Age- and sex-based heterogeneity in coronary artery plaque presence and burden in familial hypercholesterolemia:A multi-national study

Objectives: Individuals with familial hypercholesterolemia (FH) are at an increased risk for coronary artery disease (CAD). While prior research has shown variability in coronary artery calcification (CAC) among those with FH, studies with small sample sizes and single-center recruitment have been limited in their ability to characterize CAC and plaque burden in subgroups based on age and sex. Understanding the spectrum of atherosclerosis may result in personalized risk assessment and tailored allocation of costly add-on, non-statin lipid-lowering therapies. We aimed to characterize the presence and burden of CAC and coronary plaque on computed tomography angiography (CTA) across age- and sex-stratified subgroups of individuals with FH who were without CAD at baseline. Methods: We pooled 1,011 patients from six cohorts across Brazil, France, the Netherlands, Spain, and Australia. Our main measures of subclinical atherosclerosis included CAC ranges (i.e., 0, 1–100, 101–400, &gt;400) and CTA-derived plaque burden (i.e., no plaque, non-obstructive CAD, obstructive CAD). Results: Ninety-five percent of individuals with FH (mean age: 48 years; 54% female; treated LDL-C: 154 mg/dL) had a molecular diagnosis and 899 (89%) were on statin therapy. Overall, 423 (42%) had CAC=0, 329 (33%) had CAC 1–100, 160 (16%) had CAC 101–400, and 99 (10%) had CAC &gt;400. Compared to males, female patients were more likely to have CAC=0 (48% [n = 262] vs 35% [n = 161]) and no plaque on CTA (39% [n = 215] vs 26% [n = 120]). Among patients with CAC=0, 85 (20%) had non-obstructive CAD. Females also had a lower prevalence of obstructive CAD in CAC 1–100 (8% [n = 15] vs 18% [n = 26]), CAC 101–400 (32% [n = 22] vs 40% [n = 36]), and CAC &gt;400 (52% [n = 16] vs 65% [n = 44]). Female patients aged 50–59 years were less likely to have obstructive CAD in CAC &gt;400 (55% [n = 6] vs 70% [n = 19]). Conclusion: In this large, multi-national study, we found substantial age- and sex-based heterogeneity in CAC and plaque burden in a cohort of predominantly statin-treated individuals with FH, with evidence for a less pronounced increase in atherosclerosis among female patients. Future studies should examine the predictors of resilience to and long-term implications of the differential burden of subclinical coronary atherosclerosis in this higher risk population.</p

2019 ESC/EAS guidelines for the management of dyslipidaemias : Lipid modification to reduce cardiovascular risk

Correction: Volume: 292 Pages: 160-162 DOI: 10.1016/j.atherosclerosis.2019.11.020 Published: JAN 2020Peer reviewe

Is it Time for Single-Pill Combinations in Dyslipidemia?

Despite the availability of lipid-lowering therapies (LLTs) that are safe and effective, the overall rate of low-density lipoprotein cholesterol (LDL-C) control at a population level in real-life studies is low. Higher-intensity treatment, earlier intervention, and longer-term treatment have all been shown to improve outcomes. However, in clinical practice, actual exposure to LLT is a product of the duration and intensity of, and adherence to, the treatment. To increase exposure to LLTs, the European Society of Cardiology guidelines recommended a stepwise optimization of LLTs by increasing statin intensity to the maximally tolerated dose, with subsequent addition of ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. Evidence from randomized controlled trials performed in a range of patients suggested that adding ezetimibe to statins rather than doubling the statin dose resulted in significantly more patients at LDL-C goal and significantly fewer patients discontinuing treatment because of adverse events. In addition, data showed that combination treatments effectively increased exposure to LLT. Despite these data and recommendations, optimization of LLT is often limited to increasing statin dose. Therapeutic inertia and poor treatment adherence are significant and prevalent barriers to increasing treatment exposure. They are known to be influenced by pill burden and complexity of treatment. Single-pill combinations provide a strategic approach that supports the intensification of treatment without increasing pill burden or treatment complexity. Single-pill combinations, compared with free associations, have been shown to increase the adherence to LLT and the percentage of patients at LDL-C goal

Normal reference values of left ventricular strain using three-dimensional speckle tracking echocardiography: results from a multicentre study

AIMS: Three-dimensional (3D) speckle tracking echocardiography (3DSTE) has been shown to be an accurate and reliable clinical tool for the evaluation of global and regional left ventricular (LV) function through strain analysis, but the absence of normal values has precluded its widespread use in clinical practice. The aim of this prospective multicentre study was to establish normal reference values of LV strain parameters using 3DSTE in a large healthy population. METHODS AND RESULTS: A total of 303 healthy subjects (156 males [51%], between 18 and 82 years of age, ejection fraction [EF] 61 +/- 3%), stratified to provide approximately equal proportions of healthy subjects of 18-30, 31-40, 41-50, 51-60, and >60 years of age, underwent 3DSTE. Data were analysed for LV volumes, EF, mass, and global and regional circumferential, longitudinal, radial, and area strain. Significant but small differences between men and women were found for longitudinal and area strains, as well as between different age groups for all LV strain parameters. However, large differences in normal values were observed between different segments, walls, and levels of the LV for radial and longitudinal strains, whereas circumferential and area strains demonstrated generally consistent normal ranges across the LV. CONCLUSIONS: Normal ranges of global and regional LV strain using 3DSTE have been established for clinical use. Differences in the magnitude of LV strain are present between men and women as well as different age groups. Moreover, there are differences between different segments, walls, and levels as part of the functional non-uniformity of the normal LV that necessitates the use of segment-specific normal ranges for radial and longitudinal strains. Circumferential and area strains demonstrate the most consistent normal ranges overall

Curva de aprendizaje en ecocardioscopia. Utilidad de un programa docente interespecialidad

Resumen: Objetivo: Comprobar los resultados de un entrenamiento en habilidad para realizar ecocardioscopias para oncólogos por parte de cardiólogos y estudiar la variabilidad en las mediciones y la significación clínica de esa variabilidad. Métodos: Se incluyeron pacientes consecutivos que habían sido atendidos en las consultas de oncología previamente. Un oncólogo les realizó una ecocardioscopia con un equipo portátil. Por otro lado, un cardiólogo realizó un ecocardiograma reglado con un equipo de gama alta. Todos los oncólogos participantes recibieron un entrenamiento básico en ecocardioscopia por parte de cardiólogos especializados en imagen cardiovascular. Resultados: Se incluyeron 101 pacientes (31,7% varones; edad media 56,03 ± 16,88 años). Los resultados mostraron una clara curva de aprendizaje durante el periodo de reclutamiento, alcanzando a los dos meses una buena similitud entre oncólogo y cardiólogo para las medidas de los diámetros ventriculares, pero sin alcanzar la misma similitud hasta pasados 4 meses las medidas de la fracción de eyección del ventrículo izquierdo. De la misma manera, se produjo una importante reducción de las diferencias clínicamente significativas de la fracción de eyección del ventrículo izquierdo a partir del cuarto mes. Conclusiones: Un entrenamiento breve dirigido a Facultativos Especialistas en Oncología en ecocardioscopia dirigido por cardiólogos expertos en imagen cardiovascular permite al oncólogo obtener las habilidades necesarias para evaluar las dimensiones del ventrículo izquierdo y la fracción de eyección del ventrículo izquierdo de una forma precisa. El tiempo de entrenamiento se estima en una semana de formación teórico-práctica intensa, y adicionalmente cuatro meses de realización de ecocardioscopias supervisadas estrechamente por los cardiólogos. Abstract: Objective: To assess the results of a training to perform echocardioscopic studies to oncologists by cardiologists, and to study the variability in measurements, as well as the clinical significance of this variability. Methods: Participant oncologists received basic training in echocardioscopy by cardiologists specialised in cardiovascular imaging. Consecutive patients attending the oncology outpatient clinic were included in the study. Every patient underwent an echocardioscopic study performed by an oncologist with a portable device and an echocardiogram performed by a cardiologist using high-end equipment. Results: The study included 101 patients, with a mean age of 56.03 ± 16.88 years, and 31.7% were males. The results showed a clear learning curve over time, with a good similarity in ventricular diameters measurements between oncologists and cardiologist being reached in two months, but it took 4 months to reach the same similarity for left ventricular ejection fraction (LVEF) measurements. Likewise, there was a significant reduction in clinically significant differences in LVEF after the fourth month. Conclusions: A brief training in echocardioscopy for oncologists, led by cardiology experts in cardiovascular imaging, allows the oncologist to obtain the necessary skills to accurately assess left ventricular ejection fraction and diameters. The training time proposed is a week of intensive theoretical and practical training, followed by four months of completion of echocardioscopic examinations closely monitored by the cardiologist. Palabras clave: Ecocardiografía portátil, Oncología, Quimioterapia, Cardiotoxicidad, Entrenamiento, Keywords: Portable echocardiography, Oncology, Chemotherapy, Cardiotoxicity, Trainin

European multicenter study with the Soprano valve for aortic valve replacement: one-year clinical experience and hemodynamic data

During recent years, pericardial bioprostheses have gained widespread acceptance as cardiac valve substitutes. The study aim was to evaluate the early clinical and hemodynamic performance of the Sorin SopranoTM supra-annular aortic bioprosthesis, as used for aortic valve replacement (AVR)

Hiperlipidemia familiar combinada: documento de consenso

La hiperlipidemia familiar combinada (HFC) es un trastorno muy frecuente asociado a enfermedad coronaria prematura. Se transmite de forma autosómica dominante, aunque no existe un gen único asociado al trastorno. El diagnóstico se realiza mediante criterios clínicos, y son importantes la variabilidad del fenotipo lipídico y la historia familiar de hiperlipidemia. Es frecuente la asociación con diabetes mellitus tipo 2, hipertensión arterial y obesidad central. Los pacientes con HFC se consideran de riesgo cardiovascular alto y el objetivo terapéutico es un colesterol-LDL < 100 mg/dl, y < 70 mg/dl en presencia de enfermedad cardiovascular establecida o diabetes mellitus. Los pacientes con HFC requieren tratamiento con estatinas potentes y, a veces, tratamiento combinado. La identificación y el manejo de otros factores de riesgo cardiovascular, como la diabetes y la hipertensión, son fundamentales para reducir la carga de enfermedad cardiovascular. Este documento proporciona recomendaciones para el diagnóstico y el tratamiento integral de los pacientes con HFC especialmente dirigidas a médicos de atención primaria