Pub Date : 2024-09-12DOI: 10.1016/j.amjcard.2024.09.012
Reza Masoomi MD , Kathleen E. Kearney MD , Rhian E. Davies DO, MS
Complications in percutaneous coronary intervention (PCI), particularly in chronic total occlusion (CTO) cases, pose notable challenges, with a mortality rate of approximately 0.4% during hospitalization, mainly due to issues like perforation and tamponade. Although risk assessment tools can aid in evaluating periprocedural complication risk, prevention and preparedness take precedence. Guided by the “3 Ps” framework—prevention, preparedness, and planning—we navigate the complexities of managing complications in CTO PCI procedures. This emphasizes the importance of comprehensive patient discussions, adherence to appropriateness use criteria, and ensuring a well-trained team equipped with standardized equipment. Furthermore, it is crucial to extract valuable insights from encountered complications, turning potential setbacks into invaluable learning opportunities. This positive approach not only fosters individual growth but also contributes to the advancement of CTO PCI practices. Various complications specific to CTO PCI are addressed, including donor vessel injury, equipment loss/entrapment, radiation injury, and coronary perforation.
{"title":"Unlocking Success: Strategies for Preventing and Managing Complications in Chronic Total Occlusion Percutaneous Coronary Intervention Procedures","authors":"Reza Masoomi MD , Kathleen E. Kearney MD , Rhian E. Davies DO, MS","doi":"10.1016/j.amjcard.2024.09.012","DOIUrl":"10.1016/j.amjcard.2024.09.012","url":null,"abstract":"<div><div>Complications in percutaneous coronary intervention (PCI), particularly in chronic total occlusion (CTO) cases, pose notable challenges, with a mortality rate of approximately 0.4% during hospitalization, mainly due to issues like perforation and tamponade. Although risk assessment tools can aid in evaluating periprocedural complication risk, prevention and preparedness take precedence. Guided by the “3 Ps” framework—prevention, preparedness, and planning—we navigate the complexities of managing complications in CTO PCI procedures. This emphasizes the importance of comprehensive patient discussions, adherence to appropriateness use criteria, and ensuring a well-trained team equipped with standardized equipment. Furthermore, it is crucial to extract valuable insights from encountered complications, turning potential setbacks into invaluable learning opportunities. This positive approach not only fosters individual growth but also contributes to the advancement of CTO PCI practices. Various complications specific to CTO PCI are addressed, including donor vessel injury, equipment loss/entrapment, radiation injury, and coronary perforation.</div></div>","PeriodicalId":7705,"journal":{"name":"American Journal of Cardiology","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142279142","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Left ventricular (LV) thrombus formation remains a post-acute myocardial infarction (AMI) complication even in the modern era of early reperfusion. The optimal anticoagulation regimen in this clinical scenario is poorly defined. The present meta-analysis sought to investigate the efficacy and safety profile of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) for the management of LV thrombus after AMI. A systematic literature review was conducted in electronic databases to identify studies reporting efficacy and safety outcome data regarding the use of DOACs versus VKAs for patients with LV thrombus after AMI. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated, and random-effects meta-analyses were conducted to synthesize pooled ORs. Eight studies comprising a total of 605 patients were included. DOACs were associated with an almost twofold higher likelihood of thrombus resolution compared with VKAs (pooled OR 1.95 [1.25 to 3.04], p = 0.003, I2 = 0%), and decreased the risk of systemic embolism by 70% (pooled OR 0.30 [0.12 to 0.75]; p = 0.01, I2 = 0%). The use of DOACs was associated with a 54% lower risk of bleeding compared with VKAs (pooled OR 0.46 [0.26 to 0.84], p = 0.01, I2 = 0%). Overall, patients receiving DOACs had a 63% lower risk of reaching the composite outcome of safety and efficacy compared with patients using VKAs (pooled OR 0.37 [0.23 to 0.60], p <0.0001, I2 = 0%). In conclusion, DOACs appear to have a more favorable efficacy and safety profile compared with VKAs for the management of LV thrombus related to AMI.
{"title":"Direct Oral Anticoagulants Versus Vitamin K Antagonists for the Management of Left Ventricular Thrombus After Myocardial Infarction: A Meta-Analysis","authors":"Christos Gogos MD , Vasileios Anastasiou MD , Andreas S. Papazoglou MD , Stylianos Daios MD , Matthaios Didagelos MD, PhD , Nikolaos Kamperidis MD, PhD , Vasileios Moschovidis MD , Spyridon Filippos Papadopoulos MD , Fotini Iatridi MD , Pantelis Sarafidis MD, PhD , George Giannakoulas MD, PhD , Vasileios Sachpekidis MD, PhD , Antonios Ziakas MD, PhD , Vasileios Kamperidis MD, PhD","doi":"10.1016/j.amjcard.2024.09.008","DOIUrl":"10.1016/j.amjcard.2024.09.008","url":null,"abstract":"<div><div>Left ventricular (LV) thrombus formation remains a post-acute myocardial infarction (AMI) complication even in the modern era of early reperfusion. The optimal anticoagulation regimen in this clinical scenario is poorly defined. The present meta-analysis sought to investigate the efficacy and safety profile of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) for the management of LV thrombus after AMI. A systematic literature review was conducted in electronic databases to identify studies reporting efficacy and safety outcome data regarding the use of DOACs versus VKAs for patients with LV thrombus after AMI. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated, and random-effects meta-analyses were conducted to synthesize pooled ORs. Eight studies comprising a total of 605 patients were included. DOACs were associated with an almost twofold higher likelihood of thrombus resolution compared with VKAs (pooled OR 1.95 [1.25 to 3.04], p = 0.003, I<sup>2</sup> = 0%), and decreased the risk of systemic embolism by 70% (pooled OR 0.30 [0.12 to 0.75]; p = 0.01, I<sup>2</sup> = 0%). The use of DOACs was associated with a 54% lower risk of bleeding compared with VKAs (pooled OR 0.46 [0.26 to 0.84], p = 0.01, I<sup>2</sup> = 0%). Overall, patients receiving DOACs had a 63% lower risk of reaching the composite outcome of safety and efficacy compared with patients using VKAs (pooled OR 0.37 [0.23 to 0.60], p <0.0001, I<sup>2</sup> = 0%). In conclusion, DOACs appear to have a more favorable efficacy and safety profile compared with VKAs for the management of LV thrombus related to AMI.</div></div>","PeriodicalId":7705,"journal":{"name":"American Journal of Cardiology","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142279134","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-07DOI: 10.1016/j.amjcard.2024.08.034
Khawaja M. Talha MBBS , Kendall Hammonds MPH , Ayman Alhamdow PhD , Monica M. Bennett PhD , Jaccallene Vee Anne Bomar , Jason A. Ettlinger MA , Monica Martinez-Traba MD , Elisabeth Sophia Hartgers-Gubbels MS , Elisa L. Priest PhD , Courtney N. Shaver MS , Aasim Afzal MD, MBA , Robert J. Widmer MD, PhD , Robert L. Gottlieb MD, PhD , Michael J. Mack MD , Javed Butler MD, MPH, MBA
The contemporary health care resource utilization after an acute myocardial infarction (MI) is not well-known. All patients admitted because of MI between January 2015 and December 2021 across 28 hospitals in the Baylor Scott & White Health system were studied. Patient characteristics and outcomes, including all-cause and cardiovascular (CV) rehospitalizations, emergency department (ED) visits, and outpatient visits were evaluated. Of 6,804 patients admitted because of MI, 6,556 were discharged alive. The median age was 69 years, 60% were men, and 77% had non–ST-elevation MI; 17% (1,090) had multivessel disease. The number of patients with first all-cause readmissions within 30 days, 3 months, and 12 months of discharge were 844 (13%), 1,372 (21%), and 2,306 (35%), respectively, with a higher readmission rate in patients with non–ST-elevation MI, previous heart failure (HF), new-onset HF, and left ventricular ejection fraction ≤40%. ED visits at 12 months for any cause were 2,401 (37%), of which 1,321 (55%) were for any CV cause, with a higher incidence in patients with previous HF. Of the 6,556 patients, 4,102 (63%) had at least 1 primary care visit in the past year, 5,009 (76%) had CV specialty visits, and 3,860 (59%) had non-CV visits, with a similar distribution across subgroups. Patients hospitalized with an MI had a high risk of subsequent hospital readmissions and ED and outpatient visits, especially those with a previous HF diagnosis and those discharged with an MI and HF diagnosis.
{"title":"Health Care Resource Utilization Following Acute Myocardial Infarction: Findings from the RECORD-MI Registry","authors":"Khawaja M. Talha MBBS , Kendall Hammonds MPH , Ayman Alhamdow PhD , Monica M. Bennett PhD , Jaccallene Vee Anne Bomar , Jason A. Ettlinger MA , Monica Martinez-Traba MD , Elisabeth Sophia Hartgers-Gubbels MS , Elisa L. Priest PhD , Courtney N. Shaver MS , Aasim Afzal MD, MBA , Robert J. Widmer MD, PhD , Robert L. Gottlieb MD, PhD , Michael J. Mack MD , Javed Butler MD, MPH, MBA","doi":"10.1016/j.amjcard.2024.08.034","DOIUrl":"10.1016/j.amjcard.2024.08.034","url":null,"abstract":"<div><div>The contemporary health care resource utilization after an acute myocardial infarction (MI) is not well-known. All patients admitted because of MI between January 2015 and December 2021 across 28 hospitals in the Baylor Scott & White Health system were studied. Patient characteristics and outcomes, including all-cause and cardiovascular (CV) rehospitalizations, emergency department (ED) visits, and outpatient visits were evaluated. Of 6,804 patients admitted because of MI, 6,556 were discharged alive. The median age was 69 years, 60% were men, and 77% had non–ST-elevation MI; 17% (1,090) had multivessel disease. The number of patients with first all-cause readmissions within 30 days, 3 months, and 12 months of discharge were 844 (13%), 1,372 (21%), and 2,306 (35%), respectively, with a higher readmission rate in patients with non–ST-elevation MI, previous heart failure (HF), new-onset HF, and left ventricular ejection fraction ≤40%. ED visits at 12 months for any cause were 2,401 (37%), of which 1,321 (55%) were for any CV cause, with a higher incidence in patients with previous HF. Of the 6,556 patients, 4,102 (63%) had at least 1 primary care visit in the past year, 5,009 (76%) had CV specialty visits, and 3,860 (59%) had non-CV visits, with a similar distribution across subgroups. Patients hospitalized with an MI had a high risk of subsequent hospital readmissions and ED and outpatient visits, especially those with a previous HF diagnosis and those discharged with an MI and HF diagnosis.</div></div>","PeriodicalId":7705,"journal":{"name":"American Journal of Cardiology","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-09-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142279138","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-07DOI: 10.1016/j.amjcard.2024.08.036
Ovidio A. García-Villarreal MD
{"title":"Reoperation Rate Versus Failure Rate as Quality Indicators in Transcatheter Edge-to-Edge Repair for Mitral Regurgitation","authors":"Ovidio A. García-Villarreal MD","doi":"10.1016/j.amjcard.2024.08.036","DOIUrl":"10.1016/j.amjcard.2024.08.036","url":null,"abstract":"","PeriodicalId":7705,"journal":{"name":"American Journal of Cardiology","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-09-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142153050","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-07DOI: 10.1016/j.amjcard.2024.08.032
Danial Ahmad MD , Michel Pompeu Sá MD , Sarah Yousef MD , James A. Brown MD , Nandini Doshi BS , Dustin E. Kliner MD , Derek Serna-Gallegos MD , Yisi Wang MPH , Floyd Thoma BS , Catalin Toma MD , Amber Makani MD , Irsa Hasan MD , Dave West MD , Ibrahim Sultan MD
Self-expanding (SE) and balloon-expandable (BE) transcatheter heart valves (THVs) have not been extensively studied in valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR). We compared outcomes of supra-annular SE and BE THVs used for ViV-TAVR through a retrospective analysis of institutional data (2013 to 2023) including all patients who underwent ViV-TAVR (TAVR in previous surgical aortic valve replacement). Unmatched and propensity-matched (1:1) comparisons of clinical and echocardiographic outcomes were undertaken in SE and BE THVs along with Kaplan-Meier survival analysis. A total of 315 patients who underwent ViV-TAVR were included, of whom 73% received an SE THV. Median age was 77 years, and women comprised 42.5% of the population. Propensity-score matching (1:1) yielded 81 matched pairs. Implanted aortic valve size was comparable in the groups (23 mm [23 to 26] vs 23 mm [23 to 26], p = 0.457). At 30 days after ViV-TAVR, the SE group had a lower mean aortic valve gradient (14 mm Hg [11 to 18] vs 17.5 mm Hg [13 to 25], p = 0.007). A greater number of patients with BE THV had severe prosthesis-patient mismatch (16% vs 6.2%, p = 0.04). At 1-year follow-up, the SE THV group had a lower aortic valve gradient (14.0 mm Hg [9.6 to 19] vs 17 mm Hg [13 to 25], p = 0.04) than that of the BE THV group; 30-day mortality was 2.7%, whereas 1-year mortality was 7.5% and comparable in the groups. Survival and stroke incidence were similar in the groups up to 5 years. In conclusion, SE and BE THVs had comparable survival after ViV-TAVR. The higher residual aortic valve gradients in BE THVs are likely due to valve design and warrant long-term evaluation for potential structural valve degeneration.
自膨胀（SE）和球囊扩张（BE）经导管心脏瓣膜（THV）在瓣膜内经导管主动脉瓣置换术（ViV-TAVR）中的应用尚未得到广泛研究。我们通过对机构数据（2013-2023 年）的回顾性分析，比较了用于 ViV-TAVR 的环上 SE 和 BE THV 的疗效，其中包括所有接受 ViV-TAVR 的患者（既往接受过手术 AVR 的 TAVR 患者）。对 SE 和 BE THV 的临床和超声心动图结果进行了非匹配和倾向匹配（1:1）比较，并进行了 Kaplan-Meier 生存分析。共纳入了315名接受ViV-TAVR的患者，其中73%接受了SE THV。中位年龄为77岁，女性占42.5%。倾向分数匹配（1:1）产生了81对匹配对。两组的植入主动脉瓣大小相当（23 毫米 [23-26] 对 23 毫米 [23-26]，P=0.457）。在 ViV-TAVR 术后 30 天，SE 组的平均主动脉瓣梯度较低（14 mmHg [11-18] vs. 17.5 mmHg [13-25]，P=0.007）。更多的 BE 患者存在严重的假体与患者不匹配（PPM）（16% 对 6.2%，P=0.04）。随访一年时，与 BE 组相比，SE 组的主动脉瓣梯度较低（14.0 mmHg [9.6-19] vs. 17 mmHg [13-25]，P=0.04）。30 天死亡率为 2.7%，一年死亡率为 7.5%，两组死亡率相当。两组 5 年内的存活率和中风发生率相似。总之，SE和BE THV在ViV-TAVR术后的存活率相当。BE THV的主动脉瓣残余梯度较高，这可能是由于瓣膜设计造成的，因此需要对潜在的结构性瓣膜退化进行长期评估。
{"title":"Supra-Annular Self-Expanding Versus Balloon-Expandable Valves for Valve-in-Valve Transcatheter Aortic Valve Replacement","authors":"Danial Ahmad MD , Michel Pompeu Sá MD , Sarah Yousef MD , James A. Brown MD , Nandini Doshi BS , Dustin E. Kliner MD , Derek Serna-Gallegos MD , Yisi Wang MPH , Floyd Thoma BS , Catalin Toma MD , Amber Makani MD , Irsa Hasan MD , Dave West MD , Ibrahim Sultan MD","doi":"10.1016/j.amjcard.2024.08.032","DOIUrl":"10.1016/j.amjcard.2024.08.032","url":null,"abstract":"<div><div>Self-expanding (SE) and balloon-expandable (BE) transcatheter heart valves (THVs) have not been extensively studied in valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR). We compared outcomes of supra-annular SE and BE THVs used for ViV-TAVR through a retrospective analysis of institutional data (2013 to 2023) including all patients who underwent ViV-TAVR (TAVR in previous surgical aortic valve replacement). Unmatched and propensity-matched (1:1) comparisons of clinical and echocardiographic outcomes were undertaken in SE and BE THVs along with Kaplan-Meier survival analysis. A total of 315 patients who underwent ViV-TAVR were included, of whom 73% received an SE THV. Median age was 77 years, and women comprised 42.5% of the population. Propensity-score matching (1:1) yielded 81 matched pairs. Implanted aortic valve size was comparable in the groups (23 mm [23 to 26] vs 23 mm [23 to 26], p = 0.457). At 30 days after ViV-TAVR, the SE group had a lower mean aortic valve gradient (14 mm Hg [11 to 18] vs 17.5 mm Hg [13 to 25], p = 0.007). A greater number of patients with BE THV had severe prosthesis-patient mismatch (16% vs 6.2%, p = 0.04). At 1-year follow-up, the SE THV group had a lower aortic valve gradient (14.0 mm Hg [9.6 to 19] vs 17 mm Hg [13 to 25], p = 0.04) than that of the BE THV group; 30-day mortality was 2.7%, whereas 1-year mortality was 7.5% and comparable in the groups. Survival and stroke incidence were similar in the groups up to 5 years. In conclusion, SE and BE THVs had comparable survival after ViV-TAVR. The higher residual aortic valve gradients in BE THVs are likely due to valve design and warrant long-term evaluation for potential structural valve degeneration.</div></div>","PeriodicalId":7705,"journal":{"name":"American Journal of Cardiology","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-09-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142153051","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-06DOI: 10.1016/j.amjcard.2024.09.005
C. Charles Jain MD , Alexander C. Egbe MBBS , Thomas G. Allison PhD, MPH , Alexander van de Bruaene MD , Barry A. Borlaug MD , Heidi M. Connolly MD , Luke J. Burchill MBBS, PhD , William R. Miranda MD
Although cardiopulmonary exercise testing (CPET) parameters have known prognostic value in adults after Fontan palliation, there are limited data correlating treadmill CPET with invasive exercise hemodynamics. Furthermore, the invasive hemodynamic underpinnings of exercise limitations have not been thoroughly investigated. This is a retrospective analysis of 55 adults (age ≥18 years) with prior Fontan palliation who underwent treadmill CPET before invasive exercise hemodynamic testing using a supine cycle protocol between November 2018 and April 2023. The median age was 32.2 (IQR 24.1; 37.2) years. The peak heart rate (HR) was 139.7 ± 28.1 beats per minute and the peak oxygen consumption (VO2) was 19.1 ± 5.7 ml/kg/min (47.4 ± 13.5% predicted). VO2/HR was directly related to exercise stroke volume index (r = 0.50, p = 0.0002), whereas no association was seen with exercise arterio-mixed venous O2 content difference (r = 0.14, p = 0.32). Peak HR was inversely related to exercise pulmonary artery (PA) pressures (r = −0.61, p <0.0001) and PA wedge pressures (PAWP) (r = −0.61, p <0.0001). Moreover, %predicted VO2 was inversely related to exercise PA pressures (r = −0.50, p <0.0001) and PAWP (r = −0.55, p <0.0001). Peak VO2 ≤19.1 ml/kg/min had a sensitivity of 81% and a specificity of 76% (area under the curve 0.82) for predicting a ΔPAWP/ΔQs ratio >2 mmHg/L/min and/or a ΔPA/ΔQp >3 mmHg/L/min, whereas a predicted peak VO2 ≤48% had a sensitivity of 74% and a specificity of 81% (area under the curve 0.79) for the same parameters. In summary, lower peak HR and peak VO2 were associated with higher exercise PAWP and PA pressure. Peak VO2 ≤48% predicted provided the optimal cutoff for predicting increased indexed exercise PAWP or PA pressures; therefore, low peak VO2 should alert clinicians of abnormal underlying hemodynamics.
{"title":"Functional Capacity Assessment in Adults After Fontan Palliation: A Cardiopulmonary Exercise Test–Invasive Exercise Hemodynamics Correlation Study","authors":"C. Charles Jain MD , Alexander C. Egbe MBBS , Thomas G. Allison PhD, MPH , Alexander van de Bruaene MD , Barry A. Borlaug MD , Heidi M. Connolly MD , Luke J. Burchill MBBS, PhD , William R. Miranda MD","doi":"10.1016/j.amjcard.2024.09.005","DOIUrl":"10.1016/j.amjcard.2024.09.005","url":null,"abstract":"<div><div>Although cardiopulmonary exercise testing (CPET) parameters have known prognostic value in adults after Fontan palliation, there are limited data correlating treadmill CPET with invasive exercise hemodynamics. Furthermore, the invasive hemodynamic underpinnings of exercise limitations have not been thoroughly investigated. This is a retrospective analysis of 55 adults (age ≥18 years) with prior Fontan palliation who underwent treadmill CPET before invasive exercise hemodynamic testing using a supine cycle protocol between November 2018 and April 2023. The median age was 32.2 (IQR 24.1; 37.2) years. The peak heart rate (HR) was 139.7 ± 28.1 beats per minute and the peak oxygen consumption (VO<sub>2</sub>) was 19.1 ± 5.7 ml/kg/min (47.4 ± 13.5% predicted). VO<sub>2</sub>/HR was directly related to exercise stroke volume index (<em>r</em> = 0.50, p = 0.0002), whereas no association was seen with exercise arterio-mixed venous O<sub>2</sub> content difference (<em>r</em> = 0.14, p = 0.32). Peak HR was inversely related to exercise pulmonary artery (PA) pressures (r = −0.61, p <0.0001) and PA wedge pressures (PAWP) (<em>r</em> = −0.61, p <0.0001). Moreover, %predicted VO<sub>2</sub> was inversely related to exercise PA pressures (<em>r</em> = −0.50, p <0.0001) and PAWP (<em>r</em> = −0.55, p <0.0001). Peak VO<sub>2</sub> ≤19.1 ml/kg/min had a sensitivity of 81% and a specificity of 76% (area under the curve 0.82) for predicting a ΔPAWP/ΔQs ratio >2 mmHg/L/min and/or a ΔPA/ΔQp >3 mmHg/L/min, whereas a predicted peak VO<sub>2</sub> ≤48% had a sensitivity of 74% and a specificity of 81% (area under the curve 0.79) for the same parameters. In summary, lower peak HR and peak VO<sub>2</sub> were associated with higher exercise PAWP and PA pressure. Peak VO<sub>2</sub> ≤48% predicted provided the optimal cutoff for predicting increased indexed exercise PAWP or PA pressures; therefore, low peak VO<sub>2</sub> should alert clinicians of abnormal underlying hemodynamics.</div></div>","PeriodicalId":7705,"journal":{"name":"American Journal of Cardiology","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-09-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142153049","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-06DOI: 10.1016/j.amjcard.2024.09.006
Thomas O'Toole MD , Nishant P. Shah MD , Stephanie Nicole Giamberardino ScM , Lydia Coulter Kwee PhD , Deepak Voora MD , Robert W. McGarrah MD , Maros Ferencik MD, PhD, MCR , Michael T. Lu MD, MPH , William E. Kraus MD , Borek Foldyna MD , Pamela S. Douglas MD , Svati H. Shah MD , Neha J. Pagidipati MD
The role of lipoprotein (a) (Lp[a]) in the development of obstructive coronary artery disease (CAD) and high-risk plaque (HRP) in primary prevention patients with stable chest pain is unknown. We sought to evaluate the relation of Lp(a), independent of low-density lipoprotein cholesterol (LDL-C), with the presence of obstructive CAD and HRP to improve understanding of the residual risk imparted by Lp(a) on CAD. We performed a secondary analysis in Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) Trial participants who had coronary computed tomographic angiography (CTA) performed and Lp(a) data available. Lp(a) concentration was analyzed as a binary variable, with elevated Lp(a) defined as ≥50 mg/100 ml. “Stenosis ≥50%” was defined as ≥50% coronary artery stenosis in any epicardial vessel, and “stenosis ≥70%” was defined as ≥70% coronary artery stenosis in any epicardial vessel and/or ≥50% left main coronary artery stenosis. HRP was defined as presence of plaque on CTA imaging with evidence of positive remodeling, low computed tomography attenuation, or napkin-ring sign. Multivariate logistic regression models were constructed to evaluate the association between Lp(a) and the outcomes of obstructive CAD and HRP stratified by LDL-C ≥100 versus <100 mg/100 ml. Of the 1,815 patients who underwent CTA and had Lp(a) data available, those with elevated Lp(a) were more commonly women and Black than those with lower Lp(a). Elevated Lp(a) was associated with stenosis ≥50% (odds ratio 1.57, 95% confidence interval 1.14 to 2.15, p = 0.005) and stenosis ≥70% (odds ratio 2.05, 95% confidence interval 1.34 to 3.11, p = 0.0008) in the multivariate models, and this relation was not modified by LDL-C ≥100 versus <100 mg/100 ml (interaction p >0.4). Elevated Lp(a) was not associated with HRP when adjusted for obstructive CAD. This study of patients without known CAD found that elevated Lp(a) ≥50 mg/100 ml was independently associated with the presence of obstructive CAD regardless of controlled versus uncontrolled LDL-C but was not independently associated with HRP when stenosis ≥50% or ≥70% was accounted for. Further research is warranted to delineate the role of Lp(a) in the residual risk for atherosclerotic cardiovascular disease that patients may have despite optimal LDL-C lowering.
{"title":"Association Between Lipoprotein(a) and Obstructive Coronary Artery Disease and High-Risk Plaque: Insights From the PROMISE Trial","authors":"Thomas O'Toole MD , Nishant P. Shah MD , Stephanie Nicole Giamberardino ScM , Lydia Coulter Kwee PhD , Deepak Voora MD , Robert W. McGarrah MD , Maros Ferencik MD, PhD, MCR , Michael T. Lu MD, MPH , William E. Kraus MD , Borek Foldyna MD , Pamela S. Douglas MD , Svati H. Shah MD , Neha J. Pagidipati MD","doi":"10.1016/j.amjcard.2024.09.006","DOIUrl":"10.1016/j.amjcard.2024.09.006","url":null,"abstract":"<div><div>The role of lipoprotein (a) (Lp[a]) in the development of obstructive coronary artery disease (CAD) and high-risk plaque (HRP) in primary prevention patients with stable chest pain is unknown. We sought to evaluate the relation of Lp(a), independent of low-density lipoprotein cholesterol (LDL-C), with the presence of obstructive CAD and HRP to improve understanding of the residual risk imparted by Lp(a) on CAD. We performed a secondary analysis in Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) Trial participants who had coronary computed tomographic angiography (CTA) performed and Lp(a) data available. Lp(a) concentration was analyzed as a binary variable, with elevated Lp(a) defined as ≥50 mg/100 ml. “Stenosis ≥50%” was defined as ≥50% coronary artery stenosis in any epicardial vessel, and “stenosis ≥70%” was defined as ≥70% coronary artery stenosis in any epicardial vessel and/or ≥50% left main coronary artery stenosis. HRP was defined as presence of plaque on CTA imaging with evidence of positive remodeling, low computed tomography attenuation, or napkin-ring sign. Multivariate logistic regression models were constructed to evaluate the association between Lp(a) and the outcomes of obstructive CAD and HRP stratified by LDL-C ≥100 versus <100 mg/100 ml. Of the 1,815 patients who underwent CTA and had Lp(a) data available, those with elevated Lp(a) were more commonly women and Black than those with lower Lp(a). Elevated Lp(a) was associated with stenosis ≥50% (odds ratio 1.57, 95% confidence interval 1.14 to 2.15, p = 0.005) and stenosis ≥70% (odds ratio 2.05, 95% confidence interval 1.34 to 3.11, p = 0.0008) in the multivariate models, and this relation was not modified by LDL-C ≥100 versus <100 mg/100 ml (interaction p >0.4). Elevated Lp(a) was not associated with HRP when adjusted for obstructive CAD. This study of patients without known CAD found that elevated Lp(a) ≥50 mg/100 ml was independently associated with the presence of obstructive CAD regardless of controlled versus uncontrolled LDL-C but was not independently associated with HRP when stenosis ≥50% or ≥70% was accounted for. Further research is warranted to delineate the role of Lp(a) in the residual risk for atherosclerotic cardiovascular disease that patients may have despite optimal LDL-C lowering.</div></div>","PeriodicalId":7705,"journal":{"name":"American Journal of Cardiology","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-09-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142153048","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-05DOI: 10.1016/j.amjcard.2024.08.033
Vincent Chen MD , Barry R. Davis MD, PhD , Samir R. Kapadia MD , Michael W. Kattan PhD , Larisa G. Tereshchenko MD, PhD
In modern clinical practice, less than half of patients with new-onset heart failure (HF) undergo ischemic evaluation and only a minority undergo revascularization. We aimed to assess the proportion of the effect of hypertension (antihypertensive treatment) on incident HF to be eliminated by prevention of coronary heart disease (CHD) event treated with or without revascularization, considering possible treatment-mediator interaction. The causal mediation analysis of Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) included 42,418 participants (age 66.9 ± 7.7, 35.6% black, 53.2% men). A new CHD event (myocardial infarction or angina) that occurred after randomization but before the incident HF outcome was the mediator. Incident symptomatic congestive HF (CHF) and hospitalized/fatal HF (HHF) were the primary and secondary outcomes, respectively. Logistic regression (for mediator) and Cox proportional hazards regression (for outcome) were adjusted for demographics, cardiovascular disease history, and risk factors. During a median 4.5-year follow-up, 2,785 patients developed CHF, including 2,216 HHF events. Participants who developed CHD events had twice the higher incidence rate of CHF than CHD-free (28.5 vs 13.9 events/1,000 person-years). The proportion of reference interaction indicating direct harm because of a CHD event for lisinopril (234% for CHF, 355% for HHF) and amlodipine (244% for CHF, 468% for HHF) was greater than for chlortalidone (143% for CHF, 269% for HHF). In patients with revascularized CHD events, chlortalidone and amlodipine eliminated 21% to 24% and lisinopril eliminated −45% of HHF. Antihypertensive treatment could not eliminate harm from CHD events treated without revascularization. In conclusion, the antihypertensive drugs (chlortalidone, lisinopril, and amlodipine) prevent HF not principally by preventing CHD events but by way of other pathways. HF is moderated but not mediated by CHD events. Revascularization of CHD events is paramount for HF prevention.
{"title":"Prevention of Heart Failure in Hypertension—the Role of Coronary Heart Disease Events Treated With Versus Without Revascularization: The ALLHAT Study","authors":"Vincent Chen MD , Barry R. Davis MD, PhD , Samir R. Kapadia MD , Michael W. Kattan PhD , Larisa G. Tereshchenko MD, PhD","doi":"10.1016/j.amjcard.2024.08.033","DOIUrl":"10.1016/j.amjcard.2024.08.033","url":null,"abstract":"<div><p>In modern clinical practice, less than half of patients with new-onset heart failure (HF) undergo ischemic evaluation and only a minority undergo revascularization. We aimed to assess the proportion of the effect of hypertension (antihypertensive treatment) on incident HF to be eliminated by prevention of coronary heart disease (CHD) event treated with or without revascularization, considering possible treatment-mediator interaction. The causal mediation analysis of Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) included 42,418 participants (age 66.9 ± 7.7, 35.6% black, 53.2% men). A new CHD event (myocardial infarction or angina) that occurred after randomization but before the incident HF outcome was the mediator. Incident symptomatic congestive HF (CHF) and hospitalized/fatal HF (HHF) were the primary and secondary outcomes, respectively. Logistic regression (for mediator) and Cox proportional hazards regression (for outcome) were adjusted for demographics, cardiovascular disease history, and risk factors. During a median 4.5-year follow-up, 2,785 patients developed CHF, including 2,216 HHF events. Participants who developed CHD events had twice the higher incidence rate of CHF than CHD-free (28.5 vs 13.9 events/1,000 person-years). The proportion of reference interaction indicating direct harm because of a CHD event for lisinopril (234% for CHF, 355% for HHF) and amlodipine (244% for CHF, 468% for HHF) was greater than for chlortalidone (143% for CHF, 269% for HHF). In patients with revascularized CHD events, chlortalidone and amlodipine eliminated 21% to 24% and lisinopril eliminated −45% of HHF. Antihypertensive treatment could not eliminate harm from CHD events treated without revascularization. In conclusion, the antihypertensive drugs (chlortalidone, lisinopril, and amlodipine) prevent HF not principally by preventing CHD events but by way of other pathways. HF is moderated but not mediated by CHD events. Revascularization of CHD events is paramount for HF prevention.</p></div>","PeriodicalId":7705,"journal":{"name":"American Journal of Cardiology","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-09-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142144968","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-05DOI: 10.1016/j.amjcard.2024.08.022
Muhammad Shahzeb Khan MD, MSc , Rohan Kumar Ochani MD , Javed Butler MD, MPH, MBA
{"title":"Implications of Diuretic Use in Contextualizing Clinical Trial Results in Patients With Heart Failure With Preserved Ejection Fraction","authors":"Muhammad Shahzeb Khan MD, MSc , Rohan Kumar Ochani MD , Javed Butler MD, MPH, MBA","doi":"10.1016/j.amjcard.2024.08.022","DOIUrl":"10.1016/j.amjcard.2024.08.022","url":null,"abstract":"","PeriodicalId":7705,"journal":{"name":"American Journal of Cardiology","volume":null,"pages":null},"PeriodicalIF":2.3,"publicationDate":"2024-09-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142144966","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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