Cardiology News / Recent Literature Review / Last Quarter 2019

HCS Working Groups: Thessaloniki, 20-22/2/2020 ACC Meeting: Chicago, IL, USA, 28-30/3/2020 EHRA Meeting: Vienna, 29-31/3/2020 HRS Meeting: San Diego, 6-9/5/2020 EuroPCR: Paris, 19-22/5/2020 ESC Meeting: Amsterdam, 29/8-2/9/2020 Childhood Secondhand Smoke Exposure Predicts Increased Risk for Adulthood Atrial Fibrillation (AF) After Adjustment for AF Risk Factors A study analyzed Framingham Offspring cohort participants with parents in the Original cohort with known smoking status during the offspring’s childhood, evaluated every 2-8 years and being under routine surveillance for incident AF. Of 2,816 Offspring cohort participants with at least 1 parent in the Original cohort, 82% were exposed to parental smoking. For every pack/day increase in parental smoking, there was an 18% increase in offspring AF incidence (adjusted hazard ratio - HR: 1.18; p=0.04). Additionally, parental smoking was a risk factor for offspring smoking (adjusted odds ratio - OR: 1.34; p<0.001). Offspring smoking mediated 17% of the relationship between parental smoking and offspring AF (Groh CA et al, J Am Coll Cardiol 2019; 74:1658-64). When Left Untreated, Severe Aortic Stenosis (AS) is Associated With Poor Long-Term Survival / But Also Moderate AS Confers Poor Survival Rates Among 16,129 (6.7%), 3,315 (1.4%), and 6,383 (2.6%) patients had mild, moderate, and severe AS, respectively, on an adjusted basis (vs. no AS; 5-year mortality 19%), patients with mild to severe AS had an increasing risk of long-term mortality (adjusted hazard ratio: 1.44-2.09; p<0.001 for all comparisons). The 5-year mortality was 56% and 67%, respectively, in those with moderate AS (mean gradient 20.0-39.0 mmHg/peak velocity 3.0-3.9 m/s) and severe AS (≥40 mmHg, ≥4 m/s, or AV area<1 cm2 in low-flow, low-gradient severe AS). A markedly increased risk of death from all causes (5-year mortality >50%) and CV disease was evident from a mean AV gradient >20 mmHg (moderate AS) after adjusting for age, sex, LV systolic or diastolic dysfunction, and aortic regurgitation (Strange G et al, J Am Coll Cardiol 2019; 74:1851-63). Premature (Age≤45 Years) Acute or Stable Obstructive Coronary Artery Disease (CAD) is an Aggressive Disease Despite the Currently Recommended Prevention Measures, With High Rates of Recurrent Events and Mortality Among 880 patients with premature CAD, aged 40.1 ± 5.7 years, mainly men, smokers, with a family history of CAD or hypercholesterolemia, at baseline presentation, 91% underwent coronary revascularization, predominantly for acute MI (79%). Over 20 years, one-third (n = 264) of patients presented with a total of 399 ischemic events, and 36% had at least a second recurrent event. MI was the most frequent first recurrent event (n=131 of 264), mostly related to new coronary lesions (17% vs 8%; p=0.01; hazard ratio - HR: 1.45 for new vs initial culprit lesion). All-cause death (n=55; 6.3%) occurred at 8.4 years (median time). Ethnic origin (sub-Saharan African vs. Caucasian, adjusted HR - adjHR: 1.95; p=0.02), inflammatory disease (adjHR: 1.58; p=0.03), and persistent smoking (adjHR: 2.32; p<0.01) were the strongest correlates of a first recurrent event. When considering all recurrent events, the same factors and Asian ethnicity predicted poor outcome, but persistent smoking had the greatest impact on prognosis (Collet J-P et al, J Am Coll Cardiol 2019; 74:1868-78)... (excerpt

Cardiology News / Recent Literature Review / Last Quarter 2019

HCS Working Groups: Thessaloniki, 20-22/2/2020 ACC Meeting: Chicago, IL, USA, 28-30/3/2020 EHRA Meeting: Vienna, 29-31/3/2020 HRS Meeting: San Diego, 6-9/5/2020 EuroPCR: Paris, 19-22/5/2020 ESC Meeting: Amsterdam, 29/8-2/9/2020 Childhood Secondhand Smoke Exposure Predicts Increased Risk for Adulthood Atrial Fibrillation (AF) After Adjustment for AF Risk Factors A study analyzed Framingham Offspring cohort participants with parents in the Original cohort with known smoking status during the offspring’s childhood, evaluated every 2-8 years and being under routine surveillance for incident AF. Of 2,816 Offspring cohort participants with at least 1 parent in the Original cohort, 82% were exposed to parental smoking. For every pack/day increase in parental smoking, there was an 18% increase in offspring AF incidence (adjusted hazard ratio - HR: 1.18; p=0.04). Additionally, parental smoking was a risk factor for offspring smoking (adjusted odds ratio - OR: 1.34; p<0.001). Offspring smoking mediated 17% of the relationship between parental smoking and offspring AF (Groh CA et al, J Am Coll Cardiol 2019; 74:1658-64). When Left Untreated, Severe Aortic Stenosis (AS) is Associated With Poor Long-Term Survival / But Also Moderate AS Confers Poor Survival Rates Among 16,129 (6.7%), 3,315 (1.4%), and 6,383 (2.6%) patients had mild, moderate, and severe AS, respectively, on an adjusted basis (vs. no AS; 5-year mortality 19%), patients with mild to severe AS had an increasing risk of long-term mortality (adjusted hazard ratio: 1.44-2.09; p<0.001 for all comparisons). The 5-year mortality was 56% and 67%, respectively, in those with moderate AS (mean gradient 20.0-39.0 mmHg/peak velocity 3.0-3.9 m/s) and severe AS (≥40 mmHg, ≥4 m/s, or AV area<1 cm2 in low-flow, low-gradient severe AS). A markedly increased risk of death from all causes (5-year mortality >50%) and CV disease was evident from a mean AV gradient >20 mmHg (moderate AS) after adjusting for age, sex, LV systolic or diastolic dysfunction, and aortic regurgitation (Strange G et al, J Am Coll Cardiol 2019; 74:1851-63). Premature (Age≤45 Years) Acute or Stable Obstructive Coronary Artery Disease (CAD) is an Aggressive Disease Despite the Currently Recommended Prevention Measures, With High Rates of Recurrent Events and Mortality Among 880 patients with premature CAD, aged 40.1 ± 5.7 years, mainly men, smokers, with a family history of CAD or hypercholesterolemia, at baseline presentation, 91% underwent coronary revascularization, predominantly for acute MI (79%). Over 20 years, one-third (n = 264) of patients presented with a total of 399 ischemic events, and 36% had at least a second recurrent event. MI was the most frequent first recurrent event (n=131 of 264), mostly related to new coronary lesions (17% vs 8%; p=0.01; hazard ratio - HR: 1.45 for new vs initial culprit lesion). All-cause death (n=55; 6.3%) occurred at 8.4 years (median time). Ethnic origin (sub-Saharan African vs. Caucasian, adjusted HR - adjHR: 1.95; p=0.02), inflammatory disease (adjHR: 1.58; p=0.03), and persistent smoking (adjHR: 2.32; p<0.01) were the strongest correlates of a first recurrent event. When considering all recurrent events, the same factors and Asian ethnicity predicted poor outcome, but persistent smoking had the greatest impact on prognosis (Collet J-P et al, J Am Coll Cardiol 2019; 74:1868-78)... (excerpt

Arterial Stiffness

With advancing age, all organ systems undergo anatomical and functional changes. Vasculature suffers generalized stiffening as a hallmark of this process. Although this phenomenon has been described long ago, only in recent years has the clinical significance of the stiffening of the large arteries been widely understood and its correlation with hypertension, coronary heart disease, stroke, heart failure and atrial fibrillation has been recognized. It has also been accepted that it mediates the vascular effects of diabetes mellitus, atherosclerosis and renal disease. 1-5The arterial systems consists of two functional components with different structural characteristics: a) the large elastic arteries (aorta, carotid and iliac arteries) which store part of the blood ejected during systole and expel it to the periphery during diastole to provide the tissues with a relatively steady flow through the entire cardiac cycle and b) the muscular arteries (arteries below the axillary and femoral ones) which regulate the vascular tone and hence determine the peripheral resistance. The former have a thick tunica media in which the elastic fibers dominate and form numerous concentric layers. The later possess a tunica media characterized mainly by smooth muscle cells and the elastic component is confined to the thin internal and external elastic laminae. The different mechanical properties of the arterial tree along its course and the varying diameter of the arterial branches, gives rise to the reflected waves which are produced when the pulse wave encounters sites with different impedance. A part of these secondary waves amplifies the forward moving wave and another part moves backward to enhance the pressure of the central aorta. Normally it reaches its target in late systole or early diastole and it contributes to the diastolic flow towards the coronary arteries and the periphery... (excerpt

Cardiology News /Recent Literature Review / Last Quarter 2011

The ACC Meeting is slated for 24-27/3/2012 in Chicago The Athens Cardiology Update 2012 is slated for April 5-7, 2012 The HRS 33rd Meeting will be held in Boston, 9-12/5/12 The ESC Congress will be held in Munich, 25-29/8/2012 ALLHAT Trial: Once Heart Failure Develops in High-Risk Hypertensive Patients, Mortality is High At a mean follow-up of 8.9 years, of 1761 participants in the ALLHAT trial with incident heart failure (HF) in-trial, 1348 (77%) died. Mortality rates were similar across treatment comparisons, with adjusted 10-year all-cause mortality rates per 100 persons of 83 for chlorthalidone, 86 for amlodipine, and 87 for lisinopril. Mortality was similar for those with preserved (81%) and low ejection fraction (84%). Thus, once HF develops, risk of death is high and consistent across randomized treatment groups. Measures to prevent the development of HF, especially blood pressure control, must be a priority if mortality associated with the development of HF is to be addressed (Piller LB et al, Circulation 2011;124:1811-1818). Isolated Low HDL-Cholesterol is Associated with Increased Coronary RiskData from 220 060 participants (87% Asian) in 37 studies from the Asia-Pacific region indicated low HDL-C (HDL <40 mg/dl in men and <50 mg/dl in women) among 33.1% of Asians vs 27.0% of non-Asians (P<0.001). The prevalence of low HDL-C in the absence of other lipid abnormalities (isolated low HDL-C) was higher in Asians compared with non-Asians: 22.4% vs 14.5%, respectively (P<0.001). After 6.8 years, there were 574 coronary heart disease and 739 stroke events. There was an inverse relationship between low HDL-C with coronary heart disease in all individuals (hazard ratio, 1.57). In Asians, isolated low levels of HDL-C were as strongly associated with coronary heart disease risk as low levels of HDL-C combined with other lipid abnormalities (hazard ratio, 1.67 vs 1.63, respectively). There was no association between low HDL-C and stroke risk (Huxley RR et al, Circulation2011;124:2056-2064)... (excerpt

Cardiology News / Recent Literature Review / First Quarter 2018

Manolis AS, Anninos H. Cardiology News / Recent Literature Review / First Quarter 2018. Rhythmos 2018;13(2):38-43. HRS Meeting: Boston, 9-12/5/2018EuroPCR Meeting: Paris, 22-25/5/2018ESC Meeting: Munich, 25-29/8/2018ICD in Children & Adolescents with Brugada Syndrome: ~1 in 4 Patients Receive Appropriate Life-Saving Interventions Over a Period of 7 Years, Although Inappropriate Shocks and Other Adverse Events Occur Relatively Frequently  Among 35 consecutive patients (aged 13.9±6.2 years). over a mean of 88 months, sustained ventricular arrhythmias were treated by the ICD in 9 patients (26%), including shocks in 8 (23%) and antitachycardia pacing in 1 patient (3%). Three patients (9%) died in an electrical storm. Seven patients (20%) experienced inappropriate shocks, and 5 (14%) had device-related complications. Aborted sudden cardiac death and spontaneous type I ECG were identified as independent predictors of appropriate shock occurrence (Gonzalez Corcia MC et al, J Am Coll Cardiol 2018;71: 148–57).Cardiomyopathy (CM) Patients With LVEF≤35% and LBBB Demonstrate Significantly Less LV Functional Recovery With Medical Therapy Than Do Those With a Narrow QRS / Thus, They Would Benefit From Earlier Implantation of a CRT DeviceAmong 659 patients with CM, 111 having LBBB (17%), 59 wide QRS duration ≥120 ms but not LBBB (9%), and 489 narrow QRS duration (74%), adjusted mean increase in LVEF over 3-6 months in the 3 groups was 2.03%, 5.28%, and 8%, respectively (p<0.0001), with no different results for interim revascularization and myocardial infarction. The combined endpoint of heart failure hospitalization or mortality was highest for patients with LBBB (Sze et al, J Am Coll Cardiol 2017;71: 306-17).1-Year Follow-Up of PRAGUE-18 Study: Among Patients With MI Undergoing Primary PCI, Antiplatelet Therapy With Prasugrel or Ticagrelor is Associated With Similar Outcomes / Economically Motivated, Early Post-Discharge Switch To Clopidogrel was not Associated With Increased Risk of Ischemic Events Among 1,230 patients with acute myocardial infarction (MI) treated with primary PCI and randomized to prasugrel or ticagrelor, the endpoint (cardiovascular death, MI, or stroke at 1 year) occurred in 6.6% of prasugrel patients and in 5.7% of ticagrelor patients (hazard ratio: 1.167; p = 0.503). No significant differences were found in: CV death (3.3% vs 3%), MI (3% vs. 2.5%), stroke (1.1% vs 0.7%), all-cause death (4.7% vs. 4.2%), definite stent thrombosis (1.1% vs. 1.5%), all bleeding (10.9% vs. 11.1%), and TIMI major bleeding (0.9% vs. 0.7%). The percentage of patients who switched to clopidogrel for economic reasons was 34.1% (n=216) for prasugrel and 44.4% (n=265) for ticagrelor (p=0.003). Patients who were economically motivated to switch to clopidogrel had (compared with patients who continued the study medications) a lower risk of major CV events; however, they also had lower ischemic risk (Motovska Z et al, J Am Coll Cardiol 2018;71:371-81)... (excerpt

Restarting Antithrombotic Drugs After Gastrointestinal Bleeding: An Unresolved Issue of Everyday Clinical Practice

With the evolution in cardiovascular disease understanding and the application of advanced interventional therapies, antithrombotic medication has become the cornerstone of the medical management of cardiovascular patients. However, as older and new trials have confirmed, these drugs carry a substantial risk for hemorrhagic complications, especially from the gastrointestinal (GI) tract, which are accompanied by a significant mortality risk. In case of such an event, the clinician must decide whether to discontinue or not the medication and for how long, and he is called to balance the potential risk of thrombosis and recurrent bleeding. In this brief review, we present the studies which address this issue in order to elicit practical conclusions. (Rhythmos 2017;12(3): 45-49)

Electronic Cigarette: Bridge to Quitting & Not a Substitute!

Smoking is the leading cause of preventable death in the world and hence significant effort is made in order to promote, assist and maintain smoking cessation. Several methods have been recruited to this cause. Behavioral therapy had a relatively modest effect

Cardiology News / Recent Literature Review / Last Quarter 2016

AF Symposium: Orlando, 12-14/1/2017ACC.17: Washington, DC, 17-19/3/2017HRS Scientific sessions: Chicago, 10-13/5/2017EHRA Europace-Cardiostim: Vienna, 18-21/6/2017ESC Congress: Barcelona, 26-30/8/2017TOHP Study: Direct Linear Relationship of an Accurate Measure of Usual Sodium Intake to Total Mortality Over a Period of 23-26 Years, With Higher Risk at High Sodium Intake and no Evidence of a U or J Shape Based on multiple 24-h urine samples collected from pre-hypertensive adults 30 to 54 years of age, among 744 phase I and 2,382 phase II participants randomized to sodium reduction or control, 251 deaths occurred, representing a nonsignificant 15% lower risk in the active intervention (hazard ratio -HR: 0.85; p=NS). Among 2,974 participants not assigned to an active sodium intervention, 272 deaths occurred with a direct linear association between average sodium intake and mortality, with an HR of 0.75, 0.95, and 1.00 (references) and 1.07 (p trend= 0.30) for <2.3, 2.3 to <3.6, 3.6 to <4.8, and ≥4.8 g/24 h, respectively; and with an HR of 1.12 per 1 g/24 h (p = 0.05). There was no evidence of a J-shaped or nonlinear relationship. The HR per unit increase in sodium/ potassium ratio was 1.13 (p = 0.04) (Cook NR et al, J Am Coll Cardiol 2016;68:1609-1617).FRANCE-2 (FRench Aortic National CoreValve and Edwards) Registry: In High-Risk Patients With Aortic Stenosis Undergoing TAVI, Later Mortality is Due Mainly to Noncardiac Causes / Beyond the First Month After the Procedure, Prosthetic Valve Function Remains Stable, the Incidence of Clinical Events is Low, and Functional Improvement is Usually Sustained Among 4,201 patients undergoing TAVI, approaches were transfemoral 73%, transapical 18%, subclavian 6%, and transaortic or transcarotid 3% and median follow-up 3.8 years. The 3-year all-cause mortality was 42% and cardiovascular mortality 17.5%. Predictors of 3-year all-cause mortality were male gender (p< 0.001), low body mass index, (p< 0.001), AF (p< 0.001), dialysis (p< 0.001), NYHA class III or IV (p< 0.001), higher logistic EuroSCORE (p<0.001), transapical or subclavian approach (p< 0.001 for both vs transfemoral approach), need for permanent pacemaker implantation (p= 0.02), and post-implant periprosthetic aortic regurgitation grade ≥2 of 4 (p< 0.001). Severe events occurred mainly during the first month and subsequently in <2% of patients/year. Mean gradient, valve area, and residual aortic regurgitation were stable during follow-up (Gilard M et al, J Am Coll Cardiol 2016; 68:1637-1647)... (excerpt

Minimally Invasive Hemodynamic Monitoring in Intensive Care Unit. A Brief Review

To avoid use of a Swan-Ganz catheter and its attendant complications, new technologies have now become available to help the clinician perform a less invasive hemodynamic monitoring in patients in the intensive care unit (ICU). Among these, conventional echocardiography, the esophageal Doppler, pulse pressure analysis, the transpulmonary thermodilution, the indicator dilution and the thoracic electrical bioimpedance and bioreactance, all aim at measuring stroke volume and cardiac output by less invasive means and they are herein briefly reviewed

Where Smoking was Banned in Public Places, Myocardial Infarctions were Markedly Decreased!

Tobacco use is the single most important preventable health risk in the developed world. Smoking-related mortality is on the rise. Most smoking-associated deaths relate to lung cancer, chronic obstructive pulmonary disease and coronary heart disease. Epidemiological studies suggest that passive smoking is nearly as harmful as active. In the adult population passive smoking can cause coronary heart disease and lung cancer. Smoking ban in public places has been implemented in most countries of the Western World with a high degree of compliance. The results of several trials assessing the effectiveness of this measure in public health are encouraging, as a consistent decrease in the incidence of acute myocardial infarction has been reported for the period after the legislation. A brief overview of these data is herein provided