La Cardiologia Pediatrica di Francesco De Luca

Scelti dalla Letteratura

In questa pagina saranno proposti gli articoli che riteniamo di maggiore impatto clinico o scientifico/speculativo, pubblicati su alcune delle riviste internazionali di maggiore prestigio. Naturalmente la selezione è frutto di scelte personali, si tratta solo di "consigli" di lettura. Mi auguro possiate trovare spunti interessanti e, perché no, anche utili. Tutti i link sono esplorabili.

Cardiologia

BACKGROUND
The appropriate dose of aspirin to lower the risk of death, myocardial infarction, and stroke and to minimize major bleeding in patients with established atherosclerotic
cardiovascular disease is a subject of controversy.
CONCLUSIONS
In this trial involving patients with established cardiovascular disease, there was substantial dose switching to 81 mg of daily aspirin and no significant differences in cardiovascular events or major bleeding between patients assigned to 81 mg and those assigned to 325 mg of aspirin daily.

What are the clinical and public health implications of these findings? These data should spur a renewed focus on the critical need for widespread adoption of the DASH-low sodium diet in the United States. We
have known for several decades now that the DASH diet and sodium restriction can prevent and treat
hypertension (the most prevalent CV disease risk factor), reflected in multiple guideline recommendations.

Mavacamten mechanism of action and study design.
A, Hypertrophic cardiomyopathy (HCM)–associated sarcomere mutations may result in an excessive number of actin-myosin cross -bridges, leading to cardiac hypercontractility and hypertrophy. These changes are effectively countered by mavacamten, a small molecule inhibitor specific to cardiac myosin that reduces excessive myosin-actin cross-bridging. Conclusions: EXPLORER-HCM is a phase 3 trial in oHCM testing a first-in-class, targeted strategy of myosin inhibition to improve symptom burden and exercise capacity through reducing LV outflow tract obstruction. 

Voglio dedicare questo piccolo spazio di approfondimento allo Scompenso Cardiaco che in Italia rappresenta la prima causa di ricovero dopo i 65 anni, ed un rilevante problema di salute pubblica, coinvolgendo circa 600mila persone. Si stima che la prevalenza raddoppi a ogni decade di età, raggiungendo il 10% circa dopo i 65 anni. Potremmo definire il 2020 l'anno dello Scompenso Cardiaco, per gli enormi progressi registrati nel trattamento. Ne parleremo col supporto delle ultimissime novità provenienti dalla Letteratura.

Straw S, et al. BMJ Open Heart 2021

The introduction of SGLT2i to the treatment of HFrEF is a chance for us to revisit whether current guidelines
for the treatment of HFrEF are fit for purpose. Many patients have waited for weeks or months before ever
seeing a cardiologist and receiving a diagnosis, and further delays to treatments have the potential to cause great harm.

Johann Bauersachs, European Heart Journal 2021

This editorial refers to ‘Influence of neprilysin inhibition on the efficacy and safety of empagliflozin in patients with chronic heart failure and a reduced ejection fraction:
the EMPEROR-Reduced Trial by M. Packer et al.

João Pedro Ferreira et al. JACC 2021

With respect to adverse heart failure and renal out comes, the use of an MRA did not influence the effects of empagliflozin in patients with heart failure and a reduced ejection fraction. This finding indicates that MRAs and SGLT2 inhibitors can be usefully combined to reduce morbidity and mortality and improve symptoms and health status without concerns of an adverse interaction. Reduced concomitant administration of empagliflozin with MRAs to patients with heart failure was well tolerated, and MRAs did not modify the effect of empagliflozin on cardiac or renal outcomes.

Focus Miocardite

Prima di parlare degli effetti sul cuore prodotti da un'infezione da Covid 19, può essere interessante un breve "ripasso generale" sulla Miocardite, patologia molto insidiosa per le potenziali complicanze non raramente fatali e troppo spesso misconosciuta.

In questa breve revisione della letteratura più recente, ho provato a sintetizzare le nozioni in questo momento più accreditate, sulla Miocardite. Naturalmente il solo scopo è quello di fornire qualche strumento utile per potere apprezzare al meglio i bellissimi lavori citati e disponibili per tutti.

Covid 19, Cuore e Sport

Miocardite e Covid 19 di Francesco De Luca

Questo approfondimento mi è stato richiesto da Michele Fiore, grande "provocatore e moderatore" dell'eccellente Forum Pediatrico APEL. Michele mi ha posto 3 "banali" quesiti:
 1) Qual'è l'incidenza di Miocardite nella popolazione generale? (ho già risposto nel Focus)
2) Qual'è la frequenza di Miocardite nei soggetti in età pediatrica affetti da Covid 19?
3) Qual'è la frequenza e l'incidenza di Miocardite a seguito di vaccinazione?
Ecco la mia risposta, o sarebbe forse meglio dire il mio tentativo di risposta.... 
Naturalmente la cosa più importante è potere accedere liberamente alla Letteratura più recente e qualificata, di seguito riportata. Buona lettura.
In questo spazio ho selezionato, invece, alcune delle evidenze più significative sulle complicanze prodotte dall'infezione da Covid 19 sull'apparato cardiovascolare, con particolare riferimento agli atleti e ai bambini e al ritorno alla pratica sportiva. Questo approfondimento, di grande attualità, mi è stato richiesto da Alberto Ferrando, carissimo amico. I lavori sono raccolti dalla Letteratura più recente e dalle riviste con maggiore impatto. I Link sono tutti esplorabili. Buona degustazione!

Il ritorno alla pratica sportiva nei bambini dopo infezione da Covid 19

di Francesco De Luca

Si tratta di un tema delicato che i pediatri saranno chiamati ad affrontare nei prossimi mesi. L’approccio al consenso alla ripresa della pratica sportiva nei pazienti pediatrici è diverso da quello in uso nell’adulto. La maggior parte dei bambini sta bene e non necessita di attenzioni particolari, ma occorre tuttavia prestare qualche attenzione.

CONCLUSIONS: COVID-19, caused by SARS-CoV-2, is a global pandemic evolving in real time. Cardiovascular comorbidities are common in patients with COVID-19 and these patients are at higher risk of morbidity and mortality. It is not known if the presence of cardiovascular comorbid conditions pose independent risk or whether this is mediated by other factors (eg, age). Myocardial injury is present in >25% of critical cases and presents in 2 patterns: acute myocardial injury and dysfunction on presentation and myocardial injury that develops as illness severity intensifies.

CONCLUSIONS AND RELEVANCE: In this cohort study of 1597 US competitive athletes with CMR screening after COVID-19 infection, 37 athletes (2.3%) were diagnosed with clinical and subclinical myocarditis. Variability was observed in prevalence across universities, and testing protocols were closely tied to the detection of myocarditis. Variable ascertainment and unknown implications of CMR findings underscore the need for standardized timing and interpretation of cardiac testing.

RELEVANCE: On the other hand, the absence of symptoms in athletes with myocarditis is not necessarily reassuring, because more than 50% of affected individuals in an autopsy series of proven myocarditis in athletes were asymptomatic prior to death. A primary CMR imaging screening strategy would place a major burden on any health care system and athletic program.

RELEVANCE: If the diagnosis of myocarditis or myopericarditis is established, a period of
disqualification (3–6 months) is needed, according to the clinical severity and duration of the illness. After this period, it is reasonable to resume training and competition if left ventricular systolic function has returned to the normal range, serum biomarkers of myocardial injury have normalised and clinically significant arrhythmias such as frequent
or complex repetitive forms of ventricular or supraventricular arrhythmias are absent on 24-hour Holter monitoring and exercise test. We highlight that myocarditis is a cause of malignant arrhythmias, left ventricular dysfunction and sudden cardiac death in athletes.

CONCLUSIONS: Cardiac involvement is common in children with multisystem inflammatory syndrome associated with the Covid-19 pandemic. The majority of children have significantly raised levels of N-terminal pro B-type natriuretic peptide, ferritin, D-dimers, and cardiac troponin in addition to high C-reactive protein and procalcitonin levels.
In comparison with adults with COVID-19, mortality in children with multisystem inflammatory syndrome associated with COVID-19 is uncommon despite multisystem involvement, very elevated inflammatory markers, and the need for intensive care support.

CONCLUSIONS: In a propensity-score–matched analysis, we found that initial treatment with IVIG plus glucocorticoids for MIS-C was associated with a lower risk of serious short-term outcomes, including new or persistent cardiovascular dys function 2 or more days later, than initial treatment with IVIG alone.

CONCLUSIONS: We found no evidence that recovery from MIS-C differed after primary treatment with IVIG alone, IVIG plus glucocorticoids, or glucocorticoids alone, although significant differences may emerge as more data accrue.

Elettrocardiogramma

Ecocardiogramma

Pediatria e… varie…

NEJM May 27, 2021

Local Reactions and Systemic Events Reported within 7 Days after Administration of BNT162b2 or Placebo. The results shown are for the reactogenicity subset of the safety population, which included all participants in the 12-to-15-year-old cohort and the subset of participants in the 16-to-25-year-old cohort who had electronic diary data available. Pain at the injection site was graded as mild (does not interfere with activity), moderate (interferes with activity), severe (prevents daily activity), or grade 4 (led to hospitalization).

  • Una grave polmonite da Covid-19 si verifica in circa il 15% dei pazienti ed è associata ad alta mortalità. Case report e studi osservazionali hanno suggerito che il trattamento con tocilizumab provoca una rapida riduzione della febbre e riduce la necessità di supporto di ossigeno.
Collezione dei 20 articoli di maggiore impatto comparsi nell’anno 2020 su NEJM