A recent study by Dr. Chapman, published in Circulation, showed that implementation of high sensitivity cardiac troponin (hs-cTn) and the fourth universal definition of myocardial infarction (MI) increased the identification of patients at risk for cardiovascular and non-cardiovascular events, but failed to improve the outcomes. This study warrants the importance of seeking new strategies to improve outcomes in patients with type 2 MI and myocardial injury. Continue reading →

A new study by Dr. Hongwei, published in JAMA Cardiology, demonstrated that blood pressure (BP) trajectories over the life course progress more rapidly in women compared to men, a process that begins as early as the third decade of life. This concept is inconsistent with the previously accepted notion that important vascular disease processes in women occur by 10 to 20 years delay compared to men. These sex-based differences in physiology may establish the cornerstone for future cardiovascular disorders that often present differently in women compared with men.

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Maria Trinidad Soria-Florido et al. published the results of their study on high-density lipoprotein (HDL) function and coronary syndrome in Circulation. They showed that low amount of HDL sphingosine-1-phosphate (S1P) and apolipoprotein A-I and low cholesterol efflux capacity are associated with cardiovascular manifestations of angina. HDL function was studied by measuring cholesterol efflux capacity, S1P, and ApoA-I in apolipoprotein B-depleted plasma and they showed that impaired cholesterol function is associated with a higher risk of acute coronary syndrome (ACS), irrespective of HDL cholesterol (HDL-C) concentrations.

The investigators selected a subgroup of patients who were participating in PREDIMED study, which was a randomized clinical trial including patients with high cardiovascular risk factors to evaluate the effects of following a traditional Mediterranean Diet (TMD) on the primary prevention of cardiovascular outcomes. The primary endpoints were decided to be fatal or non-fatal myocardial infarction and/or fatal or non-fatal unstable angina. The committee responsible to adjudicate the events was blinded to the treatment. Dr. Trinidad et. al. implemented a nested 1:2 case-control design, matching two controls by age (±5 years), sex, body mass index, intervention group, and time-to-event. They obtained apolipoprotein B-depleted plasma samples and measured the HDL related activity in the sample.

The findings showed that except for plasma HDL-C concentrations and the levels of ApoA-I in HDL, all other HDL related biomarkers correlated weakly with each other. There was an almost linear correlation between all HDL related biomarkers (except for ApoA-IV) and the incidence of cardiovascular events. They also showed that there is a strong relationship between low cholesterol efflux capacity (CEC) and a higher incidence of myocardial infarction.

Previous studies have shown that there is an association between low CEC and ACS in hypertriglyceridemia patients, but Maria Trinidad Soria-Florido et al. showed that this association also exists in patients with normal triglyceride levels. Hypertriglyceridemia probably exaggerates the effect. They also showed that not only HDL-bound S1P can predict atherosclerotic lesions development and its extent, but also S1P levels in apolipoprotein B-depleted plasma is associated inversely with ACS risk.

The study was limited by the small sample size and lack of thorough evaluation of the HDL oxidative-inflammatory index.

A recent study by Dr. Kilic, published in the American Heart Association Journal, showed similar adverse outcomes in the 1-year survival, rejection rates, and complications of patients who received a heart transplant using hepatitis C-positive (HCV+) donors whereas those using hepatitis C-negative donors.

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A study published by Dr. Liza Chacho published in the European Heart Journal showed that in patients with three distinct genotypes of transthyretin cardiomyopathy, both diastolic and systolic echocardiographic parameters were associated with an increased risk of mortality

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In a recent randomized, three-arm, parallel, blinded study by Dr. Schnorbus, published in European Heart Journal, prasugrel was associated with improved endothelial function, more potent platelet inhibition, and decreased plasma interleukin (IL)-6 levels in patients undergoing stent placement for acute coronary syndrome (ACS) compared to ticagrelor and clopidogrel. These effects were observed in patients who received prasugrel 2 hours before stenting.

Coronary artery stenting has been associated with impaired coronary and peripheral endothelial function as well as an inflammatory response leading to the release of mediators and subsequent platelet aggregation. These phenomena are associated with in-stent restenosis as well as adverse prognostic outcomes after percutaneous coronary intervention (PCI). Platelet inhibitors, such as P2Y12 receptor inhibitors, are administered prior and after coronary interventions to address these adverse effects. However, previous studies have suggested that differences exist among P2Y12 inhibitors in terms of their efficacy.

In a prospective, single-center study, a total of 90 patients with unstable angina or non-ST elevation myocardial infarction (NSTEMI) undergoing coronary stenting were randomized to receive a single dose of clopidogrel (600mg), prasugrel (60mg), or ticagrelor (180mg) followed by chronic therapy with the same drug. Patients with elevated c reactive protein (CRP), infective or inflammatory disorders, personal history of prior coronary interventions, impaired hepatic/renal function, those with heart failure, and those with ST elevation myocardial infarction (STEMI) were excluded from the study. The primary endpoint of the study was the change in flow-mediated dilation (FMD) of the conduit artery over a period of 1 day, 1 week, and 1 month after PCI. Secondary endpoints were the effect of study medications on macrovascular and microvascular function, platelet aggregation, and inflammatory stress.

The study showed that antiplatelet therapy immediately before stenting was associated with improved FMD without a significant difference among study medications. On the first follow-up after PCI and later follow-up visits, prasugrel was associated with a stronger platelet reactivity inhibition and improved endothelial function. These effects were limited to those who received prasugrel before catheterization. Prasugrel platelet inhibitory effect was more obvious in NSETMI patients than in those with unstable angina. Prasugrel therapy also led to a more pronounced decrease in IL-6 levels. According to the author, “when administered pre-PCI, prasugrel, but not the other agents, limits stent-induced endothelial dysfunction and inflammation in ACS.” This study is limited by its small size and future studies are needed to further confirm these conclusions.

A randomized controlled trial led by Dr. Seung-Yul Lee published in Circulation: Cardiovascular Intervention showed that in patients who required percutaneous coronary intervention, the use of optical coherence tomography (OCT) to help guide bioresorbable vascular scaffold (BVS) implantation did not reduce the incidence of nonoptimal deployment as compared to angiography guided BVS implantation.

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Raphael et al. showed in a prospective cohort study, published in Circulation, that type 2 myocardial infarction (T2MI), defined as an acute imbalance between oxygen delivery to the myocardium and the demand of the myocardium in the absence of athero-thrombosis, is associated with higher all-cause mortality compared to type 1 myocardial infarction (T1MI) caused by athero-thrombotic events, with no difference between these 2 groups regarding cardiovascular death.

Raphael et al. retrospectively included 5,460 patients with high troponin levels (more than 0.01) and divided them into 2 groups of T1MI and T2MI. They followed up the patients for 5.5 years. Cases with prior MI were excluded from the analysis.

After including the cases, they retrospectively classified MI types by 2 cardiologists based on clinical signs and laboratory results. MI was defined by a rise and/or fall in cardiac troponin T (cTnT) associated with either ischemic symptoms, new/presumed new ECG changes, new imaging evidence of ischemia, or direct identification of intracoronary thrombus on angiogram or autopsy. The cardiologists defined T2MI based on elevated cardiac troponin without other necessary factors. Other different types of MI including procedure-related MI were categorized as T1MI. They encountered the first MI event as the main event in cases with multiple MI events. They further subclassified T2MI based on its cause to the following subclasses: Arrhythmia, hypotension, anemia, post-surgical status  (in the absence of other causes e.g., T1MI and arrhythmia), hypoxia, and other (including spontaneous coronary artery dissection, coronary embolism, coronary spasm, structural heart disease e.g., severe aortic stenosis and malignant hypertension). They prospectively gathered the information regarding the mortality cause in the patients from the available documents, and divided the cause of mortality into either cardiovascular or non-cardiovascular.

The results showed that 56% were adjudicated as T1MI and 43% as T2MI. Patients with T2MI were older, female gender predominant, with a higher prevalence of chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD) while patients with T1MI were more likely to present with other well known MI risk factors. They also showed a lower level of sufficient MI related medical treatment in the T2MI group compared to T1MI. The rate of MI in both types has shown a decrease in incidence in the population. The rate of all-cause mortality was calculated after sex and age adjustment, and results implicated that the all-cause mortality rate was significantly higher in T2MI compared to T1MI even after adjustments. They showed that the risk of cardiovascular death is the same in both T1MI and T2MI, which may indicate the necessity of better diagnosis and treatment of T2MI after an encounter.

There is a lack of information regarding the T2MI incidence and effect on mortality in the general population. Raphael et al. tried to add to our current knowledge regarding this common type of MI by addressing the effect of this condition on all-cause and cardiovascular mortality.

One of the major factors encountered as a limitation for this study may be the difficulty faced in the diagnosis of T2MI in the clinical setting. A question has still remained that if treatment of T2MI with the same treatment protocol as T1MI will help to decrease cardiovascular and all-cause mortality in the patient’s population.

In an original study conducted by Dr. Aleksandr Voskoboinik et al. recently published in The New England Journal of Medicine, it was found that alcohol consumption is a modifiable risk factor for Atrial Fibrillation (AFib) and abstinence from alcohol in people with AFib causes a reduction in burden and recurrence rates of AFib. Continue reading →

The study by Dr. Ajijola, published in JAMA Cardiology, found that elevated coronary sinus neuropeptide Y (NPY) level is associated with adverse cardiovascular events in stable patients with chronic heart failure and therefore, it may have prognostic value in this population.

Increased cardiac sympathetic signaling has been associated with adverse cardiovascular outcomes. Biomarkers of the sympathetic system are of significant interest in the assessment of cardiovascular outcomes. NPY is one of the circulating catecholamines, which may predict the risk of death in patients with chronic heart failure.

Dr. Ajijola and his colleagues conducted a prospective observational cohort study at a single-center, tertiary care hospital. They observed 105 patients with stable heart failure undergoing elective cardiac resynchronization therapy (CRT) device implantation between 2013 and 2015. Patients with NYHA class I, severe aortic stenosis, cardiac surgery within prior 90 days, severe obstructive pulmonary disease requiring oxygen or with recent decompensation (< 30 days), current pregnancy, primary pulmonary hypertension, continuous intravenous drug infusion for heart failure, and life expectancy under 6 months were excluded from the study. At the time of the intervention, the coronary sinus blood sample was taken and checked for the NPY levels. Patients were evaluated for major adverse cardiovascular events (MACE) as well as responses to CRT.  Composite endpoint was defined as death, cardiac transplant (OHT), or ventricular assist device (VAD) placement.

The results of the study showed that NPY levels of coronary sinus were associated with prognostic implications in patients with heart failure. 20 out of 105 (19%) patients showed composite endpoints at a median follow-up of 29 months. Also, the NPY levels of greater than 130 pg/mL were associated with worse outcomes compared with those with lower levels (HR, 8.9; 95% CI, 3.1 – 25.7; P < 0.001). The results remained significant even after adjusting for age, eGFR, and LVEF (HR, 9.5; 95% CI, 2.92 – 30.5; P < 0.001).  According to Dr. Ajijola, “Coronary sinus NPY levels may identify patients in whom close clinical monitoring and more aggressive interventions are needed to prevent adverse events. It may also identify those in whom CRT is likely to be ineffective, and such patients may be considered sooner for OHT or VAD.”

This study is limited by some points. First, although NPY levels were irrespective of CRT response, the presence of CRT devices limits the external validity of the study. Second, the sample size was small for formal statistical validation of the study including the NPY thresholds. Future studies are warranted to further validate the results of this study and to clarify the prognostic value of NPY levels.

A study led by Dr. Sotirios Tsimikas published in the New England Journal of Medicine showed that the hepatocyte-directed antisense oligonucleotide APO(a)-LRx significantly reduced the blood lipoprotein(a) [Lp(a)] levels in patients with established cardiovascular disease in a dose-dependent manner.

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