Showing papers in "Clinical Cardiology in 2014"

Lack of efficacy of drug therapy in preventing takotsubo cardiomyopathy recurrence: a meta-analysis.

Abstract: Background Efficacy of chronic drug therapy in prevention of stress-induced cardiomyopathy recurrences is not well established. We therefore aimed to evaluate in this meta-analysis whether pharmacological treatment can effectively prevent takotsubo cardiomyopathy (TTC) recurrences, according to available studies. Hypothesis There is no evidence for preventing TTC recurrence by drug therapy. Methods After a PubMed search, we conducted a meta-analysis of available studies (clinical nonrandomized registries) on efficacy of drug therapy in preventing recurrence of TTC. Results A total of 23 (4.5%) TTC recurrences occurred in the 511 patients included in the analysis. Seven studies on the effects of β-blockers on prevention of TTC recurrence were evaluated; the odds ratio (OR) was 0.44 and the 95% confidence interval (CI) was 0.15-1.31. In 5 studies on the effects of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, the OR was 0.42 and the 95% CI was 0.08-2.36; in 3 studies on statins, the OR was 0.74 and the 95% CI was 0.07-7.3; and in 4 studies on aspirin, the OR was 0.33 with a 95% CI of 0.05-2.17 (P value not significant in all cases). Conclusions A meta-analysis of the efficacy of different medications through the clinical TTC registries available showed no clinical evidence for a standard drug treatment in the chronic management of TTC. β-Blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins, and aspirin do not seem to significantly reduce recurrences of TTC. Randomized, adequately powered studies are needed to further assess this issue.

A reevaluation of the costs of heart failure and its implications for allocation of health resources in the United States.

Abstract: The annual cost of heart failure (HF) is estimated at $39.2 billion. This has been acknowledged to underestimate the true costs for care. The objective of this analysis is to more accurately assess these costs. Publicly available data sources were used. Cost calculations incorporated relevant factors such as Medicare hospital cost-to-charge ratios, reimbursement from both government and private insurance, and out-of-pocket expenditures. A recently published Atherosclerosis Risk in Communities (ARIC) HF scheme was used to adjust the HF classification scheme. Costs were calculated with HF as the primary diagnosis (HF in isolation, or HFI) or HF as one of the diagnoses/part of a disease milieu (HF syndrome, or HFS). Total direct costs for HF were calculated at $60.2 billion (HFI) and $115.4 billion (HFS). Indirect costs were $10.6 billion for both. Costs attributable to HF may represent a much larger burden to US health care than what is commonly referenced. These revised and increased costs have implications for policy makers.

Management of Postoperative Atrial Fibrillation and Subsequent Outcomes in Contemporary Patients Undergoing Cardiac Surgery: Insights From the Society of Thoracic Surgeons CAPS‐Care Atrial Fibrillation Registry

Abstract: Background Postoperative atrial fibrillation (POAF) is a well-recognized complication of cardiac surgery; however, its management remains a challenge, and the implementation and outcomes of various strategies in clinical practice remain unclear. Hypothesis We hypothesize that treatment for POAF is variable, and that it is associated with particular morbidity and mortality following cardiac surgery. Methods We compared patient characteristics, operative procedures, postoperative management, and outcomes between patients with and without POAF following coronary artery bypass grafting (CABG) in the Society of Thoracic Surgeons multicenter Contemporary Analysis of Perioperative Cardiovascular Surgical Care (CAPS-Care) registry (2004–2005). Results Of 2390 patients who underwent CABG, 676 (28%) had POAF. Compared with patients without POAF, those with POAF were older (median age 74 vs 71 years, P < 0.0001) and more likely to have hypertension (86% vs 83%, P = 0.04) and impaired renal function (median estimated glomerular filtration rate 56.9 vs 58.6 mL/min/1.73 m2, P = 0.0001). A majority of patients with POAF were treated with amiodarone (77%) and β-blockers (68%); few (9.9%) underwent cardioversion. Patients with POAF were more likely to experience complications (57% vs 41%, P < 0.0001), including acute limb ischemia (1.0% vs 0.4%, P = 0.03), stroke (4.0% vs 1.9%, P = 0.002), and reoperation (13% vs 7.9%, P < 0.0001). Length of stay (median 8 days vs 6 days, P < 0.0001), in-hospital mortality (6.8% vs 3.7%, P = 0.001), and 30-day mortality (7.8 vs 3.9, P < 0.0001) were all worse for patients with POAF. In adjusted analyses, POAF remained associated with increased length of stay following surgery (adjusted ratio of the mean: 1.27, 95% confidence interval: 1.2-1.34, P < 0.0001). Conclusions Postoperative AF is common following CABG, and such patients continue to have higher rates of postoperative complications. Postoperative AF is significantly associated with increased length of stay following surgery.

Rationale and Design of the Henry Ford ExercIse Testing Project (The FIT Project)

Abstract: Although physical fitness is a powerful prognostic marker in clinical medicine, most cardiovascular population-based studies do not have a direct measurement of cardiorespiratory fitness. In line with the call from the National Heart Lung and Blood Institute for innovative, low-cost, epidemiologic studies leveraging electronic medical record (EMR) data, we describe the rationale and design of the Henry Ford ExercIse Testing Project (The FIT Project). The FIT Project is unique in its combined use of directly measured clinical exercise data retrospective collection of medical history and medication treatment data at the time of the stress test, retrospective supplementation of supporting clinical data using the EMR and administrative databases and epidemiologic follow-up for cardiovascular events and total mortality via linkage with claims files and the death registry. The FIT Project population consists of 69 885 consecutive physician-referred patients (mean age, 54 ± 10 years; 54% males) who underwent Bruce protocol treadmill stress testing at Henry Ford Affiliated Hospitals between 1991 and 2009. Patients were followed for the primary outcomes of death, myocardial infarction, and need for coronary revascularization. The median estimated peak metabolic equivalent (MET) level was 10, with 17% of the patients having a severely reduced fitness level (METs < 6). At the end of the follow-up duration, 15.9%, 5.6%, and 6.7% of the patients suffered all-cause mortality, myocardial infarction, or revascularization procedures, respectively. The FIT Project is the largest study of physical fitness to date. With its use of modern electronic clinical epidemiologic techniques, it is poised to answer many clinically relevant questions related to exercise capacity and prognosis.

One-year outcome of patients with atrial fibrillation undergoing coronary artery stenting: an analysis of the AFCAS registry.

Abstract: Background Most evidence regarding the efficacy and safety of the antithrombotic regimens for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention with stent (PCI-S) derives from small, single-center, retrospective datasets. To obtain further data on this issue, we carried out the prospective, multicenter, observational Management of patients with Atrial Fibrillation undergoing Coronary Artery Stenting (AFCAS) registry (Clinicaltrials.gov identifier NCT00596570). Hypothesis We hypothesize that the antithrombotic treatment of AF patients undergoing PCI-S is variable and the clinical outcome may vary according to the different regimens. Methods Consecutive AF patients undergoing PCI-S at 17 European institutions were included and followed for 1 year. Outcome measures included: (1) major adverse cardiac/cerebrovascular events (MACCE), including all-cause death, myocardial infarction, repeat revascularization, stent thrombosis, or stroke/transient ischemic attack, and (2) bleeding, and were compared according to the antithrombotic regimen adopted. A propensity-score analysis was carried out to adjust for baseline and procedural differences. Results Out of the 975 patients enrolled, 914 were included in the final analysis. The mean CHADS2 score was 2.2 ± 1.2, and 71% of patients had a CHADS2 score ≥2. Triple therapy (TT) of vitamin K antagonist (VKA), aspirin, and clopidogrel was prescribed to 74% of patients, dual antiplatelet therapy to 18%, and VKA plus clopidogrel to 8%. At 1-year follow-up, no significant differences were found in the occurrence of MACCE and bleeding among the 3 antithrombotic regimens, even when adjusted for propensity score. Conclusions In this large, real-world population of AF patients undergoing PCI-S, TT was the antithrombotic regimen most frequently prescribed. Although several limitations need to be acknowledged, in our study the 1-year efficacy and safety of TT, dual antiplatelet therapy, and VKA plus clopidogrel was comparable.

Practical considerations for using novel oral anticoagulants in patients with atrial fibrillation.

Abstract: Novel oral anticoagulants, including dabigatran, rivaroxaban, and apixaban, represent new options for preventing stroke in patients with atrial fibrillation, as shown by the results from large, randomized phase III trials. Because of their greater specificity, rapid onset of action, and predictable pharmacokinetics, the novel oral anticoagulants (dabigatran, rivaroxaban, and apixaban) address several limitations of warfarin or other vitamin K antagonists in day-to-day clinical practice. However, a range of practical questions relating to the novel oral anticoagulants has emerged, including topics such as patient selection, treatment of patients with renal impairment, risk of myocardial infarction, drug interactions, switching between anticoagulants, and management of bleeding, in addition to use of these agents in patients requiring antiplatelet drug treatment or undergoing cardioversion or percutaneous interventions (eg, ablation). In this review, practical aspects of the use of novel oral anticoagulants in patients with atrial fibrillation are discussed, with reference to available data and guidance from prescribing information.

Gender differences in coronary artery diameter are not related to body habitus or left ventricular mass.

Abstract: Background Smaller coronary artery diameter portends worse outcomes after coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). The suggestion that women have smaller coronary artery diameters than men has not been validated by a large-scale study. Hypothesis We sought to confirm a gender difference with respect to coronary artery diameter, even after accounting for body habitus and left ventricular mass (LVM). Methods From 4200 subjects evaluated for cardiovascular disease by computed tomography angiography, we selected 710 subjects (383 males, 327 females) with coronary artery calcium (CAC) scores <100, eliminating patients with artery remodeling. Diameters of the left main (LM), left anterior descending (LAD), left circumflex (CX), and right coronary arteries (RCA), were measured. Measurements were compared using a 2-sample t test and the multiple regression model, accounting for body habitus and LVM. Results After adjusting for age, race, weight, height, body mass index, body surface index, LVM, and CAC, women have smaller diameters in the LM (males 4.35 mm, females 3.91 mm), LAD (males 3.54 mm, females 3.24 mm), CX (males 3.18, females 2.75 mm), and RCA (males 3.70 mm, females 3.26 mm) (P < 0.001). This difference is not related to body habitus or LVM. Conclusions Gender significantly influences artery diameter of the LM, LAD, CX, and RCA. This may warrant gender specific approaches during PCI and CABG. As neither body habitus nor LVM relate to the difference in coronary artery diameter, our study encourages a search for inherent differences between genders that can account for this difference.

FRAIL-HF, a Study to Evaluate the Clinical Complexity of Heart Failure in Nondependent Older Patients: Rationale, Methods and Baseline Characteristics

Abstract: The clinical scenario of heart failure (HF) in older hospitalized patients is complex and influenced by acute and chronic comorbidities, coexistent geriatric syndromes, the patient's ability for self-care after discharge, and degree of social support. The impact of all these factors on clinical outcomes or disability evolution is not sufficiently known. FRAIL-HF is a prospective observational cohort study designed to evaluate clinical outcomes (mortality and readmission), functional evolution, quality of life, and use of social resources at 1, 3, 6, and 12 months after admission in nondependent elderly patients hospitalized for HF. Clinical features, medical treatment, self-care ability, and health literacy were prospectively evaluated and a comprehensive geriatric assessment with special focus on frailty was systematically performed in hospital to assess interactions and relationships with postdischarge outcomes. Between May 2009 and May 2011, 450 consecutive patients with a mean age of 80 ± 6 years were enrolled. Comorbidity was high (mean Charlson index, 3.4 ± 2.9). Despite being nondependent, 118 (26%) had minor disability for basic activities of daily living, only 76 (16.2%) had no difficulty in walking 400 meters, and 340 (75.5%) were living alone or with another elderly person. In addition, 316 patients (70.2%) fulfilled frailty criteria. Even nondependent older patients hospitalized for HF show a high prevalence of clinical and nonclinical factors that may influence prognosis and are usually not considered in routine clinical practice. The results of FRAIL-HF will provide important information about the relationship between these factors and different postdischarge clinical, functional, and quality-of-life outcomes.

Stroke after transcatheter aortic valve replacement: incidence, risk factors, prognosis, and preventive strategies.

Abstract: The first transcatheter aortisc valve replacement (TAVR) was performed in 2002, and has been proven beneficial in inoperable and high-risk patients for open heart surgery. Stroke occurrence after TAVR, both periprocedure and at follow-up, has not been well described. We sought to review incidence, pathophysiology, predictors, prognosis, and current preventive strategies of cerebrovascular accidents (CVAs) after TAVR. Studies were selected from a Medline search if they contained clinical outcomes data after TAVR. Acute and subacute CVAs after TAVR have been reported in 3% to 6% of patients. Approximately 45% of CVAs occur within 2 days after TAVR; 28% between 3 and 10 days; 4% between 10 and 30 days; and 10.5% occur from 1 month to 2 years. Clinically silent cerebral embolisms have been reported, with an incidence greatly exceeding that of overt CVAs. Underlying pathophysiologic mechanisms for CVAs can be broadly categorized into embolic and nonembolic causes, as well as procedural and postprocedural (early and late). Important predictors of early CVAs are small aortic valve area, atrial fibrillation, and balloon postdilation, whereas late CVAs are mostly influenced by chronic atrial fibrillation, prior cerebrovascular disease, and transapical approach. Following stroke, patients exhibit increased morbidity and mortality. A multilevel approach for the prevention of CVAs includes improved interventional techniques, embolic protection devices, antithrombotic treatment, close monitoring, and aggressive management of modifiable risk factors. Technology advances notwithstanding stroke morbidity and mortality remains steady. The significance of silent cerebral embolism on prognosis remains uncertain, and optimal medical treatment during and after TAVR should be further investigated.

Familial hypercholesterolemia: an under-recognized but significant concern in cardiology practice.

Abstract: Familial hypercholesterolemia (FH) is a common disorder in which genetic mutations in at least 1 of several genes lead to significantly increased levels of lipoproteins, in particular, low-density lipoprotein cholesterol. Most commonly, mutations in the low-density lipoprotein receptor gene result in high plasma levels of apolipoprotein B-containing lipoproteins (eg, low-density lipoprotein and lipoprotein(a)). High plasma levels of lipoproteins increase the risk of cardiovascular events by as much as 20-fold if left untreated. A 2011 survey of cardiologists performed by the American College of Cardiology (ACC) suggests that there is a need for greater awareness of FH among cardiologists with regard to its prevalence and heritability, and of the risk of cardiovascular (CV) disease associated with the disorder, such as premature coronary heart disease. Given that many patients with FH may first present to CV specialists at the time of a major coronary event, it is critical that cardiologists have strategies to manage this high-risk subset of patients. This brief review responds to areas of need identified in the ACC survey and is intended to provide current information about FH and increase awareness about this disorder among cardiologists.

Adherence to dual antiplatelet therapy after coronary stenting: a systematic review.

Abstract: Background Adherence to dual antiplatelet therapy (DAPT) is critical after coronary stenting. Although adherence rates are frequently assessed in clinical trials, adherence rates in the unselected population recommended for treatment but beyond clinical trials are largely unknown. Therefore, we performed a systematic review of published observational studies to describe rates of DAPT adherence, trends in DAPT use over time, and patient-level factors associated with nonadherence. Hypothesis DAPT adherence declines with increasing time after drug-eluting stent implantation. Methods PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, and Web of Knowledge were searched through November 20, 2012 for studies including patients receiving 1 or more drug-eluting stents and reporting the use of aspirin and/or thienopyridines, or assessing factors associated with nonadherence to DAPT after bare metal or drug-eluting stent placement. Results We included 34 studies in the description of DAPT adherence and 11 studies in the description of factors associated with nonadherence. Adherence to DAPT and thienopyridines was high at 1 month but declined by 12 months. Aspirin adherence was at least 90% throughout. Factors associated with nonadherence included bleeding, lower education level, immigrant status, and lack of education regarding DAPT. Conclusions DAPT adherence is suboptimal at 12 months, and interventions to increase adherence should focus on reducing bleeding risk and improving communication between patients and physicians.

Primary Malignancies of the Heart and Pericardium

Abstract: Primary malignancies of the heart and pericardium are rare. All the available data come from autopsy studies, case reports, and, in recent years, from large, specialized, single-center studies. Nevertheless, if primary malignancy is present, it may have a devastating implication for patients. Malignancies may affect heart function, also causing left-sided or right-sided heart failure. In addition, they can be responsible for embolic events or arrhythmias. Today, with the widespread use of noninvasive imaging modalities, heart tumors become evident, even as an incidental finding. A multimodality imaging approach is usually required to establish the final diagnosis. Despite the increased awareness and improved diagnostic techniques, clinical manifestations of primary malignancy of the heart and pericardium are so variable that their occurrence may still come as a surprise during surgery or autopsy. No randomized clinical trials have been carried out to determine the optimal therapy for these primary malignancies. Surgery is performed for small tumors. Chemotherapy and radiation therapy can be of help. Partial resection of large neoplasms is performed to relieve mechanical effects, such as cardiac compression or hemodynamic obstruction. Most patients present with marginally resectable or technically nonresectable disease at the time of diagnosis. It seems that orthotopic cardiac transplantation with subsequent immunosuppressive therapy may represent an option for very carefully selected patients. Early diagnosis and radical exeresis are of great importance for long-term survival of a primary cardiac malignancy. This can rarely be accomplished, and overall results are very disappointing.

Efficacy and Safety of Alirocumab as Add‐on Therapy in High–Cardiovascular‐Risk Patients With Hypercholesterolemia Not Adequately Controlled With Atorvastatin (20 or 40 mg) or Rosuvastatin (10 or 20 mg): Design and Rationale of the ODYSSEY OPTIONS Studies

Abstract: The phase 3 ODYSSEY OPTIONS studies (OPTIONS I, NCT01730040; OPTIONS II, NCT01730053) are multicenter, multinational, randomized, double-blind, active-comparator, 24-week studies evaluating the efficacy and safety of alirocumab, a fully human monoclonal antibody targeting proprotein convertase subtilisin/kexin type 9, as add-on therapy in ∼ 650 high-cardiovascular (CV)-risk patients whose low-density lipoprotein cholesterol (LDL-C) levels are ≥100 mg/dL or ≥70 mg/dL according to the CV-risk category, high and very high CV risk, respectively, with atorvastatin (20-40 mg/d) or rosuvastatin (10-20 mg/d). Patients are randomized to receive alirocumab 75 mg via a single, subcutaneous, 1-mL injection by prefilled pen every 2 weeks (Q2W) as add-on therapy to atorvastatin (20-40 mg) or rosuvastatin (10-20 mg); or to receive ezetimibe 10 mg/d as add-on therapy to statin; or to receive statin up-titration; or to switch from atorvastatin to rosuvastatin (OPTIONS I only). At week 12, based on week 8 LDL-C levels, the alirocumab dose may be increased from 75 mg to 150 mg Q2W if LDL-C levels remain ≥100 mg/dL or ≥70 mg/dL in patients with high or very high CV risk, respectively. The primary efficacy endpoint in both studies is difference in percent change in calculated LDL-C from baseline to week 24 in the alirocumab vs control arms. The studies may provide guidance to inform clinical decision-making when patients with CV risk require additional lipid-lowering therapy to further reduce LDL-C levels. The flexibility of the alirocumab dosing regimen allows for individualized therapy based on the degree of LDL-C reduction required to achieve the desired LDL-C level.

Is High‐Intensity Statin Therapy Associated With Lower Statin Adherence Compared With Low‐ to Moderate‐Intensity Statin Therapy? Implications of the 2013 American College of Cardiology/American Heart Association Cholesterol Management Guidelines

Abstract: Background The recent cholesterol guideline recommends high-intensity statins in cardiovascular disease (CVD) patients. High-intensity statins are associated with more frequent side effects. Therefore, it may be of concern that these recommendations might reduce statin adherence. Hypothesis High-intensity statins are associated with lower adherence compared with low- to moderate-intensity statins. Methods In a national database of 972 532 CVD patients from the Veterans Health Administration, we identified patients receiving statins between October 1, 2010, and September 30, 2011. We assessed statin adherence by calculating proportion of days covered (PDC) and determined whether high-intensity statin therapy was independently associated with a lower PDC. Results Statins were prescribed in 629 005 (64.7%). Of those, 229 437 (36.5%) received high-intensity statins. Mean PDC (0.87 vs 0.86, P < 0.0001) and patients with PDC ≥0.80 (76.3% vs 74.2%, P < 0.0001) were slightly higher for those receiving low- to moderate-intensity compared with high-intensity statins. In adjusted analyses, high-intensity statin use was associated with a significant but modest PDC reduction compared with low- to moderate-intensity statin use, whether PDC was assessed as a continuous (β-coefficient: −0.008, P < 0.0001) or categorical (PDC ≥0.80 [odds ratio: 0.94, 95% confidence interval: 0.93-0.96]) measure of statin adherence. Conclusions An approach of high-intensity statin therapy will lead to a significant practice change, as the majority of CVD patients are not on high-intensity therapy. However, this change may be associated with a very modest reduction in statin adherence compared with low- to moderate-intensity therapy that is unlikely to be of clinical significance.

Stroke and bleeding risk in atrial fibrillation: navigating the alphabet soup of risk-score acronyms (CHADS2 , CHA2 DS2 -VASc, R2 CHADS2 , HAS-BLED, ATRIA, and more).

Abstract: Stroke prevention is central to the management of patients with atrial fibrillation (AF) As effective stroke prophylaxis essentially requires oral anticoagulants, an understanding of the risks and benefits of oral anticoagulant therapy is needed Although AF increases stroke risk 5-fold, this risk is not homogeneous Many stroke risk factors also confer an increased risk of bleeding Various stroke and bleeding risk-stratification schemes have been developed to help inform clinical decision-making These scores were derived and validated in different study cohorts, ranging from highly selected clinical-trial cohorts to real-world populations Thus, their performance and classification accuracy vary depending on their derivation cohort(s) In the present review, we provide an overview of currently available stroke and bleeding risk-stratification schemes We particularly focus on the CHA2 DS2 -VASc and HAS-BLED schemes, as these are recommended by the latest European guidelines on AF management Other risk-stratification schemes (eg, CHADS2 , R2 CHADS2 , ATRIA, HEMORR2 HAGES, QStroke) and their place in the decision-making are also considered

Plasma Soluble ST2 Levels Correlate With Disease Severity and Predict Clinical Worsening in Patients With Pulmonary Arterial Hypertension

Abstract: Background Soluble suppression of tumorigenicity (sST2) has been proposed to be a marker for biomechanical strain and a possible predictor of mortality in patients with chronic heart failure. The use of sST2 in pulmonary arterial hypertension (PAH) has not been well defined. Hypothesis Plasma sST2 levels may correlate with the disease severity and predict clinical worsening in PAH. Methods We performed a cohort study of 40 idiopathic PAH patients with data on demographics, exercise capacity, echocardiographic parameters, laboratory tests, hemodynamics, and medications. Plasma sST2 was assessed with the high-sensitivity ST2 ELISA kit at diagnostic catheterization. All patients were followed up from the date of blood sampling. The endpoint was clinical worsening. Results sST2 was significantly elevated in patients with idiopathic PAH compared with control subjects (28.9 ± 13.9 vs 20.7 ± 7.5 ng/mL, P = 0.003). Pearson correlation analysis revealed that sST2 levels correlated with cardiac index (r = −0.534, P = 0.000) and pulmonary vascular resistance (r = 0.350, P = 0.027), and could reflect disease severity of PAH. After a mean follow-up of 14 ± 5 months, 12 patients showed clinical worsening. Receiver operating characteristic analysis suggested that sST2 levels >31.4 ng/mL discriminated clinical worsening with a sensitivity and specificity of 83.3% and 78.6%, respectively. Kaplan-Meier analysis showed that higher sST2 levels (>31.4 ng/mL) were associated with poor clinical outcomes (P = 0.008). Multivariate Cox regression analysis showed that sST2 was an independent predictor of clinical worsening (hazard ratio: 6.067, 95% confidence interval: 1.317–27.948, P = 0.021). Conclusions sST2 correlates with disease severity and is a significant predictor of clinical worsening in patients with PAH.

Atrial fibrillation and incident myocardial infarction in the elderly.

Abstract: Background Atrial fibrillation (AF) has been shown to be independently associated with an increased risk of myocardial infarction (MI) in a predominantly middle-aged population; however, this association has not been examined in older populations Hypothesis AF is associated with MI in older adults Methods A total of 4608 participants (85% white, 40% male) from the Cardiovascular Health Study without evidence of baseline coronary heart disease were included in this analysis AF cases were identified during the yearly study electrocardiogram, a self-reported history of a physician diagnosis, or by hospitalization data Incident MI was identified using medical records with local and central adjudication Cox regression was used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between AF and incident MI Results A total of 434 (94%) participants had evidence of AF before incident MI Over a median follow-up of 122 years, a total of 797 (173%) participants developed MI In a multivariable Cox proportional hazards analysis adjusted for socio-demographics, cardiovascular risk factors, and potential confounders, AF was associated with an increased risk of MI (HR: 17, 95% CI: 14-22) A significant interaction was detected by race, with black (HR: 31, 95% CI: 17-56) AF participants having an increased risk of MI compared with whites (HR: 16, 95% CI: 12-21; P interaction = 0030) Conclusions AF is associated with an increased risk of MI in a population of older adults

Utility of Dobutamine Stress Echocardiography as Part of the Pre-Liver Transplant Evaluation: An Evaluation of Its Efficacy

Abstract: Background Dobutamine stress echocardiography (DSE) is commonly used to risk stratify patients in the cardiac evaluation prior to orthotopic liver transplantation (OLT). Data remain limited regarding the accuracy to predict obstructive coronary artery disease (CAD) using this approach. Hypothesis We hypothesize that DSE may have limitations in the investigation of underlying CAD in patients with end-stage liver disease. Methods A retrospective chart review of all patients who underwent OLT at Mayo Clinic in Florida between 1998 and 2010 was performed. Sixty-six underwent invasive coronary angiography (ICA) within 1 year of DSE and were included in our study. Based on DSE results, patients were stratified into 1 of 3 groups: nonischemic, ischemic, and indeterminate. The relationship between DSE, ICA, and death from all cause and cardiac-related cause with a minimum 3-year follow-up period were analyzed. Results A total of 66 patients were included in our cohort. There was no difference in age, gender, severity of liver disease, and echocardiographic findings among the groups. Forty-three percent of patients (n = 12) with an abnormal result on DSE were found to have moderate or severe obstructive CAD on cardiac catheterization, whereas 49% of patients (n = 17) with a normal finding on DSE had moderate or severe CAD. Of 5 patients who died from a documented cardiac etiology, 3 had normal stress test results, 1 had abnormal findings, and 1 had an indeterminate DSE result. When compared with ICA, our study demonstrated that DSE has a sensitivity of 41.4% (95% confidence interval [CI]: 0.24-0.61), specificity of 47.1% (95% CI: 0.30-0.65), positive predictive value of 40.0% (95% CI: 0.23-0.59), and negative predictive value of 48.0% (95% CI: 0.31-0.66) in identification of underlying CAD. Conclusions Although widely used, DSE may not always accurately reflect the severity of obstructive CAD in patients undergoing OLT.

Transfemoral aortic valve implantation of Edwards SAPIEN XT without predilatation is feasible.

Abstract: Background Transcatheter aortic valve implantation (TAVI) without predilatation has fewer procedural steps and thereby potentially fewer complications. This has been demonstrated for the antegrade transapical access; however, whether TAVI can be safely performed without predilatation using the retrograde transfemoral route is unknown. Hypothesis We postulated that TAVI is feasible with a balloon-expandable device without predilatation using the retrograde transfemoral route. Methods Twenty-six consecutive patients with stenosis of the native aortic valve (AV) undergoing transfemoral TAVI with the Edwards SAPIEN XT prosthesis without predilatation were enrolled in this retrospective study and compared with 30 patients treated previously with predilatation. Results The procedure was successfully performed in all 26 patients, irrespective of the AV area and the extent of AV calcification. At baseline mean AV area, mean AV gradient, and median left ventricular ejection fraction were 0.7 ± 0.2 cm2, 36.0 ± 17.3 mm Hg, and 55.0% (interquartile range [IQR], 35.0–60.0], respectively; prior to discharge these values were 1.7 ± 0.3 (P 2°; this was reduced by the procedure to <2° in all cases. Radiation dose and amount of contrast dye were significantly reduced in comparison with the predilatation group. No periprocedural neurological adverse events occurred. Mortality at 30 days was 0%. Conclusions TAVI without predilatation using the transfemoral Edwards SAPIEN XT valve is feasible and safe. Larger studies are required to further evaluate this approach.

Cardiac platypnea-orthodeoxia syndrome: An often unrecognized malady

Abstract: Platypnea-orthodeoxia syndrome (POS) is a rare but clinically important form of dyspnea. The syndrome is characterized by dyspnea and arterial oxygen desaturation that occurs in the upright position and improves with recumbency. In cardiac POS, an atrial septal defect or patent foramen ovale allows communication between the right- and left-sided circulations. A second defect, such as a dilated aorta, prominent eustachian valve, or pneumonectomy, then contributes to right-to-left shunting through the interatrial connection. Diagnosis is made through pulse oximetry to confirm orthodeoxia and through transesophageal echocardiography with bubble study to visualize the shunt. Although data are limited for this rare syndrome, percutaneous closure has thus far proven safe and effective.

Coronary Microvascular Dysfunction Assessed by Intracoronary Acetylcholine Provocation Testing Is a Frequent Cause of Ischemia and Angina in Patients With Exercise-Induced Electrocardiographic Changes and Unobstructed Coronary Arteries

Abstract: Background The exercise electrocardiogram (ECG) is a standard examination in patients with suspected coronary artery disease. However, despite a pathologic result, many patients undergoing diagnostic coronary angiography do not have any significant epicardial stenosis. In this study, we assessed the relation between a pathologic exercise ECG and coronary microvascular dysfunction in response to intracoronary acetylcholine (ACh) provocation in patients without any relevant epicardial stenosis. Hypothesis Coronary microvascular dysfunction is significantly more often in patients with angina, unobstructed coronary arteries and a pathologic exercise stress test compared to those without pathologic stress test. Methods This study recruited 137 consecutive patients with exertional angina pectoris who underwent diagnostic coronary angiography between September 2008 and April 2011 (68% women; mean age, 63 ± 10 years). In none of the patients was there a stenosis of >50%. All patients underwent an exercise ECG before angiography and intracoronary ACh provocation testing for assessment of coronary vasomotor responses directly after angiography. Results The exercise ECG showed an abnormal result in 69 patients (50%; ST-segment depression ≥0.1 mV and/or reproduction of the patient's usual symptoms). The ACh test revealed a coronary vasomotor abnormality (reproduction of the patient's symptoms, ischemic ECG shifts ± diffuse distal vasoconstriction) in 87 patients (64%). Such a result was significantly more often found in patients with a pathologic exercise ECG (50/69 [72%] vs 19/69 [28%], P = 0.034). There were no other statistically significant differences between patients with and those without pathologic exercise ECG. Conclusions Coronary microvascular dysfunction is frequently found in patients with exertional angina pectoris and unobstructed coronary arteries. Such a finding is found significantly more often in presence of a pathologic exercise ECG.

Total Serum Transforming Growth Factor‐β1 Is Elevated in the Entire Spectrum of Genetic Aortic Syndromes

Abstract: Background Total serum transforming growth factor-beta 1 (tsTGF-β1) is increased in patients with Marfan syndrome (MFS), but it has not been assessed in thoracic aortic aneurysm and dissection (TAAD), Loeys-Dietz syndrome (LDS), and bicuspid aortic valve disease (BAVD). Hypothesis tsTGF-β1 is increased in genetic aortic syndromes including TAAD, LDS, MFS, and BAVD. Methods We measured tsTGF-β1 and performed sequencing of the genes FBN1, TGFBR1, and TGFBR2 in 317 consecutive patients with suspected or known genetic aortic syndrome (167 men, 150 women; mean age 43 ± 14 years). TAAD was diagnosed in 20, LDS in 20, MFS in 128, and BAVD in 30 patients, and genetic aortic syndrome was excluded in 119 patients. Results Elevated tsTGF-β1 levels were associated with causative gene mutations (P = 0.008), genetic aortic syndrome (P = 0.009), and sporadic occurrence of genetic aortic syndrome (P = 0.048), whereas only genetic aortic syndrome qualified as an independent predictor of tsTGF-β1 (P = 0.001). The tsTGF-β1 levels were elevated in FBN1 and NOTCH1 mutations vs patients without mutations (both P = 0.004), and in NOTCH1 mutations vs ACTA2/MYH11 mutations (P = 0.015). Similarly, tsTGF-β1 levels were elevated in MFS (P = 0.003) and in BAVD (P = 0.006) vs patients without genetic aortic syndrome. In contrast to specific clinical features of MFS, FBN1 in-frame mutations (P = 0.019) were associated with increased tsTGF-β1 levels. Conclusions tsTGF-β1 is elevated in the entire spectrum of genetic aortic syndromes. However, gradual differences in the increases of tsTGF-β1 levels may mirror different degrees of alteration of tsTGF-β1 signaling in different genetic aortic syndromes.

Prevention of Cardiovascular Disease: Highlights for the Clinician of the 2013 American College of Cardiology/American Heart Association Guidelines

Abstract: Prevention of cardiovascular disease, undoubtedly an emphasis of clinical care in 2014, will provide both opportunities and challenges to patients and their healthcare providers. The recently-released ACC/AHA guidelines on assessment of cardiovascular risk, lifestyle management to reduce cardiovascular risk, management of overweight and obesity, and treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk, have introduced new concepts and revised prior conventional strategies. New to risk assessment are the Pooled Cohort Equations, targeting the expanded concept of atherosclerotic cardiovascular disease (ASCVD) and focusing not solely on mortality but as well on major nonfatal events. The lifestyle management focuses on diet and physical activity for lipid and blood pressure control. The cholesterol guideline identifies four high-risk groups with the greatest benefits from statin therapy: preexisting ASCVD, primary LDL-C elevations ≥ 190 mm/dl, those 45-75 years with diabetes and LDL-C 70-189 mm/dl without clinical ASCVD, and those 40-75 years without clinical ASCVD with an LDL-C 70-189 mg/dl with a 7.5% or greater 10-year ASCVD risk. Eliminated are arbitrary LDL-C treatment targets, with individual patient risk status guiding who should take statins and the appropriate intensity of statin drugs. Patient-physician discussions of individual benefits and risks are paramount. Management of high blood pressure remains controversial, with two different expert panels offering varying treatment targets; there is general agreement on a <140/90 mmHg goal, but substantial disagreement on blood pressure targets for older adults. Clinicians and their patients deserve a well-researched concensus document.

Prehospital telemedicine electrocardiogram triage for a regional public emergency medical service: is it worth it? A preliminary cost analysis.

Abstract: Background Telemedicine has been shown to improve quality of health-care delivery in several fields of medicine; its cost-effectiveness, however, is still a matter of debate. Hypothesis Pre-hospital telemedicine electrocardiogram triage for regional public emergency medical service may reduce costs. Methods An economic evaluation (cost analysis) was performed from the perspective of regional health-care system. Patients enrolled in the study and considered for cost analysis were those who called the local emergency medical service (EMS; dialing 1-1-8) during 2012 and underwent prehospital field triage with a telemedicine electrocardiogram (ECG) in the case of suspected acute cardiac disease (acute coronary syndrome, arrhythmia). The prehospital ECGs were read by a remote cardiologist, available 24/7. Cost savings associated with this method were calculated by subtracting the cost of prehospital triage with telemedicine support from the cost of conventional emergency department triage (ECG and consultation by a cardiologist). Results During 2012, the regional EMS performed 109 750 ECGs by telemedicine support. The associated total cost for the regional health-care system was €1 833 333, with a €16.70 cost per single ECG/consultation. Given the cost of similar conventional emergency department treatment from a regional rate list of €24.80 to €55.20, the savings was €8.10 to €38.40 per ECG/consultation (total savings, €891 759.50 to €4 219 379.50). The cost for ruling out an acute cardiac disease was €25.30; for a prehospital diagnosis of cardiovascular disease, €49.20. With 629 prehospital diagnoses of ST-elevation myocardial infarction and reported reductions in mortality thanks to prehospital diagnosis deduced from prior studies, 69 lives per year presumably could be saved, with a cost per quality-adjusted life year gained of €1927, €990/€ − 2508 after correction for potential savings. Conclusions Prehospital EMS triage with telemedicine ECG in patients with suspected acute cardiac disease may reduce health-care costs.

Hypoglycemia From a Cardiologist's Perspective

Abstract: Hypoglycemia in people with diabetes mellitus (DM) has been potentially linked to cardiovascular morbidity and mortality. Pathophysiologically, hypoglycemia triggers activation of the sympathoadrenal system, leading to an increase in counter-regulatory hormones and, consequently, increased myocardial workload and oxygen demand. Additionally, hypoglycemia triggers proinflammatory and hematologic changes that provide the substrate for possible myocardial ischemia in the already-diseased diabetic cardiovascular system. Hypoglycemia creates electrophysiologic alterations causing P-R-interval shortening, ST-segment depression, T-wave flattening, reduction of T-wave area, and QTc-interval prolongation. Patients who experience hypoglycemia are at an increased risk of silent ischemia as well as QTc prolongation and consequent arrhythmias. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial showed an increase in all-cause mortality with intensive glycemic control, whereas the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) study and Veteran's Affairs Diabetes Trial (VADT) showed no benefit with aggressive glycemic control. Women, elderly patients, and those with renal insufficiency are more vulnerable to hypoglycemic events. In fact, hypoglycemia is the most common metabolic complication experienced by older patients with DM in the United States. The concurrent use of medications like β-blockers warrants caution in DM because they can mask warning signs of hypoglycemia. Here we aim to elucidate the pathophysiology, review the electrocardiographic changes, analyze the current clinical literature, and consider the safety considerations of hypoglycemia as it relates to the cardiovascular system. In conclusion, in the current era of DM and its vascular ramifications, hypoglycemia from a cardiologist's perspective deserves due attention.

Fractional flow reserve: an updated review.

Abstract: Revascularization of ischemia-producing coronary lesions is widely used in the management of coronary artery disease. However, some coronary lesions appear significant on the conventional angiogram when they are truly non–flow limiting. For this reason, it is becoming increasingly important to determine the coronary physiology. Fractional flow reserve (FFR) has emerged as a useful tool to determine the lesions that require revascularization. Measurement of FFR during invasive coronary angiography now has a class IA indication from the European Society of Cardiology for identifying hemodynamically significant coronary lesions when noninvasive evidence of myocardial ischemia is unavailable. Current data on FFR can be broadly classified into studies that compare the diagnostic accuracy of FFR measurement compared with other noninvasive modalities and studies that test treatment strategies of patients with intermediate coronary stenoses using a threshold value for FFR and that have clinical outcomes as endpoints. In this review, we will discuss the concept of FFR, current evidence supporting its usage, and future perspectives.

Management of patients with atrial fibrillation by primary-care physicians in Germany: 1-year results of the ATRIUM registry.

Abstract: Background Patients with atrial fibrillation (AF) in Germany are often managed jointly by primary-care physicians in cooperation with cardiologists. We aimed to investigate the management and 1-year outcomes of AF patients in this setting. Hypothesis We set out to describe the current management of AF patients in primary care settings in Germany. Methods Observational registry with 1-year follow-up, performed by a representative, randomly selected sample of 781 primary-care physicians in Germany. Results Of 3781 patients with electrocardiographically documented AF, 3163 patients (age 71.9 ± 9.2 years, 57.9% males) were followed for 1 year; 28.4% had paroxysmal, 27.0% persistent, and 43.3% permanent AF. Comorbid conditions were common (mean CHA2DS2-VASc score 3. 8 ± 1.7). Rhythm-control therapy was used in 16.4%. Although oral anticoagulation was often used (82.7% at baseline), stroke rate during follow-up was high (2.7% stroke, 3.0% transient ischemic attack). Despite a long duration of AF (mean duration 61 months at enrollment), 18.5% of patients were hospitalized during the 1-year follow-up. Conclusions In this unselected group of patients with long-standing AF managed in primary care, hospitalizations and cardiovascular complications including strokes are frequent, illustrating the need to improve management of AF patients.

Safe-dose thrombolysis plus rivaroxaban for moderate and severe pulmonary embolism: drip, drug, and discharge.

Abstract: Background Thrombolysis, though very effective, has not been embraced as routine therapy for symptomatic pulmonary embolism (PE) except in very severe cases. Rivaroxaban recently has been approved for the treatment of venous thromboembolism (VTE). There are no data on the combined use of thrombolysis and rivaroxaban in PE. Hypothesis “Safe dose” thrombolysis (SDT) plus new oral anticoagulants are expected to become an appealing, safe and effective approach in the treatment of moderate and severe PE in the near future, thereby drastically reducing hospitalization time. Methods Over a 12-month period, 98 consecutive patients with symptomatic PE were treated by a combination of SDT and rivaroxaban. The SDT was started in parallel with unfractionated heparin and given in 2 hours. Heparin was given for a total of 24 hours and rivaroxaban started at 15 or 20 mg daily 2 hours after termination of heparin infusion. Results There was no bleeding due to SDT. Recurrent VTE occurred in 3 patients who had been switched to warfarin. No patient on rivaroxaban developed VTE. Two patients died of cancer at a mean follow-up of 12 ± 2 months. The pulmonary artery systolic pressure dropped from 52.8 ± 3.9 mm Hg before to 32 ± 4.4 mm Hg within 36 hours of SDT (P < 0.001). The duration of hospitalization for patients presenting primarily for PE was 1.9 ± 0.2 days. Conclusions “Safe dose” thrombolysis plus rivaroxaban is highly safe and effective in the treatment of moderate and severe PE, leading to favorable early and intermediate-term outcomes and early discharge.

Cardiac Repolarization Abnormalities Among Patients With Various Stages of Chronic Kidney Disease

Abstract: Background Patients with chronic kidney disease (CKD) are at increased risk of life-threatening cardiovascular arrhythmias. Although these arrhythmias are usually secondary to structural heart diseases that are commonly associated with CKD, a significant proportion of cases with sudden cardiac death have no obvious structural heart disease. This study aims to explore the relationship of cardiac repolarization in patients with CKD and worsening kidney function. Hypothesis There is cardiac repolarization abnormalities among patients with chronic kidney disease. Methods This was a retrospective, chart-review study of admissions or clinic visits to a university hospital between 2005 and 2010 by patients with a diagnosis of CKD. Inclusion criteria selected patients who had 12-lead surface electrocardiography (ECG), renal function tests within 24 hours, and transthoracic echocardiography within 6 months. Cases with a documented etiology for the corrected Qt (Qtc) interval prolongation including structural heart disease, QT prolonging drugs, or relevant disease conditions, were excluded. Results Our sample size was 154 ECGs. Two-thirds of patients with CKD had QTc interval prolongation, and about 20% had a QTc interval >500 ms. QTc interval was significantly different and increased with each successive stage of CKD using the Bazett (P < 0.006) or Fridericia (P = 0.03) formula. QTc interval correlated significantly with serum creatinine (P = 0.01). These finding were independent of age, gender, potassium, and calcium concentrations. Conclusions The progression of CKD resulted in a significant delay of cardiac repolarization, independent of other risk factors. This effect may potentially increase the risk of sudden cardiac death, and may also increase the susceptibility of drug-induced arrhythmia.

Significance of aortic valve calcification in patients with low-gradient low-flow aortic stenosis

Abstract: Background Assessment of patients with aortic stenosis (AS) and impaired left ventricular function remains challenging. Aortic valve calcium (AVC) scoring with computed tomography (CT) and fluoroscopy has been proposed as means of diagnosing and predicting outcomes in patients with severe AS. Hypothesis Severity of aortic valve calcification correlates with the diagnosis of true severe AS and outcomes in patients with low-gradient low-flow AS. Methods Echocardiography and CT database records from January 1, 2000 to September 26, 2009 were reviewed. Patients with aortic valve area (AVA) < 1.0 cm2 who had ejection fraction (EF) ≤ 25% and mean valvular gradient ≤ 25 mmHg with concurrent noncontrast CT scans were included. AVC was evaluated using CT and fluoroscopy. Mortality and aortic valve replacement (AVR) were established using the Social Security Death Index and medical records. The role of surgery in outcomes was evaluated. Results Fifty-one patients who met the above criteria were included. Mean age was 75.1 ± 9.6 years, and 15 patients were female. Mean EF was 21% ± 4.6% with AVA of 0.7 ± 0.1 cm2. The peak and mean gradients were 35.5 ± 10.6 and 19.0 ± 5.1 mmHg, respectively. Median aortic valve calcium score was 2027 Agatston units. Mean follow-up was 908 days. Patients with calcium scores above the median value were found to have increased mortality (P = 0.02). The benefit of surgery on survival was more pronounced in patients with higher valvular scores (P = 0.001). Fluoroscopy scoring led to similar findings, where increased AVC predicted worse outcomes (P = 0.04). Conclusions In patients with low-gradient low-flow AS, higher valvular calcium score predicts worse long-term mortality. AVR is associated with improved survival in patients with higher valve scores.