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WORLD HOSPITAL DIRECTORY
Cardiology Medical European Heart Journal - current issue
<span class="paragraphSection"> <span style="font-style:italic;">For the podcast associated with this article, please visit https://academic.oup.com/eurheartj/pages/Podcasts</span>.</span>
<span class="paragraphSection">‘I will love those who taught me these arts as I love my parents and I will offer my skills to the young with the same generosity that they were given to me. And I will never ask them for gold, but demand that they stand by this covenant in return. I also swear that if I earn fame and wealth, I will share it with my masters and my students’</span>
<span class="paragraphSection">The <span style="font-style:italic;">Lancet Regional Health-Europe</span> commission on inequities and disparities in cardiovascular health is a key initiative addressing critical disparities in cardiovascular health across different demographics.<sup><a href="#ehae793-B1" class="reflinks">1</a></sup> Chaired by Professor Raffaele Bugiardini from the University of Bologna, with Co-Chairs Professor Chris P. Gale from the University of Leeds and Dr Martha Gulati from Cedars-Sinai Medical Center, this Commission is a concerted effort to tackle one of the most pressing public health challenges of our time.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background and Aims</div>Skeletal muscle (SM) fat infiltration, or intermuscular adipose tissue (IMAT), reflects muscle quality and is associated with inflammation, a key determinant in cardiometabolic disease. Coronary flow reserve (CFR), a marker of coronary microvascular dysfunction (CMD), is independently associated with body mass index (BMI), inflammation and risk of heart failure, myocardial infarction, and death. The relationship between SM quality, CMD, and cardiovascular outcomes is not known.<div class="boxTitle">Methods</div>Consecutive patients (<span style="font-style:italic;">n</span> = 669) undergoing evaluation for coronary artery disease with cardiac stress positron emission tomography demonstrating normal perfusion and preserved left ventricular ejection fraction were followed over a median of 6 years for major adverse cardiovascular events (MACEs), including death and hospitalization for myocardial infarction or heart failure. Coronary flow reserve was calculated as stress/rest myocardial blood flow. Subcutaneous adipose tissue (SAT), SM, and IMAT areas (cm<sup>2</sup>) were obtained from simultaneous positron emission tomography attenuation correction computed tomography using semi-automated segmentation at the 12th thoracic vertebra level.<div class="boxTitle">Results</div>Median age was 63 years, 70% were female, and 46% were nonwhite. Nearly half of patients were obese (46%, BMI 30–61 kg/m<sup>2</sup>), and BMI correlated highly with SAT and IMAT (<span style="font-style:italic;">r</span> = .84 and <span style="font-style:italic;">r</span> = .71, respectively, <span style="font-style:italic;">P</span> < .001) and moderately with SM (<span style="font-style:italic;">r</span> = .52, <span style="font-style:italic;">P</span> < .001). Decreased SM and increased IMAT, but not BMI or SAT, remained independently associated with decreased CFR (adjusted <span style="font-style:italic;">P</span> = .03 and <span style="font-style:italic;">P</span> = .04, respectively). In adjusted analyses, both lower CFR and higher IMAT were associated with increased MACE [hazard ratio 1.78 (95% confidence interval 1.23–2.58) per −1 U CFR and 1.53 (1.30–1.80) per +10 cm<sup>2</sup> IMAT, adjusted <span style="font-style:italic;">P</span> = .002 and <span style="font-style:italic;">P</span> < .0001, respectively], while higher SM and SAT were protective [hazard ratio .89 (.81–.97) per +10 cm<sup>2</sup> SM and .94 (.91–.98) per +10 cm<sup>2</sup> SAT, adjusted <span style="font-style:italic;">P</span> = .01 and .003, respectively]. Every 1% increase in fatty muscle fraction [IMAT/(SM + IMAT)] conferred an independent 2% increased odds of CMD [CFR <2, odds ratio 1.02 (1.01–1.04), adjusted <span style="font-style:italic;">P</span> = .04] and a 7% increased risk of MACE [hazard ratio 1.07 (1.04–1.09), adjusted <span style="font-style:italic;">P</span> < .001]. There was a significant interaction between CFR and IMAT, not BMI, such that patients with both CMD and fatty muscle demonstrated highest MACE risk (adjusted <span style="font-style:italic;">P</span> = .02).<div class="boxTitle">Conclusions</div>Increased intermuscular fat is associated with CMD and adverse cardiovascular outcomes independently of BMI and conventional risk factors. The presence of CMD and SM fat infiltration identified a novel at-risk cardiometabolic phenotype.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background and Aims</div>Familial hypercholesterolaemia leads to lifelong elevated low-density lipoprotein cholesterol with increased risk of coronary heart disease and pre-mature death. It is unknown whether the prognosis for individuals with familial hypercholesterolaemia has improved over the past four decades as registration of this condition has been limited worldwide. However, in Danish nationwide registries, modified ICD coding has allowed such registration since 1978. This study tested the hypothesis that age at death and coronary heart disease has improved from 1978 to 2021 in individuals with vs. those without familial hypercholesterolaemia.<div class="boxTitle">Methods</div>From nationwide registries, all Danish residents were included in a retrospective cohort study. Inclusion and follow-up were from 1978 to 2021. Individuals diagnosed with familial hypercholesterolaemia were identified, and trends over time were examined for age at death and age at coronary heart disease.<div class="boxTitle">Results</div>During follow-up for those with (<span style="font-style:italic;">n</span> = 10 199) and without (<span style="font-style:italic;">n</span> = 9 174 926) familial hypercholesterolaemia, 27% and 27% died and 34% and 9% experienced coronary heart disease. Age at death was 22 years younger in 1978 (<span style="font-style:italic;">P</span> < .001) but similar in 2021 (<span style="font-style:italic;">P</span> = .16) in individuals with vs. without familial hypercholesterolaemia. Although the corresponding age at coronary heart disease was 20 years younger in 1978 (<span style="font-style:italic;">P</span> < .001), it was still 7 years younger in 2021 (<span style="font-style:italic;">P</span> < .001) in individuals with vs. without familial hypercholesterolaemia. These results were similar in women and men and in a 1:100 matched analysis by sex, ethnicity, and time of birth.<div class="boxTitle">Conclusions</div>Nationwide from 1978 to 2021 in Denmark, normalization of age at death but not age at coronary heart disease was observed for individuals diagnosed with familial hypercholesterolaemia.</span>
<span class="paragraphSection">An 87-year-old male patient with stage IIIA melanoma had been treated with pembrolizumab two years prior. He was admitted for treatment with a combination of nivolumab and ipilimumab after the development of liver metastases. Two weeks after admission, the patient developed bleeding from his stool and was diagnosed with immune-related adverse event (irAE)-related colitis. One week later, he complained of chest pain, and an electrocardiogram revealed ST-segment elevation in V2–V6 (<span style="font-style:italic;">Panel A</span>), with elevated serum troponin-I (2382.4 pg/mL). Emergency coronary angiography revealed filling defects in the mid-portion of the left anterior descending artery (<span style="font-style:italic;">Panel B</span>, black arrows, Supplementary data onlineSupplementary data online, <span style="font-style:italic;">Video S1</span>). Optical coherence tomography (OCT) showed coronary plaque erosion with a large platelet-rich white thrombus (<span style="font-style:italic;">Panels C1</span>–<span style="font-style:italic;">C3</span>, red arrows, Supplementary data onlineSupplementary data online, <span style="font-style:italic;">Video S2</span>). The patient was diagnosed with acute coronary syndrome (ACS) due to plaque erosion following immune checkpoint inhibitors (ICIs). Based on the OCT findings of plaque erosion, 100 mg aspirin was administered without stent placement in the culprit lesion. After discharge, the patient has no recurrence of ACS or bleeding and is currently continuing treatment with aspirin and ICIs. Recent studies have suggested that ICIs, such as anti-PD-1/PD-L1 therapy, contribute to atherosclerotic plaque destabilization, potentially triggering irAE-associated ACS.<sup><a href="#ehae817-B1" class="reflinks">1</a></sup> To our knowledge, this is the first report on the OCT-based management of plaque erosion related to irAE to determine the treatment strategy. This case highlights the diagnostic challenges posed by ACS following treatment with ICIs and the importance of OCT imaging in achieving an accurate diagnosis and effective treatment plan for cardiologists.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background and Aims</div>Overweight and obesity are modifiable risk factors for atherosclerotic cardiovascular disease (ASCVD) in the general population, but their prevalence in individuals with heterozygous familial hypercholesterolaemia (HeFH) and whether they confer additional risk of ASCVD independent of LDL cholesterol (LDL-C) remains unclear.<div class="boxTitle">Methods</div>Cross-sectional analysis was conducted in 35 540 patients with HeFH across 50 countries, in the EAS FH Studies Collaboration registry. Prevalence of World Health Organization–defined body mass index categories was investigated in adults (<span style="font-style:italic;">n</span> = 29 265) and children/adolescents (<span style="font-style:italic;">n</span> = 6275); and their association with prevalent ASCVD.<div class="boxTitle">Results</div>Globally, 52% of adults and 27% of children with HeFH were overweight or obese, with the highest prevalence noted in Northern Africa/Western Asia. A higher overweight/obesity prevalence was found in non-high-income vs. high-income countries. Median age at familial hypercholesterolaemia diagnosis in adults with obesity was 9 years older than in normal weight adults. Obesity was associated with a more atherogenic lipid profile independent of lipid-lowering medication. Prevalence of coronary artery disease increased progressively across body mass index categories in both children and adults. Compared with normal weight, obesity was associated with higher odds of coronary artery disease in children (odds ratio 9.28, 95% confidence interval 1.77–48.77, adjusted for age, sex, lipids, and lipid-lowering medication) and coronary artery disease and stroke in adults (odds ratio 2.35, 95% confidence interval 2.10–2.63 and odds ratio 1.65, 95% confidence interval 1.27–2.14, respectively), but less consistently with peripheral artery disease. Adjusting for diabetes, hypertension and smoking modestly attenuated the associations.<div class="boxTitle">Conclusions</div>Overweight and obesity are common in patients with HeFH and contribute to ASCVD risk from childhood, independent of LDL-C and lipid-lowering medication. Sustained body weight management is needed to reduce the risk of ASCVD in HeFH.</span>
<span class="paragraphSection">Cardiac myxoma (CM) is the most common benign primary cardiac tumour in adults. Almost concerns the left atrium, being more frequent in middle-aged women. They can be asymptomatic, and the diagnosis can be incidental in an echocardiography or they can cause constitutional, intracardiac obstructive, thrombus, or embolic tumour fragments manifestations. The last can occur in 25–50% of the cases and predominantly affects brain circulation.<sup><a href="#ehae211-B1" class="reflinks">1</a>,<a href="#ehae211-B2" class="reflinks">2</a></sup></span>
<span class="paragraphSection"><strong>This commentary refers to ‘Deep learning to detect left ventricular structural abnormalities in chest X-rays’, by S. Bhave <span style="font-style:italic;">et al</span>., <a href="https://doi.org/10.1093/eurheartj/ehad782">https://doi.org/10.1093/eurheartj/ehad782</a> and the discussion piece ‘Deep learning for cardiac abnormalities in chest X-rays: performance metrics with imbalanced data and extracardiac objects’, by E. Kagawa <span style="font-style:italic;">et al</span>., <a href="https://doi.org/10.1093/eurheartj/ehae759">https://doi.org/10.1093/eurheartj/ehae759</a>.</strong></span>
<span class="paragraphSection"><strong>This commentary refers to ‘Deep learning to detect left ventricular structural abnormalities in chest X-rays’, by S. Bhave <span style="font-style:italic;">et al.</span>, <a href="https://doi.org/10.1093/eurheartj/ehad782">https://doi.org/10.1093/eurheartj/ehad782</a> and the discussion piece ‘Novel technology, novel challenges: How do we compare the performance of artificial intelligence to human experts?’, by P. Elias <span style="font-style:italic;">et al</span>., <a href="https://doi.org/10.1093/eurheartj/ehae760">https://doi.org/10.1093/eurheartj/ehae760</a>.</strong></span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background and Aims</div>In the FLOW trial, semaglutide reduced the risks of kidney and cardiovascular (CV) outcomes and death in participants with type 2 diabetes and chronic kidney disease (CKD). These prespecified analyses assessed the effects of semaglutide on CV outcomes and death by CKD severity.<div class="boxTitle">Methods</div>Participants were randomized to subcutaneous semaglutide 1 mg or placebo weekly. The main outcome was a composite of CV death, non-fatal myocardial infarction (MI), or non-fatal stroke (CV death/MI/stroke) as well as death due to any cause by baseline CKD severity. CKD was categorized by estimated glomerular filtration rate < or ≥60 mL/min/1.73 m<sup>2</sup>, urine albumin-to-creatinine ratio < or ≥300 mg/g, or Kidney Disease Improving Global Outcomes (KDIGO) risk classification.<div class="boxTitle">Results</div>Three thousand, five hundred and thirty-three participants were randomized with a median follow-up of 3.4 years. Low/moderate KDIGO risk was present in 242 (6.8%), while 878 (24.9%) had high and 2412 (68.3%) had very high KDIGO risk. Semaglutide reduced CV death/MI/stroke by 18% [hazard ratio (HR) 0.82 (95% confidence interval 0.68–0.98); <span style="font-style:italic;">P</span> = .03], with consistency across estimated glomerular filtration rate categories, urine albumin-to-creatinine ratio levels, and KDIGO risk classification (all <span style="font-style:italic;">P</span>-interaction > .13). Death due to any cause was reduced by 20% [HR 0.80 (0.67–0.95); <span style="font-style:italic;">P</span> = .01], with consistency across estimated glomerular filtration rate categories and KDIGO risk class (<span style="font-style:italic;">P</span>-interaction .21 and .23, respectively). The <span style="font-style:italic;">P</span>-interaction treatment effect for death due to any cause by urine albumin-to-creatinine ratio was .01 [<300 mg/g HR 1.17 (0.83–1.65); ≥300 mg/g HR 0.70 (0.57–0.85)].<div class="boxTitle">Conclusions</div>Semaglutide significantly reduced the risk of CV death/MI/stroke regardless of baseline CKD severity in participants with type 2 diabetes.</span>
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