Relationship Between Genotype Status and Clinical Outcome in Hypertrophic Cardiomyopathy

BACKGROUND

The genetic basis of hypertrophic cardiomyopathy (HCM) is complex, and the relationship between genotype status and clinical outcome is incompletely resolved.

METHODS AND RESULTS

We assessed a large international HCM cohort to define in contemporary terms natural history and clinical consequences of genotype. Consecutive patients (n=1468) with established HCM diagnosis underwent genetic testing. Patients with pathogenic (or likely pathogenic) variants were considered genotype positive (G+; n=312; 21%); those without definite disease-causing mutations (n=651; 44%) or variants of uncertain significance (n=505; 35%) were considered genotype negative (G-). Patients were followed up for a median of 7.8 years (interquartile range, 3.5-13.4 years); HCM end points were examined by cumulative event incidence. Over follow-up, 135 (9%) patients died, 33 from a variety of HCM-related causes. After adjusting for age, all-cause and HCM-related mortality did not differ between G- versus G+ patients (hazard ratio [HR], 0.78 [95% CI, 0.46-1.31]; P=0.37; HR, 0.93 [95% CI, 0.38-2.30]; P=0.87, respectively). Adverse event rates, including heart failure progression to class III/IV, heart transplant, or heart failure death, did not differ (G- versus G+) when adjusted for age (HR, 1.20 [95% CI, 0.63-2.26]; P=0.58), nor was genotype independently associated with sudden death event risk (HR, 1.39 [95% CI, 0.88-2.21]; P=0.16). In multivariable analysis, age was the only independent predictor of all-cause and HCM-related mortality, heart failure progression, and sudden death events.

CONCLUSIONS

In this large consecutive cohort of patients with HCM, genotype (G+ or G-) was not a predictor of clinical course, including all-cause and HCM-related mortality and risk for heart failure progression or sudden death. G+ status should not be used to dictate clinical management or predict outcome in HCM.

Aficamten for Symptomatic Obstructive Hypertrophic Cardiomyopathy

BACKGROUND

One of the major determinants of exercise intolerance and limiting symptoms among patients with obstructive hypertrophic cardiomyopathy (HCM) is an elevated intracardiac pressure resulting from left ventricular outflow tract obstruction. Aficamten is an oral selective cardiac myosin inhibitor that reduces left ventricular outflow tract gradients by mitigating cardiac hypercontractility.

METHODS

In this phase 3, double-blind trial, we randomly assigned adults with symptomatic obstructive HCM to receive aficamten (starting dose, 5 mg; maximum dose, 20 mg) or placebo for 24 weeks, with dose adjustment based on echocardiography results. The primary end point was the change from baseline to week 24 in the peak oxygen uptake as assessed by cardiopulmonary exercise testing. The 10 prespecified secondary end points (tested hierarchically) were change in the Kansas City Cardiomyopathy Questionnaire clinical summary score (KCCQ-CSS), improvement in the New York Heart Association (NYHA) functional class, change in the pressure gradient after the Valsalva maneuver, occurrence of a gradient of less than 30 mm Hg after the Valsalva maneuver, and duration of eligibility for septal reduction therapy (all assessed at week 24); change in the KCCQ-CSS, improvement in the NYHA functional class, change in the pressure gradient after the Valsalva maneuver, and occurrence of a gradient of less than 30 mm Hg after the Valsalva maneuver (all assessed at week 12); and change in the total workload as assessed by cardiopulmonary exercise testing at week 24.

RESULTS

A total of 282 patients underwent randomization: 142 to the aficamten group and 140 to the placebo group. The mean age was 59.1 years, 59.2% were men, the baseline mean resting left ventricular outflow tract gradient was 55.1 mm Hg, and the baseline mean left ventricular ejection fraction was 74.8%. At 24 weeks, the mean change in the peak oxygen uptake was 1.8 ml per kilogram per minute (95% confidence interval [CI], 1.2 to 2.3) in the aficamten group and 0.0 ml per kilogram per minute (95% CI, -0.5 to 0.5) in the placebo group (least-squares mean between-group difference, 1.7 ml per kilogram per minute; 95% CI, 1.0 to 2.4; P<0.001). The results for all 10 secondary end points were significantly improved with aficamten as compared with placebo. The incidence of adverse events appeared to be similar in the two groups.

CONCLUSIONS

Among patients with symptomatic obstructive HCM, treatment with aficamten resulted in a significantly greater improvement in peak oxygen uptake than placebo. (Funded by Cytokinetics; SEQUOIA-HCM ClinicalTrials.gov number, NCT05186818.).

Looking Back at 30 Years of Alcohol Septal Ablation and Looking Forward to the Future

In the 30 years since Dr Sigwart's first pioneering procedures, alcohol septal ablation (ASA) has become the standard catheterisation procedure to reduce or eliminate obstruction in the left ventricular outflow tract. This procedure reduces the pressure gradient by 70%-80%, and only 10%-20% of patients have a residual gradient > 30 mm Hg after ASA. The mortality rate of the procedure is < 1%, and ∼ 10% of patients require permanent pacemaker implantation for higher degrees of atrioventricular block. Given the potential risks, ASA should be performed only in centres with extensive experience in the treatment of hypertrophic cardiomyopathy and with comprehensive therapeutic options, including myectomy. In the future, ASA is likely to be increasingly complemented by catheter-based mitral valve repair, which will increase its efficacy.

Effect of Body Mass Index on Effectiveness of CT versus Invasive Coronary Angiography in Stable Chest Pain: The DISCHARGE Trial

Background Recent trials support the role of cardiac CT in the evaluation of symptomatic patients suspected of having coronary artery disease (CAD); however, body mass index (BMI) has been reported to negatively impact CT image quality. Purpose To compare initial use of CT versus invasive coronary angiography (ICA) on clinical outcomes in patients with stable chest pain stratified by BMI category. Materials and Methods This prospective study represents a prespecified BMI subgroup analysis of the multicenter Diagnostic Imaging Strategies for Patients with Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) trial conducted between October 2015 and April 2019. Adult patients with stable chest pain and a CAD pretest probability of 10%-60% were randomly assigned to undergo initial CT or ICA. The primary end point was major adverse cardiovascular events (MACE), including cardiovascular death, nonfatal myocardial infarction, or stroke. The secondary end point was an expanded MACE composite, including transient ischemic attack, and major procedure-related complications. Competing risk analyses were performed using the Fine and Gray subdistribution Cox proportional hazard model to assess the impact of the relationship between BMI and initial management with CT or ICA on the study outcomes, whereas noncardiovascular death and unknown causes of death were considered competing risk events. Results Among the 3457 participants included, 831 (24.0%), 1358 (39.3%), and 1268 (36.7%) had a BMI of less than 25, between 25 and 30, and greater than 30 kg/m2, respectively. No interaction was found between CT or ICA and BMI for MACE (P = .29), the expanded MACE composite (P = .38), or major procedure-related complications (P = .49). Across all BMI subgroups, expanded MACE composite events (CT, 10 of 409 [2.4%] to 23 of 697 [3.3%]; ICA, 26 of 661 [3.9%] to 21 of 422 [5.1%]) and major procedure-related complications during initial management (CT, one of 638 [0.2%] to five of 697 [0.7%]; ICA, nine of 630 [1.4%] to 12 of 422 [2.9%]) were less frequent in the CT versus ICA group. Participants with a BMI exceeding 30 kg/m² exhibited a higher nondiagnostic CT rate (7.1%, P = .044) compared to participants with lower BMI. Conclusion There was no evidence of a difference in outcomes between CT and ICA across the three BMI subgroups. Clinical trial registration no. NCT02400229 © RSNA, 2024 Supplemental material is available for this article.

Exercise Capacity in Patients With Obstructive Hypertrophic Cardiomyopathy: SEQUOIA-HCM Baseline Characteristics and Study Design

Patients with obstructive hypertrophic cardiomyopathy (oHCM) have increased risk of arrhythmia, stroke, heart failure, and sudden death. Contemporary management of oHCM has decreased annual hospitalization and mortality rates, yet patients have worsening health-related quality of life due to impaired exercise capacity and persistent residual symptoms. Here we consider the design of clinical trials evaluating potential oHCM therapies in the context of SEQUOIA-HCM (Safety, Efficacy, and Quantitative Understanding of Obstruction Impact of Aficamten in HCM). This large, phase 3 trial is now fully enrolled (N = 282). Baseline characteristics reflect an ethnically diverse population with characteristics typical of patients encountered clinically with substantial functional and symptom burden. The study will assess the effect of aficamten vs placebo, in addition to standard-of-care medications, on functional capacity and symptoms over 24 weeks. Future clinical trials could model the approach in SEQUOIA-HCM to evaluate the effect of potential therapies on the burden of oHCM. (Safety, Efficacy, and Quantitative Understanding of Obstruction Impact of Aficamten in HCM [SEQUOIA-HCM]; NCT05186818).

Effect of metoprolol in hypertrophic obstructive cardiomyopathy patients after alcohol septal ablation

Background

The use of beta-blockers in hypertrophic obstructive cardiomyopathy (HOCM) patients after alcohol septal ablation (ASA) lacks data support. We aimed to evaluate the effect of metoprolol on exercise capacity, hemodynamic and laboratory parameters, and quality of life in HOCM patients after ASA.

Methods

This was a prospective randomized single-center open-label crossover trial in 21 HOCM patients after ASA. Patients received metoprolol and no beta-blocker for two periods of three months. The endpoints were: peak oxygen uptake (pVO2), maximal left ventricular outflow tract (LVOT) pressure gradient at peak exercise, a ratio of mitral peak velocity of the early filling (E) to early diastolic mitral annular velocity (e') (E/e') at rest, Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary score, and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) plasmatic concentration.

Results

No significant association was found between the treatment and any of the endpoints in the assessed patients: 1) pVO2 (19.5 ± 5.3 ml/kg/min vs. 19.4 ± 4.1 ml/kg/min, p = 0.90), 2) exercise-induced pressure gradient in LVOT 32 ± 37 mmHg vs. 32 ± 30 mmHg, p = 0.84, 3) E/e' ratio at rest (11 ± 4 vs. 10 ± 4, p = 0.23), 4) KCCQ overall summary score (78 ± 11 vs. 77 te ± 15, p = 0.56), 5) NT-proBNP (215 pg/ml [121-333] vs. 153 pg/ml [102-228], p = 0.19).

Conclusions

In HOCM patients after successful ASA, metoprolol treatment did not improve exercise capacity, hemodynamic and laboratory parameters, or quality of life.

Computed Tomography Versus Invasive Coronary Angiography in Patients With Diabetes and Suspected Coronary Artery Disease

OBJECTIVE

To compare cardiac computed tomography (CT) with invasive coronary angiography (ICA) as the initial strategy in patients with diabetes and stable chest pain.

RESEARCH DESIGN AND METHODS

This prespecified analysis of the multicenter DISCHARGE trial in 16 European countries was performed in patients with stable chest pain and intermediate pretest probability of coronary artery disease. The primary end point was a major adverse cardiac event (MACE) (cardiovascular death, nonfatal myocardial infarction, or stroke), and the secondary end point was expanded MACE (including transient ischemic attacks and major procedure-related complications).

RESULTS

Follow-up at a median of 3.5 years was available in 3,541 patients of whom 557 (CT group n = 263 vs. ICA group n = 294) had diabetes and 2,984 (CT group n = 1,536 vs. ICA group n = 1,448) did not. No statistically significant diabetes interaction was found for MACE (P = 0.45), expanded MACE (P = 0.35), or major procedure-related complications (P = 0.49). In both patients with and without diabetes, the rate of MACE did not differ between CT and ICA groups. In patients with diabetes, the expanded MACE end point occurred less frequently in the CT group than in the ICA group (3.8% [10 of 263] vs. 8.2% [24 of 294], hazard ratio [HR] 0.45 [95% CI 0.22-0.95]), as did the major procedure-related complication rate (0.4% [1 of 263] vs. 2.7% [8 of 294], HR 0.30 [95% CI 0.13 - 0.63]).

CONCLUSIONS

In patients with diabetes referred for ICA for the investigation of stable chest pain, a CT-first strategy compared with an ICA-first strategy showed no difference in MACE and may potentially be associated with a lower rate of expanded MACE and major procedure-related complications.

Outcomes of Alcohol Septal Ablation in Patients With Severe Left Ventricular Outflow Tract Obstruction: A Propensity Score Matching Analysis

BACKGROUND

The current ACC/AHA guidelines on hypertrophic cardiomyopathy (HCM) caution that alcohol septal ablation (ASA) might be less effective in patients with left ventricular outflow tract obstruction (LVOTO) ≥ 100 mm Hg.

METHODS

We used a multinational registry to evaluate the outcome of ASA patients according to baseline LVOTO.

RESULTS

A total of 1346 ASA patients were enrolled and followed for 5.8 ± 4.7 years (7764 patient-years). The patients with baseline LVOTO ≥ 100 mm Hg were significantly older (61 ± 14 years vs 57 ± 13 years; P < 0.01), more often women (60% vs 45%; P < 0.01), and had a more pronounced HCM phenotype than those with baseline LVOTO < 100 mm Hg. There were no significant differences in the occurrences of 30-day major cardiovascular adverse events in the 2 groups. After propensity score matching (2 groups, 257 pairs of patients), the long-term survival was similar in both groups (P = 0.10), the relative reduction of LVOTO was higher in the group with baseline LVOTO ≥ 100 mm Hg (82 ± 21% vs 73 ± 26%; P < 0.01), but the residual resting LVOTO remained higher in this group (23 ± 29 mm Hg vs 13 ± 13 mm Hg; P < 0.01). Dyspnoea (NYHA functional class) at the most recent clinical check-up was similar in the 2 groups (1.7 ± 0.7 vs 1.7 ± 0.7; P = 0.85), and patients with baseline LVOTO ≥ 100 mm Hg underwent more reinterventions (P = 0.02).

CONCLUSIONS

After propensity matching, ASA patients with baseline LVOTO ≥ 100 mm Hg had similar survival and dyspnoea as patients with baseline LVOTO < 100 mm Hg, but their residual LVOTO and risk of repeated procedures were higher.

Invasive therapies for symptomatic obstructive hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is a genetic condition with multiple different genetic and clinical phenotypes. As awareness for HCM increases, it is important to also be familiar with potential treatment options for the disease. Treatment of HCM can be divided into two different categories, medical and interventional. Typically for obstructive forms of the disease, in which increased septal hypertrophy, abnormally placed papillary muscles, abnormalities in mitral valve or subvalvular apparatus, lead to dynamic left ventricular outflow tract (LVOT) obstruction, treatment is targeted at decreasing obstructive gradients and therefore symptoms. Medications like beta blockers, calcium channel blockers, disopyramide can often accomplish this. However, in patients with severe obstruction or symptoms refractory to medical therapy, either surgical correction of the LVOT obstruction or percutaneous via alcohol septal ablation, are treatment options. In this review, we will focus on the invasive treatment of hypertrophic obstructive cardiomyopathy.

Alcohol septal ablation for hypertrophic obstructive cardiomyopathy and bilateral lung transplantation for idiopathic pulmonary fibrosis: a case report

Background

We present an uncommon case of a patient with hypertrophic obstructive cardiomyopathy and idiopathic pulmonary fibrosis. The case demonstrates the importance of pre-transplant cardiology workup and the need of interdisciplinary approach in diagnosing the cause of dyspnoea.

Case summary

The 52-year-old male patient was diagnosed with idiopathic pulmonary fibrosis in 2019 and gradually became oxygen dependent due to progression of dyspnoea. Bilateral lung transplantation was recommended in 2021. During pre-transplant cardiology workup, the patient was diagnosed with hypertrophic cardiomyopathy with left ventricular outflow tract (LVOT) obstruction. Considering the high surgical risk of the patient, alcohol septal ablation was performed with subsequent decrease of LVOT gradient. Bilateral lung transplantation was successfully performed afterwards. The patient's symptoms improved to NYHA class II at one year follow-up.

Discussion

We present a rare case of combined cause of dyspnoea-coexistence of hypertrophic obstructive cardiomyopathy and idiopathic pulmonary fibrosis in one patient. Due to high surgical risk, the patient underwent alcohol septal ablation with successful elimination of LVOT gradient and subsequently bilateral lung transplantation.

Endothelin type A receptor blockade increases renoprotection in congestive heart failure combined with chronic kidney disease: Studies in 5/6 nephrectomized rats with aorto-caval fistula

BACKGROUND

Association of congestive heart failure (CHF) and chronic kidney disease (CKD) worsens the patient's prognosis and results in poor survival rate. The aim of this study was to examine if addition of endothelin type A (ET_A) receptor antagonist to the angiotensin-converting enzyme inhibitor (ACEi) will bring additional beneficial effects in experimental rats.

METHODS

CKD was induced by 5/6 renal mass reduction (5/6 NX) and CHF was elicited by volume overload achieved by creation of aorto-caval fistula (ACF). The follow-up was 24 weeks after the first intervention (5/6 NX). The treatment regimens were initiated 6 weeks after 5/6 NX and 2 weeks after ACF creation.

RESULTS

The final survival in untreated group was 15%. The treatment with ET_A receptor antagonist alone or ACEi alone and the combined treatment improved the survival rate to 64%, 71% and 75%, respectively, however, the difference between the combination and either single treatment regimen was not significant. The combined treatment exerted best renoprotection, causing additional reduction in albuminuria and reducing renal glomerular and tubulointerstitial injury as compared with ACE inhibition alone.

CONCLUSIONS

Our results show that treatment with ET_A receptor antagonist attenuates the CKD- and CHF-related mortality, and addition of ET_A receptor antagonist to the standard blockade of RAS by ACEi exhibits additional renoprotective actions.

Endothelin type A receptor blockade attenuates aorto-caval fistula-induced heart failure in rats with angiotensin II-dependent hypertension

OBJECTIVE

Evaluation of the effect of endothelin type A (ET A ) receptor blockade on the course of volume-overload heart failure in rats with angiotensin II-dependent hypertension.

METHODS

Ren-2 renin transgenic rats (TGR) were used as a model of hypertension. Heart failure was induced by creating an aorto-caval fistula (ACF). Selective ET A receptor blockade was achieved by atrasentan. For comparison, other rat groups received trandolapril, an angiotensin-converting enzyme inhibitor (ACEi). Animals first underwent ACF creation and 2 weeks later the treatment with atrasentan or trandolapril, alone or combined, was applied; the follow-up period was 20 weeks.

RESULTS

Eighteen days after creating ACF, untreated TGR began to die, and none was alive by day 79. Both atrasentan and trandolapril treatment improved the survival rate, ultimately to 56% (18 of 31 animals) and 69% (22 of 32 animals), respectively. Combined ACEi and ET A receptor blockade improved the final survival rate to 52% (17 of 33 animals). The effects of the three treatment regimens on the survival rate did not significantly differ. All three treatment regimens suppressed the development of cardiac hypertrophy and lung congestion, decreased left ventricle (LV) end-diastolic volume and LV end-diastolic pressure, and improved LV systolic contractility in ACF TGR as compared with their untreated counterparts.

CONCLUSION

The treatment with ET A receptor antagonist delays the onset of decompensation of volume-overload heart failure and improves the survival rate in hypertensive TGR with ACF-induced heart failure. However, the addition of ET A receptor blockade did not enhance the beneficial effects beyond those obtained with standard treatment with ACEi alone.

Do female patients with hypertrophic cardiomyopathy have a worse prognosis than male patients?

Aim

Sex affects the prognosis of many cardiovascular diseases. This study aimed to assess the predicted sudden cardiac death (SCD) risk and evaluate the actual survival between male and female patients with hypertrophic cardiomyopathy (HCM).

Methods

We included 573 HCM patients diagnosed between 1998 and 2021 in a tertiary cardiovascular centre. We compared the SCD prediction values, both European (ESC) and American (ACC/AHA) systems, the ICD (implantable cardioverter-defibrillator) implantation rates and the long-term survival analysis.

Results

There were 240 (41.8%) females with HCM. Total number of 62 ICDs (10.8%) were implanted, 39 in males, 23 in females (11.7% vs 9.6%, p=0.49). Average calculated ESC SCD risk was 2.71% in 5 years; 2.77% in males, 2.65% in females (p=0.81). Average number of ACC/AHA major risk SCD factors was 0.25; 0.25 in males and 0.24 in females (p=0.94). Mean length of follow-up (FU) was 9.2 years, median 8.6 years. Total of 100 patients died during FU, 42 (12.6%) males a 58 (17.5%) females (Figure 1). The cause of death is attached in the Figure 2. Mean age at diagnosis was 48.9 years in males, 57.3 years in females, difference 8.4±1.3 years (95% CI 5.8–10.9, p&lt;0.01). Mean left ventricular wall thickness (LVWT) was 18.5 mm in males, 18.0 mm in females, not statistically significant difference (0.5±0.4 mm; 95% CI −1.3–0.3; p=0.22). In Cox-regression model, female sex was not identified as an independent predictor of mortality, on the contrary of age and LVWT (Figure 2).

Conclusion

In our patients, we predicted a low risk of SCD using both ESC and ACC/AHA models. The finding aligns with a relatively low number of implanted ICDs and actual survival rates. Female patients seemed to have a worse prognosis, probably due to older age at diagnosis and non-SCD causes of death.

Funding Acknowledgement

Type of funding sources: None.

Prediction of Sudden Cardiac Arrest After Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy: ASA-SCARRE Risk Score

This study aimed to derive a new score, the Alcohol Septal Ablation-Sudden Cardiac ARREst (ASA-SCARRE) risk score, that can be easily used to evaluate the risk of sudden cardiac arrest events (sudden cardiac death, resuscitation, or appropriate implantable cardioverter-defibrillator discharge) after alcohol septal ablation (ASA) in patients with hypertrophic obstructive cardiomyopathy. We analyzed 1,834 patients from the Euro-ASA registry (49% men, mean age 57 ± 14 years) who were followed up for 5.0 ± 4.3 years (9,202 patient-years) after ASA. A total of 65 patients (3.5%) experienced sudden cardiac arrest events, translating to 0.72 events per 100 patient-years. The independent predictors of sudden cardiac arrest events were septum thickness before ASA (hazard ratio 1.09 per 1 mm, 95% confidence interval 1.04 to 1.14, p <0.001) and left ventricular outflow tract (LVOT) gradient at the last clinical checkup (hazard ratio 1.01 per 1 mm Hg, 95% confidence interval 1.01 to 1.02, p = 0.002). The following ASA-SCARRE risk scores were derived and independently predicted long-term risk of sudden cardiac arrest events: "0" for both LVOT gradient <30 mmHg and baseline septum thickness <20 mm; "1" for LVOT gradient ≥30 mm Hg or baseline septum thickness ≥20 mm; and "2" for both LVOT gradient ≥30 mm Hg and baseline septum thickness ≥20 mm. The C statistic of the ASA-SCARRE risk score was 0.684 (SE 0.030). In conclusion, the ASA-SCARRE risk score may be a useful and easily available clinical tool to predict risk of sudden cardiac arrest events after ASA in patients with hypertrophic obstructive cardiomyopathy.

Management of Massive Pulmonary Embolism

Pulmonary embolism is a potentially lethal manifestation of venous thromboembolic disease. It is one of the three main causes of cardiovascular morbidity and mortality in developed countries. Over the years, better diagnostic and risk stratification measures were implemented. A generous range of new treatment options is becoming available, particularly for management of massive pulmonary embolism. Nonetheless, clinicians often face uncertainty in clinical practice due to lack of scientific support for available treatment options. The aim of this article is to review management of massive pulmonary embolism.

Comparison of 30-Day Outcomes after Carotid Artery Stenting in Patients with Near-Occlusion and Severe Stenosis: A Propensity Score Matching Analysis

BACKGROUND AND PURPOSE

Carotid artery near-occlusion is a type of severe stenosis with complete or partial distal luminal collapse and intracranial collaterals. This study aimed to compare 30-day outcomes and 10-year survival in patients undergoing carotid artery stenting for near-occlusion with a control group of patients with severe stenosis.

MATERIALS AND METHODS

We used data from a registry of 639 patients who underwent 789 carotid artery stenting procedures between 2005 and 2021. The primary end point was any stroke or death within 30 days after carotid artery stenting. Patients were matched using propensity scores based on 6 variables.

RESULTS

Propensity score matching yielded 84 subjects in the near-occlusion group matched with 168 subjects in the control group. In the matched cohort, the primary end point occurred in 7 (8.3%) and 11 (6.6%) patients in the near-occlusion and control groups, respectively (P = .611). In the unmatched cohort, the primary end point occurred in 7 (8.3%) and 19 (4.1%) patients (P = .101). Survival in the near-occlusion group versus the control group in the matched cohort at 5 and 10 years was 69.8% (95% CI, 58.0%-78.8%) versus 77.3% (95% CI, 70.0%-83.1%) and 53.3% (95% CI, 39.9%-65.0%) versus 53.3% (95% CI, 44.5%-61.4%) (log-rank, P = .798).

CONCLUSIONS

Carotid stent placement in patients with ICA near-occlusion was not associated with an increased 30-day risk of stroke or death compared with severe stenosis. Survival up to 10 years after carotid artery stenting was similar in both groups.

Left ventricular reverse remodelling and its predictors in non-ischaemic cardiomyopathy

Adverse remodelling following an initial insult is the hallmark of heart failure (HF) development and progression. It is manifested as changes in size, shape, and function of the myocardium. While cardiac remodelling may be compensatory in the short term, further neurohumoral activation and haemodynamic overload drive this deleterious process that is associated with impaired prognosis. However, in some patients, the changes may be reversed. Left ventricular reverse remodelling (LVRR) is characterized as a decrease in chamber volume and normalization of shape associated with improvement in both systolic and diastolic function. LVRR might occur spontaneously or more often in response to therapeutic interventions that either remove the initial stressor or alleviate some of the mechanisms that contribute to further deterioration of the failing heart. Although the process of LVRR in patients with new‐onset HF may take up to 2 years after initiating treatment, there is a significant portion of patients who do not improve despite optimal therapy, which has serious clinical implications when considering treatment escalation towards more aggressive options. On the contrary, in patients that achieve delayed improvement in cardiac function and architecture, waiting might avoid untimely implantable cardioverter‐defibrillator implantation. Therefore, prognostication of successful LVRR based on clinical, imaging, and biomarker predictors is of utmost importance. LVRR has a positive impact on prognosis. However, reverse remodelled hearts continue to have abnormal features. In fact, most of the molecular, cellular, interstitial, and genome expression abnormalities remain and a susceptibility to dysfunction redevelopment under biomechanical stress persists in most patients. Hence, a distinction should be made between reverse remodelling and true myocardial recovery. In this comprehensive review, current evidence on LVRR, its predictors, and implications on prognostication, with a specific focus on HF patients with non‐ischaemic cardiomyopathy, as well as on novel drugs, is presented.

Long-term changes after carotid stenting assessed by intravascular ultrasound and near-infrared spectroscopy

BACKGROUND

Long-term effect of carotid stenting (CAS) on the stabilization of the plaque is almost unrecognized. Vascular healing and remodeling might seal the atherosclerotic plaque with neointimal hyperplasia decreasing the vulnerability. We aimed to assess long-term change in the lipid signal, stent and luminal dimensions and restenosis after CAS with the intravascular ultrasound (IVUS) and near-infrared spectroscopy (NIRS) imaging.

METHODS

We performed follow-up angiography and NIRS-IVUS imaging of 58 carotid stents in 52 patients. Median time from CAS to the follow-up examination was 31 months (range, 5-56). The lipid signal of the stented segment was calculated from a NIRS-derived chemogram (a spectroscopic map) as the lipid core burden index (LCBI, a dimensionless number from 0 to 1,000). Planimetric and volumetric measurements from IVUS were performed to assess change in minimal stent area (MSA), minimal luminal area (MLA), stent and luminal volume, late stent expansion and percentage in-stent restenosis (ISR) volume.

RESULTS

During the follow-up period, the mean (±SD) LCBI significantly decreased from 32±56 to 17±27 (P=0.002). The mean stent volume significantly increased from 717±302 to 1,019±429 mm3 (P<0.001) with mean stent expansion 43%±24%. The mean luminal volume increased from 717±302 to 760±359 mm3 (P=0.025) due to ISR encroaching 26%±15% of the stent volume.

CONCLUSIONS

Lipid signal decreased during the follow-up period suggesting stabilization of the plaque. Late stent expansion was balanced with neointimal hyperplasia.

TRIAL REGISTRATION

The trial is registered under clinicaltrials.gov NCT03141580.

Kidney Response to Chemotherapy-Induced Heart Failure: mRNA Analysis in Normotensive and Ren-2 Transgenic Hypertensive Rats

The aim of the present study was to perform kidney messenger ribonucleic acid (mRNA) analysis in normotensive, Hannover Sprague-Dawley (HanSD) rats and hypertensive, Ren-2 renin transgenic rats (TGR) after doxorubicin-induced heart failure (HF) with specific focus on genes that are implicated in the pathophysiology of HF-associated cardiorenal syndrome. We found that in both strains renin and angiotensin-converting enzyme mRNA expressions were upregulated indicating that the vasoconstrictor axis of the renin-angiotensin system was activated. We found that pre-proendothelin-1, endothelin-converting enzyme type 1 and endothelin type A receptor mRNA expressions were upregulated in HanSD rats, but not in TGR, suggesting the activation of endothelin system in HanSD rats, but not in TGR. We found that mRNA expression of cytochrome P-450 subfamily 2C23 was downregulated in TGR and not in HanSD rats, suggesting the deficiency in the intrarenal cytochrome P450-dependent pathway of arachidonic acid metabolism in TGR. These results should be the basis for future studies evaluating the pathophysiology of cardiorenal syndrome secondary to chemotherapy-induced HF in order to potentially develop new therapeutic approaches.

Alcohol dose in septal ablation for hypertrophic obstructive cardiomyopathy

BACKGROUND

The aim of this study was to evaluate short- and long-term outcomes related to dose of alcohol administered during alcohol septal ablation (ASA) in patients with hypertrophic obstructive cardiomyopathy (HOCM). Current guidelines recommend using 1-3 mL of alcohol administered in the target septal perforator artery, but this recommendation is based more on practical experience of interventionalists rather than on systematic evidence.

METHODS

We included 1448 patients and used propensity score to match patients who received a low-dose (1.0-1.9 mL) versus a high-dose (2.0-3.8 mL) of alcohol during ASA.

RESULTS

The matched cohort analysis comprised 770 patients (n = 385 in both groups). There was a similar occurrence of 30-day post-procedural adverse events (13% vs. 12%; p = 0.59), and similar all-cause mortality rates (0.8% vs. 0.5%; p = 1) in the low-dose group and the high-dose group, respectively. In the long-term follow-up (5.4 ± 4.5 years), a total of 110 (14%) patients died representing 2.58 deaths and 2.64 deaths per 100 patient-years in the low dose and the high dose group (logrank, p = 0.92), respectively. There were no significant differences in the long-term dyspnea and left ventricular outflow gradient between the two groups. Patients treated with a low-dose of alcohol underwent more subsequent septal reduction procedures (logrank, p = 0.04).

CONCLUSIONS

Matched HOCM patients undergoing ASA with a low-dose (1.0-1.9 mL) or a high-dose (2.0-3.8 mL) of alcohol had similar short- and long-term outcomes. A higher rate of repeated septal reduction procedures was observed in the group treated with a low-dose of alcohol.

Optical Coherence Tomography of the Coronary Arteries

Intravascular imaging, particularly optical coherence tomography, has brought significant improvement in diagnostic and therapeutical approaches to coronary artery disease and has offered superior high-resolution visualization of coronary arteries. The ability to obtain images of intramural and transmural coronary structures allows the study of the process of atherosclerosis, effect of therapies, mechanism of acute coronary syndrome and stent failure, and performance of new devices and enables the interventional cardiologist to optimize the effect of percutaneous coronary intervention. In this review, we provide the summary of the latest published data on clinical use of optical coherence tomography as well as practical algorithm for optical coherence tomography-guided percutaneous coronary intervention for daily interventional practice.

A comprehensive interdisciplinary view at the Return to Sport after COVID-19 infection

The COVID-19 pandemic has affected the whole world. It applies to all age and social groups. It is no different with athletes. So far, we cannot say for sure what the long-term consequences of SARS-CoV-2 infection are. Recent evidence, however, suggests that we should be very careful when returning to sports. After self-isolation, the athlete should undergo a Preparticipation Physical Examination and then pay attention to the gradual dosing of the load to prevent complications. Lifestyle changes and care for the mental health of athletes are also necessary during the illness. In this work, we present a comprehensive methodology for returning to sports after COVID-19 for medical and coaching teams caring for athletes divided according to the course of the disease. In scientific literature, similar algorithms are called "Return to Play" or "Return to Sport". Creating an exact algorithm can make the Return to Play process more efficient and safer. However, increased attention still needs to be paid to certain organ systems and specific symptoms that could indicate long-term consequences to the new type of coronavirus.

Long-term survival of carotid stenting patients with regard to single- or double-vessel carotid artery disease: a propensity score matching analysis

INTRODUCTION

There is lack of long-term data outside of controlled clinical trials in carotid artery stenting (CAS). In this study, we compared the short-term outcome, long-term survival, and rate of re-interventions for restenosis in patients after CAS, related to the extent of carotid atherosclerosis classified as single-vessel (unilateral) or double-vessel (bilateral) carotid artery disease.

MATERIAL AND METHODS

We retrospectively evaluated 599 patients with significant carotid artery stenosis, who underwent 763 CAS procedures, and used the propensity score to match 226 pairs (452 patients) in the single- or double-vessel carotid disease.

RESULTS

There was no significant difference in the occurrence of in-hospital major adverse events (3.5% vs. 3.1% of patients in the double-vessel carotid group vs. the single-vessel carotid group; p = 1) The mean follow-up was 6.1 ±4.0 years, and a total of 181 (40%) deaths occurred during 2759 patient-years, which translates into 7.8 and 5.3 deaths per 100 patient-years in the double-vessel carotid group and the single-vessel carotid group, respectively (p < 0.01). The survival in the double-vessel carotid group vs. the single-vessel carotid group at 10 years was 46% (95% CI: 38-54%) vs. 55% (95% CI: 47-63%) (p < 0.01). Twenty-four (11%) patients and 6 (3%) patients underwent re-interventions for restenosis in the double-vessel and the single-vessel carotid disease group, respectively (p < 0.01).

CONCLUSIONS

Patients with CAS and significant double-vessel carotid artery disease had similar peri-procedural risk, but had a worse long-term survival, and a higher rate of re-interventions for restenosis compared to the single-vessel carotid artery disease patients.

Deleterious Effects of Hyperactivity of the Renin-Angiotensin System and Hypertension on the Course of Chemotherapy-Induced Heart Failure after Doxorubicin Administration: A Study in Ren-2 Transgenic Rat

Doxorubicin's (DOX) cardiotoxicity contributes to the development of chemotherapy-induced heart failure (HF) and new treatment strategies are in high demand. The aim of the present study was to characterize a DOX-induced model of HF in Ren-2 transgenic rats (TGR), those characterized by hypertension and hyperactivity of the renin-angiotensin-aldosterone system, and to compare the results with normotensive transgene-negative, Hannover Sprague-Dawley (HanSD) rats. DOX was administered for two weeks in a cumulative dose of 15 mg/kg. In HanSD rats DOX administration resulted in the development of an early phase of HF with the dominant symptom of bilateral cardiac atrophy demonstrable two weeks after the last DOX injection. In TGR, DOX caused substantial impairment of systolic function already at the end of the treatment, with further progression observed throughout the experiment. Additionally, two weeks after the termination of DOX treatment, TGR exhibited signs of HF characteristic for the transition stage between the compensated and decompensated phases of HF. In conclusion, we suggest that DOX-induced HF in TGR is a suitable model to study the pathophysiological aspects of chemotherapy-induced HF and to evaluate novel therapeutic strategies to combat this form of HF, which are urgently needed.

Effectiveness of alcohol septal ablation for hypertrophic obstructive cardiomyopathy in patients with late gadolinium enhancement on cardiac magnetic resonance

BACKGROUND

According to European guidelines, alcohol septal ablation (ASA) for hypertrophic obstructive cardiomyopathy (HOCM) may be less effective in patients with extensive septal scarring on cardiac magnetic resonance (CMR). This study aimed to analyze the impact of late gadolinium enhancement (LGE) on CMR on the effectiveness of ASA.

METHOD

We conducted an observational retrospective study involving adult patients with symptomatic drug-refractory HOCM who underwent CMR before ASA at two European centres from May 2010 through June 2019. Patients were compared in binary format based on LGE presence. Moreover, a subanalysis focused on patients with septal fibrosis was performed. The effectiveness of ASA was evaluated by echocardiographic, ECG and clinical findings.

RESULTS

Of the 113 study patients, 54 (48%) had LGE on CMR. The LGE quantification performed in 29 patients revealed septal fibrosis in 17. The mean follow-up was 4.4 ± 2.6 years. Baseline parameters were similar between groups except for basal septal thickness that was greater in LGE+ group (21.1 ± 3.9 mm for LGE+ vs. 19.2 ± 3.2 mm for LGE-: p = .005). ASA improved symptoms in all groups and reduced left ventricular outflow tract obstruction (LVOTO) (delta gradient reduction: LGE+: 62 ± 37.3%; septal LGE+: 75.6 ± 20.8%; LGE-: 72.5 ± 21.0%). However, 13% of the LGE+ and 2% of the LGE- group had residual LVOTO above 30 mmHg (p = .027).

CONCLUSION

ASA was effective in all patients with HOCM, whether they had LGE on CMR or not and whether they had septal fibrosis or not.

Patent foramen ovale screening and prevention of decompression sickness in divers

Background/Introduction

Patent foramen ovale (PFO) is associated with increased risk of decompression sickness (DCS) due to paradoxical embolization of nitrogen bubbles that form during and after ascent. Screening for PFO using transcranial Doppler ultrasonography (TCD) is currently not recommended for all divers. If a diver is diagnosed with a high-grade PFO and wishes to continue diving there are currently two options to reduce the risk of DCS: catheter-based PFO closure or recommendation of conservative approach to diving. However, to date the evidence for the long-term effectiveness of these measures is limited.

Purpose

This study sought to compare the effectiveness of catheter-based PFO closure and conservative diving in the reduction of DCS incidence in divers with a high-grade PFO.

Methods

A total of 829 consecutive divers (35.4±10.0 yrs, 81.5% males) were screened for PFO between January 2006 and December 2018 by means of TCD. All patients were prospectively included in the study registry. Patients with a high-grade PFO were offered either catheter-based PFO closure (closure group) or advised to dive within the limits of recreational diving (conservative group). A trans-telephonic follow-up was performed at the end of the study. In this study we compared the incidence rate of DCS prior to enrollment and during the follow-up period in the closure and conservative group.

Results

Follow-up was available in 748 (90%) divers. Mean follow-up was 6.5±3.5 years. There were a total of 154 divers with a high-grade PFO that continued diving after the initial screening examination. Fifty-five (36%) of them underwent a catheter-based PFO closure (closure group), the remaining 98 divers were advised to dive within the limits of recreational diving (conservative group). The 55 divers in the closure group performed a total of 63,436 dives (30,684 prior to enrollment and 32,752 during the follow-up). Prior to enrollment there were 108 DCS episodes in 33 divers (incidence rate 3.3/1000 dives) and none during follow-up (p&lt;0.001). The 98 divers in the conservative group performed a total of 48,069 dives (25,328 prior to enrollment and 22,741 during follow-up). There were 91 DCS episodes in 33 divers (incidence rate 3.6/1000 dives) prior to enrollment and 19 episodes in 11 divers (incidence rate 0.75/1000 dives) during follow-up (p&lt;0.001). The incidence rate of DCS was similar for both groups prior to enrollment (p=0.196) but lower in the closure group during the post-interventional follow-up (p&lt;0.001).

Conclusion(s)

In divers with a high-grade PFO both strategies decreased the incidence rate of DCS. Catheter-based PFO closure was more effective than conservative approach. The results also suggest that divers might benefit from screening for PFO.

Funding Acknowledgement

Type of funding source: None

Assessment of internal carotid artery stenosis and results of carotid stenting by angiography compared with intravascular ultrasound

Background/Introduction

Intravascular imaging is commonly used in coronary interventions and improves outcomes. On the contrary, it is almost unrecognized for the guidance of carotid stenting (CAS).

Purpose

The aim of this study was to compare quantitative angiography (QA) and intravascular ultrasound (IVUS) in the assessment of the severity of carotid stenosis and residual stenosis in patients undergoing CAS and to provide reference values for IVUS measurements of the internal carotid artery (ICA) in the European population.

Methods

IVUS imaging was performed during 151 CAS procedures in 140 patients from April 2013 to December 2019. In total 162 self-expanding stents of different design were implanted (66% closed-cell, 22% open-cell, 8% hybrid, 4% double layer micromesh stents). IVUS was used to measure distal reference diameter and area of ICA, minimal luminal diameter (MLD) and minimal luminal area (MLA) before and after CAS. IVUS and QA were used to measure relative stenosis area (stenosis) at baseline and relative residual stenosis area (residual stenosis) after CAS. Relative stenosis area was calculated as [1 − (MLA / distal reference area)] x 100.

Results

Mean (±SD) distal reference diameter of ICA was 4.5±0.8 mm. MLD increased from 1.9±0.4 mm to 3.6±0.6 mm after CAS (p&lt;0.001). MLA increased from 3.9±1.7 mm2 to 12.0±3.4 mm2 after CAS (p&lt;0.001). Stenosis measured by QA and IVUS was 84±9% and 76±13% respectively (p=0.01). There was a moderate correlation (Pearson's correlation coefficient r=0.575; p=0.01) between QA and IVUS measurement of ICA stenosis severity. Residual stenosis measured by QA and IVUS was 12±10% and 40±16% (p&lt;0.001) respectively with only weak correlation (r=0.433; p&lt;0.001) between the two methods.

Conclusion

Angiography slightly overestimates stenosis of internal carotid artery and substantially underestimates residual stenosis after CAS compared to IVUS. Angiography alone is inaccurate in the assessment of ICA stenosis and results of carotid stenting.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): University Hospital Motol

Short- and long-term outcomes of alcohol septal ablation for hypertrophic obstructive cardiomyopathy in patients with mild left ventricular hypertrophy: a propensity score matching analysis

AIMS

Based on European guidelines, alcohol septal ablation (ASA) for hypertrophic obstructive cardiomyopathy (HOCM) is indicated only in patients with interventricular septum (IVS) thickness >16 mm. The aim of this study was to evaluate the short- and long-term outcomes in ASA patients with mild hypertrophy (IVS ≤ 16 mm).

METHODS AND RESULTS

We retrospectively evaluated 1505 consecutive ASA patients and used propensity score to match 172 pairs (344 patients) in groups IVS ≤ 16 mm or IVS > 16 mm. There was no occurrence of post-ASA ventriculoseptal defect in the whole cohort (n = 1505). Matched patients had 30-day mortality rate 0% in IVS ≤ 16 mm group and 0.6% in IVS > 16 mm group (P = 1). Patients in IVS ≤ 16 mm group had more ASA-attributable early complications (16% vs. 9%; P = 0.049), which was driven by higher need for pacemaker implantation (13% vs. 8%; P = 0.22). The mean follow-up was 5.4 ± 4.3 years and the annual all-cause mortality rate was 1.8 and 3.2 deaths per 100-patient-years in IVS ≤ 16 group and IVS > 16 group, respectively (log-rank test P = 0.04). There were no differences in symptom relief and left ventricular (LV) gradient reduction. Patients with IVS ≤ 16 mm had less repeated septal reduction procedures (log-rank test P = 0.03).

CONCLUSION

Selected patients with HOCM and mild hypertrophy (IVS ≤ 16 mm) had more early post-ASA complications driven by need for pacemaker implantation, but their long-term survival is better than in patients with IVS >16 mm. While relief of symptoms and LV obstruction reduction is similar in both groups, a need for repeat septal reduction is higher in patients with IVS > 16 mm.

Clinical pre-test probability for obstructive coronary artery disease: insights from the European DISCHARGE pilot study

Objectives

To test the accuracy of clinical pre-test probability (PTP) for prediction of obstructive coronary artery disease (CAD) in a pan-European setting.

Methods

Patients with suspected CAD and stable chest pain who were clinically referred for invasive coronary angiography (ICA) or computed tomography (CT) were included by clinical sites participating in the pilot study of the European multi-centre DISCHARGE trial. PTP of CAD was determined using the Diamond-Forrester (D+F) prediction model initially introduced in 1979 and the updated D+F model from 2011. Obstructive coronary artery disease (CAD) was defined by one at least 50% diameter coronary stenosis by both CT and ICA.

Results

In total, 1440 patients (654 female, 786 male) were included at 25 clinical sites from May 2014 until July 2017. Of these patients, 725 underwent CT, while 715 underwent ICA. Both prediction models overestimated the prevalence of obstructive CAD (31.7%, 456 of 1440 patients, PTP: initial D+F 58.9% (28.1–90.6%), updated D+F 47.3% (34.2–59.9%), both p < 0.001), but overestimation of disease prevalence was higher for the initial D+F (p < 0.001). The discriminative ability was higher for the updated D+F 2011 (AUC of 0.73 95% confidence interval [CI] 0.70–0.76 versus AUC of 0.70 CI 0.67–0.73 for the initial D+F; p < 0.001; odds ratio (or) 1.55 CI 1.29–1.86, net reclassification index 0.11 CI 0.05–0.16, p < 0.001).

Conclusions

Clinical PTP calculation using the initial and updated D+F prediction models relevantly overestimates the actual prevalence of obstructive CAD in patients with stable chest pain clinically referred for ICA and CT suggesting that further refinements to improve clinical decision-making are needed.

Trial registration

https://www.clinicaltrials.gov/ct2/show/NCT02400229

Key Points

• Clinical pre-test probability calculation using the initial and updated D+F model overestimates the prevalence of obstructive CAD identified by ICA and CT.

• Overestimation of disease prevalence is higher for the initial D+F compared with the updated D+F.

• Diagnostic accuracy of PTP assessment varies strongly between different clinical sites throughout Europe.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-07175-z) contains supplementary material, which is available to authorized users.

Ten Tips and Tricks for Performing Alcohol Septal Ablation in Patients with Hypertrophic Obstructive Cardiomyopathy

Alcohol septal ablation (ASA) is an effective interventional therapeutic strategy to reduce or eliminate left ventricular outflow tract obstruction in patients with hypertrophic obstructive cardiomyopathy (HOCM). Although ASA was introduced 25 years ago, there are still no available guidelines to follow. Therefore, most interventional cardiologists rely on their own experience, which is often limited by a relatively low number of performed procedures. This paper presents ten tips and tricks to safe and effective ASA for HOCM.

Combined percutaneous approach for aortic valve implantation in poor vascular access

Transcatheter aortic valve implantation (TAVI) is a well-established management option for symptomatic patients with severe aortic stenosis. The minimally invasive transfemoral approach is considered to be superior to non-transfemoral accesses; however, its use is often limited by concomitant peripheral artery disease (PAD). Percutaneous transluminal angioplasty with stent implantation (PTA) is a gold-standard therapy for symptomatic PAD. We present 2 cases from our cohort of patients with severe aortic stenosis and PAD previously contraindicated for TAVI because of poor peripheral vascular access. However, the patients were eventually treated either by staged PTA and TAVI through an endothelialized stent or PTA and TAVI though a newly implanted peripheral stent during one procedure. We provide recommendations based on our experience of how to select the optimal patients for such a combined minimally invasive transfemoral approach (Fig. 2, Ref. 9). Keywords: transcatheter valve implantation, peripheral arterial disease, aortic valve disease, percutaneous intervention, atherosclerosis.

Carotid artery plaque composition and distribution: near-infrared spectroscopy and intravascular ultrasound analysis

Most atherosclerotic plaques (APs) form in typical predilection areas of low endothelial shear stress (ESS). On the contrary, previous data hinted that plaques rupture in their proximal parts where accelerated blood flow causes high ESS. It was postulated that high ESS plays an important role in the latter stages of AP formation and in its destabilization. Here, we used near-infrared spectroscopy (NIRS) to analyse the distribution of lipid core based on the presumed exposure to ESS. A total of 117 carotid arteries were evaluated using NIRS and intravascular ultrasound (IVUS) prior to carotid artery stenting. The point of minimal luminal area (MLA) was determined using IVUS. A stepwise analysis of the presence of lipid core was then performed using NIRS. The lipid core presence was quantified as the lipid core burden index (LCBI) within 2 mm wide segments both proximally and distally to the MLA. The analysed vessel was then divided into three 20 mm long thirds (proximal, middle, and distal) for further analysis. The maximal value of LCBI (231.9 ± 245.7) was noted in the segment localized just 2 mm proximally to MLA. The mean LCBI in the middle third was significantly higher than both the proximal (121.4 ± 185.6 vs. 47.0 ± 96.5, P < 0.01) and distal regions (121.4 ± 185.6 vs. 32.4 ± 89.6, P < 0.01). Lipid core was more common in the proximal region when compared with the distal region (mean LCBI 47.0 ± 96.5 vs. 32.4 ± 89.6, P < 0.01).

Correction to: Health-related qualify of life, angina type and coronary artery disease in patients with stable chest pain

An amendment to this paper has been published and can be accessed via the original article.

Nonpharmacological Treatment of Atrial Fibrillation: What Is the Role of Device Therapy?

Atrial fibrillation is the most common arrhythmia in the adult population, and its incidence and prevalence are still rising. Cardiac devices are widely used in clinical practice in the management of various rhythm disturbances and heart failure treatment. Many patients who receive a pacemaker, implantable cardioverter-defibrillator, or cardiac resynchronization therapy also experience atrial fibrillation in the course of their life. Therefore, this review aims to describe the role of these devices in the treatment and prevention of atrial fibrillation in the device recipients. In addition, all these implantable devices also serve as permanent ECG (electrocardiogram) monitors, thus providing important information about the presence and characteristics of atrial fibrillation that may or may not be detected by the patient but can modify our therapeutical approach with regard to the stroke prevention.

Patients with hypertrophic obstructive cardiomyopathy after alcohol septal ablation have favorable long-term outcome irrespective of their genetic background

Background

The genetic background of patients with hypertrophic cardiomyopathy (HCM) treated with alcohol septal ablation (ASA) and its relationship to the outcomes are not known. We aimed to investigate whether the outcome of genotype positive (G+) patients differs from genotype negative (G-) patients treated with ASA.

Methods

We included 129 HCM patients (mean age 54±13 years) treated with ASA in a tertiary cardiovascular center and performed next generation sequencing (NGS) based genomic testing. All patients were followed-up three months after the procedure and yearly thereafter.

Results

A total of 30 (23%) HCM patients were G+ patients. At the 3-months follow-up, both groups of patients had similar left ventricular outflow tract PG (16.9±15.7 mmHg in G+ vs. 16.3±18.8 mmHg in G-, P=0.73) and symptoms (follow-up NYHA class 1.40±0.62 vs. 1.37±0.53, P=0.99, follow-up CCS class 0.23±0.52 vs. 0.36±0.65, P=0.36). The independent predictors of all-cause mortality were baseline interventricular septum (IVS) thickness (HR 1.12, 95% CI: 1.00-1.26, P=0.049) and age at the time of ASA (HR 1.11, 95% CI: 1.06-1.17, P<0.01). The adjusted all-cause mortality rate did not differ significantly between G+ and G- patients (P=0.52). The adjusted combined mortality event rate did not differ between both groups (P=0.78).

Conclusions

Despite more severe phenotype in G+ HCM patients, ASA is an equally effective treatment for LVOTO in G+ patients as it is for treating LVOTO in G- patients. The long-term outcome after ASA is similar in G+ and G- patients.

Health-related qualify of life, angina type and coronary artery disease in patients with stable chest pain

BACKGROUND

Health-related quality of life (HRQoL) is impaired in patients with stable angina but patients often present with other forms of chest pain. The aim of this study was to compare the pre-diagnostic HRQoL in patients with suspected coronary artery disease (CAD) according to angina type, gender, and presence of obstructive CAD.

METHODS

From the pilot study for the European DISCHARGE trial, we analysed data from 24 sites including 1263 patients (45.9% women, 61.1 ± 11.3 years) who were clinically referred for invasive coronary angiography (ICA; 617 patients) or coronary computed tomography angiography (CTA; 646 patients). Prior to the procedures, patients completed HRQoL questionnaires: the Short Form (SF)-12v2, the EuroQoL (EQ-5D-3 L) and the Hospital Anxiety and Depression Scale.

RESULTS

Fifty-five percent of ICA and 35% of CTA patients had typical angina, 23 and 33% had atypical angina, 18 and 28% had non-anginal chest discomfort and 5 and 5% had other chest discomfort, respectively. Patients with typical angina had the poorest physical functioning compared to the other angina groups (SF-12 physical component score; 41.2 ± 8.8, 43.3 ± 9.1, 46.2 ± 9.0, 46.4 ± 11.4, respectively, all age and gender-adjusted p < 0.01), and highest anxiety levels (8.3 ± 4.1, 7.5 ± 4.1, 6.5 ± 4.0, 4.7 ± 4.5, respectively, all adjusted p < 0.01). On all other measures, patients with typical or atypical angina had lower HRQoL compared to the two other groups (all adjusted p < 0.05). HRQoL did not differ between patients with and without obstructive CAD while women had worse HRQoL compared with men, irrespective of age and angina type.

CONCLUSIONS

Prior to a diagnostic procedure for stable chest pain, HRQoL is associated with chest pain characteristics, but not with obstructive CAD, and is significantly lower in women.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02400229.

MicroRNA-331 and microRNA-151-3p as biomarkers in patients with ST-segment elevation myocardial infarction

We sought to analyse plasma levels of peripheral blood microRNAs (miRs) as biomarkers of ST-segment-elevation myocardial infarction (STEMI) due to type-1 myocardial infarction as a model situation of vulnerable plaque (VP) rupture. Samples of 20 patients with STEMI were compared both with a group of patients without angina pectoris in whom coronary angiogram did not reveal coronary atherosclerotic disease (no coronary atherosclerosis-NCA) and a group of patients with stable angina pectoris and at least one significant coronary artery stenosis (stable coronary artery disease-SCAD). This study design allowed us to identify miRs deregulated in the setting of acute coronary artery occlusion due to VP rupture. Based on an initial large scale miR assay screening, we selected a total of 12 miRs (three study miRs and nine controls) that were tested in the study. Two of the study miRs (miR-331 and miR-151-3p) significantly distinguished STEMI patients from the control groups, while ROC analysis confirmed their suitability as biomarkers. Importantly, this was observed in patients presenting early with STEMI, even before the markers of myocardial necrosis (cardiac troponin I, miR-208 and miR-499) were elevated, which suggests that the origin of miR-331 and miR-151-3p might be in the VP. In conclusion, the study provides two novel biomarkers observed in STEMI, which may be associated with plaque rupture.