American heart journal最新文献

Background: Cancer and cancer treatment may accelerate the development of cardiovascular disease. With the improved prognosis of cancer survivors, cardiovascular events are increasing in this patient group. However, it is unknown whether the prevalence of coronary atherosclerosis is increased in patients with a history of cancer. This study aims to evaluate the prevalence and severity of coronary atherosclerosis in different age groups of cancer survivors compared to matched controls.

Methods: Consecutive cancer survivors aged >30 years who underwent evaluation for stable coronary artery disease with coronary computed tomography angiography (CCTA) were included in this retrospective study. Propensity score matching was performed and cancer survivors were matched 1:2 to a control population without oncological history. The presence of coronary atherosclerosis was assessed in both groups.

Results: The study population consisted of 312 cancer survivors and 624 matched controls. Median age at CCTA scan was 59.2 [50.3-67.5] years and 66.0% was female. Coronary atherosclerosis was observed in 257 (82.4%) cancer survivors compared to 459 (73.6%) control patients with an Odds Ratio (OR) of 1.68 [95% CI: 1.19-2.36], p=0.003. Mainly younger cancer survivors aged between 30-59 years had an increased prevalence of coronary atherosclerosis with an OR of 2.21 [95% CI: 1.40-3.49] compared to control patients (p=0.001). In addition, thoracic radiotherapy showed a significant association with increased prevalence of atherosclerosis in the younger population with an OR of 3.29 ([95% CI: 1.70-6.38], p<0.001).

Conclusions: Patients with a history cancer have an increased prevalence of coronary atherosclerosis on CCTA compared to matched patients without cancer. This effect was most pronounced in younger patients aged 30-59 years.

Background: The role of lipoprotein(a) (Lp(a)) in the risk-assessment of patients with de-novo stable chest pain is sparsely investigated. We assessed the association between Lp(a) concentration and the presence of coronary stenosis on coronary computed tomography (CT) angiography in a broad population of patients referred with stable chest pain.

Methods: Lp(a) measurements and coronary CT angiography were performed in 4,346 patients with stable chest pain and no previous history of coronary artery disease. The patients were included in the trial program, the Danish study of Non-Invasive testing in Coronary artery disease, Dan-NICAD. The prevalence and odds ratios for stenosis were calculated comparing normal Lp(a) (< 20 nmol/l) with moderately elevated (20 to <125 nmol/l), high (125 to <200 nmol/l), and very high (≥200 nmol/l) Lp(a) concentrations in both univariate and multivariate analyses.

Results: In total, 2,418 (55.6%), 1,276 (29.4%), 425 (9.8%), and 227 (5.2%) patients had normal, moderately elevated, high, and very high Lp(a) levels, respectively. The prevalences of coronary stenosis increased with increasing Lp(a) concentration (n = 569 (23.5%), n = 328 (25.7%), n = 129 (30.4%), and n = 77 (33.9%) in patients with normal, moderately elevated, high, and very high Lp(a), respectively). Likewise, the prevalence of patients with multivessel disease increased with increasing Lp(a) concentration (n = 252 (10.4%), n = 149 (11.7%), n = 61 (14.4%), and n = 41 (18.1%) in patients with normal, moderately elevated, high, and very high Lp(a), respectively). In an unadjusted model, odds ratios for stenosis increased with increasing Lp(a) concentrations (odds ratio (95% CI): 1.12 (0.96-1.31), 1.42 (1.13-1.77), and 1.67 (1.24-2.22) for moderately elevated, high, and very high Lp(a) versus normal Lp(a), respectively). Adjustment for age, sex, and cardiovascular risk factors did not affect the association.

Conclusions: In stable, symptomatic patients without established coronary artery disease, Lp(a) levels are positively associated with the presence of coronary stenosis on coronary CT angiography. These findings may warrant using Lp(a) in the diagnostic management of patient with suspected coronary artery disease.

Trial registration: The three studies within the Dan-NICAD program are registered on ClinicalTrials.gov: Dan-NICAD, NCT02264717, https://clinicaltrials.gov/study/NCT02264717?term=dan-nicad&rank=1. Dan-NICAD 2, NCT03481712, https://clinicaltrials.gov/study/NCT03481712?term=dan-nicad&rank=3. Dan-NICAD 3, NCT04707859, https://clinicaltrials.gov/study/NCT04707859?term=dan-nicad&rank=2.

Background: The prevalence, chronicity and clinical impact of type 2 diabetes (T2D) defines this disease state as a critical determinant in morbidity and mortality, as encountered by individuals, health care systems, and public health in general. The need to understand and optimize T2D identification and management is now further heightened by the advent of medications with established cardiovascular (CV) and kidney benefits in such patients, namely sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1 RA). Prescription rates for these agents have remained low despite guidelines incorporating and emphasizing their use. Better understanding T2D disease and management patterns, including percentage of patients meeting guideline indications, is necessary to address undertreatment, improve patient management, and enable better strategies. We evaluated such issues, including eligibility for and utilization of SGLT2i and GLP-1 RA, in a large health system caring for over 1.5 million patients annually.

Methods: The electronic health record (EHR) at a large health network in the Northeastern United States was queried to identify patients 18 yrs of age or older with T2D and at least 1 hemoglobin A1c (HbA1c) between 1/1/2020 and 1/1/2023, examining those with T2D and 1) atherosclerotic CV disease (ASCVD), 2) an estimated 10-year ASCVD risk score ≥10% without known ASCVD, 3) heart failure (HF), and/or 4) chronic kidney disease (CKD) based on EHR listed comorbidities. Demographics, medications, comorbidities, and indications for SGLT2i and/or GLP-1 RA therapy were assessed by one or more of the 4 indications above as outlined in society guidelines.

Results: Of the 147,338 patients who met inclusion criteria, 47% were female, 28% were non-white, and 14% with a non-English language preference. Of those, 121,508 (83%) had an indication for either SGLT2i or GLP-1 RA based on guideline recommendations: 17% were prescribed an SGLT2i, 22% were prescribed GLP-1 RA, and 6% of patients were prescribed both medications, with only 32% of those eligible prescribed therapy. Of patients eligible for either an SGLT2i or GLP-1 RA therapy not currently receiving either therapy, 49% had 10-year ASCVD risk ≥10% without known ASCVD, 42% had ASCVD, 52% had CKD, and 14% had HF.

Conclusion: More than four out of five patients with T2D had a CV or kidney indication for either SGLT2i or GLP-1 RA. However, uptake of SGLT2i/GLP-1 RA in these high-risk populations remains low (just 32%) across this health network. Future studies are needed to identify better strategies to overcome provider, patient, and system-level barriers to the uptake and dissemination of guideline-concordant T2D therapies.

Background: Contrast-induced acute kidney injury (CI-AKI) is a frequent complication of coronary interventions associated with an increased risk of mortality and morbidity. The optimal intravenous hydration strategy to prevent CI-AKI is not well-established. The primary objective is to determine if a tailored hydration strategy reduces the risk of CI-AKI and of major adverse cardiovascular events (MACE) in patients undergoing coronary angiography compared with a non-tailored hydration strategy.

Methods: A study-level meta-analysis of randomized controlled trials comparing tailored versus non-tailored hydration strategies for the prevention of CI-AKI (primary outcome) and of MACE (main secondary outcome) in patients undergoing coronary angiography for any indication was performed. Tailored hydration was defined as the administration of intravenous fluids based on patient-specific parameters other than weight only.

Results: A total of 13 studies were included (n = 4,458 participants). The overall risk of bias was moderate. A tailored strategy was associated with a significant reduction in the risk of CI-AKI (RR=0.56, 95% CI, [0.46-0.69], p<0.00001; I²=26%), and of MACE (RR=0.57, 95% CI, [0.42-0.78], p=0.0005; I²=12%). A tailored hydration strategy was not associated with a significant reduction in the other pre-specified secondary outcomes, except for all-cause mortality (RR=0.57, 95% CI, [0.35, 0.94], p=0.03; I²=0%). The impact of a tailored strategy on the primary outcome was consistent in sensitivity analyses.

Conclusion: These results suggest that tailored hydration is superior to non-tailored hydration in reducing the risk of CI-AKI and MACE in patients undergoing coronary angiography. Future trials are required to identify the optimal tailored hydration strategy.

Background: - Little is known about mitral transcatheter edge-to-edge repair (TEER) performed outside of usual working hours. We aimed to explore the prevalence, correlates, and outcomes of mitral TEER initiated off-hours, i.e. before 7:30 am, after 5:30 pm, or on weekends/holidays.

Methods: - A single-center registry of isolated, first-time interventions was retrospectively analyzed in its entirety and after propensity-score matching. Outcomes included all-cause mortality, heart failure (HF) hospitalizations, and the persistence of significant mitral regurgitation (MR) and functional incapacitation along the first postprocedural year.

Results: - A total of 1,177 procedures were studied. Of them, 117 (9.9%) took place off-hours. These were more often urgent interventions (30.8% vs. 14.3%, p<0.001) performed in the midst of acute HF / hemodynamic compromise and on individuals with greater comorbidity, more advanced HF, and higher interventional risk. Overall procedural features were unaffected by interventional timing, and a high (>97%) technical success rate was achieved unanimously. MR severity and functional class similarly improved from baseline in the two study groups. Deaths and the composite of deaths or HF hospitalizations occurred earlier and more frequently following off-hours procedures (18.8% vs. 11.5%, p=0.022 and 33.3% vs. 24.6%, p=0.040, respectively). None of the explored endpoints' risks were independently associated with procedural timing. Within a 234-patient, 1-to-1 matched sub-cohort, no inter-group differences were observed in pre-, intra-, and post-procedural findings and outcomes.

Conclusions: - A non-infrequent procedure, off-hours mitral TEER is performed in high-risk cases but, in the hands of experienced interventionalists, should prove safe, feasible, and efficacious.

Background: ST-segment elevation myocardial infarction (STEMI) is treated with immediate primary percutaneous coronary intervention (pPCI) to restore coronary blood flow in the acutely ischaemic territory, but is associated with reperfusion injury limiting the benefit of the therapy. No treatment has proven effective in reducing reperfusion injury. Transcoronary hypothermia has been tested in clinical studies and is well tolerated, but is generally established after crossing the occlusion with a guidewire therefore after initial reperfusion, which might have contributed to the neutral outcomes. Transcatheter strategies may also offer additional benefit through haemodilution and the resultant controlled reperfusion, but this has not been fully investigated for pPCI.

Design: STEMI-Cool is a pragmatic, registry-based randomised clinical pilot trial to test the recruitment rate, feasibility, and safety of a simple transcoronary cooling and dilution protocol. Sixty STEMI patients undergoing pPCI will be randomised 1:1 to standard of care or continuous infusion of room temperature saline through the guiding catheter to achieve intracoronary temperature reductions of 6-8°C, commencing before crossing the coronary occlusion with a guidewire. Mechanistic outcome measures will include microvascular resistance, biomarkers of inflammation before infusion and at 24h, and magnetic resonance imaging of myocardial salvage and infarct size.

Conclusions: STEMI-Cool will investigate the recruitment rate, feasibility and safety of an innovative and simple cooling and diluting strategy for cardioprotection before and during reperfusion with pPCI, aiming to address limitations faced in other studies. Mechanistic outcome measures will allow insight into inflammatory, microvascular and structural changes induced by transcoronary cooling and dilution.

Introduction: Hospitalization rates for acute decompensated heart failure (ADHF) have increased, resulting in 6.5 million hospital days annually. Despite this, optimal diuretic strategies for managing ADHF remain unclear, highlighting the need to analyze diuretic practice patterns in ADHF treatment.

Methods: We performed a retrospective cohort analysis of adults hospitalized for ADHF, regardless of left ventricular ejection fraction (LVEF) between January 1, 2014 and December 21, 2021 at a large, quaternary healthcare system to determine diuretic practice patterns. We performed multivariable regression analyses to assess time to initial, second, and maximum diuretic therapy with hospital length of stay (LOS) and 30-day readmission.

Results: Among 4,298 adults admitted for ADHF (mean age 63 years, 62% male, 52% LVEF ≤40%) median time to max diuretic therapy was 1.8 (0.7, 3.8) days. Median time to initial IV loop diuretic dose was 3.6 (2.1, 6.5) hours, while time to second dose of IV loop diuretic dose was 10.2 (6.3, 15.1) hours. Time to initial IV loop diuretic, time to second IV loop diuretic dose, and time to maximum diuretic therapy were all positively associated with increased LOS but were not associated with 30-day readmission. There was wide variation in loop diuretic escalation strategies and use of sequential nephron blockade.

Conclusion: There was wide variation in diuretic strategies at a single academic medical center. Increased time to initial IV loop diuretic, time between diuretic doses, and longer time to max diuretic therapy were associated with increased LOS but were not associated with 30-day readmission suggesting different diuretic strategies may affect patient outcomes and warrant dedicated investigation in the future.

This review describes and evaluates the representation of women in cardiovascular randomized controlled trials (RCT), it reports significant under-representation of women in clinical trials both as participants and researchers and discusses the ethical implications of under-representation. The under-representation of women as participants in cardiovascular RCTs is evident in trials investigating cardiovascular drugs, acute coronary syndrome, heart failure and interventional procedures and devices. Under-representation of women is also evident in the authorship of cardiovascular clinical trials and in trial leadership roles, and under-representation of women as trial investigators is independently associated with under- recruitment of women as trial participants. A notable lack of RCTs investigating conditions that disproportionately affect women is also evident, this triad of underrepresentation for women as participants, and investigators, and the lack of RCTs into conditions predominantly experienced by women, all contribute to the gender gap in cardiovascular outcomes. Better representation of women in clinical trials, in trial leadership and authorship is a key factor to address to equity, distributive justice and improve outcomes for women with cardiovascular disease.