Cardiology

Arsalan, M., G. Filardo, W. K. Kim, J. J. Squiers, B. Pollock, C. Liebetrau, J. Blumenstein, J. Kempfert, A. Van Linden, A. Arsalan-Werner, C. Hamm, M. J. Mack, H. Moellmann and T. Walther (2016). “Prognostic value of body mass index and body surface area on clinical outcomes after transcatheter aortic valve implantation.” Clin Res Cardiol: 2016 Aug [Epub ahead of print].

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BACKGROUND: Inverse associations between Body Mass Index (BMI) and Body Surface Area (BSA) with mortality in patients after Transcatheter Aortic Valve Implantation (TAVI) have been reported. This “obesity paradox” is controversial, and it remains unclear which parameter, BMI or BSA, is of greater prognostic value. The aim of this study was to investigate the association of BMI and BSA on short- and mid-term outcomes after TAVI. METHODS AND RESULTS: This prospective, observational study consisted of 917 consecutive patients undergoing TAVI at our center from 2011 to 2014. The association between BMI/BSA and mortality (at 30 days and 1 year) was assessed using restricted cubic spline functions in propensity-adjusted (by Society of Thoracic Surgeons (STS) risk factors) logistic and Cox proportional models, respectively. The median age of the patients was 82.6 years, with a mean STS Predicted Risk of Mortality (STS-PROM) of 6.6 +/- 4.3 %. Throughout the study period (mean follow-up time was 297 days), 150 (16.4 %) patients died; 72 (7.9 %) patients died within 30 days of TAVI. After risk adjustment, the association between body constitution and 30-day mortality was not significant for either measure (BMI p = 0.25; BSA p = 0.32). However, BMI (p = 0.01), but not BSA (p = 0.13), was significantly associated with 1-year survival. There was no association between stroke, vascular complications, or length of stay with BMI or BSA. CONCLUSIONS: BMI was associated with survival at 1-year after TAVI. Despite the trend towards implementing BSA in risk score calculation, BMI may be more suitable for the assessment of TAVI patients.

Fallahzadeh, M. K. and P. A. McCullough (2015). “Cardiac electromechanical abnormalities in hemodialysis patients: Indicators of cardiomyopathy and future risk.” Am J Nephrol 42(3): 237-238.

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Cardiovascular diseases (CVDs) are more common in chronic kidney disease and end-stage renal disease (ESRD) patients as compared with general population and are a major of cause of morbidity and mortality in this population [1,2]. CVD accounts for approximately 50% of mortality in ESRD patients. In addition to the increased chance of coronary artery disease, the chance of developing arrhythmic events and sudden cardiac death is also higher in ESRD patients [3,4]. The underlying pathophysiology behind this increased chance of arrhythmic event in hemodialysis patients is not clearly understood. Previous studies have shown that hemodialysis patients have lower left ventricular ejection fraction and higher atrial diameters as compared with general population [5,6,7]. Using the timing of electrocardiogram and tissue Doppler on echocardiography, the time from electrical activation to muscular contraction can be assessed. Atrial electromechanical delay (AEMD) times have been reported to be longer in ESRD patients and have been shown to improve after each hemodialysis session [6,7,8]. Additionally, prolonged atrial conduction times are considered as predisposing factors for atrial fibrillation [9]. In this issue of Journal, Turkmen et al. [10] from Turkey have compared the cardiac electromechanical characteristics and biochemical profile of 60 hemodialysis patients versus 44 healthy controls. They also followed the hemodialysis patients for 2 years and compared the characteristics of 19 patients who died within this 2-year period versus 41 living hemodialysis patients.

Badhwar, V., V. H. Thourani, G. Ailawadi and M. Mack (2016). “Transcatheter mitral valve therapy: The event horizon.” J Thorac Cardiovasc Surg 152(2): 330-336.

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Transcatheter aortic valve replacement has entered the clinical armamentarium mainstream of surgeons and interventional cardiologists in the management of high- and extreme-risk patients with aortic stenosis. Transcatheter mitral valve therapies are closely following suit. A flurry of global innovation, research, and clinical activity over the last 10 years have led to dynamic changes to the technologic landscape. With 1 device commercially approved, and several more in early feasibility studies in the United States with significant equity investments by major device manufacturers, the point of no return for this field of therapy finding its way into daily clinical practice is upon us. The current progress and future development of transcatheter mitral valve repair (TMVr) and transcatheter mitral valve replacement (TMVR) are outlined.

Desai, A. S., B. L. Claggett, M. Packer, M. R. Zile, J. L. Rouleau, K. Swedberg, V. Shi, M. Lefkowitz, R. Starling, J. Teerlink, J. J. McMurray and S. D. Solomon (2016). “Influence of sacubitril/valsartan (lcz696) on 30-day readmission after heart failure hospitalization.” J Am Coll Cardiol 68(3): 241-248.

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BACKGROUND: Patients with heart failure (HF) are at high risk for hospital readmission in the first 30 days following HF hospitalization. OBJECTIVES: This study sought to determine if treatment with sacubitril/valsartan (LCZ696) reduces rates of hospital readmission at 30-days following HF hospitalization compared with enalapril. METHODS: We assessed the risk of 30-day readmission for any cause following investigator-reported hospitalizations for HF in the PARADIGM-HF trial, which randomized 8,399 participants with HF and reduced ejection fraction to treatment with LCZ696 or enalapril. RESULTS: Accounting for multiple hospitalizations per patient, there were 2,383 investigator-reported HF hospitalizations, of which 1,076 (45.2%) occurred in subjects assigned to LCZ696 and 1,307 (54.8%) occurred in subjects assigned to enalapril. Rates of readmission for any cause at 30 days were 17.8% in LCZ696-assigned subjects and 21.0% in enalapril-assigned subjects (odds ratio: 0.74; 95% confidence interval: 0.56 to 0.97; p = 0.031). Rates of readmission for HF at 30-days were also lower in subjects assigned to LCZ696 (9.7% vs. 13.4%; odds ratio: 0.62; 95% confidence interval: 0.45 to 0.87; p = 0.006). The reduction in both all-cause and HF readmissions with LCZ696 was maintained when the time window from discharge was extended to 60 days and in sensitivity analyses restricted to adjudicated HF hospitalizations. CONCLUSIONS: Compared with enalapril, treatment with LCZ696 reduces 30-day readmissions for any cause following discharge from HF hospitalization.

Grodzinsky, A., A. Goyal, K. Gosch, P. A. McCullough, G. C. Fonarow, A. Mebazaa, F. A. Masoudi, J. A. Spertus, B. F. Palmer and M. Kosiborod (2016). “Prevalence and prognosis of hyperkalemia in patients with acute myocardial infarction.” Am J Med 129(8): 858-865.

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BACKGROUND: Hyperkalemia is common and potentially dangerous in hospitalized patients; its contemporary prevalence and prognostic importance after acute myocardial infarction are not well described. METHODS: In 38,689 consecutive patients with acute myocardial infarction from the Cerner Health Facts database, we evaluated the association between maximum in-hospital potassium levels and in-hospital mortality. Patients were stratified by dialysis status and grouped by maximum potassium as follows: <5 mEq/L, 5 to <5.5 mEq/L, 5.5 to <6.0 mEq/L, 6.0 to <6.5 mEq/L, and >/=6.5 mEq/L. Multivariable logistic regression was used to adjust for multiple patient and site characteristics. The relationship between the number of hyperkalemic values and the in-hospital mortality was evaluated. RESULTS: Of 38,689 patients with acute myocardial infarction, 886 were on dialysis. The rate of hyperkalemia (maximum potassium >/=5.0 mEq/L) was 22.6% in patients on dialysis and 66.8% in patients not on dialysis. Moderate to severe hyperkalemia (maximum potassium >/=5.5 mEq/L) occurred in 9.8% of patients. There was a steep increase in mortality with higher maximum potassium levels. In-hospital mortality exceeded 15% once maximum potassium was >/=5.5 mEq/L regardless of dialysis status. The relationship between higher maximum potassium and increased mortality risk persisted after multivariable adjustment. In addition, patients with a greater number of hyperkalemic values (vs a single value) experienced higher in-hospital mortality. CONCLUSIONS: Hyperkalemia is common in patients who are hospitalized with acute myocardial infarction. Higher maximum potassium levels and number of hyperkalemic events are associated with a steep mortality increase, with higher risks for adverse outcomes observed even at mild levels of hyperkalemia. Whether more intensive management of hyperkalemia may improve outcomes in patients with acute myocardial infarction merits further study.