ISSUE @ A GLANCE
European Heart Journal (2016) 37, 2291–2293 doi:10.1093/eurheartj/ehw321
Prevention is better than cure: the new ESC Guidelines Thomas F. Lu¨scher, MD, FESC Editor-in-Chief, Zurich Heart House, Careum Campus, Moussonstrasse 4, 8091 Zurich, Switzerland
‘Prevention is better than cure’—this proverb is particularly true in cardiovascular medicine. Indeed, both lifestyle and dietary interventions, specifically the Mediterranean diet, as well as pharmacological modulation risk factors are effective preventive measures. On 12 June 1957, the US Surgeon General Leroy E. Burney declared that the evidence suggested a causal link between smoking and lung cancer and heart disease. Ever since then, smoking cessation has became a cornerstone of prevention.1,2 Later, blood pressure lowering was shown to reduce stroke, infarction, and premature death.3 A major breakthrough was the introduction of statins to lower LDL-cholesterol and proving their effectiveness in the 4S trial.4 The most recent introduction of PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors may make prevention even more effective,5,6 although the indication for the use of these drugs is still a matter of debate as the evidence is still incomplete and their price is still rather high.7 Thus, it was timely to update the ‘European Guidelines on cardiovascular disease prevention in clinical practice’.8 The authors remind us that cardiovascular prevention is defined as a co-ordinated set of actions, at the population level or targeted at an individual, that are aimed at eliminating or minimizing the risk to develop myocardial infarction, peripheral arterial disease, or stroke. Of note, in spite of all the progress made in prevention, cardiovascular disease remains a leading cause of morbidity and mortality, although age-adjusted coronary artery disease mortality has declined since the 1980s, particularly in high-income regions.9 Indeed, coronary artery disease rates are now less than half what they were in the early 1980s in many countries in Europe, due to preventive measures including the success of smoking legislation.10,11 However, inequalities between countries persist, and many risk factors, particularly obesity and diabetes mellitus, have been increasing substantially. Importantly, prevention is effective: the elimination of health risk behaviours would make it possible to prevent at least 80% of cardiovascular diseases and even 40% of cancers. The present guidelines represent an evidence-based consensus of the 6th European Joint Task Force involving 10 professional societies. The modern sedentary lifestyle is an increasingly important risk factor worldwide.12 Indeed, even standing as compared with sitting makes a difference.13 In their article entitled ‘Use of exercise Published by Oxford University Press on behalf of the European Society of Cardiology 2016.
capacity to improve SCORE risk prediction model in asymptomatic apparently healthy adults’, Ariel Israel and
Figure 1 Kaplan – Meier Survival by SCORE risk (A) and estimated metabolic equivalents (B). SCORE is based on gender, age, systolic blood pressure, smoking status, total cholesterol, and high-density lipoprotein concentrations. Metabolic equivalents: low—metabolic equivalents, 11; high— metabolic equivalents ≥11. Observations in each metabolic equivalents subgroup are matched for age and gender (from Israel A, Kivity S, Sidi Y, Segev S, Berkovitch A, Klempfner R, Lavi B, Goldenberg I, Maor E. Use of exercise capacity to improve SCORE risk prediction model in asymptomatic adults. See pages 2300–2306).
2292
Issue @ a Glance
decreasing resting heart rate, with a resting heart rate ,50 b.p.m. a significant risk factor (Figure 1). Thus, in this large prospective cohort, leisure time physical activity was associated with atrial fibrillation in a J-shaped pattern, with moderate physical activity being linked to a reduced risk, whereas higher activity levels attenuated the benefits of moderate activity. Of note, low resting heart rate was a particular risk factor for atrial fibrillation. The authors suggest that moderate and vigorous physical activity may affect atrial fibrillation risk via different pathophysiological mechanisms. The editors hope that readers of this issue of the European Heart Journal will find it of interest.
Figure 2 Risk of AF in relation to the leisure time physical activity level at baseline: (A) overall, (B) stratified by sex*, and (C) stratified by age*. *‘High activity’ and ‘vigorous activity’ were merged into a new ‘high/vigorous activity’ category due to few participants undertaking vigorous activity (from Morseth B, Graff-Iversen S, Jacobsen BK, Jorgensen L, Nyrnes A, Thelle DS, Vestergaard P, Løchen ML. Physical activity, resting heart rate, and atrial fibrillation: the Tromso Study. See pages 2307– 2313).
colleagues from the Chaim Sheba Medical Centre in Tel Hashomer in Israel evaluated in 22 878 asymptomatic men and women whether exercise capacity according to the Bruce protocol can improve the accuracy of the SCORE overall survival risk estimation (Figure 1).14 During a follow-up of 9 years, mortality was 2.2% whereby both SCORE and low exercise capacity were associated with reduced survival. When added to the SCORE risk prediction, exercise capacity allowed more accurate risk stratification: net reclassification analysis showed an improvement of 57% in the accuracy of classification, and the area under the receiver operating curve increased from 0.782 to 0.766. The authors conclude that both SCORE and exercise capacity are strong independent predictors of all-cause mortality. The addition of exercise capacity to the SCORE risk model considerably improves the accuracy of the model. As with different dosages of any drug, the preventive effects of sports may change with the degree of vigour with which a physical activity is pursued both in healthy subjects, particularly in endurance athletes,15 – 17 and in those with heart disease, most importantly in those with arrhythmogenic right ventricular cardiomyopathy18 or in those with implantable cardioverter defibrillators.19 In the second manuscript, ‘Physical activity, resting heart rate, and atrial fibrillation: the Tromsø Study’, Bente Morseth and colleagues from the Arctic University in Tromsø, Norway examined the association of physical activity and resting heart rate with hospitaldiagnosed atrial fibrillation in 20 484 Norwegian adults (Figure 2).20 At baseline in 1986 – 1987, physical activity was assessed by a validated questionnaire and resting heart rate was measured by ECG. During a follow-up of 20 years, 750 mainly male participants were diagnosed with atrial fibrillation. Compared with the low physical activity group, moderately active individuals had a 19% lower risk of any atrial fibrillation, whereas highly active individuals had a similar risk. Vigorously active individuals showed a non-significantly 37% higher risk of atrial fibrillation. Risk of atrial fibrillation increased with
References 1. Prugger C, Wellmann J, Heidrich J, De Bacquer D, Perier MC, Empana JP, Reiner Zˇ, Fras Z, Jennings C, Kotseva K, Wood D, Keil U; EUROASPIRE Study Group. Passive smoking and smoking cessation among patients with coronary heart disease across Europe: results from the EUROASPIRE III survey. Eur Heart J 2014;35:590 –598. 2. Nakanishi R, Berman DS, Budoff MJ, Gransar H, Achenbach S, Al-Mallah M, Andreini D, Cademartiri F, Callister TQ, Chang HJ, Cheng VY, Chinnaiyan K, Chow BJ, Cury R, Delago A, Hadamitzky M, Hausleiter J, Feuchtner G, Kim YJ, Kaufmann PA, Leipsic J, Lin FY, Maffei E, Pontone G, Raff G, Shaw LJ, Villines TC, Dunning A, Min JK. Current but not past smoking increases the risk of cardiac events: insights from coronary computed tomographic angiography. Eur Heart J 2015;36:1031 – 1040. 3. Burnier M, Vuignier Y, Wuerzner G. State-of-the-art treatment of hypertension: established and new drugs. Eur Heart J 2014;35:557–562. 4. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994;344: 1383 –1389. 5. Robinson JG, Farnier M, Krempf M, Bergeron J, Luc G, Averna M, Stroes ES, Langslet G, Raal FJ, El Shahawy M, Koren MJ, Lepor NE, Lorenzato C, Pordy R, Chaudhari U, Kastelein JJ; ODYSSEY LONG TERM Investigators. Efficacy and safety of alirocumab in reducing lipids and cardiovascular events. N Engl J Med 2015;372: 1489 –1499. 6. Luscher TF. LDL-cholesterol targets: perspectives for the use of PCSK9 inhibitors. Eur Heart J 2016;37:1337 –1340. 7. Langslet G. Replacing statins with PCSK9-inhibitors and delaying treatment until 18 years of age in patients with familial hypercholesterolaemia is not a good idea. Eur Heart J 2016;37:1357 –1359. 8. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corra` U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FD, Løchen ML, Lo¨ llgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WM; Authors/ Task Force Members. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: the Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts): developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016;37:2315 –2381. 9. Townsend N, Nichols M, Scarborough P, Rayner M. Cardiovascular disease in Europe: epidemiological update 2015. Eur Heart J 2015;36:2696 –2705. 10. Radke PW, Schunkert H. Public smoking ban: Europe on the move. Eur Heart J 2006; 27:2385 –1286. 11. Rigotti NA, Clair C. Managing tobacco use: the neglected cardiovascular disease risk factor. Eur Heart J 2013;34:3259 –3267. 12. Sharma S, Merghani A, Mont L. Exercise and the heart: the good, the bad, and the ugly. Eur Heart J 2015;36:1445 –1453. 13. Healy GN, Winkler EA, Owen N, Anuradha S, Dunstan DW. Replacing sitting time with standing or stepping: associations with cardio-metabolic risk biomarkers. Eur Heart J 2015;36:2643 –2649. 14. Israel A, Kivity S, Sidi Y, Segev S, Berkovitch A, Klempfner R, Lavi B, Goldenberg I, Maor E. Use of exercise capacity to improve SCORE risk prediction model in asymptomatic adults. Eur Heart J 2016;37:2300 –2306. 15. Hogstrom G, Nordstrom A, Nordstrom P. High aerobic fitness in late adolescence is associated with a reduced risk of myocardial infarction later in life: a nationwide cohort study in men. Eur Heart J 2014;35:3133 –3140. 16. La Gerche A, Claessen G, Dymarkowski S, Voigt JU, De Buck F, Vanhees L, Droogne W, Van Cleemput J, Claus P, Heidbuchel H. Exercise-induced right ventricular dysfunction is associated with ventricular arrhythmias in endurance athletes. Eur Heart J 2015;36:1998 – 2010.
2293
Issue @ a Glance
17. Gerardin B, Collet J-P, Mustafic H, Bellemain-Appaix A, Benamer H, Monsegu J, Teiger E, Livarek B, Jaffry M, Lamhaut L, Fleischel C, Aubry P; Groupe de Re´flexion sur la Cardiologie Interventionnelle. Registry on acute cardiovascular events during endurance running races: the prospective RACE Paris registry. Eur Heart J 2016; doi:10.1093/eurheartj/ehv675. Published online ahead of print 28 December 2015. 18. Ruwald AC, Marcus F, Estes NA 3rd, Link M, McNitt S, Polonsky B, Calkins H, Towbin JA, Moss AJ, Zareba W. Association of competitive and recreational sport participation with cardiac events in patients with arrhythmogenic right ventricular
cardiomyopathy: results from the North American multidisciplinary study of arrhythmogenic right ventricular cardiomyopathy. Eur Heart J 2015;36: 1735– 1743. 19. Heidbuchel H, Carre F. Exercise and competitive sports in patients with an implantable cardioverter-defibrillator. Eur Heart J 2014;35:3097 –3102. 20. Morseth B, Graff-Iversen S, Jacobsen BK, Jorgensen L, Nyrnes A, Thelle DS, Vestergaard P, Løchen ML. Physical activity, resting heart rate, and atrial fibrillation: the Tromso Study. Eur Heart J 2016;37:2307 –2313.
CARDIOVASCULAR FLASHLIGHT
doi:10.1093/eurheartj/ehw066 Online publish-ahead-of-print 18 February 2016
.............................................................................................................................................................................
The incarcerated heart: porcelain cage Lakshmi Muthukumar*, Muhammad Fuad Jan, Steven C. Port, and Abdul Jamil Tajik Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, 2801 W. Kinnickinnic River Parkway, Ste. 840, Milwaukee, WI 53215, USA
* Corresponding author. Tel: +1 414 649 3909, Fax: +1 414 649 3578, Email: [email protected]
A 54-year-old Caucasian woman with a history of systemic lupus erythematosus (SLE) and on immunosuppressants presented with NYHA Functional Class III dyspnoea with a duration of several weeks. Physical examination revealed a markedly elevated jugular venous pressure of 20 mmHg in the sitting position with rapid X and Y descents, loud pericardial knock, and hepatomegaly. Her lungs were clear to auscultation, and she had no pedal oedema. The transthoracic echocardiogram (TTE) showed diagnostic signs of constrictive pericarditis, including exaggerated interventricular dependence; intrapulmonary to intracardiac dissociation with respiration; annulus reversus; thickened, calcified, and adherent pericardium; and hepatic vein expiratory flow reversal. Two-dimensional speckle tracking myocardial longitudinal strain assessment was reduced in the mid to basal lateral wall segments to 29.5% (Panel A). A computed tomography (CT) angiogram showed minimal coronary artery disease with dense circumferential pericardial calcification (white arrows, Panel B) while reconstructed three-dimensional images from a 16-slice CT showed a circumferential calcified pericardial cage sparing the LV apex (Panels C – F ). Laboratory investigations demonstrated normal erythrocyte sedimentation rate, elevated c-reactive protein, and mildly elevated B-type natriuretic peptide. The patient subsequently underwent pericardiectomy via median sternotomy with near-resolution of symptoms, and repeat TTE showed resolution of her constrictive findings, with a 36% improvement in the longitudinal strain assessment of lateral regional segments (Panel G) at 6-month follow-up. Although pericardial effusion is known to occur at some point in the natural history of SLE in up to 50% of patients, only a miniscule number of constrictive pericarditis patients with SLE are reported in the literature. Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2016. For permissions please email: [email protected].
European Heart Journal (2016) 37, 2291–2293 doi:10.1093/eurheartj/ehw321
Prevention is better than cure: the new ESC Guidelines Thomas F. Lu¨scher, MD, FESC Editor-in-Chief, Zurich Heart House, Careum Campus, Moussonstrasse 4, 8091 Zurich, Switzerland
‘Prevention is better than cure’—this proverb is particularly true in cardiovascular medicine. Indeed, both lifestyle and dietary interventions, specifically the Mediterranean diet, as well as pharmacological modulation risk factors are effective preventive measures. On 12 June 1957, the US Surgeon General Leroy E. Burney declared that the evidence suggested a causal link between smoking and lung cancer and heart disease. Ever since then, smoking cessation has became a cornerstone of prevention.1,2 Later, blood pressure lowering was shown to reduce stroke, infarction, and premature death.3 A major breakthrough was the introduction of statins to lower LDL-cholesterol and proving their effectiveness in the 4S trial.4 The most recent introduction of PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors may make prevention even more effective,5,6 although the indication for the use of these drugs is still a matter of debate as the evidence is still incomplete and their price is still rather high.7 Thus, it was timely to update the ‘European Guidelines on cardiovascular disease prevention in clinical practice’.8 The authors remind us that cardiovascular prevention is defined as a co-ordinated set of actions, at the population level or targeted at an individual, that are aimed at eliminating or minimizing the risk to develop myocardial infarction, peripheral arterial disease, or stroke. Of note, in spite of all the progress made in prevention, cardiovascular disease remains a leading cause of morbidity and mortality, although age-adjusted coronary artery disease mortality has declined since the 1980s, particularly in high-income regions.9 Indeed, coronary artery disease rates are now less than half what they were in the early 1980s in many countries in Europe, due to preventive measures including the success of smoking legislation.10,11 However, inequalities between countries persist, and many risk factors, particularly obesity and diabetes mellitus, have been increasing substantially. Importantly, prevention is effective: the elimination of health risk behaviours would make it possible to prevent at least 80% of cardiovascular diseases and even 40% of cancers. The present guidelines represent an evidence-based consensus of the 6th European Joint Task Force involving 10 professional societies. The modern sedentary lifestyle is an increasingly important risk factor worldwide.12 Indeed, even standing as compared with sitting makes a difference.13 In their article entitled ‘Use of exercise Published by Oxford University Press on behalf of the European Society of Cardiology 2016.
capacity to improve SCORE risk prediction model in asymptomatic apparently healthy adults’, Ariel Israel and
Figure 1 Kaplan – Meier Survival by SCORE risk (A) and estimated metabolic equivalents (B). SCORE is based on gender, age, systolic blood pressure, smoking status, total cholesterol, and high-density lipoprotein concentrations. Metabolic equivalents: low—metabolic equivalents, 11; high— metabolic equivalents ≥11. Observations in each metabolic equivalents subgroup are matched for age and gender (from Israel A, Kivity S, Sidi Y, Segev S, Berkovitch A, Klempfner R, Lavi B, Goldenberg I, Maor E. Use of exercise capacity to improve SCORE risk prediction model in asymptomatic adults. See pages 2300–2306).
2292
Issue @ a Glance
decreasing resting heart rate, with a resting heart rate ,50 b.p.m. a significant risk factor (Figure 1). Thus, in this large prospective cohort, leisure time physical activity was associated with atrial fibrillation in a J-shaped pattern, with moderate physical activity being linked to a reduced risk, whereas higher activity levels attenuated the benefits of moderate activity. Of note, low resting heart rate was a particular risk factor for atrial fibrillation. The authors suggest that moderate and vigorous physical activity may affect atrial fibrillation risk via different pathophysiological mechanisms. The editors hope that readers of this issue of the European Heart Journal will find it of interest.
Figure 2 Risk of AF in relation to the leisure time physical activity level at baseline: (A) overall, (B) stratified by sex*, and (C) stratified by age*. *‘High activity’ and ‘vigorous activity’ were merged into a new ‘high/vigorous activity’ category due to few participants undertaking vigorous activity (from Morseth B, Graff-Iversen S, Jacobsen BK, Jorgensen L, Nyrnes A, Thelle DS, Vestergaard P, Løchen ML. Physical activity, resting heart rate, and atrial fibrillation: the Tromso Study. See pages 2307– 2313).
colleagues from the Chaim Sheba Medical Centre in Tel Hashomer in Israel evaluated in 22 878 asymptomatic men and women whether exercise capacity according to the Bruce protocol can improve the accuracy of the SCORE overall survival risk estimation (Figure 1).14 During a follow-up of 9 years, mortality was 2.2% whereby both SCORE and low exercise capacity were associated with reduced survival. When added to the SCORE risk prediction, exercise capacity allowed more accurate risk stratification: net reclassification analysis showed an improvement of 57% in the accuracy of classification, and the area under the receiver operating curve increased from 0.782 to 0.766. The authors conclude that both SCORE and exercise capacity are strong independent predictors of all-cause mortality. The addition of exercise capacity to the SCORE risk model considerably improves the accuracy of the model. As with different dosages of any drug, the preventive effects of sports may change with the degree of vigour with which a physical activity is pursued both in healthy subjects, particularly in endurance athletes,15 – 17 and in those with heart disease, most importantly in those with arrhythmogenic right ventricular cardiomyopathy18 or in those with implantable cardioverter defibrillators.19 In the second manuscript, ‘Physical activity, resting heart rate, and atrial fibrillation: the Tromsø Study’, Bente Morseth and colleagues from the Arctic University in Tromsø, Norway examined the association of physical activity and resting heart rate with hospitaldiagnosed atrial fibrillation in 20 484 Norwegian adults (Figure 2).20 At baseline in 1986 – 1987, physical activity was assessed by a validated questionnaire and resting heart rate was measured by ECG. During a follow-up of 20 years, 750 mainly male participants were diagnosed with atrial fibrillation. Compared with the low physical activity group, moderately active individuals had a 19% lower risk of any atrial fibrillation, whereas highly active individuals had a similar risk. Vigorously active individuals showed a non-significantly 37% higher risk of atrial fibrillation. Risk of atrial fibrillation increased with
References 1. Prugger C, Wellmann J, Heidrich J, De Bacquer D, Perier MC, Empana JP, Reiner Zˇ, Fras Z, Jennings C, Kotseva K, Wood D, Keil U; EUROASPIRE Study Group. Passive smoking and smoking cessation among patients with coronary heart disease across Europe: results from the EUROASPIRE III survey. Eur Heart J 2014;35:590 –598. 2. Nakanishi R, Berman DS, Budoff MJ, Gransar H, Achenbach S, Al-Mallah M, Andreini D, Cademartiri F, Callister TQ, Chang HJ, Cheng VY, Chinnaiyan K, Chow BJ, Cury R, Delago A, Hadamitzky M, Hausleiter J, Feuchtner G, Kim YJ, Kaufmann PA, Leipsic J, Lin FY, Maffei E, Pontone G, Raff G, Shaw LJ, Villines TC, Dunning A, Min JK. Current but not past smoking increases the risk of cardiac events: insights from coronary computed tomographic angiography. Eur Heart J 2015;36:1031 – 1040. 3. Burnier M, Vuignier Y, Wuerzner G. State-of-the-art treatment of hypertension: established and new drugs. Eur Heart J 2014;35:557–562. 4. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994;344: 1383 –1389. 5. Robinson JG, Farnier M, Krempf M, Bergeron J, Luc G, Averna M, Stroes ES, Langslet G, Raal FJ, El Shahawy M, Koren MJ, Lepor NE, Lorenzato C, Pordy R, Chaudhari U, Kastelein JJ; ODYSSEY LONG TERM Investigators. Efficacy and safety of alirocumab in reducing lipids and cardiovascular events. N Engl J Med 2015;372: 1489 –1499. 6. Luscher TF. LDL-cholesterol targets: perspectives for the use of PCSK9 inhibitors. Eur Heart J 2016;37:1337 –1340. 7. Langslet G. Replacing statins with PCSK9-inhibitors and delaying treatment until 18 years of age in patients with familial hypercholesterolaemia is not a good idea. Eur Heart J 2016;37:1357 –1359. 8. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corra` U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FD, Løchen ML, Lo¨ llgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WM; Authors/ Task Force Members. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: the Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts): developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 2016;37:2315 –2381. 9. Townsend N, Nichols M, Scarborough P, Rayner M. Cardiovascular disease in Europe: epidemiological update 2015. Eur Heart J 2015;36:2696 –2705. 10. Radke PW, Schunkert H. Public smoking ban: Europe on the move. Eur Heart J 2006; 27:2385 –1286. 11. Rigotti NA, Clair C. Managing tobacco use: the neglected cardiovascular disease risk factor. Eur Heart J 2013;34:3259 –3267. 12. Sharma S, Merghani A, Mont L. Exercise and the heart: the good, the bad, and the ugly. Eur Heart J 2015;36:1445 –1453. 13. Healy GN, Winkler EA, Owen N, Anuradha S, Dunstan DW. Replacing sitting time with standing or stepping: associations with cardio-metabolic risk biomarkers. Eur Heart J 2015;36:2643 –2649. 14. Israel A, Kivity S, Sidi Y, Segev S, Berkovitch A, Klempfner R, Lavi B, Goldenberg I, Maor E. Use of exercise capacity to improve SCORE risk prediction model in asymptomatic adults. Eur Heart J 2016;37:2300 –2306. 15. Hogstrom G, Nordstrom A, Nordstrom P. High aerobic fitness in late adolescence is associated with a reduced risk of myocardial infarction later in life: a nationwide cohort study in men. Eur Heart J 2014;35:3133 –3140. 16. La Gerche A, Claessen G, Dymarkowski S, Voigt JU, De Buck F, Vanhees L, Droogne W, Van Cleemput J, Claus P, Heidbuchel H. Exercise-induced right ventricular dysfunction is associated with ventricular arrhythmias in endurance athletes. Eur Heart J 2015;36:1998 – 2010.
2293
Issue @ a Glance
17. Gerardin B, Collet J-P, Mustafic H, Bellemain-Appaix A, Benamer H, Monsegu J, Teiger E, Livarek B, Jaffry M, Lamhaut L, Fleischel C, Aubry P; Groupe de Re´flexion sur la Cardiologie Interventionnelle. Registry on acute cardiovascular events during endurance running races: the prospective RACE Paris registry. Eur Heart J 2016; doi:10.1093/eurheartj/ehv675. Published online ahead of print 28 December 2015. 18. Ruwald AC, Marcus F, Estes NA 3rd, Link M, McNitt S, Polonsky B, Calkins H, Towbin JA, Moss AJ, Zareba W. Association of competitive and recreational sport participation with cardiac events in patients with arrhythmogenic right ventricular
cardiomyopathy: results from the North American multidisciplinary study of arrhythmogenic right ventricular cardiomyopathy. Eur Heart J 2015;36: 1735– 1743. 19. Heidbuchel H, Carre F. Exercise and competitive sports in patients with an implantable cardioverter-defibrillator. Eur Heart J 2014;35:3097 –3102. 20. Morseth B, Graff-Iversen S, Jacobsen BK, Jorgensen L, Nyrnes A, Thelle DS, Vestergaard P, Løchen ML. Physical activity, resting heart rate, and atrial fibrillation: the Tromso Study. Eur Heart J 2016;37:2307 –2313.
CARDIOVASCULAR FLASHLIGHT
doi:10.1093/eurheartj/ehw066 Online publish-ahead-of-print 18 February 2016
.............................................................................................................................................................................
The incarcerated heart: porcelain cage Lakshmi Muthukumar*, Muhammad Fuad Jan, Steven C. Port, and Abdul Jamil Tajik Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, 2801 W. Kinnickinnic River Parkway, Ste. 840, Milwaukee, WI 53215, USA
* Corresponding author. Tel: +1 414 649 3909, Fax: +1 414 649 3578, Email: [email protected]
A 54-year-old Caucasian woman with a history of systemic lupus erythematosus (SLE) and on immunosuppressants presented with NYHA Functional Class III dyspnoea with a duration of several weeks. Physical examination revealed a markedly elevated jugular venous pressure of 20 mmHg in the sitting position with rapid X and Y descents, loud pericardial knock, and hepatomegaly. Her lungs were clear to auscultation, and she had no pedal oedema. The transthoracic echocardiogram (TTE) showed diagnostic signs of constrictive pericarditis, including exaggerated interventricular dependence; intrapulmonary to intracardiac dissociation with respiration; annulus reversus; thickened, calcified, and adherent pericardium; and hepatic vein expiratory flow reversal. Two-dimensional speckle tracking myocardial longitudinal strain assessment was reduced in the mid to basal lateral wall segments to 29.5% (Panel A). A computed tomography (CT) angiogram showed minimal coronary artery disease with dense circumferential pericardial calcification (white arrows, Panel B) while reconstructed three-dimensional images from a 16-slice CT showed a circumferential calcified pericardial cage sparing the LV apex (Panels C – F ). Laboratory investigations demonstrated normal erythrocyte sedimentation rate, elevated c-reactive protein, and mildly elevated B-type natriuretic peptide. The patient subsequently underwent pericardiectomy via median sternotomy with near-resolution of symptoms, and repeat TTE showed resolution of her constrictive findings, with a 36% improvement in the longitudinal strain assessment of lateral regional segments (Panel G) at 6-month follow-up. Although pericardial effusion is known to occur at some point in the natural history of SLE in up to 50% of patients, only a miniscule number of constrictive pericarditis patients with SLE are reported in the literature. Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2016. For permissions please email: [email protected].
