Rome, Italy.

Background: Many patients requiring cardiac implantable electronic device (CIED) implantation are on long-term oral anticoagulant therapy. While continuation of warfarin has been shown to be safe and reduce bleeding complications compared to interruption of warfarin therapy and heparin bridging, it is not known which novel oral anticoagulants (NOAC) regimen (interrupted vs uninterrupted) is better in this setting.

Methods: One-hundred and one patients were randomized to receive CIED implantation with either interrupted or uninterrupted/continuous NOAC therapy before surgery. No heparin was used in either treatment arm. The primary end-point was the presence of a clinically significant pocket hematoma after CIED implantation. The secondary end-point was a composite of other major bleeding events, device-related infection, thrombotic events, and device-related admission length postdevice implantation.

Results: Both treatment groups were equally balanced for baseline variables and concomitant medications. One clinically significant pocket hematoma occurred in the uninterrupted NOAC group and none in the interrupted group (P  =  0.320). There was no difference in other bleeding complications. No thrombotic events were observed in either of the two groups.

Conclusions: Despite the paucity of bleeding events, data from this pilot study suggest that uninterrupted NOAC therapy for CIED implantation appears to be as safe as NOAC interruption and does not increase bleeding complications.
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http://dx.doi.org/10.1111/pace.13482DOI Listing
November 2018

Effect of Aortic Valve Calcium Quantity on Outcome After Balloon Aortic Valvuloplasty for Severe Aortic Stenosis.

Am J Cardiol 2018 09 4;122(6):1036-1041. Epub 2018 Aug 4.

Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Middlesex, United Kingdom.

Balloon aortic valvuloplasty has a role in a select group of patients with severe aortic stenosis. Identifying those appropriate patients who will benefit most is key. Given previous evidence demonstrating that histologically the intervention involves a physical disrupting of the cusp's calcium we hypothesized that the quantity of calcium seen at CT will influence outcome. We examined our cohort of patients who had undergone balloon aortic valvuloplasty and CT-quantified aortic valve calcium (AVC) between July 2011 and April 2014. All patients underwent echocardiography pre- and post-procedure and for those patients managed medically, again at 6 months. A potential predictive AVC value for mortality was calculated using Youden's index. A total of 240 aortic valvuloplasties were performed in 206 patients (male = 124). Valvuloplasty caused a significant (pre 0.63 ± 0.21 vs post 0.77 ± 0.27 cm, p <0.01, n = 240), but temporary (post 0.80 ± 0.27 vs 6 months: 0.64 ± 0.18 cm, p <0.01, n = 88) increase in valve area. Those patients with a non-severe AVC (<1853.5 AU) had a larger increase in valve area after valvuloplasty compared with those with more calcium (0.10 [95% confidence interval {CI} 0.05 to 0.10] vs 0.15 [95%CI 0.10 to 0.22] cm, p = 0.049). Multivariate analysis revealed severe AVC (Hazard ratio 2.79, 95% CI 1.18 to 6.63, p = 0.02) along with pulmonary artery pressure post-valvuloplasty (Hazard ratio 1.02, 95% CI 1.00 to 1.03, p = 0.03) to be predictive of survival. In conclusion, in patients with severe aortic stenosis the degree of AVC impacts on the success of valvuloplasty.
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http://dx.doi.org/10.1016/j.amjcard.2018.05.048DOI Listing
September 2018

Gorham-Stout disease and ventricular tachycardia.

Br J Hosp Med (Lond) 2018 Aug;79(8):473

Consultant, Department of Cardiology, Frimley Health NHS Foundation Trust, Slough, Bucks and International Centre for Circulatory Health, NHLI, Imperial College, London.

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http://dx.doi.org/10.12968/hmed.2018.79.8.473DOI Listing
August 2018

Intravascular imaging, histopathological analysis, and catecholamine quantification following catheter-based renal denervation in a swine model: the impact of prebifurcation energy delivery.

Hypertens Res 2018 Sep 13;41(9):708-717. Epub 2018 Jul 13.

Cardiology Department, Coimbra's Hospital and University Centre - General Hospital, Coimbra, Portugal.

The purpose of this study was to evaluate the impact of prebifurcation renal denervation in a swine model and assess its safety through optical coherence tomography (OCT). Prebifurcation renal denervation with a multi-electrode catheter was performed in one renal artery of 12 healthy pigs, with the contralateral artery and kidney being used as controls. Angiograms and OCT pullbacks were obtained peri-procedurally and 1 month post procedure. Renal tissue catecholamines were quantified, and the arterial wall and peri-adventitial tissue were analyzed histologically. Intraluminal changes (endothelial swelling, spasm, and thrombus formation) were observed acutely by OCT in most of the treated arteries and were no longer visible at follow-up. Histology revealed a statistically significant accumulation of collagen (fibrosis) and a near absence of tyrosine hydroxylase labeling in the denervated artery, suggesting a clear reduction in nervous terminals. Renal tissue catecholamine levels were similar between both sides, probably due to the low number of ablation points and the renorenal reflex. The present study demonstrates that renal denervation is associated with acute intimal disruptions, areas of fibrosis, and a reduction in nervous terminals. The lack of difference in renal tissue catecholamine levels is indicative of the need to perform the highest and safest number of ablation points in both renal arteries. These findings are important because they demonstrate the histological consequences of radiofrequency energy application and its medium-term safety.
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http://dx.doi.org/10.1038/s41440-018-0072-yDOI Listing
September 2018

Ventricular Fibrillation following Varicella Zoster Myocarditis.

Case Rep Cardiol 2017 23;2017:1017686. Epub 2017 Nov 23.

University of Cyprus Medical School, Nicosia, Cyprus.

Varicella-zoster virus (VZV) infection can rarely lead to serious cardiac complications and life-threatening arrhythmias. We present a case of a 46-year-old male patient who developed VZV myocarditis and presented with recurrent syncopal episodes followed by a cardiac arrest. He had a further collapse eight years later, and cardiac magnetic resonance imaging (MRI) demonstrated mild mid-wall basal and inferolateral wall fibrosis. He was treated with an implantable cardioverter defibrillator (ICD) and represented two years later with ICD shocks, and interrogation of the device revealed ventricular fibrillation episodes. This case demonstrates the life-threatening long-term sequelae of VZV myocarditis in adults. We suggest that VZV myocarditis should be considered in all patients who present with a syncopal event after VZV infection. In these patients, ICD implantation is a potentially life-saving procedure.
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http://dx.doi.org/10.1155/2017/1017686DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5733204PMC
November 2017

Non-valvular atrial fibrillation: impact of apixaban on patient outcomes.

Patient Relat Outcome Meas 2017 3;8:121-131. Epub 2017 Nov 3.

Cardiology Department, Medical School, University of Cyprus, Nicosia, Cyprus.

Atrial fibrillation is the most common arrhythmia worldwide, and carries a significantly increased risk of thromboembolic stroke. Initially, vitamin K antagonists were used as stroke prophylaxis; but more recently, a group of drugs known as novel oral anticoagulants have been developed. Apixaban belongs to this group of drugs, and is a factor Xa inhibitor that has emerged as a popular pharmacological agent worldwide. In this review, we will provide an overview of the pivotal trials in the development of apixaban, while also critically evaluating the new emerging real-world data, and discussing the effectiveness, safety, economic viability and future prospects of apixaban and how it impacts on patient outcomes in those with non-valvular atrial fibrillation.
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http://dx.doi.org/10.2147/PROM.S117549DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5680948PMC
November 2017

Reverse Takotsubo Cardiomyopathy and Cardiogenic Shock Associated With Methamphetamine Consumption.

J Emerg Med 2017 Nov 12;53(5):e81-e83. Epub 2017 Sep 12.

Hillingdon Hospital, London, United Kingdom.

Background: Reverse Takotsubo cardiomyopathy is characterized by transient myocardial hypokinesia affecting predominantly the basal myocardial wall. It is a rare variant of Takotsubo cardiomyopathy affecting younger patients.

Case Report: We report a case of a young man who having consumed methamphetamines presented with cardiogenic shock and severe left ventricular systolic dysfunction, affecting predominantly the basal segments with sparing of the apex. After inotropic support, the left ventricular ejection fraction improved. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is important that emergency physicians are aware of the danger of methamphetamine consumption, and how it can lead to potentially fatal acute cardiac syndromes, including reverse Takotsubo cardiomyopathy and cardiogenic shock.
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http://dx.doi.org/10.1016/j.jemermed.2017.06.027DOI Listing
November 2017

Statins in Stable Angina Pectoris.

Curr Pharm Des 2017 Aug 28. Epub 2017 Aug 28.

1st Cardiology Department, Athens University Medical School, Athens. Greece.

Background: Stable angina is a debilitating and progressive disease caused by narrowing of the coronary arteries, which in turn affects cardiac perfusion. Statins have a well-established role, modifying symptoms and progression of the disease not only through lipid lowering, but also through pleiotropic effects.

Objective: We sought to evaluate the effect of statins in stable angina pectoris Method: We performed a systematic review of the literature searching MEDLINE via Pubmed for all studies which examine the possible effects of statins in stable angina pectoris.

Results: Statins have demonstrated favourable modification of both biochemical markers (oxidative stress, inflammatory and coagulation markers/factors) and clinical symptoms (anginal and ischemic) of the disease. These effects have been demonstrated in vitro, ex vivo and in vivo in animals and humans, independently of the lipid lowering effects.

Conclusion: With an excellent safety profile and evidence of efficacy in managing patients with stable angina, statins appear an essential part of the therapeutic armoury against atherosclerotic disease.
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http://dx.doi.org/10.2174/1381612823666170828132303DOI Listing
August 2017

Impact of an Age-Adjusted Co-morbidity Index on Survival of Patients With Heart Failure Implanted With Cardiac Resynchronization Therapy Devices.

Am J Cardiol 2017 Oct 14;120(7):1158-1165. Epub 2017 Jul 14.

St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom. Electronic address:

Age is an adverse prognostic factor in patients with heart failure. We aimed to assess the impact of age and noncardiac co-morbidities in the outcome of patients undergoing cardiac resynchronization therapy (CRT), and determine which of these two factors is the most important predictor of survival. The study involved a single-center retrospective assessment of 697 consecutive CRT implants during a 12-year period. Patient co-morbidity profile was assessed using the Charlson Co-morbidity Index (CCI) and the Charlson Age-Co-morbidity Index (CACI). Predictors of survival free from heart transplantation were assessed. CRT-related complications and cause of death analysis were assessed within tertiles of the CACI. During a mean follow-up of 1,813 ± 1,177 days, 347 patients (49.9%) died and 37 (5.3%) underwent heart transplantation. On multivariate Cox regression, female gender (HR = 0.78, 95% confidence interval [CI] 0.62 to 0.99, p = 0.041), estimated glomerular filtration rate (HR per ml/min = 0.99, 95% CI 0.98 to 0.99, p < 0.001), left ventricular ejection fraction (HR per % = 0.99, 95% CI 0.98 to 1.00, p = 0.022), New York Heart Association class (HR = 1.83, 95% CI 1.53 to 2.20, p < 0.001), presence of left bundle branch block (HR = 0.70, 95% CI 0.56 to 0.87, p = 0.001), and CACI tertile (HR = 1.37, 95% CI 1.18 to 1.59, p < 0.001) were independent predictors of all-cause mortality or heart transplantation. Compared with age and the CCI, the CACI was the best discriminator of all-cause mortality. Inappropriate therapies occurred less frequently in higher co-morbidity tertiles. In conclusion, patient co-morbidity profile adjusted to age impacts on mortality after CRT implantation. Use of the CACI may help refine guideline criteria to identify patients more likely to benefit from CRT.
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http://dx.doi.org/10.1016/j.amjcard.2017.06.056DOI Listing
October 2017

Inflammatory Biomarkers in Atrial Fibrillation.

Curr Med Chem 2019 ;26(5):837-854

1st Department of Cardiology, Hippokration Hospital, University of Athens, Athens, Greece.

During the last few years, a significant number of studies have attempted to clarify the underlying mechanisms that lead to the presentation of atrial fibrillation (AF). Inflammation is a key component of the pathophysiological processes that lead to the development of AF; the amplification of inflammatory pathways triggers AF, and, in tandem, AF increases the inflammatory state. Indeed, the plasma levels of several inflammatory biomarkers are elevated in patients with AF. In addition, the levels of specific inflammatory biomarkers may provide information regarding to the AF duration. Several small studies have assessed the role of anti-inflammatory treatment in atrial fibrillation but the results have been contradictory. Large-scale studies are needed to evaluate the role of inflammation in AF and whether anti-inflammatory medications should be routinely administered to patients with AF.
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http://dx.doi.org/10.2174/0929867324666170727103357DOI Listing
May 2019

Dual-site right ventricular pacing in patients undergoing cardiac resynchronization therapy: Results of a multicenter propensity-matched analysis.

Pacing Clin Electrophysiol 2017 Oct 15;40(10):1113-1120. Epub 2017 Sep 15.

Barts Heart Centre, Barts Health NHS Trust, London, UK.

Background: Dual-site right ventricular pacing (Dual RV) has been proposed as an alternative for patients with heart failure undergoing cardiac resynchronization therapy (CRT) with a failure to deliver a coronary sinus (CS) lead. Only short-term hemodynamic and echocardiographic results of Dual RV are available. We aimed to assess the long-term results of Dual RV and its impact on survival.

Methods: Multicenter retrospective assessment of all CRT implants during a 12-year period. Patients with failed CS lead implantation, treated with Dual RV, were followed and assessed for the primary endpoint of all-cause mortality and/or heart transplant. A control group was obtained from contemporary patients using propensity matching for all available baseline variables.

Results: Ninety-three patients were implanted with Dual RV devices and compared with 93 matched controls. During a median of 1,273 days (interquartile range 557-2,218), intention-to-treat analysis showed that all-cause mortality and/or heart transplant was higher in the Dual RV group (adjusted hazard ratio [HR] = 1.66, 95% confidence interval [CI] 1.12-2.47, P = 0.012). As-treated analysis yielded similar results (HR = 1.97, 95% CI 1.31-2.96, P = 0.001). Cardiac device-related infections occurred seven times more frequently in the Dual RV site group (HR = 7.60, 95% CI 1.51-38.33, P = 0.014). Among Dual RV nonresponders, four had their apical leads switched off, five required an epicardial LV lead insertion, a transseptal LV lead was implanted in two, and in nine patients, after reviewing the CS venogram, a new CS lead insertion was successfully attempted.

Conclusion: Dual RV pacing is associated with worse clinical outcomes and higher complication rates than conventional CRT.
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http://dx.doi.org/10.1111/pace.13145DOI Listing
October 2017

Biomarkers Associated with Stroke Risk in Atrial Fibrillation.

Curr Med Chem 2019 ;26(5):803-823

1st Cardiology Department, Athens University Medical School, Hippokration Hospital, Athens, Greece.

Background: Atrial fibrillation (AF) is associated with an increased risk of cardioembolic stroke. The risk of cardioembolism is not adequately reduced with the administration of oral anticoagulants, since a number of patients continue to experience thromboembolic events despite receiving treatment. Therefore, identification of a circulating biomarker to identify these high-risk patients would be clinically beneficial.

Objective: In the present article, we aim to review the available data regarding use of biomarkers to predict cardioembolic stroke in patients with AF.

Methods: We performed a thorough search of the literature in order to analyze the biomarkers identified thus far and critically evaluate their clinical significance.

Results: A number of biomarkers have been proposed to predict cardioembolic stroke in patients with AF. Some of them are already used in the clinical practice, such as d-dimers, troponins and brain natriuretic peptide. Novel biomarkers, such as the inflammatory growth differentiation factor-15, appear to be promising, while the role of micro-RNAs and genetics appear to be useful as well. Even though these biomarkers are associated with an increased risk for thromboembolism, they cannot accurately predict future events. In light of this, the use of a scoring system, that would incorporate both circulating biomarkers and clinical factors, might be more useful.

Conclusions: Recent research has disclosed several biomarkers as potential predictors of cardioembolic stroke in patients with AF. However, further research is required to establish a multifactorial scoring system that will identify patients at high-risk of thromboembolism, who would benefit from more intensive treatment and monitoring.
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http://dx.doi.org/10.2174/0929867324666170718120651DOI Listing
May 2019

Impact of point-of-care pre-procedure creatinine and eGFR testing in patients with ST segment elevation myocardial infarction undergoing primary PCI: The pilot STATCREAT study.

Int J Cardiol 2017 Aug 5;240:8-13. Epub 2017 Apr 5.

Department of Cardiology, The Essex Cardiothoracic Centre, Essex, United Kingdom; Post Graduate Medical Institute, Anglia Ruskin University, East of England, United Kingdom. Electronic address:

Background: Contrast-induced acute kidney injury (CI-AKI) is a recognised complication during primary PCI that affects short and long term prognosis. The aim of this study was to assess the impact of point-of-care (POC) pre-PPCI creatinine and eGFR testing in STEMI patients.

Methods: 160 STEMI patients (STATCREAT group) with pre-procedure POC testing of Cr and eGFR were compared with 294 consecutive retrospective STEMI patients (control group). Patients were further divided into subjects with or without pre-existing CKD.

Results: The incidence of CI-AKI in the whole population was 14.5% and not different between the two overall groups. For patients with pre-procedure CKD, contrast dose was significantly reduced in the STATCREAT group (124.6ml vs. 152.3ml, p=0.015). The incidence of CI-AKI was 5.9% (n=2) in the STATCREAT group compared with 17.9% (n=10) in the control group (p=0.12). There was no difference in the number of lesions treated (1.118 vs. 1.196, p=0.643) or stents used (1.176 vs. 1.250, p=0.78). For non-CKD patients, there was no significant difference in contrast dose (172.4ml vs. 158.4ml, p=0.067), CI-AKI incidence (16.7% vs. 13.4%, p=0.4), treated lesions (1.167 vs. 1.164, p=1.0) or stents used (1.214 vs. 1.168, p=0.611) between the two groups.

Conclusions: Pre-PPCI point-of-care renal function testing did not reduce the incidence of CI-AKI in the overall group of STEMI patients. In patients with CKD, contrast dose was significantly reduced, but a numerical reduction in CI-AKI was not found to be statistically significant. No significant differences were found in the non-CKD group.
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http://dx.doi.org/10.1016/j.ijcard.2017.03.147DOI Listing
August 2017

Transcatheter aortic valve implantation: new hope in the management of valvular heart disease.

Postgrad Med J 2017 May 19;93(1099):280-288. Epub 2017 Jan 19.

Frimley Health NHS Foundation Trust, London, UK.

Severe calcific aortic stenosis is relatively common, and unless treated with valve replacement it carries an adverse prognosis. A large number of patients, however, are denied surgery due to their advanced age or coexistent medical conditions that increase perioperative cardiovascular risks. Transcatheter aortic valve implantation (TAVI), a technique in which a bioprosthetic valve is inserted via a catheter and implanted within the diseased native aortic valve, is a new therapeutic modality for treatment of older patients with severe symptomatic aortic stenosis and other comorbidities, who have an inherently high surgical risk. This review will provide an overview of the pivotal trials in the development of TAVI; while also investigating important complications and limitations of the procedure and evaluating how new valves are being designed and clinically evaluated, with the ultimate goal of reducing potential complications and expanding the use of TAVI to lower-risk patient cohorts.
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http://dx.doi.org/10.1136/postgradmedj-2016-134554DOI Listing
May 2017