High‐risk inferior myocardial infarction: Can speckle tracking predict proximal right coronary lesions?

Background

It is important to diagnose right ventricular (RV) infarction in the setting of acute inferior myocardial infarction (MI). We aimed to improve the diagnostic accuracy of RV infarction and identify a high‐risk subset of inferior MI patients with proximal RCA lesions.

Hypothesis

We tried to find the link between speckle tracking and coronaries in high risk inferior infarction

Methods

This study included 68 patients within 24 hours of first acute inferior MI. Group 1 (n = 49) isolated inferior MI; group 2 (n = 19) inferior and RV MI. echocardiography for RV free wall longitudinal strain (FWLS), RV fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), RV myocardial performance index (MPI) and peak systolic velocity (S′).

Results

Group 2 had higher MPI by tissue Doppler and 2D‐RV average FWLS, whereas RV FAC, S′, and TAPSE were lower (P < 0.001). In group 1, 14.4% had a significant proximal RCA lesion with impaired RV function. RV average FWLS at a cutoff value ≥ − 19.7% can predict proximal RCA culprit lesion with 91.7% sensitivity and 70.5% specificity, which was detected as an independent predictor in multivariate logistic regression (odds ratio: 37.75, P = 0.036).

Conclusions

2D RV average FWLS at a cutoff of ≥ − 19.7% is a useful added tool for diagnosis of RV involvement and an independent predictor to rule in proximal RCA culprit lesion in inferior‐wall MI patients in the emergency department.

     

Right ventricular base/apex ratio in the assessment of pediatric pulmonary arterial hypertension: Results from the European Pediatric Pulmonary Vascular Disease Network

Background

Echocardiographic determination of RV end‐systolic base/apex (RVES b/a) ratio was proposed to be of clinical value for assessment of pulmonary arterial hypertension (PAH) in adults.

Hypothesis

We hypothesized that the RVES b/a ratio will be affected in children with PAH and aimed to correlate RVES b/a ratio with conventionally used echocardiographic and hemodynamic variables, and with New York Heart Association (NYHA) functional class.

Methods

First we determined normal pediatric values for RVES b/a ratio in 157 healthy children (68 males; age range, 0.5–17.7 years). We then conducted an echocardiographic study in 51 children with PAH (29 males; age range, 0.3–17.8 years).

Results

RVES b/a ratio was lower compared with age‐ and sex‐matched healthy controls (P < 0.001). In children with PAH, RVES b/a ratio decreased with worsening NYHA class. RVES b/a ratio inversely correlated with RV/LV end‐systolic diameter ratio (ρ = ?0.450, P = 0.001) but did not correlate with RV systolic function parameters (eg, tricuspid annular plane systolic excursion) and correlated with cardiac catheterization–determined pulmonary vascular resistance index (ρ = ?0.571, P < 0.001). ROC analysis unraveled excellent performance of RVES b/a ratio to detect PAH in children (AUC: 0.95, 95% CI: 0.89–1.00, P < 0.001).

Conclusions

The RVES b/a ratio decreased in children with PAH compared with age‐ and sex‐matched healthy subjects. The RVES b/a ratio inversely correlated with both echocardiographic and hemodynamic indicators of increased RV pressure afterload and with NYHA class, suggesting that RVES b/a ratio reflects disease severity in PAH children.

     

C‐reactive protein during and after myocardial infarction in relation to cardiac injury and left ventricular function at follow‐up

Background

Acute myocardial infarction (MI) invokes a large inflammatory response, which contributes to myocardial repair.

Hypothesis

We investigated whether C‐reactive protein (CRP) measured during MI vs at 1 month follow‐up improves the prediction of left ventricular (LV) function.

Methods

We prospectively enrolled 131 consecutive patients with acute MI and without non‐cardiovascular causes of inflammation. We correlated admission and peak levels of CRP during hospitalization and high‐sensitivity (hs) CRP at 1 month follow‐up with markers of cardiac injury. Clinical follow‐up and echocardiography for LV function were performed at a mean of 17 months.

Results

Median CRP levels were 1.89 mg/L on admission with MI, peaked to 12.10 mg/L during hospitalization and dropped to 1.24 mg/L at 1 month. Although admission CRP levels only weakly correlated with ejection fraction in the acute phase of MI (coefficient ?0.164, P = 0.094), peak CRP was significantly related to ejection fraction (coefficient ?0.4, P < 0.001), hsTroponin T (0.389, P < 0.001), and white blood cell count (0.389, P < 0.001). hsCRP at 1 month was not related to the extent of acute cardiac injury. These findings were replicated in an independent cohort of 57 patients. Peak CRP predicted LV dysfunction at follow‐up (OR 11.0, 3.1‐39.5 per log CRP, P < 0.001), persisting after adjustment for infarct size (OR 5.1, 1.1‐23.6, P = 0.037), while hsCRP at 1 month was unrelated to LV function at follow‐up.

Conclusions

hsCRP 1 month post‐MI does not relate to acute cardiac injury or LV function at follow‐up, but we confirm that peak CRP is an independent predictor of LV dysfunction at follow‐up.

     

Long‐Term Outcome of Patients with Severe Biventricular Heart Failure and Severe Mitral Regurgitation After Percutaneous Edge‐to‐Edge Mitral Valve Repair

Objective

To assess long‐term outcome and parameters associated with poor and favorable outcome in patients with a left ventricular ejection fraction (LV‐EF) ≤25% and severe mitral regurgitation (MR) after percutaneous edge‐to‐edge mitral valve repair (pMVR).

Background

There is no data on long‐term outcome in this cohort of patients.

Methods

We analyzed all 34 patients with a LV‐EF ≤25% and severe MR treated with pMVR in 2 university hospitals from 2009 to 2012.

Results

Mitral regurgitation could be successfully reduced to grade ≤2 in 30 patients (88%). Long‐term follow‐up (up to 5 years) revealed a steep decline of the survival curve reaching 50% already 8 month after pMVR. In contrast, estimated survival of the remaining patients showed a favorable long‐term outcome. Patients deceased during the first year presented with higher right ventricular tricuspid pressure gradient (RVTG) (44.5 ± 8.4 mmHg vs. 35.2 ± 15.4 mmHg, P = 0.035) and worse RV‐function (P = 0.014) prior to the procedure. One‐year mortality of patients with pulmonary hypertension and depressed RV‐function (n = 22) was very high (77%) compared to the remaining patients (n = 12, mortality rate of 0%, P = 0.0001).

Conclusions

Although pMVR lead to a successful reduction of MR in patients with a LV‐EF ≤25%, 1‐year mortality in this cohort was very high. However, a subgroup of patients showed a favorable long‐term outcome after pMVR. Especially the right ventricular parameters sustained RV‐function and absence of pulmonary hypertension—easily assessed with echocardiography—might be used to identify this subgroup and encourage pMVR in these patients.

     

Left atrial function and mortality in the oldest old

Background

Previous studies demonstrated that left atrium (LA) size is associated with mortality in an elderly population. It remains unclear whether indices of LA function including reservoir, conduit, or booster elements of LA function provide incremental prognostic information.

Hypothesis

Echocardiographic measures of the various parameters of LA function would predict 5‐year mortality in a community‐dwelling population of 85 to 86 year olds independently of LA volume.

Methods

Subjects ages 85 to 86 years old underwent home echocardiography. LA volumes were assessed by the biplane Simpson's method from apical views using measurements of phasic volumes and functions of the LA, including LA expansion index. LA passive and active emptying fractions were assessed. Survival status at 5‐year follow‐up was assessed.

Results

Two hundred eighty‐two subjects were included, of whom 87 (31%) had died at follow‐up. Survival of the subjects in the lowest quartile of the LA expansion index as well as LA active filling index was significantly lower. When measurements of LA volume index were added to the model, the relationship between survival and indices of LA function remained significant.

Conclusions

This study demonstrated that elderly subjects aged 85 to 86 years with significantly impaired LA function had increased 5‐year mortality independently of indices of LA volume.

     

Coronary sinus lead delay index for optimization of coronary sinus lead placement

Aim

Optimization of coronary sinus (CS) lead position to the latest activated left ventricular (LV) area is important to increase cardiac resynchronization therapy (CRT) response. We aimed to detect the relationship between coronary sinus lead delay index (CSDI) and echocardiographic, electrocardiographic response to CRT treatment.

Methods

We prospectively included 137 consecutive patients with heart failure (HF) diagnosis, QRS ≥ 120 ms, left bundle branch block (LBBB), New York Heart Association score (NYHA) II–IV, LV ejection fraction (LVEF) <35% and scheduled for CRT (84 male, 53 female; mean age 65.1 ± 10.1 years). Echocardiographic CRT response was defined as ≥15% reduction in LV end‐systolic volume (LVESV). CS lead sensing delay was calculated as the time interval from the onset of surface QRS wave to the onset of depolarization wave recorded from the CS lead by using the CS pacing lead as a bipolar electrode. CSDI was calculated by dividing the CS lead sensing delay by the QRS duration.

Results

LVESV reduction was associated with baseline QRS width (r = .257, p = .002), QRS narrowing (r = .396, p < .001), CSDI (r = .357, p < .001), and NT‐proBNP (r = ?0.213, p = .022) in bivariate analysis. In logistic regression analysis, CSDI was found to be only independent parameter for predicting significant LVESV reduction (Beta = 0.318, p < .001). CSDI was also found to be significantly associated with LVEF increase (r = .244, p = .004) and QRS narrowing (r = .178, p = .046).

Conclusion

CSDI may be used as a marker to predict the favorable response to CRT. It may be useful to integrate CSDI to CRT implantation procedure in order to minimize nonresponders.

     

Percutaneous Trans‐Coronary Venous Mitral Annuloplasty in Patients With Functional Mitral Regurgitation: Analysis of Poznan Carillon Registry Data

Objectives

The purpose of our study is to verify, whether percutaneous mitral annuloplasty results in reverse remodeling in patients with functional mitral regurgitation (FMR) and impaired ejection fraction (EF) and to investigate which echo parameters may help in prediction of the efficacy of the procedure.

Background

FMR exacerbates left ventricular (LV) dilatation and contributes to both LV remodeling and heart failure.

Methods

We analyzed baseline and 1 month follow‐up data in 22 consecutive patients with FMR, who underwent successful percutaneous trans‐coronary venous mitral annuloplasty with the Carillon device.

Results

Significant reduction of FMR echo parameters, including vena contracta (VC), effective regurgitant orifice area (EROA), and regurgitant volume (RV) were observed and maintained throughout 1 month follow up and did not correlate with baseline annular, LV or with the left atrial diameters. Baseline mitral tenting area correlated negatively with the relative improvement (% difference) of EROA (r = ?0.5898) and RV (r = ?0.4363), but not with VC (r = 0.1341). In addition, increased EF as well as a significant reduction in left ventricular diameters were noted. The increase in EF negatively correlated with the change in EROA (r = ?0.50058), PISA (r = ?0.5327), and RV (r = ?0.5457). Baseline mitral tenting area significantly correlated with the 1 month change in EF (r = 0.5946) and stroke volume (r = 0.6913).

Conclusions

The improvement of FMR after treatment with the Carillon device is associated with LV reverse remodeling and an increase in systolic performance, that correlates with the reduction in mitral regurgitation, being not dependent on baseline heart diameters. Mitral tenting area seems to be an important parameter in prediction of benefit from percutaneous mitral annuloplasty.

     

Clinical efficacy of irrigated catheter application of amiodarone during ablation of persistent atrial fibrillation

Background

Pharmacological treatment during ablation of persistent atrial fibrillation (AF) is common, but utility of irrigated catheter application of amiodarone during ablation of persistent AF remains unclear.

Hypothesis

Irrigated catheter application of amiodarone improves quality of ablation and long‐term outcomes.

Methods

We enrolled 90 persistent AF patients who underwent catheter ablation. Patients were randomized to the amiodarone group (n = 45) or control group (n = 45). All patients underwent stepwise ablation beginning with isolation of the pulmonary veins. Next, we performed ablation of linear lesions and focal triggers until sinus rhythm (SR) was achieved. The primary endpoint was documented atrial arrhythmia during follow‐up. The secondary endpoint was cardioversion to SR during ablation.

Results

All pulmonary veins were successfully isolated. Conversion of AF to SR occurred more frequently in the amiodarone group than in the control group (33 vs 23 [73.3% vs 51.1%]; P = 0.03). The amiodarone group had lower procedure, radiofrequency, and fluoroscopy times than the control group (167.4 ± 22.5 min vs 186.7 ± 25.3 min; 78.3 ± 14.2 min vs 90.4 ± 15.5 min; and 6.5 ± 1.9 min vs 8.6 ± 2.4 min, respectively; P < 0.05). More importantly, the atrial arrhythmia recurrence‐free survival rates were 80% in the amiodarone group and 60% in the control group during the 14.7 ± 7.5‐month follow‐up (P = 0.043).

Conclusions

Irrigated catheter application of amiodarone during ablation for persistent AF resulted in higher cardioversion rates and lower procedure times and significantly reduced rates of atrial arrhythmia recurrence.

     

High‐volume forced diuresis with matched hydration using the RenalGuard System to prevent contrast‐induced nephropathy: A meta‐analysis of randomized trials

Background

Contrast‐induced nephropathy (CIN) is a well‐recognized complication of coronary angiography that is associated with poor outcomes. Several small randomized controlled trials (RCTs) have recently shown that in patients with chronic kidney disease (CKD), furosemide‐induced forced diuresis with matched hydration using the RenalGuard system can prevent its occurrence. However, individual studies have been underpowered and thus cannot show significant differences in major clinical endpoints.

Hypothesis

Forced diuresis with matched hydration using the RenalGuard system improves clinical outcomes in patients undergoing coronary angiography.

Methods

Scientific databases and websites were searched for relevant RCTs. The pooled risk ratios were calculated using random‐effects models. The primary endpoint was CIN, and the secondary endpoints were major adverse clinical events (MACEs) and the need for renal replacement therapy.

Results

Data from 3 trials including 586 patients were analyzed. High‐volume forced diuresis with matched hydration using the RenalGuard system decreased risk of CIN by 60% (risk ratio: 0.40, 95% confidence interval: 0.25 to 0.65, P < 0.001), MACE rate by 59%, and the need for renal replacement therapy by 78%, compared with the standard of care.

Conclusions

In patients with CKD undergoing coronary angiography, high‐volume forced diuresis with matched hydration using the RenalGuard system significantly reduces the risk of CIN, MACE rate, and the need for renal replacement therapy. Larger RCTs with sufficient power are needed to confirm these findings.

     

A comprehensive meta‐analysis of stem cell therapy for chronic angina

Background

A substantial proportion of patients with coronary artery disease do not achieve complete revascularization and continue to experience refractory angina despite optimal medical therapy. Recently, stem cell therapy has emerged as a potential therapeutic option for these patients. However, findings of individual trials have been scrutinized because of their small sample sizes and lack of statistical power. Therefore, we conducted an updated comprehensive meta‐analysis of available randomized controlled trials (RCTs) with the largest sample size ever reported on this subject.

Hypothesis

In patients with chronic angina stem cell therapy improves clinical outcomes.

Methods

Scientific databases and websites were searched for RCTs. Data were independently collected by 2 investigators, and disagreements were resolved by consensus. Data from 10 trials including 658 patients were analyzed.

Results

Stem cell therapy improved Canadian Cardiovascular Society angina class (risk ratio: 1.53, 95% CI: 1.09 to 2.15, P = 0.013), exercise capacity (standardized mean difference [SMD]: 0.56, 95% CI: 0.23 to 0.88, P = 0.001), and left ventricular ejection fraction (SMD: 0.63, 95% CI: 0.27 to 1.00, P = 0.001) compared with placebo. It also decreased anginal episodes (SMD: –1.21, 95% CI: –2.40 to ?0.02, P = 0.045) and myocardial perfusion defects (SMD: –0.70, 95% CI: –1.11 to ?0.29, P = 0.001). However, no improvements in all‐cause mortality were observed after a relatively short follow‐up.

Conclusions

In patients with chronic angina on optimal medical therapy, stem cell therapy improves symptoms, exercise capacity, and left ventricular ejection fraction. These findings warrant confirmation using larger trials.

     

Impact of right and left ventricular systolic dysfunction on perioperative outcome and long‐term survival after transcatheter aortic valve replacement

Background

Aim of the study was to determine the impact of right‐ and left‐ventricular systolic dysfunction on perioperative outcome and long‐term survival after TAVR.

Methods

Study population consisted of 702 TAVRs between 2009 and 2014, 345 by TF, 357 by TA route. RV and LV function were determined by TAPSE and LVEF measurement during baseline echocardiography. Patients were divided according to TAPSE (>18 mm/14‐18 mm/<14 mm) and LVEF (>50%/30‐50%/<30%) tertiles. Outcome at day‐30 and Kaplan‐Meier 4‐year survival were analyzed.

Results

Impaired RV and LV‐function did not adversely affect mortality, stroke, bleeding, and vascular‐complications at 30 days. Patients with TAPSE < 14 mm displayed elevated rate of renal failure requiring dialysis (11%; P < 0.01). Kaplan‐Meier survival was adversely affected by RV‐systolic dysfunction RVSD (P < 0.01). Multivariate analysis revealed that impaired RVSD but not LVSD was an independent determinant for late mortality (hazard ratio TAPSE 14‐18 mm: 1.53; P = 0.02; TAPSE <14 mm: 2.12; P < 0.01).

Conclusions

Peri‐operative mortality and risk of stroke after TAVR are not adversely affected by preexisting RV or LV dysfunction. Long‐term survival is impaired in patients with RVSD. RVSD but not LVSD is an independent risk factor for late mortality. TAVR should be the preferred therapy for patients with RVSD and LVSD, especially when patient is suitable for TF.

     

Long‐term use of continuous positive airway pressure therapy in coronary artery disease patients with nonsleepy obstructive sleep apnea

Background

Excessive daytime sleepiness is a frequent symptom of obstructive sleep apnea (OSA) and has been proposed as a motivator for adherence to continuous positive airway pressure (CPAP) therapy. However, excessive daytime sleepiness is absent in many patients with coronary artery disease (CAD) and concomitant OSA. We evaluated long‐term use of CPAP and predictors of CPAP use in nonsleepy and sleepy OSA patients from a CAD cohort.

Hypothesis

Long‐term CPAP use is lower in CAD patients with nonsleepy OSA vs sleepy OSA.

Methods

Nonsleepy (Epworth Sleepiness Scale [ESS] score < 10) OSA patients randomized to CPAP (n = 122) and sleepy (ESS ≥10) OSA patients offered CPAP (n = 155) in the RICCADSA trial in Sweden were included in this substudy. The median follow‐up was 4.8 years for the main trial, with a predefined minimum follow‐up of 2 years.

Results

The probability of remaining on CPAP at 2 years was 60% in nonsleepy patients and 77% in sleepy patients. Multivariate analyses indicated that age and hours of CPAP use per night at 1 month were independently associated with long‐term CPAP use in nonsleepy patients. In the sleepy phenotype, body mass index, acute myocardial infarction at baseline, and hours of CPAP use per night at 1 month were predictors of long‐term CPAP use.

Conclusions

Long‐term use of CPAP is likely to be challenging for CAD patients with nonsleepy OSA. Early CPAP use is an important predictor of continued long‐term use of CPAP, so optimizing patients' initial experience with CPAP could promote adherence.

     

Early effects of empagliflozin on exercise tolerance in patients with heart failure: A pilot study

Background

Sodium‐glucose linked transporter 2 inhibition recently emerged as a promising therapy for reducing the risk of heart failure (HF) in patients with type 2 diabetes mellitus (T2DM). However, there is a lack of data endorsing its role in symptomatic HF patients. We sought to evaluate the short‐term effects of empagliflozin on maximal exercise capacity in these patients.

Hypothesis

We postulate tretament with empagliflozin may improve functional capacity in patients with T2DM and established HF.

Methods

Nineteen T2DM patients with symptomatic HF were prospectively included and underwent cardiopulmonary exercise testing before and 30 days after initiation of empagliflozin therapy. A mixed‐effects model for repeated measures was used.

Results

Median patient age was 72 years (interquartile range, 60–79 years); 42.1% were in New York Heart Association class III. Baseline mean (± SD) peak oxygen consumption (peak VO₂) was 10.9 ± 4.0 mL/min/kg. Peak VO₂ increased significantly at 30 days (?: +1.21 [0.66 to 1.76] mL/min/kg; P < 0.001). A significant improvement in ventilatory efficiency during exercise, 6‐minute walking distance, and quality of life, and a reduction in antigen carbohydrate 125, were also found. Estimated glomerular filtration rate and natriuretic peptides did not significantly change.

Conclusions

In this pilot study, empagliflozin was associated with 1‐month improvement in exercise capacity in T2DM patients with symptomatic HF. This beneficial effect was also found for other surrogates of severity.

     

Isometric handgrip echocardiography: A noninvasive stress test to assess left ventricular diastolic function

Background

Cycle exercise echocardiography is a useful tool to “unmask” diastolic dysfunction; however, this approach can be limited by respiratory and movement artifacts. Isometric handgrip avoids these issues while reproducibly increasing afterload and myocardial oxygen demand.

Hypothesis

Isometric handgrip echocardiography (IHE) can differentiate normal from abnormal diastolic function.

Methods

First recruited 19 young healthy individuals (mean age, 24 ± 4 years) to establish the “normal” response. To extend these observations to a more at‐risk population, we performed IHE on 17 elderly individuals (mean age, 72 ± 6 years) with age‐related diastolic dysfunction. The change in the ratio of mitral valve inflow velocity to lateral wall tissue velocity (E/e'), a surrogate for left ventricular filling pressure, was used to assess the diastolic stress response in each group.

Results

In the young subjects, isometric handgrip increased heart rate and mean arterial pressure (25 ± 12 bpm and 26 ± 17 mmHg, respectively), whereas E/e' changed minimally (0.6 ± 0.9). In the elderly subjects, heart rate and mean arterial pressure were similarly increased with isometric handgrip (19 ± 16 bpm and 25 ± 11 mmHg, respectively), whereas E/e' increased more dramatically (2.3 ± 1.7). Remarkably, 11 of the 17 elderly subjects had an abnormal diastolic response (ΔE/e': 3.4 ± 1.1), whereas the remaining 6 elderly subjects showed very little change (ΔE/e': 0.3 ± 0.7), independent of age or the change in myocardial oxygen demand.

Conclusions

IHE is a simple, effective tool for evaluating diastolic function during simulated activities of daily living.

     

Culprit plaque characteristics in women vs men with a first ST‐segment elevation myocardial infarction: In vivo optical coherence tomography insights

Background

It is unclear whether more severe coronary atherosclerosis is a prerequisite to an initial acute coronary event in women vs men.

Hypothesis

Women may have more severe coronary atherosclerosis than men in patients with acute coronary event.

Methods

We used intravascular optical coherence tomography (OCT) to evaluate gender differences in culprit‐plaque morphology in patients with a first ST‐segment elevation myocardial infarction (STEMI).We retrospectively enrolled 211 consecutive patients who experienced a first STEMI and underwent an OCT examination of their infarct‐related artery before primary percutaneous coronary intervention.

Results

Of the 211 patients enrolled, 162 (76.7%) were men and 49 (23.2%) were women. The women were significantly older than the men (mean age, 60.2 ± 8.2 vs 55.7 ± 11.2 years; P = 0.01) and less likely to be current smokers (P = 0.02). Moreover, the delay from symptom onset to reperfusion was longer in women than in men (7.6 ± 6.1 vs 5.5 ± 4.4 hours; P = 0.01). The OCT data indicated that there were no gender differences in culprit‐plaque morphology, including lipid length, lipid arc, minimum fibrous cap thickness, or minimum lumen area. Additionally, no gender differences were found in the prevalence of plaque rupture, thin‐cap fibroatheroma, residual thrombus, microvessels, macrophages, cholesterol crystals, or calcification.

Conclusions

Among patients presenting with a first STEMI, there were no differences in culprit plaque features between women and men.

     

The effect of fasting status on lipids,lipoproteins, and inflammatory biomarkers assessed after hospitalization for an acute coronary syndrome: Insights from PROVE IT–TIMI 22

Background

For decades, fasting for 8 to 12 hours has been recommended for measurement of lipid profiles. The effect of fasting on low‐density lipoprotein cholesterol (LDL‐C) and triglycerides (TG) has been described in healthy cohorts and those with stable disease states. Recently, guidelines suggested that fasting may not be necessary due to its small effect on lipid measures. Little is known, however, regarding whether the impact of fasting is altered in the setting of an acute coronary syndrome (ACS).

Hypothesis

We hypothesized that the post‐ACS period would minimally effect the impact of fasting status on lipid measurements.

Methods

We evaluated the association of fasting on lipid and other biomarkers at the randomization visit, which occurred at a median of 7 days after the onset of an ACS, as well as during follow‐up, in a cohort of 4177 subjects from the Pravastatin or Atorvastatin Evaluation and Infection Therapy–Thrombolysis In Myocardial Infarction 22 (PROVE IT–TIMI 22) trial.

Results

Fasting samples were independently associated with a higher LDL‐C of 4.1 mg/dL and apolipoprotein‐B 100 of 2.6 mg/dL as well as a lower TG of 21.0 mg/dL and high‐sensitivity C‐reactive protein of 0.48 mg/dL. The relative difference was 3.8% for LDL‐C and ?11.3% for TG. Fasting did not change total cholesterol, high‐density lipoprotein cholesterol, apolipoprotein A‐I, lipoprotein(a), or apolipoprotein C‐III.

Conclusions

Although fasting does impact lipid measurements, the effect on LDL‐C is small (about 4 mg/dL), both early after ACS and during follow‐up. These data provide support for recent guidelines that no longer advocate for fasting lipid samples, including in the setting of ACS.

     

Acute kidney injury requiring dialysis and in‐hospital mortality in patients with chronic kidney disease and non–ST‐segment elevation acute coronary syndrome undergoing early vs delayed percutaneous coronary intervention: A nationwide analysis

Background

Chronic kidney disease (CKD) is a well‐known risk factor for coronary artery disease and is associated with poor outcomes following an acute coronary syndrome (NSTE‐ACS). The optimal timing of an invasive strategy in patients with CKD and NSTE‐ACS is unclear.

Hypothesis

Timing of PCI in CKD patients will not affect the risk of mortality or incidence of dialysis.

Methods

We queried the National Inpatient Sample database (NIS) to identify cases with NSTEMI and CKD. Patients who underwent percutaneous coronary intervention (PCI) day 0 or 1 vs day 2 or 3 after admission were categorized as early vs delayed PCI, respectively. The primary outcomes of the study were in‐hospital mortality and acute kidney injury requiring hemodialysis (AKI‐D). The secondary outcomes were length of stay and hospital charges. Baseline characteristics were balanced using propensity score matching (PSM).

Results

After PSM, 3708 cases from the delayed PCI group were matched with 3708 cases from the early PCI group. The standardized mean differences between the 2 groups were substantially reduced after PSM. All other recorded variables were balanced between the 2 groups. In the early and delayed PCI groups, the incidence of AKI‐D (2.5% vs 2.3%; P = 0.54) and in‐hospital mortality (1.9% vs 1.4%; P = 0.12) was similar. Hospital charges and length of stay were higher in the delayed PCI group.

Conclusions

The incidence of AKI‐D and in‐hospital mortality among patients with CKD and NSTE‐ACS were not significantly affected by the timing of PCI. However, delayed PCI added significant cost and length of stay. A prospective randomized study is required to validate this concept.

     

Comparison of mid‐ to long‐term clinical outcomes between anatomical testing and usual care in patients with suspected coronary artery disease: A meta‐analysis of randomized trials

Background

Controversies remain regarding clinical outcomes following initial strategies of coronary computed tomography angiography (CCTA) vs usual care with functional testing in patients with suspected coronary artery disease (CAD).

Hypothesis

CCTA as initial diagnostic strategy results in better mid‐ to long‐term outcomes than usual care in patients with suspected CAD.

Methods

We searched PubMed, Embase, and Cochrane Library for randomized controlled trials comparing clinical outcomes during ≥6 months' follow‐up between initial anatomical testing by CCTA vs usual care with functional testing in patients with suspected CAD. Occurrence of all‐cause mortality, nonfatal myocardial infarction (MI), and major adverse cardiovascular events (MACE), and use of invasive coronary angiography and coronary revascularization, were compared between the 2 diagnostic strategies.

Results

Twelve trials were included (20 014 patients; mean follow‐up, 20.5 months). Patients undergoing CCTA as initial noninvasive testing had lower risk of nonfatal MI compared with those treated with usual care (risk ratio [RR]: 0.70, 95% confidence interval [CI]: 0.52‐0.94, P = 0.02). There was a tendency for reduced MACE following initial CCTA strategy, but not for risk of all‐cause mortality. Compared with functional testing, the CCTA strategy increased use of invasive coronary angiography (RR: 1.53, 95% CI: 1.12‐2.09, P = 0.007) and coronary revascularization (RR: 1.49, 95% CI: 1.11‐2.00, P = 0.007).

Conclusions

Anatomical testing with CCTA as the initial noninvasive diagnostic modality in patients with suspected CAD resulted in lower risk of nonfatal MI than usual care with functional testing, at the expense of more frequent use of invasive procedures.

     

Association between ideal cardiovascular health metrics and risk of cardiovascular events or mortality: A meta‐analysis of prospective studies

Background

Observational studies evaluating the relationship between ideal cardiovascular health (CVH) metrics and risk of cardiovascular (CV) events and mortality yielded inconsistent results.

Hypothesis

Improvement in CVH metrics can result in substantial reductions in the risk of cardiovascular disease (CVD), stroke, and mortality.

Methods

We examined associations between ideal CVH metrics and CV events and mortality by conducting a meta‐analysis of data from prospective cohort studies identified by searching PubMed and Web of Science from their inception to February 2017 and reviewing the reference lists of the retrieved articles.

Results

Thirteen prospective studies involving a total of 193 126 cohort members were included in this meta‐analysis. When comparing the most to the least category of ideal CVH metrics, the overall relative risks (RRs) were 0.54 (95% confidence interval [CI]: 0.41‐0.69) for all‐cause mortality, 0.30 (95% CI: 0.18‐0.51) for CV mortality, 0.22 (95% CI: 0.11‐0.42) for CVD, and 0.33 (95% CI: 0.20‐0.55) for stroke, respectively. A linear dose–response relationship was seen in all‐cause and CV mortality. The risk decreased by 11% and 19% for each increase in ideal CVH metrics. For the analyses of ideal health status in relation to all‐cause and CV mortality, significant results were obtained from smoking, diet, physical activity, plasma glucose levels, and blood pressure.

Conclusions

Ideal CVH status, or even 1 point increase in CVH metrics, can result in substantial reductions in the risk of CVD, stroke, and mortality. Improving metrics of smoking, diet, physical activity, plasma glucose levels, and blood pressure will achieve the highest benefits.

     

The long‐term prognostic value of highly sensitive cardiac troponin I in patients with acute pulmonary embolism

Background

In patients with acute pulmonary embolism (PE), detectable levels of cardiac troponin I (cTnI) using a highly sensitive assay have been associated with increased in‐hospital mortality. We sought to investigate the impact of detectable cTnI on long‐term survival following acute PE.

Hypothesis

Detectable cTnI levels in patients presenting with acute PE predict increased long‐term mortality following hospital discharge.

Methods

In a retrospective cohort study, we analyzed consecutive patients with confirmed acute PE and cTnI assay available from the index hospitalization. The detectable cTnI level was ≥0.012 ng/mL. Patients were classified into low and high clinical risk groups according to the Pulmonary Embolism Severity Index (PESI) at presentation. Subjects were followed for all‐cause mortality subsequent to hospital discharge using chart review and Social Security Death Index.

Results

A cohort of 289 acute PE patients (mean age 56 years, 51% men), of whom 152 (53%) had a detectable cTnI, was followed for a mean of 3.1 ± 1.8 years after hospital discharge. A total of 71 deaths were observed; 44 (29%) and 27 (20%) in the detectable and undetectable cTnI groups, respectively (P = 0.05). Detectable cTnI was predictive of long‐term survival among low‐risk (P = 0.009) but not high‐risk patients (P = 0.78) who had high mortality rates irrespective of cTnI status.

Conclusions

In patients with acute PE, detectable cTnI is predictive of long‐term mortality, particularly among patients who were identified as low risk according to PESI score.