Professor Richard Sutton from the Department of Cardiology, Imperial College speaks about Tilt testing remains a valuable asset.
Link to Article:
https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehab084/6149003?login=true
Synopsis:
For more than 50 years, the head-up tilt test (TT) has been used to study heart rate/blood pressure adaptation to positional changes, model responses to haemorrhage, determine orthostatic hypotension, and analyze haemodynamic and neuroendocrine responses in congestive heart failure, autonomic dysfunction, and hypertension. Any of the participants in these studies encountered syncope as a result of the vasovagal reflex. As a consequence, tilt checking has become part of the clinical evaluation of syncope where the cause is unclear. As a consequence, clinical experience backs up TT's diagnostic importance. This is emphasized in evidence-based clinical practice guidelines, which provide recommendations for TT technique and analysis while also pointing out its weaknesses. As a result, TT continues to be a valuable therapeutic asset, one that has contributed greatly to our understanding of the pathophysiology of syncope/collapse and, as a result, has enhanced the treatment of syncopal patients.
The first paragraph is an introduction.
For more than half a century, physiologists and physicians have used the head-up tilt test (TT) to investigate heart rate and blood pressure adaptation to positional changes, to model responses to haemorrhage, to measure characteristics of orthostatic hypotension (OH), and to examine haemodynamic and neuroendocrine responses in congestive heart failure, autonomic dysfunction, and hypertension. Due to hypotension caused by TT (often followed by bradycardia/asystole), some participants suffered complete or near-total transient loss of consciousness (TLOC) during these studies. 1-4 As a result, starting in the late 1980s, TT was used in the clinical evaluation of syncope of unknown origin1 as a means of activating the vasovagal reflex in susceptible individuals by exposing them to a regulated orthostatic challenge in a healthy, monitored clinical laboratory setting. 0.5–8 However, Kulkarni et al.9 recently criticized the clinical usefulness of TT, promoting the less well-studied active stand test based on the assumption of lower cost and, possibly, greater convenience. Although recognizing TT's shortcomings, the aim of this analysis is to provide a counterpoint to Kulkarni et al.9's viewpoints by highlighting both TT's well-documented clinical importance and numerous practice guidelines' recommendations.
Tilt work is currently in progress:
When the past fails to offer a definitive reason for symptoms, a positive TT may be used to diagnose syncope/collapse.
ten, eleven If the history reveals a straightforward diagnosis, TT isn't necessary; however, TT may provide valuable patient education and reassurance, as well as pathophysiological proof of the underlying processes, which is crucial for choosing the right treatment. 12
Since its introduction into clinical practice, the approach and understanding of TT findings have grown.
1 Longer TTs, up to 2 hours at angles of 40–60 degrees, were used to cause vasovagal events in susceptible people at first. In order to improve test sensitivity, the test period was shortened, the head-up angle was specified as 60–80°, and other interventions were introduced. years 13–21 Drugs (e.g., isoproterenol, nitroglycerine, serotonin agonists) were administered alone or in combination with physical manoeuvres, such as carotid sinus massage. Several of these offensive steps increased TT sensitivity and are still used, but they may reduce specificity.
In a meta-analysis of 55 studies involving patients with unexplained syncope and asymptomatic controls without a history of syncope, Forleo et al.22 published a meta-analysis of patients with unexplained syncope and asymptomatic controls without a history of syncope. The authors omitted trials of less than ten patients and procedures with a tilt angulation of 60° or greater than 80°; the study included 4361 syncope patients (aged 41-17 years) and 1791 controls (aged 39-17 years). With a region under the curve of 0.84 [95 percent confidence interval (CI) 0.81–0.87], the overview receiver-operating curve showed strong overall ability to distinguish symptomatic patients from asymptomatic controls. Pharmacological protocols increased sensitivity but decreased specificity, as predicted. The highest diagnostic odds ratio (14.40; 95 percent CI 11.50–18.05) and sensitivity (66 percent; 95 percent CI 60–72 percent ) were found in tilt protocols that included nitroglycerine provocation.
The European Society of Cardiology (ESC)10 and the American College of Cardiology/American Heart Association/Heart Rhythm Society collaboration11 came to similar and closely coherent recommendations for TT in unexplained syncope after initial clinical assessment based on the preponderance of evidence and working independently (a few members of each group provided reviews of the other document). Furthermore, both groups suggested that when an autonomic disruption was suspected, TT (along with additional cardiovascular autonomic assessment, if necessary) could be the first step in the diagnostic process.
According to recent criticisms by Kulkarni et al.9, TT, like any diagnostic test, may be misused. Nonetheless, comprehensive experience and evidence-based practice guidance guidelines provide clear direction for its proper use and indicate when TT is a valuable, efficient diagnostic tool. Other orthostatic stressors (e.g., active standing, squat-stand test) may be considered, but they have not received the same level of scrutiny as TT as possible clinical methods, with the exception of initial and classic OH and postural orthostatic tachycardia syndrome, where active standing is well known, validated by data, and thus by guidelines. ten, eleven
Tilt and syncope testing:
Tilt-table imaging was used to evaluate sensitivity to the vasovagal reflex in patients with TLOC of unknown etiology. If the medical history is classic and diagnostic of reflex syncope, such testing is not needed for diagnosis. However, this is not always the case, particularly in older patients whose histories may be incomplete due to retrograde amnesia. 23
From history taking, four characteristics of TLOC can be deduced: I a propensity to fall as an expression of loss of motor control; (ii) amnesia for the duration of the TLOC; (iii) irregular reactions to speech/touch; and (iv) a limited duration (less than 5 minutes).
I concussion; (ii) syncope; (iii) epileptic seizures; (iv) psychogenic spells resembling syncope [psychogenic pseudosyncope (PPS)] or seizures [psychogenic non-epileptic seizures (PNES)]; and (v) intoxication/metabolic disorder (strictly not TLOC because length is >5 minutes).
It is frequently, but not always, possible to distinguish between these diagnostic agents using a thorough medical history that includes eyewitness reports.
TT is the safest next step in some patients with persistent apparent syncope for whom prior attempts at diagnosis have failed, and recommendations support this approach.
ten, eleven If PPS, PNES, or mechanical falls due to orthostatic intolerance are all possibilities, findings during TT would almost certainly be diagnostic. Electroencephalography (EEG) is commonly used in conjunction with TT and is considered important in PPS/PNES. 24 In OH, TT allows for safe long-term blood pressure monitoring without the possibility of falling or injury that may occur during active stand or squat-stand tests. When it comes to recording immediate OH, however, TT is less successful than active standing, which is why the latter is recommended. ten, eleven
Several findings indicate that observed syncope/collapse associated with positive TT is comparable to spontaneous vasovagal syncope (VVS), but it should be noted that tilt-induced syncope is not the same as VVS. On implantable loop recorders (ILR), for example, bradyarrhythmias are more prominent than during TT. 6 VVS diagnosis varies from TT in that it is based on the patient's recognition of symptom replication (Figure 1). As a consequence, TT can be helpful in VVS diagnosis but not so much in therapy selection.
Final Thoughts:
Tilt testing is an important and effective diagnostic method. The importance of it is endorsed by practice guidelines based on published and thoroughly vetted data. TT strengthens our comprehension of the pathophysiology of syncope/collapse and makes us to care for our patients. Active standing and ILR/ICMs can't replace TT; active standing is useful in certain types of OH but hasn't been shown to be useful in other syncope presentations, while ILR/ICMs are a useful addition to syncope workup.
R.S. is a consultant for Medtronic Inc., a member of Abbott Laboratories Inc.'s speakers bureau, and a stockholder in Edwards Lifesciences Corp. and Boston Scientific Inc. D.G.B. receives funding from the Dr Earl E Bakken Family for heart-brain research and reports consulting fees from Medtronic Inc. and Abbott Laboratories (SJM). Biotronik Inc. and Medtronic Inc. pay A.F. personal fees. Boston Scientific Inc., Medtronic Inc., and Abbott Laboratories have all provided H.A. research grants. NHLBI Grant RO1HL134674 has supported J.M.S. R.D.T. is funded by Medtronic for research, Theravance Biopharma for consulting, and Medtronic, Union Chimique Belge, and Novartis for lectures. Personal payments from Amarin, Boehringer Ingelheim, Sanofi Aventis, Respicardia, and Lundbeck were mentioned by B.O. There are no conflicts of interest declared by J.G.v.D., M.B., F.d.L., P.B.L., R.A.K., A.M., S.D.R., and V.R.
Professor Richard Sutton @imperialcollege @ImperialMed #TiltTest #HeartRate #BloodPressure #Cardiology #Heart #Research Tilt Testing Remains A Valuable Asset
Frank Gommans, MD, PhD @frankgommans @CUMedicalSchool @CUAnschutz @CU_MSTP #HeartFailure #Cardiology #Research Soluble Neprilysin and Corin Concentrations in Relation to Clinical Outcome ...
Frank Gommans, MD, PhD from the Radboud University Medical Centre speaks about Soluble Neprilysin and Corin Concentrations in Relation to Clinical Outcome in Chronic Heart Failure.
Link to Study -
https://www.jacc.org/doi/10.1016/j.jchf.2020.08.015
Summary -
Aims and goals
This research looked at whether soluble neprilysin and corin concentrations can be used to stratify patients with chronic heart failure (HF) and whether this is related to clinical outcomes.
Foreground
Corin and neprilysin, two enzymes that process natriuretic peptides, play a key role in the conversion of pro–natriuretic peptides to active natriuretic peptides as well as their degradation
Methodologies
A prospective cohort of 1,009 patients with chronic HF was divided into four equal classes based on their neprilysin/corin concentration relative to the median: 1) low neprilysin/low corin; 2) low neprilysin/high corin; 3) high neprilysin/low corin, and 4) high neprilysin/high corin. The composite primary outcome of cardiovascular mortality and HF hospitalization was subjected to a Cox regression survival study.
Conclusions
The median concentrations of neprilysin and corin were not associated (rho:0.04; p = 0.21). While there was no correlation with outcome in univariate research, after accounting for baseline variations in age and sex, a substantial association with survival was observed, with the highest survival in group 1 (low neprilysin/low corin) and the lowest in group 4 (high neprilysin/high corin) (adjusted hazard ratio: 1.56; p = 0.003) (adjusted hazard ratio: 1.56; p =
Final Thoughts
Clinical results are related to the stratification of patients with chronic HF based on circulating neprilysin and corin concentrations. These findings indicate that the control of these enzymes is important in chronic HF, and they may provide an intriguing mechanism for classifying patients with HF as the first step toward individualized HF patient care.
Jason G. Andrade, MD @DrJasonAndrade @VCHhealthcare @ICMtl #AtrialFibrillation #Cardioloy #Research
Jason G. Andrade, MD from Vancouver Costal Health and L’Institut de Cardiologie de Montréal discusses Cryoablation or Drug Therapy for Initial Treatment of Atrial Fibrillation.
Instract
HINTERGROUNDS
Until catheter ablation is considered in patients with atrial fibrillation, guidelines prescribe a trial of one or more antiarrhythmic medicines. The first-line ablation, however, may be more effective in preserving sinus rhythm.
FOR METHODS
303 patients with symptomatic, paroxysmal, untreated atrial fibrillation were randomly assigned to undergo cryothermia balloon catheter ablation or receive antiarrhythmic drug therapy for initial rhythm regulation. To detect atrial tachyarrhythmia, all the patients obtained an implantable cardiac monitoring unit. The time for follow-up was 12 months. The first confirmed recurrence of any atrial tachyarrhythmia (atrial fibrillation, atrial flutter, or atrial tachycardia) between 91 and 365 days after catheter ablation or antiarrhythmic drug onset was the primary endpoint. Independence from symptomatic arrhythmia, the stress of atrial fibrillation and quality of life were the secondary endpoints.
OUTCOMES
At 1 year, 66 of 154 patients (42.9%) assigned to receive ablation, and 101 of 149 patients (67.8%) assigned to receive antiarrhythmic drugs (hazard ratio, 0.48; 95% confidence interval [CI], 0.35 to 0.66; P<0.001) had a recurrence of atrial tachyarrhythmia. In 11.0 percent of the patients who underwent ablation and in 26.2 percent of those who administered antiarrhythmic medications, symptomatic atrial tachyarrhythmia recurred (hazard ratio, 0.39; 95 percent CI, 0.22 to 0.68). The median percentage of atrial fibrillation duration was 0 percent with ablation (interquartile range, 0 to 0.08) and 0.13 percent with antiarrhythmic drugs (interquartile range, 0 to 1.60). Five patients (3.2 percent) who underwent ablation and six patients (4.0 percent) who received antiarrhythmic drugs reported severe adverse events.
CONCLUSIONS
There was a substantially lower rate of atrial fibrillation recurrence with catheter cryoballoon ablation in patients undergoing initial care for symptomatic, paroxysmal atrial fibrillation than with antiarrhythmic drug therapy, as measured by continuous cardiac rhythm monitoring. (Funded by Canada's Cardiac Arrhythmia Network and others; the number of EARLY-AF ClinicalTrials.gov, NCT0282597.)
Maurice Sarano, MD @sarano_maurice @MHIF_Heart #STS21 #TricuspidRegurgitation #Cardiology #Research Discussion - STS/CSCS: Tricuspid Valve Surgery Associated with Left Sided Cardiac Disea...
Maurice Sarano, MD of the Minneapolis Heart Institute speaks about STS 2021 Discussion - STS/CSCS: Tricuspid Valve Surgery Associated with Left Sided Cardiac Disease: When, What, and How?
Link to Abstract -
https://www.eventscribe.net/2021/STS/fsPopup.asp?efp=SEJKWElTSFExMjA3NA&PresentationID=815982&rnd=0.2613683&mode=sessionInfo
Diagnosis and treatment of tricuspid regurgitation associated with left-sided heart disease are difficult. A multidisciplinary group of experts will discuss the natural history of tricuspid regurgitation, diagnosis, and surgical and transcatheter management in this session.
Learning Goals:
Explain the natural history of left-side cardiac disease-related tricuspid regurgitation and its prognostic implications
Recognize tricuspid valve care timing and indications
Describe tricuspid regurgitation surgical and transcatheter therapies
Carol Peng, MD Kashif Munir, MD @CCPeng98 @ummidtownim #HualienTzuChiHospital #Anticoagulants #Cardiology #Research Fracture Risks in Patients Treated With Different Oral Anticoagulants
Carol Chiung-Hui Peng, MD and Kashif Munir, MD, Medical Director Of The University Of Maryland Center For Diabetes And Endrocrinology, University of Maryland Medical Center Midtown Campus, University of Maryland School of Medicine speaks about Fracture Risks in Patients Treated With Different Oral Anticoagulants: A Systematic Review and Meta‐Analysis.
Link To Abstract:
https://www.ahajournals.org/doi/10.1161/JAHA.120.019618
Summary -
Background:
To evaluate the fracture risk associated with NOACs and warfarin, we performed a systematic review and meta-analysis.
Methods and Results:
From inception to May 19, 2020, we searched PubMed, Embase, Cochrane Library, Scopus, Web of Science, and ClinicalTrials.gov. We included studies that recorded measurements for any fracture in NOAC and warfarin users (regardless of major, secondary, tertiary, or safety outcomes). Two or more reviewers worked together to screen relevant papers, extract data, and evaluate accuracy. To synthesize the pooled relative risk (RR) of fractures associated with NOACs versus warfarin, data were retrieved. For data synthesis, random-effects models were used. There were 388 209 patients in 29 studies (5 cohort studies and 24 randomized controlled trials). Patients taking NOACs had a lower risk of fracture than those taking warfarin (pooled RR, 0.84; 95 percent CI, 0.77–0.91; P0.001), and there was little variability (I2=38.9%). NOACs were also linked to a lower risk of hip fracture than warfarin (pooled risk ratio, 0.89; 95 percent confidence interval, 0.81–0.98; P=0.023). There was also a nonsignificant trend of NOAC users having a lower risk of vertebral fracture (pooled RR, 0.74; 95 percent CI, 0.54–1.01; P=0.061). Specific NOACs dabigatran, rivaroxaban, and apixaban were found to be significantly associated with lower fracture risks in subgroup analyses. Furthermore, the data synthesis results from randomized controlled trials and real-world cohort studies were remarkably consistent, suggesting the validity of our findings.
Conclusions:
NOACs are associated with a lower risk of bone fracture as compared to warfarin.
Giuseppina Caligiuri, MD @pinacaligiuri @Inserm @Univ_Paris #CoronaryStint #Cardiology #Heart #Research Coronary Stent CD31-mimetic Coating Favours Endothelialization And Reduces Local In...
Giuseppina Caligiuri, MD, Ph.D. from the Laboratory for Vascular Translational Science, Université de Pari speaks about Coronary Stent CD31-mimetic Coating Favours Endothelialization And Reduces Local Inflammation And Neointimal Development In Vivo.
Link to Article:
https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehab027/6134553
Synopsis:
The rapid endothelialization of bare-metal stents (BMS) is counterbalanced by neointimal growth caused by inflammation. Drug-eluting stents (DES) inhibit endothelialization thereby preventing leukocyte activation, slowing successful system penetration into arterial walls. We previously demonstrated that the vascular CD31 co-receptor is necessary for endothelial and leukocyte homeostasis as well as arterial healing. Furthermore, we have demonstrated that P8RI, a soluble synthetic peptide, acts as a CD31 agonist. The aim of this study was to see how a CD31-mimetic metal stent coating affected endothelial cell (EC) and blood element adherence in vitro, as well as strut coverage and neointimal growth in vivo.
Methods and Actual outcomes: We used two methods to coat Cobalt-Chromium discs and stents with a CD31-mimetic peptide: plasma amination and dip-coating, both of which achieved comparable results. In vitro, CD31-mimetic discs significantly decreased EC and blood platelet/leukocyte activation in primary human coronary arteries. At 7 and 28 days after implantation in pig coronary arteries, CD31-mimetic stent properties were compared to those of DES and BMS using coronarography and microscopy (n = 9 stents/group/time point). Only CD31-mimetic struts were completely endothelialized seven days after implantation, with no activated platelets or leukocytes. On day 28, neointima formation was substantially reduced over CD31-mimetic stents compared to BMS, appearing as a normal arterial media with no thrombosis, in contrast to DES.
Response: The CD31-mimetic coating promotes vascular homeostasis and arterial wall healing, avoiding stenosis and thrombosis within the stent. As a result, such coatings seem to increase the biocompatibility of metal stents.
@CardioOncology @BalkoLab @VUMC_Cancer @VUMCHemOnc @VUMChealth #Myocarditis #CardioOnc #CancerImmunotherapy #Cancer #Research A genetic mouse model recapitulates immune checkpoint inhibit...
Javid Moslehi, MD and Justin M. Balko, Pharm.D., Ph.D. from Vanderbilt-Ingram Cancer Center discuss A genetic mouse model recapitulates immune checkpoint inhibitor-associated myocarditis and supports a mechanism-based therapeutic intervention.
Instract
Cancer therapy has been transformed by immune control point inhibitors (ICI) targeting CTLA-4 or PD-1/PD-L1 but is associated with immune-related adverse effects (irAEs), including myocarditis. A robust preclinical mouse model of ICI-associated myocarditis is reported here, in which mono-allelic loss of Ctla4 in the sense of complete genetic absence of Pdcd1 leads to premature death in about half of the mice. Premature death results from T cell and macrophage myocardial invasion and significant electrocardiographic defects, closely recapitulating the clinical and pathological characteristics of ICI-associated myocarditis found in patients. Using this model, we demonstrate that in a gene dosage-dependent way, Ctla4 and Pdcd1 interact functionally, providing a mechanism by which myocarditis occurs in the setting of combination ICI therapy with increased frequency. We show that CTLA-4-Ig (abatacept) intervention is appropriate to boost the progression of the disease and also include a case series of patients in whom abatacept mitigates the fulminant course of ICI-myocarditis.
Jeffrey J. Goldberger, MD @DrJGoldberger @UMiamiHealth #OBTAINRegistry #MyocardialInfarction #Cardiology #Heart #Research Comparison of Metoprolol versus Carvedilol After Acute Myocardial...
Jeffrey J. Goldberger, MD, MBA from the University of Miami speaks about the Comparison of Metoprolol versus Carvedilol After Acute Myocardial Infarction.
Link to Article -
https://www.ajconline.org/article/S0002-9149(21)00155-7/fulltext#%20
• Beta-blockers are commonly administered after a heart attack, but no one brand has been recommended.
• In this analysis, metoprolol and carvedilol are compared in a post-MI cohort.
• Carvedilol and metoprolol had comparable overall survival rates in the sample.
• In the ejection fraction 40 percent subgroup, carvedilol outperformed metoprolol in terms of survival.
Summary
Following a myocardial infarction (MI), beta-blockers are commonly prescribed, although no particular beta-blocker is recommended. 4142 patients were discharged on metoprolol and 1487 on carvedilol from the OBTAIN multi-center list of patients with acute MI. The beta-blocker dose was calculated as a percentage of the target daily dose used in randomized clinical trials (metoprolol 200 mg; carvedilol 50 mg). >0 percent -12.5 percent (n=1428), >12.5 percent -25 percent (n=2113), >25 percent -50 percent (n=1392), and >50 percent (n=696) were the beta-blocker dose classes. Three-year survival was calculated using the Kaplan-Meier equation. A multivariable adjustment was used to correct for baseline variations. Carvedilol patients were older (64.4 vs. 63.3 years) and had more comorbidities, including hypertension, diabetes, previous MI, congestive heart failure, lower left ventricular ejection fraction, and a longer period of stay. The mean doses of metoprolol and carvedilol did not vary substantially (37.227.8% and 35.831.0%, respectively). The 3-year survival figures for metoprolol and carvedilol were 88.2% and 83.5 percent, respectively, with an unadjusted HR=0.72 (p0.0001), but HR=1.073 (p=0.43) after multivariable adjustment. In comparison to other dose ranges, patients in the >12.5-25 percent dose range had better survival. In a subgroup of patients with a left ventricular ejection fraction of less than 40%, metoprolol was found to have a worse survival rate than carvedilol (adjusted HR=1.281; 95 percent CI: 1.024-1.602, p=0.03). There were no variations in survival between carvedilol and metoprolol in patients with a left ventricular ejection fraction greater than 40%. Overall survival after acute MI was comparable in patients treated with metoprolol or carvedilol, but carvedilol could be superior in patients with a left ventricular ejection fraction of less than 40%.
Akhil Narang, MD @AkhilNarangMD @NMCardiovasc @NorhtwesternMed #TTE #Cardiology #Research AI Guidance Helps Nurses With No Experience Obtain Echocardiograms
Akhil Narang, MD from the Bluhm Cardiovascular Institute at Northwestern University discusses AI guidance helps nurses with no experience obtain echocardiograms.
Link to Article -
https://www.cardiovascularbusiness.com/topics/imaging-physiology/ai-guidance-helps-nurses-no-experience-imaging?utm_source=newsletter&utm_medium=cvb_news
According to new research published in JAMA Cardiology, AI models will direct nurses with no previous experience through the method of obtaining 10-view transthoracic echocardiographic (TTE) studies.
To see if AI could help with this issue, Narang et al. used software designed to "emulate sonographer expertise" by tracking image quality and providing helpful cues when needed.
The team trained its AI model on images from a variety of suppliers, making it adaptable to a variety of platforms, and then put it to the test on a group of eight nurses who had never done an echocardiogram before. From March to May 2019, each nurse screened 30 adult patients who were scheduled for an echocardiogram at one of two facilities.
Each nurse's purchases were individually checked by a group of five experienced specialists. Overall, 98.8% of scans for left ventricular size, function, and pericardial effusion were of diagnostic quality, while 92.5 percent of scans for right ventricular size were of diagnostic quality.
The researchers believe that their work will help users get improved patient care in addition to improving access. If the AI model can assist nurses with no prior experience, it can also be useful for users with some prior experience, offering vital reminders that they can bring with them going forward.
The full analysis is available here -
https://jamanetwork.com/journals/jamacardiology/fullarticle/2776714
Rozh H. Al-Mashhadi, MD @AUHdk #Hypertension #Cardiology #Research Local Pressure Drives Low-Density Lipoprotein Accumulation and Coronary Atherosclerosis in Hypertensive Minipigs
Rozh H. Al-Mashhadi, MD from the Aarhus University Hospital discusses Local Pressure Drives Low-Density Lipoprotein Accumulation and Coronary Atherosclerosis in Hypertensive Minipigs.
Link to Research -
https://www.jacc.org/doi/10.1016/j.jacc.2020.11.059?utm_medium=social&utm_source=twitter_post&utm_campaign=twitter_post
Instract
Context
There is a limited understanding of the mechanisms by which hypertension accelerates coronary artery disease. There are sometimes confusing humoral changes in patients with hypertension, and to date, no experimental models have allowed the isolated effect of pressure on atherosclerosis to be studied in a setting that recapitulates the dimensions and biomechanics of human coronary arteries.
Targets
This thesis aimed to examine and explore the fundamental mechanisms of the impact of pressure on coronary atherosclerosis.
Methodology
Using inflatable suprarenal aortic cuffs, in the cephalad body portion of wild-type and hypercholesterolemic proprotein convertase subtilisin kexin type 9 (PCSK9)D374Y Yucatan minipigs, we increased mean arterial pressure by >30 mm Hg for >1 year. Pressures at the caudal remained natural.
Outcomes
Cephalad hypertension accelerated coronary atherosclerosis to nearly 5-fold under hypercholesterolemic conditions in transgenic PCSK9D374Y mini pigs, with the consistent development of fibroatheromas that were sufficiently large to induce computed tomography angiography stenosis. This was caused by local pressure forces since there were no changes in lesion formation in vascular beds shielded from hypertension but subjected to the same humoral influences. The same experiment was performed to investigate the underlying mechanisms under normocholesterolemic conditions in wild-type mini-pigs. Hypertension with increased abundance of mechanical strength proteins and decreased levels of infiltrating plasma macromolecules induced clear changes in the arterial proteome. Increased smooth muscle cells and increased intimate accumulation of low-density lipoproteins in the coronary arteries were parallel to this.
Findings
Coronary atherosclerosis is facilitated by elevated pressure per se. Our data show that redesign of the artery to balance higher tensile forces in hypertension changes the movement of macromolecules and contributes to the increased intimate accumulation of lipoproteins of low density.
Sammy Zakaria, MD @sxz110 @JohnsHopkins @HopkinsMedicine @GarimaVSharma @ErinMichos @DrAnumMinhas @DrLenaMathews #Hypertension #PreEclampsia #Cardiology #Heart #Research Acute Cardiac Eff...
Sammy Zakaria, MD, MPH from Johns Hopkins University speaks about Acute Cardiac Effects of Severe Pre-Eclampsia.
Link to Article:
https://www.jacc.org/doi/10.1016/j.jacc.2018.04.048
Summary
Background: Pre-eclampsia with severe features (PEC) is a pregnancy-related condition marked by severe hypertension and end-organ dysfunction, as well as short-term adverse cardiovascular events such as heart failure, pulmonary edema, and stroke.
Objectives include:
The authors wanted to see how right ventricular (RV) systolic pressure (RVSP) and echocardiographic-derived diastolic, systolic, and speckle monitoring parameters changed over time in women with PEC.
Methodologies:
The authors enrolled 63 women with PEC and 36 pregnant control patients in this prospective retrospective study.
The following are the outcomes:
As compared to the control cohort, the PEC cohort had a higher RVSP (31.0 7.9 mm Hg vs. 22.5 6.1 mm Hg; p 0.001) and a lower global RV longitudinal systolic strain (RVLSS) (19.6 3.2 percent vs. 23.8 2.9 percent [p 0.0001]). There were significant differences (p 0.001) in mitral septal e′ velocity (9.6 2.4 cm/s vs. 11.6 1.9 cm/s), septal E/e′ ratio (10.8 2.8 vs. 7.4 1.6), left atrial area size (20.1 3.8 cm2 vs. 17.3 2.9 cm2), and posterior and septal wall thickness for left-sided cardiac parameters (median [interquartile range]: 1.0 cm [0.9 to 1.1 cm] vs. 0.8 cm [0.7 to 0.9 cm], and 1.0 cm [0.8 to 1.2 cm] vs. 0.8 cm [0.7 to 0.9 cm]). PEC was seen in eight women (12.7%) with grade II diastolic dysfunction and six women (9.5%) with peripartum pulmonary edema.
Final Thoughts:
When compared to healthy pregnant women, women with PEC have higher RVSP, higher rates of irregular diastolic activity, decreased global RVLSS, increased left-sided chamber remodeling, and higher rates of peripartum pulmonary edema.
Carol Peng, MD Kashif Munir, MD @CCPeng98 @ummidtownim #HualienTzuChiHospital #AtrialFibrillation #Cardiology #Research Non‐vitamin K antagonist oral anticoagulants vs. warfarin
Carol Chiung-Hui Peng, MD from the University of Maryland Medical Center Midtown Campus, and Kashif Munir, MD from the University of Maryland School of Medicine, associate professor, and Medical Director of the University of Maryland Center for Diabetes and Endocrinology speak about Non‐vitamin K antagonist oral anticoagulants vs. warfarin for AFib patients: What the latest research tells us.
Twitter -
@UMMC @umms @UMmedschool
Link to Abstract:
https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.14243
Abstract
Comparison of the risk of developing diabetes in patients with non-vitamin K antagonist oral anticoagulants (NOACs) treated with atrial fibrillation (AF) and warfarin.
Materials and Methods
Using Taiwan's National Health Insurance Research Database, we carried out a nationwide retrospective cohort analysis. Adult new-onset AF patients treated with NOACs or warfarin between 2012 and 2016 have been included. The NOAC cohort was further categorized into classes of dabigatran, rivaroxaban, and apixaban. Incident diabetes requiring treatment with antidiabetic medications was the primary outcome. Subdistribution hazard models of Fine and Gray were used to estimate the adjusted hazard ratio (aHR). For each head-to-head analysis, propensity score matching was conducted.
Outcomes
Our analysis included a total of 10,746 new-onset AF patients. NOACs were associated with a lower risk of developing diabetes than warfarin during the mean 2.4-year follow-up (aHR = 0.80, 95 percent confidence interval [CI]: 0.68-0.94, P = .007). Analyses of the subgroup indicated that dabigatran, rivaroxaban, and apixaban each had a decreased risk of diabetes. Stratified studies found that the lower risk of NOAC-related diabetes was specific for patients 65 years of age or older (aHR = 0.74, 95% CI: 0.62-0.89, P = .002) and those with strong adherence to medication (aHR = 0.70, 95% CI: 0.58-0.84, P < .001).
Findings
In patients with AF, taking NOAC was associated with a lower risk of developing diabetes compared to taking warfarin.
Mads Hashiba Jensen, med.stud @MadsHashiba @uni-copenhagen @UCPH_Health @koebenhavns_uni #Atrial Fibrillation #SleepApnea #DANAPNO #Cardiology #Research DANish Patients With Atrial Fibril...
Mads Hashiba Jensen, a Medical Student at the Department of Cardiology at Herlev og Gentofle Hospital and the University of Copenhagen a presentation on DANish Patients With Atrial Fibrillation and Sleep Apnea Prevalence by Night Owl (DANAPNO).
Link to Study:
https://www.clinicaltrials.gov/ct2/show/NCT04760002?term=04760002&draw=2&rank=1
Description of the Research -
A study to see whether NightOwl could be used to detect the prevalence of obstructive sleep apnea (OSA) in patients with atrial fibrillation (AF). The long-term goal is to use the system to test for OSA in AF patients undergoing ablation and/or AF patients undergoing cardioversion in a randomized clinical trial.
Patients with some form of AF who are referred to a nurse-run ambulatory for anticoagulation initiation will be required to participate. The ambulatory consists of four regular nurse-led tracks at Herlev-Gentofte University Hospital's Department of Cardiology. In a formal partnership, Herlev-Gentofte University Hospital's Department of Pulmonology offers work-up with cardio-respiratory monitoring investigation and clinical assessment of starting sleep apnea care in patients referred from the study. Those in attendance Participants will be recruited from the Thrombosis unit (Tromboseklinikken) at Herlev-GentofteHospital who have AF without established sleep apnea and a need for anticoagulation. As part of their routine check at the anticoagulation outpatient clinic at Herlev and Gentofte Hospital, participants will be contacted and invited to participate in the research project by a local investigator or a project nurse. Participants will be given verbal details about the research project as well as the appropriate time to discuss recruitment during the interview. The written participant information will be given to the participants before the verbal information, and it will be given to them by a researcher or a project nurse who is well-versed in the project. Before a written informed consent is received, the investigators will be given the details they need to find eligible participants. The written informed consent enables the researchers to access the participant's medical health records for the purposes of the study.
The analysis is cross-sectional in nature. A third visit will be scheduled for the first 20 participants and those with an apnea-hypopnea index (AHI)>15 who are included in the sample.
The participant borrows a NightOwl and receives system guidance during the initial visit, which includes a clinical assessment and a questionnaire about OSA symptoms.
In a home setting, NightOwlTM was used for four nights of recording.
A follow-up visit to discuss the findings of the home surveillance and the soft node questionnaire.
A fourth visit to the sleep apnea clinic will be scheduled for the first 20 patients, as well as all patients whose home test shows (AHI>15).
The research will take about 6 months from the time the first patient is enrolled until the last patient is enrolled.
Timothy D. Henry, MD @HenrytTimothy @ChristHospital #CoronaryMicrovascularDysfunction #Cardiology #Research Chest Pain Linked to Underdiagnosed Heart Condition Affecting 8.3M Americans
Timothy D. Henry, MD, MSCAI of The Christ Hospital Health Network speaks about his Physician Perspective: Chest Pain Linked to Underdiagnosed Heart Condition Affecting 8.3M Americans.
Link to Dr. Henry's Biography -
https://www.thechristhospital.com/physician-details?Provider=%230010BU225
Link to Dr. Henry's ResearchGate -
https://www.researchgate.net/profile/Timothy_Henry6
The Christ Hospital’s Women’s Heart Website -
https://www.thechristhospital.com/services/heart/specialized-care-and-treatment/womens-heart-disease
The FREEDOM Trial website -
https://www.freedom-trial.com/
Additional information on the trial can be found in this press release -
Robert D. Schaller, DO @rdschaller @PennMedicine @Penn #HaroldLittMD #TamaraBrunkerPAC #MichaelPRileyMD #CIED #Cardiology #Heart #Research Magnetic Resonance Imaging in Patients With Card...
Robert D. Schaller, DO, MS, FHRS from Perelman School of Medicine at the University of Pennsylvania speaks about Magnetic Resonance Imaging in Patients With Cardiac Implantable Electronic Devices With Abandoned Leads.
Link to Article:
https://jamanetwork.com/journals/jamacardiology/article-abstract/2776350?guestAccessKey=885c40e4-d529-4ca0-ac32-eea0224bf10d&utm_source=twitter&utm_medium=social_jamacard&utm_term=4499311282&utm_campaign=article_alert&linkId=111556719
Question about the main points Is it safe to use magnetic resonance imaging (MRI) on patients who have had their cardiac implantable electronic system (CIED) leads removed?
Conclusions
There were no significant adverse effects recorded in this cohort study of 139 patients who had 200 MRIs of different anatomic regions, including the thorax. Transient decreases in lead sensing in 5 patients and subjective sternal heating in 1 patient with an abandoned subcutaneous array and sternal wires were among the CIED parameter changes.
In other words, The results of this analysis indicate that, regardless of the anatomic area being examined, the existence of abandoned CIED leads does not rule out MRI.
Summary
The meaning of for certain cases, magnetic resonance imaging (MRI) is the preferred method of diagnosis. Patients with legacy cardiac implantable electronic devices (CIEDs) now have more access to MRI thanks to conditional devices and innovative imaging protocols. The presence of abandoned leads, on the other hand, is an utter no-no.
The goal to see if performing an MRI in the presence of an abandoned CIED lead is safe and if there are any negative effects on active CIED leads nearby.
Participants, Design, and Setting Between January 2013 and June 2020, this cohort study included consecutive CIED recipients who underwent 1.5-T MRI with at least one abandoned lead. At the University of Pennsylvania Hospital, MRI scans were done. No patients were turned away.
Expositions
CIEDs were reprogrammed to satisfy the pacing needs of individual patients. Electrocardiography telemetry and pulse oximetry were constantly tracked, and if possible, live visual and voice communication with the patient was maintained during the scan. The CIED assessment was replicated after the MRI, and the programming was reset to baseline or a clinically acceptable environment.
Measures and Key Outcomes
Variations of 50% or more in pre-and post-MRI capture thresholds, ventricular sensing of 40% or more, and lead impedance of 30% or more, as well as clinical sequelae including pain and sustained tachyarrhythmia, were considered important. If data on long-term follow-up leads was available, it was analyzed.
Conclusions
A total of 139 patients (110 men [79 percent]) with an average (SD) age of 65.6 (13.4) years had 200 MRIs of different anatomic regions, including the thorax, performed. Repeat examinations were normal, with one patient receiving up to 16 examinations. There were 243 discarded leads in total, with an average (SD) of 1.22 (0.45) per patient. The average (SD) number of active leads was 2.04 (0.78), with 64 patients (46%) requiring a pacemaker. In 41 patients (20.5%) who underwent MRI of the brain, a transmit-receive radiofrequency coil was used. There were no irregular vital signs or tachyarrhythmias that continued. There were no adjustments in battery voltage, power-on reset events, or pacing volume. There were transient CIED parameter shifts, including decreased right atrial sensing in four patients and decreased left ventricular R-wave amplitude in one patient. One patient who had a subcutaneous collection that had been discarded experienced sternal heating that went away when the analysis was stopped early.
Conclusions and Implications
In this large observational study, which included patients who had their thorax examined, the risk of MRI in patients with abandoned CIED leads was minimal. The growing body of evidence casts doubt on the utter contraindication of MRI in patients with CIED leads that have been abandoned.
Prof. Murray Esler @EslerMurray @BakerResearchAu #AutonomicCardiology #Cardiology #Research Editorial - Reflections on the past four decades of mental stress research in autonomic cardiology
Professor Murray Esler from the Baker Heart & Diabetes Institute discusses the Editorial - Reflections on the past four decades of mental stress research in autonomic cardiology.
Link to Full Article -
https://link.springer.com/article/10.1007/s10286-020-00761-7
This commentary, with some observations and a description of my experience in the field of mental stress science, is my contribution to the celebration of the thirtieth anniversary of Clinical Autonomic Research, a journal that has become the benchmark publication for all those interested in the autonomic nervous system in recent years, regardless of their primary medical specialty, which in my case is the automobile.
In 1977, I returned to the Baker Medical Research Institute and the Alfred Hospital in Melbourne, Australia, after 4 years of postgraduate research and clinical training with Prof. Stevo Julius in the Hypertension Division of the University of Michigan Medical Center, where I worked as a clinical cardiologist and founded a laboratory for cardiovascular neuroscience.
I recall being struck by how the involvement of patients with myocardial infarction or ventricular arrhythmias was often precipitated by emotional turmoil in my early clinical practice in Melbourne. "I saw patients in whom armed robbery, robberies, and even an owner's racehorse winning by a "nose" had induced a heart attack. I was delighted to accept, in 1985, an invitation to participate in what I expected would be an influential national panel to discuss the relationship between mental stress and heart disease with this clinical exposure. However, I was not ready for the meeting chair's opening remark (whose name I will not say): "There is no proof that stress causes heart disease, nor will there ever be." I was saddened, but not discouraged, as this could not be true, of course. Where was his crystal ball? Even if the comment captured the pessimism that was prevalent in that era's cardiology.
Faced with this setback, by researching cardiac sympathetic responses to mental stress, I applied my newly developed noradrenaline spillover methodology[4] to the stress-heart issue, tapping into research possibilities that are open to a cardiologist. I performed this study in a cardiac catheterization facility, using a tritiated noradrenaline infusion to measure the isotope dilution release of this catecholamine from sympathetic nerves, with sampling from the heart's coronary sinus. This was to make these measurements of noradrenaline release unique to the cardiac sympathetic nerves, all achieved during the study participants' exposure to laboratory mental stress (Fig. 1a)[4]. The applied stressor, as accepted by my institutional ethics committee, was 10 minutes of challenging mental arithmetic, only to surpass the arithmetic competence of the volunteer, and paced by a metronome. For the mathematically talented, an additional tweak was made by informing the individual that they were incorrect... when they were actually correct! In a standard experiment, we measured the secretion of adrenaline by the adrenal medulla, the release of noradrenaline from the sympathetic nerves and sympathetic nerves of the whole body, the concentrations of noradrenaline and adrenaline plasma sampled from the antecubital vein, and the firing of sympathetic outflow using microneurography in the innervation of the vasculature of the skeletal muscle in the leg.
Milind Desai, MD, MBA @DesaiMilindY @ClevelandClinic #HypertrophicCardiomyopathy #Cardiology #Research Current Concepts in Diagnosis and Management of Hypertrophic Cardiomyopathy
Milind Desai, MD, MBA of the Cleveland Clinic, speaks about Current Concepts in Diagnosis and Management of Hypertrophic Cardiomyopathy.
Link to what Hypertrophic Cardiomyopathy is -
https://www.ccjm.org/content/85/5/399/tab-figures-data
Link to Milind Desai, MD's Bio -
https://my.clevelandclinic.org/staff/6670-milind-desai#research-publications
Paul W. Armstrong, MD @CVC_UAlberta @UAlberta @MerkCanada @Merk #Cardiovascular #HeartFailure #Research U.S. FDA Approval of VERQUVO
Paul W. Armstrong, MD Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada speaks about Merck Announces U.S. FDA Approval of VERQUVO® (vericiguat).
The primary efficacy objective of VICTORIA was to evaluate if VERQUVO, in conjunction with other heart failure therapies, is superior to placebo in reducing the risk of cardiovascular mortality or hospitalization for heart failure in adults with symptomatic recurrent heart failure and less than 45% of the ejection fraction following a worsening heart failure case. Based on a time-to-event study, VERQUVO reached the primary efficacy objective (hazard ratio [HR]: 0.90, 95 percent confidence interval [CI], 0.82-0.98; p=0.019). There was a 4.2 percent reduction in annualized absolute risk with VERQUVO compared to placebo over the course of the study. Therefore, to avoid one primary endpoint case, 24 patients will need to be monitored for an average of one year.
Information Supporting the Approval
VERQUVO approval was based on evidence from VICTORIA (NCT02861534), a randomized, concurrent, placebo-controlled, double-blind, event-driven, multi-center clinical trial comparing VERQUVO with placebo in 5,050 adult patients with New York Heart Association (NYHA) class II-IV symptomatic chronic heart failure and left ventricular ejection fraction (LVEF) less than 45% after a wound of symptomatic chronic heart failure (NYHA) class II-IV. A worsening case of heart failure was described as hospitalization for heart failure within six months or less prior to randomization or use for heart failure of outpatient IV diuretics within three months or less prior to randomization. In VICTORIA, the primary outcome was time-to-first cardiovascular death or heart failure hospitalization. The median follow-up time was 11 months for the primary endpoint. Based on a time-to-event analysis, VERQUVO was superior to placebo in reducing the risk of cardiovascular death or hospitalization for heart failure.
Patients were given VERQUVO 10 mg once daily or a matched placebo up to the target maintenance dose. Therapy started with VERQUVO 2.5 mg once daily and increased to 5 mg once daily and then 10 mg once daily, as tolerated, at roughly two-week intervals. The placebo doses were adjusted similarly. 90 percent of patients in both the VERQUVO and placebo arms were treated with the 10 mg target maintenance dose after approximately one year.
Participants in the study were: 76% male, 64% Caucasian, 22% Asian and 5% Black. The mean age was 67. 59 percent of patients were NYHA Class II at randomization, 40 percent were NYHA Class III and 1 percent were NYHA Class IV. The mean LVEF was 29 percent . Approximately half of all patients had an EF of less than 30%, and 14% of patients had an EF of between 40% and 45%. Sixty-seven percent of VICTORIA patients were enrolled within three months of a hospitalization index case for heart failure; 17 percent were enrolled within three to six months of hospitalization for heart failure; and 16 percent were enrolled within three months of outpatient care for worsening heart failure with IV diuretics. At randomization, the median NT-pro B-type natriuretic peptide (NT-proBNP) level was 2800 pg/mL.
Participants in the study were on quality of treatment. At baseline, 93 percent of patients received a beta-blocker, 73 percent received an angiotensin-converting enzyme (ACE) or angiotensin II receptor blocker (ARB) inhibitor, 70 percent received a mineralocorticoid receptor antagonist (MRA), 15 percent received an angiotensin receptor and neprilysin inhibitor (ARNI) combination, 28 percent had an implantable cardiac receptor antagonist (MRA), and 28 percent had an implantable cardiac inhibitor (ARNI). Ninety-one percent of patients were treated with two or more drugs for heart failure (beta-blocker, any receptor of the renin-angiotensin system [RAS], or MRA) and all three were treated in 60 percent of patients. At baseline, 6% of patients received an inhibitor of ivabradine and 3% of sodium glucose co-transporter 2 (SGLT2).
VERQUVO showed an adverse effect profile comparable to placebo in the VICTORIA trial. Hypotension (16% vs 15%) and anemia were the adverse drug reactions that occurred more frequently with VERQUVO than with placebo and in more than or equivalent to 5% of patients treated with VERQUVO in VICTORIA (10 percent vs 7 percent ). The VICTORIA trial included a total of 2,519 patients treated with VERQUVO (up to 10 mg once daily). The mean period of exposure to VERQUVO was one year, with a median duration of 2.6 years.
B. Daan Westenbrink, MD @WestenbrinkDaan @CardiologyUmcg @univgroningen #CardiovascularDisease #Cardiology #Research Ketone Supplementation: A Novel Intervention for CVD?
B. Daan Westenbrink, MD, Ph.D., Senior Author and Cardiologist at the University of Groningen, UMCG Cardiology speaks about Ketone Supplementation: A Novel Intervention for CVD?
Link to Article:
https://www.medscape.com/viewarticle/946647?src=soc_lk_share
According to a recent study, regardless of the procedure used to increase ketone bodies' presence in the heart, they could have therapeutic benefits for patients with cardiovascular disease (CVD).
The authors examined the current body of experimental and clinical research on the potential function of ketone bodies in improving CVD and discovered that increasing circulating ketone levels can provide protective benefits in patients with the disease.
A ketogenic diet, which consists of a very low carbohydrate and high-fat intake, is a common way to induce ketosis; however, exogenous ketones could be a viable and superior alternative to the diet for increasing circulating ketone bodies, according to the researchers.
The study was published in the Journal of the American College of Cardiology on February 23.
This realization prompted Westenbrink and colleagues to conduct a clinical trial to examine the impact of exogenous ketones on exercise efficiency in patients with heart failure.
The aim of this review was to "summarize the existing literature from animal and human studies, in the hopes of facilitating more research into the benefits of ketones as therapeutic agents in CVD."
Beyond Fuel Efficiency
The authors have looked at the processes of ketone metabolism, such as ketogenesis and ketolysis, as well as cardiac metabolism in both healthy and diseased hearts.
The reactions that lead to the formation of the ketone bodies acetoacetate (AcAc), -hydroxybutyrate (OHB), and acetone are known as ketogenesis.
Fasting causes a reduction in the insulin-to-glucagon ratio, which mobilizes fatty acids, which the liver then converts into ketone bodies. They are then moved to peripheral tissues, where they go through a process known as "terminal oxidation."
The heart appears to "reprogram metabolism to increased dependence on ketone bodies as a fuel source" as heart failure progresses, according to the authors, with increased circulating ketone concentrations and cardiac ketone consumption.
Todd Chapin, PharmD, BCPS @SanfordHealth #AtrialFibrillation #Cardiology #Heart #Research Apixaban Versus Warfarin for the Management of Post-operative Atrial Fibrillation
Todd Chapin, PharmD, BCPS from Sanford Health speaks about Apixaban Versus Warfarin for the Management of Post-operative Atrial Fibrillation.
Link to Study:
https://clinicaltrials.gov/ct2/show/NCT02889562?recrs=dem&cond=Atrial+Fibrillation&cntry=US&phase=123&draw=2&rank=51
Patients who experience atrial fibrillation after isolated coronary artery bypass grafting surgery will be identified in this open-label, prospective, randomized pilot study. Patients with chronic prolonged atrial fibrillation (>2 episodes of atrial fibrillation lasting longer than 30 minutes) or persistent atrial fibrillation (>12 hours) would be qualified. Patients will be randomized to either the standard of care (warfarin per protocol) or the apixaban arms of the trial after meeting research inclusion and exclusion requirements and giving informed consent. Both groups will receive routine postoperative treatment after CABG. The anticoagulation clinic will treat anticoagulation in both classes after discharge. After surgery, patients will be monitored for 30 days.
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