Publications by authors named "Charalambos Vlachopoulos"

277 Publications

Is it Time for Single-Pill Combinations in Dyslipidemia?

Am J Cardiovasc Drugs 2021 Sep 22. Epub 2021 Sep 22.

First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.

Despite the availability of lipid-lowering therapies (LLTs) that are safe and effective, the overall rate of low-density lipoprotein cholesterol (LDL-C) control at a population level in real-life studies is low. Higher-intensity treatment, earlier intervention, and longer-term treatment have all been shown to improve outcomes. However, in clinical practice, actual exposure to LLT is a product of the duration and intensity of, and adherence to, the treatment. To increase exposure to LLTs, the European Society of Cardiology guidelines recommended a stepwise optimization of LLTs by increasing statin intensity to the maximally tolerated dose, with subsequent addition of ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. Evidence from randomized controlled trials performed in a range of patients suggested that adding ezetimibe to statins rather than doubling the statin dose resulted in significantly more patients at LDL-C goal and significantly fewer patients discontinuing treatment because of adverse events. In addition, data showed that combination treatments effectively increased exposure to LLT. Despite these data and recommendations, optimization of LLT is often limited to increasing statin dose. Therapeutic inertia and poor treatment adherence are significant and prevalent barriers to increasing treatment exposure. They are known to be influenced by pill burden and complexity of treatment. Single-pill combinations provide a strategic approach that supports the intensification of treatment without increasing pill burden or treatment complexity. Single-pill combinations, compared with free associations, have been shown to increase the adherence to LLT and the percentage of patients at LDL-C goal.
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http://dx.doi.org/10.1007/s40256-021-00498-2DOI Listing
September 2021

Central Over Peripheral Blood Pressure: An Emerging Issue in Hypertension Research.

Heart Lung Circ 2021 Aug 20. Epub 2021 Aug 20.

First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.

Measurement of blood pressure is one of the most important and powerful clinical tools in clinical practice. Physicians use the classical method that was introduced more than 100 years ago with the emergence of the brachial cuff sphygmomanometer. The use of this method, despite its initial setbacks, spread like fire throughout the medical community with the boost by the early adoption by insurance companies to assess risk as well as the ease of use, the availability with the wide variety of devices, the good reproducibility and its predictive role. However, a long-forgotten dispute between measurements of peripheral (brachial) and central (aortic, carotid) blood pressure has resurfaced after the introduction of techniques and devices that can easily and accurately estimate non-invasively the central pressure waveform. Clinicians, until recently, focussed only on the pressure waveform trough (diastole) and peak (systole), ignoring the possible information provided by the rest of the arterial pressure waveform. Several restrictions exist with peripheral blood pressures measured with either an oscillometric or a sphygmomanometer device that blur the existing image of the ideal biomarker to describe the haemodynamic characteristics of the cardiovascular system. On the other hand, central pressures seem to be more pathophysiologically relevant to end-organ damage of the brain, heart and kidneys and on future events. Furthermore, measurement of the central waveform can provide clinically useful information, like the quantification of wave reflections with augmentation index, beyond blood pressure measured in the brachial artery. This article will explain the pathophysiological mechanisms linking central pressures to cardiovascular outcomes, review the evidence for the use of central blood pressure over peripheral pressures, elaborate on the prognostic role of central blood pressures and finally review the latest developments on the pharmacological modulation of central blood pressures.
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http://dx.doi.org/10.1016/j.hlc.2021.07.019DOI Listing
August 2021

Lymphoma Severity and Type Are Associated With Aortic FDG Uptake by F-FDG PET/CT Imaging.

JACC CardioOncol 2020 Dec 15;2(5):758-770. Epub 2020 Dec 15.

Center for Experimental Surgery, Clinical and Translational Research, Biomedical Research Foundation, Academy of Athens, Athens, Greece.

Background: There is evidence that metabolic disease burden in lymphoma influences patient outcome. However, the impact of disease severity on the cardiovascular system is unknown.

Objectives: The aim of this study was to examine whether lymphoma is associated with arterial inflammation by investigating the relationship between disease metabolic burden and arterial fluorodeoxyglucose (FDG) uptake.

Methods: Sixty-two chemotherapy-naïve patients with active Hodgkin's or non-Hodgkin's lymphoma were matched (2:1) to individual control groups of lymphoma patients previously treated and free of active disease. All groups underwent F-FDG position emission tomography-computed tomography imaging. Disease severity was quantified by metabolic tumor volume (MTV) and total lesion glycolysis corresponding to standardized uptake values (SUVs) ≥41% or ≥2.5 of the maximum SUV within lymphoma regions, and aortic FDG uptake was quantified through the target-to-background ratio (TBR). Inflammatory and disease severity biomarkers were also measured.

Results: MTV and total lesion glycolysis measurements were significantly correlated with inflammatory and disease biomarkers. Aortic TBR was higher in patients with active non-Hodgkin's lymphoma compared with control subjects (median difference 0.51; 95% confidence interval [CI]: 0.28 to 0.78; p < 0.001). Similarly, patients with active Hodgkin's lymphoma had higher values of aortic TBR compared with control subjects (median difference 0.31; 95% CI: 0.15 to 0.49; p < 0.001). In addition, aortic TBR was modestly increased in patients with stage III to IV disease compared with those with stage I to II disease (median aortic TBR: 2.23 [interquartile range: 2.01 to 2.54] vs. 2.06 [interquartile range: 1.83 to 2.27; p = 0.050). In multivariable analysis, aortic FDG uptake and MTV values were independently associated (β = 0.425; 95% CI: 0.189 to 0.662; p = 0.001; R = 0.208), as were aortic FDG uptake and MTV (β = 0.407; 95% CI: 0.167 to 0.649, p = 0.001; R = 0.191).

Conclusions: Aortic wall FDG uptake is related with disease severity indicative of a possible vascular effect of lymphoma. This work highlights a new potential role of molecular imaging in cardio-oncology for evaluating disease severity and its consequences on the vasculature.
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http://dx.doi.org/10.1016/j.jaccao.2020.11.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8352324PMC
December 2020

Arterial biomarkers in the evaluation, management and prognosis of aortic stenosis.

Atherosclerosis 2021 Sep 13;332:1-15. Epub 2021 Jul 13.

Hypertension and Cardiometabolic Unit, First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece. Electronic address:

Degenerative aortic valve stenosis is the most common primary valve disease and a significant cause of cardiovascular morbidity and mortality. In an era when new techniques for the management of aortic stenosis are gaining ground, the understanding of this disease is more important than ever to optimize treatment. So far, the focus has been placed on the assessment of the valve itself. However, the role that the arterial system plays in the pathogenesis and natural history of the disease needs to be further elucidated. Arteriosclerosis, when it coexists with a stenotic valve, augments the load posed on the left ventricle contributing to greater impairment of cardiovascular function. Arterial stiffness, a well-established predictor for cardiovascular disease and all-cause mortality, could play a role in the prognosis and quality of life of this population. Several studies using a variety of indices to assess arterial stiffness have tried to address the potential utility of arterial function assessment in the case of aortic stenosis. Importantly, reliable data identify a prognostic role of arterial biomarkers in aortic stenosis and stress their possible use to optimize timing and method of treatment. This review aims at summarizing the existing knowledge on the interplay between the heart and the vessels in the presence of degenerative aortic stenosis, prior, upon and after interventional management. Further, it discusses the evidence supporting the potential clinical application of arterial biomarkers for the assessment of progression, severity, management and prognosis of aortic stenosis.
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http://dx.doi.org/10.1016/j.atherosclerosis.2021.07.006DOI Listing
September 2021

Diagnostic and Prognostic Value of Cardiovascular Magnetic Resonance in Neuromuscular Cardiomyopathies.

Pediatr Cardiol 2021 Aug 3. Epub 2021 Aug 3.

CMR Unit, Royal Brompton and Harefield Hospital NHS Foundation Trust, Sydney Street, Chelsea, London, SW3 6NP, UK.

Neuromuscular diseases (NMD) encompass a broad spectrum of diseases with variable type of cardiac involvement and there is lack of clinical data on Cardiovascular Magnetic Resonance (CMR) phenotypes or even prognostic value of CMR in NMD. We explored the diagnostic and prognostic value of CMR in NMD-related cardiomyopathies. The study included retrospective analysis of a cohort of 111 patients with various forms of NMD; mitochondrial: n = 14, Friedreich's ataxia (FA): n = 27, myotonic dystrophy: n = 27, Becker/Duchenne's muscular dystrophy (BMD/DMD): n = 15, Duchenne's carriers: n = 6, other: n = 22. Biventricular volumes and function and myocardial late gadolinium enhancement (LGE) pattern and extent were assessed by CMR. Patients were followed-up for the composite clinical endpoint of death, heart failure development or need for permanent pacemaker/intracardiac defibrillator. The major NMD subtypes, i.e. FA, mitochondrial, BMD/DMD, and myotonic dystrophy had significant differences in the incidence of LGE (56%, 21%, 62% & 30% respectively, chi = 9.86, p = 0.042) and type of cardiomyopathy phenotype (chi = 13.8, p = 0.008), extent/pattern (p = 0.006) and progression rate of LGE (p = 0.006). In survival analysis the composite clinical endpoint differed significantly between NMD subtypes (p = 0.031), while the subgroup with LGE + and LVEF < 50% had the worst prognosis (Log-rank p = 0.0034). We present data from a unique cohort of NMD patients and provide evidence on the incidence, patterns, and the prognostic value of LGE in NMD-related cardiomyopathy. LGE is variably present in NMD subtypes and correlates with LV remodelling, dysfunction, and clinical outcomes in patients with NMD.
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http://dx.doi.org/10.1007/s00246-021-02686-yDOI Listing
August 2021

Pericarditis and pericardial effusion: one or two distinct diseases?

Minerva Cardiol Angiol 2021 Aug 2. Epub 2021 Aug 2.

First Cardiology Clinic, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece.

The main pericardial syndromes include acute and recurrent pericarditis, constrictive pericarditis and chronic pericardial effusion in the absence of overt inflammation. Despite recent advances in pericardial syndromes, certain clinical scenarios depict remarkable peculiarities and their management is often challenging for the clinician. Acute pericarditis is the most common pericardial disease and in most instances is accompanied by pericardial effusion. On the other hand, pericardial effusion may appear as a separate clinical entity occasionally characterized by absence of inflammatory markers elevation. In cases that effusions are accompanied by C-reactive protein (CRP) elevation, the administration of empiric anti-inflammatory treatment as in acute pericarditis, is the guidelines recommended approach. Conversely, the optimal management of patients with pericardial effusions in the absence of clinical or subclinical inflammation (as depicted by CRP levels and cardiac magnetic resonance findings), is not supported by solid evidence. Patients with chronic pericardial effusions should be followed in specialized centers according to tailored timelines, based on the specific clinical scenarios which should take into account etiology, effusion size, disease duration and stability as regards symptoms and effusion volume. Patients should also be advised to seek medical care at any time if symptoms like chest pain, dyspnea and fatigue should appear.
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http://dx.doi.org/10.23736/S2724-5683.21.05721-5DOI Listing
August 2021

Interactions between erectile dysfunction, cardiovascular disease and cardiovascular drugs.

Nat Rev Cardiol 2021 Jul 30. Epub 2021 Jul 30.

Cardiovascular Diseases and Sexual Health Unit, First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.

Sexual health has a fundamental role in overall health and well-being, and a healthy and dynamic sex life can make an important contribution to a good quality of life. Sexual dysfunction, and especially erectile dysfunction (ED) in men, is highly prevalent in patients with cardiovascular disease (CVD). CVD and ED have shared risk factors and pathophysiological links, such as endothelial dysfunction, inflammation and low plasma testosterone levels. ED has been shown to be an independent and early harbinger of future CVD events, providing an important window to initiate preventive measures. Therefore, screening and diagnosing ED is essential for the primary and secondary prevention of CVD because the assessment of ED offers an easy and low-cost prognostic tool that is an alternative to other investigational cardiovascular biomarkers. Moreover, ED is a major contributing factor to the discontinuation of, or poor adherence to, cardiovascular therapy. Cardiovascular drugs have divergent effects on erectile function, with diuretics and β-blockers having the worst profiles, and renin-angiotensin-aldosterone system inhibitors and nebivolol having the best profiles. Pharmacological treatment of ED has an equivocal effect on the risk of CVD, suggesting a complex interaction between ED and drugs for CVD. In this Review, we discuss how sexual function could be incorporated into the patient history taken by physicians treating individuals with CVD, not merely as part of the diagnostic work-up but as a means to pursue tangible and essential benefits in quality of life and cardiovascular outcomes.
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http://dx.doi.org/10.1038/s41569-021-00593-6DOI Listing
July 2021

Angiography-based estimation of coronary physiology: A frame is worth a thousand words.

Trends Cardiovasc Med 2021 Jul 28. Epub 2021 Jul 28.

First Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Hippokration Hospital, Athens, Greece.

Cumulative evidence has shown that coronary revascularization should be guided by functional significance of coronary lesions. Fractional flow reserve (FFR) is the gold standard for assessment of hemodynamic significance of coronary stenosis and FFR-guided percutaneous coronary intervention has improved clinical outcomes in patients with coronary artery disease. However, limitations of FFR such as increased operational time and cost, requirement of pressure wire and adenosine and technical difficulties have led to significant underutilization of the method in clinical practice. In the last few years, several methods of FFR estimation based on coronary angiography images have emerged to overcome invasive FFR limitations. The common elements of the novel indices include a 3D anatomical reconstruction of coronary vessels by angiographic projections and various approaches to fluid dynamics computation. Angiography-derived FFR methods have shown high diagnostic accuracy compared to invasive FFR. Although there are promising results regarding their prognostic role, large randomized trials evaluating clinical outcomes are lacking. The aim of this review is to present currently available angiography-derived FFR indices and highlight their differences, advantages, disadvantages and potential clinical implications.
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http://dx.doi.org/10.1016/j.tcm.2021.07.004DOI Listing
July 2021

New Approaches to Management of Pericardial Effusions.

Curr Cardiol Rep 2021 07 1;23(8):106. Epub 2021 Jul 1.

First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Vas. Sofias 114, 11528, Athens, Greece.

Purpose Of Review: Pericardial effusion is a challenging pericardial syndrome and a cause of serious concern for physicians and patients due to its potential progression to life-threatening cardiac tamponade. In this review, we summarize the contemporary evidence of the etiology; diagnostic work-up, with particular emphasis on the contribution of multimodality imaging; therapeutic options; and short- and long-term outcomes of these patients.

Recent Findings: In recent years, an important piece of information has contributed to put together several missing parts of the puzzle of pericardial effusion. The most recent 2015 guidelines of the European Society of Cardiology for the diagnosis and management of pericardial diseases are a valuable aid for a tailored approach to this condition. Actually, current guidelines suggest a 4-step treatment algorithm depending on the presence or absence of hemodynamic impairment; the elevation of inflammatory markers; the presence of a known or first-diagnosed underlying condition, possibly related to pericardial effusion; and finally the duration and size of the effusion. In contrast to earlier perceptions, based on the most recent evidence, it seems that in the subgroup of asymptomatic patients with large (> 2-cm end-diastolic diameter), chronic (> 3 months) C-reactive protein negative, idiopathic (without an apparent cause) pericardial effusion, a conservative approach is the most reasonable option. At present there is an increasing interest in the pericardial syndromes in general and pericardial effusions in specific, which has consistently expanded our knowledge in this "hazy landscape." Apart from general recommendations applied to all cases, an individualized, etiologically driven treatment is of paramount importance.
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http://dx.doi.org/10.1007/s11886-021-01539-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8246136PMC
July 2021

A risk score for pericarditis recurrence.

Eur J Clin Invest 2021 May 29:e13602. Epub 2021 May 29.

First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece.

Background: Currently, we remain uncertain about which patients are at increased risk for recurrent pericarditis. We developed a risk score for pericarditis recurrence in patients with acute pericarditis.

Materials And Methods: We prospectively recruited 262 patients with a first episode of acute pericarditis. Baseline patients' demographics, clinical, imaging and laboratory data were collected. Patients were followed up for a median of 51 months (interquartile range 21-71) for recurrence. Variables with <10% missingness were entered into multivariable logistic regression models with stepwise elimination to explore independent predictors of recurrence. The final model performance was assessed by the c-index whereas model's calibration and optimism-corrected c-index were evaluated after 10-fold cross-validation.

Results: We identified six independent predictors for pericarditis recurrence, that is age, effusion size, platelet count (negative predictors) and reduced inferior vena cava collapse, in-hospital use of corticosteroids and heart rate (positive predictors). The final model had good performance for recurrence, c-index 0.783 (95% CI 0.725-0.842), while the optimism-corrected c-index after cross-validation was 0.752. Based on these variables, we developed a risk score point system for recurrence (0-22 points) with equally good performance (c-index 0.740, 95% CI 0.677-0.803). Patients with a low score (0-7 points) had 21.3% risk for recurrence, while those with high score (≥12 points) had a 69.8% risk for recurrence. The score was predictive of recurrence among most patient subgroups.

Conclusions: A simple risk score point system based on 6 variables can be used to predict the individualized risk for pericarditis recurrence among patients with a first episode of acute pericarditis.
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http://dx.doi.org/10.1111/eci.13602DOI Listing
May 2021

The cardiovascular burden of light smoking.

Arch Med Sci Atheroscler Dis 2021 12;6:e48-e56. Epub 2021 Apr 12.

First Department of Cardiology, 'Hippokration' Hospital of Athens, Athens, Greece.

The assumption that light cigarette smoking, meaning smoking one to five cigarettes per day, is not so harmful has been dissipated by several studies. Regardless of the quantity of tobacco cigarettes, smoking remains a leading risk factor for the development and progression of cardiovascular diseases. Smoke is a mixture of several toxic chemicals, such as nicotine, carbon monoxide, and oxidants, implicated in the pathogenesis of cardiovascular and pulmonary diseases. Despite anti-smoking campaigns, a misconception concerning "safe smoking" still exists. The purpose of this literature review is to highlight the deleterious effect of light cigarette smoking and claim the consensus that there is no safe smoking.
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http://dx.doi.org/10.5114/amsad.2021.105313DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8117079PMC
April 2021

'Apples to oranges' and 'Less is more'.

J Hypertens 2021 06;39(6):1262-1264

Cardiovascular Prevention and Research Unit, Clinic/Laboratory of Pathophysiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece.

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http://dx.doi.org/10.1097/HJH.0000000000002827DOI Listing
June 2021

Management of Hypertension and Blood Pressure Dysregulation in Patients with Parkinson's Disease-a Systematic Review.

Curr Hypertens Rep 2021 05 7;23(5):26. Epub 2021 May 7.

Cardiology Department, Hippokration General Hospital, Athens, Greece.

Purpose Of Review: The aim of this review article was to summarize the cardiovascular and blood pressure profile regarding Parkinson disease patients and to provide an update on the recent advancements in the field of the diagnosis and management of blood pressure abnormalities in these patients. Our goal was to guide physicians to avoid pitfalls in current practice while treating patients with Parkinson disease and blood pressure abnormalities. For this purpose, we searched bibliographic databases (PubMed, Google Scholar) for all publications published on blood pressure effects in Parkinson disease until May 2020. Furthermore, we highlight some thoughts and potential perspectives for the next possible steps in the field.

Recent Findings: Blood pressure dysregulation in patients with Parkinson's disease has several implications in clinical practice and presents an ongoing concern. Compared with chronic essential hypertension, the syndrome of combined neurogenic orthostatic hypotension and supine hypertension in Parkinson's disease has received little attention. If left untreated, hypertension may lead to cardiovascular disease whereas hypotension may lead to fall-related complications, with tremendous impact on the quality of life of affected individuals. The effect of blood Epressure control and the risk of death from cardiovascular disease in Parkinson disease are largely unexplored. Blood pressure abnormalities in Parkinson disease present bidirectional relationship and the rationale for treating and controlling hypertension in persons with Parkinson disease and concurrent neurogenic orthostatic hypotension and/or supine hypertension is compelling. Further research is warranted in order to clarify the mechanisms, clinical implications, and potential reversibility of compromised cardiovascular function, in persons with Parkinson disease.
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http://dx.doi.org/10.1007/s11906-021-01146-5DOI Listing
May 2021

MiRNAs as Biomarkers in Hypertrophic Cardiomyopathy: Current State of the Art.

Curr Med Chem 2021 Apr 5. Epub 2021 Apr 5.

EKKAN (Unit for the athletes and for hereditary cardiovascular diseases), 1st Department of Cardiology, Hippokration Hospital, Medical School of National and Kapodistrian University of Athens, Athens. Greece.

Background: Hypertrophic Cardiomyopathy (HCM) is the most common inherited Cardiomyopathy. The hallmark of HCM is myocardial fibrosis that contributes to heart failure, arrhythmias and sudden cardiac death.

Objective: Currently there are no reliable serum biomarkers for detection of myocardial fibrosis, while cardiac magnetic resonance (CMR) is an imaging technique to detect myocardial fibrosis. MicroRNAs (miRNAs) have been increasingly suggested as biomarkers in cardiovascular diseases. However, in HCM there is as yet no identified and verified specific circulating miRNA signature.

Methods: We conducted a review of literature to identify the studies that indicate the possible roles of miRNAs in HCM.

Results: From studies in transgenic mice with HCM, miR-1, -133 may identify HCM in the early asymptomatic phase. Human miR-29a could be used as a circulating biomarker for detection of both myocardial hypertrophy and fibrosis in HCM, while it could also have a possible additional role in discrimination of hypertrophic obstructive cardiomyopathy from non-obstructive HCM. Additionally, miR-29a-3p is associated with diffuse myocardial fibrosis in HCM while miR-1-3p could discriminate end-stage HCM from dilated cardiomyopathy and left ventricle dilation. Another role of miRNAs could also be the contribution in differential diagnosis between HCM and phenocopies. Moreover, miRNA-targeted therapy (miR-133 mimics) is promising in inhibiting cardiac hypertrophy but this is still in the early stages.

Conclusion: A more reliable and specific signature of miRNAs is expected with forthcoming studies in samples from HCM patients and correlation of miRNAs with CMR and serum markers of fibrosis may implicate novel diagnostic and therapeutic pathways.
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http://dx.doi.org/10.2174/0929867328666210405122703DOI Listing
April 2021

The tale of refractory recurrent pericarditis.

Intern Emerg Med 2021 04 18;16(3):537-539. Epub 2021 Mar 18.

First Cardiology Clinic, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece.

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http://dx.doi.org/10.1007/s11739-021-02676-1DOI Listing
April 2021

Permanent pacemaker implantation in unexplained syncope patients with borderline sinus bradycardia and electrophysiology study-proven sinus node disease.

J Arrhythm 2021 Feb 22;37(1):189-195. Epub 2020 Nov 22.

First Department of Cardiology National and Kapodistrian University "Hippokration" Hospital Athens Greece.

Background: Significant sinus bradycardia (SB) in the context of sinus node dysfunction (SND) has been associated with neurological symptoms. The objective was to evaluate the effect of permanent pacing on the incidence of syncope in patients with rather mild degrees of SB, unexplained syncope, and "positive" invasive electrophysiologic testing.

Methods: This was an observational study based on a prospective registry of 122 consecutive mild SB patients (61.90 ± 18.28 years, 61.5% male, 57.88 ± 7.73 bpm) presenting with recurrent unexplained pre and syncope attacks admitted to our hospital for invasive electrophysiology study (EPS). Τhe implantation of a permanent antibradycardia pacemaker (ABP) was offered to all patients according to the results of the EPS. Eighty patients received the ABP, while 42 denied.

Results: The mean of reported syncope episodes was 2.23 ± 1.29 (or presyncope 2.36 ± 1.20) in the last 12 months before they were referred for a combined EP guided diagnostic and therapeutic approach. Over a mean follow-up of approximately 4 years (50.39 ± 32.40 months), the primary outcome event (syncope) occurred in 18 of 122 patients (14.8%), 6 of 80 (7.5%) in the ABP group as compared to 12 of 42 (28.6%) in the no pacemaker group ( = .002).

Conclusions: Among patients with mild degree of SB and a history of unexplained syncope, a set of positivity criteria for the presence of EPS defined SND after differentiating reflex syncope, identifies a subset of patients who will benefit from permanent pacing.
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http://dx.doi.org/10.1002/joa3.12460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7896452PMC
February 2021

Optimal use of lipid-lowering therapy after acute coronary syndromes: A Position Paper endorsed by the International Lipid Expert Panel (ILEP).

Pharmacol Res 2021 04 17;166:105499. Epub 2021 Feb 17.

Department of Internal Medicine, University Hospital Center Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia. Electronic address:

Atherosclerotic cardiovascular disease (ASCVD) and consequent acute coronary syndromes (ACS) are substantial contributors to morbidity and mortality across Europe. Much of these diseases burden is modifiable, in particular by lipid-lowering therapy (LLT). Current guidelines are based on the sound premise that with respect to low density lipoprotein cholesterol (LDL-C), "lower is better for longer", and the recent data have strongly emphasized the need of also "the earlier the better". In addition to statins, which have been available for several decades, the availability of ezetimibe and inhibitors of proprotein convertase subtilisin/kexin type 9 (PCSK9) are additional very effective approach to LLT, especially for those at very high and extremely high cardiovascular risk. LLT is initiated as a response to an individual's calculated risk of future ASCVD and is intensified over time in order to meet treatment goals. However, in real-life clinical practice goals are not met in a substantial proportion of patients. This Position Paper complements existing guidelines on the management of lipids in patients following ACS. Bearing in mind the very high risk of further events in ACS, we propose practical solutions focusing on immediate combination therapy in strict clinical scenarios, to improve access and adherence to LLT in these patients. We also define an 'Extremely High Risk' group of individuals following ACS, completing the attempt made in the recent European guidelines, and suggest mechanisms to urgently address lipid-medicated cardiovascular risk in these patients.
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http://dx.doi.org/10.1016/j.phrs.2021.105499DOI Listing
April 2021

EU-Wide Cross-Sectional Observational Study of Lipid-Modifying Therapy Use in Secondary and Primary Care: the DA VINCI study.

Eur J Prev Cardiol 2021 Sep;28(11):1279-1289

Imperial Clinical Trials Unit, Imperial College London, Stadium House, 68 Wood Lane, London W12 7RH, UK.

Aims: To provide contemporary data on the implementation of European guideline recommendations for lipid-lowering therapies (LLTs) across different settings and populations and how this impacts low-density lipoprotein cholesterol (LDL-C) goal achievement.

Methods And Results: An 18 country, cross-sectional, observational study of patients prescribed LLT for primary or secondary prevention in primary or secondary care across Europe. Between June 2017 and November 2018, data were collected at a single visit, including LLT in the preceding 12 months and most recent LDL-C. Primary outcome was the achievement of risk-based 2016 European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) LDL-C goal while receiving stabilized LLT; 2019 goal achievement was also assessed. Overall, 5888 patients (3000 primary and 2888 secondary prevention patients) were enrolled; 54% [95% confidence interval (CI) 52-56] achieved their risk-based 2016 goal and 33% (95% CI 32-35) achieved their risk-based 2019 goal. High-intensity statin monotherapy was used in 20% and 38% of very high-risk primary and secondary prevention patients, respectively. Corresponding 2016 goal attainment was 22% and 45% (17% and 22% for 2019 goals) for very high-risk primary and secondary prevention patients, respectively. Use of moderate-high-intensity statins in combination with ezetimibe (9%), or any LLT with PCSK9 inhibitors (1%), was low; corresponding 2016 and 2019 goal attainment was 53% and 20% (ezetimibe combination), and 67% and 58% (PCSK9i combination).

Conclusion: Gaps between clinical guidelines and clinical practice for lipid management across Europe persist, which will be exacerbated by the 2019 guidelines. Even with optimized statins, greater utilization of non-statin LLT is likely needed to reduce these gaps for patients at highest risk.
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http://dx.doi.org/10.1093/eurjpc/zwaa047DOI Listing
September 2021

Evaluating the Safety and Tolerability of Azilsartan Medoxomil alone or in combination with Chlorthalidone in the Management of Hypertension: A Systematic Review.

Curr Hypertens Rev 2021 Jan 12. Epub 2021 Jan 12.

First Cardiology Department, Hippokration Hospital, Athens Medical School, National and Kapodistrian University of Athens. Greece.

Background And Aim: Azilsartan medoxomil (AZM) is the newest representative in the class of angiotensin receptor blockers. Azilsartan medoxomil in combination with the older diuretic chlorthalidone (CLD) in fixed-doses of AZM/CLD 40/12.5 mg and 40/25 mg has been approved by the FDA for use in patients with essential hypertension. We sought to evaluate the safety and tolerability of AZL-M alone and in combination with CLD.

Methods: We conducted a search of pubmed using the keywords 'azilsartan', 'azilsartan medoxomil', 'chlorthalidone, 'safety', 'tolerability' in order to find scientific studies evaluating the safety of these drugs. We included studies report ing side effects of these drugs, alone or in combination, in comparison to placebo or other antihypertensive medications. For our systematic review we followed the PRISMA guidelines.

Results: Azilsartan medoxomil is a potent antihypertensive medicine with an acceptable safety profile. Most commonly reported adverse events are dizziness, headache, fatigue, upper respiratory tract infection and urinary tract infection. Chlorthalidone is more potent and has a considerably longer duration of action than the most commonly prescribed diuretic hydrochlorothiazide. Safety and tolerability between these two drugs is similar with the exception of higher serum uric acid and lower potassium levels with chlorthalidone.

Conclusions: The combination of azilsartan medoxomil with chlorthalidone has been shown to be effective in lowering blood pressure with an acceptable safety and tolerability profile. This fixed-dose combination is an attractive treatment option for hypertension management.
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http://dx.doi.org/10.2174/1573402117666210112144505DOI Listing
January 2021

Clinical characteristics and management of patients with diabetes mellitus and stable coronary artery disease in daily clinical practice. The SCAD-DM Registry.

Hellenic J Cardiol 2021 Jan 5. Epub 2021 Jan 5.

Cardiology Dpt., Mitera Hospital, Hygeia Group, Athens, Greece.

Background: Patients with diabetes mellitus (DM) and coronary artery disease (CAD) represent a high-risk population, where comorbidities are common and the progression of coronary heart disease is relatively rapid and extensive. The present survey, conducted nationwide in a Eurozone country, Greece, with a properly organized national health system, aimed to record specific data from a significant number of patients with diabetes and documented stable CAD (SCAD).

Methods And Results: We conducted our survey across the country, in private and public primary, secondary, and tertiary care centers. A total of 1900 patients aged 71 ± 10 years old who suffered from both DM and chronic coronary syndromes were registered. Of the patients registered, 574 (30.24%) were women. It was found that 506 (26.6%) of the 1900 surveyed patients showed typical angina symptoms, while another 560 (29.5%) patients had developed angina-equivalent symptoms according to their history. Additionally, 324 (17%) patients had atypical symptoms that could not easily be attributed to existing CAD and the remaining 510 (26.8%) of the 1900 patients did not exhibit any angina symptoms during their daily activities. Functional testing for myocardial ischemia was not performed in 833 patients (43.8%). Myocardial scintigraphy was the most commonly used noninvasive technique (644 patients, 34%), while 492 patients (25.9%) had an exercise test and 159 (8.4%) underwent stress echocardiography.

Conclusion: Real-world data in this specific high-risk population of diabetic patients with SCAD offer the opportunity to identify and improve diagnostic and therapeutic practice in the healthcare system of a European Union country.
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http://dx.doi.org/10.1016/j.hjc.2020.12.006DOI Listing
January 2021

The Mediterranean Diet Benefit on Cardiovascular Hemodynamics and Erectile Function in Chronic Heart Failure Male Patients by Decoding Central and Peripheral Vessel Rheology.

Nutrients 2020 Dec 30;13(1). Epub 2020 Dec 30.

First Cardiology Clinic, Hippokration Hospital, School of Medicine, University of Athens, 11527 Athens, Greece.

Background: Mediterranean diet was evaluated on erectile performance and cardiovascular hemodynamics, in chronic heart failure patients.

Methods: 150 male stable heart failure patients were enrolled in the study (62 ± 10 years, New York Heart Association (NYHA) classes I-II, ejection fraction ≤40%). A detailed echocardiographic evaluation including estimation of the global longitudinal strain of the left ventricle and the systolic tissue doppler velocity of the tricuspid annulus was performed. Erectile dysfunction severity was assessed by the Sexual Health Inventory for Men-5 (SHIM-5) score. Adherence to the Mediterranean diet was evaluated by the MedDietScore.

Results: The SHIM-5 score was positively correlated with the MedDietScore ( = 0.006) and augmentation index ( = 0.031) and inversely correlated with age ( = 0.002). MedDietScore was negatively associated with intima-media-thickness ( < 0.001) and serum prolactin levels ( = 0.05). Multi-adjusted analysis revealed that the inverse relation of SHIM-5 and prolactin levels remained significant only among patients with low adherence to the Mediterranean diet ( = 0.012).

Conclusion: Consumption of Mediterranean diet benefits cardiovascular hemodynamics, while suppressing serum prolactin levels. Such physiology may enhance erectile ability independently of the of the left ventricle ejection fraction.
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http://dx.doi.org/10.3390/nu13010108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7824543PMC
December 2020

Contemporary management of pericardial effusion.

Panminerva Med 2021 Jan 4. Epub 2021 Jan 4.

First Cardiology Clinic, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece.

Pericardial effusion is a relatively common clinical condition with a variety of clinical manifestations ranging from incidentally discovered asymptomatic cases to life-threatening cardiac tamponade. The etiology encompasses idiopathic cases and forms secondary to different conditions, including autoimmune diseases, malignancies, metabolic disorders, etc. While medical therapy should be offered to patients with elevation of inflammatory markers, in specific forms treatment should be appropriate to the underlying disorder. In cases with hemodynamic compromise pericardial drainage either with pericardiocentesis or pericardial "window" is indicated for therapeutic and diagnostic purposes. In the remainder, factors like comorbidities, size and location of the pericardial effusion will influence the clinical decision making. In asymptomatic or minimally symptomatic chronic large idiopathic pericardial effusions, according to recent evidence, a conservative approach with watchful waiting seems the most reasonable option. The prognosis of pericardial effusions largely depends on the underlying etiologies. Metastatic spread to the pericardium has an ominous prognosis whereas large to moderate effusions have been often associated with known or newly discovered specific underlying causes. Chronic small idiopathic effusions have an excellent prognosis and do not require specific monitoring. Large chronic idiopathic effusions in clinically stable patients require a 3 to 6-month assessment ideally in a specialized unit.
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http://dx.doi.org/10.23736/S0031-0808.20.04197-XDOI Listing
January 2021

Do SGLT2 inhibitors increase the risk of amputation? Make haste slowly.

Eur Heart J 2021 05;42(18):1739-1741

First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece.

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http://dx.doi.org/10.1093/eurheartj/ehaa1022DOI Listing
May 2021

COVID-19 and cerebrovascular diseases: a comprehensive overview.

Ther Adv Neurol Disord 2020 8;13:1756286420978004. Epub 2020 Dec 8.

Fourth Department of Internal Medicine, 'Attikon' University Hospital, National and Kapodistrian University of Athens, Athens, Greece.

Neurological manifestations are not uncommon during infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A clear association has been reported between cerebrovascular disease and coronavirus disease 2019 (COVID-19). However, whether this association is causal or incidental is still unknown. In this narrative review, we sought to present the possible pathophysiological mechanisms linking COVID-19 and cerebrovascular disease, describe the stroke syndromes and their prognosis and discuss several clinical, radiological, and laboratory characteristics that may aid in the prompt recognition of cerebrovascular disease during COVID-19. A systematic literature search was conducted, and relevant information was abstracted. Angiotensin-converting enzyme-2 receptor dysregulation, uncontrollable immune reaction and inflammation, coagulopathy, COVID-19-associated cardiac injury with subsequent cardio-embolism, complications due to critical illness and prolonged hospitalization can all contribute as potential etiopathogenic mechanisms leading to diverse cerebrovascular clinical manifestations. Acute ischemic stroke, intracerebral hemorrhage, and cerebral venous sinus thrombosis have been described in case reports and cohorts of COVID-19 patients with a prevalence ranging between 0.5% and 5%. SARS-CoV-2-positive stroke patients have higher mortality rates, worse functional outcomes at discharge and longer duration of hospitalization as compared with SARS-CoV-2-negative stroke patients in different cohort studies. Specific demographic, clinical, laboratory and radiological characteristics may be used as 'red flags' to alarm clinicians in recognizing COVID-19-related stroke.
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http://dx.doi.org/10.1177/1756286420978004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7727052PMC
December 2020

Acute Pericarditis Clinical Features and Outcome: An Update on the Latest Evidence.

Chest 2020 12;158(6):2262-2263

1st Cardiology Clinic, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece.

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http://dx.doi.org/10.1016/j.chest.2020.08.007DOI Listing
December 2020

Recurrence of Pericardial Effusion After Pericardiocentesis: Does Catheter-Induced Acute Pericardial Inflammation Play a Role?

Am J Med Sci 2021 05 12;361(5):676-678. Epub 2020 Oct 12.

1st Cardiology Clinic, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece.

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http://dx.doi.org/10.1016/j.amjms.2020.10.012DOI Listing
May 2021

Mobile phones and applications in the management of patients with arterial hypertension.

Am J Cardiovasc Dis 2020 15;10(4):419-431. Epub 2020 Oct 15.

First Department of Cardiology, Hippokration Hospital, Athens Medical School, National and Kapodistrian University of Athens Greece.

The use of mobile health (mHealth) in the field of medicine is constantly evolving and advancing. Arterial hypertension, a major modifiable cardiovascular risk factor with a high prevalence in the general population, frequently remains underdiagnosed and thus untreated. Furthermore, the majority of hypertensive patients fail to achieve blood pressure target levels. The purpose of this review is to identify and evaluate current use of mHealth strategies, with focus on mobile phones, smartphones and applications, in the management of patients with arterial hypertension. Current mobile technology has the capacity to inform and motivate the general public for timely diagnosis of hypertension, to facilitate communication between physicians and patients, to aid in the monitoring of blood pressure levels and the optimization of treatment and to promote, in general, a healthy lifestyle and assist in the management of other cardiovascular risk factors. There is potential for positive impact of mHealth technology in the management of arterial hypertension, as well as probable detrimental effects that warrant caution. The research in this field is ongoing and future well-conducted studies are needed in order to establish the use of mobile technology in arterial hypertension management.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675159PMC
October 2020

Cardiologists should not lose their peripheral vision: a plea against 'peri-anopsy' in cardiology.

Eur Heart J 2020 11;41(44):4219-4220

Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.

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http://dx.doi.org/10.1093/eurheartj/ehaa621DOI Listing
November 2020
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