IJC Heart and Vasculature最新文献

In contrast to beta-blockers and renin-angiotensin system inhibitors, the role of calcium channel blockers (CCBs) in patients with heart failure with preserved ejection fraction (HFpEF) remains uncertain. Despite several randomized controlled trials (RCTs) and cohort studies exploring the effects of CCBs on prognosis and exercise capacity in HFpEF patients, the findings have been inconsistent, likely due to limited statistical power and/or variations in study design. We aimed to conduct a systematic review and meta-analysis of studies on the effects of CCBs in HFpEF patients. The search of electronic databases identified 2 RCTs including 35 patients and 4 cohort studies including 25,078 patients. In cases of significant heterogeneity (I² > 50 %), data were pooled using a random-effects model; otherwise, a fixed-effects model was used. In pooled analysis of the cohort studies, use of CCBs was not associated with the risk of all-cause death (hazard ratio [95 % CI] = 0.913 [0.732, 1.139], P_random = 0.420) or hospitalization for heart failure (1.050 [0.970, 1.137], P_fix = 0.230). Separate analyses for dihydropyridine and non-dihydropyridine CCBs revealed similar results. In pooled analysis of the RCTs, verapamil increased exercise time (weighted mean difference [95 % CI] = 0.953 [0.109, 1.797] min; P_fix = 0.027) and decreased the congestive heart failure score (2.019 [1.673, 2.365] points; P_fix < 0.001) compared with placebo. In conclusion, in HFpEF patients, verapamil may improve exercise capacity and symptoms but use of CCBs, regardless of subclass, may not be associated with better prognosis. Our meta-analysis is limited by the inclusion of only several studies for each outcome and further research is necessary to confirm our findings.

Background

Diuretic resistance is common and results in poor outcome. Spot urine sodium (UrNa) is suggested as a tool to tailor diuretics and improve efficacy of therapy. We prospectively evaluate the prevalence of diuretic resistance, predictors of low spot-UrNa and the prognostic value of spot-UrNa in an unselected ADHF population.

Methods

Patients admitted for ADHF and treated with iv diuretics were included. Spot-UrNa was collected 2 h after administration of an IV diuretic bolus. The main endpoint was a composite of HF re-hospitalizations and all-cause mortality at 90 days follow-up.

Results

143 patients were included in this study (median age 81 [75 – 85] years, 55 % male), of which 50 % were newly diagnosed with HF. Low spot-UrNa was independently associated with worse renal function, low serum sodium, and systolic blood pressure, previous loop diuretic and SGLT2i use and loop diuretic administered dose. Both absolute spot-UrNa (HR 0.87, 95 % CI 0.79 – 0.95, P=0.003 per 10 mmol/L increase) and a urinary sodium ≥ 100 mmol/l (HR=0.51, 95 % CI 0.27 – 0.97, P=0.04) significantly predicted the composite endpoint. This association was no longer significant after correction for confounders. Patients with low spot-UrNa attained longer IV diuretic treatment and a higher cumulative IV diuretic dose.

Conclusions

Spot-UrNa is prevalent and occurs more often in patients with more progressed cardio-renal disease. Spot-UrNa significantly predicts 90-day HF hospital-free survival in ADHF. Further studies are needed evaluating the effect of UrNa guided diuretic treatment on clinical endpoints.

Background

Optical coherence tomography (OCT) has gained increasing popularity in coronary artery intervention due to its high resolution and excellent tissue correlation as a novel intravascular imaging modality. However, the current use of OCT requires contrast agent injection for imaging, and excessive use of contrast agents may adversely affect renal function, exacerbate cardiac burden, and even lead to contrast agent-induced nephropathy and heart failure. In recent years, several researchers have proposed the use of low molecular weight dextran (LMWD) as a substitute for contrast agents in OCT imaging because of its low toxicity, low cost, and wide availability. However, the inclusion of lesions in these studies is relatively simple, and the image quality criteria remain to be optimized.

Methods

This study included 26 patients with coronary artery disease who were scheduled for OCT imaging in a real-world clinical practice involving various complex lesions. All patients underwent two OCT examinations at the same vascular site, one each using contrast agent and LMWD. Both contrast media and LMWDs were infused by an autoinjector. The primary endpoint of the study was the average image quality score. Secondary endpoints included clear image length, clear image segments, minimum lumen area, average lumen area, and contrast-induced nephropathy, among others.

Results

In terms of image clarity, the average image quality score was similar when comparing contrast media with LMWD (3.912 ± 0.175 vs. 3.769 ± 0.392, P = 0.071). The lengths of the clear images and the segments of the clear images were also similar between the two groups (50.97 ± 16.25 mm vs. 49.12 ± 18.15 mm, P = 0.110; 255.5 ± 81.29 vs. 250.5 ± 89.83, P = 0.095). Additionally, strong correlations were noted between the two flushing solutions regarding the minimum lumen area and mean lumen area. During their hospital stay, none of the patient exhibited deterioration in renal function, and no patient experienced any major adverse cardiovascular events.

Conclusions

The quality of coronary artery OCT imaging using LMWD may be comparable to that achieved with traditional contrast agents, even in real-world clinical practice involving various complex lesions. For high-risk patients, LMWD may serve as an excellent substitute for contrast agents in OCT examinations.

Background

Several observational cohort studies have been conducted to investigate the effectiveness and safety of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) in patients who have both atrial fibrillation (AF) and cancer. Herein, we conducted a meta-analysis to present a comprehensive overview of the real-world evidence on DOACs in patients with AF and cancer.

Methods

A comprehensive search strategy was performed in PubMed and Embase until February 2024 for studies that enrolled AF patients with cancer who received DOACs or VKAs. The adjusted risk ratios (RRs) and 95% confidence intervals (CIs) of each outcome were extracted and pooled by a random-effects model.

Results

Seven observational cohort studies were eligible for data extraction. The random-effects model analysis indicated that compared with VKA use, the use of DOACs was significantly associated with reduced risks of stroke or systemic embolism (RR=0.79, 95 % CI 0.64–––0.97), major bleeding (RR=0.84, 95 % CI 0.71–––0.99), intracranial bleeding (RR=0.61, 95 % CI 0.54–––0.69), and gastrointestinal bleeding (RR=0.87, 95 % CI 0.80–––0.95) in AF patients with concurrent cancer.

Conclusions

Compared with VKAs, the use of DOACs was associated with decreased risks of thrombotic and bleeding events in AF patients with cancer. Data from real-world scenarios support the use of DOACs as a favorable treatment option for this specific patient population.

Background

Coronary artery disease (CAD) and coronary microvascular disease (CMD) are significant contributors to angina pectoris, necessitating reliable diagnostic techniques for effective management. While positron emission tomography has been the non-invasive gold standard for myocardial blood flow (MBF) quantification, stress dynamic CT myocardial perfusion imaging (CTMPI) has emerged as a promising alternative. This study aimed to evaluate the test–retest reproducibility of MBF measurements obtained using dynamic CTMPI.

Methods

The study retrospectively analyzed MBF values from two dynamic CTMPI examinations conducted in the same patient cohort (n = 30) to examine the consistency of MBF quantification and the ability to visually detect and grade abnormal perfusion suggesting ischemia between the tests. Global and remote MBF were defined as the mean MBF and the maximum MBF of all segments, respectively.

Results

MBF quantification revealed strong linear correlations between the tests (r = 0.89 for global MBF, r = 0.88 for remote MBF, and r = 0.82 for all segments), and intraclass correlation coefficients reflected high agreement between the tests (0.94 for global MBF, 0.93 for remote MBF, and 0.90 for all segments). Bland-Altman plots indicated a negligible mean difference with acceptable limits of agreements between the tests for global MBF, remote MBF, and all segments. Visual assessment of the CTMPI maps for abnormal perfusion suggesting ischemia yielded a good inter-test agreement with a weighted kappa value of 0.80.

Conclusion

Dynamic CTMPI can consistently reproduce absolute MBF values and reliably detect myocardial perfusion abnormalities, potentially making it a robust diagnostic tool for evaluating the presence and severity of CAD and CMD.

Background

Unexpectedly low natriuretic peptide (NP) levels in proportion to heart failure severity are often observed in obese individuals. However, the magnitude of NP elevation in response to acute cardiac stress in obesity has not yet been extensively studied. This study aimed to determine the impact of obesity on the increase in plasma NP in response to cardiac hemodynamic stress during acute coronary syndrome (ACS) attacks.

Methods and Results

The study population included 557 consecutive patients with ACS for whom data were collected during emergency cardiac catheterization. To determine the possible impact of body mass index (BMI) on the relationship between left ventricular ejection fraction (LVEF) and plasma B-type NP (BNP) levels, the study population was divided into two groups (Group 1: BMI <25, Group 2: BMI ≥25 [kg/m²]). Both BMI and LVEF were significantly and negatively correlated with BNP. Although a significant negative correlation between LVEF and BNP was observed in both groups, the regression line of Group 2 was significantly less steep than that of Group 1. Accordingly, BNP/LVEF ratio in Group 2, which indicates the extent of BNP increase in response to LVEF change, was significantly lower than that in Group 1.

Conclusions

Blunted increase in plasma BNP in response to cardiac hemodynamic stress during ACS attacks was observed in obese individuals. In addition to the relatively low plasma BNP levels at baseline in obese individuals, the blunted response of BNP elevation to ACS attacks may have important pathophysiological implications for hemodynamic regulation and myocardial energy metabolism.

Background

Polypharmacy is associated with an increased risk of adverse events due to the higher number of drugs used. This is particularly notable in patients with chronic coronary syndrome (CCS), who are known to use a large number of drugs. Therefore, we investigated polypharmacy in patients with CCS, using CLIDAS, a multicenter database of patients who underwent percutaneous coronary intervention.

Method and results

Between 2017 and 2020, 1411 CCS patients (71.5 ± 10.5 years old; 77.3 % male) were enrolled. The relationship between cardiovascular events occurring during the median follow-up of 514 days and the number of drugs at the time of PCI was investigated. The median number of drugs prescribed was nine. Major adverse cardiovascular events (MACE), defined as cardiovascular death, myocardial infarction, stroke, heart failure, transient ischemic attack, or unstable angina, occurred in 123 patients, and all-cause mortality occurred in 68 patients. For each additional drug, the adjusted hazard ratios for MACE and all-cause mortality increased by 2.069 (p = 0.003) and 1.102 (p = 0.010). The adjusted hazard ratios for MACE and all-cause mortality were significantly higher in the group using nine or more drugs compared to the group using eight or fewer drugs (1.646 and 2.253, both p < 0.001).

Conclusion

This study showed that an increase in the number of drugs used for CCS may be associated with MACE and all-cause mortality. In patients with CCS, it might be beneficial to minimize the number of medications as much as possible, while managing comorbidities and using guideline-recommended drugs.

Background

Valvular calcification (VC) refers to the calcified valvular remodeling associated with kidney dysfunction, especially end-stage kidney disease (ESKD). ESKD patients with VC had significantly higher cardiovascular risk than those without. Factors interacted with VC regarding prognostic prediction in this population were seldom investigated. We aimed to examine the potential synergetic effects of VC and alkaline phosphatase (Alk-P) on ESKD patients’ cardiovascular risk and mortality.

Methods

ESKD patients undergoing hemodialysis were prospectively enrolled from a medical center in 2018. We identified patients with echocardiography and available serum Alk-P levels. Cox proportional hazard regression was performed to analyze the risk of major adverse cardiovascular events (MACEs), cardiovascular and overall mortality among 4 participant groups (with or without VC versus low or high Alk-P levels). The models were further adjusted for age, sex, and clinical variables.

Results

Of the 309 ESKD patients, 38, 46, 112, and 113 had no VC with low Alk-P, no VC with high Alk-P, VC with low Alk-P, and VC with high Alk-P, respectively. After adjusting for age and sex, patients with VC and high Alk-P had a higher risk of developing MACE, cardiovascular and overall mortality (HR, 3.07, 3.67, 3.65; 95% CI 1.38–6.84, 1.1–12.24, 1.29–10.36, respectively). Patients with VC and high Alk-P remained at higher risk of MACE (HR, 2.76; 95% CI 1.17–6.48) than did those without VC and with low Alk-P.

Conclusion

Serum Alk-P could be used to identify a subgroup of ESKD patients with elevated cardiovascular risk among those with VC.