Dysglycemia, in this survey defined as impaired glucose tolerance (IGT) or type 2 diabetes, is common in patients with coronary artery disease (CAD) and associated with an unfavorable prognosis. This European survey investigated dysglycemia screening and risk factor management of patients with CAD in relation to standards of European guidelines for cardiovascular subjects. RESEARCH DESIGN AND METHODS The European Society of Cardiology's European Observational Research Programme (ESC EORP) European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) V (2016-2017) included 8,261 CAD patients, aged 18-80 years, from 27 countries. If the glycemic state was unknown, patients underwent an oral glucose tolerance test (OGTT) and measurement of glycated hemoglobin A 1c. Lifestyle, risk factors, and pharmacological management were investigated. RESULTS A total of 2,452 patients (29.7%) had known diabetes. OGTT was performed in 4,440 patients with unknown glycemic state, of whom 41.1% were dysglycemic. Without the OGTT, 30% of patients with type 2 diabetes and 70% of those with IGT would not have been detected. The presence of dysglycemia almost doubled from that selfreported to the true proportion after screening. Only approximately one-third of all coronary patients had completely normal glucose metabolism. Of patients with known diabetes, 31% had been advised to attend a diabetes clinic, and only 24% attended. Only 58% of dysglycemic patients were prescribed all cardioprotective drugs, and use of sodium-glucose cotransporter 2 inhibitors (3%) or glucagon-like peptide 1 receptor agonists (1%) was small. CONCLUSIONS Urgent action is required for both screening and management of patients with CAD and dysglycemia, in the expectation of a substantial reduction in risk of further cardiovascular events and in complications of diabetes, as well as longer life expectancy.

Clogging due to artificial recharge in laboratory-simulated unconsolidated aquifers displayed two types of patterns. The first type, resulting from recharge with turbid water containing an effective microbial inhibitor, showed clogging throughout the aquifers ranging in length from 48 to 123 cm. The rate of clogging at different depths was dependent on the size distribution of the particles in the water relative to the pore size distribution of the porous media. Clogging tended to be more severe at the infiuent portion of the sample; however, when the particles in the recharge water were smaller in size or when the pore sizes of the porous media were larger, the result was a'more uniform rate of clogging with respect to depth. The second type, resulting from recharge with nonturbid water and no effective microbial inhibitor, shows clogging only in the top few centimeters. If it is not understood that these two patterns result from different causes, such a pattern resulting from the combined factors could be ........... • to ordy one cause, namely, •1,5 bI'LD tl bt•l turbidity. Such a decision could lead to the conclusion that clogging due to turbidity will not penetrate deeply into the porous media, whereas if little microbial clogging is occurring, the result will be more clogging at greater depths. 1047

Our perspectives on aortic stenosis (AS) are changing. Evolving from the traditional thought of a passive degenerative disease, developing a greater understanding of the condition’s mechanistic underpinning has shifted the paradigm to an active disease process. This advancement from the ‘wear and tear’ model is a result of the growing economic and health burden of AS, particularly within industrialised countries, prompting further research. The pathophysiology of calcific AS (CAS) is complex, yet can be characterised similarly to that of atherosclerosis. Progressive remodelling involves lipid-protein complexes, with lipoprotein(a) being of particular interest for diagnostics and potential future treatment options.There is an unmet clinical need for asymptomatic patient management; no pharmacotherapies are proven to slow progression and intervention timing varies. Novel approaches are developing to address this through: (1) screening with circulating biomarkers; (2) development of drugs to slow disease progression and (3) early valve intervention guided by medical imaging. Existing biomarkers (troponin and brain natriuretic peptide) are non-specific, but cost-effective predictors of ventricular dysfunction. In addition, their integration with cardiovascular MRI can provide accurate risk stratification, aiding aortic valve replacement decision making. Currently, invasive intervention is the only treatment for AS. In comparison, the development of lipoprotein(a) lowering therapies could provide an alternative; slowing progression of CAS, preventing left ventricular dysfunction and reducing reliance on surgical intervention.The landscape of AS management is rapidly evolving. This review outlines current understanding of the pathophysiology of AS, its management and future perspectives for the condition’s assessment and treatment.

Coronary artery disease continues to be the leading cause of morbidity and mortality worldwide. Recent clinical trials have not demonstrated any mortality benefit of percutaneous coronary intervention compared to medical management alone in the treatment of stable angina. While invasive coronary angiography remains the gold standard for diagnosing coronary artery disease, it comes with significant risks, including myocardial infarction, stroke and death. There have been significant advances in imaging techniques to diagnose coronary artery disease in haemodynamically stable patients. The latest National Institute for Health and Care Excellence and European College of Cardiology guidelines emphasise the importance of using these imaging techniques first to inform diagnosis. This review discusses these guidelines and imaging techniques, alongside their benefits and drawbacks.

BackgroundCardiac studies of patients with rheumatoid arthritis (RA) have demonstrated abnormalities in left ventricular (LV) remodelling that is associated with development of heart failure and cardiovascular (CV) morbidity and mortality1,2. No studies to date have evaluated for changes in myocardial and vascular function in treatment-naïve early RA (ERA).ObjectivesTo evaluate whether patients with newly diagnosed, treatment-naïve ERA demonstrate myocardial and vascular changes on cardiac MRI (CMR) compared with matched controls.MethodsSixty-six ERA patients fulfilling ACR/EULAR classification criteria and with no CVD history underwent 3.0T CMR (Philips Achieva TX) at a cardiology-CMR unit. All patients had symptoms for less than 1 year, were DMARD treatment-naïve and with minimum disease activity score (DAS28) ≥3.2. Thirty healthy controls (HC) were matched by age, sex and blood pressure.Standard balanced steady state free precession cine images were acquired and LV dimensions calculated. For aortic distensibility, multi-phase SSFP cine images (50 phases) were acquired in a plane transverse to the ascending aorta at the level of the pulmonary artery bifurcation. Aortic contours were drawn by manual planimetry of the endovascular–blood pool interface at the times of minimal and maximal distension. Additional parameters measured include strain analysis and extracellular volume (results awaited). Body surface area (BSA) index values are presented.ResultsPatients in ERA and HC groups were similar mean (SD) age [49.4 (13.08) and 46.7 (11.4) respectively, p=0.33] and systolic BP [122 (23) and 126 (16) respectively, p=0.18]. Mean (SD) BSA was lower in the ERA group vs HC [(1.83 (0.22) vs 1.9 (0.21) respectively, p=0.09]. In the ERA group, median (IQR) ESR, CRP and mean (SD) DAS28 were 39.5 (28.7)mm/hr, 18.9 (27.1)mg/L and 5.65 (1.6) respectively. 54 (82%) and 48 (73%) patients were ACPA and RF positive respectively.Table 1 details CMR parameters. Aortic distensibility was significantly reduced in ERA patients compared to HC (median ± IQR, 3.19±2.16 10-3mmHg-1 versus 4.4±2.1 10-3mmHg-1, p=0.001). Other measures of arterial stiffness including aortic stiffness index, compliance and strain showed similar significant differences. Left ventricular and right ventricular end-systolic and end-diastolic volumes were all significantly lower in the ERA vs HC. A trend for lower LVmass index in the ERA group was observed and seemed to be associated with seropositivity (see table 2). Evidence for overt inflammation/fibrosis was seen in 4 patients with focal non-ischaemic patterns of LGE.ConclusionsThis first CMR study in treatment-naive ERA demonstrates abnormalities at the earliest stage of RA. Reduced vascular function, ventricular volumes, and trend change in LV geometry suggest an early cardiomyopathy. This might imply higher risk for CV morbidity and mortality at time of diagnosis. Further investigation will clarify the natural history, clinical implications and the scope to modify outcome with effective RA therapy.ReferencesGi...

Background and Objectives: Interest in artificial intelligence (AI) for outcome prediction has grown substantially in recent years. However, the prognostic role of AI using advanced cardiac magnetic resonance imaging (CMR) remains unclear. This systematic review assesses the existing literature on AI in CMR to predict outcomes in patients with cardiovascular disease. Materials and Methods: Medline and Embase were searched for studies published up to November 2021. Any study assessing outcome prediction using AI in CMR in patients with cardiovascular disease was eligible for inclusion. All studies were assessed for compliance with the Checklist for Artificial Intelligence in Medical Imaging (CLAIM). Results: A total of 5 studies were included, with a total of 3679 patients, with 225 deaths and 265 major adverse cardiovascular events. Three methods demonstrated high prognostic accuracy: (1) three-dimensional motion assessment model in pulmonary hypertension (hazard ratio (HR) 2.74, 95%CI 1.73–4.34, p < 0.001), (2) automated perfusion quantification in patients with coronary artery disease (HR 2.14, 95%CI 1.58–2.90, p < 0.001), and (3) automated volumetric, functional, and area assessment in patients with myocardial infarction (HR 0.94, 95%CI 0.92–0.96, p < 0.001). Conclusion: There is emerging evidence of the prognostic role of AI in predicting outcomes for three-dimensional motion assessment in pulmonary hypertension, ischaemia assessment by automated perfusion quantification, and automated functional assessment in myocardial infarction.

Figure 1 Short axis cine SSFP images in end-diastole, corresponding native T1 mapping, late gadolinium enhancement (LGE) images, ECV mapping and myocardial blood flow mapping in two patients with cardiac amyloidosis, the same mass, but different LGE patterns. Top: subendocardial LGE, high ECV values and borderline myocardial rest perfusion values. Bottom: transmural LGE, very high ECV values and reduced myocardial rest perfusion values.

No abstract