Transcatheter tricuspid valve replacement has become a feasible alternative to surgery in patients deemed to be at high risk of adverse events, and in the past decade, various devices have been designed to meet this clinical need. In his Focused Clinical Research session on the opening day of the American College of Cardiology 2021 Scientific Sessions, Dr. Susheel Kodali, director of the Structural Heart & Valve Center at New York-Presbyterian/ Columbia University Medical Center presented the 30-day results from the implantation of the EVOQUE valve, as part of the TRISCEND study. Continue reading →

The WATCHMAN left atrial appendage occluder device has been widely accepted as an alternative to oral anticoagulation for stroke prevention in patients with underlying atrial fibrillation. However, the indications for WATCHMAN implantation laid forth by the Centers for Medicare & Medicaid Services in the United States differ from the original trials supporting its use. Real-world practice, therefore, highlights significant differences in the characteristics of patients receiving the therapy from those originally studied.  In a Focused Clinical Research Session at the 2021 American College of Cardiology meeting, Dr. Matthew Price, Director of the Cardiac Cath Lab at Scripps Green Hospital and Assistant Professor at the Scripps Translational Science Institute, La Jolla, California, presented the results of his study from the NCDR LAAO Registry (NCT02699957), assessing one- year real-world outcomes for patients undergoing WATCHMAN implantation.

Continue reading →

Subclinical valve thrombosis after transcatheter aortic valve intervention (TAVI) has emerged as a challenge to the standardization of antithrombotic therapy after valve implantation. Results of the randomized ATLANTIS trial, presented also today, May 15, as a Late Breaking Clinical Trial at ACC 2021, showed no superiority of apixaban over standard of care after transcatheter aortic valve intervention, irrespective of the baseline need for anticoagulants. In his Focused Clinical Research Session, Gilles Montalescot, MD, PhD, Professor of Cardiology at the Pitié-Salpêtrière Hospital, Paris, presented the 4D-CT substudy results to assess the incidence and implications of CT-proven valve thrombosis. Continue reading →

The administration of apixaban monotherapy after transcatheter aortic valve replacement is not superior to the standard of the care antithrombotic treatment, results of the randomized, phase IIIb, prospective, open label, ATLANTIS trial, Anti-Thrombotic Strategy After Trans-Aortic Valve Implantation for Aortic Stenosis (NCT02664649), show. These findings hold true regardless of a patient’s baseline requirement for anticoagulation. Continue reading →

KEY POINTS

• Sacubitril/valsartan did not provide a lower rate of cardiovascular death, heart failure hospitalization, or outpatient development of heart failure when compared to active treatment with ramipril in patients after high-risk myocardial infarction.
• When examining total adjudicated events and investigator reported primary endpoints, there was a trend toward clinical benefit in patients randomized to sacubitril/valsartan.

Continue reading →

KEY POINTS:

• There was no significant difference in primary composite endpoint of all-cause mortality, hospitalization for myocardial infarction, or hospitalization for stroke in patients with coronary artery disease taking 81 mg versus 325 mg of aspirin every day.
• There was no significant difference in the safety endpoint of hospitalization for major bleeding with blood product transfusion in patients with coronary artery disease taking 81 mg versus 325 mg of aspirin every day.
• Conducting pragmatic study in a real world, patient-centric approach will likely continue to emerge as an appealing, cost effective trial design in the field of cardiology.

Cardiovascular disease is costly and a major cause of death worldwide. Aspirin has been the mainstay of treatment in secondary prevention of coronary artery disease for over thirty years. More recently, several analyses have suggested varying doses aspirin (81 mg vs 325 mg) as well as the use of other, newer antiplatelet agents for the treatment of coronary artery disease. Continue reading →

EXPLORER-HCM presented at the American College of Cardiology 2021 meeting by John A. Spertus, MD, MPH, and simultaneously published in The Lancet, demonstrated that the use of mavacamten, a first-in-class cardiac myosin inhibitor, was associated with a highly significant improvement in patients’ health status. 1 out of 5 patients treated with mavacamten tended to experience a significant improvement in health status. Continue reading →

Patients with atrial fibrillation undergoing cardiac surgery should have concomitant atrial appendage occlusion, according to a new study presented at the American College of Cardiology 2021 Scientific Sessions.

“We have shown that left atrial appendage occlusion is not only a viable option but should be standard of care for patients with atrial fibrillation undergoing cardiac surgery,” says Dr. Richard Whitlock, primary investigator of the LAAOS III trial, a cardiovascular surgeon and professor of surgery at McMaster University. The results of LAAOS III were concurrently published in the New England Journal of Medicine . Continue reading →

Medications acting on the renin-angiotensin-aldosterone system (RAAS), such as ACE inhibitors and angiotensin receptor blockers, did not increase the likelihood of a positive test for Covid-19 or the severity of the Covid-19. A cohort study of more than 12,500 patients conducted in a large health network in New York City, led by Dr. Reynolds, revealed. The findings of the study were recently published in the New England Journal of Medicine. Continue reading →

A recent study by Dr. Mehra, published in the New England Journal of Medicine, disapproved of the previously concerning idea regarding the potential harmful effect of angiotensin-converting–enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) in the clinical context of Coronavirus disease 2019 (Covid-19). This study also demonstrated that Covid-19 may disproportionately affect individuals with cardiovascular disorders.
Continue reading →

The results of a pooled analysis of the ORION-10 and ORION-11 trials were recently presented at the American College of Cardiology 2020 Conference. The combined results published in the New England Journal of Medicine, demonstrated that inclisiran, a drug that inhibits hepatic synthesis of proprotein convertase subtilisin–kexin type 9, reduced low-density lipoprotein (LDL) cholesterol by 50% over 510 days.

Continue reading →

In an original investigation done by Dr. Alexander C. Fanaroff et al and recently published in JAMA Cardiology, it was found that there was discordance in medication persistence as measured by patient-reported and the pharmacy fill data. The patient self-reports overestimated and pharmacy fill data underestimated medication persistence. Those who had non-persistence by both measures had the highest rate of major adverse cardiovascular events (MACE). The authors also noted the need for giving preference to interventions that will promote medication-taking behavior. Continue reading →

A recent study by Dr. Knott, published in Circulation, have shown the prognostic value of measuring myocardial blood flow (MBF) using artificial intelligence quantification of cardiovascular magnetic resonance (CMR) perfusion mapping in cardiovascular outcomes. According to this study, both MBF and myocardial perfusion reserve (MPR) were associated with death and major adverse cardiovascular events (MACE) independently of other clinical risk markers. Using this technique, quantitative analysis of myocardial perfusion for clinical use is now available. Continue reading →

A recent study by Dr. Lopez-Sendon, published in European Heart Journal, showed that cardiotoxicity in the form of left ventricular dysfunction or myocardial injury affects a large portion of patients receiving high-risk anticancer therapy with only severe form strongly associated with all-cause mortality.

Cardiotoxicity has been known as one of the major side effects of anti-cancer therapy that may present with left ventricular dysfunction and heart failure. Given that the early recognition and treatment of these side effects have been associated with a higher recovery rate, a united diagnostic and management guideline seems necessary.

The CARDIOTOX (CARDIOvascular TOXicity induced by cancer-related therapies) registry has been established to determine the prevalence of cardiotoxicity markers as well as their association with guideline-based heart failure criteria and treatment in patients receiving chemotherapeutic agents. To achieve this purpose, a total of 865 patients receiving anticancer regimens associated with moderate to high cardiotoxicity were selected and followed for a median of 24 months. Clinical data, blood samples, and echocardiographic features were collected before the initiation of anticancer therapy and then at 3 weeks, 3 months, 6 months, 1 year, 1.5 years, and 2 years afterward. Patients with past or current history of heart failure or reduced left ventricular ejection fraction (< 40%) and those with a history of previous cancer therapy including chemotherapy and radiation therapy were excluded from the study. Cardiotoxicity was defined as any new deterioration from the baseline of myocardial/ventricular function during follow-up periods. Cardiotoxicity was also sub-classified into four stages depending on the worst myocardial dysfunction/injury observed in the follow-up period. Myocardial dysfunction/injury stages include the following: normal, normal biomarkers (high-sensitivity troponin T and N-terminal natriuretic pro-peptide), and left ventricular (LV) function; mild, abnormal biomarkers, and/or LV dysfunction (LVD) maintaining an LV ejection fraction (LVEF) ≥ 50%; moderate, LVD with LVEF 40–49%; and severe, LVD with LVEF ≤ 40% or symptomatic heart failure.

The study indicated a high incidence (37.5%) of ventricular dysfunction among the patients, of whom only 3.1% were classified as having severe dysfunction and the majority have been classified as mild (31.6%). All-cause mortality was also observed to be higher among those with severe cardiotoxicity than other groups. According to the author, the relatively low prevalence of severe cardiotoxicity in the study population was due to the exclusion of patients with a previous history of cardiac dysfunction and the improvement in the follow-up of the cancer patients in the context of cardio-oncology service. Severe cardiotoxicity has also been associated with a 10-fold increase in total mortality compared to a less severe form of cardiotoxicity. A classification of cardiotoxicity using current heart failure guidelines is also proposed by the authors for future studies. This study acknowledged the critical role of comprehensive monitoring and follow-up for the development of cardiovascular symptoms and left ventricular dysfunction in patients receiving chemotherapeutic agents with potential cardiotoxicity.

Limitations that are worthy of mentioning include the inclusion of patients with some degree of abnormality in biomarkers and echocardiographic findings at baseline. Secondly, the prevalence of myocardial damage may be underestimated due to a number of missing visits or incomplete data collection during the follow-up period. Future research is warranted to approve the relationship of different stages of cardiotoxicity with clinical outcomes.

A trial led by Dr. Holger Thiele showed that there was no difference in outcomes by 30 days when comparing the use of self-expandable and balloon-expandable valves in transcatheter aortic valve implantation (TAVI). The findings of this study published in the European Heart Journal suggest that both can be safely used in the majority of the population.

Continue reading →

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.

Continue reading →

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

Continue reading →

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.

Continue reading →

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.