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Heartbeat: Chronic inflammatory disorders and cardiovascular disease

2016-11-25T04:57:48-08:00

Inflammation is thought to be a key pathophysiologic factor in atherosclerotic cardiovascular disease (CVD). In addition, patients with systemic inflammatory disorders, such as rheumatoid arthritis (RA), are at increased risk of CVD events, possibly modulated by disease-modifying anti-inflammatory therapy.1–3 However, few studies have examined whether these patients receive appropriate evaluation and treatment for conventional CVD risk factors in the primary care setting.

In this issue of Heart, Emanuel and colleagues (see page 1957) used electronic primary care health records to evaluate CVD risk factor measurement and treatment in 1121 RA and 1875 inflammatory bowel disease (IBD) patients compared to control patients without these conditions. Evaluation of CVD risk factors was incomplete in most patients, with adequate data recorded for calculation of risk scores in only 11% of RA patients and 9% of IBD patients (figure 1). On the other hand,...




Cardiovascular risk factor assessment: still an unmet need in chronic inflammatory diseases

2016-11-25T04:57:48-08:00

Suboptimal assessment of vascular risk in rheumatoid arthritis and inflammatory bowel diseasePatients in primary care

A recent matched cohort study using primary care electronic health records for one London borough indicates that only a minority of patients with rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) are assessed for the presence of cardiovascular (CV) disease risk factors in primary care settings.1

CV disease is one of the leading causes of comorbidity in patients with chronic inflammatory diseases. It is especially true for patients with inflammatory arthritis. In this regard, the risk of CV events in patients with RA, psoriatic arthritis and ankylosing spondylitis is significantly increased compared with the general population.2

Although the reasons for the augmented CV mortality due to CV events in patients with chronic inflammatory conditions are not fully understood, the combined effect of classic (traditional) CV risk factors and...




Biomarkers for cardiovascular risk in patients with diabetes

2016-11-25T04:57:48-08:00

Diabetes mellitus (DM) remains one of the leading factors of morbidity and mortality worldwide augmenting social and medical care burden.1 Currently, advances in pathophysiological understanding of the innate mechanisms of DM-related complications in part affecting heart and vessels are impressed, while they are not fully clear. Recent basic and clinical studies have shown that DM directly induces changes in various organ systems in close conjunction with glucotoxicity, lipid toxicity, oxidative stress and low-grade inflammation, which lead to microvascular and macrovascular complications mediating cardiovascular (CV) risk.2 Moreover, accelerating atherosclerosis, endothelial dysfunction and cardiomyopathy play a causative role in the development and progression of DM-related CV outcomes and death.3 In this context, use of cardiac biomarkers for risk stratification in patients with DM appears to be promising, especially in individuals without known CV disease.

The abundant biomarkers representing several pathophysiological pathways of DM development have...




An unusual shadow above the aortic valve

2016-11-25T04:57:48-08:00

Clinical introduction

A 55-year-old West African man was referred for routine echocardiography. He was completely asymptomatic, a non-smoker, working out at the gym several times weekly. He was taking hydrochlorothiazide for hypertension.

Clinical examination revealed a blood pressure of 156/74 mm Hg and systolic and diastolic murmurs suggestive of aortic insufficiency. Pulses were equal bilaterally and he had no marfanoid features or hyperelasticity. ECG showed mild left ventricular hypertrophy and chest X-ray revealed a normal cardiac shadow and mediastinum.

Transthoracic echocardiography demonstrated an unusual appearance above the aortic valve (figure 1A), moderate aortic regurgitation and a shadow in the aortic arch. Transoesophageal echocardiography was performed to evaluate the dilated aorta, arch and aortic valve further (figure 1B, C). The native aortic valve was trileaflet with moderate regurgitation. CT was also performed (figure 1D).

Question

What is the most likely diagnosis?

  • Acute type A aortic dissection

  • Williams syndrome

  • Loa loa worm infection

  • Intimo-intimal intussusception

  • Giant cell aortitis




  • Atrial appendage occlusion for stroke prevention in patients with atrial fibrillation

    2016-11-25T04:57:48-08:00

    In the developed countries, stroke is an important cause of mortality and disability. Cardioembolism is the most frequent cause of ischaemic stroke, in the presence of atrial fibrillation (AF).1 AF is the most common cardiac arrhythmia in the general population and its prevalence increases with age; the lifetime risk of AF development is 25% in people over 40 years old.2 Anticoagulation has been established as an effective treatment strategy for stroke prevention in patients with AF and risk factors for stroke.3 The new oral anticoagulants (NOACs) seem to be similarly efficacious compared with vitamin K antagonists (VKAs) but with a decreased risk for intracranial bleeding.4 Despite the more safe profile of the NOACs, there remain patients with AF at risk for stroke, but with a contraindication for any form of anticoagulation or at high risk of bleeding (eg, non-treatable digestive bleeding). Furthermore,...




    Trends in the epidemiology of cardiovascular disease in the UK

    2016-11-25T04:57:48-08:00

    Cardiovascular disease (CVD) mortality in the UK is declining; however, CVD burden comes not only from deaths, but also from those living with the disease. This review uses national datasets with multiple years of data to present secular trends in mortality, morbidity, and treatment for all CVD and specific subtypes within the UK. We produced all-ages and premature age-standardised mortality rates by gender, standardised to the 2013 European Standard Population, using data from the national statistics agencies of the UK. We obtained data on hospital admissions from the National Health Service records, using the main diagnosis. Prevalence data come from the Quality and Outcome Framework and national surveys. Total CVD mortality declined by 68% between 1980 and 2013 in the UK. Similar decreases were seen for coronary heart disease and stroke. Coronary heart disease prevalence has remained constant at around 3% in England and 4% in Scotland, Wales, and Northern Ireland. Hospital admissions for all CVD increased by over 46 000 between 2010/2011 and 2013/2014, with more than 36 500 of these increased admissions for men. Hospital admission trends vary by country and CVD condition. CVD prescriptions and operations have increased over the last decade. CVD mortality has declined notably for both men and women while hospital admissions have increased. CVD prevalence shows little evidence of change. This review highlights that improvements in the burden of CVD have not occurred equally between the four constituent countries of the UK, or between men and women.




    Influenza vaccine as a coronary intervention for prevention of myocardial infarction

    2016-11-25T04:57:48-08:00

    Cardiovascular disease (CVD) is the leading cause of morbidity and mortality globally. Influenza is one of the leading infectious causes of morbidity and mortality globally, and evidence is accumulating that it can precipitate acute myocardial infarction (AMI). This is thought to be due to a range of factors including inflammatory release of cytokines, disruption of atherosclerotic plaques and thrombogenesis, which may acutely occlude a coronary artery. There is a large body of observational and clinical trial evidence that shows that influenza vaccine protects against AMI. Estimates of the efficacy of influenza vaccine in preventing AMI range from 15% to 45%. This is a similar range of efficacy compared with the accepted routine coronary prevention measures such as smoking cessation (32–43%), statins (19–30%) and antihypertensive therapy (17–25%). Influenza vaccine should be considered as an integral part of CVD management and prevention. While it is recommended in many guidelines for patients with CVD, rates of vaccination in risk groups aged <65 years are very low, in the range of 30%. The incorporation of vaccination into routine CVD prevention in patient care requires a clinical practice paradigm change.




    Cardiovascular risk assessment and treatment in chronic inflammatory disorders in primary care

    2016-11-25T04:57:48-08:00

    Objective

    To compare differences in cardiovascular (CV) risk factors assessment and management among patients with rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) with that of matched controls.

    Methods

    A matched cohort study was conducted using primary care electronic health records for one London borough. All patients diagnosed with RA or IBD, and matched controls registered with local general practices on 12th of January 2014 were identified. The study compared assessment and treatment of CV risk factors (blood pressure, body mass index, cholesterol and smoking) in the year before, the year after, and 5 years after RA and IBD diagnosis.

    Results

    A total of 1121 patients with RA and 1875 patients with IBD were identified and matched with 4282 and, respectively, 7803 controls. Patients with RA were 25% (incidence rate ratio, 1.25, 95% CI 1.12 to 1.35) more likely to have a CV risk factor measured compared with matched controls. The difference declined to 8% (1.08, 1.04 to 1.14) over 5 years of follow-up. The corresponding figures for IBD were 26% (1.26, 1.16 to 1.38) and 10% (1.10, 1.05 to 1.15). Patients with RA showed higher antihypertensive prescription rates during 5 years of follow-up (OR, 1.37, 95% CI 1.14 to 1.65) and patients with IBD showed higher statin prescription rates in the year preceding diagnosis (2.30, 1.20 to 4.42). Incomplete CV risk assessment meant that QRISK scores could be calculated for less than a fifth (17%) and clinical recording of CV disease (CVD) risk scores among patients with RA and IBD was 11% and 6%, respectively.

    Conclusions

    The assessment and treatment of vascular risk in patients with RA and IBD in primary care is suboptimal, particularly with reference to CVD risk score calculation.




    Targeted multiple biomarker approach in predicting cardiovascular events in patients with diabetes

    2016-11-25T04:57:48-08:00

    Objective

    We hypothesised that biomarkers representing different pathophysiological pathways of atherosclerosis namely growth differentiation factor 15 (GDF-15), N-terminal pro B-type natriuretic peptide (NT-proBNP) and high-sensitive troponin T (hs-TnT) could enhance cardiovascular risk prediction in patients with type 2 diabetes mellitus.

    Methods

    This is a prospective study in 746 patients with type 2 diabetes mellitus, who were followed up for 60 months. The primary endpoint was defined as unplanned hospitalisation for cardiovascular disease or death. The prognostic performance of the biomarkers of interest (GDF-15 in comparison with NT-proBNP and hs-TnT) was evaluated in univariate as well as in stepwise Cox regression models. HRs are presented per standard unit increase.

    Results

    The primary endpoint was registered in 171 patients (22.9%). In univariate Cox regression models, GDF-15 as well as hs-TnT provided significant prognostic information. Even after adjusting for established cardiovascular risk factors, GDF-15, hs-TnT and NT-proBNP remained strong independent predictors of the endpoint (logGDF-15: HR 1.37, p<0.01, CI 1.12 to 1.68; loghs-TnT: HR 1.43, p<0.01, CI 1.13 to 1.1.82; logNT-proBNP: HR 1.45, p<0.01, CI 1.26 to 1.66). The number of elevated markers showed a strong complementarity to predict future long-term risk. Adding hs-TnT and GDF-15 to a zero model already including NT-proBNP led to a net reclassification improvement (NRI) of 33.6% (CI 16.0% to 50.8%, NRI for patients with event: 11.1% CI –4.7% to 26.6%, for patients without event: 22.5% CI 13.6% to 30.5%).

    Conclusions

    GDF-15 and hs-TnT are strong independent cardiovascular biomarkers augmenting the predictive value of NT-proBNP in patients with diabetes.




    Left atrial appendage occlusion in high-risk patients with non-valvular atrial fibrillation

    2016-11-25T04:57:48-08:00

    Objective

    Percutaneous left atrial appendage (LAA) occlusion has been developed as a viable option for stroke and thromboembolism prevention in patients with non-valvular atrial fibrillation (NVAF) and at high risk for cerebral cardioembolic events. Data on device implantation and long-term follow-up from large cohorts are limited.

    Methods

    110 consecutive patients with NVAF and contraindications to oral anticoagulants (OACs) underwent LAA occlusion procedures and achieved a longer than 1 year follow-up. All patients were enrolled in a prospective registry. Procedures were performed using the Amplatzer Cardiac Plug or Amulet guided by fluoroscopy and intracardiac echocardiography.

    Results

    Mean age of the population was 77±6 years old; 68 were men. Atrial fibrillation was paroxysmal in 20%, persistent in 15.5% and permanent in 64.5% of cases, respectively. Mean CHA2DS2-VASc and HAS-BLED scores were 4.3±1.3 and 3.4±1, respectively. Technical success (successful deployment and implantation of device) was achieved in 100% of procedures. Procedural success (technical success without major procedure-related complications) was achieved in 96.4%, with a 3.6% rate of major procedural complications (three cases of pericardial tamponade requiring drainage and one case of major bleeding). Mean follow-up was 30±12 months (264 patient-years). Annual rates for ischaemic stroke and for other thromboembolic events were respectively 2.2% and 0%, and annual rate for major bleeding was 1.1%.

    Conclusions

    Our data suggest LAA occlusion in high-risk patients with NVAF not suitable for OACs is feasible and associated with low complication rates as well as low rates of stroke and major bleeding at long-term follow-up.




    A nationwide evaluation of spontaneous coronary artery dissection in pregnancy and the puerperium

    2016-11-25T04:57:48-08:00

    Objective

    Spontaneous coronary artery dissection (SCAD) is a rare and potentially lethal cause of myocardial infarction (MI). The purpose of our study was to estimate the prevalence and maternal outcomes of pregnancies complicated by SCAD.

    Materials and methods

    A population-based cohort study on all births identified in the Healthcare Cost and Utilization Project from 2008 to 2012. Disease prevalence was calculated and logistic regression was used to estimate the adjusted odds ratio (aOR) for risk factors and different maternal complications.

    Results

    A total of 4 363 343 pregnancy-related discharges were evaluated. 79 cases of SCAD were identified resulting in a prevalence of 1.81 per 100 000 pregnancies. The mean maternal age at the time of diagnosis was 33.4 years (±5.2). Chronic hypertension (aOR, 2.67; 95% CI 1.18 to 6.03), lipid profile abnormalities (aOR, 48.22; 95% CI 24.25 to 95.90), chronic depression (aOR, 3.56; 95% CI 1.43 to 8.83) and history of migraine (aOR, 3.93; 95% CI 1.52 to 10.17) were associated with an elevated risk for SCAD. MI was diagnosed in 66 (85.5%) cases of SCAD with anterior and subendocardial territories being the most common locations. Thirty one patients (40%) with SCAD underwent angioplasty with the majority receiving stents, which was associated with a longer hospital stay than those treated conservatively or with bypass.

    Conclusions

    SCAD is a rare aetiology of MI; risk factors and outcomes are illustrated in the current study. The puerperium is an important period for the development of pregnancy-related SCAD. Careful evaluation of pregnant and postpartum women with chest pain is warranted, especially if these risk factors are identified.




    Infarct size and left ventricular remodelling after preventive percutaneous coronary intervention

    2016-11-25T04:57:48-08:00

    Objective

    We hypothesised that, compared with culprit-only primary percutaneous coronary intervention (PCI), additional preventive PCI in selected patients with ST-elevation myocardial infarction with multivessel disease would not be associated with iatrogenic myocardial infarction, and would be associated with reductions in left ventricular (LV) volumes in the longer term.

    Methods

    In the preventive angioplasty in myocardial infarction trial (PRAMI; ISRCTN73028481), cardiac magnetic resonance (CMR) was prespecified in two centres and performed (median, IQR) 3 (1, 5) and 209 (189, 957) days after primary PCI.

    Results

    From 219 enrolled patients in two sites, 84% underwent CMR. 42 (50%) were randomised to culprit-artery-only PCI and 42 (50%) were randomised to preventive PCI. Follow-up CMR scans were available in 72 (86%) patients. There were two (4.8%) cases of procedure-related myocardial infarction in the preventive PCI group. The culprit-artery-only group had a higher proportion of anterior myocardial infarctions (MIs) (55% vs 24%). Infarct sizes (% LV mass) at baseline and follow-up were similar. At follow-up, there was no difference in LV ejection fraction (%, median (IQR), (culprit-artery-only PCI vs preventive PCI) 51.7 (42.9, 60.2) vs 54.4 (49.3, 62.8), p=0.23), LV end-diastolic volume (mL/m2, 69.3 (59.4, 79.9) vs 66.1 (54.7, 73.7), p=0.48) and LV end-systolic volume (mL/m2, 31.8 (24.4, 43.0) vs 30.7 (23.0, 36.3), p=0.20). Non-culprit angiographic lesions had low-risk Syntax scores and 47% had non-complex characteristics.

    Conclusions

    Compared with culprit-only PCI, non-infarct-artery MI in the preventive PCI strategy was uncommon and LV volumes and ejection fraction were similar.




    Clinical and prognostic value of poststenting fractional flow reserve in acute coronary syndromes

    2016-11-25T04:57:48-08:00

    Objectives

    Fractional flow reserve (FFR) has been suggested to have value in acute coronary syndromes (ACSs). The clinical and prognostic value of ischaemia reduction assessed by post-percutaneous coronary intervention (PCI) FFR has not been studied in this population.

    Methods

    Consecutive stable ischaemic heart disease (SIHD) (N=390) and patients with ACS (N=189) who had pre-PCI FFR and post-PCI FFR were followed for 2.4±1.5 years. Primary endpoint was major adverse cardiac events (MACE) (composite of myocardial infarction, target vessel revascularisation and death).

    Results

    In patients with ACS, PCI led to significant improvement in FFR from 0.62±0.15 to post-PCI FFR 0.88±0.08 (p<0.0001). Post-PCI FFR identified 29 patients (15%) who had persistently low FFR<0.80 (0.75±0.06) despite angiographically optimal results prompting subsequent interventions improving repeat FFR (0.85±0.06; p<0.0001). The difference in MACE events between patients with ACS and patients with SIHD varied according to the post-PCI FFR value (interaction p=0.044). Receiver operator curve analysis identified a final FFR cut-off of ≤0.91 as having the best predictive accuracy for MACE in the ACS study population (30% vs 19%; p=0.03). Patients with ACS achieving final FFR of >0.91 had similar outcomes compared with patients who had SIHD (19% vs 16%; p=0.51). However, in patients with final FFR of ≤0.91 there was increased MACE versus patients with SIHD (30% vs 16%; p<0.01).

    Conclusions

    Post-PCI FFR is valuable in assessing the functional outcome of PCI in patients with ACS. Use of post-PCI FFR in patients with ACS allows for functional optimisation of PCI results and is predictive of long-term outcomes in patients with ACS.




    Cardiac rehabilitation increases physical capacity but not mental health after heart valve surgery: a randomised clinical trial

    2016-11-25T04:57:48-08:00

    Objective

    The evidence for cardiac rehabilitation after valve surgery remains sparse. Current recommendations are therefore based on patients with ischaemic heart disease. The aim of this randomised clinical trial was to assess the effects of cardiac rehabilitation versus usual care after heart valve surgery.

    Methods

    The trial was an investigator-initiated, randomised superiority trial (The CopenHeartVR trial, VR; valve replacement or repair). We randomised 147 patients after heart valve surgery 1:1 to 12 weeks of cardiac rehabilitation consisting of physical exercise and monthly psycho-educational consultations (intervention) versus usual care without structured physical exercise or psycho-educational consultations (control). Primary outcome was physical capacity measured by VO2 peak and secondary outcome was self-reported mental health measured by Short Form-36.

    Results

    76% were men, mean age 62 years, with aortic (62%), mitral (36%) or tricuspid/pulmonary valve surgery (2%). Cardiac rehabilitation compared with control had a beneficial effect on VO2 peak at 4 months (24.8 mL/kg/min vs 22.5 mL/kg/min, p=0.045) but did not affect Short Form-36 Mental Component Scale at 6 months (53.7 vs 55.2 points, p=0.40) or the exploratory physical and mental outcomes. Cardiac rehabilitation increased the occurrence of self-reported non-serious adverse events (11/72 vs 3/75, p=0.02).

    Conclusions

    Cardiac rehabilitation after heart valve surgery significantly improves VO2 peak at 4 months but has no effect on mental health and other measures of exercise capacity and self-reported outcomes. Further research is needed to justify cardiac rehabilitation in this patient group.

    Trial registration number

    NCT01558765, Results.




    Genetic causes of dilated cardiomyopathy

    2016-11-25T04:57:48-08:00

    Learning objectives

  • To understand the key role of clinical genetics in the diagnosis and management of dilated cardiomyopathy (DCM), with specific reference to clinical family screening and the investigation of cardiac and extracardiac markers.

  • To understand the concept of extreme genetic heterogeneity of DCM and give practical suggestions for genetic testing.

  • To appreciate the molecular and clinical interpretation of genetic testing in DCM families and its impact on family health programmes.

  • To learn about gene-specific prognosis for selected genetic causes of DCM.

  • Introduction

    Cardiomyopathies (CMPs) are "myocardial diseases characterized by structurally and functionally abnormal heart muscle and absence of other diseases sufficient to cause the observed myocardial abnormality".1 They are currently classified according to their morphofunctional phenotype as hypertrophic cardiomyopathy (HCM), restrictive cardiomyopathy (RCM), dilated cardiomyopathy (DCM) and arrhythmogenic right ventricular cardiomyopathy (ARVC).1 2 Familial CMP...




    Cardiovascular highlights from non-cardiology journals

    2016-11-25T04:57:48-08:00

    Long-term survival benefit for coronary artery bypass grafting surgery in ischemic cardiomyopathy

    The Surgical Treatment for Ischemic Heart Failure (STICH) trial asked the important question whether coronary artery bypass grafting surgery (CABG) in patients with severe ischemic cardiomyopathy would provide a survival advantage over contemporary medical therapy alone. Reporting 5-year data in 2011, the study reported no significant difference but did demonstrate a tantalizing divergence in survival graphs between 2 and 5 years, which appeared to be increasing with time. In an extension to the study, 10 year follow-up data is reported. Out of the original 1212 patients in the study, data was available on 98% of the cohort at long-term follow-up. Over this long time period the primary outcome of death from any cause occurred in 58.9% in the CABG group and in 66.1% in the medical-therapy group (HR with CABG vs. medical therapy, 0.84; 95% CI,...




    Loneliness and social isolation and increased risk of coronary heart disease and stroke: clinical implications

    2016-11-25T04:57:48-08:00

    To the Editor

    The recent meta-analysis published in Heart by Valtorta et al1 showed that loneliness and social isolation are associated with increased incidence of coronary heart disease (CHD) and stroke in 16 large longitudinal studies conducted in high-income countries. This finding is not surprising given the extensive literature documenting such harmful consequences of social isolation, including a study my research group published in 19922 showing in a large sample of CHD patients that those who were not married and did not have a confident—and hence likely to be lonely and socially isolated—had a 5-year mortality (50%) that was nearly three times larger than that observed (18%) in patients with a spouse and/or partner.

    The most important implication of this finding is that, interventions that reduce loneliness and social isolation have the potential to prevent disease development and improve prognosis once the disease is present....