Data-Driven Approach to Identify Subgroups of Heart Failure With Reduced Ejection Fraction Patients With Different Prognoses and Aldosterone Antagonist Response Patterns

BACKGROUND

Patients with heart failure with reduced ejection fraction have a poor prognosis. The identification of subgroups with different outcomes and treatment response patterns may help to tailor strategies to each individual patient. We present an exploratory study of patients enrolled in the EMPHASIS-HF trial (Eplerenone in Patients With Systolic Heart Failure and Mild Symptoms) using latent class analysis with validation using the EPHESUS trial (Eplerenone, a Selective Aldosterone Blocker, in Patients With Left Ventricular Dysfunction After Myocardial Infarction) to identify subgroups of patients with different prognosis and response to eplerenone therapy.

METHODS AND RESULTS

Latent class analysis identifies mutually exclusive groups of individuals maximizing within-group similarities and between-group differences. In the EMPHASIS-HF trial, 2279 heart failure with reduced ejection fraction patients were randomized to eplerenone or placebo and were characterized according to 18 clinical features. Subgroup definitions were applied to 6472 patients enrolled in the EPHESUS trial to validate observations. Event-free survival and effect of eplerenone on the composite of cardiovascular death and heart failure hospitalization were determined for each subgroup. Four subgroups were identified with significant differences in event-free survival (P=0.002). The subgroup C had the worst event-free survival in both studies and was characterized by older age, lower body mass index, worse renal function, higher baseline potassium levels, high prevalence of anemia, diabetes mellitus, previous revascularization and higher rates of eplerenone discontinuation, and hyperkalemia during follow-up. Two subgroups (B and C) showed a poorer response to eplerenone in both studies and these groups shared common features such as lower body mass index and high prevalence of anemia. Clinical profiles, prognosis, and treatment response patterns of the 4 subgroups applied in EPHESUS trial presented similarities to those observed in EMPHASIS.

CONCLUSIONS

Using a data-driven approach, we identified heart failure with reduced ejection fraction subgroups with significantly different prognoses and potentially different responses to eplerenone. However, these data should be regarded as hypothesis-generating and prospective validation is warranted, to assess the potential clinical implications of these subgroups.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00232180.

Detrimental Impact of Chronic Obstructive Pulmonary Disease in Atrial Fibrillation: New Insights from Umbria Atrial Fibrillation Registry

Background and objectives: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Among extra-pulmonary manifestations of COPD, atrial fibrillation (AF) is commonly observed in clinical practice. The coexistence of COPD and AF significantly affects the risk of cardiovascular morbidity and mortality. Nonetheless, the mechanisms explaining the increased risk of vascular events and death associated to the presence of COPD in AF are complex and not completely understood. We analyzed data from an Italian network database to identify markers and mediators of increased vascular risk among subjects with AF and COPD. Materials and Methods: Cross-sectional analysis of the Umbria Atrial Fibrillation (Umbria-FA) Registry, a multicenter, observational, prospective on-going registry of patients with non-valvular AF. Of the 2205 patients actually recruited, 2159 had complete clinical data and were included in the analysis. Results: the proportion of patients with COPD was 15.6%. COPD patients had a larger proportion of permanent AF when compared to the control group (49.1% vs. 34.6%, p < 0.0001) and were more likely to be obese and current smokers. Other cardiovascular risk factors including chronic kidney disease (CKD), peripheral artery disease and subclinical atherosclerosis were more prevalent in COPD patients (all p < 0.0001). COPD was also significantly associated with higher prevalence of previous vascular events and a history of anemia (all p < 0.0001). The thromboembolic and bleeding risk, as reflected by the CHA2DS2VASc and HAS-BLED scores, were higher in patients with COPD. Patients with COPD were also more likely to have left ventricular (LV) hypertrophy at standard ECG than individuals forming the cohort without COPD (p = 0.018). Conclusions: AF patients with COPD have a higher risk of vascular complications than AF patients without this lung disease. Our analysis identified markers and mediators of increased risk that can be easily measured in clinical practice, including LV hypertrophy, CKD, anemia, and atherosclerosis of large arteries.

Long-Term Survival after Acute Myocardial Infarction in Lithuania during Transitional Period (1996-2015): Data from Population-Based Kaunas Ischemic Heart Disease Register

Background and Objective: There is a lack of reliable epidemiological data on the long-term survival after acute myocardial infarction (AMI) in the Lithuanian population. The aim of the study was to evaluate the long-term (36 months) survival after AMI among persons aged 25–64 years, who had experienced AMI in four time-periods 1996, 2003–2004, 2008, and 2012. Material and Methods: The source of the data was Kaunas population-based Ischemic heart disease (IHD) register. Long-term survival after AMI (36 months) was evaluated using the Kaplan–Meier method. The survival curves significantly differed when p < 0.05. Hazard ratio for all-cause mortality and their 95% CIs, adjusted for baseline characteristics, were estimated with the Cox proportional hazards regression model. Results: The analysis of data on 36 months long-term survival among Kaunas population by sex and age groups showed that the survival rates among men and women were 83.4% and 87.6%, respectively (p < 0.05) and among 25–54 years-old and 55–64 years-old persons, 89.2% and 81.7%, respectively (p < 0.05). The rates of long-term survival of post-AMI Kaunas population were better in past periods than in first period. According to the data of the Kaplan-Meier survival analysis, long-term survival of 25 to 64-year-old post-AMI Kaunas population was without significantly difference in 1996, 2003–2004, 2008 and 2012 (Log-rank = 6.736, p = 0.081). The adjusted risk of all-cause mortality during 36 months among men and 25 to 54-year-old patients was on the average by 35% and 60% lower in 2012 than in 1996, respectively. Conclusion: It was found that 36 months survival post MI among women and younger (25–54 years) persons was significant better compared to men and older (55–64 years) persons. Long-term survival among 55 to 64-year-old post-AMI Kaunas population had a tendency to decrease during last period, while among 25–54 years old persons long-term survival was without significant changes. The results highlight the fact that AMI survivors, especially in youngest age, remain a high-risk group and reinforce the importance of primary and secondary prevention for the improvement of long-term prognosis of AMI patients.

Outcomes after surgery for functional tricuspid regurgitation: a systematic review and meta-analysis

Aims 

This study aims to provide a contemporary overview of outcomes after tricuspid valve (TV) surgery for functional tricuspid regurgitation (TR).

Methods and results 

The literature was systematically searched for papers published between January 2005 and December 2017 reporting on clinical/echocardiographic outcomes after TV surgery for functional TR. A random effects meta-analysis was conducted for outcome variables, and late outcomes are visualized by pooled Kaplan–Meier curves. Subgroup analyses were performed for studies with a within-study comparison of suture vs. ring repair and flexible vs. rigid ring repair. Eighty-seven publications were included, encompassing 13 184 patients (mean age: 62.1 ± 11.8 years, 55% females). A mitral valve procedure was performed in 92% of patients. Pooled mean follow-up was 4.0 ± 2.8 years. Pooled early mortality was 3.9% (95% CI: 3.2–4.6), and late mortality rate was 2.7%/year (95% CI: 2.0–3.5), of which approximately half was cardiac-related 1.2%/year (95% CI: 0.8–1.9). Pooled risk of early moderate-to-severe TR at discharge was 9.4% (95% CI: 7.0–12.1). Late moderate-to-severe TR rate after discharge was 1.9%/year (95% CI: 1.0–3.5). Late reintervention rate was 0.3%/year (95% CI: 0.2–0.4). Mortality and overall (early and late) TR rate were comparable between suture vs. ring annuloplasty (14 studies), whereas overall TR rate was higher after flexible ring vs. rigid ring annuloplasty (6 studies) (7.5%/year vs. 3.9%/year, P = 0.002).

Conclusion 

This study shows that patients undergoing surgery for functional tricuspid regurgitation (FTR) have an acceptable early and late mortality. However, TR remains prevalent after surgery. The results of this study can be used to inform patients and clinicians about the expected outcome after surgery for FTR and can results serve as a benchmark for the performance of emerging transcatheter TV interventions.

Impact of stroke volume on severe aortic stenosis in patients with normal left ventricular function

BACKGROUND

Low-flow (LF) aortic stenosis (AS) with a normal ejection fraction reportedly has a worse prognosis than normal-flow (NF) AS. We assessed whether the stroke volume affects early- and long-term survival of patients with AS undergoing aortic valve replacement.

METHODS AND RESULTS

From 2007 to 2016, 179 patients with AS and a normal ejection fraction (≥ 50%) and without other valve diseases were divided into two groups according to the stroke volume index (SVI): NF group (SVI ≥ 35 ml/m², n = 167) and LF group (SVI < 35 ml/m², n = 12). Early- and long-term survival was compared between the two groups. Preoperative echocardiography showed that the end-diastolic diameter and aortic valve area were smaller in the LF than NF group (43 ± 1.9 vs. 48 ± 0.4 mm, p < 0.005 and 0.33 ± 0.14 vs. 0.49 ± 0.14 cm²/m², p < 0.0005, respectively). Hospital mortality was significantly higher (16.7% vs. 1.8%, p < 0.05) and 5-year overall survival was lower (58 ± 17 vs. 84 ± 4.2 months, p < 0.005) in the LF than NF group.

CONCLUSION

Patients with LF AS had worse operative and long-term outcomes than those with NF, even though they had preserved LV function.

Right Transaxillary Transcatheter Aortic Valve Replacement Using the "Flip-n-Flex" Technique

BACKGROUND

Right transaxillary transcatheter aortic valve replacement (TAx-TAVR) is rarely performed due to challenging vascular tortuosity and unfavorable implantation angles. We explored this procedure using the newer-generation balloon-expandable SAPIEN 3 (Edwards Lifesciences, Irvine, CA) valve and our novel "flip-n-flex" technique. The safety and effectiveness of the procedure and the learning curve of our early experiences were investigated.

METHODS

The first 10 consecutive patients undergoing right TAx-TAVR performed at our center from June 2016 to May 2018 were included in the study. Patients' preoperative characteristics, procedural outcomes, and clinical outcomes were studied. Intraoperative fluoroscopy times were also reviewed to analyze the procedural learning curve.

RESULTS

The 10 patients were a mean age of 81.8 ± 8.7 years, and 5 patients (50%) were women. Mean Society of Thoracic Surgeons Predicted Risk of Mortality was 12.0% ± 9.5%. Procedural success was achieved in all cases without vascular complications. Paravalvular leak was absent or mild in all patients. Two patients (20%) required permanent pacemaker implantation. The median postoperative length of stay was 4 days (range, 2-13 days). The 30-day mortality was 0%. Mean transvalvular gradient improved from 38.4 ± 12.6 mm Hg to 9 ± 4.4 mm Hg postoperatively. New York Heart Association Functional Classification improved in all patients. The fluoroscopy time showed marked reduction from 44.1 ± 8.2 minutes to 17.4 ± 2.9 minutes with the use of the flip-n-flex technique.

CONCLUSIONS

Our early experience of right TAx-TAVR with the SAPIEN 3 valve demonstrated satisfactory outcomes and a quick learning as facilitated by the flip-n-flex technique. This could be a beneficial TAVR approach to suitable patients.

Poor long-term outcomes after carotid endarterectomy: a retrospective analysis of two portuguese centers

Objetives. Carotid endarterectomy (CEA) is an established treatment for carotid stenosis (CS). However, this procedure is not risk-free and it is insufficient to control disseminated atherosclerosis. Our aim was to determine long-term cardiovascular morbidity and mortality after CEA and identify associated risk predictors. Design. Consecutive cohorts of CEAs performed between 2010 and 2018 in two Portuguese hospitals were retrospectively analysed. The major end-points were acute myocardial infarction (AMI), stroke, all-cause death and major adverse cardiovascular events (MACE). Results. 248 patients (mean age 69 years; 79% male) were enrolled in the study. 24% had postoperative complications. At 52 months median follow-up, 9 ± 2.0% (mean ± standard error) of patients experienced an acute myocardial infarction (AMI), 12 ± 2.4% a stroke and 26 ± 3.2% a MACE. All-cause mortality rate was 21 ± 3.0%. Multivariate analysis identified coronary artery disease (CAD) as significant predictor of AMI (p < .001; Hazard Ratio (HR):9.628; 95% Confidence Interval (95%CI):2.805-33.046), whereas no statistically significant risk factor of stroke was found. Predictors of death included left sided CS (p = .042; HR:1.886; 95%CI:1.024-3.475), chronic kidney disease (CKD) (p = .007; HR:2.352; 95%CI:1.266-4.372) and anticoagulant medication (p = .015; HR:2.107; 95%CI:1.216-6.026), while statin use was significantly protective (p = .049; HR:0.482; 95%CI:0.233-0.998). Concerning MACE, male gender (p = .040; HR:1.709; 95%CI:1.025-2.849), tobacco use (p = .004; HR:2.181; 95%CI:1.277-3.726), CAD (p = .002; HR:2.235; 95%CI:1.340-3.727) and CKD (p < .001; HR:3.029; 95%CI:1.745-5.258) were risk predictors. Conclusions. Patients continue to have high rates of AMI, MACE and death after CEA. Prior CAD is a risk factor for future AMI, whereas CKD is a significant predictor of MACE and death. Aggressive best medical treatment and risk factors modification should be advised in all patients with systemic atherosclerosis.

Triple, dual, and single antithrombotic therapy for patients with atrial fibrillation undergoing percutaneous coronary intervention

In patients with atrial fibrillation (AF), concomitant coronary artery disease is often present, and vice versa. Although both AF and coronary artery disease need antithrombotic therapy to reduce ischemic events, optimal antithrombotic regimens for patients with AF undergoing percutaneous coronary intervention (PCI) remain unclear. Triple therapy, a combination of oral anticoagulant plus dual antiplatelet therapy with aspirin and P2Y₁₂ inhibitor, has been used for patients with AF undergoing PCI as an initial antithrombotic strategy in the recent decade. However, triple therapy is well-known to induce severe bleeding events. Recently, several clinical trials have been published and guideline recommendations have been updated. This review article summarizes current evidence concerning antithrombotic therapy in patients with AF undergoing PCI.

Effects of Exercise-Based Cardiac Rehabilitation in Patients with Acute Coronary Syndrome: A Meta-Analysis

BACKGROUND Acute coronary syndrome (ACS) has become an important cause of death from cardiovascular disease. Cardiac rehabilitation (CR) plays an essential role in ACS patients after treatment. Therefore, in order to detect the impact of CR on mortality and major adverse cardiac events in patients with ACS, we conducted this meta-analysis. MATERIAL AND METHODS We searched PubMed, Web of science, and EMBASE databases to obtain published research results from 2010 to August 2018 to determine the relevant research. Random-effects model or fixed-effects model were used to calculate relative risk (RR) and 95% confidence interval (CI). RESULTS Overall, a total of 25 studies with 55 035 participants were summarized in our meta-analysis. The results indicated that the hazard ratio (HR) of mortality significantly lower in the CR group than in the non-CR group (HR=-0.47; 95% CI=(-0.56 to -0.39; P<0.05). Fourteen studies on mortality rate showed exercise was associated with reduced cardiac death rates (RR=0.40; 95% CI=0.30 to 0.53; P<0.05). We found the risk of major adverse cardiac events (MACE) was lower in the rehabilitation group (RR=0.49; 95% CI=0.44 to 0.55; P<0.05). In 11 articles on CR including 8098 participants, the benefit in the CR group was greater than in the control group concerning revascularization (RR=0.69, 95% CI: 0.53 to 0.88; P=0.003). The recurrence rate of MI was reported in 13 studies, and the risk was lower in the CR group (RR=0.63, 95% CI: 0.57-0.70; P<0.05). CONCLUSIONS Our meta-analysis results suggest that CR is clearly associated with reductions in cardiac mortality, recurrence of MI, repeated PCI, CABG, and restenosis.

Iatrogenic Arteriovenous Fistula and Atrial Septal Defect Following Cryoballoon Ablation for Atrial Fibrillation - Two Correctable Causes of Right Heart Failure

Patient: Female, 61

Final Diagnosis: Iatrogenic arteriovenous fistula and atrial septal defect following cryoballoon ablation for atrial fibrillation

Symptoms: Exercise intolerance • exertional dyspnea • peripheral edema

Medication: —

Clinical Procedure: Catheter ablation for persistent atrial fibrillation, corrective surgery for arteriovenous fistula

Specialty: Cardiology

Modern Concepts of Fibromuscular Dysplasia of the Coronary Arteries

Fibromuscular dysplasia of the coronary arteries is a rare non-atherosclerotic and non-inflammatory vascular lesion that is asymptomatic until serious complications develop: stenosis, dissection, rupture, sudden cardiac death. Since there are no long-term numerous clinical observations of patients with fibromuscular dysplasia of the coronary arteries, recommendations have not been developed for diagnosing and treating the disease, which often manifests with acute coronary syndrome. In 2014, the European Consensus was published, and in 2019, the first international consensus document on the diagnosis and treatment of fibromuscular dysplasia with lesions of vessels from different regions (renal, cerebrovascular, coronary, and others). The documents state that the development of fibromuscular dysplasia of the coronary arteries considers the participation of the PHACTR1 gene mutation and the transcriptional activity of the EDN1 gene, smoking, prolonged exertion of the vascular wall, and possibly female sex hormones. In the case of acute coronary syndrome, the most informative diagnostic method is computed tomography with angiography, which reveals a smooth narrowing of the lumen in the middle or distal section in the epicardial artery, often due to intramural hematoma, and also finds dissection, spasm, and tortuous vessel. Additional diagnostic methods ‒ intravascular ultrasound and optical coherence tomography allow differentiation of fibromuscular dysplasia with atherosclerosis of the coronary artery, vasculitis, and other diseases. The choice of treatment tactics for fibromuscular dysplasia of the coronary arteries depends on the severity of the clinical manifestations ‒ conservative medical treatment and interventional methods are used.

Features of Thromboembolic and Hemorrhagic Complications in Planned Surgical Interventions in Patients with Atrial Fibrillation

Aim. To study the frequency and characteristics of the development of thromboembolic and hemorrhagic complications in patients with atrial fibrillation (AF) during planned surgical interventions.Material and methods. Preoperative examination and postoperative observation of 214 patients with AF (139 men and 75 women) who received anticoagulant therapy (ACT) and underwent planned surgery was carried out. The consistency of the used perioperative ACT regimens when performing interventions with current international recommendations was analyzed.Results. Complications developed in 33 patients (15.4%) from the total sample of 214 patients: in 14 (6.5%) thromboembolism, in 19 (8.9%) hemorrhagic complications. Analysis of the complication frequency in various types of surgical interventions showed that the frequency of thromboembolism during heart and vascular operations was 9.8% (4 cases), with interventions for malignant tumors – 7 (6.2%), while performing general surgical abdominal tumors operations – 3 (5.0%). The frequency of bleeding was maximum during operations for cancer 18.6%, this value was significantly higher compared with the frequency of these complications when performing general surgical abdominal operations – 3 cases (5.0%), and during interventions on the heart and vascular vessels bleedings were not observed. The total frequency of complications was also maximal when performing interventions for malignant tumors – 24.8%. This value was significantly higher than in the groups of patients who underwent general surgical abdominal operations – 10.0%, and interventions on the heart and vessels – 9.8%. Analysis of the frequency of compliance with the recommendations of the European Society of Cardiology in terms of ACT usage in patients with AF in the perioperative period and the structure of errors in choosing the ACT regimen showed that among the examined patients the recommendations were followed only in 102 (47.7%), while the frequency of non-recommended regimens use reached 52.3% (112 patients). The most frequently incorrectly used scheme was “bridge therapy” with the possibility of canceling oral anticoagulants in 107 (50.0%) patients.Conclusion. A significantly higher frequency of complications was found in patients, whose management did not follow the recommendations for perioperative ACT.

Common Postcardiothoracic Surgery Arrhythmias

Cardiac arrhythmias are common after cardiac surgery and have profound sequelae. Bradycardias are typically transient and have reversible causes; however, persistent atrioventricular block is an indicator for permanent pacemaker implantation after valvular surgery. Transcatheter aortic valve surgery is associated with even higher rates of permanent pacemaker implantation. Atrial fibrillation, the most common postoperative arrhythmia, is associated with ischemic stroke, myocardial infarction, congestive heart failure, and short-term mortality. Ventricular arrhythmias have extremely high in-hospital mortality, as well as long-term mortality for those who survive the initial event. Implantable cardioverter-defibrillators have been shown to reduce long-term mortality for these patients.

Early and long-term results of surgery for secondary mitral regurgitation with a damaged heart

BACKGROUND

Surgery for secondary mitral regurgitation is still controversial, especially when the left ventricle is damaged. The Mitra Clip has been shown to be safe and effective for certain patient groups but does not offer superior control of mitral regurgitation compared with the surgery. If performed safely, the surgery can provide greater benefits over the long-term. The objective of this study was to retrospectively investigate the early and long-term results of mitral valve surgery for secondary mitral valve regurgitation with a damaged, dilated left ventricle.

METHODS

Patients with ejection fraction <40% and left ventricular end-diastolic/systolic diameter >50/40 mm who underwent mitral valve surgery for secondary mitral regurgitation were investigated retrospectively.

RESULTS

The mean age of the 80 identified cases was 65.7 years, and 63 patients were male. Preoperative echocardiograms showed a mean ejection fraction of 25.2% and mean left ventricular diameters in diastole/systole of 64.5/56.9 mm, respectively. Mitral valve replacement was performed in 39 cases, and mitral valve plasty in 41 cases. The most common concomitant procedures were coronary artery bypass grafting and tricuspid valve surgery (41.3% each). Mitral regurgitation improved significantly from 3.5 to 0.83, and no operative or in-hospital deaths were encountered. Long-term results showed actual 1-, 3- and 5-year survival rates of 93.1%, 80.0%, and 64.7%, respectively (mean follow-up, 1264 days).

CONCLUSIONS

Early results of this study were good and long-term results were acceptable. Our results suggest that mitral valve surgery is feasible for secondary mitral valve regurgitation even in dilated, damaged hearts.

Management of cardiogenic shock complicating myocardial infarction: an update 2019

Cardiogenic shock (CS) remains the most common cause of death in patients admitted with acute myocardial infarction (AMI) and mortality remained nearly unchanged in the range of 40–50% during the last two decades. Early revascularization, vasopressors and inotropes, fluids, mechanical circulatory support, and general intensive care measures are widely used for CS management. However, there is only limited evidence for any of the above treatment strategies except for revascularization and the relative ineffectiveness of intra-aortic balloon pumping. This updated review will outline the management of CS complicating AMI with major focus on state-of-the art treatment.

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ICD replacement in patients with intermediate left ventricular dysfunction under optimal medical treatment

BACKGROUND

Implantable cardioverter-defibrillators (ICD) have a pivotal role in preventing major arrhythmic events in patients with severely reduced left ventricular ejection fraction (LVEF). Device replacement strategy is still controversial in patients without severely reduced left ventricular ejection fraction (LVEF) at the end of battery life.

OBJECTIVE

To evaluate the long-term arrhythmic outcome of patients with ICD or and cardiac resynchronization therapy defibrillators (CRT-D) with normal or intermediate LVEF at the time of device replacement.

METHODS

All consecutive patients with reduced ejection fraction heart failure, both from ischemic and non-ischemic origin, implanted with ICD or CRT-D for primary prevention from 2002 to 2009, were considered. The study population included patients without previous ICD interventions and without severe dysfunction (i.e. LVEF ≥ 35%) 60 [53-65] months after implantation (average battery duration). The outcome measure was the occurrence of appropriate ICD interventions in the long-term.

RESULTS

Among the 255 patients (150 ICDs; 105 CRT-D) evaluated, 45 (18%) had LVEF ≥ 35% without ICD interventions 5-year follow-up after implantation (15 ICD [10%]; 30 CRT-D [29%]). In the long term, ICD interventions were 4 (27%) in the ICD group and 5 (17%) in the CRT-D group.

CONCLUSIONS

Despite the absence of severe left ventricular dysfunction at the time of battery replacement, a not negligible number of patients with ICD and CRT-D maintained a high risk of appropriate interventions in the long term, suggesting the opportunity of replacing the ICD regardless the amount of LV dysfunction.

Prognostic implications of post-percutaneous coronary intervention neutrophil-to-lymphocyte ratio on infarct size and clinical outcomes in patients with acute myocardial infarction

This study evaluated the prognostic implications of post-percutaneous coronary intervention (PCI) neutrophil-to-lymphocyte ratio (NLR) in patients with acute myocardial infarction (AMI). A total of 309 patients with AMI who underwent cardiac magnetic resonance imaging (CMR) and a complete blood cell count within 24 hours before and after PCI were enrolled. Primary outcome was infarct size. Patients were assigned to high (n = 118) or low (n = 191) NLR groups according to the best cut-off value of 3.88. Infarct size (% of total left ventricular mass) was significantly higher in the high NLR group than in the low NLR group (24.1 ± 11.0 vs. 16.7 ± 9.1, p < 0.001). Post-PCI NLR ≥ 3.88 was associated with risk of a large-sized infarction (≥20%) (OR 2.91, 95% CI 1.73-4.88, p < 0.001). The risk of MACE was also significantly higher in the high NLR group than in the low NLR group (15.8% vs. 7.4%, HR 2.60, 95% CI 1.21-5.60, p = 0.015). Among patients with AMI who underwent PCI, high post-PCI NLR value was associated with higher risk of large-sized infarction as measured by CMR, as well as adverse clinical outcomes. Our findings suggest that post-PCI NLR is a useful tool for risk assessment in patients with AMI who undergo PCI.

Contemporary Imaging of Aortic Stenosis

Degenerative or fibrocalcific aortic stenosis (AS) is now the most common native valvular heart disease assessed and managed by cardiologists in developed countries. Transthoracic echocardiography remains the quintessential imaging modality for the non-invasive characterisation of AS due to its widespread availability, superior assessment of flow haemodynamics, and a wealth of prognostic data accumulated over decades of clinical utility and research applications. With expanding technologies and increasing availability of treatment options such as transcatheter aortic valve replacements, in addition to conventional surgical approaches, accurate and precise assessment of AS severity is critical to guide decisions for and timing of interventions. Despite clear guideline echocardiographic parameters demarcating severe AS, discrepancies between transvalvular velocities, gradients, and calculated valve areas are commonly encountered in clinical practice. This often results in diagnostically challenging cases with significant implications. Greater emphasis must be placed on the quality of performance of basic two dimensional (2D) and Doppler measurements (attention to detail ensuring accuracy and precision), incorporating ancillary haemodynamic surrogates, understanding study- or patient-specific confounders, and recognising the role and limitations of stress echocardiography in the subgroups of low-flow low-gradient AS. A multiparametric approach, along with the incorporation of multimodality imaging (cardiac computed tomography or magnetic resonance imaging) in certain scenarios, is now mandatory to avoid incorrect misclassification of severe AS. This is essential to ensure appropriate selection of patients who would most benefit from interventions on the aortic valve to relieve the afterload mismatch resulting from truly severe valvular stenosis.

[Relevant aspects of the ESC guidelines for the management of cardiovascular diseases during pregnancy for obstetric anaesthesia (update 2018)]

The current update of the ESC (European Society of Cardiology) guidelines on managing cardiovascular diseases during pregnancy provides instructions for doctors in daily practice. Heart diseases are the most common reason for maternal death during pregnancy in western countries. Among other things, the following topics are dealt with: congenital heart disease, pulmonary hypertension, aortic and valvular diseases as well as arrhythmias and hypertensive disorders. Compared to the guidelines from 2011 some changes have been made regarding the recommendations to classify maternal risk according to the modified World Health Organization (mWHO) classification or in recommendations on anticoagulation for low-dose and high-dose requirements of vitamin K antagonists. The main focus of this summary of recent recommendations is the impact on the anesthesia management in order to provide responsible anesthesiologists with relevant background knowledge.

Familial combined hyperlipidemia: An overview of the underlying molecular mechanisms and therapeutic strategies

Among different types of dyslipidemia, familial combined hyperlipidemia (FCHL) is the most common genetic disorder, which is characterized by at least two different forms of lipid abnormalities: hypercholesterolemia and hypertriglyceridemia. FCHL is an important cause of cardiovascular diseases. FCHL is a heterogeneous condition linked with some metabolic defects that are closely associated with FCHL. These metabolic features include dysfunctional adipose tissue, delayed clearance of triglyceride-rich lipoproteins, overproduction of very low-density lipoprotein and hepatic lipids, and defect in the clearance of low-density lipoprotein particles. There are also some genes associated with FCHL such as those affecting the metabolism and clearance of plasma lipoprotein particles. Due to the high prevalence of FCHL especially in cardiovascular patients, targeted treatment is ideal but this necessitates identification of the genetic background of patients. This review describes the metabolic pathways and associated genes that are implicated in FCHL pathogenesis. We also review existing and novel treatment options for FCHL. © 2019 IUBMB Life, 71(9):1221-1229, 2019.

Heart failure with mid-range ejection fraction: characterization of patients from the PINNACLE Registry®

AIMS

Guidelines for management of patients with heart failure with mid-range ejection fraction [HFmrEF; left ventricular EF (LVEF) 41-49%] do not exist. Disagreement exists whether HFmrEF should be considered a distinct group. The aim of this study is to examine characteristics of patients with HFmrEF with HF with reduced EF (HFrEF; LVEF ≤ 40%) or preserved EF (HFpEF; LVEF ≥ 50%).

METHODS AND RESULTS

We examined data collected in the American College of Cardiology's National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) Registry® for first HF patient visits between 1 May 2008 and 30 June 2016. Analysis was performed using ANOVA F-tests (or Kruskal-Wallis tests for non-normally distributed variables) for continuous parameters and χ² tests for nominal covariates at the first diagnosed HF visit. Given the NCDR PINNACLE Registry® is a US-based registry, we opted to define HFmrEF as per the US guidelines, which define HFmrEF as LVEF 41-49% in contrast to European guidelines, which define HFmrEF as LVEF 40-49%. Among 1 103 386 patients with available data, 36.1% (N = 398 228) had HFrEF, 7.5% (N = 82 292) had HFmrEF, and 56.5% (N = 622 866) had HFpEF. Compared with patients with HFrEF or HFpEF, patients with HFmrEF had more prevalent coronary and peripheral artery disease and more history of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery (all P < 0.001). Patients with HFmrEF were also more likely to have atrial fibrillation/flutter, diabetes, and chronic kidney disease and to have a history of tobacco use (both P < 0.001). Among those with EF assessment prior to this analysis, only 4.8% (N = 1032) previously had HFrEF that improved to HFmrEF; 32.9% (N = 7072) had HFpEF previously and progressed to HFmrEF. Those patients who transitioned from HFpEF to HFmrEF had considerably more complex profiles and were less aggressively managed compared with those who remained with HFmrEF (all P < 0.001).

CONCLUSIONS

In this large descriptive analysis, patients with HFmrEF had an atherothrombotic phenotype distinct from other forms of HF. Interventions aimed at treating coronary ischaemia and addressing prevalent risk factors may play a particularly important role in the management of patients with HFmrEF.

Frequency and Reasons of Dual Antiplatelet Therapy Discontinuation and Switching of P2Y12 Inhibitors in Patients with Acute Coronary Syndrome Treated with Stent Implantation

BACKGROUND

Incidence and reasons of dual antiplatelet therapy (DAPT) discontinuation and switching between P2Y12 inhibitors in acute coronary syndrome (ACS) patients treated with a stent have been poorly studied.

METHODS AND RESULTS

In a prospective single-center study, 283 consecutive patients presenting with ACS were treated with stent implantation between July 2015 and January 2016. Follow-up was achieved at 12 months in 273 patients using the electronic patient file and telephone interview. Switching from clopidogrel to a new antiplatelet agent (ticagrelor or prasugrel) or vice versa occurred in 60 (21.2%) patients. The most frequent reasons for switching were medical decisions not associated with bleeding events and concomitant use of chronic oral anticoagulation. Among the patients with a 1-year follow-up, 42 (15.4%) prematurely discontinued DAPT; 25 of them did so due to the need for an invasive procedure. DAPT premature discontinuation was not significantly associated with an increased 1-year risk of cardiovascular death or serious cardiac ischemic events (HR 2.08 [CI 95%: 0.88-4.94, p = 0.099]).

CONCLUSIONS

DAPT discontinuation and switching between P2Y12 inhibitors are not uncommon in patients with ACS treated with a stent. The most frequent reasons were the need for an invasive procedure and medical decisions.

Optimized Treatment of ST-Elevation Myocardial Infarction

Primary percutaneous coronary intervention is nowadays the preferred reperfusion strategy for patients with acute ST-segment-elevation myocardial infarction, aiming at restoring epicardial infarct-related artery patency and achieving microvascular reperfusion as early as possible, thus limiting the extent of irreversibly injured myocardium. Yet, in a sizeable proportion of patients, primary percutaneous coronary intervention does not achieve effective myocardial reperfusion due to the occurrence of coronary microvascular obstruction (MVO). The amount of infarcted myocardium, the so-called infarct size, has long been known to be an independent predictor for major adverse cardiovascular events and adverse left ventricular remodeling after myocardial infarction. Previous cardioprotection studies were mainly aimed at protecting cardiomyocytes and reducing infarct size. However, several clinical and preclinical studies have reported that the presence and extent of MVO represent another important independent predictor of adverse left ventricular remodeling, and recent evidences support the notion that MVO may be more predictive of major adverse cardiovascular events than infarct size itself. Although timely and complete reperfusion is the most effective way of limiting myocardial injury and subsequent ventricular remodeling, the translation of effective therapeutic strategies into improved clinical outcomes has been largely disappointing. Of importance, despite the presence of a large number of studies focused on infarct size, only few cardioprotection studies addressed MVO as a therapeutic target. In this review, we provide a detailed summary of MVO including underlying causes, diagnostic techniques, and current therapeutic approaches. Furthermore, we discuss the hypothesis that simultaneously addressing infarct size and MVO may help to translate cardioprotective strategies into improved clinical outcome following ST-segment-elevation myocardial infarction.

Updating EuroSCORE by including emotional, behavioural, social and functional factors to the risk assessment of patients undergoing cardiac surgery: a study protocol

INTRODUCTION

Conventional risk assessment in cardiac surgery focus on medical and physiological factors and have been developed to predict mortality. Other relevant risk factors associated with increased risk of poor outcomes are not included. Adding non-medical variables as potential prognostic factors to risk assessments direct attention away from specific diagnoses towards a more holistic view of the patients and their predicament. The aim of this paper is to describe the method and analysis plan for the development and validation of a prognostic screening tool as a supplement to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) to predict mortality, readmissions and prolonged length of admission in patients within 90 days after cardiac surgery, as individual outcomes.

METHODS AND ANALYSIS

The development of a prognostic screening tool with inclusion of emotional, behavioural, social and functional factors complementing risk assessment by EuroSCORE will adopt the methods recommended by the PROGnosis RESearch Strategy Group and report using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis statement. In the development stage, we will use data derived from three datasets comprising 1143, 3347 and 982 patients for a prospective cohort study of patients undergoing cardiac surgery, respectively. We will construct logistic regression models to predict mortality, prolonged length of admission and 90-day readmissions. In the validation stage, we will use data from a separate sample of 333 patients planned to undergo cardiac surgery to assess the performance of the developed prognostic model. We will produce validation plots showing the overall performance, area under the curve statistic for discrimination and the calibration slope and intercept.

ETHICS AND DISSEMINATION

The study will follow the requirements from the Ethical Committee System ensuring voluntary participation in accordance with the Helsinki declarations. Data will be filed in accordance with the requirements of the Danish Data Protection Agency.

Coexisting Frailty With Heart Failure

People over 65 years of age constitute over 80% of patients with heart failure (HF) and the incidence of HF is 10 per 1,000 in people aged above 65 years. Approximately 25% of older patients with HF exhibit evidence of frailty. Frail patients with cardiovascular disease (CVD) have a worse prognosis than non-frail patients, and frailty is an independent risk factor for incident HF among older people. Planning the treatment of individuals with HF and concomitant frailty, one should consider not only the limitations imposed by frailty syndrome (FS) but also those associated with the underlying heart disease. It needs to be emphasized that all patients with HF and concomitant FS require individualized treatment.

Percutaneous cardiological intervention and cardiac surgery: patient-centered care. Position statement of the Spanish Society of Cardiology

The percutaneous treatment of coronary artery disease and some structural cardiovascular diseases has undergone spectacular changes. More and more patients with different types of heart disease are being treated by percutaneous or transcatheter interventions, with no such increase in patients undergoing cardiac surgery. This situation has led to different types of approach, requiring an objective analysis that includes all the factors possibly influencing these changes. This document assesses the 2 scenarios where this problem is most evident: coronary revascularization and the treatment of aortic stenosis. The document analyzes the situation of coronary revascularization in Spain, and the causes that may explain the differences between the number of patients who currently undergo percutaneous revascularization and those who undergo coronary surgery. In contrast, treatment of aortic stenosis through transcatheter aortic valve implantation will lead to a foreseeable reduction in the number of candidates for surgical replacement. Several international scientific societies have published the requirements on training and experience and the necessary operator and center volumes to implement a transcatheter aortic valve implantation program, conditions that the Spanish Society of Cardiology, adopting a patient-centered approach, considers absolutely essential. Given that the 2 forms of intervention (percutaneous and surgical) are complementary, multidisciplinary patient assessment (Heart Team) remains crucial to offer the best treatment option. In this scenario of diverse approaches, a key figure is the clinical cardiologist. Finally, the changes currently occurring in the treatment of structural heart disease will, in future, lead to the performance of procedures requiring the participation of professionals from both specialties. This approach will require a redesign of current training programs.

Association between serum potassium levels and short-term mortality in patients with atrial fibrillation or flutter co-treated with diuretics and rate- or rhythm-controlling drugs

Aims

We investigated the association between potassium levels and 90-day all-cause mortality in atrial fibrillation or flutter (AF) patients co-treated with diuretics and rate- or rhythm-controlling drugs.

Methods and results

During 2000–12, first-time AF patients treated with beta-blockers, amiodarone, sotalol, verapamil, or digoxin combined with any diuretic within 90 days post-AF discharge were included. Following co-treatment, a potassium measurement within 90 days after initiating diuretic treatment was required. Mortality risk associated with potassium &lt;3.5, 3.5–3.7, 3.8–4.0, 4.5–4.7, 4.8–5.0, and &gt;5.0 mmol/L (reference: 4.1–4.4 mmol/L) was assessed using multivariable Cox regression. In total, 14 425 AF patients were included (median age: 78 years; women: 52%). Patients most often received beta-blocker monotherapy (29%), beta-blockers and digoxin combined (25%), digoxin monotherapy (24%), amiodarone monotherapy (3%), and verapamil monotherapy (3%). Increased 90-day mortality risk was associated with &lt;3.5 mmol/L [hazard ratio (HR) 2.05, 95% confidence interval (CI) 1.68–2.50], 3.5–3.7 mmol/L (HR 1.28, 95% CI 1.05–1.57), 4.5–4.7 mmol/L (HR 1.20, 95% CI 1.02–1.41), 4.8–5.0 mmol/L (HR 1.37, 95% CI 1.14–1.66), and &gt;5.0 mmol/L: (HR 1.84, 95% CI 1.53–2.21). Compared with beta-blocker monotherapy, rate- or rhythm-controlling drugs did not modify the association between potassium groups and mortality risk.

Conclusion

In addition to hypo- and hyperkalaemia, low and high normal range potassium levels were associated with increased 90-day mortality risk in AF patients co-treated with diuretics and rate- or rhythm-controlling drugs. These associations were independent of rate- or rhythm-controlling drugs.

Epilepsy and ultra-structural heart changes: The role of catecholaminergic toxicity and myocardial fibrosis. What can we learn from cardiology?

In this article, we explore the interaction of brain and heart in patients with epilepsy (PWE), focusing on new insights into possible pathways from epilepsy, catecholaminergic toxicity, subtle cardiac changes and sudden death. Initial evidence and biological plausibility point to an interaction between autonomic dysfunction, higher sympathetic drive, myocardial catecholaminergic toxicity and cardiac fibrosis resulting in subtle myocardial changes in structure, function, arrhythmogenesis and/or a heart failure-like phenotype in PWE. Non invasive imaging and biomarkers of cardiac injury and fibrosis are emerging as possible diagnostic tools to better stratify the risk of such individuals. Translational lessons from cardiac models of disease and ultra-structural lesions are used to support these considerations.

Incidence and Predictors of Intracardiac Thrombus on Pre-electrophysiological Procedure Transesophageal Echocardiography

Background

Cerebral thromboembolism is a potentially devastating complication of atrial fibrillation (AF) and atrial flutter (AFl). The use of transesophageal echocardiogram (TEE) before electrophysiological procedures in anticoagulated patients is variable. Our objective was to determine the incidence and identify predictors of intracardiac left atrial appendage (LAA) thrombus on TEE in patients with AF/AFl before electrical cardioversion or ablation.

Methods

We reviewed TEEs of 401 patients undergoing an electrical cardioversion, AF, or AFl ablation from April 2013 to September 2015 at the McGill University Health Center. Clinical and echocardiographic variables were collected at the time of the TEE and follow-up visits. Multivariate logistic regression was used to determine predictors of LAA thrombus.

Results

Of 401 patients, 11.2% had LAA thrombus on TEE. The majority (87%) of patients were anticoagulated for at least 3 weeks before the TEE. The incidence of LAA thrombus was 21% (23/110) in patients taking warfarin vs 6.4% (15/236) in patients taking direct oral anticoagulants. Multivariate analysis identified prior stroke (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.1-6.9) and heart failure (OR, 2.2; 95% CI, 1.0-4.7) as predictors of thrombus, whereas direct oral anticoagulant use (OR, 0.4; 95% CI, 0.2-0.8) was associated with reduced odds of thrombus.

Conclusions

LAA thrombus was identified in a significant proportion of patients undergoing TEE before cardioversion or ablation of AF/AFl despite preprocedural anticoagulation. Patients at increased risk of LAA thrombus (heart failure and prior stroke) may benefit from TEE before cardioversion, AF, or AFl ablation.

The RITMIA™ Smartphone App for Automated Detection of Atrial Fibrillation: Accuracy in Consecutive Patients Undergoing Elective Electrical Cardioversion

Background

The RITMIA™ app (Heart Sentinel™, Parma, Italy) is a novel application that combined with a wearable consumer-grade chest-strap Bluetooth heart rate monitor, provides automated detection of atrial fibrillation (AF), and may be promising for sustainable AF screening programs, since it is known that prolonged monitoring leads to increased AF diagnosis.

Objective

The purpose of this study was to examine whether RITMIA™ could accurately differentiate sinus rhythm (SR) from AF compared with gold-standard physician-interpreted 12-lead electrocardiogram (ECG).

Design

In this observational prospective study consecutive patients presenting for elective cardioversion (ECV) of AF, from November 2017 to November 2018, were enrolled. Patients underwent paired 12-lead ECG and RITMIA™ recording, both before and after ECV procedure. The RITMIA™ automated interpretation was compared with 12-lead ECG interpreted by the agreement of two cardiologists. The latter were blinded to the results of the App automated diagnosis. Feasibility, sensitivity, specificity, and K coefficient for RITMIA™ automated diagnosis were calculated.

Results

A total of 100 consecutive patients were screened and enrolled. Five patients did not undergo ECV due to spontaneous restoration of SR. 95 patients who actually underwent ECV were included in the final analysis. Mean age was 66.2±10.7 years; female patients were 20 (21.1%). There were 190 paired ECGs and RITMIA™ recordings. The RITMIA™ app correctly detected AF with 97% sensitivity, 95.6% specificity, and a K coefficient of 0.93.

Conclusions

The automated RITMIA™ algorithm very accurately differentiated AF from SR before and after elective ECV. The only hardware required by this method is a cheap consumer-grade Bluetooth heart rate monitor of the chest-strap type. This robust and affordable RITMIA™ technology could be used to conduct population-wide screening in patients at risk for silent AF, thanks to the long-term monitoring applicability.

Contribution of the Lung to the Genesis of Cheyne-Stokes Respiration in Heart Failure: Plant Gain Beyond Chemoreflex Gain and Circulation Time

Background The contribution of the lung or the plant gain ( PG ; ie, change in blood gases per unit change in ventilation) to Cheyne-Stokes respiration ( CSR ) in heart failure has only been hypothesized by mathematical models, but never been directly evaluated. Methods and Results Twenty patients with systolic heart failure (age, 72.4±6.4 years; left ventricular ejection fraction, 31.5±5.8%), 10 with relevant CSR (24-hour apnea-hypopnea index [ AHI ] ≥10 events/h) and 10 without ( AHI <10 events/h) at 24-hour cardiorespiratory monitoring underwent evaluation of chemoreflex gain (CG) to hypoxia ([Formula: see text]) and hypercapnia ([Formula: see text]) by rebreathing technique, lung-to-finger circulation time, and PG assessment through a visual system. PG test was feasible and reproducible (intraclass correlation coefficient, 0.98; 95% CI , 0.91-0.99); the best-fitting curve to express the PG was a hyperbola ( R2≥0.98). Patients with CSR showed increased PG , [Formula: see text] (but not [Formula: see text]), and lung-to-finger circulation time, compared with patients without CSR (all P<0.05). PG was the only predictor of the daytime AHI ( R=0.56, P=0.01) and together with the [Formula: see text] also predicted the nighttime AHI ( R=0.81, P=0.0003) and the 24-hour AHI ( R=0.71, P=0.001). Lung-to-finger circulation time was the only predictor of CSR cycle length ( R=0.82, P=0.00006). Conclusions PG is a powerful contributor of CSR and should be evaluated together with the CG and circulation time to individualize treatments aimed at stabilizing breathing in heart failure.

Type 2 Valvular Heart Disease Affects Decision Making for Anticoagulation in Patients with Atrial Fibrillation: The UMBRIA-Fibrillazione Atriale Prospective Study

Background  Valvular heart disease (VHD) and atrial fibrillation (AF) often coexist.

Aim  We investigated whether type 2 VHD (other than moderate-severe rheumatic mitral stenosis or mechanical heart valve) influences the prescription of anticoagulants in AF.

Methods  Umbria-Fibrillazione Atriale is a prospective multicenter registry in patients with AF. For the purpose of this study, type 2 VHD patients were propensity matched with non-VHD counterparts in a 1:1 ratio. Patients with type 1 VHD (moderate-severe mitral stenosis or mechanical heart valve) were excluded.

Results  We identified 2,212 patients with AF and excluded 46 because data on VHD were unavailable. Type 2 VHD was present in 426 patients (19.7%). Before registry entry visit, 77.1% of type 2 VHD and 66.8% of non-VHD patients were on anticoagulants. At discharge, 90.8 and 85.2% of patients, respectively, were on anticoagulants. After propensity-score matching, 386 patient-pairs were created. In the matched sample, the likelihood of being on anticoagulants before (odds ratio [OR]: 1.43, 95% confidence interval [CI]: 1.02–2.01, p  = 0.036) and after (1.63, 95% CI: 1.04–2.57, p  = 0.034) the entry visit was higher in type 2 VHD than in non-VHD patients. Patients with type 2 VHD were 70% more likely to receive vitamin K antagonists (VKAs) (OR: 1.70, 95% CI: 1.28–2.27, p  < 0.001), and 32% less likely to receive non–vitamin K oral anticoagulants (NOACs; OR: 0.68, 95% CI: 049–0.94, p  = 0.011) than non-VHD patients.

Conclusion  VKAs consistently outperformed NOACs as preferred treatment option in patients with type 2 VHD. This could potentially deny to these patients the well-established benefits of NOACs observed in phase III trials.

Effects of Mokuboito, a Japanese Kampo medicine, on symptoms in patients hospitalized for acute decompensated heart failure - A prospective randomized pilot study

BACKGROUND

Although standard treatment for heart failure (HF) has been established, it remains difficult to relieve HF-associated symptoms in some patients. Kampo medicines have been used to treat various diseases; however, it remains unclear whether they are effective in HF patients. We therefore performed a prospective, randomized, controlled trial to investigate whether Mokuboito, a Kampo medicine, affected symptoms and other parameters in hospitalized patients with acute decompensated HF (ADHF), as compared to standard therapy alone.

METHODS

Forty patients were allocated randomly to Group S (standard therapy alone) or Group M (oral administration of Mokuboito plus standard therapy). The primary outcome was changes in global clinical status based on a visual analog scale (VAS) from baseline at day 10 or discharge if earlier.

RESULTS

The decrease in VAS score was significantly greater in Group M than Group S (p=0.001). Although there were no differences between the groups in changes in the secondary endpoints of body weight, peripheral edema, biochemical and echocardiographic parameters, left ventricular end-diastolic diameter, and serum total bilirubin levels were significantly reduced in Group M (p=0.038; 0.002, respectively) but not in Group S, implying that Mokuboito might attenuate organ congestion and cardiac preload.

CONCLUSIONS

Oral administration of Mokuboito significantly improved ADHF-related symptoms. Our observations might provide the basis for a novel therapeutic strategy in hospitalized patients with ADHF.

Influence of Cardiovascular Risk Factors, Comorbidities, Medication Use and Procedural Variables on Remote Ischemic Conditioning Efficacy in Patients with ST-Segment Elevation Myocardial Infarction

Remote ischemic conditioning (RIC) confers cardioprotection in patients with ST-segment elevation myocardial infarction (STEMI). Despite intense research, the translation of RIC into clinical practice remains a challenge. This may, at least partly, be due to confounding factors that may modify the efficacy of RIC. The present review focuses on cardiovascular risk factors, comorbidities, medication use and procedural variables which may modify the efficacy of RIC in patients with STEMI. Findings of such efficacy modifiers are based on subgroup and post-hoc analyses and thus hold risk of type I and II errors. Although findings from studies evaluating influencing factors are often ambiguous, some but not all studies suggest that smoking, non-statin use, infarct location, area-at-risk of infarction, pre-procedural Thrombolysis in Myocardial Infarction (TIMI) flow, ischemia duration and coronary collateral blood flow to the infarct-related artery may influence on the cardioprotective efficacy of RIC. Results from the on-going CONDI2/ERIC-PPCI trial will determine any clinical implications of RIC in the treatment of patients with STEMI and predefined subgroup analyses will give further insight into influencing factors on the efficacy of RIC.

Antithrombotics: From Aspirin to DOACs in Coronary Artery Disease and Atrial Fibrillation (Part 3/5)

For secondary prevention of coronary artery disease (CAD), oral antiplatelet therapy is essential. In case of coronary intervention, temporary dual antiplatelet therapy is mandatory as well. Recently, low-dose oral anticoagulation has entered the CAD arena. Atrial fibrillation (AF) is often seen in CAD and vice versa. In most patients stroke prevention in AF consists of oral anticoagulation. In many cases of CAD in patients with AF, anticoagulation has to be combined with antiplatelet agents (so called, dual pathway antithrombotic therapy). Excess bleeding in these conditions is a rapidly rising problem. This review addresses the antithrombotic options in CAD alone, in AF alone, and in their combination, when either an invasive or a noninvasive approach has been chosen.

Current perspectives on location of monitoring and length of stay following PPCI for ST elevation myocardial infarction

IMPORTANCE

There is marked variability in location of care and hospital length of stay after primary percutaneous coronary intervention for ST elevation myocardial infarction (STEMI).

OBSERVATIONS

We performed a literature review on non-critical care monitoring and early discharge following primary percutaneous coronary intervention and describe a framework for implementation in the real world. The medical literature was searched from 1 January 1988 to 31 April 2019 using PubMed and Cochrane Central Register of Controlled Trials. Randomized clinical trials, observational studies and guideline statements were included. Available data suggest that carefully selected low-risk STEMI patients identified using Zwolle or CADILLAC risk stratification scores after primary percutaneous coronary intervention may be considered for discharge after 48 hours of hospital care. There was no increase in major adverse cardiac events, medication non-compliance or hospital readmission with this treatment strategy. There are limited data on non-critical monitoring of uncomplicated STEMI patients; however, given the low adverse events rate, this strategy is likely to be safe in selected patients and may facilitate reduced length of stay and reduce resource utilization.

CONCLUSIONS AND RELEVANCE

Available evidence supports the safety of early discharge after 48 hours of care and omission of critical care monitoring in carefully selected patients following primary percutaneous coronary intervention. Early risk stratification and structured discharge planning are imperative. Adoption of this treatment strategy could reduce hospital costs, resource utilization and enhance patient satisfaction without affecting outcomes.

Aortic stenosis and diabetes mellitus: An ominous combination

Aortic stenosis and diabetes mellitus are both progressive diseases which, if left untreated, result in significant morbidity and mortality. There is evidence that the prevalence of diabetes is substantially increased in patients with aortic stenosis and those with diabetes have increased rates of progression from mild to severe aortic stenosis. There are good data supporting the hypothesis that aortic stenosis and diabetes mellitus are associated with diabetes mellitus being detrimental towards the quality of life and survival of patients. Thus, a thorough understanding of the pathogenesis of both of these disease processes and the relationship between them aids in designing appropriate preventive and therapeutic approaches. This review aims to give a comprehensive and up-to-date insight into the influence of diabetes mellitus on patients with degenerative aortic stenosis, as well as the prognosis and therapeutic approach to these patients.