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Heartbeat: Chocolate and atrial fibrillation

2017-07-14T06:45:54-07:00

Moderate chocolate consumption has been associated with lower rate of adverse cardiac events and mortality, with the mechanism of this association postulated to be the vasodilatory, antioxidant and anti-inflammatory effects of flavanols in chocolate. Motstofsky and colleagues1 hypothesized that the anti-inflammatory and anti-platelet effects of chocolate might also be associated with a lower rate of atrial fibrillation or flutter (AF). In the over 55 thousand subjects in the population based Danish Diet, Cancer and Health Study, there were 3346 cases of AF (6%) over a median 13.5 years. This data showed that the rate of AF was lower for people consuming chocolate more than once a month, with a hazard ratio (HR) of 0.90 for 1–3 servings/month, HR 0.83 for 1 serving/week, HR 0.80 for 2-6 servings per week and HR 0.84 for ≥1 serving/day, with similar results in women and men. (figure 1) Although...




Chocolate and prevention of atrial fibrillation: what is bad for the pancreas might be good for the atria?

2017-07-14T06:45:54-07:00

Atrial fibrillation (AF) is the most common arrhythmia, affecting over 33 million patients worldwide, and 25% of adults will develop AF over their lifetime.1 Patients with AF have higher rates of heart failure, hospitalisation, stroke and cognitive impairment as well as lower quality of life; these factors result in large direct and indirect costs to the healthcare system and society.1 The mechanisms of AF are multifactorial and not well understood, although genetic and cardiovascular risk factors are associated with AF.2–4 Because there is no cure for AF and patients are forced to manage AF as a chronic disease, prevention of AF is the optimal approach, although most AF-related studies focus on treatment instead of prevention.4

Unfortunately, there are no effective, proven therapies for the primary prevention of AF. Nearly 60% of AF can be attributed to modifiable risk factors. For example,...




Predicting long-term bleeding risk after acute coronary syndrome: a step closer to optimising dual antiplatelet therapy duration?

2017-07-14T06:45:54-07:00

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 antagonist improves cardiovascular outcomes in patients with acute coronary syndrome but at a cost of an increased risk of bleeding complications.1 There is marked variability in the thrombotic and bleeding risk between individuals with multiple patient and procedural factors identified but not yet fully understood. Generic recommendations for DAPT duration inevitably expose some patients to an excessive duration of treatment and bleeding risk while simultaneously disadvantaging other patients by withdrawing therapy that could protect them from atherothrombotic events. This is increasingly recognised as a major clinical problem, and current European and North American Acute Coronary Syndromes (ACS) guidelines now acknowledge that shorter durations of DAPT may be considered in patients at high risk of bleeding while extended treatment (>12 months) is an option in selected patients. To implement these guideline recommendations, robust prediction tools are required to facilitate...




Optimal stent treatment of cardiogenic shock complicating acute myocardial infarction: bare-metal or drug-eluting stent?

2017-07-14T06:45:54-07:00

Implantation of bare-metal stents (BMS) in the early 1990s was a milestone in the development of interventional cardiology.1 Stents provided benefits compared with balloon angioplasty alone by reducing the risk of acute vessel occlusion and recurrent ischaemia, and by optimising acute lumen gain and preventing early vessel recoil. A decade later the implementation of drug-eluting stents (DES) has further improved clinical outcomes mainly by substantially reducing restenosis, the Achilles' heel of BMS. However, because of impaired vascular healing, there was a higher risk of late and very late stent thrombosis (ST) associated with the first-generation DES when compared with BMS. ST is a potentially catastrophic event so the widespread perception that BMS may be safer than DES was initiated and, as a consequence, the frequency of DES implantations substantially decreased around the world.

To overcome the safety concerns of the first-generation DES, newer devices have been developed...




Diagnosis, imaging and clinical management of aortic coarctation

2017-07-14T06:45:54-07:00

Coarctation of the aorta (CoA ) is a well-known congenital heart disease (CHD) , which is often associated with several other cardiac and vascular anomalies, such as bicuspid aortic valve (BAV), ventricular septal defect, patent ductus arteriosus and aortic arch hypoplasia. Despite echocardiographic screening, prenatal diagnosis of C o A remains difficult. Most patients with CoA present in infancy with absent, delayed or reduced femoral pulses, a supine arm-leg blood pressure gradient (> 20 mm Hg), or a murmur due to rapid blood flow across the CoA or associated lesions (BAV). Transthoracic echocardiography is the primary imaging modality for suspected CoA. However, cardiac magnetic resonance imaging is the preferred advanced imaging modality for non-invasive diagnosis and follow-up of CoA. Adequate and timely diagnosis of CoA is crucial for good prognosis, as early treatment is associated with lower risks of long-term morbidity and mortality. Numerous surgical and transcatheter treatment strategies have been reported for CoA. Surgical resection is the treatment of choice in neonates, infants and young children. In older children (> 25 kg) and adults, transcatheter treatment is the treatment of choice. In the current era, patients with CoA continue to have a reduced life expectancy and an increased risk of cardiovascular sequelae later in life, despite adequate relief of the aortic stenosis. Intensive and adequate follow-up of the left ventricular function, valvular function, blood pressure and the anatomy of the heart and the aorta are , therefore, critical in the management of CoA. This review provides an overview of the current state-of-the-art clinical diagnosis, diagnostic imaging algori thms, treatment and follow-up of patients with CoA.




Streamlining cardiovascular clinical trials to improve efficiency and generalisability

2017-07-14T06:45:54-07:00

Controlled trials provide the most valid determination of the efficacy and safety of an intervention, but large cardiovascular clinical trials have become extremely costly and complex, making it difficult to study many important clinical questions. A critical question, and the main objective of this review, is how trials might be simplified while maintaining randomisation to preserve scientific integrity and unbiased efficacy assessments. Experience with alternative approaches is accumulating, specifically with registry-based randomised controlled trials that make use of data already collected. This approach addresses bias concerns while still capitalising on the benefits and efficiencies of a registry. Several completed or ongoing trials illustrate the feasibility of using registry-based controlled trials to answer important questions relevant to daily clinical practice. Randomised trials within healthcare organisation databases may also represent streamlined solutions for some types of investigations, although data quality (endpoint assessment) is likely to be a greater concern in those settings. These approaches are not without challenges, and issues pertaining to informed consent, blinding, data quality and regulatory standards remain to be fully explored. Collaboration among stakeholders is necessary to achieve standards for data management and analysis, to validate large data sources for use in randomised trials, and to re-evaluate ethical standards to encourage research while also ensuring that patients are protected. The rapidly evolving efforts to streamline cardiovascular clinical trials have the potential to lead to major advances in promoting better care and outcomes for patients with cardiovascular disease.




Chocolate intake and risk of clinically apparent atrial fibrillation: the Danish Diet, Cancer, and Health Study

2017-07-14T06:45:54-07:00

Objective

To evaluate the association between chocolate intake and incident clinically apparent atrial fibrillation or flutter (AF).

Methods

The Danish Diet, Cancer, and Health Study is a large population-based prospective cohort study. The present study is based on 55 502 participants (26 400 men and 29 102 women) aged 50–64 years who had provided information on chocolate intake at baseline. Incident cases of AF were ascertained by linkage with nationwide registries.

Results

During a median of 13.5 years there were 3346 cases of AF. Compared with chocolate intake less than once per month, the rate of AF was lower for people consuming 1–3 servings/month (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.82 to 0.98), 1 serving/week (HR 0.83, 95% CI 0.74 to 0.92), 2–6 servings/week (HR 0.80, 95% CI 0.71 to 0.91) and ≥1 servings/day (HR 0.84, 95% CI 0.65 to 1.09; p-linear trend <0.0001), with similar results for men and women.

Conclusions

Accumulating evidence indicates that moderate chocolate intake may be inversely associated with AF risk, although residual confounding cannot be ruled out.




Predicting the risk of bleeding during dual antiplatelet therapy after acute coronary syndromes

2017-07-14T06:45:54-07:00

Objectives

Dual antiplatelet therapy (DAPT) with aspirin + a P2Y12 inhibitor is recommended for at least 12 months for patients with acute coronary syndrome (ACS), with shorter durations considered for patients with increased bleeding risk. However, there are no decision support tools available to predict an individual patient’s bleeding risk during DAPT treatment in the post-ACS setting.

Methods

To develop a longitudinal bleeding risk prediction model, we analy sed 9240 patients with unstable angina/non-ST segment elevation myocardial infarction (NSTEMI) from the Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes (TRILOGY ACS) trial, who were managed without revasculari sation and treated with DAPT for a median of 14.8 months.

Results

We identified 10 significant baseline predictors of non-coronary artery bypass grafting (CABG)-related Global Use of Strategies to Open Occluded Arteries (GUSTO) severe/life-threatening/moderate bleeding: age, sex, weight, NSTEMI (vs unstable angina), angiography performed before randomi sation, prior peptic ulcer disease, creatinine, systolic blood pressure, haemoglobin and treatment with beta-blocker. The five significant baseline predictors of Thrombolysis In Myocardial Infarction (TIMI) major or minor bleeding included age, sex, angiography performed before randomi sation, creatinine and haemoglobin. The models showed good predictive accuracy with Therneau’s C-indices: 0.78 (SE = 0.024) for the GUSTO model and 0.67 (SE = 0.023) for the TIMI model. Internal validation with bootstrapping gave similar C-indices of 0.77 and 0.65, respectively. External validation demonstrated an attenuated C-index for the GUSTO model (0.69) but not the TIMI model (0.68).

Conclusions

Longitudinal bleeding risks during treatment with DAPT in patients with ACS can be reliably predicted using selected baseline characteristics. The TRILOGY ACS bleeding models can inform risk –benefit considerations regarding the duration of DAPT following ACS.

Trial registration

ClinicalTrials.gov identifier: https://clinicaltrials.gov/ct2/show/NCT00699998




Drug-eluting stents versus bare-metal stents in acute myocardial infarction with cardiogenic shock

2017-07-14T06:45:54-07:00

Objectives

The aim of the present study was to assess the outcome of patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) receiving drug-eluting stents (DES) compared with bare-metal stents (BMS). Data comparing these two stent technologies in AMI with CS were limited.

Methods

A total of 783 patients with AMI and CS undergoing early revascularisation were included in the randomised Intra-aortic Balloon Pump in Cardiogenic Shock II trial (n=600) and the associated registry (n=183). Patients receiving no stent or both, DES and BMS, were excluded. Primary end point was the composite of 1-year mortality or re-AMI.

Results

Of the total cohort, 652 (83%) patients received either solely DES or BMS and were included in the present analysis. Of these, 276 (42%) patients received DES and 376 (58%) received BMS. After adjustment for baseline characteristics, there was no significant difference between DES and BMS regarding the primary end point (HR 0.83 (CI 0.64 to 1.06); p=0.14). There was an independent association of BMS use with older age, atrial fibrillation and coronary single-vessel disease. DES use was associated with prior known dyslipidaemia, baseline haemoglobin level, anterior AMI and treatment at frequently enrolling centres.

Conclusions

Despite the frequent use of DES nowadays, a substantial number of patients were treated by BMS in AMI complicated by CS. After adjustment for risk factors, the 1-year outcome of patients treated by DES compared with BMS was similar.

Trial registrationnumber

www.clinicaltrials.gov: NCT00491036.




Hepatocyte growth factor demonstrates racial heterogeneity as a biomarker for coronary heart disease

2017-07-14T06:45:54-07:00

Objective

To determine if hepatocyte growth factor (HGF), a promising biomarker of coronary heart disease (CHD) given its release into circulation in response to endothelial damage, is associated with subclinical and clinical CHD in a racial/ethnic diverse population.

Methods

HGF was measured in 6738 participants of the Multi-Ethnic Study of Atherosclerosis (MESA). Highest mean HGF values (pg/mL) were observed in Hispanic, followed by African, non-Hispanic white, then Chinese Americans.

Results

In all races/ethnicities, HGF levels were associated with older age, higher systolic blood pressure (SBP) and body mass index, lower high-density lipoprotein, diabetes and current smoking. In fully adjusted models, each SD higher HGF was associated with an average increase in coronary artery calcium (CAC) of 55 Agatston units for non-Hispanic whites (p<0.001) and 51 Agatston units for African-Americans (p=0.007) but was not in the other race/ethnic groups (interaction p=0.02). There were 529 incident CHD events, and CHD risk was 41% higher in African (p<0.001), 17% in non-Hispanic white (p=0.026) and Chinese (p=0.36), and 6% in Hispanic Americans (p=0.56) per SD increase in HGF.

Conclusion

In a large and diverse population-based cohort, we report that HGF is associated with subclinical and incident CHD. We demonstrate evidence of racial/ethnic heterogeneity within these associations, as the results are most compelling in African-Americans and non-Hispanic white Americans. We provide evidence that HGF is a biomarker of atherosclerotic disease that is independent of traditional risk factors.




Contemporary cardiac surgery for adults with congenital heart disease

2017-07-14T06:45:54-07:00

Objective

Advances in early management of congenital heart disease (CHD) have led to an exponential growth in adults with CHD (ACHD). Many of these patients require cardiac surgery. This study sought to examine outcome and its predictors for ACHD cardiac surgery.

Methods

This is an observational cohort study of prospectively collected data on 1090 consecutive adult patients with CHD, undergoing 1130 cardiac operations for CHD at the Royal Brompton Hospital between 2002 and 2011. Early mortality was the primary outcome measure. Midterm to longer-term survival, cumulative incidence of reoperation, other interventions and/or new-onset arrhythmia were secondary outcome measures. Predictors of early/total mortality were identified.

Results

Age at surgery was 35±15 years, 53% male, 52.3% were in New York Heart Association (NYHA) class I, 37.2% in class II and 10.4% in class III/IV. Early mortality was 1.77% with independent predictors NYHA class ≥ III, tricuspid annular plane systolic excursion (TAPSE) <15 mm and female gender. Over a mean follow-up of 2.8±2.6 years, 46 patients died. Baseline predictors of total mortality were NYHA class ≥ III, TAPSE <15 mm and non-elective surgery. The number of sternotomies was not independently associated with neither early nor total mortality. At 10 years, probability of survival was 94%. NYHA class among survivors was significantly improved, compared with baseline.

Conclusions

Contemporary cardiac surgery for ACHD performed at a single, tertiary reference centre with a multidisciplinary approach is associated with low mortality and improved functional status. Also, our findings emphasise the point that surgery should not be delayed because of reluctance to reoperate only.




Echocardiographic diagnosis of total or left congenital pericardial absence with positional change

2017-07-14T06:45:54-07:00

Objectives

Congenital absence of the pericardium (CAP) is often confused with other conditions presenting with right ventricular dilatation and usually warrants CT or cardiac MR (CMR) to confirm. It would be desirable to have more specific echocardiographic criteria to provide a conclusive diagnosis.

Methods

11 patients who were diagnosed with CAP (four patients with total CAP) based on CT/CMR were consecutively enrolled. Thirteen patients with atrial septal defect (ASD) and 16 normal subjects served as controls. To investigate spatial changes of heart in the thoracic cavity in CAP, following echocardiographic measurements were made in the left and right decubitus positions: the angle between the ultrasound beam and the left ventricular posterior wall (Angle-PW) in end-diastole at the parasternal long axis, and the distance between the chest wall and the most distal part of the left ventricular posterior wall (Distance-PW) at the parasternal mid-ventricular short axis.

Results

Angle-PW in patients with CAP were significantly greater than in those with ASD (100.1±12.5° vs 74.5±8.6°, p<0.017) or in normal subjects (100.1±12.5° vs 69.9±7.6°, p<0.017) at the left decubitus, and the difference in Angle-PW according to posture (left vs right) was significantly greater in CAP compared with the other groups (CAP 20.7±12.7°, ASD 0.31±1.80°, normal 0.31±1.40°, all p<0.017). The differences in Distance-PW according to patient position (CAP 2.43±0.77°, ASD 0.42±0.45°, normal 0.26±0.55°) or cardiac cycle in each position (left: CAP 1.60±0.76°, ASD 0.41±0.27°, normal 0.17±0.12°; right: CAP 0.70±0.32°, ASD 0.22±0.19°, normal 0.22±0.13°) were significantly higher in the CAP group than in the other groups (all p<0.017).

Conclusions

Patients with CAP have dynamic alteration in cardiac position depending on posture, which is not observed in ASD or in normal controls. Hence, total or left-sided CAP can be reliably diagnosed with positional changes during routine echocardiography.




Moderate sedation in cardiac electrophysiology laboratory: a retrospective safety analysis

2017-07-14T06:45:54-07:00

Objective

Cardiac electrophysiology (EP) procedures can be performed under moderate sedation without the direct involvement of an anaesthetist. However, concerns have been raised over the safety of this approach. This study examines the use of a standardised nurse-led physician-directed sedation protocol for EP procedures to determine the safety of moderate sedation administered by non-anaesthesia personnel who have been trained in sedation techniques.

Methods and results

Consecutive EP procedures done under moderate sedation over 12 years at our institution were evaluated. Serious adverse events were defined as (i) procedural death related to sedation; (ii) intubation and ventilation; and (iii) hypotension requiring inotropic support. Reversal of sedation constituted a minor adverse event. Up to 7117 procedures were included. These comprised ablations (55%), devices (43%) and other procedures (2%). A majority of patients were men with a mean age of 61±10 years. 99.98% of procedures were completed successfully without sedation-related serious adverse events. Two patients (0.02%) required anaesthetic support for intubation. Sedation was reversed in 1.2% of procedures with less than 1% requiring reversal because of persistent drop in oxygen saturation, hypoventilation or markedly reduced level of consciousness. There was no significant difference in the patient characteristics, mean doses of sedative agents and procedure types in the group requiring reversal of sedation when compared with the whole cohort.

Conclusions

Our study demonstrates that nurse-led, physician-directed moderate sedation is safe. Anaesthesia services are not required routinely for invasive cardiac EP procedures and should be available on a need basis.




21-year-old with exertional dyspnoea

2017-07-14T06:45:54-07:00

Clinical introduction

A 21-year-old, previously healthy, woman presents to the emergency department with 2 months of dyspnoea on exertion. She is short of breath walking up a flight of stairs. She has a history of intravenous drug use and takes no medications. Family history is negative for cardiac disease. Heart rate is 110 bpm and blood pressure is 125/55 mmHg. She has an elevated jugular venous pressure, bibasilar rales, a soft S1 and a systolic in addition to a diastolic murmur. Shortly after initial presentation in the emergency department, she is intubated for respiratory failure. A transthoracic echocardiogram is obtained (figure 1).

Figure 1

(A) M-mode recording of the mitral valve. (B) Continuous-wave Doppler of transmitral flow.

Question

In addition to abstinence from drug use, which of the following is the most appropriate definitive therapy?

  • Mitral valve repair

  • Aortic...




  • Non-invasive fractional flow reserve using computed tomographic angiography: where are we now and where are we going?

    2017-07-14T06:45:54-07:00

    Learning objectives

  • It has now become possible to measure fractional flow reserve from standard coronary computed tomographic angiography.

  • The rapid accumulation in clinical data behind this technique has culminated in a Food and Drug Administration approval and also approval by the National Institute for Health and Clinical Excellence (NICE).

  • The aims of the current manuscript are to explore the scientific principles behind this technique, the published data validating its use, the potential benefits to healthcare systems and also the challenges it is likely to face as it attempts to enter the clinical domain.

  • Introduction

    Coronary computed tomographic angiography (CTA) is now established as a clinically valuable non-invasive anatomical test for the detection and exclusion of significant coronary disease. A number of prospective multicentre trials have shown coronary CTA to be an ideal test for the exclusion and detection of coronary disease using invasive...




    Cardiovascular highlights from non-cardiology journals

    2017-07-14T06:45:54-07:00

    Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis

    The use of percutaneous coronary intervention (PCI) for unprotected left main coronary artery stenosis is increasing but it remains unclear whether this approach is non-inferior to coronary artery bypass grafting (CABG). Both the Nordic-Baltic-British left main revascularisation study (NOBLE, n=1201) and Evaluation of an everolimus eluting stent versus coronary artery bypass surgery for effectiveness of left main revascularisation study (EXCEL, n=1905) randomised patients with severe left main coronary artery stenosis to PCI or CABG to address this question. Though similar, there are important differences in these studies’ design and results. Primary outcomes were defined as all cause death, stroke and non-procedural myocardial infarction (MI) in both trials with the addition of repeat revascularisation in NOBLE and post-procedural MI in EXCEL. Other study differences include intended duration of follow-up, non-inferiority margins, allowable coronary complexity,...




    Fifty-year-old woman with lightheadedness

    2017-07-14T06:45:54-07:00

    Clinical introduction

    A 50-year-old woman presented to the emergency department with a 3-year history of worsening episodes of lightheadedness, anxiety and diaphoresis. She was otherwise healthy. Her cardiovascular physical examination was normal apart from an irregularly irregular pulse of 105 beats per minute. When she arrived in the emergency department, a 12-lead ECG was obtained (figure 1).

    Question

    What is the most likely diagnosis?

  • Atrial fibrillation (AF)

  • Atrial premature beats

  • Atrioventricular (AV) reciprocating tachycardia

  • Dual AV nodal non-reentrant tachycardia (DAVNNT)

  • AV nodal re-entrant tachycardia

  • Answer: D

    Figure 1

    Patient’s ECG.

    Discussion

    The ECG demonstrates a single P wave followed by two QRS complexes. Discrete sinus P waves and the regularity of the paired QRS complexes exclude AF. The absence of a premature P wave preceding the extra QRS complexes excludes atrial premature beats. Normally, AV reciprocating...