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The British Cardiovascular Society Annual Conference, Manchester, 5-7 June 2017: the Vice-Presidents message

2017-05-10T22:35:36-07:00

One of the first questions I am asked whenever a forthcoming British Cardiovascular Society (BCS) Annual Conference is being discussed is the proposed ‘theme’ of the meeting. Initially I found this surprising as the main function of the conference, at least as far as the programme committee and I are concerned, is to provide a reasonably comprehensive coverage of the latest developments in all the subspecialist areas of cardiology rather than focus on a particular area. The concept of a theme arose a few years ago as a means of adding interest to the programme and as a stimulus for generation of ideas for novel session titles. The theme needs to be both broad enough to have relevance across the cardiological spectrum and specific enough to grab the attention and interest of potential delegates. This year’s theme ‘Cardiology at the Extremes’ fulfils these requirements well and also opens up...




Heartbeat: Managing cardiovascular disease as a family of diseases in the community

2017-05-10T22:35:36-07:00

Although at least 80% of cardiovascular disease (CVD) is potentially preventable by the elimination of health risk behaviours, implementation of effective, large scale and sustainable CVD prevention programs is still a challenge. In this issue of Heart, Connolly et al1 describe an experience in which patients at high risk of or with established CVD underwent a 12 week community-based nurse-led prevention programme called My Action (figure 1) which included lifestyle and risk factor management, prescription of medication and weekly exercise and education sessions. The programme is in accordance to recent British recommendations that CVD should be managed as a family of diseases in the community. The study was conducted in Westminster, a culturally and socioeconomically diverse borough in central London. Over a 6 year period, 3232 patients attended an initial assessment, 63% were male and 48% belonged to black and minority ethnic groups; 56% attended an end...




Integrated programmes for cardiovascular disease risk reduction: the need for new models of care

2017-05-10T22:35:36-07:00

Cardiovascular disease (CVD) remains a leading cause of mortality and morbidity worldwide. Although mortality rates for CVD have fallen by up to three-quarters in the UK, it still accounts for 26% of all deaths there. It costs the UK economy over £15 billion each year.1 Declining CVD mortality rates increases the number of individuals surviving into old age with CVD, leaving them at increased risk for a subsequent event. For individuals who have not suffered an event, the presence of certain genetic, behavioural and biological factors increases their risk of CVD. At least 80% of CVDs are potentially preventable by the elimination of health risk behaviours through a combination of changes to lifestyle—diet, physical activity, smoking cessation and reduction in the harmful use of alcohol.2 These behaviours are modifiable when evidence-based behavioural models of change are employed.3 Across Europe and other western countries, there...




Oral anticoagulation in end-stage renal disease and atrial fibrillation: is it time to just say no to drugs?

2017-05-10T22:35:36-07:00

Atrial fibrillation (AF) frequently complicates the management of chronic kidney disease, especially in patients with end-stage renal disease (ESRD). AF occurs in approximately one in five of the 650 000 patients with ESRD in the USA.1 ESRD confers increased risk for AF, while AF hastens progression to ESRD. The presence of chronic kidney disease in patients with AF is associated with an increased risk for ischaemic stroke independent of traditional risk factors. In addition, chronic kidney disease and particularly ESRD are associated with an increased risk of bleeding.

Little is understood about how to safely reduce the risk of thromboembolic events in patients with AF and ESRD. Prospective trials of AF have uniformly excluded patients with a glomerular filtration rate (GFR) <30 mL/hour. ESRD produces alterations in haemostasis that predispose patients to haemorrhagic (platelet α granule depletion, reduced endothelial cell adhesion molecule expression) and thrombotic (increased circulating fibrinogen) complications,...




Drug-induced liver injury with oral anticoagulants: a threat or not?

2017-05-10T22:35:36-07:00

Drug-induced liver injury (DILI) can develop with the use of virtually any drug. The growing list of medications or herbal products reported in association with DILI presently includes >1000 compounds, but the annual incidence of DILI has been estimated to only 1–1.5 per 1000–10 000 exposed persons.1 Nonetheless, DILI accounts for ~10% of all acute hepatitis cases and is the most common cause of acute liver failure (ALF).1 2

Drugs (or their metabolites) can affect the liver in a dose-dependent, predictable fashion (eg, acetaminophen) or via unpredictable immune-mediated (eg, phenytoin) or metabolic (eg, isoniazid) idiosyncratic reactions.2 While immune-mediated response typically occurs with short latency of 1–4 weeks, metabolic idiosyncrasies may occur ≤1 year later.2 Generally, adults have a higher risk of DILI than children. Age, female sex, alcohol abuse, malnutrition, pre-existent liver disease and the P-450 gene mutations are the main risk factors for DILI.




Amyloid heart disease: genetics translated into disease-modifying therapy

2017-05-10T22:35:36-07:00

Given increased awareness and improved non-invasive diagnostic tools, cardiac amyloidosis has become an increasingly recognised aetiology of increased ventricular wall thickness and heart failure with preserved ejection fraction. Once considered a rare disease with no treatment options, translational research has harnessed novel pathways and led the way to promising treatment options. Gene variants that contribute to amyloid heart disease provide unique opportunities to explore potential disease-modifying therapeutic strategies. Amyloidosis has become the model disease through which gene therapy using small interfering RNAs and antisense oligonucleotides has evolved.




Warfarin utilisation and anticoagulation control in patients with atrial fibrillation and chronic kidney disease

2017-05-10T22:35:36-07:00

Objective

To evaluate warfarin prescription, quality of international normalised ratio (INR) monitoring and of INR control in patients with atrial fibrillation (AF) and chronic kidney disease (CKD).

Methods

We performed a retrospective cohort study of patients with newly diagnosed AF in the Veterans Administration (VA) healthcare system. We evaluated anticoagulation prescription, INR monitoring intensity and time in and outside INR therapeutic range (TTR) stratified by CKD.

Results

Of 123 188 patients with newly diagnosed AF, use of warfarin decreased with increasing severity of CKD (57.2%–46.4%), although it was higher among patients on dialysis (62.3%). Although INR monitoring intensity was similar across CKD strata, the proportion with TTR≥60% decreased with CKD severity, with only 21% of patients on dialysis achieving TTR≥60%. After multivariate adjustment, the magnitude of TTR reduction increased with CKD severity. Patients on dialysis had the highest time markedly out of range with INR <1.5 or >3.5 (30%); 12% of INR time was >3.5, and low TTR persisted for up to 3 years.

Conclusions

There is a wide variation in anticoagulation prescription based on CKD severity. Patients with moderate-to-severe CKD, including dialysis, have substantially reduced TTR, despite comparable INR monitoring intensity. These findings have implications for more intensive warfarin management strategies in CKD or alternative therapies such as direct oral anticoagulants.




Impact of urbanisation and altitude on the incidence of, and risk factors for, hypertension

2017-05-10T22:35:36-07:00

Background

Most of the data regarding the burden of hypertension in low-income and middle-income countries comes from cross-sectional surveys instead of longitudinal studies. We estimated the incidence of, and risk factors for, hypertension in four study sites with different degree of urbanisation and altitude.

Methods

Data from the CRONICAS Cohort Study, conducted in urban, semiurban and rural areas in Peru, was used. An age-stratified and sex-stratified random sample of participants was taken from the most updated census available in each site. Hypertension was defined as systolic blood pressure ≥140 mm Hg, or diastolic blood pressure ≥90 mm Hg, or self-report physician diagnosis and current treatment. The exposures were study site and altitude as well as modifiable risk factors. Incidence, incidence rate ratios (IRRs), 95% CIs and population-attributable fractions (PAFs) were estimated using generalised linear models.

Results

Information from 3237 participants, mean age 55.8 (SD±12.7) years, 48.4% males, was analysed. Overall baseline prevalence of hypertension was 19.7% (95% CI 18.4% to 21.1%). A total of 375 new cases of hypertension were recorded, including 5266 person-years of follow-up, with an incidence of 7.12 (95% CI 6.44 to 7.88) per 100 person-years. Individuals from semiurban site were at higher risk of hypertension compared with highly urbanised areas (IRR=1.76; 95% CI 1.39 to 2.23); however, those from high-altitude sites had a reduced risk (IRR=0.74; 95% CI 0.58 to 0.95). Obesity was the leading risk factor for hypertension with a great variation according to study site with PAF ranging from 12.5% to 42.4%.

Conclusions

Our results suggest heterogeneity in the progression towards hypertension depending on urbanisation and site altitude.




Prospective study of oral anticoagulants and risk of liver injury in patients with atrial fibrillation

2017-05-10T22:35:36-07:00

Objective

To assess the risk of liver injury hospitalisation in patients with atrial fibrillation (AF) after initiation of direct oral anticoagulants (DOACs) or warfarin and to determine predictors of liver injury hospitalisation in this population.

Methods

We studied 113 717 patients (mean age 70, 39% women) with AF included in the MarketScan Commercial and Medicare Supplemental databases with a first prescription for oral anticoagulation after 4 November 2011, followed through 31 December 2014. Of these, 56 879 initiated warfarin, 17 286 initiated dabigatran, 30 347 initiated rivaroxaban and 9205 initiated apixaban. Liver injury hospitalisation and comorbidities were identified from healthcare claims.

Results

During a median follow-up of 12 months, 960 hospitalisations with liver injury were identified. Rates of liver injury hospitalisation (per 1000 person-years) by oral anticoagulant were 9.0 (warfarin), 4.0 (dabigatran), 6.6 (rivaroxaban) and 5.6 (apixaban). After multivariable adjustment, liver injury hospitalisation rates were lower in initiators of DOACs compared with warfarin: HR (95% CI) of 0.57 (0.46 to 0.71), 0.88 (0.75 to 1.03) and 0.70 (0.50 to 0.97) for initiators of dabigatran, rivaroxaban, and apixaban, respectively (vs. warfarin). Compared with dabigatran initiators, rivaroxaban initiators had a 56% increased risk of liver injury hospitalisation (HR 1.56, 95% CI 1.22 to 1.99). In addition to type of anticoagulant, prior liver, gallbladder and kidney disease, cancer, anaemia, heart failure and alcoholism significantly predicted liver injury hospitalisation. A predictive model including these variables had adequate discriminative ability (C-statistic 0.67, 95% CI 0.64 to 0.70).

Conclusions

Among patients with non-valvular AF, DOACs were associated with lower risk of liver injury hospitalisation compared with warfarin, with dabigatran showing the lowest risk.




A 38-year-old man with progressive dyspnoea and ventricular tachycardia

2017-05-10T22:35:36-07:00

Clinical introduction

A previously healthy 38-year-old man presented with a 3-month history of progressive dyspnoea and ventricular tachycardia (VT). He suffered a viral illness 4 months earlier. There was no family history of cardiac disease or sudden cardiac death (SCD). ECG showed left bundle branch block (LBBB). Echocardiography revealed a dilated left ventricle with severely impaired systolic function. Coronary angiogram showed angiographically normal coronary arteries. He was diagnosed as having dilated cardiomyopathy and was referred for further assessment with cardiovascular magnetic resonance (CMR) (figure 1) and subsequently CT thorax.

Question

What is the most likely diagnosis?

  • Dilated cardiomyopathy secondary to HIV

  • Granulomatosis with polyangiitis (GPA)

  • Sarcoidosis

  • Tuberculosis

  • Underlying malignancy with lung and cardiac metastases




  • Outcomes of an integrated community-based nurse-led cardiovascular disease prevention programme

    2017-05-10T22:35:36-07:00

    Background

    National guidance for England recommends that cardiovascular disease (CVD) should be managed as a family of diseases in the community. Here, we describe the results of such an approach.

    Methods

    Patients with established CVD or who were at high multifactorial risk (HRI) underwent a 12-week community-based nurse-led prevention programme (MyAction) that included lifestyle and risk factor management, prescription of medication and weekly exercise and education sessions.

    Results

    Over a 6-year period, 3232 patients attended an initial assessment; 63% were male, and 48% belonged to black and minority ethnic groups. 56% attended an end-of-programme assessment, and 33% attended a one year assessment. By the end of the programme, there was a significant reduction in smoking prevalence but only in HRI (–3.7%, p<0.001). Mediterranean diet score increased in both CVD (+1.2, p<0.001) and HRI (+1.5; p<0.001), as did fitness levels (CVD +0.8 estimated Mets maximum, p<0.001, HRI +0.9 estimated Mets maximum, p<0.001) and the proportions achieving their physical activity targets (CVD +40%, p<0.001, HRI +37%, p<0.001). There were significant increases in proportions achieving their blood pressure (CVD +15.4%, p<0.001, HRI +25%, p<0.001 and low-density lipoprotein cholesterol targets (CVD +6%, p=0.004, HRI +23%, p<0.001). Statins and antihypertensive medications significantly increased in HRI. Significant improvements in depression scores and quality-of-life measures were also seen. The majority of improvements were maintained at 1 year.

    Conclusion

    These results demonstrate that an integrated vascular prevention programme is feasible in practice and reduces cardiovascular risk in patients with established CVD and in those at high multifactorial risk.




    Morphological variability of the arterial valve in common arterial trunk and the concept of normality

    2017-05-10T22:35:36-07:00

    Objective

    Until now, no study established a morphometric evaluation of the truncal valve dysplasia and a description of its different presentation patterns. Thus, authors conducted an anatomopathological study describing the gross features and histological findings of the truncal valve.

    Methods

    50 common arterial trunk (CAT) specimens were examined. The number of valvar leaflets was determined and valvar dysplasia was classified as absent, mild, moderate or severe. Selected leaflets were sectioned and submitted to histological analysis and linear measurements (thickness, length and area), besides quantification of collagen area fraction.

    Results

    28 (56%) valves presented three, 15 (30%) four and 7 (14%) two leaflets. Valvar dysplasia was absent in 13 (26%) cases, mild in 19 (38%), moderate in 6 (12%) and severe in 12 (24%). A significant association was found between the presence of four leaflets and valvar dysplasia (p<0.001). Single coronary ostium was more common in two-leaflet cases than in three-leaflet cases (p=0.037). Leaflets medial thirds were thicker in the more dysplastic valves (p=0.006) and in those presenting anarchic collagen distribution (p=0.002).

    Conclusions

    CAT semilunar valves present two main patterns. The first characterised by three leaflets and absent or mild dysplasia and the second by four leaflets and severe dysplasia. Still, great variability regarding thickness, microscopic organisation of the extracellular matrix and proportions of leaflets' dimensions exists, which may impact on the surgical outcomes.




    Fibroblast growth factor 23 as novel biomarker for early risk stratification after ST-elevation myocardial infarction

    2017-05-10T22:35:36-07:00

    Objective

    Adverse left ventricular (LV) remodelling is the major determinant of heart failure and mortality in survivors of ST-elevation myocardial infarction (STEMI). The role of fibroblast growth factor 23 (FGF-23) for LV remodelling prediction after STEMI is unknown. We therefore aimed to investigate the relation between circulating FGF-23 and LV remodelling following revascularised STEMI.

    Methods

    In this prospective observational study, we included 88 consecutive patients with STEMI treated by primary percutaneous coronary intervention. FGF-23 concentrations were measured 2 (IQR: 2–2) days after symptom onset. Cardiac magnetic resonance was performed 2 (IQR: 1–3) days as well as 4 (IQR: 4–5) months after infarction to evaluate LV remodelling, defined as ≥20% increase in LV end-diastolic volume.

    Results

    Levels of FGF-23 were significantly higher in patients who developed LV remodelling (n=11, 13%) as compared with those without LV remodelling (152.6 (102.5–241.3) vs 75.8 (58.6–105.4) relative units per millilitre, p=0.002). The association between FGF-23 and LV remodelling remained significant (OR: 14.1, 95% CI 2.8 to 70.9; p=0.001) after adjustment for biomarkers reflecting myocardial necrosis (high-sensitivity cardiac troponin T (hs-cTnT)), myocardial stress (N-terminal pro B-type natriuretic peptide (NT-proBNP)) and inflammatory state (high-sensitivity C reactive protein (hs-CRP)). Moreover, a multimarker approach adding FGF-23 to the established LV remodelling-predictive biomarkers (hs-cTnT, NT-proBNP and hs-CRP) led to a net reclassification improvement of 0.92 (95% CI 0.44 to 1.41, p<0.001) and to an integrated discrimination improvement of 0.16 (95% CI 0.08 to 0.24, p<0.001).

    Conclusions

    Circulating FGF-23 is independently associated with LV remodelling after reperfused STEMI. A comprehensive multimarker strategy that includes FGF-23 provides incremental prognostic value for prediction of LV remodelling.




    Sex differences in prodromal symptoms in acute coronary syndrome in patients aged 55 years or younger

    2017-05-10T22:35:36-07:00

    Background

    Studies suggest that young women are at highest risk for failing to recognise early symptoms of acute coronary syndrome (ACS).

    Objectives

    To examine sex differences in prodromal symptoms occurring days and weeks prior to the acute presentation of ACS. We also examined health-seeking behaviours and prehospital management in young patients.

    Methods

    Prospective cross-sectional analysis of 1145 patients (368 women) hospitalised for ACS, aged ≤55 years, from the GENdEr and Sex DetermInantS of Cardiovascular Disease: From Bench to Beyond Premature Acute Coronary SYndrome cohort study (January 2009–April 2013). Prodromal symptoms were determined using the McSweeney Acute and Prodromal Myocardial Infarction Symptom questionnaire. Health-seeking behaviour and prehospital care were determined by questionnaires.

    Results

    The median age was 49 years. The prevalence of prodromal symptoms was high and more women reported symptoms than men (85% vs 72%, p<0.0001). Symptoms were similar between sexes and included unusual fatigue, sleep disturbances, anxiety and arm weakness/discomfort. Chest pain was less common in both sexes (24%). Women were more likely to seek care (49% vs 42%, p=0.04). Among those who sought care, women were more likely to use an ambulance for their ACS compared with men (52% vs 39%). Cardiovascular risk-reduction therapy use was low (≤40%) in all patients and less than half perceived their care provider suspected a cardiac source.

    Conclusions

    Prior to ACS, women were more likely to experience prodromal symptoms and seek medical attention than men. Prehospital care was generally similar between sexes but demonstrated underutilisation of risk-reduction therapies in at-risk young adults.




    Optimal duration of dual antiplatelet therapy after acute coronary syndromes and coronary stenting

    2017-05-10T22:35:36-07:00

    Learning objectives

  • To provide an overview on the concept of dual antiplatelet therapy (DAPT).

  • To review the evidence regarding shorter and longer DAPT duration.

  • To describe the benefits and risks associated with shorter or longer duration of DAPT in patients with acute coronary syndrome and in patients with stable coronary artery disease after coronary stenting.

  • To suggest an algorithm for optimal duration of DAPT.

  • Introduction

    Dual antiplatelet therapy (DAPT) consisting of aspirin and a P2Y12 receptor antagonist (either a thienopyridine (clopidogrel or prasugrel) or a cyclopentyl-triazolopyrimidine (ticagrelor)) is the cornerstone of antithrombotic treatment after an acute coronary syndrome (ACS) and after coronary stenting. Treatment with DAPT after stent implantation reduces both stent thrombosis (ST) and cardiac ischaemic events that are caused by coronary lesions outside the stented segment, albeit at the cost of an increased risk of bleeding. The optimal duration of...




    47-year-old female with an apical mass

    2017-05-10T22:35:36-07:00

    Clinical introduction

    A 47-year-old female with no medical history presented with a sudden collapse. Physical examination, chest X-ray and high-sensitivity cardiac troponin I were normal, however ECG demonstrated anterior T-wave inversion. CT pulmonary angiography was performed which ruled out pulmonary embolism but revealed a non-calcified, homogenous mass at the left ventricular (LV) apex. It was not clear whether this mass was intramyocardial or pericardial. Transthoracic echocardiography confirmed the apical mass but was unable to establish its aetiology. Subsequent cardiac MR (CMR) demonstrated a highly vascular intramyocardial mass on perfusion imaging (Figure 1A, online ), with striking, homogenous late gadolinium enhancement (Figure 1B) consistent with a diagnosis of cardiac fibroma.1 The patient underwent successful surgical excision of the mass (see online ) and made a good symptomatic recovery, quickly mobilising around the ward. On examination, the patient was afebrile but had a blood pressure of 90/40 mm Hg and raised venous pressure. Postoperative imaging with echocardiography (see online ) and CMR (Figure 1C, D and online ) revealed some unexpected findings. Study the provided images.

    Question

    What is the next most appropriate management step?

  • Antibiotic therapy for pericardial abscess

  • Anticoagulation for LV thrombus

  • Intravenous fluids with close clinical and imaging follow-up of the intramyocardial haemorrhage and pericardial haematoma

  • Return to theatre for excision of residual tumour

  • Urgent pericardiocentesis to drain pericardial collection