Cardiology

Szerlip, M., D. N. Feldman, H. D. Aronow, J. C. Blankenship, J. W. Choi, I. Y. Elgendy, S. Elmariah, S. Garcia, B. H. Goldstein, H. Herrmann, R. S. Hira, M. R. Jaff, A. Kalra, E. Kaluski, C. J. Kavinsky, D. M. Kolansky, D. F. Kong, J. C. Messenger, D. Mukherjee, R. A. G. Patel, R. Piana, E. Senerth, M. Shishehbor, G. Singh, V. Singh, P. K. Yadav and D. Cox (2020). “SCAI publications committee manual of standard operating procedures.” Catheter Cardiovasc Interv 2020 Feb 14. [Epub ahead of print].

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Evidence-based recommendations for clinical practice are intended to help health care providers and patients make decisions, minimize inappropriate practice variation, promote effective resource use, improve clinical outcomes, and direct future research. The Society for Cardiovascular Angiography and Interventions (SCAI) has been engaged in the creation and dissemination of clinical guidance documents since the 1990s. These documents are a cornerstone of the society’s education, advocacy, and quality improvement initiatives. The publications committee is charged with oversight of SCAI’s clinical documents program and has created this manual of standard operating procedures to ensure consistency, methodological rigor, and transparency in the development and endorsement of the society’s documents. The manual is intended for use by the publications committee, document writing groups, external collaborators, SCAI representatives, peer reviewers, and anyone seeking information about the SCAI documents program.

Schaffer, J. M. and W. T. Brinkman (2020). “Invited Commentary.” Ann Thorac Surg 109(3): 686-687.

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In this issue of The Annals of Thoracic Surgery, the aortic team at the University of Maryland led by Dr Bradley S. Taylor presents a series of patients treated endovascularly for ascending aortic pathology. All patients in their series were considered to have a prohibitive risk for open ascending aortic aneurysm repair, and thus would have been treated medically if not for the off-label use of endovascular technology that the authors describe in this study. It is laudable that the “heart team concept” was used to evaluate, risk stratify, and treat these patients. Cardiovascular surgeons, vascular surgeons, and interventional cardiologists were all important members of their aortic team. The study was limited by significant heterogeneity of underlying pathology and patient anatomy. Patient risk stratification was somewhat arbitrary, and the follow-up was short term (median, 388 days). Despite these limitations, we believe that the results presented in this study are excellent, and that Ghoreishi and colleagues are appropriately finding solutions to address the unmet clinical need in patients with ascending aortic (zone 0) pathology at high risk or ineligible for traditional surgical treatment. (Excerpt from text, p. 686; no abstract available.)

Sabate, M. and M. Mack (2020). “Very Late Outcomes After Stent Implantation: It Is Time to Target the Nontarget Sites.” J Am Coll Cardiol 75(6): 605-607.

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Coronary stents were initially designed to prevent acute vessel closure after balloon dilatation. Soon after their introduction, it became obvious that the benefit of metallic stents further extended beyond the acute angiographic result. As a matter of fact, seminal randomized controlled trials demonstrated reductions in binary restenosis and subsequently, in target lesion revascularization rates. Technology evolved from bare-metal stents (BMS) to first-generation drug-eluting stents (DES), with the aim to design more efficacious devices (i.e., with higher suppression of neointimal proliferation) to be used in all types of lesions and clinical scenarios. However, this first-generation DES carried very late safety concerns related to stent thrombosis that could be associated with delayed neointimal healing, chronic inflammatory reaction to polymer, and development of in-stent neoatherosclerosis, among others. DES evolved to a second-generation, which was demonstrated to have a much improved safety profile compared with both first-generation DES and BMS (4). Consequently, second-generation DES are now recommended as the default technique in recent myocardial revascularization guidelines. Although several trials have reported very late outcomes following stent implantation, their analysis should be taken as merely hypothesis-generating due to lack of power to demonstrate differences in hard events. Therefore, the individual patient-data pooled analysis involving a total of 25,032 patients from 19 large-scale, randomized, metallic stent trials reported in this issue of the Journal is most welcome. (Excerpt from text of this commentary, p. 605; refers to M.V. Madhavan, A.J. Kirtane, B. Redfors, et al. Stent-related adverse events >1 year after percutaneous coronary intervention.; no abstract available.)

Rorth, R., P. S. Jhund, M. B. Yilmaz, S. L. Kristensen, P. Welsh, A. S. Desai, L. Kober, M. F. Prescott, J. L. Rouleau, S. D. Solomon, K. Swedberg, M. R. Zile, M. Packer and J. J. V. McMurray (2020). “Comparison of BNP and NT-proBNP in Patients With Heart Failure and Reduced Ejection Fraction.” Circ Heart Fail Epub 2020 Feb 17.

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BACKGROUND: Both BNP (B-type natriuretic peptide) and NT-proBNP (N-terminal pro B-type natriuretic peptide) are widely used to aid diagnosis, assess the effect of therapy, and predict outcomes in heart failure and reduced ejection fraction. However, little is known about how these 2 peptides compare in heart failure and reduced ejection fraction, especially with contemporary assays. Both peptides were measured at screening in the PARADIGM-HF trial (Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure). METHODS: Eligibility criteria in PARADIGM-HF included New York Heart Association functional class II to IV, left ventricular ejection fraction /=150 pg/mL or NT-proBNP >/=600 pg/mL (for patients with HF hospitalization within 12 months, BNP >/=100 pg/mL or NT-proBNP >/=400 pg/mL). BNP and NT-proBNP were measured simultaneously at screening and only patients who fulfilled entry criteria for both natriuretic peptides were included in the present analysis. The BNP/NT-proBNP criteria were not different for patients in atrial fibrillation. Estimated glomerular filtration rate <30 mL/min per 1.73 m(2) was a key exclusion criterion. RESULTS: The median baseline concentration of NT-proBNP was 2067 (Q1, Q3: 1217-4003) and BNP 318 (Q1, Q3: 207-559), and the ratio, calculated from the raw data, was approximately 6.25:1. This ratio varied considerably according to rhythm (atrial fibrillation 8.03:1; no atrial fibrillation 5.75:1) and with age, renal function, and body mass index but not with left ventricular ejection fraction. Each peptide was similarly predictive of death (all-cause, cardiovascular, sudden and pump failure) and heart failure hospitalization, for example, cardiovascular death: BNP hazard ratio, 1.41 (95% CI, 1.33-1.49) per 1 SD increase, P<0.0001; NT-proBNP, 1.45 (1.36-1.54); P<0.0001. CONCLUSIONS: The ratio of NT-proBNP to BNP in heart failure and reduced ejection fraction appears to be greater than generally appreciated, differs between patients with and without atrial fibrillation, and increases substantially with increasing age and decreasing renal function. These findings are important for comparison of natriuretic peptide concentrations in heart failure and reduced ejection fraction.

Pollifrone, M., S. Sikka and R. Hamilton (2020). “Takotsubo cardiomyopathy in a chronic spinal cord injury patient with autonomic dysreflexia: A case report.” J Spinal Cord Med Feb 11:1-4. [Epub ahead of print].

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Context: Takotsubo cardiomyopathy (TC) is a transient stress-induced cardiomyopathy with left ventricular dysfunction of unknown etiology. A well accepted theory for the pathophysiology of TC is attributed to a massive catecholamine release [1]. This case report will review a chronic tetraplegia patient who was diagnosed with TC after a severe episode of autonomic dysreflexia (AD). He experiences mild episodes of AD several times a day; however, he had never experienced the severity of symptoms that was associated with this episode which led to his hospitalization. Autonomic dysreflexia is a syndrome of imbalanced sympathetic input secondary to loss of descending central sympathetic control in spinal cord injury due to noxious stimuli below the level of the injury, which occurs when the injury level is at thoracic level 6 (T6) or above [2].Findings: In this specific case, it is presumed that the massive catecholamine release associated with this severe AD episode resulted in TC. Although TC has been diagnosed after other instances of acute stress, it is unknown for it to be diagnosed after AD in a chronic setting.Clinical Relevance: The long-term effects of AD have not been well studied, and this case illustrates the importance of education to recognize and manage AD in the spinal cord patient who frequently has episodes of AD.