Research Spotlight

Hise, J. H. (2017). “And then came the pacs.” Jama 318(4): 331.

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I graduated from medical school in 1984 and entered a diagnostic radiology residency. No internship was required for radiology, soI beganmymedical training without a clinical year. This was long before the implementation of PACS (the picture archiving and computer system); therefore, clinical training occurredeverymorning. The referring physicians would arrive without fail inquiring about the x-rays of their patients. If one was even a marginally astute radiologist, you quickly learned that this exchange was the highlight of the day and key to a good radiology report.

Baron, S. J., S. V. Arnold, K. Wang, E. A. Magnuson, K. Chinnakondepali, R. Makkar, H. C. Herrmann, S. Kodali, V. H. Thourani, S. Kapadia, L. Svensson, D. L. Brown, M. J. Mack, C. R. Smith, M. B. Leon and D. J. Cohen (2017). “Health status benefits of transcatheter vs surgical aortic valve replacement in patients with severe aortic stenosis at intermediate surgical risk: Results from the partner 2 randomized clinical trial.” JAMA Cardiol: 2017 Jun [Epub ahead of print].

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Importance: In patients with severe aortic stenosis (AS) at intermediate surgical risk, treatment with transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) results in similar 2-year survival. The effect of TAVR vs SAVR on health status in patients at intermediate surgical risk is unknown. Objective: To compare health-related quality of life among intermediate-risk patients with severe AS treated with either TAVR or SAVR. Design, Setting, and Participants: Between December 2011 and November 2013, 2032 intermediate-risk patients with severe AS were randomized to TAVR with the Sapien XT valve or SAVR in the Placement of Aortic Transcatheter Valve 2 Trial and were followed up for 2 years. Data analysis was conducted between March 1, 2016, to April 30, 2017. Main Outcomes and Measures: Health status was assessed at baseline, 1 month, 1 year, and 2 years using the Kansas City Cardiomyopathy Questionnaire (KCCQ) (23 items covering physical function, social function, symptoms, self-efficacy and knowledge, and quality of life on a 0- to 100-point scale; higher scores indicate better quality of life), Medical Outcomes Study Short Form-36 (36 items covering 8 dimensions of health status as well as physical and mental summary scores; higher scores represent better health status), and EuroQOL-5D (assesses 5 dimensions of general health on a 3-level scale, with utility scores ranging from 0 [death] to 1 [ideal health]). Analysis of covariance was used to examine changes in health status over time, adjusting for baseline status. Results: Of the 2032 randomized patients, baseline health status was available for 1833 individuals (950 TAVR, 883 SAVR) who formed the primary analytic cohort. A total of 1006 (54.9%) of the population were men; mean (SD) age was 81.4 (6.8) years. Over 2 years, both TAVR and SAVR were associated with significant improvements in both disease specific (16-22 points on the KCCQ-OS scale) and generic health status (3.9-5.1 points on the SF-36 physical summary scale). At 1 month, TAVR was associated with better health status than SAVR, but this difference was restricted to patients treated via transfemoral access (mean difference in the KCCQ overall summary [KCCQ-OS] score, 14.1 points; 95% CI, 11.7 to 16.4; P < .01) and was not seen in patients treated via transthoracic access (mean difference in KCCQ-OS, 3.5 points; 95% CI, -1.4 to 8.4; P < .01 for interaction). There were no significant differences between TAVR and SAVR in any health status measures at 1 or 2 years. Conclusions and Relevance: Among intermediate-risk patients with severe AS, health status improved significantly with both TAVR and SAVR through 2 years of follow up. Early health status improvement was greater with TAVR, but only among patients treated via transfemoral access. Longer term follow-up is needed to assess the durability of quality-of-life improvement with TAVR vs SAVR in this population.

Flores, A. and S. K. Asrani (2017). “The donor risk index: A decade of experience.” Liver Transpl: 2017 Jun [Epub ahead of print].

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In 2006, derivation of the donor risk index (DRI) highlighted the importance of donor factors for successful liver transplantation. Over the last decade, the DRI has served as a useful metric of donor quality and enhanced our understanding of donor factors and their impact upon recipients with hepatitis C, those with low model for end-stage liver disease (MELD) score, and individuals undergoing retransplantation. DRI has provided the transplant community with a common language for describing donor organ characteristics and has served as the foundation for several tools for organ risk assessment. It is a useful tool in assessing the interactions of donor factors with recipient factors and their impact on posttransplant outcomes. However, limitations of statistical modeling, choice of donor factors, exclusion of unaccounted donor and geographic factors, and the changing face of the liver transplant recipient have tempered its widespread use. In addition, the DRI was derived from data before the MELD era but is currently being applied to expand the donor pool while concurrently meeting the demands of a dynamic allocation system. A decade after its introduction, DRI remains relevant but may benefit from being updated to provide guidance in the use of extended criteria donors, tailored for recipients with nonalcoholic fatty liver disease and account for the impact of geography and unmeasured donor characteristics.

Kotecha, D., M. D. Flather, D. G. Altman, J. Holmes, G. Rosano, J. Wikstrand, M. Packer, A. J. S. Coats, L. Manzano, M. Bohm, D. J. van Veldhuisen, B. Andersson, H. Wedel, T. G. von Lueder, A. S. Rigby, A. Hjalmarson, J. Kjekshus and J. G. F. Cleland (2017). “Heart rate and rhythm and the benefit of beta-blockers in patients with heart failure.” J Am Coll Cardiol 69(24): 2885-2896.

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BACKGROUND: The relationship between mortality and heart rate remains unclear for patients with heart failure with reduced ejection fraction in either sinus rhythm or atrial fibrillation (AF). OBJECTIVES: This analysis explored the prognostic importance of heart rate in patients with heart failure with reduced ejection fraction in randomized controlled trials comparing beta-blockers and placebo. METHODS: The Beta-Blockers in Heart Failure Collaborative Group performed a meta-analysis of harmonized individual patient data from 11 double-blind randomized controlled trials. The primary outcome was all-cause mortality, analyzed with Cox proportional hazard ratios (HR) modeling heart rate measured at baseline and approximately 6 months post-randomization. RESULTS: A higher heart rate at baseline was associated with greater all-cause mortality for patients in sinus rhythm (n = 14,166; adjusted HR: 1.11 per 10 beats/min; 95% confidence interval [CI]: 1.07 to 1.15; p < 0.0001) but not in AF (n = 3,034; HR: 1.03 per 10 beats/min; 95% CI: 0.97 to 1.08; p = 0.38). Beta-blockers reduced ventricular rate by 12 beats/min in both sinus rhythm and AF. Mortality was lower for patients in sinus rhythm randomized to beta-blockers (HR: 0.73 vs. placebo; 95% CI: 0.67 to 0.79; p < 0.001), regardless of baseline heart rate (interaction p = 0.35). Beta-blockers had no effect on mortality in patients with AF (HR: 0.96, 95% CI: 0.81 to 1.12; p = 0.58) at any heart rate (interaction p = 0.48). A lower achieved resting heart rate, irrespective of treatment, was associated with better prognosis only for patients in sinus rhythm (HR: 1.16 per 10 beats/min increase, 95% CI: 1.11 to 1.22; p < 0.0001). CONCLUSIONS: Regardless of pre-treatment heart rate, beta-blockers reduce mortality in patients with heart failure with reduced ejection fraction in sinus rhythm. Achieving a lower heart rate is associated with better prognosis, but only for those in sinus rhythm.

Habib, P. J. and S. M. Joseph (2017). “Why all the pushback against counterpulsation?” Cardiology 138(1): 66-68.

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Intra-aortic balloon counterpulsation (IABP) has been a mainstay of mechanical circulatory support (MCS) for over 50 years. There are many intuitive reasons for this: the expansive familiarity with the technology, the ease of insertion, the low risk profile, and the relatively low costs. Despite this, following the IABP-SHOCK II trial, there has been a substantial decline in the use of IABP in cardiogenic shock (CS), and its value as a viable option has been heatedly debated. Indeed, the European Society of Cardiology even gave the IABP a class III recommendation and stated that routine use cannot be recommended [1].