Cardiology

Prasad, A., A. Sohn, J. Morales, K. Williams, S. R. Bailey, D. Levin, P. A. McCullough, R. Mehran, G. Lopez-Cruz and J. Harder (2016). “Contemporary practice patterns related to the risk of acute kidney injury in the catheterization laboratory: Results from a survey of society of cardiovascular angiography and intervention (scai) cardiologists.” Catheter Cardiovasc Interv: 2016 June [Epub ahead of print].

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OBJECTIVES: The goal of the present study was to survey the Society of Cardiovascular Angiography and Intervention (SCAI) member cardiologists to evaluate contemporary practice patterns with regards to contrast use, acute kidney injury (AKI) risk assessment, and prevention in patients undergoing invasive angiography. We sought to compare the physician responses against guideline statements and evidence-based data from clinical studies. METHODS: A 20-question online survey based on a modified Likert scale was sent out via email to the Society of Cardiovascular Angiography and Intervention (SCAI) member cardiologists. The survey questions focused on prophylaxis methods, medication management, risk assessment, contrast agent use, and postprocedure care. A scoring system was developed which examined the individual responses to analyze the 10 questions with the greatest strength of evidence in the literature and guidelines. RESULTS: The survey was completed by 506 individuals. Selected responses of note included the use of standardized volume expansion protocols: 64.8%, use of iso-osmolar contrast (iodixanol) in the majority of patients at risk of AKI: 55%, and 27% of individuals reported diluting contrast with saline for patients at risk of AKI during coronary angiography. For questions with support from guideline documents, 56.9% of the responses were scored as concordant with evidence-based data. Individuals who reported that the risk of AKI was often or always important in planning angiography for “at risk patients” were more likely to closely monitor renal function (76.7% vs. 40.0%, P = 0.003), obtain nephrology consultation (45.2% vs. 13.3%, P = 0.016) and use iso-osmolar contrast agents (56.0% vs. 26.7%, P = 0.033). CONCLUSIONS: The majority of cardiologists participating in this survey, reported practice patterns consistent with guideline and evidence-based recommendations. However, over 40% of responses to questions were inconsistent with these recommendations, suggesting continued opportunities for education and quality improvement concerning AKI prevention.

Maron, B. J. and W. C. Roberts (2016). “The father of septal myectomy for obstructive HCM, who also had HCM: The unbelievable story.” J Am Coll Cardiol 67(24): 2900-2903.

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Andrew Glenn Morrow, MD, was Chief of the Clinic of Surgery at the National Institutes of Health (NIH), Bethesda, Maryland, from 1953 until his death in 1982 (Figure 1). During that time, he established an international training program for future cardiac surgeons, and among many other accomplishments, the ventricular septal myectomy operation for obstructive hypertrophic cardiomyopathy (HCM) 1 and 2.

Roberts, W. C., V. S. Won, A. Vasudevan, P. Kapoor, J. M. Ko, D. M. Meyer, S. A. Hall and G. V. Gonzalez-Stawinski (2016). “Comparison of characteristics of patients undergoing heart transplantation at the same hospital in two different time periods (1997-2012 and 2013-2015).” Am J Cardiol 118(2): 288-291.

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Heart transplantation (HT) increases at some centers each year and decreases at others. We examined characteristics of patients having HT at the same hospital in 2 different time periods (1997-2012 and 2013-2015) by 2 different surgical groups. We compared certain clinical and morphological finding in 291 patients having HT 1997 to 2012 to finding in 228 other patients having HT from 2013 to 2015. Several significant (p <0.05) differences were found: in the most recent time period (2013-2015) compared to the earlier time period (1997-2012), the mean ages of the men were older (57 years -vs- 55 years); diabetes mellitus was more frequent (37% -vs- 21%); systemic hypertension (by history) was more frequent (59% -vs- 32%); the mean body mass index was higher (29.2 kg/m(2) -vs- 26.5 kg/m(2)), and mean heart weight was lower in both men (509 g -vs- 549 g) and women (422 g -vs- 454 g). There were insignificant (p >0.05) differences in gender, frequency of massive cardiac adiposity, underlying cardiac condition, frequency of coronary heart disease, and frequency of previous insertion of a left ventricular assist device. In conclusion, certain characteristics of patients having HT at one Texas hospital changed in several respects in 2 time periods corresponding to changes in surgeons doing the HTs.

Vardeny, O., B. Claggett, M. Packer, M. R. Zile, J. Rouleau, K. Swedberg, J. R. Teerlink, A. S. Desai, M. Lefkowitz, V. Shi, J. J. McMurray and S. D. Solomon (2016). “Efficacy of sacubitril/valsartan vs. enalapril at lower than target doses in heart failure with reduced ejection fraction: The paradigm-hf trial.” Eur J Heart Fail: 2016 June [Epub ahead of print].

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AIMS: In this analysis, we utilized data from PARADIGM-HF to test the hypothesis that participants who exhibited any dose reduction during the trial would have similar benefits from lower doses of sacubitril/valsartan relative to lower doses of enalapril. METHODS AND RESULTS: In a post-hoc analysis from PARADIGM-HF, we characterized patients by whether they received the maximal dose (200 mg sacubitril/valsartan or 10 mg enalapril twice daily) throughout the trial or had any dose reduction to lower doses (100/50/0 mg sacubitril/valsartan or 5/2.5/0 mg enalapril twice daily). The treatment effect for the primary outcome was estimated, stratified by dose level using time-updated Cox regression models. In the two treatment arms, participants with a dose reduction (43% of those randomized to enalapril and 42% of those randomized to sacubitril/valsartan) had similar baseline characteristics and similar baseline predictors of the need for dose reduction. In a time-updated analysis, any dose reduction was associated with a higher subsequent risk of the primary event [hazard ratio (HR) 2.5, 95% confidence interval (CI) 2.2-2.7]. However, the treatment benefit of sacubitril/valsartan over enalapril following a dose reduction was similar (HR 0.80, 95% CI 0.70-0.93, P < 0.001) to that observed in patients who had not experienced any dose reduction (HR 0.79, 95% CI 0.71-0.88, P < 0.001). CONCLUSIONS: In PARADIGM-HF, study medication dose reduction identified patients at higher risk of a major cardiovascular event. The magnitude of benefit for patients on lower doses of sacubitril/valsartan relative to those on lower doses of enalapril was similar to that of patients who remained on target doses of both drugs.

Desai, A. S., S. Solomon, B. Claggett, J. J. McMurray, J. Rouleau, K. Swedberg, M. Zile, M. Lefkowitz, V. Shi and M. Packer (2016). “Factors associated with noncompletion during the run-in period before randomization and influence on the estimated benefit of lcz696 in the paradigm-hf trial.” Circ Heart Fail 9(6).

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BACKGROUND: The 8442 patients randomized in the Prospective Comparison of Angiotensin Receptor-Neprilysin Inhibitor With an Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial, in which sacubitril/valsartan (LCZ696) reduced both death and HF hospitalization more than enalapril, were a subset of 10 521 patients entering sequential, single-blind run-in periods (enalapril 10 mg twice daily for 2 weeks followed by LCZ696 200 mg twice daily for 4 to 6 weeks) to ensure short-term tolerability of the 2 study medications. We identified the predictors of run-in noncompletion and estimated the implications of noncompletion for the overall study result. METHODS AND RESULTS: Patient factors associated with run-in noncompletion were defined in multivariable logistic regression models. The effectiveness of LCZ696 in a broader cohort approximating the full run-in population was estimated by weighting randomized patients according to the inverse probability of run-in completion; 2079 (19.8%) subjects discontinued the study during the run-in period, including 1102 (10.5%) during the enalapril phase and 977 (9.3%) during the LCZ696 phase. In multivariable models, lower systolic blood pressure, lower estimated glomerular filtration rate, higher N-terminal pro-B-type natriuretic peptide, and ischemic cause of heart failure were associated with higher risk for run-in noncompletion. Repeat analysis of the effect of randomized treatment giving greater weight to randomized patients resembling those who did not complete the run-in did not alter the hazard ratio favoring LCZ696 over enalapril for the primary end point of cardiovascular death or heart failure hospitalization, or the additional key end points of cardiovascular death and all-cause mortality. CONCLUSIONS: Patients with lower blood pressure, lower glomerular filtration rate, and more severe heart failure were at higher risk for noncompletion during the run-in period of PARADIGM-HF. Weighted analysis of key study outcomes accounting for the effect of run-in noncompletion did not alter the benefit of LCZ696 over enalapril.