Cardiology

McCullough, P. A., T. Ball, K. M. Cox and M. D. Assar (2016). “Use of oral anticoagulation in the management of atrial fibrillation in patients with esrd: Pro.” Clin J Am Soc Nephrol 11(11): 2079-2084.

Full text of this article.

Warfarin has had a thin margin of benefit over risk for the prevention of stroke and systemic embolism in patients with ESRD because of higher bleeding risks and complications of therapy. The successful use of warfarin has been dependent on the selection of patients with nonvalvular atrial fibrillation at relatively high risk of stroke and systemic embolism and lower risks of bleeding over the course of therapy. Without such selection strategies, broad use of warfarin has not proven to be beneficial to the broad population of patients with ESRD and nonvalvular atrial fibrillation. In a recent meta-analysis of use of warfarin in patients with nonvalvular atrial fibrillation and ESRD, warfarin had no effect on the risks of stroke (hazard ratio, 1.12; 95% confidence interval, 0.69 to 1.82; P=0.65) or mortality (hazard ratio, 0.96; 95% confidence interval, 0.81 to 1.13; P=0.60) but was associated with increased risk of major bleeding (hazard ratio, 1.30; 95% confidence interval, 1.08 to 1.56; P<0.01). In pivotal trials, novel oral anticoagulants were generally at least equal to warfarin for efficacy and safety in nonvalvular atrial fibrillation and mild to moderate renal impairment. Clinical data for ESRD are limited, because pivotal trials excluded such patients. Given the very high risk of stroke and systemic embolism and the early evidence of acceptable safety profiles of novel oral anticoagulants, we think that patients with ESRD should be considered for treatment with chronic anticoagulation provided that there is an acceptable bleeding profile. Apixaban is currently indicated in ESRD for this application and may be preferable to warfarin given the body of evidence for warfarin and its difficulty of use and attendant adverse events.

Morfin, J. A., R. J. Fluck, E. D. Weinhandl, S. Kansal, P. A. McCullough and P. Komenda (2016). “Intensive hemodialysis and treatment complications and tolerability.” Am J Kidney Dis 68(5s1): S43-s50.

Full text of this article.

Hemodialysis (HD) treatment can be difficult to tolerate. Common complications are intradialytic hypotension (IDH) and long time to recovery after an HD session. IDH, as defined by nadir systolic blood pressure < 90mmHg and intradialytic decline > 30mmHg, occurs in almost 8% of HD sessions. IDH may be caused by aggressive ultrafiltration in response to interdialytic weight gain, can lead to myocardial stunning and cardiac arrhythmias, and is associated with increased risk for death. Long recovery time after a treatment session is also common. In DOPPS (Dialysis Outcomes and Practice Patterns Study), recovery time was 2 to 6 hours for 41% of HD patients and longer than 6 hours for 27%; recovery time was linearly associated with increased risks for death and hospitalization. Importantly, both decreases in blood pressure and feeling washed out or drained have been identified by patients as more important outcomes than death or hospitalization. Intensive HD likely reduces the likelihood of IDH. In the Frequent Hemodialysis Network trial, short daily and nocturnal schedules reduced the per-session probability of IDH by 20% and 68%, respectively, relative to 3 sessions per week. Due to lower ultrafiltration volume and/or rate, intensive HD may reduce intradialytic blood pressure variability. In a cross-sectional study, short daily and nocturnal schedules were associated with slower ultrafiltration and less dialysis-induced myocardial stunning than 3 sessions per week. In FREEDOM (Following Rehabilitation, Economics, and Everyday-Dialysis Outcome Measurements), a prospective cohort study of short daily HD, recovery time was reduced after 12 months from 8 hours to 1 hour, according to per-protocol analysis. Recovery time after nocturnal HD may be minutes. In conclusion, intensive HD can improve the tolerability of HD treatment by reducing the risk for IDH and decreasing recovery time after HD. These changes may improve the patient centeredness of end-stage renal disease care.

Baumgarten, H., J. J. Squiers, W. T. Brinkman, J. M. DiMaio, A. Gopal, M. J. Mack and R. L. Smith (2016). “Implantation of transcatheter aortic prosthesis in 3 patients with mitral annular calcification.” Ann Thorac Surg 102(5): e433-e435.

Full text of this article.

Mitral annular calcification (MAC) is a chronic degenerative process at the fibrous base of the mitral valve. It is a feared diagnosis in the context of mitral valve operations because of the risk of severe adverse events such as atrioventricular disruption, injury to the circumflex artery during debridement, and difficult placement of annular sutures. We report a series of 3 consecutive female patients with severe circular MAC who underwent successful mitral valve replacement through a lateral minithoracotomy with use of an inverted transcatheter aortic valve.

Filardo, G., G. Ailawadi, B. D. Pollock, B. da Graca, D. M. Sass, T. K. Phan, D. E. Montenegro, V. Thourani and R. Damiano (2016). “Sex differences in the epidemiology of new-onset in-hospital post-coronary artery bypass graft surgery atrial fibrillation: A large multicenter study.” Circ Cardiovasc Qual Outcomes: 2016 Oct [Epub ahead of print].

Full text of this article.

BACKGROUND: New-onset atrial fibrillation (AF) after coronary artery bypass graft surgery (CABG) is associated with increased morbidity and poorer long-term survival. Although many studies show differences in outcome in women versus men after CABG, little is known about the sex-specific incidence and characteristics of post-CABG AF. METHODS AND RESULTS: Overall, 11 236 consecutive patients without preoperative AF underwent isolated CABG from 2002 to 2010 at 4 US academic medical centers and 1 high-volume specialty cardiac hospital. Data routinely collected for the Society of Thoracic Surgeons database were augmented with details on new-onset post-CABG AF events detected via continuous in-hospital ECG/telemetry monitoring. Unadjusted incidence of post-CABG AF was 29.5% (3312/11 236) overall, 30.2% (2485/8214) in men, and 27.4% (827/3022) in women. After adjustment for Society of Thoracic Surgeons-recognized risk factors, women had significantly lower risk for post-CABG AF (odds ratio [95% confidence interval]=0.75 [0.64-0.89]), shorter first, longest, and total duration of AF episodes (mean difference [95% confidence interval]=-2.7 [-4.7 to -0.8] hours; -4.1 [-6.9 to -1.2] hours; -2.4 [-2.5 to -2.3] hours, respectively). At 48 hours, AF-free probabilities were 77% for women and 72% for men (P<0.001). Number of episodes (P=0.18), operative mortality (P=0.048), stroke (P=0.126), and discharge in AF (P=0.234) did not differ significantly by sex. CONCLUSIONS: These novel data on sex-specific characteristics of new-onset AF after isolated CABG show that women had lower adjusted risk for post-CABG AF and experienced shorter episodes. Investigation of sex-specific impacts on outcomes is needed to identify optimal strategies for prevention and management to ensure all patients achieve the best possible outcomes.

Packer, M. (2016). “Angiotensin neprilysin inhibition for patients with heart failure: What if sacubitril/valsartan were a treatment for cancer?” JAMA Cardiol.

Full text of this article.

Oncologists would adopt the new drug as the standard of care in a heartbeat, but US physicians who treat patients with heart failure often do little. Heart failure is a fatal disorder, and current drugs achieve only a brief clinical remission. Twoyears ago, sacubitril/valsartanwas shown to be superior to a conventional inhibitor of the renin-angiotensin system in reducing the risk of cardiovascular death,1 and it received expedited US Food and Drug Administration approval for treatment of chronic heart failure. Owing to cost, third-party payors discouraged the use of the drug by requiring high patient copays and administrative preapprovals. Oncologists are accustomed to overcoming these distractions, but other physicians are not. Consequently, uptake of sacubitril/ valsartan by US practitioners has been slow.