Maja Stefanović

Background/Objectives: This study aimed to evaluate the incidence and outcomes of emergency medical service (EMS)-treated out-of-hospital cardiac arrest (OHCA) and to determine whether predictors of outcomes differed across the pre-pandemic, pandemic, and post-pandemic periods. Methods: A retrospective observational study was conducted over a six-year period and included 1150 patients with EMS-treated OHCA. Patients were categorized into three groups according to the study period. Results: The incidence of EMS-treated OHCA differed significantly across the three study periods (χ² = 15.184, p = 0.001), with the highest number of cases observed during the pandemic. The rate of return of spontaneous circulation (ROSC) also varied significantly between periods (p = 0.035). Although the highest overall mortality was observed during the pandemic period (97.5%), differences in overall mortality across the study periods did not reach statistical significance (p = 0.079). Variables independently associated with ROSC were EMS response time, initial cardiac rhythm, and the administration of adrenaline and atropine. Age and initial cardiac rhythm were independently associated with mortality. No significant interactions were observed between study period and the identified predictors of ROSC or mortality. Conclusions: The COVID-19 pandemic was associated with a significant increase in EMS-treated OHCA incidence and poorer patient outcomes, including lower ROSC and survival rates. Although outcomes improved in the post-pandemic period, multivariable analysis demonstrated that the pandemic period itself was not independently associated with ROSC or mortality after adjustment for relevant clinical factors. Instead, outcome differences were primarily explained by established clinical predictors, including patient age, initial cardiac rhythm, EMS response time, and resuscitation-related factors. Prospective studies incorporating more detailed data on patient characteristics, the quality of resuscitation, and organizational characteristics of the healthcare system may enable more accurate outcome modeling.

Background/Objectives: Coronary microvascular dysfunction (CMD) is emerging as a critical factor in patients presenting with anginal symptoms without obstructive coronary artery disease (CAD). This study aims to investigate the relationship between invasive measurements of coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR) using thermodilution techniques, compared to non-invasive assessments of CFR with transthoracic Doppler echocardiography (TDE). Methods: In this observational prospective cross-sectional study, a total of 49 patients, clinically characterized as having angina with no obstructive CAD (ANOCA) or ischemia with no obstructive CAD (INOCA), underwent both TDE and invasive coronary angiography (ICA) followed by thermodilution assessment of CFR and IMR. Results: It was found that there is a statistically significant negative correlation between both non-invasive and invasive CFR measurements and IMR. Specifically, a negative moderate correlation was observed between non-invasive CFR and IMR (r_s = −0.477, p < 0.01), as well as a high negative correlation between invasive CFR and IMR (r = −0.541, p < 0.01). Receiver operating characteristic (ROC) analysis indicated that both non-invasive and invasive CFRs are effective predictors of CMD, defined as IMR > 25. Conclusions: Both noninvasive and invasive CFR measurements are significant independent predictors of CMD. Our results indicate that noninvasive TDE CFR can be a reliable tool for assessing CMD in patients with ANOCA, potentially facilitating earlier diagnosis and management strategies for this patient population.

Gestational hypertension (GH) and preeclampsia (PE) are associated with the onset of hypertension. This study aimed to investigate whether the blood pressure (BP) pattern in GH is associated with the prevalence of hypertension later in life. In this prospective cohort study pregnant women screened for GH underwent medical history, laboratory analysis, ambulatory blood pressure monitoring (AMBP), and transthoracic echocardiography (with left ventricular global longitudinal strain (LVGLS)) assessment. Overall, 138 GH (67 non-dippers and 71 dippers), 55 preeclamptic, and 72 normotensive pregnant controls were included. Women were followed in the postpartum period, first after 6 weeks and later on, for the occurrence of hypertension. The median follow-up was 8.97 years (8.23; 9.03). Non-dippers and PE compared with normotensives and dippers had a higher prevalence of hypertension onset (p < 0.01), as well as significantly reduced absolute values of LVGLS during pregnancy, after delivery, and at the time of onset of hypertension during follow-up (p < 0.01). Night-time diastolic BP, LVGLS, age, and left ventricular ejection fraction were the strongest predictors of postpartum onset of hypertension. The non-dipping BP pattern in GH was significantly associated with the onset of hypertension later in life, as well as with decreased systolic function.

Background: There is evidence that right ventricular (RV) contractile function, especially its coupling with the pulmonary circulation, has an important prognostic value in patients with left ventricular dysfunction. Aims: This study aimed to identify the best echocardiographic parameters of RV function and pulmonary artery systolic pressure (PASP) alone or in the form of the index of right ventricular-pulmonary artery coupling (RV-PA coupling) to determine the best predictor of 1-year major adverse cardiovascular events (MACE), which were defined as cardiovascular death and cardiac decompensation in heart failure patients with reduced ejection fraction (HFrEF). Methods and results: The study enrolled 191 HFrEF patients (mean age 62.28 ± 12.79 years, 74% males, mean left ventricular ejection fraction (LVEF) 25.53 ± 6.87%). All patients underwent clinical, laboratory, and transthoracic echocardiographic (TTE) evaluation, focusing on assessing RV function and non-invasive parameters of RV-PA coupling. RV function was evaluated using fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), and peak tricuspid annular systolic velocity (TAS’). PASP was estimated by peak tricuspid regurgitation velocity (TRVmax) and corrected by assumed right atrial pressure relative to the dimension and collapsibility of the inferior vena cava. The TAPSE/PASP and TAS’/PASP ratios were taken as an index of RV-PA coupling. During the follow-up (mean period of 340 ± 84 days), 58.1% of patients met the composite endpoint. The independent predictors of one-year outcome were shown to be advanced age, atrial fibrillation, indexed left atrial systolic volume (LAVI), LVEF, TAPSE/PASP, and TAS’/PASP. TAS’/PASP emerged as the strongest independent predictor of prognosis, with a hazard ratio (HR) of 0.67 (0.531–0.840), p < 0.001. Reconstructing the ROC curve 0.8 (0.723–0.859), p < 0.001, we obtained a threshold value of TAS’/PASP ≤ 0.19 (cm/s/mm Hg) (sensitivity 74.0, specificity 75.2). Patients with TAS’/RVSP ≤ 0.19 have a worse prognosis (Log Rank p < 0.001). Conclusions: This study confirmed previously known independent predictors of adverse outcomes in patients with HfrEF—advanced age, atrial fibrillation, LAVI, and LVEF—but non-invasive parameters of RV-PA coupling TAPSE/PASP and TAS’/PASP improved risk stratification in patients with HFrEF. Variable TAS’/PASP has been shown to be the most powerful, independent predictor of one-year outcome.

Introduction: Takotsubo cardiomyopathy (TCM) is a reversible form of cardiomyopathy characterized by transient regional systolic dysfunction of the left ventricle. Case outline: A 78-year-old woman was admitted to the general hospital due to acute inferior STEMI late presentation. Two days after admission, the patient reported intense chest pain and an ECG registered diffuse ST-segment elevation in all leads with ST-segment denivelation in aVR. The patient also showed clinical signs of cardiogenic shock and was referred to a reference institution for further evaluation. Echocardiography revealed akinesia of all medioapical segments, dynamic obstruction of the left ventricular outflow tract (LVOT), moderate mitral regurgitation, and pericardial effusion. Coronary angiography showed the suboccluded right coronary artery, and a primary percutaneous coronary intervention was performed, which involved implanting a drug-eluting stent. The patient’s condition worsened as pericardial effusion increased and led to tamponade. Pericardiocentesis was performed, resulting in the patient’s stabilization. At this point, significant gradients at the LVOT and pericardial effusion were not registered. After eight days without symptoms and stable status, the patient was discharged. Conclusions: The simultaneous presence of AMI and TCM increases the risk of developing cardiogenic shock. The cardio-circulatory profile of these patients is different from those with AMI.

Background: Pulmonary valve infective endocarditis (PVIE) is a rare form of infective endocarditis (IE) and is associated with high mortality and severe complications. Guidelines for treatment of this form of IE are scarce and based on general recommendations. We report a case series of PVE. Detailed Case Description: Case 1—A 36-year-old female with congenital pulmonary artery stenosis, dyspnea and leg edema symptoms for 2 months. Blood cultures yielded Staphylococcus spp. and Corynebacterium sp., and echocardiography revealed multiple floating vegetation at the pulmonic valve and surrounding structures. The clinical course was complicated with sepsis and multi-organ failure. Urgent surgery with pulmonary homograft implantation resulted in successful five-year outcome. Case 2—In a 38-year-old male with previous tetralogy of Fallot correction and symptoms of fatigue, fever, myalgia, and photophobia, echocardiography was suggestive of PVIE. The clinical course was complicated with septic shock, multi-organ failure, ischemic stroke with hemorrhagic transformation and death on the 12th day of hospitalization. Case 3—A 41-year-old male without previous medical history was hospitalized due to prolonged fatigue, fever, dyspnea, and leg edema. He was diagnosed with multi-valve infective endocarditis, affecting the aortic, tricuspid, and pulmonary valve. Acute heart failure and hemodynamic instability indicated urgent surgery with aortic valve replacement and reconstruction of the tricuspid and pulmonary valves. At four-year follow up he was doing well. Conclusion: Symptoms in PVIE may be versatile, and diagnosis is often delayed. High level of suspicion, early recognition, and echocardiography are cornerstones in diagnostics. Despite the standpoint that medical therapy is first-line, the role of surgery needs to be advocated in particular cases.

Background and Objectives: There is emerging evidence of the usefulness of left atrial strain (LAS) in the assessment of diastolic dysfunction (DD). In this study we assess the sensitivity and specificity of LAS, to determine cut-off values and their association to DD with increased left atrial pressure (LAP) in patients with well-treated arterial hypertension. Materials and Methods: We performed a cross-sectional study on 180 subjects with well-treated arterial hypertension. All patients underwent transthoracic echocardiography. Patients were divided into two groups: a group without increased LAP and/or DD and a group with increased LAP DD. Results: In multivariate logistic regression, LAS proved to be the strongest statistically significant predictor of DD with increased LAP (OR 0.834, p < 0.0005), with AUC 0.885 and a set cut-off value of 24.27% with high sensitivity of 78.9% and specificity of 84.6%. The set cut-off for LAS > 24.27% was significantly highly prevalent in the group of DD with increased LAP 78.9% when compared to the group without increased LAP 15.4%, p < 0.0001. Conclusion: The findings of this study suggest that LAS could be a useful and highly sensitive and specific marker in the evaluation of DD. There is the potential for using LAS in everyday practice as a standard parameter in diastolic function assessment.