Patient perceptions of anticoagulant treatment with dabigatran or a vitamin K antagonist for stroke prevention in atrial fibrillation according to region and age : an exploratory analysis from the RE-SONANCE study

Funding Information: The authors thank all the patients who participated in this study. Medical writing support was provided by Parexel, with funding from Boehringer Ingelheim GmbH. Funding Information: Dragos Vinereanu received grants and personal fees from Boehringer Ingelheim during the conduct of the study; grants and personal fees from Bristol-Myers Squibb, Pfizer, Bayer, Johnson & Johnson, and Daiichi Sankyo outside the submitted work. Dmitry Napalkov received research grants and has participated in scientific advisory boards for Boehringer Ingelheim and has received speaker’s honoraria from Bayer, Boehringer Ingelheim, Pfizer, and Takeda. Bela Benczur received speaker’s/consultancy fees from Bayer, Berlin-Chemie/Menarini, Boehringer Ingelheim, Krka Pharma, Novartis, Pfizer, Sandoz, and Sanofi. Martin Ciernik, Alexey Medvedchikov, and Wenbo Tang are employees of Boehringer Ingelheim. Pentti Põder received educational grants from Boehringer Ingelheim. Maria Trusz-Gluza received personal fees from Boehringer Ingelheim (null during the conduct of the study), personal fees and non-financial support from Boehringer Ingelheim, and personal fees from Bayer outside the submitted work. Jiří Vesely received personal fees and non-financial support from Bayer, Boehringer Ingelheim, Pfizer, MSD, and PRO.MED.CS outside the submitted work. All other authors report no conflicts of interest. Publisher Copyright: © 2021, The Author(s).Background: The oral anticoagulant dabigatran offers an effective alternative to vitamin K antagonists (VKAs) for stroke prevention in atrial fibrillation (AF), yet patient preference data are limited. The prospective observational RE-SONANCE study demonstrated that patients with AF, newly initiated on dabigatran, or switching to dabigatran from long-term VKA therapy, reported improved treatment convenience and satisfaction compared with VKA therapy. This pre-specified sub-study aimed to assess the impact of country and age on patients’ perceptions of dabigatran or VKA therapy in AF. Methods: RE-SONANCE was an observational, prospective, multi-national study (NCT02684981) that assessed treatment satisfaction and convenience in patients switching from VKAs to dabigatran (Cohort A), or newly diagnosed with AF receiving dabigatran or VKAs (Cohort B), using the PACT-Q questionnaire. Pre-specified exploratory outcomes: variation in PACT-Q2 scores by country and age (< 65, 65 to < 75, ≥ 75 years) (both cohorts); variation in PACT-Q1 responses at baseline by country and age (Cohort B). Results: Patients from 12 countries (Europe/Israel) were enrolled in Cohort A (n = 4103) or B (n = 5369). In Cohort A, mean (standard deviation) PACT-Q2 score increase was highest in Romania (convenience: 29.6 [23.6]) and Hungary (satisfaction: 26.0 [21.4]) (p < 0.001). In Cohort B, mean (standard error) increase in PACT-Q2 scores between dabigatran and VKAs was highest in Romania (visit 3: 29.0 [1.3]; 24.5 [0.9], p < 0.001). Mean PACT-Q2 score increase by age (all p < 0.001) was similar across ages. PACT-Q1 responses revealed lowest expectations of treatment success in Romania and greatest concerns about payment in Estonia, Latvia, and Romania, but were similar across ages. Conclusions: Treatment satisfaction and convenience tended to favor dabigatran over VKAs. Regional differences in treatment expectations exist across Europe. Trial and clinical registry: Trial registration number: ClinicalTrials.gov NCT02684981. Trial registration date: February 18, 2016.publishersversionPeer reviewe

Tricuspid regurgitation is associated with increased risk of mortality in patients with low-flow low-gradient aortic stenosis and reduced ejection fraction : results of the multicenter TOPAS study (true or pseudo-severe aortic stenosis)

Objectives : This study sought to examine the impact of tricuspid regurgitation (TR) on mortality in patients with low-flow, low-gradient (LF-LG) aortic stenosis (AS) and reduced left ventricular ejection fraction (LVEF). Background : TR is often observed in patients with LF-LG AS and low LVEF, but its impact on prognosis remains unknown. Methods : A total of 211 patients (73 ± 10 years of age; 77% men) with LF-LG AS (mean gradient <40 mm Hg and indexed aortic valve area [AVA] =0.6 cm2/m2) and reduced LVEF (=40%) were prospectively enrolled in the TOPAS (True or Pseudo-Severe Aortic Stenosis) study and 125 (59%) of them underwent aortic valve replacement (AVR) within 3 months following inclusion. The severity of AS was assessed by the projected AVA (AVAproj) at normal flow rate (250 ml/s), as previously described and validated. The severity of TR was graded according to current guidelines. Results : Among the 211 patients included in the study, 22 (10%) had no TR, 113 (54%) had mild (grade 1), 50 (24%) mild-to-moderate (grade 2), and 26 (12%) moderate-to-severe (grade 3) or severe (grade 4) TR. During a mean follow-up of 2.4 ± 2.2 years, 104 patients (49%) died. Univariable analysis showed that TR =2 was associated with increased risk of all-cause mortality (hazard ratio [HR]: 1.82, 95% confidence interval [CI]: 1.22 to 2.71; p = 0.004) and cardiovascular mortality (HR: 1.85, 95% CI: 1.20 to 2.83; p = 0.005). After adjustment for age, sex, coronary artery disease, AVAproj, LVEF, stroke volume index, right ventricular dysfunction, mitral regurgitation, and type of treatment (AVR vs. conservative), the presence of TR =2 was an independent predictor of all-cause mortality (HR: 1.88, 95% CI: 1.08 to 3.23; p = 0.02) and cardiovascular mortality (HR: 1.92, 95% CI: 1.05 to 3.51; p = 0.03). Furthermore, in patients undergoing AVR, TR =3 was an independent predictor of 30-day mortality compared with TR = 0/1 (odds ratio [OR]: 7.24, 95% CI: 1.56 to 38.2; p = 0.01) and TR = 2 (OR: 4.70, 95% CI: 1.00 to 25.90; p = 0.05). Conclusions : In patients with LF-LG AS and reduced LVEF, TR is independently associated with increased risk of cumulative all-cause mortality and cardiovascular mortality regardless of the type of treatment. In patients undergoing AVR, moderate/severe TR is associated with increased 30-day mortality. Further studies are needed to determine whether TR is a risk marker or a risk factor of mortality and whether concomitant surgical correction of TR at the time of AVR might improve outcomes for this high-risk population

Recent advances in cardio-oncology:a report from the 'Heart Failure Association 2019 and World Congress on Acute Heart Failure 2019'

While anti-cancer therapies, including chemotherapy, immunotherapy, radiotherapy, and targeted therapy, are constantly advancing, cardiovascular toxicity has become a major challenge for cardiologists and oncologists. This has led to an increasing demand of cardio-oncology units in Europe and a growing interest of clinicians and researchers. The Heart Failure 2019 meeting of the Heart Failure Association of the European Society of Cardiology in Athens has therefore created a scientific programme that included four dedicated sessions on the topic along with several additional lectures. The major points that were discussed at the congress included the implementation and delivery of a cardio-oncology service, the collaboration among cardio-oncology experts, and the risk stratification, prevention, and early recognition of cardiotoxicity. Furthermore, sessions addressed the numerous different anti-cancer therapies associated with cardiotoxic effects and provided guidance on how to treat cancer patients who develop cardiovascular disease before, during, and after treatment

Wiener klinische Wochenschrift / Whats new in the ESC 2018 guidelines for arterial hypertension : The ten most important messages

The new guidelines on hypertension of the European Society of Cardiology (ESC) 2018 have refined the treatment cut-offs and therapy decisions in adults. This review highlights important recommendations of the guidelines and also on the situation of hypertension in Austria. The general treatment targets of blood pressure have been lowered to at least 130/80 mmHg for most patients. The definition of hypertension is specified as a repeated systolic blood pressure in the office of 140 and or diastolic BP 90 mmHg. For home blood pressure monitoring, an average value of 135/85 mmHg is now defined as hypertension. Ambulatory 24h-blood pressure measurement is recommended for diagnosis of hypertension and to demask lack of nocturnal blood pressure dipping. Whether drug treatment should be initiated immediately or after a delay with lifestyle intervention is focused on the individual high or low cardiovascular risk of the patients and the degree of hypertension. For most patients a combination therapy with single pill is now recommended as initial therapy for hypertension from the start. The salt consumption should be reduced in the majority of patients. The new guidelines have clarified the treatment of hypertension in different comorbidities.(VLID)365981

Can Blood Biomarkers Help Predicting Outcome in Transcatheter Aortic Valve Implantation?

Transcatheter aortic valve implantation (TAVI) has become the method of choice for patients with severe aortic valve stenosis, who are ineligible or at high risk for surgery. In this high risk patient population, early and late mortality and rehospitalization rates after TAVI are still relatively high. In spite of recent improvements in procedural TAVI, and establishment of risk models for poor outcome, determining individual risk remains challenging. In this context, current data from several small studies strongly suggest that blood biomarkers of myocardial injury, cardiac mechanical stretch, inflammation, and hemostasis imbalance might play an important role by providing informations on patient risk at baseline, and postprocedural progression of patient clinical conditions from days up to years post-TAVI. Although the role of biomarkers for predicting survival post-TAVI remains to be validated in large randomized studies, implementing biomarkers in clinical practice might improve risk stratification, thereby further reducing TAVI-associated morbidity and mortality

Blood, tissue and imaging biomarkers in calcific aortic valve stenosis : past, present and future

Purpose of review : Calcific aortic valve stenosis is the most prevalent valvular heart disease in the high-income countries. To this date, no medical therapy has been proven to prevent or to stop the progression of aortic valve stenosis. The physiopathology of aortic valve stenosis is highly complex and involves several signalling pathways, as well as genetic related factors, which delay the elaboration of effective pharmacotherapies. Moreover, it is difficult to predict accurately the progression of the valve stenosis and finding the optimal timing for aortic valve replacement remains challenging. Therefore, the present review makes an inventory of the most recent and promising circulating and imaging biomarkers related to the underlying mechanisms involved in the physiopathology of aortic valve stenosis, as well as the biomarkers associated with the left ventricular (LV) remodelling and subsequent dysfunction in patients with aortic valve stenosis. Recent findings : Over the last decade, several blood, tissue and imaging biomarkers have been investigated in aortic valve stenosis patients. At the aortic valve level, these biomarkers are mostly associated and/or involved with processes such as lipid infiltration and oxidation, chronic inflammation and fibrocalcific remodelling of the valve. Moreover, recent findings suggest that aging and sex hormones might interact with these multiple processes. Several studies demonstrated the usefulness of circulating biomarkers such as lipoprotein(a), brain natriuretic peptides and high-sensitivity cardiac troponin, which are very close to clinical routine. Furthermore, noninvasive imaging biomarkers including positron emission tomography and cardiac magnetic resonance, which provide a detailed view of the disease activity within the aortic valve and its repercussion on the left ventricle, may help to improve the understanding of aortic valve stenosis physiopathology and enhance the risk stratification. Other biomarkers such as von Willebrand factor and microRNAs are promising but further studies are needed to prove their additive value in aortic valve stenosis. Summary : Most of the biomarkers are used in research and thus, are still being investigated. However, some biomarkers including plasma level of lipoprotein(a), 18F-sodium fluoride, brain natriuretic peptides and high-sensitivity cardiac troponin can be or are very close to be used for the clinical management of patients with aortic valve stenosis. Moreover, a multibiomarker approach might provide a more global view of the disease activity and improve the management strategies of these patients