Pre-treatment with a sinus node blockade, ivabradine, before coronary CT angiography: A retrospective audit

Liraglutide treatment is associated with progression of coronary artery fibrous plaque: a prospective 1-year follow-up study in asymptomatic patients with type 2 diabetes

OBJECTIVE

The objective of this study was to assess the association between clinically indicated liraglutide treatment and coronary artery plaque progression during 1-year follow-up in asymptomatic diabetes.

METHODS

Patients were divided into a group receiving liraglutide (Lira+) and a group not receiving liraglutide (Lira-). Coronary computed tomography angiography (CCTA) was performed to assess total atheroma volume (TAV) and subtypes of plaque volumes (dense calcium, fibrous, fibrous-fatty, and necrotic core plaque) and the plaque progression during one year follow-up.

RESULTS

Fifty-five patients (27%) receiving liraglutide and 149 (73%) how did not were included. Changes in TAV during 1-year of follow-up were similar in the two groups (38 ± 180 (Lira+) vs. -1 ± 160 mm³ (Lira-), P = 0.13). A greater increase in fibrous plaque volume was seen in the Lira + vs. the Lira- group (34 ± 129 vs. -2 ± 101 mm³, P = 0.04). Changes over 1-year in the other plaque subtypes were similar in the two groups. Treatment duration of liraglutide was not associated with changes in TAV.

CONCLUSION

In patients with T2D without known prior coronary artery disease, liraglutide treatment was associated with a significant increase in coronary artery fibrous plaque volume during 1-year follow-up.

The Effect of Clinically Indicated Liraglutide on Pericoronary Adipose Tissue in Type 2 Diabetic Patients

Vascular inflammation can be detected in the pericoronary adipose tissue (PCAT) by coronary computed tomography angiography (CCTA) attenuation. Treatment with liraglutide is associated with anti-inflammatory effects and reduces cardiovascular risk in diabetic patients. This study is aimed at examining the effect of clinically indicated liraglutide on PCAT attenuation. Asymptomatic patients with type 2 diabetes mellitus (T2DM) and without known ischemic heart disease underwent clinical examination, blood analysis, and CCTA. The main coronary arteries were outlined and PCAT attenuation was measured on the proximal 40 mm. Patients treated with liraglutide on a clinical indication were compared to patients not receiving liraglutide. The study included 190 patients; 53 (28%) received liraglutide (Lira+) and 137 (72%) did not (Lira-). There were no significant differences in PCAT attenuation between the two groups in either artery. However, PCAT attenuation measured around the left anterior descending artery (LAD) was lower in the Lira+ group after adjustment for age, sex, body mass index, and T2DM duration (b coefficient -2.4, p = 0.029). In a population of cardiac asymptomatic T2DM patients, treatment with clinically indicated liraglutide was not associated with differences in PCAT attenuation compared to nonliraglutide treatment in the unadjusted model. An association was seen in the adjusted model for the left anterior descending artery, possibly indicating an anti-inflammatory effect.

High-risk coronary artery plaque in asymptomatic patients with type 2 diabetes: clinical risk factors and coronary artery calcium score

BACKGROUND

High-risk coronary artery plaque (HRP) is associated with increased risk of acute coronary syndrome. We aimed to investigate the prevalence of HRP in asymptomatic patients with type 2 diabetes (T2D), and its relation to patient characteristics including cardiovascular risk factors, diabetes profile, and coronary artery calcium score (CACS).

METHODS

Asymptomatic patients with T2D and no previous coronary artery disease (CAD) were studied using coronary computed tomography angiography (CCTA) in this descriptive study. Plaques with two or more high-risk features (HRP) defined by low attenuation, positive remodeling, spotty calcification, and napkin-ring sign were considered HRP. In addition, total atheroma volume (TAV), proportions of dense calcium, fibrous, fibrous-fatty and necrotic core volumes were assessed. The CACS was obtained from non-enhanced images by the Agatston method. Cardiovascular and diabetic profiles were assessed in all patients.

RESULTS

In 230 patients CCTA was diagnostic and 161 HRP were detected in 86 patients (37%). Male gender (OR 4.19, 95% CI 1.99-8.87; p < 0.01), tobacco exposure in pack years (OR 1.02, 95% CI 1.00-1.03; p = 0.03), and glycated hemoglobin (HbA1c) (OR 1.04, 95% CI 1.02-1.07; p < 0.01) were independent predictors of HRP. No relationship was found to other risk factors. HRP was not associated with increased CACS, and 13 (23%) patients with zero CACS had at least one HRP.

CONCLUSION

A high prevalence of HRP was detected in this population of asymptomatic T2D. The presence of HRP was associated with a particular patient profile, but was not ruled out by the absence of coronary artery calcium. CCTA provides important information on plaque morphology, which may be used to risk stratify this high-risk population. Trial registration This trial was retrospectively registered at clinical trials.gov January 11, 2017 trial identifier NCT03016910.

Beyond Heart Failure and Ischemic Heart Disease: A Scoping Review of Novel Uses of Ivabradine in Adults

Ivabradine lowers heart rate by inhibiting the hyperpolarization-activated current in pacemaker cells, and its use for the treatment of heart failure (HF) and ischemic heart disease (IHD) is well described. Ivabradine may be an attractive treatment option for other conditions for which a reduction in heart rate is desirable but less is known about its role in these settings. The primary objective was to perform a scoping review summarizing the literature evaluating novel uses for ivabradine other than HF and IHD in adults. PubMed and EMBASE were searched for articles for all dates through September 2019. Search strategies combined terms generic, commercial/trade, and international names for ivabradine. Manual search of references was also performed to identify additional articles. Studies were included if they were published in English, evaluated the efficacy of ivabradine for indications other than HF or IHD in patients aged 18 years or older, and the primary outcome included clinically relevant end points. Articles were screened first by title and abstract followed by full-text screening of the remaining articles. After removal of duplicates, 1807 records were screened for inclusion and 84 studies were included in this scoping review. Novel uses of ivabradine were reported for various tachyarrhythmias, valvular heart disease, premedication for coronary computed tomography angiography, perioperative risk reduction, sepsis with and without multi-organ dysfunction syndrome, cor pulmonale, reactive airway disease, and erectile dysfunction. This scoping review identified several potential novel uses for ivabradine in adults. This review may help to identify existing gaps where further research is needed to elucidate the role of ivabradine for indications beyond HF and IHD.

Ivabradine: Evidence and current role in cardiovascular diseases and other emerging indications

Increased heart rate (HR) is associated with deleterious effects on several disease conditions. Chronic heart failure (CHF) is one of the cardiovascular diseases with recurrent hospitalization burden and an ongoing drain on health-care expenditure. Despite advancement in medicine, management of CHF remains a challenge to health-care providers. Ivabradine selectively and specifically inhibits the pacemaker I(f) ionic current which reduces the cardiac pacemaker activity. The main effect of ivabradine therapy is the substantial lowering of HR. It does not influence intracardiac conduction, contractility, or ventricular repolarization. As shown in numerous clinical studies, ivabradine improves clinical outcomes and quality of life and reduces the risk of death from heart failure (HF) or other cardiovascular causes. Recently updated HF guidelines recommend ivabradine as a class II indication for reduction of HF hospitalizations. Based on the principle of benefits of reduced HR, the ivabradine in patients with ischemic heart disease, sepsis, and multiple organ dysfunction syndrome has also been studied. It can also be a useful agent for HR reduction in patients with contraindications to use beta-blockers or those who cannot tolerate them. In this review, we provide an overview of efficacy and safety of ivabradine and its combination with currently recommended pharmacological therapy in different conditions.

Heart rate-reducing therapy with add-on ivabradine and bisoprolol before coronary computed tomographic angiography in a fast-track ambulatory setting

Objective

This study was performed to determine whether add-on oral ivabradine in patients treated with beta blockers 1 hour before coronary computed tomographic angiography (CCTA) is effective in lowering the heart rate and thus improving CCTA quality.

Methods

In this single-center cohort study, the data of 294 patients referred for ambulant CCTA were retrospectively screened. Patients with an initial heart rate of ≥75 bpm (n = 112) were pretreated with either a combination of bisoprolol and ivabradine or with bisoprolol alone.

Results

During the scan, there was no difference in heart rate between the two groups Likewise, there was no significant difference in additionally administered intravenous bradycardic agents, the number of motion artifacts, or the radiation dose. Both drug regimens were tolerated well.

Conclusion

Additive oral ivabradine 1 hour before CCTA does not result in a further reduction of the heart rate. Consequently, neither movement artifacts nor radiation dose can be reduced. Therefore, pretreatment with ivabradine does not seem reasonably appropriate in an outpatient clinical setting with short patient contact.

Efficacy of Ivabradine versus β-Blockers for Heart Rate Reduction during Computed Tomography Coronary Angiography: A Meta-Analysis of Randomized Controlled Trials

Objective: To quantify the efficacy of pretreatment with ivabradine compared to β-blockers before computed tomography coronary angiography (CTCA) via a meta-analysis of clinical randomized controlled trial data. Methods: We conducted a search for randomized controlled trials of pretreatment with ivabradine compared to β-blockers before CTCA in Medline, PubMed, Embase, SCI/SSCI/A&amp;HCI, SAS Publishers, Web of Science, and the Cochrane Central Register. The Jadad quality score of the included studies, and the mean difference (MD) in heart rate reduction, were indicators of efficacy. RevMan 5.2 and Stata 12.0 software were used for the meta-analysis. Results: Eight studies involving a total of 1,324 patients were included in the final analysis. The results showed that ivabradine was significantly more effective at improving the heart rate of patients achieving the target heart rate (<65 bpm) during CTCA (OR 5.02; 95% CI 3.16-7.98, p < 0.00001, I2 = 20%). A comparison of efficacy between ivabradine and β-blockers showed a statistically significant effect of ivabradine on heart rate reduction during CTCA (MD -4.39; 95% CI −4.80 to −3.99, p < 0.00001, I2 = 0%). Ivabradine also led to a significant reduction in heart rate prior to CTCA (MD −5.33; 95% CI −10.26 to −0.39, p = 0.03, I2 = 92%). In terms of the total reduction in heart rate during CTCA, significant differences were noted between the ivabradine group and the β-blocker group (MD 2.64; 95% CI 1.25-4.02, p = 0.0002, I2 = 0%). The mean percentage reduction in heart rate in the ivabradine group was significantly higher than that in the β-blocker group (MD 7.18; 95% CI 5.64-8.72, p < 0.00001, I2 = 43%). Ivabradine had no significant effect on either systolic blood pressure (BP) (MD 11.41; 95% CI 6.43-16.40, p < 0.00001, I2 = 85%) or diastolic BP (MD 1.79; 95% CI -0.00 to 3.58, p = 0.05, I2 = 56%). Conclusion: Compared to β-blockers for heart rate reduction, ivabradine is a potentially attractive alternative for patients undergoing CTCA.

Impact of a motion correction algorithm on quality and diagnostic utility in unselected patients undergoing coronary CT angiography

AIMS

The aims of the study were to investigate the diagnostic utility of motion correction reconstruction algorithm Snapshot Freeze (SSF) compared to the standard reconstruction algorithm (STD) in coronary computed tomography angiography (CCTA) images where a prescan heart-rate-lowering protocol is fully integrated.

METHODS

CCTA was performed in 140 patients. Two independent blinded readers made image evaluation of the SSF and STD images.

RESULTS

SSF reduced the motion artifacts (30% vs. 41%; P<.05) and improved the image quality ("excellent" images: 52% vs. 42%; P=.022), but did not influence diagnostic utility ("nondiagnostic" images: 10% vs. 14%; P=.104).

CONCLUSION

The use of the SSF algorithm reduced the presence of motion artifacts and improved image quality, but did not influence the diagnostic utility.