Biochemical Pharmacology

The purpose of this paper is to summarize the recent myocardial perfusion cardiovascular magnetic resonance (CMR) studies in the context of the diagnostic and prognostic value of epicardial coronary artery disease (CAD), coronary microvascular dysfunction (CMD) and the non-ischemic heart disease. Recent developments of the sequence and the post-processing of myocardial perfusion CMR images have enabled the quantitative assessment of myocardial perfusion, facilitating a significant shift from qualitative to quantitative assessment of stress perfusion CMR. Quantitative assessment of perfusion CMR allows objective and accurate assessment of myocardial ischemia in the detection of CAD, and may have the potential to assess CMD. Moreover, the integration of quantitative perfusion CMR with cine for functional assessment and late gadolinium enhancement and T1/T2 mapping for tissue characterization techniques allows for a deeper understanding of the pathophysiology and a capability of prognostic stratification for various cardiovascular diseases.

Systemic inflammation is a major trigger for cardiovascular disease (CVD) and consequent heart failure (HF). Our purpose is to present the impact of inflammation in the development of HF in autoimmune rheumatic diseases (ARDs) and the emerging role of Cardiovascular Magnetic Resonance (CMR). ARDs represent the best example of systemic inflammation and are associated with increased risk of cardiovascular disease (CVD) finally leading to heart failure with preserved (HFpEF) or reduced ejection fraction (HFrEF). Systemic and local inflammation of the CV system may lead to myo-pericarditis, autoimmune inflammatory cardiomyopathy (AIC), valvular heart disease (VHD) and macro-/micro-coronary artery disease (CAD). Furthermore, the anti-rheumatic medication, used to control systemic inflammation, may also lead to myocardial cytotoxic effect. Silent clinical presentation is the main characteristic of CVD in ARDs, which makes the early, accurate diagnosis challenging. Furthermore, although there is great progress in the development of new anti-rheumatic medication, the CVD incidence/mortality in ARDs is still higher, compared to the rest of the population. High clinical awareness and use of new advanced technologies, such as CMR that can perform function and tissue characterization in the same examination, was proven useful for early diagnosis, risk stratification and treatment evaluation of CVD in ARDs. Lastly, the cardio-protective effect of anti-rheumatic and the immunomo-dulatory effect of cardiac medication hold the promise for better CVD control and potentially mortality reduction.

Abstract Purpose of Review The purpose of this paper is to review the results of studies from the last 3 years, presenting the current state of knowledge on the pathophysiological effect of polycystic ovary syndrome (PCOS) on the cardiovascular system, with cardiac involvement using non-invasive cardiovascular investigations. Recent Findings PCOS is a complex endocrine disorder that has a significant impact on the cardiovascular system. Recent studies confirm that PCOS increases the risk of cardiovascular disease (CVD) as well as the occurrence of cardiovascular events (CVE), including myocardial infarction (MI), coronary artery disease, and revascularization. These findings support the need for early screening and implementation of CVD prevention in women with PCOS. Summary Current evidence documents important and previously unrecognized mechanisms by which PCOS may adversely affect the cardiovascular system in affected women. Further studies are needed to in-depth characterisation of the cardiovascular phenotype of patients with PCOS. There is still a lack of studies using advanced cardiac imaging methods, including cardiac magnetic resonance imaging (CMR). Graphical Abstract

Abstract Purpose of Review 4-dimensional phase-contrast flow measurement (4D Flow) has an increasing clinical and scientific potential in patients with congenital heart disease (CHD). In this review, we present up-to-date information about the benefits of 4D Flow in adults with CHD (ACHD). Recent Findings Due to sequence and software developments 4D is now routinely used for clinical blood flow measurements in ACHD patients. An increasing number of studies also shows that 4D Flow-derived advanced hemodynamic markers cannot only explain cardiovascular conditions but that they can help in ACHD management. Moreover, with the use of computational fluid dynamics and deep learning techniques 4D Flow might help in exploring and developing personalized medical treatment strategies. Summary Utilization of 4D Flow has become widely spread in research as well as in clinical practice allowing to explore morphological and hemodynamical consequences in ACHD.

Abstract Purpose of Review It was previously believed that the presence of myocardial viability in patients with significant coronary artery disease improved outcomes following revascularisation, but the landmark STITCH trial found no significant correlation between viability and overall survival. However, the study used single photon emission contrast tomography or dobutamine stress echocardiography for viability assessment, but late gadolinium enhanced cardiac magnetic resonance imaging (LGE-CMR) has since become the gold standard for viability assessment. Additionally, there has been significant progress in heart failure pharmacotherapy. Leveraging these advances, the REVIVED study authors revisited the role of revascularisation on heart failure patient clinical outcomes. Similar to the STITCH study, REVIVED also identified a lack of correlation between viability and outcomes, confirming its limited role in revascularisation decision making. The purpose of this review is to discuss the advances in myocardial viability imaging and the role of LGE-CMR scar assessment beyond the REVIVED study. Recent Findings Myocardial scar predisposes to ventricular arrythmias and sudden cardiac death (SCD). It is the authors’ opinion that beyond REVIVED, focus should be placed on optimising the management of ventricular arrhythmias through visualisation and characterisation of cardiac scar to improve clinical outcomes. A significant proportion of SCDs occur in patients who remain unprotected if guided by current recommendations. Several studies have confirmed the presence and burden of scar as a better predictor of clinical outcomes in comparison to the current gold standard of left ventricular ejection fraction (LVEF). Summary The potential of machine learning and radiomics to visualise cardiac anatomy and characterise scar, leveraged with the ability to integrate segmented CMR and clinical electroanatomic maps intraoperatively shows promise in improving outcomes in VT ablations and delivering precision treatment based on individual risk.

Recently, machine learning (ML) has developed rapidly in the field of medicine, playing an important role in disease diagnosis and treatment. Our aim of this paper is to provide an overview of the advancements in ML techniques applied to invasive coronary angiography (ICA) for segmentation of coronary arteries and quantitative evaluation, such as stenosis detection and fractional flow reserve (FFR) assessment. Machine learning techniques are used extensively along with ICA for the segmentation of arteries and quantitative evaluation of stenosis and measurement of FFR, representing a trend towards using computational methods for enhanced diagnostic precision in cardiovascular medicine. Various research studies with different algorithms and datasets have been conducted in this field. The performance of these studies largely depends on the algorithms employed and the datasets used for training and validation. However, despite the progress made, there remains a need for ML algorithms that can be easily integrated into clinical practice.

This review aims to evaluate the current diagnostic standards for cardiac allograft vasculopathy (CAV) in heart transplant recipients, with a focus on the role of positron emission tomography (PET) myocardial perfusion imaging (MPI). The review addresses the efficacy of PET as a non-invasive alternative to invasive coronary angiography (ICA) and discusses recent guidelines and advancements in the detection and management of CAV. Recent research underscores the potential role of PET imaging in detecting CAV, particularly by assessing myocardial blood flow (MBF) and myocardial flow reserve (MFR). PET has emerged as a highly effective tool, offering potential advantages in diagnostic accuracy, cost-effectiveness, and reduced radiation exposure compared to ICA. The 2023 International Society for Heart and Lung Transplantation guidelines list PET MPI as a Class IIa indication for non-invasive CAV screening, highlighting its superior prognostic value. Studies demonstrate that PET-derived MBF and MFR correlate well with invasive measures and predict adverse outcomes, emphasizing the role of PET MPI in the early detection and management of CAV. Additionally, PET MPI can potentially reduce the need for frequent invasive procedures, thereby lowering healthcare costs. PET MPI significantly enhances the detection and prognostication of CAV in heart transplant recipients, providing a non-invasive, accurate, and cost-effective alternative to ICA. Integrating PET into routine surveillance protocols can improve early diagnosis and management of CAV, ultimately enhancing patient outcomes. Large multicenter studies are needed to optimize surveillance strategies and to further validate the role of PET in CAV detection and management.

Abstract Purpose of the Review The purpose of this paper is to review the current knowledge regarding imaging inflammation in cardiac sarcoidosis (CS). Recent Findings Noninvasive imaging methods like cardiac magnetic resonance (CMR) and 18-fluorodeoxyglucose (18FDG) positron-emission tomography-computed tomography (PET-CT) scans have emerged as the most important modalities in diagnosing and monitor therapy efficacy in CS. The differentiation between an active and a chronic, silent clinical state is crucial for decision making. T1- and T2-mapping by CMR provide a unique opportunity to discriminate normal and diseased myocardium by detecting myocardial edema and fibrosis. While T1-mapping is sensitive to fibrosis and edema, T2 is primarily influenced by tissue water content. Increased 18-fluorodeoxyglucose (18FDG) uptake in positron-emission tomography-computed tomography (PET-CT) scan is a hallmark feature of CS and defines active inflammation. Therefore, the hybrid application of both CMR and 18FDG-PET-CT scans has evolved as the standard procedure to detect CS and monitor the therapeutic response. Summary Imaging inflammation in CS is basically performed by CMR T2-mapping and 18FDG uptake in PET-CT scan. Both are reliable methods in identifying active CS and follow up therapy and can be used synergistically. Additionally CMR provides further prognostic insights by late gadolinium enhancement that increases the risk for malignant arrhythmia and for relapse after therapy weaning.

Abstract Backgrounds Takotsubo syndrome (TTS) is an intriguing clinical entity characterized by transient myocardial dysfunction. The precise pathophysiological mechanism of TTS is still unknown, but recent evidence suggests a central role of systemic inflammation associated with adrenergic discharge. Although initially considered benign, TTS has shown several potential short-term and long-term complications and adverse outcomes. To improve understanding and management, advanced cardiovascular magnetic resonance (CMR) techniques, such as feature tracking (FT) and parametric mapping, have gained attention. Purpose of Review The purpose of this review is to summarize the current literature on the clinical applications of CMR-FT and mapping in TTS. Additionally, the most significant and recent findings will be discussed. Recent Findings FT-CMR enables the parametric quantification of myocardial deformation, allowing a comprehensive evaluation of left ventricular, right ventricular, and atrial function. It provides an accurate definition of areas of myocardial dysfunction and potentially serves as a superior prognostic tool compared to ejection fraction. Tissue mapping techniques enable precise and comprehensive tissue characterization by quantifying areas of oedema, and myocardial fibrosis. Summary FT-CMR and mapping techniques serve as valuable prognostic tools both in the acute and chronic phases of TTS. They can detect subtle alterations and pan-cardiac involvement, while also providing important insights into the complex underlying mechanisms of the syndrome.

Medical education has evolved remarkably during the last decade whereby the conventional large lecture halls, long didactic presentations, and textbooks have been replaced by smaller groups with a mentor–mentee pairing coupled with technological advances that permit a more intimate and yet comprehensive learning experience. The purpose of this review is to summarize the novel models of education and serve as a reference for educators. In the wake of a global pandemic, coronavirus-19 infection, higher education replaced conventional lecture hall formats with novel methods that are not face-to-face classes ushering in a new era of medical education. Recent studies have shown that social media has gradually emerged as an essential ancillary educational tool in cardiology. These studies recommend the integration of social media as well as other remote learning tools such as augmented reality, virtual reality, and smart glasses into the standard bedside and didactic curricula. However, educators will need research-based guidelines to inform instructional planning and implementation that ensure adequate exposure and fulfillment of the necessary competency requirements. The current role of social media, medical computer software applications, online tools, and virtual platforms and technology play a valuable role in modern-day cardiology training. This review examines each of these tools’ advantages and disadvantages as well as the notable gap in knowledge.

This abstract aims to examine the advancements in the utilization, indications, and implementation of ultrasound enhancing agents (UEAs) and their potential to enhance cost-effective diagnostics. The review highlights significant progress in the application of UEAs, particularly in improving the delineation of endocardial borders, enhancing interpretation of wall motion, and increasing diagnostic accuracy. Moreover, UEAs contribute to streamlining workflows and help avoid more expensive procedures, especially in cases with technically challenging or suboptimal studies. UEAs have shown great promise in various medical scenarios, such as enhancing the visualization of the cardiac blood pool and enabling better assessment of ventricular borders, ventricular function, masses, and other intracavitary or myocardial abnormalities. This abstract presents an overview of the recent findings that underscore the potential benefits of UEAs in optimizing cardiac diagnostics while considering cost-effectiveness.

To explore and highlight the important role that Cardiac MRI (CMR) plays as an imaging tool that not only facilitates the diagnosis of pericardial disease but is increasingly used to guide initiation of treatment and gauge adequacy of response to therapy in patients with acute and recurrent pericarditis is a specific focus of this review. An emphasis will be placed on the sequences that are currently utilized and novel sequences that could potentially be utilized for the diagnosis of pericarditis and pericardial disease. This article focuses on the CMR characteristics of the most encountered pericardial diseases and novel CMR techniques that may play an adjunctive role in the diagnosis, management, prognosis and the assessment of adequacy of response to therapy in patients with acute pericarditis. CMR has emerged as a powerful tool in the diagnosis of pericardial disease. This is a review of the current and future roles that CMR-based sequences play in not only the diagnosis of pericardial disease, but also in evaluating the need for medical therapy and gauging adequacy of response to therapy in this cohort.

Abstract Purpose of the Review This paper delves into the emerging realm of T1 mapping, exploring recent innovations and their relevance across several cardiac diseases. Recent Findings T1 mapping with cardiovascular magnetic resonance (CMR) imaging has emerged as a valuable tool for cardiac disease evaluation, offering diagnostic, therapeutic, and prognostic insights. Tissue characterization using parametric mapping methods holds the promise of identifying and quantifying both focal and diffuse changes in myocardial structure, which cannot be adequately assessed through late gadolinium enhancement (LGE). Summary CMR imaging, particularly LGE, has enhanced cardiac tissue characterization. However, the detection of diffuse interstitial fibrosis remains challenging, necessitating the exploration of alternative techniques. T1 mapping could probably represent a game changer in the evaluation of diffuse and focal fibrosis in multiple cardiovascular conditions.

Abstract Purpose of Review To evaluate the potential role of advanced cardiac imaging and cardiopulmonary exercise testing in the diagnosis and evaluation of persistent cardiovascular conditions after SARS-CoV-2 infection. Recent Findings SARS-COV-2 has shown an overwhelming capacity to attack multiple organs, with the respiratory system being the most frequently involved. However, various cardiovascular complications have been reported during the course of the disease, becoming one of the most important causes of morbidity and mortality. Many articles have addressed the acute cardiovascular complications of SARS-CoV-2; however, chronic cardiovascular conditions that persist beyond acute infection are less well studied. Echocardiography has a role during the initial approach, but advanced cardiac images such as cardiac magnetic resonance and cardiac CT can be required since a normal echo finding does not exclude cardiovascular involvement. Cardiopulmonary exercise testing has proven to be a highly valuable tool in cases where the symptoms persist besides normal advanced images. Summary The present review includes the most relevant articles regarding the use of cardiac imaging and cardiopulmonary exercise testing in the evaluation of chronic cardiovascular manifestations of COVID-19.