Cardiology

Kim, D. Y., W. Biffl, F. Bokhari, S. Brackenridge, E. Chao, J. A. Claridge, D. Fraser, R. Jawa, A. Kerwin, G. Kasotakis, U. Khan, S. Kurek, D. Plurad, B. R. Robinson, N. Stassen, R. Tesoriero, B. Yorkgitis and J. J. Como (2020). “EVALUATION AND MANAGEMENT OF BLUNT CEREBROVASCULAR INJURY: A PRACTICE MANAGEMENT GUIDELINE FROM THE EASTERN ASSOCIATION FOR THE SURGERY OF TRAUMA.” J Trauma Acute Care Surg Mar 14. [Epub ahead of print].E

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BACKGROUND: Blunt cerebrovascular injuries (BCVIs) are associated with significant morbidity and mortality. This guideline evaluates several aspects of BCVI diagnosis and management including the role of screening protocols, criteria for screening cervical spine injuries, and the use of antithrombotic therapy and endovascular stents. METHODS: Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a taskforce of the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of currently available evidence. Four population, intervention, comparison, and outcome questions were developed to address diagnostic and therapeutic issues relevant to BCVI. RESULTS: A total of 98 articles were identified. Of these, 23 articles were selected to construct the guidelines. In these studies, the detection of BCVI increased with the use of a screening protocol vs. no screening protocol (OR 4.74, 95% CI 1.76-12.78; p = 0.002), as well as among patients with high-risk versus low-risk cervical spine injuries (OR 12.7, CI, 6.24-25.62; p = 0.003). The use of antithrombotic therapy vs. no antithrombotic therapy resulted in a decreased risk of stroke (OR 0.20, CI 0.06-0.65; p < 0.0001) and mortality (OR 0.17, CI 0.08-0.34; p < 0.0001). There was no significant difference in the risk of stroke among patients with Grade II or III injuries who underwent stenting as an adjunct to antithrombotic therapy vs. antithrombotic therapy alone (OR=1.63, CI=0.2-12.14; p = 0.63). CONCLUSIONS: We recommend using a screening protocol to identify patients at-risk for BCVI. Among patients with high-risk cervical spine injuries, we recommend screening CTA to detect BCVI. For patients with low-risk risk cervical injuries, we conditionally recommend performing a CTA to detect BCVI. We recommend the use of antithrombotic therapy in patients diagnosed with BCVI. Finally, we recommend against the routine use of endovascular stents as an adjunct to antithrombotic therapy in patients with Grade II or III BCVIs. LEVEL OF EVIDENCE: Systematic Review/Meta-analysis, level IIIStudy DesignDiagnostic test, therapeutic.

Rosol, Z. P., K. F. Kopecky, B. R. Minehart, K. M. Tecson, A. Vasudevan, P. A. McCullough, P. A. Grayburn and J. M. Schussler (2020). “Limitations of transoesophageal echocardiogram in acute ischaemic stroke.” Open Heart 7(1): e001176.

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Objective: The role of transoesophageal echocardiography (TOE) in identifying ischaemic stroke aetiology is debated. In 2018, the American Heart Association/American Stroke Association (AHA/ASA) issued class IIa recommendation for echocardiography, with the qualifying statement of use in cases where it will alter management. Hence, we sought to determine the rate at which TOE findings altered management in cases of confirmed ischaemic stroke. Methods: We retrospectively analysed TOE cases with confirmed ischaemic stroke at our centre between April 2015 and February 2017. We defined a change in management as the initiation of anticoagulation therapy, antibiotic therapy or patent foramen ovale closure as a direct result of TOE findings. Results: There were 185 patients included in this analysis; 19 (10%) experienced a change in management. However, only 7 of the 19 (4% of all subjects) experienced a change in management due to TOE findings. The remaining 12 were initiated on oral antigoagulation as a result of discoveries during routine workup, mainly atrial fibrillation on telemetry monitoring. Conclusions: This work suggests an overuse of TOE and provides support for the 2018 AHA/ASA stroke guidelines, which recommend against the routine use of echocardiography in the work up of cerebrovascular accident due to a cardioembolic source.

Szerlip, M., S. Anwaruddin, H. D. Aronow, M. G. Cohen, M. J. Daniels, P. Dehghani, D. E. Drachman, S. Elmariah, D. N. Feldman, S. Garcia, J. Giri, P. Kaul, N. Kapur, D. J. Kumbhani, P. M. Meraj, B. Morray, K. R. Nayak, S. A. Parikh, R. Sakhuja, J. M. Schussler, A. Seto, B. Shah, R. V. Swaminathan, D. A. Zidar and S. S. Naidu (2020). “Considerations for Cardiac Catheterization Laboratory Procedures During the COVID-19 Pandemic Perspectives from the Society for Cardiovascular Angiography and Interventions Emerging Leader Mentorship (SCAI ELM) Members and Graduates.” Catheter Cardiovasc Interv Mar 25. [Epub ahead of print].

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The COVID-19 pandemic will impact many patients we care for with cardiovascular
disease. The preparedness of healthcare providers is critical in providing the best quality of care with soon to be limited resources, while keeping all personnel as safe as possible. The current key elements include 1) rescheduling of all non-urgent, elective CCL procedures, 2) careful patient selection for urgent and emergent CCL procedures with recognition of potential shifts in risk/benefit ratios in the setting of a highly contagious virus, 3) meticulous donning and doffing of PPE along with cleaning of CCL areas, 4) performance of bedside procedures when possible, and 5) staffing modifications to limit infectivity and preserve staff availability. (Excerpt from text, no abstract available)

Weir, M. R., P. A. McCullough, J. B. Buse and J. Anderson (2020). “Renal and Cardiovascular Effects of Sodium Glucose Co-Transporter 2 Inhibitors in Patients with Type 2 Diabetes and Chronic Kidney Disease: Perspectives on the Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation Trial Results.” Am J Nephrol Mar 13:1-13. [Epub ahead of print].

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BACKGROUND: Chronic kidney disease (CKD) risk is elevated in patients with type 2 diabetes mellitus (T2DM). Disease management in these patients has been generally focused on glycemic control and controlling other renal and cardiac risk factors as, historically, few protective therapies have been available. The Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation -(CREDENCE) trial of canagliflozin was the first study to demonstrate renal protection with a sodium glucose co-transporter 2 inhibitor in patients with T2DM and CKD, and these results could have important implications for clinical practice. SUMMARY: In CREDENCE, participants with T2DM and estimated glomerular filtration rate 30-<90 mL/min/1.73 m2 and urinary albumin-creatinine ratio >300-5,000 mg/g who were treated with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for >/=4 weeks prior to randomization at either the maximum labeled or tolerated dose were randomized to receive either canagliflozin 100 mg or placebo. Canagliflozin significantly reduced the risk of the primary composite outcome of doubling of serum creatinine, end-stage kidney disease, or renal or cardiovascular (CV) death compared with placebo (hazard ratio 0.70, 95% CI 0.59-0.82; p = 0.00001). Canagliflozin also reduced the risk of secondary renal and CV outcomes. The safety profile of canagliflozin in CREDENCE was generally similar to previous studies of canagliflozin. No imbalances were observed between canagliflozin and placebo in the risk of amputation or fracture in the CREDENCE population. Key Messages: The positive renal and CV effects of canagliflozin observed in the -CREDENCE trial could have a substantial impact on improving outcomes for patients with T2DM and CKD.

Shah, P. B., F. G. P. Welt, E. Mahmud, A. Phillips, N. S. Kleiman, M. N. Young, M. Sherwood, W. Batchelor, D. D. Wang, L. Davidson, J. Wyman, S. Kadavath, M. Szerlip, J. Hermiller, D. Fullerton and S. Anwaruddin (2020). “Triage Considerations for Patients Referred for Structural Heart Disease Intervention During the Coronavirus Disease 2019 (COVID-19) Pandemic: An ACC /SCAI Consensus Statement.” JACC Cardiovasc Interv Apr 3. pii: S1936-8798(20)30867-0. [Epub ahead of print].

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The COVID-19 pandemic has strained health care resources around the world causing many institutions to curtail or stop elective procedures. This has resulted in the inability to care for patients valvular and structural heart disease (SHD) in a timely fashion potentially placing these patients at increased risk for adverse cardiovascular complications including congestive heart failure and death. The effective triage of these patients has become challenging in the current environment as clinicians have had to weigh the risk of bringing susceptible patients into the hospital environment during the COVID-19 pandemic versus the risk of delaying a needed procedure. In this document, we suggest guidelines as to how to triage patients in need of SHD interventions and provide a framework of how to decide when it may be appropriate to proceed with intervention despite the ongoing pandemic. In particular, we address the triage of patients in need of trans-catheter aortic valve replacement and percutaneous mitral valve repair. We also address procedural issues and considerations for the function of structural heart disease teams during the COVID-19 pandemic