Left Ventricular Myocardial Stiffness, an Early Sign of Stage B HFpEF, Is Observed in Patients With Left Ventricular Hypertrophy and Elevated Cardiac Biomarkers

A study led by Dr. Michinari Hieda published in Circulation showed that left ventricular myocardial stiffness is greater in patients with left ventricular hypertrophy and elevated cardiac biomarkers as compared to healthy controls. This may represent the transitional state from a normal healthy heart to heart failure with preserved ejection fraction (HFpEF).

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Study Shows Heart Transplants From Hepatitis C Positive Donors Safe; Potential for Expanding Donor Pool and Shortening Wait-Times

In an observational case series of 80 patients who underwent heart transplant using hearts from hepatitis C (HCV)–positive donors, it has been shown that short-term (30-day) and long-term survival (1-year) of recipients testing positive for HCV exceeds 90% and is not significantly different to that of patients receiving heart transplants from HCV negative donors.

Results of the study titled “Expanding Heart Transplant in the Era of Direct-Acting Antiviral Therapy for Hepatitis C” were published in JAMA Cardiology. Dr. Kelly H. Schlendorf, MD (Vanderbilt University Medical Center, Nashville, Tennessee) and colleagues analyzed data from 80 patients (median age, 54.5 years; 71% men; 69% white) who underwent heart transplants with HCV-positive donors between September 2016 and April 2019. The authors found that the median active wait-list time from the time patients consented to accept HCV-positive donor hearts was 4 days (interquartile range [IQR], 1-18) versus 28 days (IQR, 6-168) for patients before providing consent. This was significantly lower than the national reported median wait times between 70 and 535 days.

The investigators categorized HCV positive donors into two groups: viremia positive and viremia negative (as determined by nucleic acid amplification test [NAAT]). Those with presence of viremia, a total of 70 donors had 95.7% transmission rate of HCV to their recipients, while none of the 10 recipients of hearts from NAT-negative donors developed infection (transmission rate, 0%). In patients testing positive with donor-derived HCV (ddHCV) 30-day and 1-year patient survival rates were 92.5% and 90.4%, respectively. A total of 6 (8.5%) patients with ddHCV died (5 due to primary allograft rejection and 1 due to development of pulmonary embolism). In addition, in the ddHCV cohort, 10 (14.9%) had acute cellular rejection and 1 patient (1.5%) had a single antibody-mediated graft rejection. Length of hospital stay and readmissions of ddHCV recipients were not significantly different from those who received heart transplants from HCV negative donors (median length of stay 15 days vs. 17 days, respectively; P = .79 for difference). Similarly, rates of coronary allograft vasculopathy in recepients also did not reveal any difference regardless of HCV positivity in donors. However, the authors noted that the recipients of transplants from HCV-positive donors exhibited significantly higher rates of severe primary graft dysfunction than recipients of transplants from HCV-negative donors (13.7% vs 3.1%; P = .002). Recipients suffering from ddHCV received direct anti-virals combinations using either Ledipasvir-sofosbuvir (90 mg-400 mg), Sofosbuvir-velpatasvir (400 mg-100 mg) or Glecaprevir-pibrentasvir (100 mg-40 mg) for 12 weeks. It was found that sustained virologic response at 12 weeks was 100% for ddHCV positive recepients.

Extended periods of wait-times for patients requiring heart transplants leads to significant morbidity and mortality. It has been shown that atleast 10% of patients requiring heart transplants die due to long wait-list times and the numbers get worse as wait times increase further. Results from the current study indicate that in the current era of direct acting anti-virals for HepC treatment, heart transplants from HepC positive donors is a viable option for expansion of donor pools and reduce wait list times for those awaiting transplants. Nevertheless, results from this study need to be interpreted with caution due to its limitations. The study was done at a single-center with surrounding municipalities that were affected by opioid crisis with an increased load of HepC donors, which may fail to account for geographical differences that exist in other areas.

The Sarcomeric Human Cardiomyopathy Registry: Race Associated with Disease Expression and Clinical Outcomes Among Patients with Hypertrophic Cardiomyopathy Hypertrophic cardiomyopathy and race: differences in disease expression, inequitable care provision, and disparate clinical outcomes

Hypertrophic cardiomyopathy (HCM) is the most common inherited genetic disorder of the myocardium, and the number one culprit of sudden cardiac death in athletes, particularly African Americans.

“Is race associated with differential disease expression, inequitable care provision, or disparate clinical outcomes among patients with hypertrophic cardiomyopathy?”

In order to answer the above question, Lauren A. Eberly, et al. studied 2,467 patients with hypertrophic cardiomyopathy. In a retrospective cohort study, black and white patients with hypertrophic cardiomyopathy from the US-based sites of the Sarcomeric Human Cardiomyopathy Registry from 1989 through 2018 compared in terms of baseline characteristics; genetic architecture; adverse outcomes such as cardiac arrest, cardiac transplantation or left ventricular assist device implantation, cardioverter-defibrillator implantation, all-cause mortality, atrial fibrillation, stroke,  prevalence and likelihood of developing heart failure; and receiving septal reduction therapies.

According to the results of this study (8.3 percent black; 91.7 percent white), published in the JAMA CARDIOLOGY (December 2019), compared with white patients, black patients with HCM were younger (mean age, 36.5 versus 41.9 years), were less likely to have sarcomere mutations (26.1 versus 40.5 percent), had a higher prevalence of New York Heart Association (NYHA) class III or IV heart failure at presentation (22.6 versus 15.8 percent) and were more prone to developing heart failure (hazard ratio, 1.45). Lower rates of genetic testing (26.1 versus 40.5 percent) have been observed in black patients. Although there were no racial differences in implantation of implantable cardioverter-defibrillators, the invasive septal reduction was less common among African Americans (14.6 versus 23 percent). Nevertheless, Black patients had fewer incidents of atrial fibrillation (35 [17.1 percent] versus 608 [26.9 percent].

The results of this study were in accordance with the previous studies that mentioned a higher prevalence of complicated hypertrophic cardiomyopathy in African Americans in contrast to the lower prevalence of HCM in this community.  Eberly, et al. believe that racial differences in disease expression and adverse clinical outcomes are not only because of different characteristics of the disease in African Americans but also inequities in clinical care provision might be responsible for these observed differences.

SYNTAX III REVOLUTION Trial: Non-invasive CT Scanning as a Potential Alternative to Invasive Coronary Angiography for Treatment Decision-Making in Patients with Complex Coronary Artery Disease FFRCT or multi-slice CT scanning changed heart team’s treatment decision-making and procedural planning in 1/5th of the patients

A cross-sectional observational study enrolling 223 patients with 3-vessel coronary artery disease, has shown that compared to conventional invasive coronary angiography, a noninvasive physiology assessment using fractional flow reserve CT scanning (FFRCT or multi-slice CT scanning) changed heart team’s treatment decision-making and procedural planning in 1/5th of the patients.

The SYNTAX III REVOLUTION Trial was a randomized, multi-center study which randomized two heart teams to make a treatment decision between percutaneous coronary interventions (PCI) and coronary artery bypass grafting (CABG) using either coronary computed tomography angiography (CTA) or conventional invasive angiography while blinded to the other imaging modality. The study included patients with complex coronary artery disease, defined as, left main (isolated, or associated with 1, 2 or 3 vessel disease) or de novo 3-vessel coronary artery disease (DS ≥50%), who were able to receive cardiac CT with a multi-slice CT scanner. Coronary CTA was performed with the GE Revolution CT scanner that has a nominal spatial resolution of 230 microns along the X–Y planes, a rotational speed of 0.28 s, and a Z-plane coverage of 16 cm enabling to image the heart in one heartbeat. Patients with concomitant atrial fibrillation, cardiac valve disease and prior history of PCI or CABG were excluded from the study. The primary outcome was the inter-rater agreement (assessed by Cohen’s Kappa Kappa; a value of 0.82) on revascularization strategy of two heart teams by employing the use of either an “Angio-first” algorithm or a “CT First” algorithm 1 to 2 weeks after patient enrollment. The addition of FFRCT changed the treatment decision in 7% of the patients and modified selection of vessels for revascularization in 12%. With conventional angiography as a reference, FFRCT assessment resulted in reclassification of 14% of patients from intermediate and high to low SYNTAX score tertile.

The American and European guidelines recommend a heart team based approach for the decision-making process regarding the revascularization strategy and recommend the evaluation of the anatomical complexity using the SYNTAX score. Patients with SYNTAX scores >34 have been found to do much better with bypass surgery than those with lower SYNTAX scores. The SYNTAX scores can be divided into three tertiles. Higher scores signify complex conditions and indicate greatest risks to patients undergoing PCI. Calculation of the SYNTAX score takes into account complex lesions including bifurcations, chronic total occlusions, thrombus, calcification, and small diffuse disease with a total of 11 measures of lesion complexity. The score ranges from 0 to greater than 60 in very complex coronary anatomy.

Previously validated SYNTAX II score utilizes SYNTAX I score and then combines it with clinical prognostic variables such as age, creatinine clearance, gender, left main vessel involvement, left ventricular ejection fraction, chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD) in order to guide selection between PCI and CABG for patients with multivessel coronary disease. The results of the SYNTAX III Trial suggest the potential feasibility of a treatment decision-making and planning that stems from a non-invasive imaging modality and clinical information.

Persistently Elevated Neuropeptide Y, a Sympathetic Neurotransmitter, is Found to be Associated with Ventricular Arrhythmias in Patients with Myocardial Infarction

The sympathetic drive leading to the release of arrhythmogenic agents after myocardial infarction (MI) is the target of pharmacologic treatment to reduce the mortality associated with post-MI arrhythmias. Beta-blockers, so far, are the only primary prevention antiarrhythmic drugs that decrease the mortality following MI.  However, ventricular arrhythmias still complicate up to 10% of the cases despite sufficient beta-blockade. Additionally, MI has been associated with the release of non-catecholaminergic co-transmitters such as neuropeptide Y (NPY). This cardiac sympathetic co-transmitter can affect calcium electrophysiology of the cardiomyocytes and trigger arrhythmic events.

The new study by Dr. Kalla and his colleagues hypothesized that NPY is the pro-arrhythmic agent after an MI. To evaluate their hypothesis, they monitored 78 patients with ST-elevation MI  treated with primary percutaneous coronary intervention (PPCI) for the development of ventricular arrhythmias. Peripheral venous blood sampling was done at the time of intervention to assess the NPY level. To compare, they also measured the NPY level of peripheral venous blood in 12 candidates of elective angiography of similar age and gender, who had normal coronary arteries.

Ventricular arrhythmias occurred in 7% of the STEMI patients within 48 hours. Their venous NPY level has observed to be significantly (P < 0.05) higher compared to control patients. The author also suggested that an NPY level of 27.3 pg/mL has a sensitivity of 0.83 and a specificity of 0.71 for ventricular arrhythmias threshold. To further evaluate their hypothesis regarding the arrhythmogenic effect of sympathetic-induced NPY release, they experimented with an animal model. Through their rat model experiment, Dr. Kalla demonstrated that despite maximal beta-blockade with metoprolol, prolonged stimulation of the sympathetic system caused an enormous increase in NPY level and subsequent decrease in ventricular arrhythmias threshold. Interestingly, NPY, antagonized by Y1 receptor antagonist BIBO3304, prevented these effects.

The authors added, ” In patients presenting with STEMI treated with PPCI, NPY levels are associated with an increased incidence of ventricular arrhythmia in the immediate postinfarct period, independent of classical risk factors, such as late presentation, larger infarct size, and prior beta-blocker usage.” The author concluded that sympathetic-induced release of NPY is associated with post-MI arrhythmia and drugs reversing its effect work along with beta-blockers as a new anti-arrhythmic therapy.

385,000 Patient Study Shows Poor Sleep Behavior Associated With Increased Risk of Coronary Heart Disease and Stroke

A study led by Dr. Mengyu Fan published in the European Heart Journal showed that a healthy sleep pattern was associated with a lower risk of cardiovascular disease (CVD), congestive heart failure (CHF), and stroke in patients with low, intermediate or high genetic risk.

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TIM-HF2 Trial: Morbidity and Mortality Benefit of Remote Telemedical Interventional Management In Heart Failure No Longer Observed 1 Year After End of Trial​ Extended follow-up results from the telemedical interventional management in patients with heart failure II (TIM-HF2) randomised trial

The positive effect of the remote patient management (RPM) intervention on morbidity and mortality, seen in the Telemedical Interventional Management in Heart Failure II (TIM-HF2) trial was no longer observed 1 year after stopping the RPM intervention. The extended follow-up results of the TIM-HF2 trial led by Dr. Koehler (Department of Cardiology and Angiology, Centre for Cardiovascular Telemedicine, Charité–Universitätsmedizin Berlin, Berlin, Germany) was recently published in the Lancet. Continue reading

Patients with Out-Of-Hospital Cardiac Arrest Treated at Teaching Hospitals Are More Likely to Survive to 30 Days, Compared with Non-Teaching Hospitals

In a large population-based study, a significant and sustained survival benefit was observed in patients with out-of-hospital cardiac arrest treated at teaching hospitals. The report of the study led by Dr. Czarnecki was recently published in Circulation: Cardiovascular Quality and Outcomes. Continue reading

Study Shows High-Intensity Statin Associated With Low Risk of Death, Stroke, ACS or Bleeding As Compared to Low to Moderate Intensity Statins or No Statins

Statins, especially high-intensity statins, could reduce the risk of a composite of death, stroke, acute coronary syndrome, or major bleeding as compared to a placebo in patients with acute ischemic stroke and atrial fibrillation. The observational study that was published in the Journal of the American Heart Association highlights the need for a further randomized control trial to further explore this observation.

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Severe Coronary Calcification Might Delay Healing Following Implantation of Newer-Generation Drug-Eluting Stents

In an autopsy-based, histopathological analysis of stented coronary lesions, severe calcification was an independent risk factor for delayed strut coverage and healing after newer-generation DES. The report of the study led by Torri was recently published in the European Heart Journal.

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Lower Levels of Circulating Progenitor Cells Associated with Increased Risk of Myocardial Infarction and Death In Patients with Stable Coronary Artery Disease

In patients with stable coronary artery disease, a decrease in circulating progenitor cell count during exercise is associated with worse disease prognosis compared to the presence of stress-induced myocardial ischemia. The study led by Dr. Kasra Moazzami that was published in JAMA Cardiology highlights the need to identify whether strategies to improve circulating progenitor cell count response during exercise will lead to a better prognosis.

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Study Suggests Coronary Microvascular Dysfunction and Not Glomerular Filtration Rate Associated with Abnormal Cardiac Mechanics and Worse Clinical Outcomes in Patients with Chronic Kidney Disease

A study led by Dr. Navakaranbir Bajaj published in Circulation showed that coronary microvascular dysfunction, but not estimated glomerular filtration rate was associated with abnormal cardiac mechanics and an increased risk of cardiovascular events. The findings of this study suggest that coronary microvascular dysfunction may play a role in determining how chronic kidney disease can lead to abnormal cardiac function in patients without ischemic heart disease.

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Three Million Patient Study Shows Patients With Cancer At Higher Risk of Dying from Cardiovascular Disease As Compared to the General Population

A study led by Dr. Kathleen Sturgeon published in the European Heart Journal showed that in patients diagnosed with cancer, the majority of cardiovascular deaths in the United States occur in patients diagnosed with breast, prostate or bladder cancer. Additionally, the investigators demonstrated that patients with cancer are at a higher risk of dying from cardiovascular disease as compared to the general population.

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One in Eight Patients with Atherosclerotic Cardiac Disease Experience Cost-Related Medication Nonadherence

One in eight patients with atherosclerotic cardiovascular disease reports medication nonadherence due to cost, according to a nationally representative survey of more than 14,000 US adults. The findings of the study led by Dr. Rohan Khera (University of Texas Southwestern Medical Center, Dallas, US) was recently published in Circulation.

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