Favorable effects of statins in the treatment of heart failure with preserved ejection fraction in patients without ischemic heart disease

BACKGROUND

The effects of statins in patients with heart failure with preserved ejection fraction (HFpEF) remain unclear. This study aimed to assess whether statin therapy is associated with a decreased risk of mortality in patients with HFpEF.

METHODS

We used data from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial. The primary outcome was all-cause mortality. We analyzed hazard ratios (HRs) for outcomes with 95% confidence intervals (95% CIs) in patients taking statins compared with those not taking statins using multivariable Cox proportional hazard models.

RESULTS

This study included 3378 patients with HFpEF. The mean follow-up period was 3.3years; 497 patients died during the study period. Among all patients, the adjusted HR for all-cause death was significantly lower in those taking statins compared with those not taking statins (HR 0.79, 95% CI 0.63-0.99, P=0.04). The risks of all-cause and cardiovascular mortality in patients without ischemic heart disease (IHD) were significantly lower in those taking statins compared with those not taking statins (HR 0.63, 95% CI 0.44-0.91, P=0.01 and HR 0.59, 95% CI 0.37-0.94, P=0.02, respectively), whereas the risks in patients with IHD did not differ significantly between those taking and not taking statins (HR 0.97, 95% CI 0.72-1.31, P=0.83 and HR 0.95, 95% CI 0.66-1.36, P=0.77, respectively). Among propensity score-matched patients without IHD, the risks of all-cause and cardiovascular death were significantly lower in those taking statins compared with those not taking statins.

CONCLUSIONS

Statin therapy was associated with improved outcomes in HFpEF patients, particularly those without IHD.

Implantable cardioverter-defibrillator use in elderly patients receiving cardiac resynchronization: A meta-analysis

BACKGROUND

Implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) reduce sudden cardiac death and all-cause mortality in patients with heart failure with reduced ejection fraction (HFrEF). Current guidelines do not suggest any upper age limit for ICD and CRT but recommend avoidance of ICD and CRT in frail patients with a life expectancy of less than 1 year. It remains unclear whether elderly patients undergoing CRT derive the same additional benefit from ICDs as younger patients. We aimed to assess the use of ICDs in elderly compared to younger patients receiving CRT.

METHODS

We searched electronic databases, up to April 11, 2016, for all studies reporting on ICD use stratified by age in patients who received CRT. We used random-effects meta-analysis models to calculate the summarized baseline characteristics and rates of implantation of ICD among patients enrolled in the studies.

RESULTS

We retained six observational studies enrolling 613 patients ≥75 years old and 2810 patients <75 years old. The aggregate mean age was 82.7 years for the elderly patients compared to 66.3 years in the younger patients. There was a significantly lower use of ICDs in elderly patients compared to that in younger patients (37.9% versus 64.3%) (odds ratio: 0.26; 95% confidence intervals: 0.14-0.46; p < 0.0001).

CONCLUSIONS

In conclusion, ICD was less frequently used in patients ≥75 years old receiving CRT compared to younger patients receiving CRT. Future studies that evaluate the efficacy and effectiveness of ICDs in elderly patients with indications for CRT are needed to guide management of this increasing population.

Efficacy of a one-catheter concept for transradial coronary angiography

Introduction

Transradial coronary angiography (TRC) can be performed with a one-catheter approach for the right and left coronary ostium (R/LCO). We investigated the performance of a special diagnostic catheter widely used for the one-catheter-approach, the Tiger (Tiger II, Terumo^TM).

Methods

In a dual center registry we analyzed 1412 TRC-procedures exclusively performed by experienced TRC-operators. We compared the performance of the Tiger with Judkins catheters by retrospectively judging ostial catheter stability during contrast injection, and by measuring contrast use, fluoroscopy time (FT) and complication rate.

Results

Poor or failed ostial engagement was found in 40.5% in the Tiger group, compared to 46.6% with the use of Judkins catheters (p<0.183). Ostial instability of the Tiger was found more often during engagement of the LCO than the RCO (34.4% vs. 10.8%, p<0.001), whereas it was similar in the LCO and RCO for Judkins catheters (27.4% vs. 26.7%, p = 0.840). TRC-procedures performed with Tiger catheters were associated with less contrast volume (63.48 ± 29.83mL vs. 82.51 ± 56.58mL, p<0.004) and shorter FT than with Judkins catheters. (198.27 ± 194.8sec vs. 326.85 ± 329.70sec). Forearm hematomas occurred less often with the Tiger (1.2% vs. 6.6%, p< 0.02).

Conclusion

The Tiger employed as a single catheter in TRC is an effective tool to achieve lower contrast volume and fluoroscopy time at a low complication rate. Unstable engagement affects predominantly the left coronary artery, but its overall frequency is similar for both, the Tiger and Judkins catheters.

Early cardiac abnormalities in obese children and their relationship with adiposity

OBJECTIVES

Childhood obesity rates are increasing as well as chronic disease and cardiovascular risk factors for patients at young ages. In this study, we evaluate the correlation between cardiac parameters, body mass index (BMI), and other body composition indicators in children and adolescents.

METHODS

In this cross-sectional study, we evaluated anthropometric measurements, bioelectrical impedance parameters, and echocardiographic measurements including the left ventricular mass (LVM), LVM index (LVMI), and left atrial diameter (LAD) in children and adolescents ages 7 to 15 y. We performed linear and multivariate regression analyses and analyzed the correlations between cardiac parameters, BMI, and other body composition parameters.

RESULTS

We analyzed 96 children and adolescents and found 40.6% to be obese and 29.2% overweight. LVMI and LAD indexed to height were significantly higher in individuals who were obese. LVMI increased significantly with increasing BMI (r = 0.717; P < 0.001), waist circumference (r = 0.670; P < 0.001), waist-to-height ratio (r = 0.650; P < 0.001), and body surface (r = 0.570; P < 0.001). Only BMI was significant in the multivariate analysis. LVMI was directly and positively correlated with fat mass (FM) and percentage of visceral and abdominal FM and negatively correlated with percentage of lean body mass. LAD was significantly correlated with body surface (r = 0.728; P < 0.001), BMI (r = 0.611; P < 0.001), waist circumference (r = 0.614; P < 0.001), and waist-to-height ratio (r = 0.341; P < 0.01). When indexed to height, LAD was only correlated with BMI and waist-to-height ratio.

CONCLUSIONS

Obesity is associated with cardiac disturbances at a very early age and these changes are closely related to the degree of adiposity. Cardiac structural parameters are significantly correlated with BMI and waist circumference in pediatric patients ages 7 to 15 y.

Heart failure with mid-range ejection fraction in patients admitted to internal medicine departments: Findings from the RICA Registry

AIM

To improve the knowledge on characteristics, treatment and prognosis in patients with heart failure (HF) and mid-range ejection fraction discharged after an acute HF episode.

METHODS

We prospectively included and followed 2753 patients admitted with HF to Internal Medicine units. Patients were classified according to ejection fraction (EF) into three strata: reduced, EF <40% (HFrEF); mid-range EF 40-49% (HFmrEF); and preserved EF ≥50% (HFpEF). Clinical, echocardiographic, laboratory data and treatment at discharge were recorded and the groups were compared. A multivariable analysis was performed to evaluate the association of EF with outcomes in these three groups.

RESULTS

A total of 10.2% of patients had HFmrEF. They were more likely to be men and to have a history of chronic kidney disease and higher levels of NT-proBNP than those with HFpEF. Compared to patients with HFrEF, these patients had less frequently ischaemic aetiology and chronic obstructive pulmonary disease, and a higher proportion of atrial fibrillation and hypertension. In HFmrEF, the use of beta-blockers, aldosterone antagonists and antiplatelet drugs was lower than in HFrEF, but the use of calcium channel blockers and anticoagulants was higher. There were no differences between groups in 30-day and 1-year readmission rates. However, patients with HFrEF had significantly higher 1-year mortality (28%) than patients with HFmrEF and HFpEF (20% and 22%, p<0.001).

CONCLUSIONS

Clinical characteristics and treatment among patients with HF differ depending on EF strata. Prognosis of patients with HFmrEF is closer to that of HFpEF, being medium term survival better than in HFrEF.

Implementation of smart technology to improve medication adherence in patients with cardiovascular disease: is it effective?

INTRODUCTION

Medication adherence is of key importance in the treatment of cardiovascular disease. Studies consistently show that a substantial proportion of patients is non-adherent.

AREAS COVERED

For this review, telemedicine solutions that can potentially improve medication adherence in patients with cardiovascular disease were reviewed. A total of 475 PubMed papers were reviewed, of which 74 were assessed.

EXPERT COMMENTARY

Papers showed that evidence regarding telemedicine solutions is mostly conflictive. Simple SMS reminders might work for patients who do not take their medication because of forgetfulness. Educational interventions and coaching interventions, primarily delivered by telephone or via a web-based platform can be effective tools to enhance medication adherence. Finally, it should be noted that current developments in software engineering may dramatically change the way non-adherence is addressed in the nearby future.

Transcatheter Aortic Valve Implantation in Small Anatomy: Patient Selection and Technical Challenges

Transcatheter aortic valve implantation (TAVI) has become a standard treatment for severe aortic stenosis. Although this technique has reached relative maturity, further optimisation of patient selection and device implantation is essential to improve prognosis. Smaller body size is a predictor of a challenging TAVI procedure due to specific anatomical difficulty and adverse events including annulus rupture, acute coronary obstruction and vascular complications. A newer generation, lower profile TAVI system is useful for patients with smaller anatomy. Moreover, TAVI is superior to surgical aortic valve replacement in patients with a narrowing annulus because this treatement has a low incidence of prosthesis-patient mismatch.

Anticoagulation for Stroke Prevention in Older Adults with Atrial Fibrillation and Comorbidity: Current Evidence and Treatment Challenges

The burden of atrial fibrillation (AF) is projected to increase substantially over the next decade in parallel with the aging of the population. The increasing age, level of comorbidity, and polypharmacy will complicate the treatment of older adults with AF. For instance, advanced age and chronic kidney disease have been shown to increase the risk of both thromboembolism and bleeding in patients with AF. Frailty, recurrent falls and polypharmacy, while very common among elderly patients with AF, are often overlooked in the clinical decision making despite their significant interaction with oral anticoagulant (OAC) and profound impact on the patient's clinical outcomes. Such factors should be recognized, evaluated and considered in a comprehensive decision-making process. The introduction of non-vitamin K oral anticoagulants has radically changed the management of AF allowing for a more individualized selection of OAC. An understanding of the available data regarding the performance of each of the available OAC in a variety of at risk patient populations is paramount for the safe and effective management of this patient population. The aim of this review is to appraise the current evidence, point out the gaps in knowledge, and provide recommendations regarding stroke prevention in older adults with AF and comorbid conditions.

Do We Need an Implantable Cardioverter-defibrillator for Primary Prevention in Cardiac Resynchronisation Therapy Patients?

Collapse

Non-vitamin K Antagonist Oral Anticoagulant After Acute Coronary Syndrome: Is There a Role?

Despite dual antiplatelet therapy (DAPT) including potent P2Y12 inhibitors, recurrent ischaemic events occur in a significant number of patients after acute coronary syndrome (ACS), warranting new antithrombotic strategies. Combinations of non-vitamin K antagonist oral anticoagulant (NOAC) with antiplatelet therapy have been tested in several large phases II and III randomised trials. Overall, current evidence suggests that the use of NOACs on top of DAPT after ACS reduces the rate of recurrent ischaemic events, albeit at the price of increased risk for major bleeding. In the particular field of patients with ACS and atrial fibrillation, NOACs may be associated with reduced bleeding complications compared with vitamin K antagonist. Further randomised trials evaluating low-dose NOAC combined with single antiplatelet therapy are warranted.

Novel electrocardiographic dyssynchrony criteria improve patient selection for cardiac resynchronization therapy

Aims

We hypothesized that the greater the intra- or interventricular dyssynchrony (intraD, interD), the more effective cardiac resynchronization therapy (CRT) is. We sought to improve patient selection for CRT by using novel ECG dyssynchrony criteria.

Methods and results

Left ventricular (LV) intraD was estimated by the absolute time difference between the intrinsicoid deflections (ID) in leads aVL and aVF divided by the QRS duration (QRSd): [aVLID - aVFID]/QRSd (%). InterD was estimated from the formula: [V5ID - V1ID]/QRSd (%). Their >25% value indicated electrical dyssynchrony present (ED+) and ≤25% value electrical dyssynchrony absent (ED-) diagnoses. Using the intraD + interD criteria (intra + interDC) together, if at least one of them indicated ED+ diagnosis, a final ED+ diagnosis, if both indicated ED- diagnosis, a final ED- diagnosis was made. Two authors, blinded to CRT response, retrospectively analysed pre-CRT ECGs of 124 patients with known CRT outcome. CRT response was defined as improvement of ≥ 1 NYHA class, being alive and having no hospitalizations for heart failure during 6 months of follow-up. 35/124 (28%) patients were non-responders (NRs), using the traditional criteria (TC) correct diagnosis was made in the remaining 89/124 (72%) responder (R) cases. The test accuracy (TA) of intra + interDC + TC [100/124 (81%), P < 0.001] was superior to that of TC [89/124 (72%)] due to its superior TA [36/43 (84%) vs. 29/43 (67%), respectively, P = 0.0156] in the non-specific intra-ventricular conduction disturbance (NICD) subgroup [43/124 (35%)]. In the left bundle branch block subgroup [70/124 (56%)] there was no between-criteria difference in TA.

Conclusion

The intra + interDC + TC predicts clinical response after CRT more accurately than TC alone, due to greater TA in the NICD subgroup.

Protein O-GlcNAcylation in Cardiac Pathologies: Past, Present, Future

O-GlcNAcylation is a ubiquitous and reversible post-translational protein modification that has recently gained renewed interest due to the rapid development of analytical tools and new molecules designed to specifically increase the level of protein O-GlcNAcylation. The level of O-GlcNAc modification appears to have either deleterious or beneficial effects, depending on the context (exposure time, pathophysiological context). While high O-GlcNAcylation levels are mostly reported in chronic diseases, the increase in O-GlcNAc level in acute stresses such as during ischemia reperfusion or hemorrhagic shock is reported to be beneficial in vitro, ex vivo, or in vivo. In this context, an increase in O-GlcNAc levels could be a potential new cardioprotective therapy, but the ambivalent effects of protein O-GlcNAcylation augmentation remains as a key problem to be solved prior to their transfer to the clinic. The emergence of new analytical tools has opened new avenues to decipher the mechanisms underlying the beneficial effects associated with an O-GlcNAc level increase. A better understanding of the exact roles of O-GlcNAc on protein function, targeting or stability will help to develop more targeted approaches. The aim of this review is to discuss the mechanisms and potential beneficial impact of O-GlcNAc modulation, and its potential as a new clinical target in cardiology.

Standard and reduced doses of dabigatran, rivaroxaban and apixaban for stroke prevention in atrial fibrillation: a nationwide cohort study

BACKGROUND

Comparative data of non-vitamin K antagonist oral anticoagulants (NOAC) are lacking in patients with atrial fibrillation (AF).

OBJECTIVE

We compared effectiveness and safety of standard and reduced dose NOAC in AF patients.

METHODS

Using Danish nationwide registries, we included all oral anticoagulant-naïve AF patients who initiated NOAC treatment (2012-2016). Outcome-specific and mortality-specific multiple Cox regressions were combined to compute average treatment effects as 1-year standardized differences in stroke and bleeding risks (g-formula).

RESULTS

Amongst 31 522 AF patients, the distribution of NOAC/dose was as follows: dabigatran standard dose (22.4%), dabigatran-reduced dose (14.0%), rivaroxaban standard dose (21.8%), rivaroxaban reduced dose (6.7%), apixaban standard dose (22.9%), and apixaban reduced dose (12.2%). The 1-year standardized absolute risks of stroke/thromboembolism were 1.73-1.98% and 2.51-2.78% with standard and reduced NOAC dose, respectively, without statistically significant differences between NOACs for given dose level. Comparing standard doses, the 1-year standardized absolute risk (95% CI) for major bleeding was for rivaroxaban 2.78% (2.42-3.17%); corresponding absolute risk differences (95% CI) were for dabigatran -0.93% (-1.45% to -0.38%) and apixaban, -0.54% (-0.99% to -0.05%). The results for major bleeding were similar for reduced NOAC dose. The 1-year standardized absolute risk (95% CI) for intracranial bleeding was for standard dose dabigatran 0.19% (0.22-0.50%); corresponding absolute risk differences (95% CI) were for rivaroxaban 0.23% (0.06-0.41%) and apixaban, 0.18% (0.01-0.34%).

CONCLUSIONS

Standard and reduced dose NOACs, respectively, showed no significant risk difference for associated stroke/thromboembolism. Rivaroxaban was associated with higher bleeding risk compared with dabigatran and apixaban and dabigatran was associated with lower intracranial bleeding risk compared with rivaroxaban and apixaban.

Beta-blockers for heart failure with reduced, mid-range, and preserved ejection fraction: an individual patient-level analysis of double-blind randomized trials

Aims

Recent guidelines recommend that patients with heart failure and left ventricular ejection fraction (LVEF) 40-49% should be managed similar to LVEF ≥ 50%. We investigated the effect of beta-blockers according to LVEF in double-blind, randomized, placebo-controlled trials.

Methods and results

Individual patient data meta-analysis of 11 trials, stratified by baseline LVEF and heart rhythm (Clinicaltrials.gov: NCT0083244; PROSPERO: CRD42014010012). Primary outcomes were all-cause mortality and cardiovascular death over 1.3 years median follow-up, with an intention-to-treat analysis. For 14 262 patients in sinus rhythm, median LVEF was 27% (interquartile range 21-33%), including 575 patients with LVEF 40-49% and 244 ≥ 50%. Beta-blockers reduced all-cause and cardiovascular mortality compared to placebo in sinus rhythm, an effect that was consistent across LVEF strata, except for those in the small subgroup with LVEF ≥ 50%. For LVEF 40-49%, death occurred in 21/292 [7.2%] randomized to beta-blockers compared to 35/283 [12.4%] with placebo; adjusted hazard ratio (HR) 0.59 [95% confidence interval (CI) 0.34-1.03]. Cardiovascular death occurred in 13/292 [4.5%] with beta-blockers and 26/283 [9.2%] with placebo; adjusted HR 0.48 (95% CI 0.24-0.97). Over a median of 1.0 years following randomization (n = 4601), LVEF increased with beta-blockers in all groups in sinus rhythm except LVEF ≥50%. For patients in atrial fibrillation at baseline (n = 3050), beta-blockers increased LVEF when < 50% at baseline, but did not improve prognosis.

Conclusion

Beta-blockers improve LVEF and prognosis for patients with heart failure in sinus rhythm with a reduced LVEF. The data are most robust for LVEF < 40%, but similar benefit was observed in the subgroup of patients with LVEF 40-49%.

Alternate Access for TAVI: Stay Clear of the Chest

Transcatheter aortic valve implantation (TAVI) is currently performed through an alternative access in 15% of patients. The transapical access is progressively being abandoned as a result of its invasiveness and poor outcomes. Existing data does not allow TAVI operators to favour one access over another - between transcarotid, trans-subclavian and transaortic - because all have specific strengths and weaknesses. The percutaneous trans-subclavian access might become the main surgery-free alternative access, although further research is needed regarding its safety. Moreover, the difficult learning curve might compromise its adoption. The transcaval access is at an experimental stage and requires the development of dedicated cavo-aortic crossing techniques and closure devices.

Echo- and B-Type Natriuretic Peptide-Guided Follow-Up versus Symptom-Guided Follow-Up: Comparison of the Outcome in Ambulatory Heart Failure Patients

Recent European Society of Cardiology and American Heart Association/American College of Cardiology Guidelines did not recommend biomarker-guided therapy in the management of heart failure (HF) patients. Combination of echo- and B-type natriuretic peptide (BNP) may be an alternative approach in guiding ambulatory HF management. Our aim was to determine whether a therapy guided by echo markers of left ventricular filling pressure (LVFP), lung ultrasound (LUS) assessment of B-lines, and BNP improves outcomes of HF patients. Consecutive outpatients with LV ejection fraction (EF) ≤ 50% have been prospectively enrolled. In Group I (n=224), follow-up was guided by echo and BNP with the goal of achieving E-wave deceleration time (EDT) ≥ 150 ms, tissue Doppler index E/e' < 13, B-line numbers < 15, and BNP ≤ 125 pg/ml or decrease >30%; in Group II (n=293), follow-up was clinically guided, while the remaining 277 patients (Group III) did not receive any dedicated follow-up. At 60 months, survival was 88% in Group I compared to 75% in Group II and 54% in Group III (χ ² 53.5; p < 0.0001). Survival curves exhibited statistically significant differences using Mantel-Cox analysis. The number needed to treat to spare one death was 7.9 (Group I versus Group II) and 3.8 (Group I versus Group III). At multivariate Cox regression analyses, major predictors of all-cause mortality were follow-up E/e' (HR: 1.05; p=0.0038) and BNP >125 pg/ml or decrease ≤30% (HR: 4.90; p=0.0054), while BNP > 125 pg/ml or decrease ≤30% and B-line numbers ≥15 were associated with the combined end point of death and HF hospitalization. Evidence-based HF treatment guided by serum biomarkers and ultrasound with the goal of reducing elevated BNP and LVFP, and resolving pulmonary congestion was associated with better clinical outcomes and can be valuable in guiding ambulatory HF management.

Bicuspid Aortic Valve Registry of the Italian Society of Echocardiography and Cardiovascular Imaging (REgistro della valvola aortica bicuspide della società italiana di ECocardiografia e CArdiovascular imaging): Rationale and Study Design

Background:

Bicuspid aortic valve (BAV) is the most common congenital heart disease, affecting 0.5%–2% of the general population. It is associated not only with notable valvular risk (aortic stenosis and/or regurgitation, endocarditis) but also with aortopathy with a wide spectrum of unpredictable clinical presentations, including aneurysmal dilation of the aortic root and/or ascending thoracic aorta, isthmic coarctation, aortic dissection, or wall rupture.

Methods:

The REgistro della Valvola Aortica Bicuspide della Società Italiana di ECocardiografia e CArdiovascular Imaging is a retrospective (from January 1, 2010)/prospective, multicenter, observational registry, expected to enroll 3000 patients with definitive diagnosis of BAV made by transthoracic and/or transesophageal echocardiography, computed tomography, cardiovascular magnetic resonance, or at surgery. Inclusion criteria were definitive diagnosis of BAV. Patients will be enrolled regardless of the presence and severity of aortic valve dysfunction or aortic vessel disease and the coexistence of other congenital cardiovascular malformations. Exclusion criteria were uncertain BAV diagnosis, impossibility of obtaining informed consent, inability to carry out the follow-up. Anamnestic, demographic, clinical, and instrumental data collected both at first evaluation and during follow-up will be integrated into dedicated software. The aim is to derive a data set of unselected BAV patients with the main purpose of assessing the current clinical presentation, management, and outcomes of BAV.

Conclusions:

A multicenter registry covering a large population of BAV patients could have a profound impact on the understanding of the natural history of this disease and could influence its management.

Prevalence of Non-valvular Atrial Fibrillation Based on Geographical Distribution and Socioeconomic Status in the Entire Korean Population

BACKGROUND AND OBJECTIVES

Prevalence of atrial fibrillation (AF) varies based on geographical location and socioeconomic status. We aimed to evaluate the prevalence of AF and utilization of antithrombotic therapy based on geographical regions and income levels in the entire Korean population.

METHODS

We performed a cross-sectional analysis of Korean adults (aged ≥20 years) using the 2015 National Health Insurance Service database (n=41,505,679). The study population was stratified into 17 geographical regions and 21 income levels.

RESULTS

We identified 276,842 patients diagnosed with AF. Overall prevalence of AF in suburban/rural regions was significantly higher than that observed in urban regions (0.72% vs. 0.61%, respectively, p<0.001). Elderly patients (age ≥75 years) showed a higher prevalence of AF and comorbidities related to AF development showed a higher prevalence among the population residing in suburban/rural regions. Among AF patients with a CHA₂DS₂-VASc score ≥2, oral anticoagulation (OAC) therapy utilization was lower in the suburban/rural regions than that observed in the urban regions (48.2% vs. 51.8%, respectively, p<0.001). The relationship between income levels and AF prevalence showed a J-shaped curve. The OAC prescription rate showed a positive correlation with income levels. Non-vitamin K antagonist oral anticoagulants tended to be more commonly prescribed among the higher income groups.

CONCLUSIONS

Geographical location of residence and income levels were closely associated with the prevalence of AF and antithrombotic therapy utilization. This information may provide further insights for more effective surveillance of AF and stroke prevention for improved clinical outcomes.

Imaging of Valvular Heart Disease in Heart Failure

Valvular heart disease (VHD) and heart failure (HF) are major health issues that are steadily increasing in prevalence in Western populations. VHD and HF frequently co-exist, which can complicate the accurate diagnosis of the severity of valve stenosis or regurgitation and affect decisions about therapeutic options. Transthoracic echocardiography is the first-line imaging modality to determine left ventricular (LV) systolic function, to grade valvular stenosis or regurgitation and to characterise the mechanism underlying valvular dysfunction. 3D transoesophageal echocardiography, cardiovascular magnetic resonance and cardiac CT are alternative imaging modalities that help in the diagnosis of patients with HF and VHD. The integration of multimodality cardiovascular imaging is important when deciding whether the patient should receive transcatheter aortic valve repair and replacement therapies. In this article, the use of multimodality imaging to diagnose and treat patients with VHD and HF is reviewed.

Renal function monitoring in heart failure - what is the optimal frequency? A narrative review

The second most common cause of hospitalization due to adverse drug reactions in the UK is renal dysfunction due to diuretics, particularly in patients with heart failure, where diuretic therapy is a mainstay of treatment regimens. Therefore, the optimal frequency for monitoring renal function in these patients is an important consideration for preventing renal failure and hospitalization. This review looks at the current evidence for optimal monitoring practices of renal function in patients with heart failure according to national and international guidelines on the management of heart failure (AHA/NICE/ESC/SIGN). Current guidance of renal function monitoring is in large part based on expert opinion, with a lack of clinical studies that have specifically evaluated the optimal frequency of renal function monitoring in patients with heart failure. Furthermore, there is variability between guidelines, and recommendations are typically nonspecific. Safer prescribing of diuretics in combination with other antiheart failure treatments requires better evidence for frequency of renal function monitoring. We suggest developing more personalized monitoring rather than from the current medication-based guidance. Such flexible clinical guidelines could be implemented using intelligent clinical decision support systems. Personalized renal function monitoring would be more effective in preventing renal decline, rather than reacting to it.

Iron Therapy in Heart Failure: Ready for Primetime?

There is an increasing awareness of the prevalence of iron deficiency (ID) in patients with heart failure (HF) and its contributory role in the morbidity and mortality of HF. It is important to note that many HF patients have ID without being anaemic, hence it is vital to screen for ID even in patients with haemoglobin within the normal laboratory range. This review summarises the pathophysiology and epidemiology of ID in HF before discussing the evidence for iron replacement therapy in HF patients. Finally, it discusses the ongoing large outcome trials evaluating iron replacement in HF.

Precision Medicine and Personalized Medicine in Cardiovascular Disease

Precision medicine aims to offer "the right treatment to the right patient at the right time." In cardiovascular medicine the potential of precision medicine applies to all stages of the disease development and includes risk prediction, preventative measures, and targeted therapeutic approaches. Precision medicine will benefit from new developments in the area of genomics and other omics but equally heavily depends on established biomarkers, functional tests, and imaging. Cardiovascular medicine often relies on noninvasive diagnostic procedures and symptom-based disease management. In contrast, other clinical disciplines including oncology and immunology have already moved to molecular diagnostics that lend themselves to precision medicine approaches. There are opportunities to implement precision medicine approaches by focusing on common diseases such as hypertension, conditions with diagnostic and prognostic uncertainty such as angina, and conditions that are associated with high mortality and involve costly and potentially harmful interventions such as dilated cardiomyopathy and cardiac resynchronization therapy. Sex and gender issues have not yet been fully explored in precision medicine although the opportunity to use molecular data to more accurately manage men and women with cardiovascular disease has been acknowledged. A mindshift is required in order to fully exploit the potential of precision medicine to tackle the global burden of cardiovascular diseases.

The Role of Nutritional Status in Elderly Patients with Heart Failure

Evidence indicates that malnutrition very frequently co-occurs with chronic heart failure (HF) and leads to a range of negative consequences. Studies show associations between malnutrition and wound healing disorders, an increased rate of postoperative complications, and mortality. In addition, considering the increasing age of patients with HF, a specific approach to their treatment is required. Guidelines proposed by the European Society of Cardiology (ESC) for treating acute and chronic HF refer to the need to monitor and prevent malnutrition in HF patients. However, the guidelines feature no strict nutritional recommendations for HF patients, who are at high nutritional risk as a group, nor do they offer any such recommendations for the poor nutritional status subgroup, for which high morbidity and mortality rates have been observed. In the context of multidisciplinary healthcare, recommended by the ESC and proven by research to offer multifaceted benefits, nutritional status should be systematically assessed in HF patients. Malnutrition has become a challenge within healthcare systems and day-to-day clinical practice, especially in developed countries, where it affects the course of disease and patients' prognosis.

Transcatheter Aortic Valve Replacement and Cardiac Resynchronization Therapy in Cancer-Related Cardiotoxicity

Cardiotoxicity related to antineoplastic agents is a rising and growing issue, therefore early recognition and prompt management can impact on the overall prognosis of cancer patients. We report the case of a 70-year-old woman without cardiovascular risk factors, with a medical history of non-Hodgkin lymphoma and chronic myeloid leukemia treated with chemotherapy and radiotherapy, who underwent transcatheter aortic valve replacement for severe aortic stenosis and cardiac resynchronization therapy for further development of complete left bundle branch block, with a significant improvement of her functional status and left ventricle systolic function in a long-term follow-up.

Prognostic Significance of Left Axis Deviation in Acute Heart Failure Patients with Left Bundle branch block: an Analysis from the Korean Acute Heart Failure (KorAHF) Registry

Background and Objectives

The prognostic impact of left axis deviation (LAD) on clinical outcomes in acute heart failure syndrome (AHFS) with left bundle branch block (LBBB) is unknown. The aim of this study was to determine the prognostic significance of axis deviation in acute heart failure patients with LBBB.

Methods

Between March 2011 and February 2014, 292 consecutive AHFS patients with LBBB were recruited from 10 tertiary university hospitals. They were divided into groups with no LAD (n=189) or with LAD (n=103) groups according to QRS axis <−30 degree. The primary outcome was all-cause mortality.

Results

The median follow-up duration was 24 months. On multivariate analysis, the rate of all-cause death did not significantly differ between the normal axis and LAD groups (39.7% vs. 46.6%, adjusted hazard ratio, 1.01; 95% confidence interval, 0.66, 1.53; p=0.97). However, on the multiple linear regression analysis to evaluate the predictors of the left ventricular ejection fraction (LVEF), presence of LAD significantly predicted a worse LVEF (adjusted beta, −3.25; 95% confidence interval, −5.82, −0.67; p=0.01). Right ventricle (RV) dilatation was defined as at least 2 of 3 electrocardiographic criteria (late R in lead aVR, low voltages in limb leads, and R/S ratio <1 in lead V₅) and was more frequent in the LAD group than in the normal axis group (p<0.001).

Conclusions

Among the AHFS with LBBB patients, LAD did not predict mortality, but it could be used as a significant predictor of worse LVEF and RV dilatation (Trial registry at KorAHF registry, ClinicalTrial.gov, NCT01389843).

Updated clinical overview on cardiac laminopathies: an electrical and mechanical disease

Cardiac laminopathies, associated with mutations in the LMNA gene, encompass a wide spectrum of clinical manifestations, involving electrical and mechanical alterations of cardiomyocytes. Thus, dilated cardiomyopathy, bradyarrhythmias and atrial or ventricular tachyarrhythmias may occur in a number of combined phenotypes. Nowadays, some attempt has been made to identify clinical predictors for the most life-threatening complications of LMNA-associated heart disease, i.e. sudden cardiac death and end-stage heart failure. The goal of this manuscript is to combine the most recent evidences in an updated review to show the state-of-the-art of such a complex disease group. This is supposed to be the starting point to collect more data and design new ad hoc studies to identify clinically useful predictors to stratify risk in mutation carriers, including probands and their asymptomatic relatives.

Heart Failure with Mid-range Ejection Fraction: Lessons from CHARM

The newly defined category of heart failure (HF) with mid-range ejection fraction (HFmrEF; EF 40-49 %) is beginning to be characterised but little is known about the potential for treating it. Trials and observational studies suggest that standard therapy for HF with reduced ejection fraction (HFrEF; EF <40 %) may also offer some benefit to patients with EF ≥40 %; however, any difference between its effects on HFmrEF and true HF with preserved ejection fraction (HFpEF) have until now not been explored. This study summarises randomised trial data from the CHARM programme that suggest that candesartan may improve outcomes in HFmrEF.

First-in-man implantation of the retrievable and repositionable VenusA-Plus valve

BACKGROUND

No retrievable and repositionable second generation transcatheter aortic valve is available in China. Here, we report the first-in-man implantation of the retrievable and repositionable VenusA-Plus valve.

METHODS

A 76-year-old patient with symptomatic severe aortic stenosis and high surgical risk (STS 13.8%) was recommended for transcatheter aortic valve replacement (TAVR) by heart valve team. Type 0 bicuspid aortic valve with asymmetric calcification was identified by dual source computed tomography, and the unfavorable anatomies increased the possibility of malposition and paravalvular leakage during TAVR. Therefore, we used the retrievable and repositionable VenusA-Plus valve for the patient.

RESULTS

Transfemoral TAVR was performed under local anesthesia with sedation, and a 26mm VenusA-Plus valve was successfully implanted. No transvalvular pressure gradient and trace paravalvular leakage were found.

CONCLUSION

The successful first-in-man implantation indicates the retrievable and repositionable VenusA-Plus valve is feasible in complicated TAVR cases such as bicuspid aortic valve.

Cardiolaminopathies from bench to bedside: challenges in clinical decision-making with focus on arrhythmia-related outcomes

Lamin A/C gene mutations can be associated with cardiac diseases, usually referred to as 'cardiolaminopathies' characterized by arrhythmic disorders and/or left ventricular or biventricular dysfunction up to an overt picture of heart failure. The phenotypic cardiac manifestations of laminopathies are frequently mixed in complex clinical patterns and specifically may include bradyarrhythmias (sinus node disease or atrioventricular blocks), atrial arrhythmias (atrial fibrillation, atrial flutter, atrial standstill), ventricular tachyarrhythmias and heart failure of variable degrees of severity. Family history, physical examination, laboratory findings (specifically serum creatine phosphokinase values) and ECG findings are often important 'red flags' in diagnosing a 'cardiolaminopathy'. Sudden arrhythmic death, thromboembolic events or stroke and severe heart failure requiring heart transplantation are the most dramatic complications of the evolution of cardiolaminopathies and appropriate risk stratification is clinically needed combined with clinical follow-up. Treatment with cardiac electrical implantable devices is indicated in case of bradyarrhythmias (implant of a device with pacemaker functions), risk of life-threatening ventricular tachyarrhythmias (implant of an ICD) or in case of heart failure with wide QRS interval (implant of a device for cardiac resynchronization). New technologies introduced in the last 5 years can help physicians to reduce device-related complications, thanks to the extension of device longevity and availability of leadless pacemakers or defibrillators, to be implanted in appropriately selected patients. An improved knowledge of the complex pathophysiological pathways involved in cardiolaminopathies and in the determinants of their progression to more severe forms will help to improve clinical management and to better target pharmacological and non-pharmacological treatments.

Early Surgery in Valvular Heart Disease

The burden of valvular heart disease (VHD) is increasing with age, and the elderly patients with moderate or severe VHD are notably common. When to operate in asymptomatic patients with VHD remains controversial. The controversy is whether early surgical intervention should be preferred, or a watchful waiting approach should be followed. The beneficial effects of early surgery should be balanced against operative mortality and long-term results. Indications of early surgery in each of the VHD will be discussed in this review on the basis of the latest American and European guidelines.

Left Atrial Appendage Closure Devices for Stroke Prevention in Patients with Non-Valvular AF

The left atrial appendage (LAA) may be involved in offloading atrial pressure during left ventricular systole. As ventricular rate increases, LAA emptying decreases during early diastole causing increased risk of thrombus formation particularly in patients with non-valvular AF (NVAF). The LAA is the site of thrombus formation in more than 90 % of patients with NVAF, so is an important target for thromboembolic prophylaxis in these patients. Anticoagulation therapy is used to treat NVAF, but it has long-term complications and may be contraindicated in some patients. Therefore, alternative strategies to reduce embolic risk in patients with AF have been developed. These include percutaneous, thoracoscopic, and open closure strategies. This study reviews the safety and efficacy of these strategies, comparing these approaches and devices with pharmacological strategies. There is little data to endorse one strategy over another. Given the minimal evidence available, recommendations in support of LAA occlusion remain weak and guidelines have called for more research and coding of endpoints for this emerging technology.

The Heart Valve Clinic at the Heart Hospital in Doha, Qatar: An Evidence-Based Standard of Care

The incidence of degenerative heart valve disease is rising in developing countries and diagnosis, assessment and management are becoming increasingly complex. The availability of new interventional procedures has further expanded the therapeutic armamentarium, but at the same time, it has increased the proportion of high-risk patients, in whom risk-benefit analysis and the choice of the most appropriate therapy are particularly difficult. Accordingly, international societies have recommended dedicated heart valve clinics (HVCs) to meet these needs. The HVC is a specialist outpatient clinic linked with multidisciplinary inpatient care as well as education and training. The main functions of the HVC are to confirm and refine the diagnosis of heart valve disease, follow patients and to determine the correct timing of referral to the appropriate heart valve team. We report on why an HVC was set up at the Heart Hospital in Doha, Qatar.

Treatment of Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is a growing epidemiologic problem affecting more than half of the patients with heart failure (HF). HFpEF has a significant morbidity and mortality and so far no treatment has been clearly demonstrated to improve the outcomes in HFpEF, in contrast to the efficacy of treatment in heart failure with reduced ejection fraction (HFrEF).The failure of proven beneficial drugs in HFrEF to influence the outcome of patients with HFpEF could be related to the heterogeneity of the disease, its various phenotypes and multifactorial pathophysiology, incompletely elucidated yet. The diagnosis of HFpEF could be demanding or even inaccurate. Moreover, the therapeutic strategies were influenced by different cut-offs used to define preserved ejection fraction (EF). From this perspective, the current guidelines have classified HFpEF by an EF ≥ 50%, together with a distinct entity, heart failure with mid-range ejection fraction (HFmrEF), defined by an EF ranging from 41-49%.New therapies have been developed to interfere with the mediator pathways of HFpEF at the cellular and molecular level, including mineralocorticoid receptor antagonists, soluble guanylate cyclase stimulators, or angiotensin receptor-neprilysin inhibitors. A number of antidiabetic drugs, such as sodium/glucose cotransporter 2 inhibitors and dipeptidyl peptidase-4 inhibitors are promising options, being under research in large clinical trials. Until the results of ongoing trials shed light on these therapies, guidelines recommend empirical treatment for established HFpEF, and emphasize the crucial role of addressing cardiovascular comorbidities leading to HFpEF, in particular arterial hypertension.

Effects of incretin treatment on cardiovascular outcomes in diabetic STEMI-patients with culprit obstructive and multivessel non obstructive-coronary-stenosis

BACKGROUND

No proper data on prognosis and management of type-2 diabetic ST elevation myocardial infarction (STEMI) patients with culprit obstructive lesion and multivessel non obstructive coronary stenosis (Mv-NOCS) exist. We evaluated the 12-months prognosis of Mv-NOCS-diabetics with first STEMI vs.to non-diabetics, and then Mv-NOCS-diabetics previously treated with incretin based therapy vs. a matched cohort of STEMI-Mv-NOCS never treated with such therapy.

METHODS

1088 Patients with first STEMI and Mv-NOCS were scheduled for the study. Patients included in the study were categorized in type 2 diabetics (n 292) and non-diabetics (n 796). Finally, we categorized diabetics in current-incretin-users (n 76), and never-incretin-users (n 180). The primary end point was all cause deaths, cardiac deaths, and major adverse cardiac events (MACE) at 12 months of follow up.

RESULTS

The study results evidenced higher percentage of all cause deaths (2.2% vs. 1.1%, p value 0.05), cardiac deaths (1.6% vs. 0.5%, p value 0.045), and MACE (12.9% vs. n 5.9%), p value 0.001) in diabetic vs. no diabetic patients at 12 months follow up. Among diabetic patients, the current vs never-incretin-users, did not present a significant difference about all cause of deaths, and cardiac deaths through 12-months. The MACE rate at 1 year was 7.4% in diabetic incretin-users STEMI Mv-NOCS patients vs. 12.9% in diabetic never-incretin-users STEMI-Mv-NOCS patients (p value 0.04). In a risk-adjusted hazard analysis, MACE through 12 months were lower in diabetic STEMI-Mv NOCS incretin-users vs never-incretin-users patients (HR 0.513, CI [0.292-0.899], p 0.021). Consequently, lower levels of glucagon-like peptide 1(GLP-1) were predictive of MACE at follow up (HR 1.528, CI [1.059-2.204], p 0.024).

CONCLUSION

In type 2 diabetic patients with STEMI-Mv-NOCS, we observed higher incidence of 1-year mortality and adverse cardiovascular outcomes, as compared to non-diabetic STEMI-Mv-NOCS patients. In diabetic patients, never-incretin-users have worse prognosis as compared to current-incretin-users.Trail registration Clinical trial number: NCT03312179, name of registry: clinicaltrialgov, URL: clinicalltrialgov.com, date of registration: September 2017, date of enrollment first participant: September 2009.

Risk Factor Management in Atrial Fibrillation

Atrial fibrillation (AF) is the most common clinical arrhythmia and is associated with increased morbidity and mortality. There is growing evidence that numerous cardiovascular diseases and risk factors are associated with incident AF and that lone AF is rare. Beyond oral anticoagulant therapy, rate and rhythm control, therapy targeting risk factors and underlying conditions is an emerging AF management strategy that warrants better implementation in clinical practice. This review describes current evidence regarding the association between known modifiable risk factors and underlying conditions and the development and progression of AF. It discusses evidence for the early management of underlying conditions to improve AF outcomes. It also provides perspective on the implementation of tailored AF management in daily clinical practice.