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European Heart Journal - current issue - Recent Medical Updates

Old and new enemies: psychological stress, occupational stress, COVID-19, and a glimpse of the future
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The Jessa Hospital experience for cardiac rehabilitation
<span class="paragraphSection"><strong>The ESC and EAPC reference centre for cardiac rehabilitation presents its accelerated programme for cardiac rehabilitation brought about by COVID-19</strong></span>

A call to action for new global approaches to cardiovascular disease drug solutions
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Whilst we continue to wrestle with the immense challenge of implementing equitable access to established evidence-based treatments, substantial gaps remain in our pharmacotherapy armament for common forms of cardiovascular disease including coronary and peripheral arterial disease, heart failure, hypertension, and arrhythmia. We need to continue to invest in the development of new approaches for the discovery, rigorous assessment, and implementation of new therapies. Currently, the time and cost to progress from lead compound/product identification to the clinic, and the success rate in getting there reduces the incentive for industry to invest, despite the enormous burden of disease and potential size of market. There are tremendous opportunities with improved phenotyping of patients currently batched together in syndromic ‘buckets’. Use of advanced imaging and molecular markers may allow stratification of patients in a manner more aligned to biological mechanisms that can, in turn, be targeted by specific approaches developed using high-throughput molecular technologies. Unbiased ‘omic’ approaches enhance the possibility of discovering completely new mechanisms in such groups. Furthermore, advances in drug discovery platforms, and models to study efficacy and toxicity more relevant to the human disease, are valuable. Re-imagining the relationships among discovery, translation, evaluation, and implementation will help reverse the trend away from investment in the cardiovascular space, establishing innovative platforms and approaches across the full spectrum of therapeutic development.</span>

Prevention of cardiovascular disease: does ‘every step counts’ apply for occupational work?
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The physical activity paradox in cardiovascular disease and all-cause mortality: the contemporary Copenhagen General Population Study with 104 046 adults
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims </div>Leisure time physical activity associates with reduced risk of cardiovascular disease and all-cause mortality, while these relationships for occupational physical activity are unclear. We tested the hypothesis that leisure time physical activity associates with reduced major adverse cardiovascular events (MACE) and all-cause mortality risk, while occupational physical activity associates with increased risks.<div class="boxTitle">Methods and results </div>We studied 104 046 women and men aged 20–100 years in the Copenhagen General Population Study with baseline measurements in 2003–2014 and median 10-year follow-up. Both leisure and occupational physical activity were based on self-report with four response categories. We observed 7913 (7.6%) MACE and 9846 (9.5%) deaths from all causes. Compared to low leisure time physical activity, multivariable adjusted (for lifestyle, health, living conditions, and socioeconomic factors) hazard ratios for MACE were 0.86 (0.78–0.96) for moderate, 0.77 (0.69–0.86) for high, and 0.85 (0.73–0.98) for very high activity; corresponding values for higher occupational physical activity were 1.04 (0.95–1.14), 1.15 (1.04–1.28), and 1.35 (1.14–1.59), respectively. For all-cause mortality, corresponding hazard ratios for higher leisure time physical activity were 0.74 (0.68–0.81), 0.59 (0.54–0.64), and 0.60 (0.52–0.69), and for higher occupational physical activity 1.06 (0.96–1.16), 1.13 (1.01–1.27), and 1.27 (1.05–1.54), respectively. Similar results were found within strata on lifestyle, health, living conditions, and socioeconomic factors, and when excluding individuals dying within the first 5 years of follow-up. Levels of the two domains of physical activity did not interact on risk of MACE (<span style="font-style:italic;">P</span> = 0.40) or all-cause mortality (<span style="font-style:italic;">P</span> = 0.31).<div class="boxTitle">Conclusion </div>Higher leisure time physical activity associates with reduced MACE and all-cause mortality risk, while higher occupational physical activity associates with increased risks, independent of each other.</span>

Decoding stroke risk scores in atrial fibrillation: still more work to do
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Erratum to: “ESC Core Curriculum for the Cardiologist”
<span class="paragraphSection">Upon the original publication of this correction notice, the following requested author corrections to the original article “’ESC Core Curriculum for the Cardiologist’ Felix C Tanner, Nicolas Brooks, Kevin F Fox, Lino Gonçalves, Peter Kearney, Lampros Michalis, Agnès Pasquet, Susanna Price, Eric Bonnefoy, Mark Westwood, Chris Plummer, Paulus Kirchhof, ESC Scientific Document Group <span style="font-style:italic;">European Heart Journal</span>, Volume 41, Issue 38, 7 October 2020, Pages <strong><a href="article.aspx?volume=&amp;page=">3605–3692<span></span></a></strong>, <a href=""></a>”, were inadvertently not listed and not made. The Publisher would like to apologize for these omissions and has since corrected the errors listed in this erratum.</span>

Validation of risk scores for ischaemic stroke in atrial fibrillation across the spectrum of kidney function
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims </div>The increasing prevalence of ischaemic stroke (IS) can partly be explained by the likewise growing number of patients with chronic kidney disease (CKD). Risk scores have been developed to identify high-risk patients, allowing for personalized anticoagulation therapy. However, predictive performance in CKD is unclear. The aim of this study is to validate six commonly used risk scores for IS in atrial fibrillation (AF) patients across the spectrum of kidney function.<div class="boxTitle">Methods and results </div>Overall, 36 004 subjects with newly diagnosed AF from SCREAM (Stockholm CREAtinine Measurements), a healthcare utilization cohort of Stockholm residents, were included. Predictive performance of the AFI, CHADS<sub>2</sub>, Modified CHADS<sub>2</sub>, CHA<sub>2</sub>DS<sub>2</sub>-VASc, ATRIA, and GARFIELD-AF risk scores was evaluated across three strata of kidney function: normal kidney function [estimated glomerular filtration rate (eGFR) &gt;60 mL/min/1.73 m<sup>2</sup>], mild CKD (eGFR 30–60 mL/min/1.73 m<sup>2</sup>), and advanced CKD (eGFR &lt;30 mL/min/1.73 m<sup>2</sup>). Predictive performance was assessed by discrimination and calibration. During 1.9 years, 3069 (8.5%) patients suffered an IS. Discrimination was dependent on eGFR: the median c-statistic in normal eGFR was 0.75 (range 0.68–0.78), but decreased to 0.68 (0.58–0.73) and 0.68 (0.55–0.74) for mild and advanced CKD, respectively. Calibration was reasonable and largely independent of eGFR. The Modified CHADS<sub>2</sub> score showed good performance across kidney function strata, both for discrimination [c-statistic: 0.78 (95% confidence interval 0.77–0.79), 0.73 (0.71–0.74) and 0.74 (0.69–0.79), respectively] and calibration.<div class="boxTitle">Conclusion </div>In the most clinically relevant stages of CKD, predictive performance of the majority of risk scores was poor, increasing the risk of misclassification and thus of over- or undertreatment. The Modified CHADS<sub>2</sub> score performed good and consistently across all kidney function strata, and should therefore be preferred for risk estimation in AF patients.</span>

In-hospital resuscitation of Covid-19 patients is impeded by serious delays, but the problem is obscured by poor time data
<span class="paragraphSection"><strong>This commentary refers to ‘Cardiac arrest in COVID-19: characteristics and outcomes of in- and out-of-hospital cardiac arrest. A report from the Swedish Registry for Cardiopulmonary Resuscitation’, by P. Sultanian <span style="font-style:italic;">et al</span>., doi:10.1093/eurheartj/ehaa1067 and the discussion piece ‘Handling time elements for in-hospital cardiac arrest’, by P. Sultanian <span style="font-style:italic;">et al</span>., doi:<strong><a href="article.aspx?volume=&amp;page=">10.1093/eurheartj/ehaa163<span></span></a></strong>.</strong></span>

Handling time elements for in-hospital cardiac arrest

The value of sotagliflozin in patients with diabetes and heart failure detracted by an unexpected ending
<span class="paragraphSection">Comment on ‘Sotagliflozin in patients with diabetes and recent worsening heart failure’ published in the <span style="font-style:italic;">New England Journal of Medicine</span>, doi:10.1056/NEJMoa2030183. <div class="boxedTextSection"><div class="boxTitle">Key Points</div></div></span>

The collateral cardiovascular damage of COVID-19: only history will reveal the depth of the iceberg
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All-cause mortality and location of death in patients with established cardiovascular disease before, during, and after the COVID-19 lockdown: a Danish Nationwide Cohort Study
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>On 13 March 2020, the Danish authorities imposed extensive nationwide lockdown measures to prevent the spread of the coronavirus disease 2019 (COVID-19) and reallocated limited healthcare resources. We investigated mortality rates, overall and according to location, in patients with established cardiovascular disease before, during, and after these lockdown measures.<div class="boxTitle">Methods and results</div>Using Danish nationwide registries, we identified a dynamic cohort comprising all Danish citizens with cardiovascular disease (i.e. a history of ischaemic heart disease, ischaemic stroke, heart failure, atrial fibrillation, or peripheral artery disease) alive on 2 January 2019 and 2020. The cohort was followed from 2 January 2019/2020 until death or 16/15 October 2019/2020. The cohort comprised 340 392 and 347 136 patients with cardiovascular disease in 2019 and 2020, respectively. The overall, in-hospital, and out-of-hospital mortality rate in 2020 before lockdown was significantly lower compared with the same period in 2019 [adjusted incidence rate ratio (IRR) 0.91, 95% confidence interval (CI) CI 0.87–0.95; IRR 0.95, 95% CI 0.89–1.02; and IRR 0.87, 95% CI 0.83–0.93, respectively]. The overall mortality rate during and after lockdown was not significantly different compared with the same period in 2019 (IRR 0.99, 95% CI 0.97–1.02). However, the in-hospital mortality rate was lower and out-of-hospital mortality rate higher during and after lockdown compared with the same period in 2019 (in-hospital, IRR 0.92, 95% CI 0.88–0.96; out-of-hospital, IRR 1.04, 95% CI1.01–1.08). These trends were consistent irrespective of sex and age.<div class="boxTitle">Conclusions</div>Among patients with established cardiovascular disease, the in-hospital mortality rate was lower and out-of-hospital mortality rate higher during lockdown compared with the same period in the preceding year, irrespective of age and sex.</span>

A broken heart after child loss
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Death of a child and the risk of atrial fibrillation: a nationwide cohort study in Sweden
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims</div>The role of psychological stress in the aetiology of atrial fibrillation (AF) is unclear. The death of a child is one of the most severe sources of stress. We aimed to investigate whether the death of a child is associated with an increased risk of AF.<div class="boxTitle">Methods and results</div>We studied parents with children born during 1973–2014 included the Swedish Medical Birth Register (<span style="font-style:italic;">n</span> = 3 924 237). Information on death of a child, AF and socioeconomic, lifestyle and health-related covariates was obtained through linkage to nationwide population and health registers. We examined the link between death of a child and AF risk using Poisson regression. Parents who lost a child had a 15% higher risk of AF than unexposed parents [incidence rate ratio (IRR) and 95% confidence intervals (CI): 1.15 (1.10–1.20)]. An increased risk of AF was observed not only if the child died due to cardiovascular causes [IRR (95% CI): 1.35 (1.17–1.56)], but also in case of deaths due to other natural [IRR (95% CI): 1.15 (1.09–1.21)] or unnatural [IRR (95% CI): 1.10 (1.02–1.19)] causes. The risk of AF was highest in the 1st week after the loss [IRR (95% CI): 2.87 (1.44–5.75)] and remained 10–40% elevated on the long term.<div class="boxTitle">Conclusions</div>Death of a child was associated with a modestly increased risk of AF. Our finding that an increased risk was observed also after loss of a child due to unnatural deaths suggests that stress-related mechanisms may also be implicated in the development of AF.</span>

Taking a stand against air pollution – the impact on cardiovascular diseaseA Joint Opinion from the World Heart Federation, American College of Cardiology, American Heart Association, and the European Society of Cardiology
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Although the attention of the world and the global health community specifically is deservedly focused on the COVID-19 pandemic, other determinants of health continue to have large impacts and may also interact with COVID-19. Air pollution is one crucial example. Established evidence from other respiratory viruses and emerging evidence for COVID-19 specifically indicates that air pollution alters respiratory defense mechanisms leading to worsened infection severity. Air pollution also contributes to co-morbidities that are known to worsen outcomes amongst those infected with COVID-19, and air pollution may also enhance infection transmission due to its impact on more frequent coughing. Yet despite the massive disruption of the COVID-19 pandemic, there are reasons for optimism: broad societal lockdowns have shown us a glimpse of what a future with strong air pollution measures could yield. Thus, the urgency to combat air pollution is not diminished, but instead heightened in the context of the pandemic.</span>

Professor Anthony H. Gershlick
<span class="paragraphSection"><strong>Interventional cardiology has lost one of its most prominent leaders, trainers, and researchers in Professor Tony Gershlick who died from COVID-19 on 20th November 2020 at the hospital he had worked in for over 30 years</strong></span>

Cardiology training using technology
<span class="paragraphSection"><strong>Technology-enabled cardiology training and education for effective learning in the COVID-19 era and beyond</strong></span>

‘Heart of stone’: an unusual post-actinic sequela
<span class="paragraphSection">A 60-year-old man with a history of Hodgkin's lymphoma was admitted to our institution for congestive heart failure. Twenty years earlier, he had received chemotherapy and radiotherapy and had developed late post-actinic sequela involving the lungs and heart. Chest X-ray and echocardiographic examination showed pulmonary congestion and fibrosis, pleural, and pericardial effusion along with reduced left ventricular ejection fraction (<span style="font-style:italic;">Panel A</span>). However, the clinical picture was predominantly characterized by evidence of severe left ventricular calcifications extending inward from the epicardium and involving the interventricular septum and mitral apparatus, as documented on computed tomography chest scan (<span style="font-style:italic;">Panels B</span> and <span style="font-style:italic;">C</span>; Supplementary material online, Video S1Supplementary material online, <span style="font-style:italic;">Video S1</span>). These impressive calcifications were also the prevailing features on coronary angiography which revealed the absence of significant coronary stenoses (<span style="font-style:italic;">Panel D</span>; Supplementary material online, Video S2Supplementary material online, <span style="font-style:italic;">Video S2</span>). Chest radiation exposure is associated with a substantial risk for the subsequent development of pulmonary and cardiovascular disease; however, massive calcifications that penetrate deep into the myocardial layers of the left ventricle have rarely been reported. </span>

Primary cardiac epithelioid haemangioendothelioma
<span class="paragraphSection">A 28-year-old man presented with sudden severe palpitations and moderate dyspnoea for 1 day.</span>