Peripheral artery disease and clinical outcomes in patients with atrial fibrillation: A systematic review and meta‐analysis

BackgroundAtrial fibrillation (AF) is the most common cardiac rhythm disturbance and leads to morbidity and mortality. Peripheral artery disease (PAD) is associated with atherosclerotic risk factors and always classified as a vascular disease and deemed to be a bad complication of AF. In patients with AF, the risk and prognostic value of PAD have not been estimated comprehensively.HypothesisPAD is associated with all‐cause mortality, cardiovascular (CV) mortality, and other outcomes in patients with AF.MethodsWe searched PubMed, Embase, and Cochrane Library databases for prospective studies published before April 2021 that provided outcomes data on PAD in confirmed patients with AF. Heterogeneity was estimated using the I ² statistic. The fixed‐effects model was used for low to moderate heterogeneity studies, and the random‐effects model was used for high heterogeneity studies.ResultsEight prospective studies (Newcastle‐Ottawa score range, 7–8) with 39 654 patients were enrolled. We found a significant association between PAD and all‐cause mortality (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.25–1.62; p < .001), CV mortality (HR, 1.64; 95% CI, 1.32–2.05; p < .001) and MACE (HR, 1.75; 95% CI, 1.38–2.22; p < .001) in patients with AF. No significant relationship was found in major bleeding (HR, 1.22; 95% CI, 0.95–1.57; p = 0.118), myocardial infarction (MI) (HR, 2.07; 95% CI, 1.17–3.67; p = .038), and stroke (HR, 1.14; 95% CI, 0.87–1.50, p = 0.351).ConclusionsPAD is associated with an increased risk of all‐cause mortality, CV mortality, and MACE in patients with AF. However, no significant association was found with major bleeding, MI, and stroke.     

Acute cardiovascular hospitalizations and illness severity before and during the COVID‐19 pandemic

BackgroundCardiovascular disease (CVD) hospitalizations declined worldwide during the COVID‐19 pandemic. It is unclear how shelter‐in‐place orders affected acute CVD hospitalizations, illness severity, and outcomes.HypothesisCOVID‐19 pandemic was associated with reduced acute CVD hospitalizations (heart failure [HF], acute coronary syndrome [ACS], and stroke [CVA]), and worse HF illness severity.MethodsWe compared acute CVD hospitalizations at Duke University Health System before and after North Carolina''s shelter‐in‐place order (January 1–March 29 vs. March 30–August 31), and used parallel comparison cohorts from 2019. We explored illness severity among admitted HF patients using ADHERE (“high risk”: >2 points) and GWTG‐HF (“>10%”: >57 points) in‐hospital mortality risk scores, as well as echocardiography‐derived parameters.ResultsComparing hospitalizations during January 1–March 29 (N = 1618) vs. March 30–August 31 (N = 2501) in 2020, mean daily CVD hospitalizations decreased (18.2 vs. 16.1 per day, p = .0036), with decreased length of stay (8.4 vs. 7.5 days, p = .0081) and no change in in‐hospital mortality (4.7 vs. 5.3%, p = .41). HF hospitalizations decreased (9.0 vs. 7.7 per day, p = .0019), with higher ADHERE (“high risk”: 2.5 vs. 4.5%; p = .030), but unchanged GWTG‐HF (“>10%”: 5.3 vs. 4.6%; p = .45), risk groups. Mean LVEF was lower (39.0 vs. 37.2%, p = .034), with higher mean LV mass (262.4 vs. 276.6 g, p = .014).ConclusionsCVD hospitalizations, HF illness severity, and echocardiography measures did not change between admission periods in 2019. Evaluating short‐term data, the COVID‐19 shelter‐in‐place order was associated with reductions in acute CVD hospitalizations, particularly HF, with no significant increase in in‐hospital mortality and only minor differences in HF illness severity.     

Non‐vitamin K oral anticoagulants versus vitamin K antagonists in post transcatheter aortic valve replacement patients with clinical indication for oral anticoagulation: A meta‐analysis

BackgroundCurrent guidelines recommend oral anticoagulation (OAC) following transcatheter aortic valve replacement (TAVR) in patients with clinical indication, but the optimal antithrombotic regimen remains uncertain. We aimed to compare the efficacy and safety of non‐vitamin K oral anticoagulants (NOACs) versus vitamin K antagonists (VKAs) in patients undergoing TAVR with concomitant indication of OAC.HypothesisComparing with VKAs therapy, NOACs are similar in reducing the all‐cause mortality and major bleeding in post‐TAVR patients requiring OAC medication.MethodsWe searched the databases of PubMed, Embase, and Cochrane library databases to identify studies that investigated NOACs versus VKAs after TAVR in patients with another indication of OAC, which were published before 28th September 28, 2021. The effectiveness of outcomes was all‐cause mortality and stroke or systemic embolism, while the main safety outcome was major and/or life‐threatening bleeding. The hazard ratio (HR) with 95% confidence interval (CI) was used as a measure of treatment effect.ResultsOur search identified eight studies. We included 4947 post‐TAVR patients with another indication of OAC allocated to the NOAC (n = 2146) or VKA groups (n = 2801). There were no significant differences in the all‐cause mortality (HR: 0.91, 95% CI: 0.77–1.08, p = .29, I ² = 47%), stroke or systemic embolism (HR: 0.96, 95% CI: 0.68–1.37, p = .84, I ² = 0%), and major and/or life‐threatening bleeding (HR: 1.09, 95% CI: 0.89–1.32, p = .40, I ² = 30%) in both groups.ConclusionAmong post‐TAVR patients who required OAC therapy, NOACs therapy compared to VKAs is similar in reducing the all‐cause mortality, stroke or systemic embolism, and major and/or life‐threatening bleeding events.     

Cardiac rehabilitation performance predicts 1‐year major adverse cardiovascular events

BackgroundCardiac Rehabilitation is an essential following major adverse cardiovascular events however there is no current data correlating rehab performance to long term outcomes.HypothesisPatient exercise performance during cardiac rehabilitation reliably predicts future cardiovascular events.MethodsWe conducted a single‐center study of 486 consecutive patients who participated in a CR program between January 2018 and August 2021. We assessed patient performance using a novel index, the CR‐score, which integrated duration, speed of work, and workload conducted on each training device (TD). We used a binary recursive partition model to determine the optimal thresholds for cumulative CR score. We used Cox regression analysis to assess the mortality rate among patients who developed MACE (“study group”) and those who did not ("control group”).ResultsAmong 486 eligible patients, 1‐year MACE occurred in 27 (5.5%) patients and was more common in patients with prior cerebrovascular accident or transient ischemic attack (14.8% vs. 3.5%, p < .001). Age, gender, comorbidities, heart failure, and medical treatment did not significantly affect the outcome. The median cumulative CR score of the study group was significantly lower than the control group (595 ± 185.6 vs. 3500 ± 1104.7, p < .0001). A cumulative CR‐score of ≥1132 correlated with the outcome (98.5% sensitivity, 99.6% specificity, 95% CI: 0.985−0.997, area 0.994, p < .0001). Patients older than 55 with a cumulative CR score of <1132 were at particularly high risk (OR: 7.4, 95% CI: 2.84−18.42) for 1‐year MACE (log‐rank p = .03).ConclusionOur proposed CR‐score accurately identifies patients at high risk for 1‐year MACE following the rehabilitation program. Multicenter validation is required.     

Efficacy and safety of rivaroxaban versus placebo after lower extremity bypass surgery: A post hoc analysis of a “CASPAR like” outcome from VOYAGER PAD

BackgroundThe Clopidogrel and Acetylsalicylic Acid in Bypass Surgery for Peripheral Arterial Disease (CASPAR) trial is the only large, double‐blind, placebo‐controlled trial of dual antiplatelet therapy (DAPT) versus aspirin in patients with peripheral artery disease (PAD) after lower extremity revascularization (LER). The trial was neutral for index‐graft occlusion/revascularization, amputation or death (hazard ratio [HR] 0.98, 95% confidence interval [CI] 0.78–1.23, p = .87) with an excess of global utilization of streptokinase and tissue plasminogen activator for occluded coronary arteries moderate or severe bleeding (HR 2.84, 95% CI 1.32–6.08, p = .007).Hypothesis and MethodsVOYAGER‐PAD demonstrated that rivaroxaban significantly reduces acute limb ischemia (ALI), major amputation, myocardial infarction (MI), stroke and CV death but increased bleeding. The relative efficacy and safety of rivaroxaban in a CASPAR like population and for similar outcomes is unknown. The current analysis is a post‐hoc exploratory analysis of a “CASPAR like” composite of ALI, unplanned index limb revascularization (UILR), amputation or CV death in surgical patients.ResultsIn the 2185 who underwent surgical LER, rivaroxaban reduced the CASPAR endpoint at 1 (HR 0.76, 95% CI 0.62−0.95, p = .0133) and 3 years (HR 0.84, 95% CI 0.71−1.00, p = .0461, Figure). There were similar reductions in composites of ALI, amputation or CV death (HR 0.79, p = .0228) and ALI, UILR, amputation, MI, IS or CV death (HR 0.85, p = .0410).ConclusionsThe combination of rivaroxaban and aspirin significantly reduces ischemic outcomes in patients with PAD after LER. Although no formal head‐to‐head comparison exists, in a similar population and for similar outcomes, this regimen demonstrated benefit where trials of DAPT were neutral. These data suggest that factor Xa inhibition may provide specific benefits in this population and that DAPT should not be considered a proven substitution.     

Adherence with cardiovascular medications and the outcomes in patients with coronary arterial disease: “Real‐world” evidence

BackgroundCardiovascular medications are vital for the secondary prevention of coronary arterial disease (CAD). However, the effect of cardiovascular medication may depend on the optimal adherence of the patients. This meta‐analysis aims to determine the magnitude of adherence to vascular medications that influences the absolute and relative risks (RRs) of mortality in patients with CAD in real‐world settings.MethodsThe Cochrane Library, PubMed, and EMBASE databases were searched through March 1, 2022. Prospective studies reporting association as RR and 95% confidence interval between cardiovascular medication adherence and any cardiovascular events and/or all‐cause mortality in patients with CAD were included. A one‐stage robust error meta‐regression method was used to summarize the dose‐specific relationships.ResultsA total of 18 studies were included. There is a significant inverse linear association between cardiovascular medication adherence and cardiovascular events (p _nonlinearity = .68) or mortality (p _nonlinearity = .82). The exposure‐effect analysis showed that an improvement of 20% cardiovascular medication adherence was associated with 8% or 12% lower risk of any cardiovascular events or mortality, respectively. In subgroup analysis, the benefit was observed in adherence of stain (RR: 0.90, for cardiovascular events, RR: 0.85, for mortality), angiotensin‐converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARB)(RR: 0.90, for mortality), and antiplatelet agent (RR: 0.89 for mortality) but not in beta‐blocker (RR: 0.90, p = .14, for cardiovascular events, RR: 0.97, p = .32 for mortality). Estimated absolute differences per 1 million individuals per year for mortality associated with 20% improvement were 175 cases for statin, 129 cases for antiplatelet, and 117 cases for ACEI/ARB.ConclusionEvidence from the real word showed poor adherence to vascular medications contributes to a considerable proportion of all cardiovascular disease events and mortality in patients with CAD.     

Prognostic value of global longitudinal strain in hypertrophic cardiomyopathy: A systematic review and meta‐analysis

BackgroundAs previously reported, impairment of left ventricular global longitudinal strain (LVGLS) is associated with myocardial fibrosis, arrhythmias, and heart failure in hypertrophic cardiomyopathy (HCM) patients.HypothesisThis study aimed to estimate the association between LVGLS measured by echocardiography and major adverse cardiovascular events (MACE) in patients with HCM.MethodsPubmed, Embase, Scopus, and Cochrane Library databases were systematically searched for evaluating the difference of LVGLS between MACE and non‐MACE and the relevance of LVGLS and MACE in HCM patients, mean difference (MD), and pooled hazard ratios (HR) with 95% confidence interval (CI) were calculated. Publication bias was detected by funnel plots and Egger''s test, and trim‐and‐fill analysis was employed when publication bias existed.ResultsA total of 13 studies reporting 2441 HCM patients were included in this meta‐analysis. Absolute value of LVGLS was lower in the group of HCM with MACE (MD = 2.74, 95% CI: 2.50–2.99, p < .001; I ² = 0, p = .48). In the pooled unadjusted model, LVGLS was related to MACE (HR = 1.14, 95% CI: 1.06–1.22, p < .05, I ² = 58.4%, p < .01) and there is a mild heterogeneity, and sensitivity analysis showed stable results. In the pooled adjusted model, LVGLS was related to MACE (HR = 1.12, 95% CI: 1.08–1.16, p < .05; I ² = 0%, p = .442). Egger''s tests showed publication bias, and trim‐and‐fill analysis was applied, with final results similar to the previous and still statistically significant.ConclusionThe meta‐analysis suggested that impaired LVGLS was associated with poor prognosis in HCM patients.     

Survival benefit of overweight patients undergoing MitraClip® procedure in comparison to normal‐weight patients

BackgroundThe number of MitraClip® implantations increased significantly in recent years. Data regarding the impact of weight class on survival are sparse.HypothesisWe hypothesized that weight class influences survival of patients treated with MitraClip® implantation.MethodsWe investigated in‐hospital, 1‐year, 3‐year, and long‐term survival of patients successfully treated with isolated MitraClip® implantation for mitral valve regurgitation (MR) (June 2010–March 2018). Patients were categorized by weight classes, and the impact of weight classes on survival was analyzed.ResultsOf 617 patients (aged 79.2 years; 47.3% females) treated with MitraClip® implantation (June 2010–March 2018), 12 patients were underweight (2.2%), 220 normal weight (40.1%), 237 overweight (43.2%), and 64 obesity class I (11.7%), 12 class II (2.2%), and 4 class III (0.7%). Preprocedural Logistic EuroScore (21.1 points [IQR 14.0–37.1]; 26.0 [18.5–38.5]; 26.0 [18.4–39.9]; 24.8 [16.8–33.8]; 33.0 [25.9–49.2]; 31.6 [13.1–47.6]; p = .291) was comparable between groups. Weight class had no impact on in‐hospital death (0.0%; 4.1%; 1.5%; 0.0%; 7.7%; 0.0%; p = .189), 1‐year survival (75.0%; 72.0%; 76.9%; 75.0%; 75.0%; 33.3%; p = .542), and 3‐year survival (40.0%; 36.8%; 38.2%; 48.6%; 20.0%; 33.3%; p = .661). Compared to normal weight, underweight (hazard ratio [HR]: 1.35 [95% confidence interval [CI]: 0.65–2.79], p = .419), obesity‐class I (HR: 0.93 [95% CI: 0.65–1.34], p = .705), class II (HR: 0.39 [95% CI: 0.12–1.24], p = .112), and class III (HR: 1.28 [95% CI: 0.32–5.21], p = .726) did not affect long‐term survival. In contrast, overweight was associated with better survival (HR: 1.32 [95% CI: 1.04–1.68], p = .023).ConclusionOverweight affected the long‐term survival of patients undergoing MitraClip® implantation beneficially compared to normal weight.     

Impact of frailty on mortality and quality of life in patients with a history of cancer undergoing transcatheter aortic valve replacement

BackgroundTranscatheter aortic valve replacement (TAVR) is increasingly offered for aortic stenosis (AS) treatment in patients with a history of cancer. The impact of frailty on outcomes in this specific patient population is not well described.HypothesisFrailty is associated with mortality and poorer quality of life (QOL) outcomes in patients undergoing TAVR with a history of cancer.MethodsThis retrospective single center cohort study included AS patients who underwent TAVR from August 1, 2012 to May 15, 2020. Frailty was measured using serum albumin, hemoglobin, gait speed, functional dependence, and cognitive impairment. The primary outcome was a composite of all‐cause mortality and QOL at 1 year. A poor primary outcome was defined as either all‐cause mortality, Kansas City Cardiomyopathy Questionnaire overall summary (KCCQ‐OS) score <45 or a KCCQ‐OS score decline of ≥10 points from baseline. Regression analysis was used to determine the impact of frailty on the primary outcome.ResultsThe study population was stratified into active/recent cancer (n = 107), remote cancer (n = 85), and non‐cancer (n = 448). Univariate analysis of each cohort showed that frailty was associated with the primary outcome only in the non‐cancer cohort (p = .004). Multivariate analysis showed that cancer history was not associated with a poor primary outcome, whereas frailty was (1.7 odds ratio, 95% confidence interval [CI]: 1.1–2.8; p = .028).ConclusionsFrailty is associated with mortality and poor QOL in the overall and non‐cancer cohorts. Further investigation is warranted to understand frailty''s effect on the cancer population. Frailty should be heavily considered during TAVR evaluation.     

Percutaneous coronary intervention in insulin‐treated diabetic patients: A meta‐analysis

BackgroundThis meta‐analysis of randomized controlled trials (RCTs) compared long‐term adverse clinical outcomes of percutaneous coronary intervention (PCI) in insulin‐treated diabetes mellitus (ITDM) and non‐ITDM patients.MethodsThis is a meta‐analysis study. The PubMed and Embase databases were searched for articles on long‐term adverse clinical outcomes of PCI in ITDM and non‐ITDM patients. The risk ratios (RR) and 95% confidence intervals (CI) were calculated.ResultsA total of 11 related RCTs involving 8853 DM patients were included. Compared with non‐ITDM patients, ITDM patients had significantly higher all‐cause mortality (ACM) (RR = 1.52, 95% CI: 1.25–1.85, p _{heterogeneity} = .689, I ² = 0%), major adverse cardiac and cerebrovascular events (MACCE) (RR = 1.35, 95% CI: 1.18–1.55, p _{heterogeneity} = .57, I ² = 0%), myocardial infarction (MI) (RR = 1.41, 95% CI: 1.16–1.72, p _{heterogeneity} = .962, I ² = 0%), and stent thrombosis (ST) (RR = 1.75, 95% CI: 1.23–2.48, p _{heterogeneity} = .159, I ² = 32.4%). No significant difference was found in the target lesion revascularization (TLR) and target vessel revascularization (TVR) between the ITDM and non‐ITDM groups.ConclusionsThe results showed that ITDM patients had significantly higher ACM, MACCE, MI, and ST, compared with non‐ITDM patients.     

Comparison of prognosis and outcomes of catheter ablation versus drug therapy in patients with atrial fibrillation and stable coronary artery disease: A prospective propensity‐score matched cohort study

BackgroundAtrial fibrillation (AF) and stable coronary artery disease (SCAD) frequently coexist.HypothesisTo investigate the prognosis of catheter ablation versus drug therapy in patients with AF and SCAD.MethodsIn total, 25 512 patients with AF in the Chinese AF Registry between 2011 and 2019 were screened for SCAD. 815 patients with AF and SCAD underwent catheter ablation therapy were matched with patients by drug therapy in a 1:1 ratio. Primary end point was composite of thromboembolism, coronary events, major bleeding, and all‐cause death. The secondary endpoints were each component of the primary endpoint and AF recurrence.ResultsOver a median follow‐up of 45 ± 23 months, the patients in the catheter ablation group had a higher AF recurrence‐free rate (53.50% vs. 18.41%, p < .01). In multivariate analysis, there was no significant difference between the strategy of catheter ablation and drug therapy in primary composite end point (adjusted HR 074, 95%CI 0.54–1.002, p = .0519). However, catheter ablation was associated with fewer all‐cause death independently (adjusted HR 0.36, 95%CI 0.22–0.59, p < .01). In subgroup analysis, catheter ablation was an independent risk factor for all‐cause death in the high‐stroke risk group (adjusted HR 0.39, 95%CI 0.23–0.64, p < .01), not in the low‐medium risk group (adjusted HR 0.17, 95%CI 0.01–2.04, p = .17).ConclusionsIn the patients with AF and SCAD, catheter ablation was not independently associated with the primary composite endpoint compared with drug therapy. However, catheter ablation was an independent protective factor of all‐cause death     

Effect of positive airway pressure on cardiac troponins in patients with sleep‐disordered breathing: A meta‐analysis

BackgroundCardiac troponins are highly sensitive and specific biomarkers for cardiac injury. Previous studies evaluating the effect of positive airway pressure (PAP) on cardiac troponins in patients with sleep‐disordered breathing (SDB) have yielded conflicting results. The meta‐analysis was performed to examine the effect of PAP on cardiac troponins in SDB patients.MethodsPubMed, Web of Science, and EMBASE before September 2021 on original English language studies were searched. The data on cardiac troponins in both baseline and post‐PAP treatment were extracted from all studies. The data on the change of cardiac troponins in both PAP and control group were extracted from randomized controlled trials. Standardized mean difference (SMD) was used to synthesize quantitative results.ResultsA total of 11 studies were included. PAP treatment was not associated with a significant change in cardiac troponin T between the baseline and post‐PAP treatment (SMD = −0.163, 95% confidence interval [CI] = −0.652 to 0.326, z = 0.65, p = .514). The pooled estimate of SMD of cardiac troponin I between the pre‐ and post‐PAP treatment was 0.287, and the 95% CI was −0.586 to 1.160 (z = 0.64, p = .519). The pooled SMD of change of cardiac troponin T between the PAP group and control group was −0.473 (95% CI = −1.198 to 0.252, z = 1.28, p = .201).ConclusionsThis meta‐analysis revealed that PAP treatment was not associated with any change of cardiac troponin in SDB patients.     

Sex differences in treatment and outcomes of patients with in‐hospital ST‐elevation myocardial infarction

Background and HypothesisTwo cohorts face high mortality after ST‐elevation myocardial infarction (STEMI): females and patients with in‐hospital STEMI. The aim of this study was to evaluate sex differences in ischemic times and outcomes of in‐hospital STEMI patients.MethodsConsecutive STEMI patients treated with percutaneous coronary intervention (PCI) were prospectively recruited from 30 hospitals into the Victorian Cardiac Outcomes Registry (2013−2018). Sex discrepancies within in‐hospital STEMIs were compared with out‐of‐hospital STEMIs. The primary endpoint was 12‐month all‐cause mortality. Secondary endpoints included symptom‐to‐device (STD) time and 30‐day major adverse cardiovascular events (MACE). To investigate the relationship between sex and 12‐month mortality for in‐hospital versus out‐of‐hospital STEMIs, an interaction analysis was included in the multivariable models.ResultsA total of 7493 STEMI patients underwent PCI of which 494 (6.6%) occurred in‐hospital. In‐hospital versus out‐of‐hospital STEMIs comprised 31.9% and 19.9% females, respectively. Female in‐hospital STEMIs were older (69.5 vs. 65.9 years, p = .003) with longer adjusted geometric mean STD times (104.6 vs. 94.3 min, p < .001) than men. Female versus male in‐hospital STEMIs had no difference in 12‐month mortality (27.1% vs. 20.3%, p = .92) and MACE (22.8% vs. 19.3%, p = .87). Female sex was not independently associated with 12‐month mortality for in‐hospital STEMIs which was consistent across the STEMI cohort (OR: 1.26, 95% CI: 0.94–1.70, p = .13).ConclusionsIn‐hospital STEMIs are more frequent in females relative to out‐of‐hospital STEMIs. Despite already being under medical care, females with in‐hospital STEMIs experienced a 10‐min mean excess in STD time compared with males, after adjustment for confounders. Adjusted 12‐month mortality and MACE were similar to males.     

Management and outcome across the spectrum of high‐risk patients with myocardial infarction according to the thrmobolysis in myocardial infarction (TIMI) risk‐score for secondary prevention

BackgroundPatients with myocardial infarction (MI) are at increased risk for recurrent cardiovascular events, yet some patients, such as the elderly and those with prior comorbidities, are particularly at the highest risk. Whether these patients benefit from contemporary management is not fully elucidated.MethodsIncluded were consecutive patients with MI who underwent percutaneous coronary intervention (PCI) in a large tertiary medical center. Patients were stratified according to the thrombolysis in myocardial infarction (TIMI) risk score for secondary prevention (TRS2°P) to high (TRS2°P = 3), very high (TRS2°P = 4), or extremely high‐risk (TRS2°P = 5–9). Excluded were low and intermediate‐risk patients (TRS2°P < 3). Outcomes included 30‐day/1‐year major adverse cardiac events (MACE) and 1‐year mortality. Temporal trends were examined in the early (2004–2010) and late (2011–2016) time‐periods.ResultsAmong 2053 patients, 50% were high‐risk, 30% very high‐risk and 20% extremely high‐risk. Extremely high‐risk patients were older (age 74 ± 10 year) and had significant comorbidities (chronic kidney disease 68%, prior CABG 40%, heart failure 78%, peripheral artery disease 29%). Drug‐eluting stents and potent antiplatelets were more commonly used over time in all risk‐strata. Over time, 30‐day MACE rates have decreased, mainly attributed to the very high (11.3% to 5.1%, p = .006) and extremely high‐risk groups (15.9% to 8.0%, p = .016), but not the high‐risk group, with similar quantitative results for 1‐year MACE. The rates of 1‐year mortality remained unchanged in either group.ConclusionWithin a particularly high‐risk cohort of MI patients who underwent PCI, the implementation of guideline‐recommended therapies has improved over time, with the highest‐risk groups demonstrating the greatest benefit in outcomes.     

Proenkephalin and the risk of new‐onset heart failure: data from prevention of renal and vascular end‐stage disease

BackgroundEnkephalins of the opioid system exert several cardiorenal effects. Proenkephalin (PENK), a stable surrogate, is associated with heart failure (HF) development after myocardial infarction and worse cardiorenal function and prognosis in patients with HF. The association between plasma PENK concentrations and new‐onset HF in the general population remains to be established.HypothesisWe hypothesized that plasma PENK concentrations are associated with new‐onset HF in the general population.MethodsWe included 6677 participants from the prevention of renal and vascular end‐stage disease study and investigated determinants of PENK concentrations and their association with new‐onset HF (both reduced [HFrEF] and preserved ejection fraction [HFpEF]).ResultsMedian PENK concentrations were 52.7 (45.1–61.9) pmol/L. Higher PENK concentrations were associated with poorer renal function and higher NT‐proBNP concentrations. The main determinants of higher PENK concentrations were lower estimated glomerular filtration rate (eGFR), lower urinary creatinine excretion, and lower body mass index (all p < .001). After a median 8.3 (7.8–8.8) years follow‐up, 221 participants developed HF; 127 HFrEF and 94 HFpEF. PENK concentrations were higher in subjects who developed HF compared with those who did not, 56.2 (45.2–67.6) versus 52.7 (45.1–61.6) pmol/L, respectively (p = .003). In competing‐risk analyses, higher PENK concentrations were associated with higher risk of new‐onset HF (hazard ratio [HR] = 2.09[1.47–2.97], p < .001), including both HFrEF (HR = 2.31[1.48–3.61], p < .001) and HFpEF (HR = 1.74[1.02–2.96], p = .042). These associations were, however, lost after adjustment for eGFR.ConclusionsIn the general population, higher PENK concentrations were associated with lower eGFR and higher NT‐proBNP concentrations. Higher PENK concentrations were not independently associated with new‐onset HFrEF and HFpEF and mainly confounded by eGFR.     

Assessment of left ventricular myocardial work done by noninvasive pressure–strain loop technique in patients with essential hypertension

ObjectiveTo investigate the value of the noninvasive pressure–strain loop (PSL) technique for assessing left ventricular myocardial work done in patients with essential hypertension.MethodsProspectively, 60 patients with hypertension visiting the hospital from August 2020 to July 2021 were collected and divided into the mild hypertension group (SBP 140–159 mmHg, 35 cases) and the moderate‐to‐severe hypertension group (SBP ≥160 mmHg, 25 cases). Another 40 cases of healthy adults were collected as the control group. The differences in the global long‐axis strain (GLS) and peak strain dispersion (PSD) of the left ventricle, global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) were compared among the three groups. The receiver operating characteristic curve was used to evaluate the PSD, GWI, GCW, and GWW. The myocardial work index (MWI) and MWI percentages in the apical, middle, and basal segments of the heart were also compared among the groups.Results(1) The PSD, GWI, GCW, and GWW were significantly different among the groups (Χ ² = 57.605, 79.203, 76.973, and 17.429, respectively, p < .05), while the GLS and GWE were not (Χ ² = 1.559 and 5.849, respectively, p > .05). (2) The GWI had the highest specificity (97.5%) and the GCW the highest sensitivity (95%) in predicting hypertension. The percentage of apical MWI gradually increased (F = 11.230, p < .05) and the percentage of basal MWI gradually decreased (F = 10.665, p < .05) from the control group to the mild hypertension group to the moderate‐to‐severe hypertension group; there was no significant difference in the percentage of mid‐MWI (F = 0.593, p > .05).ConclusionsThe noninvasive PSL technique could be used to assess myocardial work done in patients with essential hypertension.     

Cardiology clinic visit increases likelihood of evidence‐based cholesterol prescribing in severe hypercholesterolemia

BackgroundPatients with phenotypic severe hypercholesterolemia (SH), low‐density lipoprotein‐cholesterol (LDL‐c) ≥ 190 mg/dl, atherosclerotic cardiovascular disease (ASCVD) or adults 40–75 years with diabetes with risk factors or 10‐year ASCVD risk ≥20% benefit from maximally tolerated statin therapy. Rural patients have decreased access to specialty care, potentially limiting appropriate treatment.HypothesisPrior visit with cardiology will improve treatment of severe hypercholesterolemia.MethodsWe used an electronic medical record‐based SH registry defined as ever having an LDL‐c ≥ 190 mg/dl since January 1, 2000 (n = 18 072). We excluded 3205 (17.7%) patients not alive or age 20–75 years. Patients defined as not seen by cardiology if they had no visit within the past 3 years (2017–2019).ResultsWe included 14 867 patients (82.3%; mean age 59.7 ± 10.3 years; 58.7% female). Most patients were not seen by cardiology (n = 13 072; 72.3%). After adjusting for age, sex, CVD, hypertension, diabetes and obesity, patients seen by cardiology were more likely to have any lipid‐lowering medication (OR = 1.46, 95% CI: 1.29–1.65), high‐intensity statin (OR = 1.81, 95% CI: 1.61–2.03), or proprotein convertase subtilisin‐kexin type 9 (PCSK9) inhibitor (OR = 5.96, 95% CI: 3.34–10.65) compared to those not seen by cardiology. Mean recent LDL‐c was lower in patients seen by cardiology (126.8 ± 51.6 mg/dl vs. 152.4 ± 50.2 mg/dl, respectively; p < .001).ConclusionIn our predominantly rural population, a visit with cardiology improved the likelihood to be prescribed any statin, a high‐intensity statin, or PCSK9 inhibitor. This more appropriately addressed their high life‐time risk of ASCVD. Access to specialty care could improve SH patient''s outcomes.     

Influence of angiotensin converting enzyme inhibitors/angiotensin receptor blockers on the risk of all‐cause mortality and other clinical outcomes in patients with confirmed COVID‐19: A systemic review and meta‐analysis

Since the COVID‐19 pandemic, physicians concerned about the potential adverse effects of angiotensin converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs). To explore the relationship between ACEIs/ARBs and the risk of mortality and other clinical outcomes in COVID‐19 patients, the authors conducted a systemic review and meta‐analysis. An electronic search was performed from inception to November 12, 2020 in PubMed, Medline, EMBASE, ClinicalTrials, TRIP, the Cochrane Library, CNKI, Wanfang, and CBM database. Risk of bias was assessed using the Risk Of Bias In Non‐randomized Studies of Interventions tool. The primary outcome was in‐hospital all‐cause mortality. Secondary outcomes included all‐cause mortality measured at 30‐day or longer term, mechanical ventilation, length of hospital stay, readmission, and cardiac adverse events. A total of 28 studies with 73 465 patients was included. Twenty‐two studies with 19 871 patients reported the incidence of all‐cause mortality. Results showed no association between using ACEIs/ARBs and risk of mortality crude odds ratio （OR） of 1.02, 95% CI 0.71–1.46, p = .90, I ² = 88%, adjusted OR in 6260 patients of 0.96, 95% CI 0.77–1.18, p = .68, I ² = 0%. While six studies with 10 030 patients reported a lower risk of mortality in ACEIs/ARBs group hazard ratio (HR) of 0.53, 95% CI 0.34–0.84, p = .007, I ² = 68%. Similar association (for HR) was found in hypertension subgroup. There was no significant association for the secondary outcomes. Based on the available data, we concluded that ACEIs/ARBs is not associated with the risk of in‐hospital all‐cause mortality in COVID‐19 patients, but may be associated with a decreased risk of 30‐day all‐cause mortality. Patients with hypertension may benefit from using ACEIs/ARBs.     

Coronary artery calcium and cystatin C for risk stratification of MACCEs and all‐cause death in symptomatic patients

ObjectivesThe aim of this study was to examine the independent and joint associations of baseline coronary artery calcium score (CACS) and cystatin C (Cys‐C) with the risk of major adverse cardiac and cerebrovascular events (MACCEs) and all‐cause death in symptomatic populations.MethodsThe study included 7140 patients with symptom of chest pain who underwent cardiac computerized tomography examinations to measure CACS. All of them had serum Cys‐C results. Endpoints were set for MACCEs and all‐cause death events.ResultsA total of 7140 participants were followed for a median of 1106 days. A total of 305 patients had experienced MACCEs and 191 patients had experienced all‐cause death. CACS ≥ 100 and Cys‐C ≥ 0.995 mg/L were independently associated with an increased risk of MACCEs (adjusted hazard ratio [HR]: 1.46; 95% confidence interval [CI]: 1.15–1.85; p = .002 and adjusted HR: 1.57; 95% CI: 1.24–2.00; p < .001, respectively). Compared with CACS < 100 and Cys‐C < 0.995 mg/L patients, CACS ≥ 100 and Cys‐C ≥ 0.995 mg/L patients had the highest risk of MACCEs and all‐cause death (adjusted HR: 2.33; 95% CI: 1.64–3.29; p < .001 and adjusted HR: 2.85; 95% CI: 1.79–4.55; p < .001, respectively). Even in patients with CACS < 100, Cys‐C ≥ 0.995 mg/L was also associated with a higher risk of MACCEs and all‐cause death than Cys‐C < 0.995 mg/L (adjusted HR: 1.76; p = .003 and adjusted HR: 2.02; p = .007, respectively).ConclusionsThe combined stratification of CACS and Cys‐C showed an incremental risk of MACCEs and all‐cause death, reflecting complementary prognostic value. Our results support the combination of the two indicators for risk stratification and event prediction.