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Heartbeat: What is the best emergency treatment for decompensated severe aortic stenosis?

2017-12-11T04:10:28-08:00

The cornerstone of treatment for patients with severe aortic stenosis (AS) is prompt valve replacement as soon as even mild symptoms are present. Even so, many patients are referred much later in the disease course, either because the primary care provider did not make the correct diagnosis or erroneously assumed the patient was ‘too old’ or ‘too sick’ to undergo valve replacement. In this situation, transfer to a heart valve centre often occurs only when the patient becomes haemodynamically unstable. Optimal emergency management of decompensated severe AS is controversial—attempts at medical stabilisation typically are futile, surgical risk is prohibitive and the decision to perform balloon aortic valvuloplasty (BAV) or transcatheter aortic valve implantation (TAVI) is not straightforward.

In this issue of Heart, Bongiovanni and colleagues1 report the outcomes of 141 patients with decompensated severe AS treated with TAVI (n=23) or BAV (n=118). Procedural mortality was 8.7% for...




Emergency interventions for the treatment of decompensated aortic stenosis

2017-12-11T04:10:28-08:00

‘Whosoever wishes to know about the world must learn about it in its particular details.’ —Heraklietos of Ephesos

Transcatheter aortic valve implantation (TAVI) is endorsed in both the European and North American guidelines as the treatment of choice for symptomatic severe aortic stenosis in patients considered unsuitable for surgical aortic valve replacement.1 2 Neither of these documents places an upper limit of risk precluding TAVI, although patients should have an expected post-TAVI survival of at least 1 year. In patients with acutely decompensated severe aortic stenosis where the longer-term prognosis is poor or unclear, balloon aortic valvuloplasty (BAV) may be considered either as a palliative procedure or as a potential bridge to definitive therapy. The terms used to define this subset of patients are necessarily vague, as they attempt to encompass a diverse population and avoid being overly prescriptive. A number of case series and...




Heritability of resting heart rate and association with mortality in middle-aged and elderly twins

2017-12-11T04:10:28-08:00

Resting heart rate (RHR) is a well-recognised risk factor for cardiovascular morbidity and mortality.1 An increase of 20 beats per minute (bpm) in RHR leads to a 30%–50% excess mortality that is independent of confounding factors.2 This association of increased RHR with higher mortality rates has been shown in a number of epidemiological studies. For example, in Paris Prospective Study I, the risk of sudden death increased over threefold (relative risk 3.9) in individuals with an RHR >75 bpm compared with those with one under 60 bpm.3 Also, heart rate has moderate genetic influences, with heritable factors from twin studies accounting for up to 65% of the variation. A large-scale genetic study has indicated that the heritability of RHR using directly genotyped genetic variants is 21.2%,4 and identified >70 genetic loci explaining <3% of the variance in RHR. The authors also reported that a...




Cochrane Corner: stem cell therapy for chronic ischaemic heart disease and congestive heart failure

2017-12-11T04:10:28-08:00

Cell therapy provides a promising approach in the treatment of chronic ischaemic heart disease (IHD) and heart failure (HF) secondary to IHD. Preclinical and clinical studies have suggested that cell therapies may potentially reverse left ventricular dysfunction in chronic IHD and congestive heart failure (CHF). The cell therapy procedure involves stem or progenitor cells being collected from the recipient, either harvested from bone marrow (BM) or through mobilisation of BM cells into circulation by a growth factor stimulant, most commonly granulocyte colony-stimulating factor. In both procedures, the cells are infused directly into the recipient’s coronary arteries or heart. Delivery of cells to the coronary arteries is made via a special balloon catheter during angioplasty, whereas administration of cells into the heart muscle is made during an angioplasty-like procedure using electromechanical mapping and direct intramyocardial injection or during cardiac surgery (eg, coronary artery bypass grafting).

This treatment is currently only...




Achieving high-quality care: a view from NICE

2017-12-11T04:10:28-08:00

The National Institute for Health and Care Excellence (NICE) was established in 1999 to provide evidence-based guidance. The task of producing guidance by reviewing primary research data and using an advisory committee to develop evidence-based recommendations, is not straightforward. Guidance production is, however, less challenging than the task of putting evidence-based recommendations into practice.

NICE is very sensitive to this challenge as, since 1999, over 1500 pieces of NICE guidance have been published. A number of pieces of guidance relate to heart disease, including pharmaceutical agents, new medical technologies and clinical guidelines. Examples include guidelines on acute heart failure and atrial fibrillation, and advice on technologies including edoxaban and implantable cardioverter defibrillators.

The research evidence is clear that a change in practice rarely comes about as a result of simply disseminating guidance on best practice. Simple dissemination is particularly ineffective if the guidance has not been produced by a well-respected, credible organisation. It is also clear from the literature that implementation is more successful when more than one approach is taken, and when there is alignment between efforts at organisational, local and national levels.

At an organisational level, there should be support from the Board for quality improvement, with ongoing measurement of progress. Resources should be provided for targeted change programmes, particularly where new guidance suggests improvements are required. A systematic process for putting change in place should include identifying barriers to change, agreeing interventions to overcome the barriers and drive forward improvement and planning for implementation and evaluation.




Mitral regurgitation in patients with severe aortic stenosis: diagnosis and management

2017-12-11T04:10:28-08:00

Severe aortic stenosis (AS) and mitral regurgitation (MR) frequently coexist. Although some observational studies have reported that moderate or severe MR is associated with higher mortality, the optimal management of such patients is still unclear. Simultaneous replacement of both aortic and mitral valves is linked to significantly higher morbidity and mortality. Recent advances in minimally invasive surgical or transcatheter therapies for MR allow for staged procedures in which surgical or transcatheter aortic valve replacement (SAVR/TAVR) is done first and MR severity re-evaluated afterwards. Current evidence suggests MR severity improves in some patients after SAVR or TAVR, depending on several factors (MR aetiology, type of valve used for TAVR, presence/absence of atrial fibrillation, residual aortic regurgitation, etc). However, as of today, the absence of randomised clinical trials does not allow for evidence-based recommendations about whether or not MR should be addressed at the time of SAVR or TAVR. A careful patient evaluation and clinical judgement are recommended to distinguish patients who might benefit from a double valve intervention from those in which MR should be left alone. The aim of this review is to report and critique the available data on this subject in order to help guide the clinical decision making in this challenging subset of patients.




Emergency treatment of decompensated aortic stenosis

2017-12-11T04:10:28-08:00

Objective

The optimal treatment of patients with acute and severe decompensation of aortic stenosis is unclear due to recent advances in transcatheter interventions and supportive therapies. Our aim was to assess the early outcome of emergency transcatheter aortic valve implantation (eTAVI) versus emergency balloon aortic valvuloplasty (eBAV) followed by TAVI under elective circumstances.

Methods

Emergency conditions were defined as: cardiogenic shock with requirement of catecholamine therapy, severe acute dyspnoea (NYHA IV), cardiac resuscitation or mechanic respiratory support. The data were collected according to the Valve Academic Research Consortium 2 (VARC-2) criteria.

Results

In five German centres, 23 patients (logistic Euroscore 37.7%±18.1) underwent eTAVI and 118 patients underwent eBAV (logistic Euroscore 35.3%±20.8). In the eTAVI group, immediate procedural mortality was 8.7%, compared with 20.3% for the eBAV group (p=0.19). After 30 days, cardiovascular mortality for the eTAVI group was 23.8% and for the eBAV group 33.0% (p=0.40). Analyses adjusting for potential confounders did not provide evidence of a difference between groups. Of note, the elective TAVI performed after eBAV (n=32, logistic Euroscore 25.9%±13.9) displayed an immediate procedural mortality of 9.4% and a cardiovascular mortality after 30 days of 15.6%. Major vascular complications were significantly more likely to occur after eTAVI (p=0.01) as well as stroke (p=0.01).

Conclusion

In this multicentre cohort, immediate procedural and 30-day mortality of eTAVI and eBAV were high, and mortality of secondary TAVI subsequent to eBAV was higher than expected. Randomised study data are required to define the role of emergency TAVI in tertiary care centres with current device generations.




Heritability of resting heart rate and association with mortality in middle-aged and elderly twins

2017-12-11T04:10:28-08:00

Objective

Resting heart rate (RHR) possibly has a hereditary component and is associated with longevity. We used the classical biometric twin study design to investigate the heritability of RHR in a population of middle-aged and elderly twins and, furthermore, studied the association between RHR and mortality.

Methods

In total, 4282 twins without cardiovascular disease were included from the Danish Twin Registry, hereof 1233 twin pairs and 1816 ‘single twins’ (twins with a non-participating co-twin); mean age 61.7 (SD 11.1) years; 1334 (31.2%) twins died during median 16.3 (IQR 13.8–16.5) years of follow-up assessed through Danish national registers. RHR was assessed by palpating radial pulse.

Results

Within pair correlations for RHR adjusted for sex and age were 0.23 (95% CI 0.14 to 0.32) and 0.10 (0.03 to 0.17) for RHR in monozygotic (MZ) and dizygotic (DZ) twin pairs, respectively. Overall, heritability estimates were 0.23 (95% CI 0.15 to 0.30); 0.27 (0.15 to 0.38) for males and 0.17 (0.06 to 0.28) for females. In multivariable models adjusting for age, gender, body mass index, diabetes, hypertension, pulmonary function, smoking, physical activity and zygosity, RHR was significantly associated with mortality (eg, RHR >90 vs 61–70 beats per min: all-cause HR 1.56 (95% CI 1.21 to 2.03); cardiovascular 2.19 (1.30 to 3.67). Intrapair twin comparison revealed that the twin with the higher RHR was significantly more likely to die first and the probability increased with increase in intrapair difference in RHR.

Conclusions

RHR is a trait with a genetic influence in middle-aged and elderly twins free of cardiovascular disease. RHR is independently associated with longevity even when familial factors are controlled for in a twin design.




Major adverse events and atrial tachycardia in Ebsteins anomaly predicted by cardiovascular magnetic resonance

2017-12-11T04:10:28-08:00

Objectives

Patients with Ebstein’s anomaly of the tricuspid valve (EA) are at risk of tachyarrhythmia, congestive heart failure and sudden cardiac death. We sought to determine the value of cardiovascular magnetic resonance (CMR) for predicting these outcomes.

Methods

Seventy-nine consecutive adult patients (aged 37±15 years) with unrepaired EA underwent CMR and were followed prospectively for a median 3.4 (range 0.4–10.9) years for clinical outcomes, namely major adverse cardiovascular events (MACEs: sustained ventricular tachycardia/heart failure hospital admission/cardiac transplantation/death) and first-onset atrial tachyarrhythmia (AT).

Results

CMR-derived variables associated with MACE (n=6) were right ventricular (RV) or left ventricular (LV) ejection fraction (EF) (HR 2.06, 95% CI 1.168 to 3.623, p=0.012 and HR 2.35, 95% CI 1.348 to 4.082, p=0.003, respectively), LV stroke volume index (HR 2.82, 95% CI 1.212 to 7.092, p=0.028) and cardiac index (HR 1.71, 95% CI 1.002 to 1.366, p=0.037); all remained significant when tested solely for mortality. History of AT (HR 11.16, 95% CI 1.30 to 95.81, p=0.028) and New York Heart Association class >2 (HR 7.66, 95% CI 1.54 to 38.20, p=0.013) were also associated with MACE; AT preceded all but one MACE, suggesting its potential role as an early marker of adverse outcome (p=0.011).

CMR variables associated with first-onset AT (n=17; 21.5%) included RVEF (HR 1.55, 95% CI 1.103 to 2.160, p=0.011), total R/L volume index (HR 1.18, 95% CI 1.06 to 1.32, p=0.002), RV/LV end diastolic volume ratio (HR 1.55, 95% CI 1.14 to 2.10, p=0.005) and apical septal leaflet displacement/total LV septal length (HR 1.03, 95% CI 1.00 to 1.07, p=0.041); the latter two combined enhanced risk prediction (HR 6.12, 95% CI 1.67 to 22.56, p=0.007).

Conclusion

CMR-derived indices carry prognostic information regarding MACE and first-onset AT among adults with unrepaired EA. CMR may be included in the periodic surveillance of these patients.




Platelet count and mean platelet volume predict outcome in adults with Eisenmenger syndrome

2017-12-11T04:10:28-08:00

Objectives

Although a significant proportion of patients with cyanotic congenital heart disease are thrombocytopaenic, its prevalence and clinical significance in adults with Eisenmenger syndrome (ES) is not well studied. Accordingly, we examined the relationship of thrombocytopaenia and mean platelet volume (MPV) to bleeding or thrombotic complications and survival in a contemporary cohort of patients with ES, including patients with Down syndrome.

Methods

Demographics, laboratory and clinical data were analysed from 226 patients with ES under active follow-up over 11 years.

Results

Age at baseline was 34.6±11.4 years and 34.1% were men. Mean platelet count and MPV were 152.6±73.3x109/L and 9.6±1.2 fL, respectively. A strong inverse correlation was found between platelet count and haemoglobin concentration and MPV. During the study, there were 39 deaths, and 21 thrombotic and 43 bleeding events. On univariate Cox regression analysis, patients with a platelet count <100x109/L had a twofold increased mortality (HR 2.10, 95% CI 1.10 to 4.01, p=0.024). Platelet count was not associated with an increased risk of thrombosis. However, there was a threefold increased thrombotic risk with MPV >9.5 fL (HR 3.50, 95% CI 1.28 to 9.54, p=0.015). Patients with either severe secondary erythrocytosis (>220g/L) or anaemia (<130g/L) were at higher risk of thrombotic events (HR 3.93, 95% CI 1.60 to 9.67, p=0.003; and HR 4.75, 95% CI 1.03 to 21.84, p=0.045, respectively).

Conclusions

Thrombocytopaenia significantly increased the risk of mortality in ES. Furthermore, raised MPV, severe secondary erythrocytosis and anaemia, but not platelet count, were associated with an increased risk of thrombotic events in our adult cohort.




First and recurrent ischaemic heart disease events continue to decline in New Zealand, 2005-2015

2017-12-11T04:10:28-08:00

Objectives

To examine recent trends in first and recurrent ischaemic heart disease (IHD) deaths and hospitalisations.

Methods

Using anonymous patient-linkage of routinely collected data, all New Zealanders aged 35–84 years who experienced an International Statistical Classification of Diseases and Related Health Problems I(CD)-coded IHD hospitalisation and/or IHD death between 1 January 2005 and 31 December 2015 were identified. A 10-year look-back period was used to differentiate those experiencing first from recurrent events. Age-standardised hospitalisation and mortality rates were calculated for each calendar year and trends compared by sex and age.

Results

160 109 people experienced at least one IHD event (259 678 hospitalisations and 35 548 deaths) over the 11-year study period, and there was a steady decline in numbers (from almost 24 000 in 2005 to just over 16 000 in 2015) and in age-standardised rates each year. With the exception of deaths in younger (35–64 years) women with prior IHD, there was a significant decline in IHD events in men and women of all ages, with and without a history of IHD. The decline in IHD mortality was greater for those experiencing a first rather than recurrent IHD event (3.8%–5.2% vs 0%–3.7% annually on average). In contrast, the decline in IHD hospitalisations was greater for those experiencing a recurrent compared with a first IHD event (5.6%–7.3% vs 3.2%–5.7% annually on average).

Conclusions

The substantial decline in IHD hospitalisations and mortality observed in New Zealanders with and without prior IHD between 2005 and 2015 suggests that primary and secondary prevention efforts have been effective in reducing the occurrence of IHD events.




Ischaemic heart disease in the former Soviet Union 1990-2015 according to the Global Burden of Disease 2015 Study

2017-12-11T04:10:28-08:00

Objective

The objective of this study was to compare ischaemic heart disease (IHD) mortality and risk factor burden across former Soviet Union (fSU) and satellite countries and regions in 1990 and 2015.

Methods

The fSU and satellite countries were grouped into Central Asian, Central European and Eastern European regions. IHD mortality data for men and women of any age were gathered from national vital registration, and age, sex, country, year-specific IHD mortality rates were estimated in an ensemble model. IHD morbidity and mortality burden attributable to risk factors was estimated by comparative risk assessment using population attributable fractions.

Results

In 2015, age-standardised IHD death rates in Eastern European and Central Asian fSU countries were almost two times that of satellite states of Central Europe. Between 1990 and 2015, rates decreased substantially in Central Europe (men –43.5% (95% uncertainty interval –45.0%, –42.0%); women –42.9% (–44.0%, –41.0%)) but less in Eastern Europe (men –5.6% (–9.0, –3.0); women –12.2% (–15.5%, –9.0%)). Age-standardised IHD death rates also varied within regions: within Eastern Europe, rates decreased –51.7% in Estonian men (–54.0, –47.0) but increased +19.4% in Belarusian men (+12.0, +27.0). High blood pressure and cholesterol were leading risk factors for IHD burden, with smoking, body mass index, dietary factors and ambient air pollution also ranking high.

Conclusions

Some fSU countries continue to experience a high IHD burden, while others have achieved remarkable reductions in IHD mortality. Control of blood pressure, cholesterol and smoking are IHD prevention priorities.




Public knowledge of cardiovascular disease and response to acute cardiac events in three cities in China and India

2017-12-11T04:10:28-08:00

Objective

To inform interventions targeted towards reducing mortality from acute myocardial infarction (AMI) and sudden cardiac arrest in three megacities in China and India, a baseline assessment of public knowledge, attitudes and practices was performed.

Methods

A household survey, supplemented by focus group and individual interviews, was used to assess public understanding of cardiovascular disease (CVD) risk factors, AMI symptoms, cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs). Additionally, information was collected on emergency service utilisation and associated barriers to care.

Results

5456 household surveys were completed. Hypertension was most commonly recognised among CVD risk factors in Beijing and Shanghai (68% and 67%, respectively), while behavioural risk factors were most commonly identified in Bangalore (smoking 91%; excessive alcohol consumption 64%). Chest pain/discomfort was reported by at least 60% of respondents in all cities as a symptom of AMI, but 21% of individuals in Bangalore could not name a single symptom. In Beijing, Shanghai and Bangalore, 26%, 15% and 3% of respondents were trained in CPR, respectively. Less than one-quarter of participants in all cities recognised an AED. Finally, emergency service utilisation rates were low, and many individuals expressed concern about the quality of prehospital care.

Conclusions

Overall, we found low to modest knowledge of CVD risk factors and AMI symptoms, infrequent CPR training and little understanding of AEDs. Interventions will need to focus on basic principles of CVD and its complications in order for patients to receive timely and appropriate care for acute cardiac events.




25-year-old man with chest pain

2017-12-11T04:10:28-08:00

Clinical introduction

A 25-year-old man presented with complaints of acute-onset chest pain for 2 hours associated with diaphoresis and generalised weakness. He had history of smoking for 10 years. There was no history of hypertension, diabetes, family history of premature coronary artery disease or drug abuse. On evaluation, his heart rate was 76/min, blood pressure 130/90 mm Hg and oxygen saturation 97% on room air. Cardiovascular examination was normal. The ECG is shown in figure 1.

Figure 1




Non-surgical septal reduction therapy in hypertrophic cardiomyopathy

2017-12-11T04:10:28-08:00

Learning objectives

  • To understand the effects of left ventricular outflow tract (LVOT) obstruction on clinical outcome.

  • To be aware of the treatment modalities available to deal with LVOT obstruction in hypertrophic cardiomyopathy.

  • To be aware of new developments in non-surgical septal reduction therapy.

  • Introduction

    Hypertrophic cardiomyopathy (HCM) is an inherited disease characterised by otherwise unexplained hypertrophy of the myocardium. It is transmitted in an autosomal dominant pattern with variable penetrance, with an estimated phenotypic prevalence of up to 1 in 500.1 HCM is a highly heterogeneous disease with varied patterns of hypertrophy. The prevalence of left ventricular outflow tract (LVOT) obstruction in HCM is 20%–30% at rest2 and up to 70% with provocation.3

    LVOT pathophysiology

    Basal septal hypertrophy and systolic anterior motion (SAM) of the mitral valve (MV) are the key components to LVOT obstruction in HCM....




    Oral anticoagulants and liver injury: the threat of uncontrolled confounding

    2017-12-11T04:10:28-08:00

    The Authors’ reply: We value the comments from Drs De Ponti and Raschi about our manuscript reporting the association of oral anticoagulation initiation with the risk of hospitalisation for liver injury1 As they summarise in their letter,2 we showed that among patients with non-valvular atrial fibrillation (AF) initiating oral anticoagulation, the risk of liver injury hospitalisation was highest among those starting warfarin and lowest for dabigatran. Our findings are consistent with those from the large phase III randomised trials supporting the approval of the new direct oral anticoagulants (DOACs), complement prior pharmacovigilance studies that suggested no increased hepatotoxicity in DOAC users compared with warfarin users and should contribute to allaying concerns regarding the comparative liver toxicity of DOACs versus warfarin.3

    One important consideration raised by Drs De Ponti and Raschi is the potential for uncontrolled confounding due to bias by indication. Since specific oral...