Cardiology

Nasir, J. M., W. Pomeroy, A. Marler, M. Hann, T. Baykaner, R. Jones, R. Stoll, K. Hursey, A. Meadows, J. Walker and S. Kindsvater (2017). “Predicting determinants of atrial fibrillation or flutter for therapy elucidation in patients at risk for thromboembolic events (predate af) study.” Heart Rhythm 14(7): 955-961.

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BACKGROUND: Atrial fibrillation (AF) is the most common clinically significant cardiac rhythm disorder. There is considerable interest in screening for AF, as it is a leading cause of stroke, and oral anticoagulants (OACs) have been shown to significantly reduce the risk of stroke in patients with AF. Improved screening for AF with subsequent treatment may help improve long-term outcomes, but the optimal patient population and screening intensity are unknown. OBJECTIVES: In this study, we prospectively evaluated the use of the CHA2DS2-VASc score for the prediction of new-onset AF using insertable cardiac monitors (ICMs) and examined whether this screening led to the initiation of OAC therapy. METHODS: We enrolled 245 subjects with no history of AF and CHA2DS2-VASc score >/=2 to be screened for AF with an ICM. The ICMs were programmed to record AF episodes >/=6 minutes in duration. Subjects were followed for 18 months with monthly remote interrogations and all events adjudicated by cardiologists. In subjects diagnosed with AF, medical records were reviewed to determine subsequent care. RESULTS: During a mean follow-up of 451 +/- 185 days, the incidence of AF was 22.4% (95% confidence interval 17.2%-27.7%) with a mean time to detection of 141.3 +/- 139.5 days. Among subjects newly diagnosed with AF, 76.4% were prescribed anticoagulation with either a novel OAC (n = 38) or warfarin (n = 4). CONCLUSION: In this large prospective cohort of subjects with CHA2DS2-VASc scores >/=2, 22.4% were newly diagnosed with AF and the majority of these subjects were given OACs, suggesting a potential role of ICMs in AF screening.

Patel, M. R., J. H. Calhoon, G. J. Dehmer, J. A. Grantham, T. M. Maddox, D. J. Maron and P. K. Smith (2017). “Acc/aats/aha/ase/asnc/scai/scct/sts 2017 appropriate use criteria for coronary revascularization in patients with stable ischemic heart disease : A report of the american college of cardiology appropriate use criteria task force, american association for thoracic surgery, american heart association, american society of echocardiography, american society of nuclear cardiology, society for cardiovascular angiography and interventions, society of cardiovascular computed tomography, and society of thoracic surgeons.” J Nucl Cardiol: 2017 Jun [Epub ahead of print].

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The American College of Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and American Association for Thoracic Surgery, along with key specialty and subspecialty societies, have completed a 2-part revision of the appropriate use criteria (AUC) for coronary revascularization. In prior coronary revascularization AUC documents, indications for revascularization in acute coronary syndromes and stable ischemic heart disease (SIHD) were combined into 1 document. To address the expanding clinical indications for coronary revascularization, and to align the subject matter with the most current American College of Cardiology/American Heart Association guidelines, the new AUC for coronary artery revascularization were separated into 2 documents addressing SIHD and acute coronary syndromes individually. This document presents the AUC for SIHD.Clinical scenarios were developed to mimic patient presentations encountered in everyday practice. These scenarios included information on symptom status; risk level as assessed by noninvasive testing; coronary disease burden; and, in some scenarios, fractional flow reserve testing, presence or absence of diabetes, and SYNTAX score. This update provides a reassessment of clinical scenarios that the writing group felt were affected by significant changes in the medical literature or gaps from prior criteria. The methodology used in this update is similar to the initial document but employs the recent modifications in the methods for developing AUC, most notably, alterations in the nomenclature for appropriate use categorization.A separate, independent rating panel scored the clinical scenarios on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization is considered appropriate for the clinical scenario presented. Scores of 1 to 3 indicate that revascularization is considered rarely appropriate for the clinical scenario, whereas scores in the mid-range of 4 to 6 indicate that coronary revascularization may be appropriate for the clinical scenario.As seen with the prior coronary revascularization AUC, revascularization in clinical scenarios with high symptom burden, high-risk features, and high coronary disease burden, as well as in patients receiving antianginal therapy, are deemed appropriate. Additionally, scenarios assessing the appropriateness of revascularization before kidney transplantation or transcatheter valve therapy are now rated. The primary objective of the AUC is to provide a framework for the assessment of practice patterns that will hopefully improve physician decision making.

Puskas, J. D., J. E. Bavaria, L. G. Svensson, E. H. Blackstone, B. Griffith, J. S. Gammie, D. A. Heimansohn, J. Sadowski, K. Bartus, D. R. Johnston, J. Rozanski, T. Rosengart, L. N. Girardi, C. T. Klodell, M. A. Mumtaz, H. Takayama, M. Halkos, V. Starnes, P. Boateng, T. A. Timek, W. Ryan, S. Omer and C. R. Smith (2017). “The commence trial: 2-year outcomes with an aortic bioprosthesis with resilia tissuedagger.” Eur J Cardiothorac Surg: 2017 Jun [Epub ahead of print].

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OBJECTIVES: The COMMENCE trial was conducted to evaluate the safety and effectiveness of a novel bioprosthetic tissue for surgical aortic valve replacement (AVR). METHODS: Patients underwent clinically indicated surgical AVR with the Carpentier-Edwards PERIMOUNT Magna Ease aortic valve with RESILIA tissue (Model 11000A) in a prospective, multinational, multicentre ( n = 27), single-arm, FDA Investigational Device Exemption trial. Events were adjudicated by an independent Clinical Events Committee; echocardiograms were analysed by an independent Core Laboratory. RESULTS: Between January 2013 and February 2016, 689 patients received the study valve. Mean age was 67.0 +/- 11.6 years; 71.8% were male; 26.3% were New York Heart Association Class III/IV. Mean STS PROM was 2.0 +/- 1.8 (0.3-17.5). Isolated AVR was performed in 59.1% of patients; others had additional concomitant procedures, usually CABG. Thirty-day outcomes for all patients included all-cause mortality 1.2%, thromboembolism 2.2%, bleeding 0.9%, major paravalvular leak 0.1% and permanent pacemaker implantation 4.7%. Median intensive care unit and hospital length of stay were 2 (range: 0.2-66) and 7 days (3.0-121.0), respectively. At 2 years, New York Heart Association class improved in 65.7%, effective orifice area was 1.6 +/- 0.5 cm 2 ; mean gradient was 10.1 +/- 4.3 mmHg; and paravalvular leak was none/trivial in 94.5%, mild in 4.9%, moderate in 0.5% and severe in 0.0%. One-year actuarial freedom from all-cause mortality for isolated AVR and for all patients was 98.2% and 97.6%, respectively. Two-year actuarial freedom from mortality in these groups was 95.3% and 94.3%, respectively. CONCLUSIONS: These data demonstrate excellent early safety and effectiveness of aortic valve replacement with a novel bioprosthetic tissue (RESILIA).

Packer, M. and J. J. V. McMurray (2017). “Importance of endogenous compensatory vasoactive peptides in broadening the effects of inhibitors of the renin-angiotensin system for the treatment of heart failure.” Lancet 389(10081): 1831-1840.

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The magnitude of the clinical benefits produced by inhibitors of the renin-angiotensin system in heart failure has been modest, possibly because of the ability of renin-angiotensin activity to escape from suppression during long-term treatment. Efforts to intensify pharmacological blockade by use of dual inhibitors that interfere with the renin-angiotensin system at multiple sites have not yielded consistent incremental clinical benefits, but have been associated with serious adverse reactions. By contrast, potentiation of endogenous compensatory vasoactive peptides can act to enhance the survival effects of inhibitors of the renin-angiotensin system, as evidenced by trials that have compared angiotensin-converting enzyme inhibitors with drugs that inhibit both the renin-angiotensin system and neprilysin. Several endogenous vasoactive peptides act as adaptive mechanisms, and their augmentation could help to broaden the benefits of renin-angiotensin system inhibitors for patients with heart failure.

Karakkattil, P. P. M., E. P. P. Trudelle-Jackson, H. H. D. Brown, P. D. Hammontree and M. D. Okolo (2017). “Outcomes of botulinum toxin type a for equinovarus deformity in patients with cva: A case series.” Physiother Theory Pract 33(5): 410-419.

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BACKGROUND: There is evidence that Botulinum Toxin-A (BTX-A) reduces focal spasticity associated with equinovarus to improve gait in patients poststroke. However, there is little research examining whether gait improvements are maintained after the effectiveness period of BTX-A injections. The purpose of this observational study was to determine whether there was a difference in gait parameters in three patients before BTX-A injection versus four and ten weeks after. CASE SERIES: Three women, ages 63, 60, and 42 postischemic stroke with hemiparesis and equinovarus underwent measurements for: plantar flexor spasticity, ankle dorsiflexion ROM, temporal-spatial gait parameters, and gait endurance. All participants improved in ankle ROM. At week 10, spasticity had returned to initial measurement levels in participants A and C. Base of support and step length symmetry ratios did not improve following injections. Participants A and B, who received physical therapy during the study, showed modest gains in gait endurance and velocity. CONCLUSION: Although BTX-A injections improved spasticity, this improvement did not translate to gait outcomes. Addition of physical therapy interventions appeared to improve gait outcomes in this case series. We suggest future randomized control studies to compare effects of physical therapy alone to BTX-A combined with physical therapy on gait outcomes.