Globally, hot weather and heatwaves are claiming lives and are predicted to become increasingly deadly under all future climate change scenarios. Rising global temperatures pose a significant risk on cardiovascular health, disproportionately impacting the elderly and people with cardiovascular disease (CVD). However, despite convincing epidemiological data demonstrating this increased cardiovascular risk, the physiological mechanisms that underpin this risk are less known. Exposure to elevated temperatures leads to increased inflammation, myocardial oxygen demand and dehydration, predisposing people to myocardial stress. Additionally, health and social inequities like low income, poor housing and limited access to cooling further exacerbate the health risks during heatwaves. This scientific statement provides a comprehensive discussion on the epidemiological evidence of heat-related CVD, the human physiological responses to hot environments, the impact of heat on cardiovascular health, and the relative impact of social inequalities. Finally, an agenda is provided that calls for research to understand and reduce the health risks associated with heatwaves for people with CVD.

Background: Studies demonstrated sex differences in outcomes following acute myocardial infarction, with women more likely to develop heart failure (HF). Sacubitril/valsartan has been shown to reduce cardiovascular death and HF hospitalizations in patients with HF with reduced ejection fraction. Methods and Results: A total of 5661 patients (1363 women [24%]) with acute myocardial infarction complicated by reduced left ventricular ejection fraction (≤40%), pulmonary congestion, or both and ≥1 of 8 risk‐augmenting factors were randomized to receive sacubitril/valsartan or ramipril. The primary outcome was cardiovascular death or incident HF. Baseline characteristics, clinical outcomes, and safety events were compared according to sex, a prespecified subgroup. Female participants were older and had more comorbidities. After multivariable adjustment, women and men were at similar risks for cardiovascular death or all‐cause death. Women were more likely to have first HF hospitalization (hazard ratio [HR], 1.34 [95% CI, 1.05–1.70]; P =0.02) and total HF hospitalizations (HR, 1.39 [95% CI, 1.05–1.84]; P =0.02). Sex did not significantly modify the treatment effect of sacubitril/valsartan compared with ramipril on the primary outcome ( P for interaction=0.11). Conclusions: In contemporary patients who presented with reduced left ventricular ejection fraction, pulmonary congestion, or both, following acute myocardial infarction, women had a higher incidence of HF during follow‐up. Sex did not modify the treatment effect of sacubitril/valsartan relative to ramipril. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02924727.

Background: Infective endocarditis (IE) continues to be a disease with high mortality despite medical advances. Objective: The objective of this study was to investigate the characteristics and prognosis of IE according to the affected valves. Materials and methods: This study was retrospective and single-centered, and it included 270 patients with a diagnosis of IE, for the period 2005–2021, who received treatment at the University Hospital “St. Georgi” in Plovdiv, Bulgaria. Results: Single-valve IE (SIE) was found in 82.6% (n-223), multivalvular IE (MIE) in 16.66% (n = 45) and device IE (CDRIE) in 0.74% (n = 2) of patients. The most commonly affected valve was the aortic valve, in 44.8% (n = 121). The predominant multivalvular involvement was aortic–mitral valves (AV-MV) (13.7%, n = 37). The patients with tricuspid valve (TV) IE were significantly younger, at 39 (30) years, and were more frequently male (80.8%). Mortality was higher in MIE than in SIE (31.1% vs. 23.8%) and was the highest in multivalve aortic–tricuspid (AV-TV) IE (75%). Early surgery was performed most in AV-MV IE, in 29.7% (n = 11). The Charlson comorbidity index (CCI) was significantly higher in MV 4 (4) and AV 3 (3) vs. TV IE 1 (5) (p = 0.048 and p = 0.011, respectively). Septic shock occurred most frequently in AV-TV involvement (75%; p = 0.0001). The most common causative agents were of the Staphylococcus group. Staphylococcus aureus more often affected TV alone (46.2%, n = 124) vs. AV (9.9%, n = 14; p = 0.0001) and vs. MV (22.6%, n = 17; p = 0.022); Staphylococcus coagulase-negative (CNG) was the prevalent cause of MV IE (22.7%, n = 17) vs. AV-MV (2.7%, n = 1; p = 0.007). Streptococci were represented in a low percentage and only in left-sided IE, more frequently in AV-MV (18.9%, n = 7) vs. AV (6.6%, n = 8; p = 0.025). Conclusions: The aortic valve is the most frequently affected valve, as single-valve IE or as multivalve AV-MV, with the predominant causative agents being of the Staphylococcus group. AV-TV IE has the worst prognosis, with the most common complication of septic shock and the highest in-hospital mortality.

Introduction: Tako-tsubo syndrome is a novel cardio-vascular disease affecting predominantly postmenopausal women exposed to unexpected strong emotional or physical stress, in the absence of significant coronary heart disease. It is characterized by acute onset of severe chest pain and/or acute left ventricular failure, ECG-changes, typical left ventricular angiographic findings, good prognosis and positive resolution of the morphological and clinical manifestations. First described in 1990 in Japan by Sato, Tako-tsubo cardiomyopathy is characterized by transient contractile abnormalities of the left ventricle, causing typical left ventricular apical ballooning at end-systole with concomitant compensatory basal hyperkinesia. There are also atypical forms, presenting with left ventricular systolic dysfunction which affects the mid-portions of the left ventricle. The etiology of the disease still remains unclear. Many theories have been put forward about the potential underlying pathophysiological mechanisms that may trigger this syndrome among which are the theory of catecholamine excess, the theory of multivessel coronary vasospasm, the ischemic theory, and the theory of microvascular dysfunction and dynamic left ventricular gradient induced by elevated circulating catecholamine levels. Adequate management of Tako-tsubo syndrome demands immediate preparation for coronary angiography. Once the diagnosis is made, treatment is primarily symptomatic and includes monitoring for complications. Patients with Tako-tsubo syndrome most frequently develop acute LV failure, pulmonary edema, rhythm and conductive disturbances and apical thrombosis. Treatment is symptomatic and includes administration of diuretics, vasodilators and mechanical support of circulation with intra-aortic balloon counterpulsation.

A major feature of the atherosclerotic process is its systemic and progressive character. The plaque pathogenetic mechanisms, morphology, evolution, and predilection site (bifurcation zones) determine the frequent coincidence of carotid and coronary atherosclerosis in the same patient. The present overview chronologically traces the history, effectiveness, and benefit of surgical and continuously improving interventional carotid revascularization. It thereby analyzes the indications, results, and complications based on a number of randomized clinical trials, industry-sponsored registries, and large single-center series in the last 3 decades. Carotid endarterectomy (CEA) and percutaneous carotid angioplasty (CAS) have evolved from ‘dubious’ procedures to a modern strategy resulting in a significantly lower incidence of stroke and death compared to medical treatment only. Although almost every second patient with carotid stenosis and indications for CAS has coronary atherosclerosis, studies on therapeutic modeling in such a combination are few, showing controversial results. Having both CHD and CS doubles the risk of myocardial infarction, stroke, HF, and death. An isolated revascularization approach compromises the results of therapeutic strategies and worsens patient survival. The high risk associated with coronary heart disease in CAS and CEA is a fact and minimization requires both an individualized and uniform stepwise revascularization strategy.

Background: Infective endocarditis (IE) remains a difficult disease to diagnose and treat, with a persistently high mortality rate. There is a lack of recent data on IE in Bulgaria over the last decades. Methods: This study is retrospective, single-centered, and includes 270 patients diagnosed with IE for the period 2005–2021. We compared two periods, 2005–2015 (n = 119) and 2016–2021 (n = 151), to find the characteristics changes. Results: The study included 177 (65.5%) male patients. In the second period, there is a significant increase in age from 62 (44–73) to 67 (53–75), (p = 0.023); in the Charlson comorbidities index (CCI) from 3 (1–4) to 4 (2–6), (p = 0.000); in cases with chronic kidney diseases (CKDs) from 15 (12.6%) to 55 (36.9%), (p = 0.001); coronary arterial diseases (CADs) from 20 (16.85%) to 44 (29.1%), (p = 0.018); and atrial fibrillation (AF) from 13 (10.9%) to 36 (23.8%), (p = 0.006). Ejection fraction decreased significantly in the second period from 63 (56–70) to 59 (51–66), (p = 0.000). Almost half of the patients 123 (45.6%) had no known predisposing cardiac condition, and 125 (46.3%) had an unknown port of entry. IE was community-acquired in 174 (64.4%), healthcare-associated in 72 (26.7%), and injection-drug-use-related IE in 24 (8.9%). The study population included 183 (67.8%) native valve IE, 85 (31.5%) prosthetic IE, and 2 (0.74%) intracardiac-device-related IE. The hemocultures were positive in 159 (59.6%), and the most frequent pathogenic agent was staphylococci—89 (33.3%) (Staphylococcus aureus—44 (16.5%) and coagulase negative staphylococci—45 (16.8%)). Only 54 (20%) of patients underwent early surgery. The all-cause 30-day mortality rate was 67 (24.8%). There is no significant difference between the two periods in terms of the characteristics listed above. Conclusions: The profile of IE in Bulgaria has changed with increasing age and comorbidity, changing predisposing cardiac conditions, and entry door. The most common pathogen was the Staphylococcus spp. The 30-day mortality rate remains high.