Cardiology

Cogswell, R., Alam, A. and Joseph, S.M. (2021). “Letter by Cogswell et al Regarding Article, “Polypharmacy in Older Adults Hospitalized for Heart Failure”.” Circ Heart Fail 14(3): e008160.

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In the era of modern medicine, the older adult HF patient with reduced ejection fraction will be at least on a 4-drug regimen to help reduce morbidity and mortality, at the expense of polypharmacy. While the issues highlighted by Unlu and Denny et al demonstrate the need for further research in the domain of polypharmacy, our own community must standardize basic fundamental definitions and engage in research to inform our recommendations. Without this, the right polypharmacy may not be achieved. [No abstract; excerpt from article].

Butler, J., Anker, S.D., Filippatos, G., Khan, M.S., Ferreira, J.P., Pocock, S.J., Giannetti, N., Januzzi, J.L., Piña, I.L., Lam, C.S.P., Ponikowski, P., Sattar, N., Verma, S., Brueckmann, M., Jamal, W., Vedin, O., Peil, B., Zeller, C., Zannad, F. and Packer, M. (2021). “Empagliflozin and health-related quality of life outcomes in patients with heart failure with reduced ejection fraction: the EMPEROR-Reduced trial.” Eur Heart J 42(13): 1203-1212.

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AIMS: In this secondary analysis of the EMPEROR-Reduced trial, we sought to evaluate whether the benefits of empagliflozin varied by baseline health status and how empagliflozin impacted patient-reported outcomes in patients with heart failure with reduced ejection fraction. METHODS AND RESULTS: Health status was assessed by the Kansas City Cardiomyopathy Questionnaires-clinical summary score (KCCQ-CSS). The influence of baseline KCCQ-CSS (analyzed by tertiles) on the effect of empagliflozin on major outcomes was examined using Cox proportional hazards models. Responder analyses were performed to assess the odds of improvement and deterioration in KCCQ scores related to treatment with empagliflozin. Empagliflozin reduced the primary outcome of cardiovascular death or heart failure hospitalization regardless of baseline KCCQ-CSS tertiles [hazard ratio (HR) 0.83 (0.68-1.02), HR 0.74 (0.58-0.94), and HR 0.61 (0.46-0.82) for <62.5, 62.6-85.4, and ≥85.4 score tertiles, respectively; P-trend = 0.10]. Empagliflozin improved KCCQ-CSS, total symptom score, and overall summary score at 3, 8, and 12 months. More patients on empagliflozin had ≥5-point [odds ratio (OR) 1.20 (1.05-1.37)], 10-point [OR 1.26 (1.10-1.44)], and 15-point [OR 1.29 (1.12-1.48)] improvement and fewer had ≥5-point [OR 0.75 (0.64-0.87)] deterioration in KCCQ-CSS at 3 months. These benefits were sustained at 8 and 12 months and were similar for other KCCQ domains. CONCLUSION: Empagliflozin improved cardiovascular death or heart failure hospitalization risk across the range of baseline health status. Empagliflozin improved health status across various domains, and this benefit was sustained during long-term follow-up. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03057977.

Brinkman, W.T. and Gable, D. (2021). “Make new friends, but keep the old.” Ann Thorac Surg Apr 5;S0003-4975(21)00650-0. {Epub ahead of print].

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In this issue of The Annals, Chang and colleagues report on their experience with Zone 2 TEVAR in patients with an acute B aortic dissection (ATBAD) and an unfavorable proximal landing zone. The authors should be commended for their good results in a challenging cohort of patients. We are, however, concerned with avoidance of standard techniques (such as left subclavian artery bypass and transposition) in favor of more complicated and “off-label” techniques to revascularize the LSCA. This paper’s conclusions suggest that these techniques are non-inferior to traditional approaches. [No abstract; excerpt from article].

Brener, M.I., George, I., Kosmidou, I., Nazif, T., Zhang, Z., Dizon, J.M., Garan, H., Malaisrie, S.C., Makkar, R., Mack, M., Szeto, W.Y., Fearon, W.F., Thourani, V.H., Leon, M.B., Kodali, S. and Biviano, A.B. (2021). “Atrial Fibrillation Is Associated With Mortality in Intermediate Surgical Risk Patients With Severe Aortic Stenosis: Analyses From the PARTNER 2A and PARTNER S3i Trials.” J Am Heart Assoc 10(7): e019584.

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Background The impact of atrial fibrillation (AF) in intermediate surgical risk patients with severe aortic stenosis who undergo either transcatheter or surgical aortic valve replacement (AVR) is not well established. Methods and Results Data were assessed in 2663 patients from the PARTNER (Placement of Aortic Transcatheter Valve) 2A or S3i trials. Analyses grouped patients into 3 categories according to their baseline and discharge rhythms (ie, sinus rhythm [SR]/SR, SR/AF, or AF/AF). Among patients with transcatheter AVR (n=1867), 79.2% had SR/SR, 17.6% had AF/AF, and 3.2% had SR/AF. Among patients with surgical AVR (n=796), 71.7% had SR/SR, 14.1% had AF/AF, and 14.2% had SR/AF. Patients with transcatheter AVR in AF at discharge had increased 2-year mortality (SR/AF versus SR/SR; hazard ratio [HR], 2.73; 95% CI, 1.68-4.44; P<0.0001; AF/AF versus SR/SR; HR, 1.56; 95% CI, 1.16-2.09; P=0.003); patients with SR/AF also experienced increased 2-year mortality relative to patients with AF/AF (HR, 1.77; 95% CI, 1.04-3.00; P=0.03). For patients with surgicalAVR, the presence of AF at discharge was also associated with increased 2-year mortality (SR/AF versus SR/SR; HR, 1.93; 95% CI, 1.25-2.96; P=0.002; and AF/AF versus SR/SR; HR, 1.67; 95% CI, 1.06-2.63; P=0.027). Rehospitalization and persistent advanced heart failure symptoms were also more common among patients with transcatheter AVR and surgical AVR discharged in AF, and major bleeding was more common in the transcatheter AVR cohort. Conclusions The presence of AF at discharge in patients with intermediate surgical risk aortic stenosis was associated with worse outcomes-especially in patients with baseline SR-including increased all-cause mortality at 2-year follow-up. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01314313 and NCT03222128.

Arnold, S.V., Manandhar, P., Vemulapalli, S., Kosinski, A., Desai, N.D., Bavaria, J.E., Carroll, J.D., Mack, M.J., Thourani, V.H. and Cohen, D.J. (2021). “Impact of short-term complications of transcatheter aortic valve replacement on longer-term outcomes: results from the STS/ACC Transcatheter Valve Therapy Registry.” Eur Heart J Qual Care Clin Outcomes 7(2): 208-213.

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AIMS: While complications of transcatheter aortic valve replacement (TAVR) have decreased, they still occur commonly and may negatively impact both short- and long-term outcomes. We sought to examine the association of complications after TAVR with survival and health status in a real-world cohort. METHODS AND RESULTS: Among 45 884 TAVR patients from 513 US sites who survived 30 days, 21.4% had at least one major complication [stroke, bleed, vascular complication, new pacemaker, acute kidney injury (AKI), and moderate/severe paravalvular leak (PVL)]. In multivariable models, Stage 3 AKI [hazard ratio (HR) 3.43, 95% confidence interval (CI) 2.64-4.45], stroke (HR 2.62, 95% CI 2.06-3.32), and bleeding (HR 1.83, 95% CI 1.55-2.16) were independently associated with significantly increased risk of early death (<3 months) with slight attenuation in these hazards between 3 and 12 months. Moderate/severe PVL (HR 1.37, 95% CI 1.21-1.55) and new pacemaker (HR 1.15, 95% CI 1.05-1.25) were associated with more modest risk of excess mortality that was consistent through 12 months. Among surviving patients, stroke (-6.1 points, 95% CI -8.4 to -3.7), moderate/severe PVL (-3.2 points, 95% CI -4.9 to -1.6), and new pacemaker (-2.3 points, 95% CI -3.2 to -1.5) were associated with less improvement in 1-year health status, as assessed by the Kansas City Cardiomyopathy Questionnaire. CONCLUSION: In this study of contemporary TAVR, we found that complications remain common within the first 30 days after TAVR and are associated with worse 1-year survival and health status among survivors. These findings support continued efforts to reduce major complications of TAVR and may also help define quality of care.