Showing papers in "Heart in 2017"

Structured telephone support or non-invasive telemonitoring for patients with heart failure

Abstract: Heart failure is a common and growing problem, worldwide, often leading to repeated hospitalisations, reduced quality of life, disability, loss of independence and shortened life expectancy. Managing heart failure is costly and complex for individual patients, their families and healthcare systems. A range of pharmacological agents, devices and disease management programmes have proven to be effective but are not available to all patients. Non-invasive telemonitoring and structured telephone support for patients with heart failure have been researched for almost two decades; however the jury still appears to be out for the use of this intervention in clinical practice.1 The effectiveness of structured telephone support and non-invasive telemonitoring to reduce hospitalisations and mortality in patients with heart failure was assessed by a recent Cochrane review.2 This review was undertaken as an update to a previously published version. Randomised controlled trials (RCTs) that compared structured telephone support or non-invasive telemonitoring to standard practice were included. Studies were excluded if the telemonitoring intervention included other interventions such as home visits or frequent clinic visits or implanted monitoring devices. Compared with the previously published Cochrane review, 17 new studies were identified and 24 had been included in the previous review (total of 41 studies). Two studies were multiarm and included both structured telephone support and telemonitoring; hence there were 43 comparisons in the review. The primary outcomes included all-cause mortality and all-cause and heart failure related hospitalisations which were analysed using fixed-effects models. The review demonstrated that both non-invasive telemonitoring and structured telephone support offer statistically and clinically meaningful benefits to people with heart failure.2 For non-invasive telemonitoring, a 20% reduction in the risk of all-cause mortality was observed (Relative Risk (RR) 0.80, 95% Confidence Interval (CI) 0.68 to 0.94; participants=3740; studies=17; I2=24%; Grading of Recommendations Assessment, Development and …

Evolving antithrombotic treatment patterns for patients with newly diagnosed atrial fibrillation

Abstract: Objective We studied evolving antithrombotic therapy patterns in patients with newly diagnosed non-valvular atrial fibrillation (AF) and ?1 additional stroke risk factor between 2010 and 2015. Methods 39 670 patients were prospectively enrolled in four sequential cohorts in the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF): cohort C1 (2010'2011), n=5500; C2 (20112013), n=11 662; C3 (2013-2014), n=11 462; C4 (2014- 2015), n=11 046. Baseline characteristics and antithrombotic therapy initiated at diagnosis were analysed by cohort. Results Baseline characteristics were similar across cohorts. Median CHA2DS2-VASc (cardiac failure, hypertension, age ?75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65-74 and sex category (female)) score was 3 in all four cohorts. From C1 to C4, the proportion of patients on anticoagulant (AC) therapy increased by almost 15% (C1 57.4%; C4 71.1%). Use of vitamin K antagonist (VKA)±antiplatelet (AP) (C1 53.2%; C4 34.0%) and AP monotherapy (C1 30.2%; C4 16.6%) declined, while use of non-VKA oral ACs (NOACs)±AP increased (C1 4.2%; C4 37.0%). Most CHA2DS2-VASc ?2 patients received AC, and this proportion increased over time, largely driven by NOAC prescribing. NOACs were more frequently prescribed than VKAs in men, the elderly, patients of Asian ethnicity, those with dementia, or those using non-steroidal antiinflammatory drugs, and current smokers. VKA use was more common in patients with cardiac, vascular, or renal comorbidities. Conclusions Since NOACs were introduced, there has been an increase in newly diagnosed patients with AF at risk of stroke receiving guideline-recommended therapy, predominantly driven by increased use of NOACs and reduced use of VKA±AP or AP alone.

Epidemiology of valvular heart disease in a Swedish nationwide hospital-based register study.

Abstract: Objective Transitions in the spectrum of valvular heart diseases (VHDs) in developed countries over the 20th century have been reported from clinical case series, but large, contemporary population-based studies are lacking. Methods We used nationwide registers to identify all patients with a first diagnosis of VHD at Swedish hospitals between 2003 and 2010. Age-stratified and sex-stratified incidence of each VHD and adjusted comorbidity profiles were assessed. Results In the Swedish population (n=10 164 211), the incidence of VHD was 63.9 per 100 000 person-years, with aortic stenosis (AS; 47.2%), mitral regurgitation (MR; 24.2%) and aortic regurgitation (AR; 18.0%) contributing most of the VHD diagnoses. The majority of VHDs were diagnosed in the elderly (68.9% in subjects aged ≥65 years), but pulmonary valve disease incidence peaked in newborns. Incidences of AR, AS and MR were higher in men who were also more frequently diagnosed at an earlier age. Mitral stenosis (MS) incidence was higher in women. Rheumatic fever was rare. Half of AS cases had concomitant atherosclerotic vascular disease (48.4%), whereas concomitant heart failure and atrial fibrillation were common in mitral valve disease and tricuspid regurgitation. Other common comorbidities were thoracic aortic aneurysms in AR (10.3%), autoimmune disorders in MS (24.5%) and abdominal hernias or prolapse in MR (10.7%) and TR (10.3%). Conclusions Clinically diagnosed VHD was primarily a disease of the elderly. Rheumatic fever was rare in Sweden, but specific VHDs showed a range of different comorbidity profiles . Pronounced sex-specific patterns were observed for AR and MS, for which the mechanisms remain incompletely understood.

Long-term and short-term outcomes of using bilateral internal mammary artery grafting versus left internal mammary artery grafting: a meta-analysis

Abstract: Background A substantial body of evidence demonstrates that myocardial revascularisation using bilateral internal mammary arteries (BIMA) improves long-term survival compared with single/left internal mammary artery (LIMA) grafting. To date, limited analyses have been made regarding other short-term and long-term outcomes in BIMA strategy. Objectives The primary aim of the present review is to update the difference in long-term survival between BIMA and LIMA grafting and to thoroughly investigate other secondary short-term and long-term clinical outcomes between these two grafting procedures. Methods Electronic searches were performed using three databases from their inception to November 2015. Relevant studies comparing long-term survival between BIMA and LIMA grafting were identified. Data were extracted by two independent reviewers and analysed according to predefined clinical outcomes. Results Twenty-nine observational studies were identified, with a total of 89 399 patients. Overall, BIMA cohort had significantly improved long-term survival compared with LIMA cohort (HR 0.78; p Conclusions BIMA grafting is associated with enhanced overall long-term outcomes compared with LIMA grafting. While the BIMA cohort demonstrates an increased incidence of DSWI, the survival benefits and other morbidity advantages outweigh this short-term risk.

Integrated care in atrial fibrillation: a systematic review and meta-analysis

Abstract: Objective Atrial fibrillation (AF) is an emerging global epidemic associated with significant morbidity and mortality. Whilst other chronic cardiovascular conditions have demonstrated enhanced patient outcomes from coordinated systems of care, the use of this approach in AF is a comparatively new concept. Recent evidence has suggested that the integrated care approach may be of benefit in the AF population, yet has not been widely implemented in routine clinical practice. We sought to undertake a systematic review and meta-analysis to evaluate the impact of integrated care approaches to care delivery in the AF population on outcomes including mortality, hospitalisations, emergency department visits, cerebrovascular events and patient-reported outcomes. Methods PubMed, Embase and CINAHL databases were searched until February 2016 to identify papers addressing the impact of integrated care in the AF population. Three studies, with a total study population of 1383, were identified that compared integrated care approaches with usual care in AF populations. Results Use of this approach was associated with a reduction in all-cause mortality (OR 0.51, 95% CI 0.32 to 0.80, p=0.003) and cardiovascular hospitalisations (OR 0.58, 95% CI 0.44 to 0.77, p=0.0002) but did not significantly impact on AF-related hospitalisations (OR 0.82, 95% CI 0.56 to 1.19, p=0.29) or cerebrovascular events (OR 1.00, 95% CI 0.48 to 2.09, p=1.00). Conclusions The use of the integrated care approach in AF is associated with reduced cardiovascular hospitalisations and all-cause mortality. Further research is needed to identify optimal settings, methods and components of delivering integrated care to the burgeoning AF population.

Light-chain cardiac amyloidosis: strategies to promote early diagnosis and cardiac response

Abstract: Amyloid light chain (AL) amyloidosis is a systemic disease characterised by the aggregation of misfolded immunoglobulin light chain (LC), predominantly in the heart and kidneys, causing organ failure. If untreated, the median survival of patients with cardiac AL amyloidosis is 6 months from the onset of heart failure. Protracted time to establish a diagnosis, often lasting >1 year, is a frequent factor in poor treatment outcomes. Cardiologists, to whom patients are often referred, frequently miss the opportunity to diagnose cardiac AL amyloidosis. Nearly all typical cardiac support measures, with the exception of diuretics, are ineffective and may even worsen clinical symptoms, emphasising the need for accurate diagnosis. Patients with severe cardiac involvement face poor outcomes; heart transplantation is rarely an option because of multiorgan involvement, rapid clinical decline and challenges in predicting which patients will respond to treatment of the underlying plasma cell disorder. Early diagnosis and prompt treatment with A¢â'¬Eœsource therapiesA¢â'¬â"¢ that limit the production of amyloidogenic LC are associated with better survival and improvement in organ function after a median of 2.4 months following haematological complete response. However, organ recovery is often incomplete because these source therapies do not directly target deposited amyloid. Emerging amyloid-directed therapies may attenuate, and potentially reverse, organ dysfunction by clearing existing amyloid and inhibiting fibril formation of circulating aggregates. Improved recognition of AL amyloidosis by cardiologists allows for earlier treatment and improved outcomes.

Takotsubo syndrome: aetiology, presentation and treatment

Abstract: ### Learning objectives In the clinical setting, Takotsubo syndrome (TTS) is one of the most important diseases that must be accurately differentiated from acute coronary syndrome (ACS) to enable appropriate follow-up and medical management. The prevalence of TTS is estimated to be approximately 2%–3% in all patients presenting with suspected ACS.1 However, it may be underestimated because knowledge of diagnostic criteria is often incomplete, such as the possible coexistence of coronary artery disease (CAD). According to the widely used Mayo Clinic Diagnostic Criteria modified in 2008, incidental obstructive CAD not related to the wall motion abnormality may be an inclusion criterion for the diagnosis of TTS. However, this fact has been cited only as a footnote in a paper by Prasad and colleagues.2 In addition, atypical variants are not very well recognised by physicians, which may contribute to the underestimation of TTS.3 In 2015, the International Takotsubo Registry (www.takotsubo-registry.com), which is the largest systematic database on patients suffering from TTS, revealed novel data pertaining to TTS, which aided to the understanding of this enigmatic disease.4 This review summarises current knowledge on the aetiology, presentation and treatment of TTS. The exact aetiology of TTS is still unknown, but several hypotheses are considered relevant for its pathophysiology. A number of observational clinical studies and preclinical models have helped to illuminate how the cardiovascular system responds to sudden extreme stress. These studies frequently provide a simplified and reductionist approach to a complex situation; therefore, it is important to note that a full understanding …

Contemporary natural history of bicuspid aortic valve disease: a systematic review

Abstract: We performed a systematic review of the current state of the literature regarding the natural history and outcomes of bicuspid aortic valve (BAV). PubMed and the reference lists of the included articles were searched for relevant studies reporting on longitudinal follow-up of BAV cohorts (mean follow-up ≥2 years). Studies limited to patients undergoing surgical interventions were excluded. 13 studies (11 502 patients with 2-16 years of follow-up) met the inclusion criteria. There was a bimodal age distribution (30-40 vs ≥50 years), with a 3:1 male to female ratio. Complications included moderate to severe aortic regurgitation (prevalence 13%-30%), moderate to severe aortic stenosis (12%-37%), infective endocarditis (2%-5%) and aortic dilatation (20%-40%). Aortic dissection or rupture was rare, occurring in 38 patients (0.4%, 27/6446 in native BAV and 11/2232 in post). With current aggressive surveillance and prophylactic surgical interventions, survival in three out of four studies was similar to that of a matched general population. In this systematic review, valvular dysfunction warranting surgical intervention in patients with BAV were common, aortic dissection was rare and, with the current management approach, survival was similar to that of the general population.

Mendelian randomisation in cardiovascular research: an introduction for clinicians

Abstract: Understanding the causal role of biomarkers in cardiovascular and other diseases is crucial in order to find effective approaches (including pharmacological therapies) for disease treatment and prevention. Classical observational studies provide naive estimates of the likely role of biomarkers in disease development; however, such studies are prone to bias. This has direct relevance for drug development as if drug targets track to non-causal biomarkers, this can lead to expensive failure of these drugs in phase III randomised controlled trials. In an effort to provide a more reliable indication of the likely causal role of a biomarker in the development of disease, Mendelian randomisation studies are increasingly used, and this is facilitated by the availability of large-scale genetic data. We conducted a narrative review in order to provide a description of the utility of Mendelian randomisation for clinicians engaged in cardiovascular research. We describe the rationale and provide a basic description of the methods and potential limitations of Mendelian randomisation. We give examples from the literature where Mendelian randomisation has provided pivotal information for drug discovery including predicting efficacy, informing on target-mediated adverse effects and providing potential new evidence for drug repurposing. The variety of the examples presented illustrates the importance of Mendelian randomisation in order to prioritise drug targets for cardiovascular research.

Diagnosis, imaging and clinical management of aortic coarctation.

Abstract: Coarctation of the aorta (CoA ) is a well-known congenital heart disease (CHD) , which is often associated with several other cardiac and vascular anomalies, such as bicuspid aortic valve (BAV), ventricular septal defect, patent ductus arteriosus and aortic arch hypoplasia. Despite echocardiographic screening, prenatal diagnosis of C o A remains difficult. Most patients with CoA present in infancy with absent, delayed or reduced femoral pulses, a supine arm-leg blood pressure gradient (> 20 mm Hg), or a murmur due to rapid blood flow across the CoA or associated lesions (BAV). Transthoracic echocardiography is the primary imaging modality for suspected CoA. However, cardiac magnetic resonance imaging is the preferred advanced imaging modality for non-invasive diagnosis and follow-up of CoA. Adequate and timely diagnosis of CoA is crucial for good prognosis, as early treatment is associated with lower risks of long-term morbidity and mortality. Numerous surgical and transcatheter treatment strategies have been reported for CoA. Surgical resection is the treatment of choice in neonates, infants and young children. In older children (> 25 kg) and adults, transcatheter treatment is the treatment of choice. In the current era, patients with CoA continue to have a reduced life expectancy and an increased risk of cardiovascular sequelae later in life, despite adequate relief of the aortic stenosis. Intensive and adequate follow-up of the left ventricular function, valvular function, blood pressure and the anatomy of the heart and the aorta are , therefore, critical in the management of CoA. This review provides an overview of the current state-of-the-art clinical diagnosis, diagnostic imaging algori thms, treatment and follow-up of patients with CoA.

Assessment and classification of patients with myocardial injury and infarction in clinical practice

Abstract: Myocardial injury is common in patients without acute coronary syndrome, and international guidelines recommend patients with myocardial infarction are classified by aetiology. The universal definition differentiates patients with myocardial infarction due to plaque rupture (type 1) from those due to myocardial oxygen supply-demand imbalance (type 2) secondary to other acute illnesses. Patients with myocardial necrosis, but no symptoms or signs of myocardial ischaemia, are classified as acute or chronic myocardial injury. This classification has not been widely adopted in practice, because the diagnostic criteria for type 2 myocardial infarction encompass a wide range of presentations, and the implications of the diagnosis are uncertain. However, both myocardial injury and type 2 myocardial infarction are common, occurring in more than one-third of all hospitalised patients. These patients have poor short-term and long-term outcomes with two-thirds dead in 5 years. The classification of patients with myocardial infarction continues to evolve, and future guidelines are likely to recognise the importance of identifying coronary artery disease in type 2 myocardial infarction. Clinicians should consider whether coronary artery disease has contributed to myocardial injury, as selected patients are likely to benefit from further investigation and in these patients targeted secondary prevention has the potential to improve outcomes.

Heart failure in patients with kidney disease

Abstract: Heart failure (HF) is a leading cause of morbidity and mortality in patients with chronic kidney disease (CKD), and the population of CKD patients with concurrent HF continues to grow. The accurate diagnosis of HF is challenging in patients with CKD in part due to a lack of validated imaging and biomarkers specifically in this population. The pathophysiology between the heart and the kidneys is complex and bidirectional. Patients with CKD have greater prevalence of traditional HF risk factors as well as unique kidney-specific risk factors including malnutrition, acid-base alterations, uraemic toxins, bone mineral changes, anemia and myocardial stunning. These risk factors also contribute to the decline of kidney function seen in patients with subclinical and clinical HF. More targeted HF therapies may improve outcomes in patients with kidney disease as current HF therapies are underutilised in this population. Further work is also needed to develop novel HF therapies for the CKD population.

Antibiotic prophylaxis for infective endocarditis: a systematic review and meta-analysis

Abstract: © © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted. Objective The use of antibiotic prophylaxis (AP) for prevention of infective endocarditis (IE) is controversial. In recent years, guidelines to cardiologists and dentists have advised restriction of AP to high-risk groups (in Europe and the USA) or against its use at all (in the UK). The objective of this systematic review was to appraise the evidence for use of AP for prevention of bacteraemia or IE in patients undergoing dental procedures. Methods We conducted electronic searches in Medline, Embase, Cochrane Library and ISI Web of Science. We assessed the methodological characteristics of included studies using the Strengthening the Reporting of Observational Studies in Epidemiology criteria for observational studies and the Cochrane Risk of Bias Tool for trials. Two reviewers independently determined the eligibility of studies, assessed the methodology of included studies and extracted the data. Results We identified 178 eligible studies, of which 36 were included in the review. This included 10 time-Trend studies, 5 observational studies and 21 trials. All trials identified used bacteraemia as an endpoint rather than IE. One time-Trend study suggests that total AP restriction may be associated with a rising incidence of IE, while data on the consequences of relative AP restriction are conflicting. Meta-Analysis of trials indicates that AP is effective in reducing the incidence of bacteraemia (risk ratio 0.53, 95% CI 0.49 to 0.57, p<0.01), but case-control studies suggest this may not translate to a statistically significant protective effect against IE in patients at low risk of disease. Conclusions The evidence base for the use of AP is limited, heterogeneous and the methodological quality of many studies is poor. Postprocedural bacteraemia is not a good surrogate endpoint for IE. Given the logistical challenges of a randomised trial, high-quality case-control studies would help to evaluate the role of dental procedures in causing IE and the efficacy of AP in its prevention.

Factors associated with long-term mortality after Fontan procedures: a systematic review

Abstract: Background Despite an ageing Fontan population, data on late outcomes are still scarce. Reported outcome measures and determinants vary greatly between studies making comprehensive appraisal of mortality hazard challenging. Methods We conducted a systematic review to evaluate causes and factors associated with late mortality in patients with Fontan circulation. Late mortality was defined as mortality beyond the first postoperative year. Studies were included if they had ≥90 patients or ≥20 late mortalities and/or transplants. Studies with overlapping patients were rationalised to include only the most recent studies to avoid duplication. Results From 28 studies, a total of 6707 patients with an average follow-up time of 8.23±5.42 years was identified. There were 1000 deaths. Causes of late death were reported in 697 cases. The five most common causes were heart/Fontan failure (22%), arrhythmia (16%), respiratory failure (15%), renal disease (12%) and thrombosis/bleeding (10%). Factors associated with late mortality were evaluated and classified into 9 categories. Conclusions Causes and factors associated with late mortality after the Fontan operation are summarised in this study. The presented information will aid in identifying patients at highest risk for mortality and guide our risk stratification efforts in this patient population.

Gender differences in clinical presentation and 1-year outcomes in atrial fibrillation

Abstract: Objectives Our objective was to examine gender differences in clinical presentation, management and prognosis of atrial fibrillation (AF) in a contemporary cohort. Methods In 6412 patients, 39.7% women, of the PREvention oF thromboembolic events – European Registry in Atrial Fibrillation, we examined gender differences in symptoms, risk factors, therapies and 1-year incidence of adverse outcomes. Results Men with AF were on average younger than women (mean±SD: 70.1±10.7 vs 74.1±9.7 years, p Men were more frequently treated with electrical cardioversion and ablation (20.6% and 6.3%, respectively) than women (14.9% and 3.3%, respectively), p Conclusion In a ‘real-world’ European AF registry, women were more symptomatic but less likely to receive invasive rhythm control therapy such as electrical cardioversion or ablation. Further study is needed to confirm that these differences do not disadvantage women with AF.

Screening for atrial fibrillation in 13 122 Hong Kong citizens with smartphone electrocardiogram

Abstract: Objective The purpose of this study was to assess the feasibility of community screening for atrial fibrillation (AF) using a smartphone-based wireless single-lead ECG (SL-ECG) and to generate epidemiological data on the prevalence and risk factors of AF in Hong Kong. Methods In the period between 1 May 2014 to 30 April 2015, 13 122 Hong Kong citizens consented and voluntarily participated in a territory-wide community-based AF screening programme. Results 56 (0.4%) out of 13 122 SL-ECG were uninterpretable. 101 (0.8%) participants had newly diagnosed AF, with 66 (65.3%) being asymptomatic. The congestive heart failure, hypertension, age>75(doubled), diabetes, stroke(doubled), vascular disease, age 65–74, sex(female) score (CHA2DS2VASc score) of participants with newly diagnosed AF was 3.1±1.3. The prevalence rates for AF detected by SL-ECG was 1.8% and for AF detected by SL-ECG or self-reported by participants was 8.5%. Using multivariable logistic regression analysis, independent predictors of AF include age, sex, height, weight, body mass index, history of heart failure, valvular heart disease, stroke, hyperlipidaemia, coronary artery disease, peripheral artery disease and cardiothoracic surgery. Conclusion Community screening for AF with SL-ECG was feasible and it identified a significant proportion of citizens with newly diagnosed AF. The prevalence of AF in a Chinese population in Hong Kong was comparable with that of contemporary Western counterparts. Apart from age and sex, different anthropometric parameters and cardiovascular comorbid conditions were identified as independent predictors of AF.

Diffuse myocardial fibrosis in patients with mitral valve prolapse and ventricular arrhythmia

Abstract: Objective We aimed to investigate the association of diffuse myocardial fibrosis by cardiac magnetic resonance (CMR) T 1 with complex ventricular arrhythmia (ComVA) in mitral valve prolapse (MVP). Methods A retrospective analysis was performed on 41 consecutive patients with MVP referred for CMR between 2006 and 2011, and 31 healthy controls. Arrhythmia analysis was available in 23 patients with MVP with Holter/event monitors. Left ventricular (LV) septal T 1 times were derived from Look-Locker sequences after administration of 0.2 mmol/kg gadopentetate dimeglumine. Late gadolinium enhancement (LGE) CMR images were available for all subjects. Results Patients with MVP had significantly shorter postcontrast T 1 times when compared with controls (334±52 vs 363±58 ms; p=0.03) despite similar LV ejection fraction (LVEF) (63±7 vs 60±6%, p=0.10). In a multivariable analysis, LV end-diastolic volume, LVEF and mitral regurgitation fraction were all correlates of T 1 times, with LVEF and LV end-diastolic volume being the strongest (p=0.005, p=0.008 and p=0.045, respectively; model adjusted R 2 =0.30). Patients with MVP with ComVA had significantly shorter postcontrast T 1 times when compared with patients with MVP without ComVA (324 (296, 348) vs 354 (327, 376) ms; p=0.03) and only 5/14 (36%) had evidence of papillary muscle LGE. Conclusions MVP may be associated with diffuse LV myocardial fibrosis as suggested by reduced postcontrast T 1 times. Diffuse interstitial derangement is linked to subclinical systolic dysfunction, and may contribute to ComVA in MVP-related mitral regurgitation, even in the absence of focal fibrosis.

Outcomes with type 2 myocardial infarction compared with non-ischaemic myocardial injury

Abstract: Objective To identify patients with type 2 myocardial infarction (MI) and patients with non-ischaemic myocardial injury (NIMI) and to compare their prognosis with those of patients with type 1 MI. Methods A retrospective observational study was performed in 1010 patients admitted to the emergency department of a university hospital with at least one troponin I test between 2012 and 2013. Participants were identified using laboratory records and divided into three groups: type 1 MI (rupture of atheromatous plaque), type 2 MI (imbalance between myocardial oxygen supply and/or demand) and NIMI (patients who did not meet diagnostic criteria for type 1 or type 2 MI). Clinical characteristics and 2-year outcomes were analysed. Results Patients with type 2 MI and NIMI were older, with higher proportion of women and more comorbidities than patients with type 1 MI. Absolute mortality and the adjusted risk for all-cause mortality in both groups were significantly higher than that of patients with type 1 MI (39.7%, HR: 1.41 95% CI 1.02 to 1.94, p=0.038 and 40.0%, HR: 1.54 95% CI 1.16 to 2.04, p=0.002, respectively). Patients with type 2 MI and NIMI tended to present more readmissions due to heart failure (16.5%, HR: 1.55 95% CI 0.87 to 2.76, p=0.133 and 12.3%, HR: 1.15 95% CI 0.70 to 1.90, p=0.580) and less readmission rates due to acute coronary syndrome (ACS) than patients with type 1 MI (2.1%, HR: 0.11 95% CI 0.04 to 0.31, p Conclusions Patients diagnosed with type 2 MI and NIMI have higher rates of mortality and lower readmission rates for ACS compared with patients with type 1 MI.

Sex differences in risk factor management of coronary heart disease across three regions.

Abstract: Objective To investigate whether there are sex differences in risk factor management of patients with established coronary heart disease (CHD), and to assess demographic variations of any potential sex differences. Methods Patients with CHD were recruited from Europe, Asia, and the Middle East between 2012-2013. Adherence to guideline-recommended treatment and lifestyle targets was assessed and summarised as a Cardiovascular Health Index Score (CHIS). Age-adjusted regression models were used to estimate odds ratios for women versus men in risk factor management. Results 10 112 patients (29% women) were included. Compared with men, women were less likely to achieve targets for total cholesterol (OR 0.50, 95% CI 0.43 to 0.59), low-density lipoprotein cholesterol (OR 0.57, 95% CI 0.51 to 0.64), and glucose (OR 0.78, 95% CI 0.70 to 0.87), or to be physically active (OR 0.74, 95% CI 0.68 to 0.81) or non-obese (OR 0.82, 95% CI 0.74 to 0.90). In contrast, women had better control of blood pressure (OR 1.31, 95% CI 1.20 to 1.44) and were more likely to be a non-smoker (OR 1.93, 95% CI 1.67 to 2.22) than men. Overall, women were less likely than men to achieve all treatment targets (OR 0.75, 95% CI 0.60 to 0.93) or obtain an adequate CHIS (OR 0.81, 95% CI 0.73 to 0.91), but no significant differences were found for all lifestyle targets (OR 0.93, 95% CI 0.84 to 1.02). Sex disparities in reaching treatment targets were smaller in Europe than in Asia and the Middle East. Women in Asia were more likely than men to reach lifestyle targets, with opposing results in Europe and the Middle East. Conclusions Risk factor management for the secondary prevention of CHD was generally worse in women than in men. The magnitude and direction of the sex differences varied by region.

Gender inequalities in cardiovascular risk factor assessment and management in primary healthcare.

Abstract: Objectives To quantify contemporary differences in cardiovascular disease (CVD) risk factor assessment and management between women and men in Australian primary healthcare services. Methods Records of routinely attending patients were sampled from 60 Australian primary healthcare services in 2012 for the Treatment of Cardiovascular Risk using Electronic Decision Support study. Multivariable logistic regression models were used to compare the rate of CVD risk factor assessment and recommended medication prescriptions, by gender. Results Of 53 085 patients, 58% were female. Adjusting for demographic and clinical characteristics, women were less likely to have sufficient risk factors measured for CVD risk assessment (OR (95% CI): 0.88 (0.81 to 0.96)). Among 13 294 patients (47% women) in the CVD/high CVD risk subgroup, the adjusted odds of prescription of guideline-recommended medications were greater for women than men: 1.12 (1.01 to 1.23). However, there was heterogeneity by age (p Conclusions Women attending primary healthcare services in Australia were less likely than men to have risk factors measured and recorded such that absolute CVD risk can be assessed. For those with, or at high risk of, CVD, the prescription of appropriate preventive medications was more frequent in older women, but less frequent in younger women, compared with their male counterparts. Trial registration number 12611000478910, Pre-results.

Recurrent pre-eclampsia and subsequent cardiovascular risk

Abstract: Objective To determine the association between recurrent pre-eclampsia and long-term cardiovascular hospitalisation. Methods This study identified cardiovascular hospitalisations up to 25 years after pregnancy for all women who delivered between 1989 and 2013 in Quebec, Canada. Exposures included recurrent and non-recurrent pre-eclampsia in women with two deliveries or more (N=606 820), and pre-eclampsia in women with only one delivery (N=501 761). Incidence, timing and risk of cardiovascular complications were calculated using accelerated failure time models adjusted for age, pre-existing disease, socioeconomic deprivation and period. Outcomes included a range of cardiovascular hospitalisations and procedures. Results Women with recurrent pre-eclampsia had higher incidence of cardiovascular hospitalisation (281.4 per 1000) than women with non-recurrent (167.7 per 1000) or no pre-eclampsia (72.6 per 1000). Mean time to cardiovascular hospitalisation was 10.5 years for recurrent, 11.6 years for non-recurrent and 12.7 years for no pre-eclampsia, a difference of 17.3% for recurrent and 8.7% for non-recurrent relative to no pre-eclampsia. Compared with no pre-eclampsia, recurrent pre-eclampsia was associated with 2 times the risk of heart disease (95% CI 1.69 to 2.29) and 3 times the risk of cerebrovascular disease (95% CI 2.25 to 4.05). Pre-eclampsia in women with one delivery was associated with 3 times greater risk of cardiovascular hospitalisation compared with no pre-eclampsia in women with two deliveries or more (95% CI 2.96 to 3.25). Conclusions Recurrent pre-eclampsia is associated with higher risk of future cardiovascular hospitalisation compared with no pre-eclampsia, and significantly shorter time to first cardiovascular event. Cardiovascular screening should be performed earlier for women with recurrent pre-eclampsia.

Systemic inflammation as a novel QT-prolonging risk factor in patients with torsades de pointes.

Abstract: Objective Increasing evidence indicates systemic inflammation as a new potential cause of acquired long QT syndrome (LQTS), via cytokine-mediated changes in cardiomyocyte ion channels. Torsade de pointes (TdP) is a life-threatening polymorphic ventricular tachycardia occurring in patients with LQTS, usually when multiple QT-prolonging factors are simultaneously present. Since classical risk factors cannot fully explain TdP events in a number of patients, we hypothesised that systemic inflammation may represent a currently overlooked risk factor contributing to TdP development in the general population. Methods Forty consecutive patients who experienced TdP (TdP cohort) were consecutively enrolled and circulating levels of C-reactive protein (CRP) and proinflammatory cytokines (interleukin-6 (IL-6), tumour necrosis factor alpha (TNFα), interleukin-1 (IL-1)) were compared with patients with active rheumatoid arthritis (RA), comorbidity or healthy controls. An additional 46 patients with different inflammatory conditions (acute infections, n=31; immune-mediated diseases, n=12; others, n=3) and elevated CRP (inflammatory cohort) were prospectively enrolled, and corrected QT (QTc) and cytokine levels were measured during active disease and after a CRP decrease of >75% subsequent to therapy. Results In the TdP cohort, 80% of patients showed elevated CRP levels (median: ~3 mg/dL), with a definite inflammatory disease identifiable in 18/40 cases (acute infections, n=12; immune-mediated diseases, n=5; others, n=1). In these subjects, IL-6, but not TNFα and IL-1, was ~15–20 times higher than in controls, and comparable to RA patients. In the inflammatory cohort, where QTc prolongation was common (mean values: 456.6±30.9 ms), CRP reduction was associated with IL-6 level decrease and significant QTc shortening (−22.3 ms). Conclusion The data are first to show that systemic inflammation via elevated IL-6 levels may represent a novel QT-prolonging risk factor contributing to TdP occurrence in the presence of other classical risk factors. If confirmed, this could open new avenues in antiarrhythmic therapy.

Cardiac αVβ3 integrin expression following acute myocardial infarction in humans.

Abstract: The study and MRD, WJ and DEN are supported by the British Heart Foundation (FS/12/84, FS/10/026, CH/09/002, R M/13/2/30158, RE/13/3/30183). DEN is the recipient of a Wellcome Trust Senior Investigator Award (WT103782AIA). JHFR is part-funded by the NIHR Cambridge Biomedical Research Centre. The Wellcome Trust Clinical Research Facility and Clinical Research Imaging Centre are supported by NHS Research Scotland (NRS) through NHS Lothian.

Point-of-care cardiac ultrasound techniques in the physical examination: better at the bedside

Abstract: The development of hand-carried, battery-powered ultrasound devices has created a new practice in ultrasound diagnostic imaging, called 'point-of-care' ultrasound (POCUS). Capitalising on device portability, POCUS is marked by brief and limited ultrasound imaging performed by the physician at the bedside to increase diagnostic accuracy and expediency. The natural evolution of POCUS techniques in general medicine, particularly with pocket-sized devices, may be in the development of a basic ultrasound examination similar to the use of the binaural stethoscope. This paper will specifically review how POCUS improves the limited sensitivity of the current practice of traditional cardiac physical examination by both cardiologists and non-cardiologists. Signs of left ventricular systolic dysfunction, left atrial enlargement, lung congestion and elevated central venous pressures are often missed by physical techniques but can be easily detected by POCUS and have prognostic and treatment implications. Creating a general set of repetitive imaging skills for these entities for application on all patients during routine examination will standardise and reduce heterogeneity in cardiac bedside ultrasound applications, simplify teaching curricula, enhance learning and recollection, and unify competency thresholds and practice. The addition of POCUS to standard physical examination techniques in cardiovascular medicine will result in an ultrasound-augmented cardiac physical examination that reaffirms the value of bedside diagnosis.

Incidence and risk of heart failure in systemic lupus erythematosus

Abstract: Background Although case series suggest a higher burden of cardiovascular risk factors in patients with systemic lupus erythematosus (SLE) compared with the general population, the association between SLE and heart failure (HF) remains undefined. We sought to investigate the incidence and risk of HF in patients with SLE. Methods In April 2016, we performed a retrospective cohort analysis using the Explorys platform, which provides aggregated electronic medical record data from 26 major integrated healthcare systems across the USA from 1999 to present. Demographic and regression analyses were performed to assess the impact of SLE on HF incidence. Results Among 45 284 540 individuals in the database, we identified 95 400 (0.21%) with SLE and 98 900 (0.22%) with a new diagnosis of HF between May 2015 and April 2016. HF incidence was markedly higher in the SLE group compared with controls (0.97% vs 0.22%, relative risk (RR): 4.6 (95% CI 4.3 to 4.9)), as were other cardiovascular risk factors. In regression analysis, SLE was an independent predictor of HF (adjusted OR: 3.17 (2.63 to 3.83), p Conclusions The findings of this study suggest that patients with SLE have significantly higher risk of developing HF and a worse cardiovascular risk profile compared with the general population. These results need to be confirmed by prospective studies.

Effects of dabigatran according to age in atrial fibrillation

Abstract: Objective The prevalence of atrial fibrillation (AF) and the risk of stroke and bleeding vary according to age. To estimate effects of dabigatran, compared with warfarin, on stroke, bleeding and mortality in patients with AF in the Randomized Evaluation of Long-Term Anticoagulant Therapy (RE-LY) trial according to age, we analysed treatment effects using age as a continuous variable and using age categories. Methods RE-LY included 10 855 (59.9%) patients aged Results Benefits of dabigatran versus warfarin regarding stroke (HR range 0.63 (95% CI 0.46 to 0.86) to 0.70 (0.31 to 1.57) for dabigatran 150 mg twice daily), HR range 0.52 (0.21 to 1.29) to 1.08 (0.73 to 1.60) for dabigatran 110 mg twice daily) and intracranial bleeding were maintained across all age groups (interaction p values all not significant). There was a highly significant interaction (p value interaction Conclusion Effects of dabigatran compared with warfarin on stroke prevention and intracranial bleeding are consistent across all age groups. Effects of dabigatran on extracranial major bleeding are age dependent, supporting selection of dabigatran 110 mg twice daily for elderly patients (age ≥80 years). Trial registration number Clinical trial registration number: https://clinicaltrials.govNCT00262600.

Warfarin utilisation and anticoagulation control in patients with atrial fibrillation and chronic kidney disease.

Abstract: Objective To evaluate warfarin prescription, quality of international normalised ratio (INR) monitoring and of INR control in patients with atrial fibrillation (AF) and chronic kidney disease (CKD). Methods We performed a retrospective cohort study of patients with newly diagnosed AF in the Veterans Administration (VA) healthcare system. We evaluated anticoagulation prescription, INR monitoring intensity and time in and outside INR therapeutic range (TTR) stratified by CKD. Results Of 123 188 patients with newly diagnosed AF, use of warfarin decreased with increasing severity of CKD (57.2%–46.4%), although it was higher among patients on dialysis (62.3%). Although INR monitoring intensity was similar across CKD strata, the proportion with TTR≥60% decreased with CKD severity, with only 21% of patients on dialysis achieving TTR≥60%. After multivariate adjustment, the magnitude of TTR reduction increased with CKD severity. Patients on dialysis had the highest time markedly out of range with INR 3.5 (30%); 12% of INR time was >3.5, and low TTR persisted for up to 3 years. Conclusions There is a wide variation in anticoagulation prescription based on CKD severity. Patients with moderate-to-severe CKD, including dialysis, have substantially reduced TTR, despite comparable INR monitoring intensity. These findings have implications for more intensive warfarin management strategies in CKD or alternative therapies such as direct oral anticoagulants.

Risk score for cardiac surgery in active left-sided infective endocarditis.

Abstract: Objective To develop and validate a calculator to predict the risk of in-hospital mortality in patients with active infective endocarditis (IE) undergoing cardiac surgery. Methods Thousand two hundred and ninety-nine consecutive patients with IE were prospectively recruited (1996–2014) and retrospectively analysed. Left-sided patients who underwent cardiac surgery (n=671) form our study population and were randomised into development (n=424) and validation (n=247) samples. Variables statistically significant to predict in-mortality were integrated in a multivariable prediction model, the Risk-Endocarditis Score (RISK-E). The predictive performance of the score and four existing surgical scores (European System for Cardiac Operative Risk Evaluation (EuroSCORE) I and II), Prosthesis, Age ≥70, Large Intracardiac Destruction, Staphylococcus, Urgent Surgery, Sex (Female) (PALSUSE), EuroSCORE ≥10) and Society of Thoracic Surgeons’s Infective endocarditis score (STS-IE)) were assessed and compared in our cohort. Finally, an external validation of the RISK-E in a separate population was done. Results Variables included in the final model were age, prosthetic infection, periannular complications, Staphylococcus aureus or fungi infection, acute renal failure, septic shock, cardiogenic shock and thrombocytopaenia. Area under the receiver operating characteristic curve in the validation sample was 0.82 (95% CI 0.75 to 0.88). The accuracy of the other surgical scores when compared with the RISK-E was inferior (p=0.010). Our score also obtained a good predictive performance, area under the curve 0.76 (95% CI 0.64 to 0.88), in the external validation. Conclusions IE-specific factors (microorganisms, periannular complications and sepsis) beside classical variables in heart surgery (age, haemodynamic condition and renal failure) independently predicted perioperative mortality in IE. The RISK-E had better ability to predict surgical mortality in patients with IE when compared with other surgical scores.

Long-term efficacy of catheter ablation as first-line therapy for paroxysmal atrial fibrillation: 5-year outcome in a randomised clinical trial

Abstract: OBJECTIVE: The Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation (MANTRA-PAF) trial compared radiofrequency catheter ablation (RFA) with antiarrhythmic d ...

A current approach to heart failure in Duchenne muscular dystrophy

Abstract: Duchenne muscular dystrophy (DMD) is a genetic, progressive neuromuscular condition that is marked by the long-term muscle deterioration with significant implications of pulmonary and cardiac dysfunction. As such, end-stage heart failure (HF) in DMD is increasingly becoming the main cause of death in this population. The early detection of cardiomyopathy is often challenging, due to a long subclinical phase of ventricular dysfunction and difficulties in assessment of cardiovascular symptomatology in these patients who usually loose ambulation during the early adolescence. However, an early diagnosis of cardiovascular disease in patients with DMD is decisive since it allows a timely initiation of cardioprotective therapies that can mitigate HF symptoms and delay detrimental heart muscle remodelling. Echocardiography and ECG are standardly used for screening and detection of cardiovascular abnormalities in these patients, although these tools are not always adequate to detect an early, clinically asymptomatic phases of disease progression. In this regard, cardiovascular magnetic resonance (CMR) with late gadolinium enhancement is emerging as a promising method for the detection of early cardiac involvement in patients with DMD. The early detection of cardiac dysfunction allows the therapeutic institution of various classes of drugs such as corticosteroids, beta-blockers, ACE inhibitors, antimineralocorticoid diuretics and novel pharmacological and surgical solutions in the multimodal and multidisciplinary care for this group of patients. This review will focus on these challenges and available options for HF in patients with DMD.