Journal: Heart

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Abstract

Association between exercise habit changes and mortality following a cardiovascular event.

Kang DS, Sung JH, Kim D, Jin MN, ... Yang PS, Joung B
Objective
To investigate the associations between exercise habit changes following an incident cardiovascular event and mortality in older adults.
Methods
We analysed the relationship between exercise habit change and all-cause, cardiovascular and non-cardiovascular deaths in adults aged ≥60 years between 2003 and 2012 who underwent two consecutive health examinations within 2 years before and after diagnosis of cardiovascular disease (CVD). They were categorised into four groups according to exercise habit changes: persistent non-exercisers, exercise dropouts, new exercisers and exercise maintainers. Differences in baseline characteristics were adjusted using inverse probability of treatment weighting.
Results
Of 6076 participants, the median age was 72 (IQR 69-76) years and men accounted for 50.6%. Compared with persistent non-exercisers (incidence rate (IR) 4.8 per 100 person-years), new exercisers (IR 3.5, HR 0.73, 95% CI 0.58 to 0.91) and exercise maintainers (IR 2.9, HR 0.53, 95% CI 0.38 to 0.73) were associated with reduced risk of all-cause death. The rate of non-cardiovascular death was significantly lower in new exercisers (IR 2.3, HR 0.73, 95% CI 0.56 to 0.95) and exercise maintainers (IR 2.3, HR 0.61, 95% CI 0.42 to 0.90) than in persistent non-exercisers (IR 3.2). Also, trends towards reduced cardiovascular death in new exercisers and exercise maintainers were observed (p value for trend <0.001).
Conclusions
More virtuous exercise trajectories in older adults with CVD are associated with lower mortality rates. Our results support public health recommendations for older adults with CVD to perform physical activity.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 19 May 2022; epub ahead of print
Kang DS, Sung JH, Kim D, Jin MN, ... Yang PS, Joung B
Heart: 19 May 2022; epub ahead of print | PMID: 35589378
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Abstract

Perioperative outcomes and readmissions following cardiac operations in kidney transplant recipients.

Madrigal J, Richardson S, Hadaya J, Verma A, ... Sanaiha Y, Benharash P
Objective
Although kidney transplant (KTx) recipients are at significant risk for cardiovascular disease, outcomes following cardiac operations have been examined in limited series. The present study thus aimed to assess the impact of KTx on in-hospital perioperative outcomes and readmissions in a nationally representative cohort.
Methods
All adults undergoing elective coronary artery bypass grafting, valve repair/replacement or a combination thereof were identified from the 2010-2018 Nationwide Readmissions Database. Patients were stratified by history of KTx. Transplant-capable centres were defined as hospitals performing at least one KTx annually. To perform risk-adjustment in assessing outcomes, multivariable regression models were developed.
Results
Of an estimated 1 407 351 patients included for analysis, 0.2% (n=2849) were KTx recipients. Compared with the general cardiac surgical population, patients with prior KTx experienced higher adjusted odds of in-hospital mortality (adjusted OR (AOR) 2.44, 95% CI 1.72 to 3.47, p<0.001) and perioperative complication (AOR 1.67, 95% CI 1.44 to 1.94, p<0.001). Additionally, KTx was independently associated with greater readmission rates within 30 days (AOR 1.96, 95% CI 1.65 to 2.34, p<0.001) with kidney injury contributing significantly to the burden of rehospitalisation (4.6 vs 1.8%, p=0.005). In a subpopulation comprised of only KTx recipients, treatment at a transplant-capable centre reduced odds of kidney injury with non-transplant hospitals as reference (AOR 0.65, 95% CI 0.43 to 0.98, p=0.037).
Conclusions
Kidney transplant recipients undergoing cardiac operations encounter significant risks compared with the general surgical population. Referral to transplant-capable centres should be explored to improve outcomes and to preserve allograft function in this population.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 19 May 2022; epub ahead of print
Madrigal J, Richardson S, Hadaya J, Verma A, ... Sanaiha Y, Benharash P
Heart: 19 May 2022; epub ahead of print | PMID: 35589379
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Abstract

Early and long-term outcomes of conventional and valve-sparing aortic root replacement.

Jahangiri M, Mani K, Acharya M, Bilkhu R, ... Morgan R, Edsell M
Objective
To determine the early and long-term outcomes of conventional aortic root (ARR) and valve-sparing root replacement (VSRR) using a standard perioperative and operative approach.
Methods
We present prospectively collected data of 609 consecutive patients undergoing elective and urgent aortic root surgery (470 ARR, 139 VSRR) between 2006 and 2020. Primary outcomes were operative mortality and incidence of postoperative complications. Secondary outcomes were long-term survival and requirement for reintervention. Median follow-up was 7.6 years (range 0.5-14.5).
Results
189 patients (31%) had bicuspid aortic valves and 17 (6.9%) underwent redo procedures. Median cross-clamp time was 88 (range 54-208) min with cardiopulmonary bypass of 108 (range 75-296) min. In-hospital mortality was 10 (1.6%), with transient ischaemic attacks/strokes occurring in 1.1%. In-hospital mortality for VSRR was 0.7%. 12 patients (2.0%) required a resternotomy for bleeding and 14 (2.3%) received haemofiltration. Intensive care unit and hospital stay were 1.7 and 7.0 days, respectively. During follow-up, redo surgery for native aortic valve replacement was required in 1.4% of the VSRR group. Overall survival was 95.1% at 3 years, 93.1% at 5 years, 91.2% at 7 years and 88.6% at 10 years.
Conclusions
ARR and VSRR can be performed with low mortality and morbidity as well as a low rate of reintervention during the period of long-term follow-up, if performed by an experienced team with a consistent perioperative approach. This series provides contemporary evidence to balance the risks of aortic aneurysms and their rupture at diameters of <5.5 cm against the risks and benefits of surgery.

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Heart: 17 May 2022; epub ahead of print
Jahangiri M, Mani K, Acharya M, Bilkhu R, ... Morgan R, Edsell M
Heart: 17 May 2022; epub ahead of print | PMID: 35580978
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Abstract

Fractional flow reserve versus angiography alone in guiding myocardial revascularisation: a systematic review and meta-analysis of randomised trials.

Elbadawi A, Sedhom R, Dang AT, Gad MM, ... Elgendy IY, Jneid H
Background
Randomised trials evaluating the efficacy and safety of fractional flow reserve (FFR)-guided versus angiography-guided revascularisation among patients with obstructive coronary artery disease (CAD) have yielded mixed results.
Aims
To examine the comparative efficacy and safety of FFR-guided versus angiography-guided revascularisation among patients with obstructive CAD.
Methods
An electronic search of MEDLINE, SCOPUS and Cochrane databases without language restrictions was performed through November 2021 for randomised controlled trials that evaluated the outcomes of FFR-guided versus angiography-guided revascularisation. The primary outcome was major adverse cardiac events (MACE). Data were pooled using a random-effects model.
Results
The final analysis included seven trials with 5094 patients. The weighted mean follow-up duration was 38 months. Compared with angiography guidance, FFR guidance was associated with fewer number of stents during revascularisation (standardised mean difference=-0.80; 95% CI -1.33 to -0.27), but no difference in total hospital cost. There was no difference between FFR-guided and angiography-guided revascularisation in long-term MACE (13.6% vs 13.9%; risk ratio (RR) 0.97, 95% CI 0.85 to 1.11). Meta-regression analyses did not reveal any evidence of effect modification for MACE with acute coronary syndrome (p=0.36), proportion of three-vessel disease (p=0.88) or left main disease (p=0.50). There were no differences between FFR-guided and angiography-guided revascularisation in the outcomes all-cause mortality (RR 1.16, 95% CI 0.80 to 1.68), cardiovascular mortality (RR 1.27, 95% CI 0.50 to 3.26), repeat revascularisation (RR 0.99, 95% CI 0.81 to 1.21), recurrent myocardial infarction (RR 0.92, 95% CI 0.74 to 1.14) or stent thrombosis (RR 0.61, 95% CI 0.31 to 1.21).
Conclusion
Among patients with obstructive CAD, FFR-guided revascularisation did not reduce the risk of long-term adverse cardiac events or the individual outcomes. However, FFR-guided revascularisation was associated with fewer number of stents.
Prospero registration number
CRD42021291596.

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Heart: 13 May 2022; epub ahead of print
Elbadawi A, Sedhom R, Dang AT, Gad MM, ... Elgendy IY, Jneid H
Heart: 13 May 2022; epub ahead of print | PMID: 35568392
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Abstract

Contemporary demographics, diagnostics and outcomes in non-bacterial thrombotic endocarditis.

Quintero-Martinez JA, Hindy JR, El Zein S, Michelena HI, ... DeSimone DC, Baddour LM
Objective
Non-bacterial thrombotic endocarditis (NBTE) is a syndrome characterised by cardiac valve vegetations and/or thickening due to non-infective mechanisms. Nowadays, a premortem diagnosis of NBTE is possible based on echocardiographic findings. Therefore, to better characterise this disease, we performed a contemporary review of the epidemiology, demographics, diagnosis and clinical outcomes of these patients.
Methods
Adults with a diagnosis of NBTE seen within the Mayo Clinic Enterprise from December 2014 to December 2021 were included. NBTE diagnosis was identified by clinicians representing at least two specialties including cardiology, infectious diseases, rheumatology and oncology. Patients with positive blood cultures, infective endocarditis, culture-negative endocarditis and denial of research authorisation were excluded. All patients had a 1-year follow-up.
Results
Forty-eight cases were identified; mean age was 60.0±13.8 years, 75% were female. The most prevalent comorbidities were malignancy (52.1%) and connective tissue disease (37.5%). Valvular abnormalities included 41 (85.4%) patients with vegetations, 43 (89.6%) patients with thickening and 26 (54.2%) with moderate to severe regurgitation. Thirty-eight (79.2%) patients had an embolic event (stroke in 26 (54.2%) patients) within 1 month of NBTE diagnosis and 16 (33.3%) patients died within 1 year of NBTE diagnosis. Metastatic tumours and lung cancer were associated with 1-year all-cause mortality (p=0.0017 and p=0.0004, respectively).
Conclusions
NBTE was more prevalent in females and embolic complications were the most frequent clinical finding. Overall, patients with NBTE had a poor prognosis, particularly in those with lung cancer or metastatic tumours. Further studies in patients with NBTE are needed given its morbidity and mortality.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 09 May 2022; epub ahead of print
Quintero-Martinez JA, Hindy JR, El Zein S, Michelena HI, ... DeSimone DC, Baddour LM
Heart: 09 May 2022; epub ahead of print | PMID: 35534050
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Abstract

Diagnostic and prognostic role of the electrocardiogram in patients with pericarditis.

Imazio M, Squarotti GB, Andreis A, Agosti A, ... Giustetto C, Deferrari GM
Objective
The ECG has been traditionally used to support the diagnosis of pericarditis. However, the pericardium is electrically silent and ECG changes may imply concurrent myocardial involvement rather than simple pericarditis. The aim of the present paper is to analyse the frequency, type and clinical implication of ECG changes in patients with pericarditis compared with those with myocarditis.
Methods
Consecutive patients with pericarditis and/or myocarditis were included in a prospective cohort study from January 2017 to December 2020. A clinical and echocardiographic follow-up was performed at 1, 3, 6 months and then every 6 months. Cardiac magnetic resonance was used to diagnose concurrent myocarditis.
Results
166 patients (median age 47 years, 95% CI 44 to 51) with 66 men (39.8%) were included: 110 cases with pericarditis (mean age 47.7 years, 29.1% male) and 56 cases with myocarditis (mean age 44.8, 60.7% male). ECG changes were reported in 61 of 166 (36.7%) patients: 27 of 110 (24.5%) among those with pericarditis and 34 of 56 (60.7%) among those with myocarditis (p<0.0001). In multivariate logistic regression analysis, ECG changes were associated with troponin elevation (risk ratio 1.97; 95% CI 1.13 to 3.43), suggesting myocardial involvement. ECG changes were not associated with increased risk of adverse events.
Conclusions
ECG changes, mainly widespread ST-segment elevation, can be recorded in about one-quarter of patients with pericarditis, and were not associated with a worse prognosis. These changes may reflect concurrent myocarditis that should be ruled out.

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Heart: 06 May 2022; epub ahead of print
Imazio M, Squarotti GB, Andreis A, Agosti A, ... Giustetto C, Deferrari GM
Heart: 06 May 2022; epub ahead of print | PMID: 35523541
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Abstract

Right ventricular remodelling in pulmonary arterial hypertension predicts treatment response.

Goh ZM, Balasubramanian N, Alabed S, Dwivedi K, ... Kiely DG, Swift AJ
Objectives
To determine the prognostic value of patterns of right ventricular adaptation in patients with pulmonary arterial hypertension (PAH), assessed using cardiac magnetic resonance (CMR) imaging at baseline and follow-up.
Methods
Patients attending the Sheffield Pulmonary Vascular Disease Unit with suspected pulmonary hypertension were recruited into the ASPIRE (Assessing the Spectrum of Pulmonary hypertension Identified at a REferral Centre) Registry. With exclusion of congenital heart disease, consecutive patients with PAH were followed up until the date of census or death. Right ventricular end-systolic volume index adjusted for age and sex and ventricular mass index were used to categorise patients into four different volume/mass groups: low-volume-low-mass, low-volume-high-mass, high-volume-low-mass and high-volume-high-mass. The prognostic value of the groups was assessed with one-way analysis of variance and Kaplan-Meier plots. Transition of the groups was studied.
Results
A total of 505 patients with PAH were identified, 239 (47.3%) of whom have died at follow-up (median 4.85 years, IQR 4.05). The mean age of the patients was 59±16 and 161 (32.7%) were male. Low-volume-low-mass was associated with CMR and right heart catheterisation metrics predictive of improved prognosis. There were 124 patients who underwent follow-up CMR (median 1.11 years, IQR 0.78). At both baseline and follow-up, the high-volume-low-mass group had worse prognosis than the low-volume-low-mass group (p<0.001). With PAH therapy, 73.5% of low-volume-low-mass patients remained in this group, whereas only 17.4% of high-volume-low-mass patients transitioned into low-volume-low-mass.
Conclusions
Right ventricular adaptation assessed using CMR has prognostic value in patients with PAH. Patients with maladaptive remodelling (high-volume-low-mass) are at high risk of treatment failure.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.

Heart: 05 May 2022; epub ahead of print
Goh ZM, Balasubramanian N, Alabed S, Dwivedi K, ... Kiely DG, Swift AJ
Heart: 05 May 2022; epub ahead of print | PMID: 35512982
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Abstract

Safety of proprotein convertase subtilisin/kexin 9 inhibitors: a systematic review and meta-analysis.

Li J, Du H, Wang Y, Aertgeerts B, ... Tian H, Li S
Objective
To determine the harms of proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors in people who need lipid-lowering therapy.
Methods
This systematic review included randomised controlled trials that compared PCSK9 inhibitors with placebo, standard care or active lipid-lowering comparators in people who need lipid-lowering therapy with the follow-up duration of at least 24 weeks. We summarised the relative effects for potential harms from PCSK9 inhibitors using random-effect pairwise meta-analyses and assessed the certainty of evidence using GRADE (Grading of Recommendation Assessment, Development and Evaluation) for each outcome.
Results
We included 32 trials with 65 861 participants (with the median follow-up duration of 40 weeks, ranging from 24 to 146 weeks). The meta-analysis showed an incidence of injection-site reaction leading to discontinuation (absolute incidence of 15 events (95% CI 11 to 20) per 1000 persons in a 5-year time frame, high certainty evidence). PCSK9 inhibitors do not increase the risk of new-onset diabetes mellitus, neurocognitive events, cataracts or gastrointestinal haemorrhage with high certainty evidence. PCSK9 inhibitors probably do not increase the risks of myalgia or muscular pain leading to discontinuation or any adverse events leading to discontinuation with moderate evidence certainty. Given very limited evidence, PCSK9 inhibitors might not increase influenza-like symptoms leading to discontinuation (risk ratio 1.5; 95% CI 0.06 to 36.58). We did not identify credible subgroup analyses results, including shorter versus longer follow-up duration of trials.
Conclusions
PCSK9 inhibitors slightly increase the risk of severe injection-site reaction but not cataracts, gastrointestinal haemorrhage, neurocognitive events, new-onset diabetes or severe myalgia or muscular pain.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 04 May 2022; epub ahead of print
Li J, Du H, Wang Y, Aertgeerts B, ... Tian H, Li S
Heart: 04 May 2022; epub ahead of print | PMID: 35508401
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Abstract

History of the British Cardiovascular Society.

Coats CJ
In 2022, the British Cardiovascular Society celebrates the centenary of its foundation. Starting out as a small group of government-appointed physicians interested in heart disease, the Cardiac Club has grown and adapted to represent all those working in cardiovascular care and research. The historical stages of the organisation\'s development are outlined, alongside major innovations in science and technology providing context for a rapidly changing medical world. Only a small part of the history of cardiology in Britain is told, with greater emphasis on describing the broader need for services, skilled workforce, healthcare policy and continuing education. Above all, the history of the British Cardiovascular Society is a story of people and places. The people are those with vision, attitude and leadership to improve the care of communities across the world. The places are those that enabled conversation, innovation and freedom to bring about change. It is hard to believe the remarkable progress in diagnosis, prevention and treatment of heart disease over 100 years, but a thriving modern Society must be the greatest legacy of its founders.

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Heart: 30 Apr 2022; 108:761-766
Coats CJ
Heart: 30 Apr 2022; 108:761-766 | PMID: 35459725
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Abstract

Changing concepts in heart muscle disease: the evolving understanding of hypertrophic cardiomyopathy.

Moody WE, Elliott PM
Sixty years ago, hypertrophic cardiomyopathy (HCM) was considered a rare lethal disease that affected predominantly young adults and for which there were few treatment options. Today, it is recognised to be a relatively common disorder that presents throughout the life course with a heterogeneous clinical phenotype that can be managed effectively in the majority of individuals. A greater awareness of the condition and less reluctance from healthcare practitioners to make the diagnosis, coupled with improvements in cardiac imaging, including greater use of artificial intelligence and improved yields from screening efforts, have all helped facilitate a more precise and timely diagnosis. This enhanced ability to diagnose HCM early is being paired with innovations in treatment, which means that the majority of patients receiving a contemporary diagnosis of HCM can anticipate a normal life expectancy and expect to maintain a good functional status and quality of life. Indeed, with increasing translation of molecular genetics from bench to bedside associated with a growing number of randomised clinical trials of novel therapies aimed at ameliorating or perhaps even preventing the disease, the next chapter in the story for HCM will provide much excitement and more importantly, offer much anticipated reward for our patients.

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Heart: 30 Apr 2022; 108:768-773
Moody WE, Elliott PM
Heart: 30 Apr 2022; 108:768-773 | PMID: 35459726
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Abstract

Heart valve disease: a journey of discovery.

Dobson LE, Prendergast BD
In the centenary year of the British Cardiovascular Society (BCS), this review article outlines the influence of UK cardiologists and surgeons on the field of heart valve disease, many of whom can rightly claim \'world firsts\' in the field. From the description of endocarditis as we know it today at the turn of the 20th century, to the first mitral valvotomy, heart valve replacement and invention of the Ross procedure. These advances have transformed the outlook of patients with symptomatic valve disease from palliation and certain death to curative treatment and near normal life expectancy. Transcatheter aortic valve implantation (TAVI) was adopted early in the UK, and thanks to the comprehensive national database, the UK TAVI registry is one of the world\'s largest, contributing real-world patient data to inform clinical practice. The more recent concepts of \'Heart Valve Centres of Excellence\' and specialist valve clinics have been developed by the BCS-affiliated British Heart Valve Society which continues to drive improved standards for patients with heart valve disease. The next 100 years will no doubt be equally thrilling in terms of innovation for heart valve disease, with artificial intelligence, transcatheter therapies and cutting-edge technology continuing to improve patient care and clinical outcomes.

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Heart: 30 Apr 2022; 108:774-779
Dobson LE, Prendergast BD
Heart: 30 Apr 2022; 108:774-779 | PMID: 35459727
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Abstract

Let there be light! The meteoric rise of cardiac imaging.

Reid A, Dweck MR
Imaging plays a central role in modern cardiovascular practice. It is a field characterised by exciting technological advances that have shaped our understanding of pathology and led to major improvements in patient diagnosis and care. The UK has played a key international role in the development of this subspecialty and is the current home to many of the leading global centres in multimodality cardiovascular imaging. In this short review, we will outline some of the key contributions of the British Cardiovascular Society and its members to this rapidly evolving field and look at how this relationship may continue to shape future cardiovascular practice.

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Heart: 30 Apr 2022; 108:780-786
Reid A, Dweck MR
Heart: 30 Apr 2022; 108:780-786 | PMID: 35459728
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Abstract

Cardiac surgery and congenital heart disease: reflections on a modern revolution.

Lim JCE, Elliott MJ, Wallwork J, Keogh B
The success of cardiac surgery has transformed the prospects of children with congenital heart disease with over 90% now surviving to adulthood. The early pioneering surgeons took on significant risk, whilst current surgical practice emphasises safety and consistency. In this article we review important British contributions to the field and consider challenges for the future, specifically how to better manage and reduce the adverse sequelae of congenital cardiac surgery by continuing to innovate safely.

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Heart: 30 Apr 2022; 108:787-793
Lim JCE, Elliott MJ, Wallwork J, Keogh B
Heart: 30 Apr 2022; 108:787-793 | PMID: 35459729
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Abstract

History and evolution of pacing and devices.

Haydock P, Camm AJ
Cardiac implanted electronic devices are commonplace in the modern practice of cardiology. This article reviews the history of the development of these technologies, with particular reference to the role played by UK physicians and members of the British Cardiovascular Society. Key breakthroughs in the treatment of heart block, ventricular arrhythmia and heart failure are presented in their historical and contemporary context so that the reader might look back on the incredible progress and achievements of the last 100 years and also look forward to what may be achieved in the coming decades.

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Heart: 30 Apr 2022; 108:794-799
Haydock P, Camm AJ
Heart: 30 Apr 2022; 108:794-799 | PMID: 35459730
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Abstract

The British Cardiovascular Society and clinical studies in ischaemic heart disease: from RITA to ORBITA, and beyond.

Al-Lamee R, Aubiniere-Robb L, Berry C
In this article, we provide a historical view of key aspects of British Cardiovascular Society (BCS) influence in clinical trials of ischaemic heart disease (IHD) followed by key research and developments, notable publications and future perspectives. We discuss the role of the BCS and its members. The scope of this article covers clinical trials in stable IHD and acute coronary syndromes, including interventions relating to diagnosis, treatment and management. We discuss the role of the BCS in supporting the original RITA trials. We highlight the changing face of angina and its management providing contemporary and future insights into microvascular disease, ischaemic symptoms with no obstructive coronary arteries and, relatedly, myocardial infarction with no obstructive coronary arteries. The article is presented as a brief overview of the BCS in IHD research, relationships with stakeholders, patient and public involvement and clinical trials from the perspective of past, present and future possibilities.

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Heart: 30 Apr 2022; 108:800-806
Al-Lamee R, Aubiniere-Robb L, Berry C
Heart: 30 Apr 2022; 108:800-806 | PMID: 35459731
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Abstract

Longitudinal changes of thoracic aortic diameters in the general population aged 55 years or older.

Thijssen CGE, Mutluer FO, van der Toorn JE, Bons LR, ... Kavousi M, Bos D
Objective
Longitudinal data on age-related changes in the diameters of the thoracic aorta are scarce. To better understand normal variation and to identify factors influencing this process, we aimed to report male-female-specific and age-specific aortic growth rate in the ageing general population and identify factors associated with growth rate.
Methods
From the prospective population-based Rotterdam Study, 943 participants (52.0% females, median age at baseline 65 years (62-68)) underwent serial non-enhanced cardiac CT. We measured the diameters of the ascending (AA) and descending aorta (DA) at two time points and expressed absolute and relative differences. Linear mixed effects analysis was performed to identify determinants associated with change in aortic diameters.
Results
Mean AA diameter at baseline was 37.3±3.6 mm in male population and 34.7±3.2 mm in female population, mean DA diameter was 29.6±2.3 in male population and 26.9±2.2 mm in female population. The median absolute change in diameters during follow-up (mean scan interval 14.1±0.3 years) was 1 mm (0-2) for both the AA and DA. Absolute change per decade in AA diameter was significantly larger in males than in females (0.72 mm/decade (0.00-1.43) vs 0.70 mm/decade (0.00-1.41), p=0.006), as well as absolute change in AD diameter (0.71 mm/decade (0.00-1.42) vs 0.69 mm/decade (0.00-1.36), p=0.008). There was no significant difference between male and female population in relative change of their aortic diameters during follow-up. Age, male sex, higher body mass index (BMI) and higher diastolic blood pressure (DBP) showed a statistically significant independent association with increase in AA and DA diameters over time.
Conclusions
Some degree of increase in thoracic aortic diameters is typical in both men and women of an aging population. Factors associated with this change in thoracic aortic diameters were sex, age, BMI and DBP.

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Heart: 28 Apr 2022; epub ahead of print
Thijssen CGE, Mutluer FO, van der Toorn JE, Bons LR, ... Kavousi M, Bos D
Heart: 28 Apr 2022; epub ahead of print | PMID: 35483871
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Abstract

Supplemental calcium and vitamin D and long-term mortality in aortic stenosis.

Kassis N, Hariri EH, Karrthik AK, Ahuja KR, ... Desai MY, Kapadia SR
Objective
Calcium metabolism has long been implicated in aortic stenosis (AS). Studies assessing the long-term safety of oral calcium and/or vitamin D in AS are scarce yet imperative given the rising use among an elderly population prone to deficiency. We sought to identify the associations between supplemental calcium and vitamin D with mortality and progression of AS.
Methods
In this retrospective longitudinal study, patients aged ≥60 years with mild-moderate native AS were selected from the Cleveland Clinic Echocardiography Database from 2008 to 2016 and followed until 2018. Groups were stratified into no supplementation, supplementation with vitamin D alone and supplementation with calcium±vitamin D. The primary outcomes were mortality (all-cause, cardiovascular (CV) and non-CV) and aortic valve replacement (AVR), and the secondary outcome was AS progression by aortic valve area and peak/mean gradients.
Results
Of 2657 patients (mean age 74 years, 42% women) followed over a median duration of 69 months, 1292 (49%) did not supplement, 332 (12%) took vitamin D alone and 1033 (39%) supplemented with calcium±vitamin D. Calcium±vitamin D supplementation was associated with a significantly higher risk of all-cause mortality (absolute rate (AR)=43.0/1000 person-years; HR=1.31, 95% CI (1.07 to 1.62); p=0.009), CV mortality (AR=13.7/1000 person-years; HR=2.0, 95% CI (1.31 to 3.07); p=0.001) and AVR (AR=88.2/1000 person-years; HR=1.48, 95% CI (1.24 to 1.78); p<0.001). Any supplementation was not associated with longitudinal change in AS parameters in a linear mixed-effects model.
Conclusions
Supplemental calcium with or without vitamin D is associated with lower survival and greater AVR in elderly patients with mild-moderate AS.

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Heart: 25 Apr 2022; epub ahead of print
Kassis N, Hariri EH, Karrthik AK, Ahuja KR, ... Desai MY, Kapadia SR
Heart: 25 Apr 2022; epub ahead of print | PMID: 35470234
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Abstract

Joint British Societies\' guideline on management of cardiac arrest in the cardiac catheter laboratory.

Dunning J, Archbold A, de Bono JP, Butterfield L, ... Swindell P, Ray S
More than 300 000 procedures are performed in cardiac catheter laboratories in the UK each year. The variety and complexity of percutaneous cardiovascular procedures have both increased substantially since the early days of invasive cardiology, when it was largely focused on elective coronary angiography and single chamber (right ventricular) permanent pacemaker implantation. Modern-day invasive cardiology encompasses primary percutaneous coronary intervention, cardiac resynchronisation therapy, complex arrhythmia ablation and structural heart interventions. These procedures all carry the risk of cardiac arrest.We have developed evidence-based guidelines for the management of cardiac arrest in adult patients in the catheter laboratory. The guidelines include recommendations which were developed by collaboration between nine professional and patient societies that are involved in promoting high-quality care for patients with cardiovascular conditions. We present a set of protocols which use the skills of the whole catheter laboratory team and which are aimed at achieving the best possible outcomes for patients who suffer a cardiac arrest in this setting. We identified six roles and developed a treatment algorithm which should be adopted during cardiac arrest in the catheter laboratory. We recommend that all catheter laboratory staff undergo regular training for these emergency situations which they will inevitably face.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 25 Apr 2022; epub ahead of print
Dunning J, Archbold A, de Bono JP, Butterfield L, ... Swindell P, Ray S
Heart: 25 Apr 2022; epub ahead of print | PMID: 35470236
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Abstract

Getting It Right First Time (GIRFT): transforming cardiology care.

Ray S, Clarke SC
The Getting It Right First Time (GIRFT) process is designed to improve the care of patients in the National Health Service (NHS) in England through in-depth review of services, benchmarking and presenting a data-driven evidence base to support change. Although it started as a pilot project targeting unwarranted variation in elective orthopaedic surgery, it rapidly became apparent that the approach of clinically led deep dives to review the activity in individual orthopaedic units was effective in improving standards of care and resulted in substantial cost savings that could be reinvested in the clinical service. GIRFT has now expanded to encompass 40 clinical specialties and is funded nationally by the NHS in England. The purpose of this article is to describe its application and benefit to cardiology.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 21 Apr 2022; epub ahead of print
Ray S, Clarke SC
Heart: 21 Apr 2022; epub ahead of print | PMID: 35450853
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Abstract

Directly observed therapy for resistant/refractory hypertension diagnosis and blood pressure control.

Pio-Abreu A, Trani-Ferreira F, Silva GV, Bortolotto LA, Drager LF
Objective
To test the impact of directly observed therapy (DOT) at hospital for checking not only adherence/diagnosis in patients with resistant (RHTN) and refractory (RefHTN) hypertension but also blood pressure (BP) control after hospital discharge.
Methods
During 2 years, Brazilian patients with clinical suspicion of RHTN/RefHTN after several attempts (≥3) to control BP in the outpatient setting were invited to perform DOT (including low-sodium diet and supervised medications intake) at the hospital. RHTN and RefHTN were categorised using standard definitions. After hospital discharge, we evaluated the BP values and the number of antihypertensive drugs prescribed by physicians who were not involved with the investigation.
Results
We studied 83 patients clinically suspected for RHTN (31%) and RefHTN (69%) (mean age: 53 years; 76% female; systolic BP 177±28 mm Hg and diastolic BP 106±21 mm Hg; number of antihypertensive drugs: 5.3±1.3). DOT confirmed RHTN in 77%, whereas RefHTN was confirmed in only 32.5%. The number of antihypertensive drugs reduced to 4.5±1.3 and systolic/diastolic BP at hospital discharge reduced to 131±17 mm Hg/80±12 mm Hg. After hospital discharge, systolic BP remained significantly lower than the last outpatient visit prehospital admission (delta changes (95% CI): 1 month: -25.7 (-33.8 to -17.6) mm Hg; 7 months: -27.3 (-35.5 to -19.1) mm Hg) despite fewer number of antihypertensive classes (1 month: -1.01 (-1.36 to -0.67); 7 months: -0.77 (-1.11 to -0.42)). Similar reductions were observed for diastolic BP.
Conclusions
DOT at hospital is helpful not only in confirming/excluding RHTN/RefHTN phenotypes, but also in improving BP values and BP control and in reducing the need for antihypertensive drugs after hospital discharge.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 20 Apr 2022; epub ahead of print
Pio-Abreu A, Trani-Ferreira F, Silva GV, Bortolotto LA, Drager LF
Heart: 20 Apr 2022; epub ahead of print | PMID: 35444006
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Abstract

Pregnancy-related cardiovascular conditions and outcomes in a United States Medicaid population.

Marschner S, von Huben A, Zaman S, Reynolds HR, ... Mehta LS, Chow CK
Objective
This study aims to examine the incidence of pregnancy-related cardiometabolic conditions and severe cardiovascular outcomes, and their relationship in US Medicaid-funded women.
Methods
Medicaid is a government-sponsored health insurance programme for low-income families in the USA. We report the incidence of pregnancy-related cardiometabolic conditions (hypertensive disorders and diabetes in, or complicated by, pregnancy) and severe cardiovascular outcomes (myocardial infarction, stroke, acute heart failure, cardiomyopathy, cardiac arrest, ventricular fibrillation, ventricular tachycardia, aortic dissection/aneurysm and peripheral vascular disease) among Medicaid-funded women with a birth (International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code O80 or O82) over the period January 2015-June 2019, from the states of Georgia, Ohio and Indiana. In this cross-sectional cohort, we examined the relationship between pregnancy-related cardiometabolic conditions and severe cardiovascular outcomes from pregnancy through to 60 days after birth using multivariable models.
Results
Among 74 510 women, mean age 26.4 years (SD 5.5), the incidence per 1000 births of pregnancy-related cardiometabolic conditions was 224.3 (95% CI 221.3 to 227.3). The incidence per 1000 births of severe cardiovascular conditions was 10.8 (95% CI 10.1 to 11.6). Women with pregnancy-related cardiometabolic conditions were at greater risk of having a severe cardiovascular condition with an age-adjusted OR of 3.1 (95% CI 2.7 to 3.5).
Conclusion
This US cohort of Medicaid-funded women have a high incidence of severe cardiovascular conditions during pregnancy. Cardiometabolic conditions of pregnancy conferred threefold higher odds of severe cardiovascular outcomes.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 13 Apr 2022; epub ahead of print
Marschner S, von Huben A, Zaman S, Reynolds HR, ... Mehta LS, Chow CK
Heart: 13 Apr 2022; epub ahead of print | PMID: 35418486
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Abstract

Cardiopulmonary exercise testing for heart failure: pathophysiology and predictive markers.

Buber J, Robertson HT
Despite the numerous recent advancements in therapy, heart failure (HF) remains a principle cause of both morbidity and mortality. HF with preserved ejection fraction (HFpEF), a condition that shares the prevalence and adverse outcomes of HF with reduced ejection fraction, remains poorly recognised in its initial manifestations. Cardiopulmonary exercise testing (CPET), defined as a progressive work exercise test that includes non-invasive continuous measurement of cardiovascular and respiratory parameters, provides a reliable mode to evaluate for early features and for the assessment of prognostic features of both forms of HF. While CPET measurements are standard of care for advanced HF and transplant programmes, they merit a broader clinical application in the early diagnosis and assessment of patients with HFpEF. In this review, we provide an overview of the pathophysiology of exercise intolerance in HF and discuss key findings in CPETs used to evaluate both severity of impairment and the prognostic implications.

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Heart: 11 Apr 2022; epub ahead of print
Buber J, Robertson HT
Heart: 11 Apr 2022; epub ahead of print | PMID: 35410893
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Abstract

Clinical outcomes in spontaneous coronary artery dissection.

Garcia-Guimaraes M, Masotti M, Sanz-Ruiz R, Macaya F, ... Alfonso F, Spanish Registry on SCAD investigators
Objective
Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome. Our aim was to assess adverse events at follow-up from a nationwide prospective cohort.
Methods
The Spanish Registry on SCAD (SR-SCAD) included patients from 34 hospitals. All coronary angiograms were analysed by two experts. Those cases with doubts regarding the diagnosis of SCAD were excluded. The angiographic SCAD classification by Saw et al was followed. Major adverse cardiovascular and cerebrovascular event (MACCE) was predefined as composite of death, myocardial infarction, unplanned revascularisation, SCAD recurrence or stroke. All events were assigned by a Clinical Events Committee.
Results
After corelab evaluation, 389 patients were included. Most patients were women (88%); median age 53 years (IQR 47-60). Most patients presented as non-ST-segment-elevation myocardial infarction (54%). A type 2 intramural haematoma (IMH) was the most frequent angiographic pattern (61%). A conservative initial management was selected in 78% of patients. At a median time of follow-up of 29 months (IQR 17-38), 46 patients (13%) presented MACCE, mainly driven by reinfarctions (7.6%) and unplanned revascularisations (6.2%). Previous history of hypothyroidism (HR 3.79; p<0.001), proximal vessel involvement (HR 2.69; p=0.009), type 2 IMH (HR 2.12; p=0.037) and dual antiplatelet therapy (DAPT) at discharge (HR 2.18; p=0.042) were independent predictors of MACCE.
Conclusions
In this large prospective cohort of patients with SCAD, prognosis was overall favourable, with events mainly driven by reinfarctions or unplanned revascularisations. History of hypothyroidism, proximal vessel involvement, type 2 IMH and DAPT at discharge were associated with MACCE.
Trial registration number
NCT03607981.

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Heart: 11 Apr 2022; epub ahead of print
Garcia-Guimaraes M, Masotti M, Sanz-Ruiz R, Macaya F, ... Alfonso F, Spanish Registry on SCAD investigators
Heart: 11 Apr 2022; epub ahead of print | PMID: 35410894
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Abstract

Predicting outcome after cardiac resynchronisation therapy defibrillator implantation: the CRT-D Futility score.

Maille B, Bodin A, Bisson A, Herbert J, ... Deharo JC, Fauchier L
Background
Risk-benefit for cardiac resynchronisation therapy (CRT) defibrillator (CRT-D) over CRT pacemaker remains a matter of debate. We aimed to identify patients with a poor outcome within 1 year of CRT-D implantation, and to develop a CRT-D Futility score.
Methods
Based on an administrative hospital-discharge database, all consecutive patients treated with prophylactic CRT-D implantation in France (2010-2019) were included. A prediction model was derived and validated for 1-year all-cause death after CRT-D implantation (considered as futility) by using split-sample validation.
Results
Among 23 029 patients (mean age 68±10 years; 4873 (21.2%) women), 7016 deaths were recorded (yearly incidence rate 7.2%), of which 1604 (22.8%) occurred within 1 year of CRT-D implantation. In the derivation cohort (n=11 514), the final logistic regression model included-as main predictors of futility-older age, diabetes, mitral regurgitation, aortic stenosis, history of hospitalisation with heart failure, history of pulmonary oedema, atrial fibrillation, renal disease, liver disease, undernutrition and anaemia. Area under the curve for the CRT-D Futility score was 0.716 (95% CI: 0.698 to 0.734) in the derivation cohort and 0.692 (0.673 to 0.710) in the validation cohort. The Hosmer-Lemeshow test had a p-value of 0.57 suggesting accurate calibration. The CRT-D Futility score outperformed the Goldenberg and EAARN scores for identifying futility. Based on the CRT-D Futility score, 15.9% of these patients were categorised at high risk (predicted futility of 16.6%).
Conclusions
The CRT-D Futility score, established from a large nationwide cohort of patients treated with CRT-D, may be a relevant tool for optimising healthcare decision-making.

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Heart: 11 Apr 2022; epub ahead of print
Maille B, Bodin A, Bisson A, Herbert J, ... Deharo JC, Fauchier L
Heart: 11 Apr 2022; epub ahead of print | PMID: 35410895
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Abstract

Getting the best from the Heart Team: guidance for cardiac multidisciplinary meetings.

Archbold A, Akowuah E, Banning AP, Baumbach A, ... Watt V, Ray S
The purpose of this document is to update the existing joint British Societies recommendations on multidisciplinary meetings (MDMs) published in 2015 to reflect changes in practice. We aim to provide guidance on the structure and function of MDMs which should be taking place in every cardiac surgical centre. Out of scope are MDMs that do not require the routine presence of a cardiac surgeon such as electrophysiology MDMs and those which are not provided in every centre, such as complex aortic surgery.

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Heart: 08 Apr 2022; epub ahead of print
Archbold A, Akowuah E, Banning AP, Baumbach A, ... Watt V, Ray S
Heart: 08 Apr 2022; epub ahead of print | PMID: 35396217
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Abstract

Adult patients with congenital heart disease in the intensive care unit.

Ramlakhan KP, van der Bie M, den Uil CA, Dubois EA, Roos-Hesselink JW
Objective
Current data on intensive care unit (ICU) admissions in patients with adult congenital heart disease (ACHD) are limited and focus on admissions after elective cardiac surgery. This study describes non-elective ICU admissions in patients with ACHD.
Methods
A retrospective matched cohort study was performed from January 2000 until December 2015 in a tertiary care centre ICU (there was no cardiac care unit). Primary outcomes were short-term (during hospital stay or <30 days after discharge) and long-term (>30 days after discharge until end of follow-up) mortality. Outcomes were compared with non-ACHD non-elective ICU admissions, matched 1:1 on age, sex and admission diagnosis.
Results
A total of 138 admissions in 104 patients with ACHD (65.9% male, median age 30 years) were included, during 8.6 years of follow-up. The majority had a moderate-to-severe heart defect. Arrhythmia was the most common admission diagnosis (44.2%), followed by haemorrhage (10.9%), heart failure (8.7%) and pulmonary disease (8.7%). Short-term mortality and total mortality were lower in the ACHD admissions than in the non-ACHD admissions (4.8% vs 16.3%, p=0.005 and 17.3% vs 28.9%, p=0.030), whereas long-term (12.5% vs 12.6%, p=0.700) did not differ. Severe CHD (HR 3.1, 95% CI 1.1 to 8.6) at baseline, and mechanical circulatory support device use (8.3, 1.4 to 47.4) and emergency intervention (0.2, 0.1 to 0.7) during the ICU stay were independently associated with mortality in the ACHD group.
Conclusions
Non-elective ICU admissions in patients with ACHD are most often for arrhythmia and in patients with moderate-to-severe CHD. Reassuringly, short-term and total mortality are lower compared with patients without ACHD, however, long-term mortality is higher than expected for patients with ACHD.

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Heart: 05 Apr 2022; epub ahead of print
Ramlakhan KP, van der Bie M, den Uil CA, Dubois EA, Roos-Hesselink JW
Heart: 05 Apr 2022; epub ahead of print | PMID: 35383106
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Abstract

Diagnosis and management of cardiac allograft vasculopathy.

Ortega-Legaspi JM, Bravo PE
One of the main causes of death beyond the first year after heart transplantation is cardiac allograft vasculopathy (CAV). This review summarises the current understanding of its complex pathophysiology, detection and treatment, including the available data on non-invasive imaging modalities used for screening and diagnosis. A better understanding of this entity is crucial to improving the long-term outcomes of the growing population of patients with a heart transplant.

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Heart: 31 Mar 2022; 108:586-592
Ortega-Legaspi JM, Bravo PE
Heart: 31 Mar 2022; 108:586-592 | PMID: 34340994
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Abstract

Evaluation of the causes of sex disparity in heart failure trials.

Morgan H, Sinha A, Mcentegart M, Hardman SM, Perera D
Objectives
Cardiovascular disease is one of the leading causes of mortality and morbidity in women. Despite this, even in contemporary research, female patients are poorly represented in trials. This study aimed to explore reasons behind the sex disparity in heart failure (HF) trials.
Methods
HF trials published in seven high-impact clinical journals (impact factor >20), between 2000 and 2020, were identified. Trials with over 300 participants of both sexes were included. Large HF registries, as well as population statistics, were also identified using the same criteria.
Results
We identified 146 HF trials, which included 248 620 patients in total. The median proportion of female patients was 25.8%, with the lowest proportions seen in trials enrolling patients with ischaemic cardiomyopathy (17.9%), severe systolic dysfunction (left ventricular ejection fraction (LVEF) <35%) (21.4%) and those involving an invasive procedure (21.1%). The highest proportion of women was seen in trials assessing HF with preserved LVEF (51.6%), as well as trials including older participants (40.5%). Significant differences were seen between prevalence of female trial participants and population prevalence in all LVEF categories (25.8% vs 49.0%, p<0.01).
Conclusions
A significant sex disparity was identified in HF trials, most visible in trials assessing patients with severely reduced LVEF and ischaemic aetiology. This is likely due to a complex interplay between enrolment bias and biological variation. Furthermore, the degree of both these aspects may vary according to trial type. Going forward, we should encourage all HF trials to appraise their recruitment log and suggest reasons for any reported sex disparity.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 31 Mar 2022; epub ahead of print
Morgan H, Sinha A, Mcentegart M, Hardman SM, Perera D
Heart: 31 Mar 2022; epub ahead of print | PMID: 35361671
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Abstract

Beta-blockers are associated with better long-term survival in patients with Takotsubo syndrome.

Silverio A, Parodi G, Scudiero F, Bossone E, ... Galasso G, Citro R
Objective
The advantage of beta-blockers has been postulated in patients with Takotsubo syndrome (TTS) given the pathophysiological role of catecholamines. We hypothesised that beta-blocker treatment after discharge may improve the long-term clinical outcome in this patient population.
Methods
This was an observational, multicentre study including consecutive patients with TTS diagnosis prospectively enrolled in the Takotsubo Italian Network (TIN) register from January 2007 to December 2018. TTS was diagnosed according to the TIN, Heart Failure Association and InterTAK Diagnostic Criteria. The primary study outcome was the occurrence of all-cause death at the longest available follow-up; secondary outcomes were TTS recurrence, cardiac and non-cardiac death.
Results
The study population included 825 patients (median age: 72.0 (63.0-78.0) years; 91.9 % female): 488 (59.2%) were discharged on beta-blockers and 337 (40.8%) without beta-blockers. The median follow-up was 24.0 months. The adjusted Cox regression analysis showed a significantly lower risk for all-cause death (adjusted HR: 0.563; 95% CI: 0.356 to 0.889) and non-cardiac death (adjusted HR: 0.525; 95% CI: 0.309 to 0.893) in patients receiving versus those not receiving beta-blockers, but no significant differences in terms of TTS recurrence (adjusted HR: 0.607; 95% CI: 0.311 to 1.187) and cardiac death (adjusted HR: 0.699; 95% CI: 0.284 to 1.722). The positive survival effect of beta-blockers was higher in patients with hypertension than in those without (pinteraction=0.014), and in patients who developed cardiogenic shock during the acute phase than in those who did not (pinteraction=0.047).
Conclusions
In this real-world register population, beta-blockers were associated with a significantly higher long-term survival, particularly in patients with hypertension and in those who developed cardiogenic shock during the acute phase.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 31 Mar 2022; epub ahead of print
Silverio A, Parodi G, Scudiero F, Bossone E, ... Galasso G, Citro R
Heart: 31 Mar 2022; epub ahead of print | PMID: 35361673
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Impact:
Abstract

Unscheduled care pathways in patients with myocardial infarction in Scotland.

Hodgins P, McMinn M, Shah A, Reed MJ, Mercer S, Guthrie B
Objective
Treatment of acute myocardial infarction (MI) requires rapid transfer of people with chest pain to hospital, however, unscheduled care pathways vary in their directness (the minimal number of contacts to hospital admission). The aim was to examine unscheduled care pathways and the associations with mortality in people admitted with MI.
Methods
Retrospective population study of all people admitted to Scottish hospitals with a diagnosis of MI between 1 January 2015 and 31 December 2017. Linked data for all National Health Service Scotland unscheduled care services (NHS24 telephone triage service, primary care out of hours, ambulance, emergency department (ED)) was used to define continuous unscheduled care pathways (pathways), which were categorised by initial contact, and whether they were \'direct\' (had minimum number of contacts between first contact and admission). Analysis estimated ORs and 95% CIs in adjusted models in which all covariates were included.
Results
26 325 people admitted with MI (63.1% men, 61.6% aged 65+ years), of whom 5.6% died from coronary heart disease within 28 days. For 47.0%, the first unscheduled care contact was ambulance, 23.3% attended ED directly and 18.7% called telephone triage. 92.1% of pathways were direct. Pathways starting with telephone triage were more likely to be indirect compared with other initial contacts (adjusted OR (aOR) 1.97, 95% CI 1.61 to 2.40). Compared to direct pathways, indirect pathways starting with telephone triage were associated with higher mortality (aOR 1.97, 95% CI 1.61 to 2.40) as were indirect pathways starting with another service (aOR 1.55, 95% CI 1.19 to 2.01), but not direct pathways starting with telephone triage (aOR 0.87, 95% CI 0.74 to 1.02).
Conclusion
Unscheduled care pathways leading to admission with MI in Scotland are usually direct, but those starting with telephone triage were more commonly indirect. Those indirect pathways were associated with higher mortality.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 31 Mar 2022; epub ahead of print
Hodgins P, McMinn M, Shah A, Reed MJ, Mercer S, Guthrie B
Heart: 31 Mar 2022; epub ahead of print | PMID: 35361675
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Impact:
Abstract

Trends in the pharmacological management of atrial fibrillation in UK general practice 2008-2018.

Phillips K, Subramanian A, Thomas GN, Khan N, ... Fabritz L, Adderley NJ
Objective
The pharmacological management of atrial fibrillation (AF) comprises anticoagulation, for stroke prophylaxis, and rate or rhythm control drugs to alleviate symptoms and prevent heart failure. The aim of this study was to investigate trends in the proportion of patients with AF prescribed pharmacological therapies in the UK between 2008 and 2018.
Methods
Eleven sequential cross-sectional analyses were performed yearly from 2008 to 2018. Data were derived from an anonymised UK primary care database. Outcomes were the proportion of patients with AF prescribed anticoagulants, rhythm and rate control drugs in the whole cohort, those at high risk of stroke and those with coexisting heart failure.
Results
Between 2008 and 2018, the proportion of patients prescribed anticoagulants increased from 45.3% (95% CI 45.0% to 45.7%) to 71.1% (95% CI 70.7% to 71.5%) driven by increased prescription of non-vitamin K antagonist anticoagulants. The proportion of patients prescribed rate control drugs remained constant between 2008 and 2018 (69.3% (95% CI 68.9% to 69.6%) to 71.6% (95% CI 71.2% to 71.9%)). The proportion of patients prescribed rhythm control therapy by general practitioners (GPs) decreased from 9.5% (95% CI 9.3% to 9.7%) to 5.4% (95% CI 5.2% to 5.6%).
Conclusions
There has been an increase in the proportion of patients with AF appropriately prescribed anticoagulants following National Institute for Health and Care Excellence and European Society of Cardiology guidelines, which correlates with improvements in mortality and stroke outcomes. Beta-blockers appear increasingly favoured over digoxin for rate control. There has been a steady decline in GP prescribing rates for rhythm control drugs, possibly related to concerns over efficacy and safety and increased availability of AF ablation.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 30 Mar 2022; 108:517-522
Phillips K, Subramanian A, Thomas GN, Khan N, ... Fabritz L, Adderley NJ
Heart: 30 Mar 2022; 108:517-522 | PMID: 34226195
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Impact:
Abstract

The utility of strain imaging in the cardiac surveillance of bone marrow transplant patients.

Deshmukh T, Emerson P, Geenty P, Mahendran S, ... Gottlieb D, Thomas L
Objective
To evaluate the utility of two-dimensional multiplanar speckle tracking strain to assess for cardiotoxicity post allogenic bone marrow transplantation (BMT) for haematological conditions.
Methods
Cross-sectional study of 120 consecutive patients post-BMT (80 pretreated with anthracyclines (BMT+AC), 40 BMT alone) recruited from a late effects haematology clinic, compared with 80 healthy controls, as part of a long-term cardiotoxicity surveillance study (mean duration from BMT to transthoracic echocardiogram 6±6 years). Left ventricular global longitudinal strain (LV GLS), global circumferential strain (LV GCS) and right ventricular free wall strain (RV FWS) were compared with traditionl parameters of function including LV ejection fraction (LVEF) and RV fractional area change.
Results
LV GLS (-17.7±3.0% vs -20.2±1.9%), LV GCS (-14.7±3.5% vs -20.4±2.1%) and RV FWS (-22.6±4.7% vs -28.0±3.8%) were all significantly (p=0.001) reduced in BMT+AC versus controls, while only LV GCS (-15.9±3.5% vs -20.4±2.1%) and RV FWS (-23.9±3.5% vs -28.0±3.8%) were significantly (p=0.001) reduced in BMT group versus controls. Even in patients with LVEF >53%, ~75% of patients in both BMT groups demonstrated a reduction in GCS.
Conclusion
Multiplanar strain identifies a greater number of BMT patients with subclinical LV dysfunction rather than by GLS alone, and should be evaluated as part of post-BMT patient surveillence. Reduction in GCS is possibly due to effects of preconditioning, and is not fully explained by AC exposure.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 30 Mar 2022; 108:550-557
Deshmukh T, Emerson P, Geenty P, Mahendran S, ... Gottlieb D, Thomas L
Heart: 30 Mar 2022; 108:550-557 | PMID: 34301770
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Impact:
Abstract

Early invasive versus non-invasive assessment in patients with suspected non-ST-elevation acute coronary syndrome.

Kite TA, Ladwiniec A, Arnold JR, McCann GP, Moss AJ
Non-ST-elevation acute coronary syndrome (NSTE-ACS) comprises a broad spectrum of disease ranging from unstable angina to myocardial infarction. International guidelines recommend a routine invasive strategy for managing patients with NSTE-ACS at high to very high-risk, supported by evidence of improved composite ischaemic outcomes as compared with a selective invasive strategy. However, accurate diagnosis of NSTE-ACS in the acute setting is challenging due to the spectrum of non-coronary disease that can manifest with similar symptoms. Heterogeneous clinical presentations and limited uptake of risk prediction tools can confound physician decision-making regarding the use and timing of invasive coronary angiography (ICA). Large proportions of patients with suspected NSTE-ACS do not require revascularisation but may unnecessarily undergo ICA with its attendant risks and associated costs. Advances in coronary CT angiography and cardiac MRI have prompted evaluation of whether non-invasive strategies may improve patient selection, or whether tailored approaches are better suited to specific subgroups. Future directions include (1) better understanding of risk stratification as a guide to investigation and therapy in suspected NSTE-ACS, (2) randomised clinical trials of non-invasive imaging versus standard of care approaches prior to ICA and (3) defining the optimal timing of very early ICA in high-risk NSTE-ACS.

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Heart: 30 Mar 2022; 108:500-506
Kite TA, Ladwiniec A, Arnold JR, McCann GP, Moss AJ
Heart: 30 Mar 2022; 108:500-506 | PMID: 34234006
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Impact:
Abstract

Professionals\' views on shared decision-making in severe aortic stenosis.

van Beek-Peeters JJAM, van der Meer JBL, Faes MC, de Vos AJBM, ... van der Meer NJM, Minkman MMN
Objective
To provide insight into professionals\' perceptions of and experiences with shared decision-making (SDM) in the treatment of symptomatic patients with severe aortic stenosis (AS).
Methods
A semistructured interview study was performed in the heart centres of academic and large teaching hospitals in the Netherlands between June and December 2020. Cardiothoracic surgeons, interventional cardiologists, nurse practitioners and physician assistants (n=21) involved in the decision-making process for treatment of severe AS were interviewed. An inductive thematic analysis was used to identify, analyse and report patterns in the data.
Results
Four primary themes were generated: (1) the concept of SDM, (2) knowledge, (3) communication and interaction, and (4) implementation of SDM. Not all respondents considered patient participation as an element of SDM. They experienced a discrepancy between patients\' wishes and treatment options. Respondents explained that not knowing patient preferences for health improvement hinders SDM and complicating patient characteristics for patient participation were perceived. A shared responsibility for improving SDM was suggested for patients and all professionals involved in the decision-making process for severe AS.
Conclusions
Professionals struggle to make highly complex treatment decisions part of SDM and to embed patients\' expectations of treatment and patients\' preferences. Additionally, organisational constraints complicate the SDM process. To ensure sustainable high-quality care, professionals should increase their awareness of patient participation in SDM, and collaboration in the pathway for decision-making in severe AS is required to support the documentation and availability of information according to the principles of SDM.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 30 Mar 2022; 108:558-564
van Beek-Peeters JJAM, van der Meer JBL, Faes MC, de Vos AJBM, ... van der Meer NJM, Minkman MMN
Heart: 30 Mar 2022; 108:558-564 | PMID: 34952859
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Impact:
Abstract

Ideal cardiovascular health duration and risk of chronic kidney disease and cardiovascular disease.

Cho SMJ, Jeon JY, Yoo TH, Lee HY, Lee YH, Kim HC
Objective
Increasing number of clinical guidelines are adopting comprehensive cardiovascular risk assessment tools for treatment decision and disease management. Yet, little is known regarding cardiovascular risks associated with the length of favourable cardiometabolic profile. In this context, we examined whether the duration of strictly ideal cardiovascular health (CVH), based on body mass index, blood pressure, fasting glucose, total cholesterol, cigarette smoking, alcohol drinking and physical activity, in middle age is associated with risk of developing chronic kidney disease (CKD) and cardiovascular disease (CVD) in mid-to-late life.
Methods
From the Korean Genome and Epidemiology Study Ansung-Ansan cohort, we included 8020 participants (median age 50.0 years, 47.9% male), of whom, 7854 without CKD and 7796 without CVD at baseline. Cox proportional hazards models were employed to assess CKD and CVD risks, adjusting for age, sex, education level, examination sites and renal markers.
Results
Over a median follow-up of 15.0 years, 1401 cases of CKD and 493 cases of CVD were newly developed. Compared with participants with <5 years of ideal CVH duration, HR (95% CI) of those who maintained for 5-<10 years or ≥10 years had negatively graded risks for CKD (5-<10 years, 0.63 (0.39 to 0.93); ≥10 years, 0.33 (0.15 to 0.74)) and CVD (5-<10 years, 0.83 (0.54 to 1.27); ≥10 years, 0.22 (0.08 to 0.60)). In parallel, participants with delayed decline to suboptimal level had lower disease risks compared with counterparts with consistently suboptimal CVH.
Conclusion
Our findings confer that maintaining favourable health behaviours and clinical risk factor levels in midlife will improve later-life cardiovascular outcomes.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 30 Mar 2022; 108:523-528
Cho SMJ, Jeon JY, Yoo TH, Lee HY, Lee YH, Kim HC
Heart: 30 Mar 2022; 108:523-528 | PMID: 34916271
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Impact:
Abstract

Adverse cardiac mechanics and incident coronary heart disease in the Cardiovascular Health Study.

Massera D, Hu M, Delaney JA, Bartz TM, ... Kizer JR, Shah SJ
Objectives
Speckle-tracking echocardiography enables detection of abnormalities in cardiac mechanics with higher sensitivity than conventional measures of left ventricular (LV) dysfunction and may provide insight into the pathogenesis of coronary heart disease (CHD). We investigated the relationship of LV longitudinal strain, LV early diastolic strain rate (SR) and left atrial (LA) reservoir strain with long-term CHD incidence in community-dwelling older adults.
Methods
The association of all three strain measures with incidence of non-fatal and fatal CHD (primary outcome of revascularisation, non-fatal and fatal myocardial infarction) was examined in the population-based Cardiovascular Health Study using multivariable Cox proportional hazards models. Follow-up was truncated at 10 years.
Results
We included 3313 participants (mean (SD) age 72.6 (5.5) years). During a median follow-up of 10.0 (25th-75th percentile 7.7-10.0) years, 439 CHD events occurred. LV longitudinal strain (HR=1.25 per SD decrement, 95% CI 1.09 to 1.43) and LV early diastolic SR (HR=1.31 per SD decrement, 95% CI 1.14 to 1.50) were associated with a significantly greater risk of incident CHD after adjustment for potential confounders. By contrast, LA reservoir strain was not associated with incident CHD (HR=1.06 per SD decrement, 95% CI 0.94 to 1.19). Additional adjustment for biochemical and echocardiographic measures of myocardial stress, dysfunction and remodelling did not meaningfully alter these associations.
Conclusion
We found an association between echocardiographic measures of subclinically altered LV mechanics and incident CHD. These findings inform the underlying biology of subclinical LV dysfunction and CHD. Early detection of asymptomatic myocardial dysfunction may offer an opportunity for prevention and early intervention.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 30 Mar 2022; 108:529-535
Massera D, Hu M, Delaney JA, Bartz TM, ... Kizer JR, Shah SJ
Heart: 30 Mar 2022; 108:529-535 | PMID: 34257074
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Impact:
Abstract

Cross-sectional analysis of educational inequalities in primary prevention statin use in UK Biobank.

Carter AR, Gill D, Davey Smith G, Taylor AE, Davies NM, Howe LD
Objective
Identify whether participants with lower education are less likely to report taking statins for primary cardiovascular prevention than those with higher education, but an equivalent increase in underlying cardiovascular risk.
Methods
Using data from a large prospective cohort study, UK Biobank, we calculated a QRISK3 cardiovascular risk score for 472 097 eligible participants with complete data on self-reported educational attainment and statin use (55% female participants; mean age 56 years). We used logistic regression to explore the association between (i) QRISK3 score and (ii) educational attainment on self-reported statin use. We then stratified the association between QRISK3 score and statin use, by educational attainment to test for interactions.
Results
There was evidence of an interaction between QRISK3 score and educational attainment. Per unit increase in QRISK3 score, more educated individuals were more likely to report taking statins. In women with ≤7 years of schooling, a one unit increase in QRISK3 score was associated with a 7% higher odds of statin use (OR 1.07, 95% CI 1.07 to 1.07). In women with ≥20 years of schooling, a one unit increase in QRISK3 score was associated with an 14% higher odds of statin use (OR 1.14, 95% CI 1.14 to 1.15). Comparable ORs in men were 1.04 (95% CI 1.04 to 1.05) for ≤7 years of schooling and 1.08 (95% CI 1.08, 1.08) for ≥20 years of schooling.
Conclusion
Per unit increase in QRISK3 score, individuals with lower educational attainment were less likely to report using statins, likely contributing to health inequalities.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.

Heart: 30 Mar 2022; 108:536-542
Carter AR, Gill D, Davey Smith G, Taylor AE, Davies NM, Howe LD
Heart: 30 Mar 2022; 108:536-542 | PMID: 34315717
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Impact:
Abstract

Coronary revascularisation outcomes in patients with cancer.

Leedy D, Tiwana JK, Mamas M, Hira R, Cheng R
Cancer and coronary artery disease (CAD) overlap in traditional risk factors as well as molecular mechanisms underpinning the development of these two disease states. Patients with cancer are at increased risk of developing CAD, representing a high-risk population that are increasingly undergoing coronary revascularisation. Over 1 in 10 patients with CAD that require revascularisation with either percutaneous coronary intervention or coronary artery bypass grafting have either a history of cancer or active cancer. These patients are typically older, have more comorbidities and have more extensive CAD compared with patients without cancer. Haematological abnormalities with competing risks of thrombosis and bleeding pose further unique challenges during and after revascularisation. Management of patients with concurrent cancer and CAD requiring revascularisation is challenging as these patients carry a higher risk of morbidity and mortality compared with those without cancer, often driven by the underlying cancer and associated comorbidities. However, due to variability by different types and stages of cancer, revascularisation outcomes are specific to cancer characteristics such as the timing of onset, cancer subtype and site, stage, presence of metastases, and cancer-related therapies received. Recent studies have provided insights into defining revascularisation outcomes, procedural considerations and best practices in managing patients with cancer. Nevertheless, many gaps remain that require further studies to inform clinical best practices in this population.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 30 Mar 2022; 108:507-516
Leedy D, Tiwana JK, Mamas M, Hira R, Cheng R
Heart: 30 Mar 2022; 108:507-516 | PMID: 34415850
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Impact:
Abstract

Proteomics profiling reveals a distinct high-risk molecular subtype of hypertrophic cardiomyopathy.

Liang LW, Raita Y, Hasegawa K, Fifer MA, ... Reilly MP, Shimada YJ
Objective
Hypertrophic cardiomyopathy (HCM) is a heterogeneous disease, likely encompassing several subtypes of disease with distinct biological mechanisms (ie, molecular subtypes). Current models based solely on clinical data have yielded limited accuracy in predicting the risk of major adverse cardiovascular events (MACE). Our aim in this study was to derive molecular subtypes in our multicentre prospective cohort of patients with HCM using proteomics profiling and to examine their longitudinal associations with MACE.
Methods
We applied unsupervised machine learning methods to plasma proteomics profiling data of 1681 proteins from 258 patients with HCM who were prospectively followed for a median of 2.8 years. The primary outcome was MACE, defined as a composite of arrhythmia, heart failure, stroke and sudden cardiac death.
Results
We identified four molecular subtypes of HCM. Time-to-event analysis revealed significant differences in MACE-free survival among the four molecular subtypes (plogrank=0.007). Compared with the reference group with the lowest risk of MACE (molecular subtype A), patients in molecular subtype D had a higher risk of subsequently developing MACE, with an HR of 3.41 (95% CI 1.54 to 7.55, p=0.003). Pathway analysis of proteins differentially regulated in molecular subtype D demonstrated an upregulation of the Ras/mitogen-activated protein kinase and associated pathways, as well as pathways related to inflammation and fibrosis (eg, transforming growth factor-β pathway).
Conclusions
Our prospective plasma proteomics study not only exhibited the presence of HCM molecular subtypes but also identified pathobiological mechanisms associated with a distinct high-risk subtype of HCM.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 29 Mar 2022; epub ahead of print
Liang LW, Raita Y, Hasegawa K, Fifer MA, ... Reilly MP, Shimada YJ
Heart: 29 Mar 2022; epub ahead of print | PMID: 35351822
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Impact:
Abstract

Transcatheter aortic valve implantation in patients with rheumatic aortic stenosis.

Okuno T, Tomii D, Buffle E, Lanz J, ... Windecker S, Pilgrim T
Background
Rheumatic heart disease (RHD) accounts for the highest number of deaths from valvular heart disease globally. Yet, rheumatic aortic stenosis (AS) was excluded from landmark studies investigating the safety and efficacy of transcatheter aortic valve implantation (TAVI). We aimed to describe the clinical and anatomical characteristics of patients with rheumatic AS undergoing TAVI, and to compare procedural and clinical outcomes with patients undergoing TAVI for degenerative AS.
Methods
In a prospective TAVI registry, patients with rheumatic AS were identified based on International Classification of Diseases version 10 codes and/or a documented history of acute rheumatic fever and/or the World Heart Federation criteria for echocardiographic diagnosis of RHD, and were propensity score-matched in a 1:4 ratio to patients with degenerative AS.
Results
Among 2329 patients undergoing TAVI, 105 (4.5%) had rheumatic AS. Compared with patients with degenerative AS, patients with rheumatic AS were more commonly female, older, had higher surgical risk and more commonly suffered from multivalvular heart disease. In the unmatched cohort, both technical success (85.7% vs 85.9%, p=0.887) and 1-year cardiovascular mortality (10.0% vs 8.6%; HR 1.16, 95% CI 0.61 to 2.18, p=0.656) were comparable between patients with rheumatic and degenerative AS. In contrast, patients with rheumatic AS had lower rates of 30-day and 1-year cardiovascular mortality compared with matched patients with degenerative AS (1.9% vs 8.9%, adjusted HR (HRadj) 0.18, 95% CI 0.04 to 0.80, p=0.024; and 10.0% vs 20.3%, HRadj 0.44, 95% CI 0.24 to 0.84, p=0.012, respectively).
Conclusion
TAVI may be a safe and effective treatment strategy for selected elderly patients with rheumatic AS.
Trial registration number
NCT01368250.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 29 Mar 2022; epub ahead of print
Okuno T, Tomii D, Buffle E, Lanz J, ... Windecker S, Pilgrim T
Heart: 29 Mar 2022; epub ahead of print | PMID: 35351823
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Impact:
Abstract

Sex difference in atrial fibrillation recurrence after catheter ablation and antiarrhythmic drugs.

Park YJ, Park JW, Yu HT, Kim TH, ... Lee MH, Pak HN
Objective
The risk of recurrence after atrial fibrillation (AF) catheter ablation (AFCA) is higher in women than in men. However, it is unknown whether a sex difference exists in antiarrhythmic drug (AAD) responsiveness among patients with recurrence.
Methods
Among 2999 consecutive patients (26.5% women, 58.3±10.9 years old, 68.1% paroxysmal AF) who underwent de novo AFCA, we compared and evaluated the sex differences in rhythm outcome in 1094 patients with recurrence and in 788 patients who subsequently underwent rhythm control with AAD.
Results
During a follow-up of 48.2±34.9 months, 1094 patients (36.5%) had AF recurrence after AFCA, and 508 of 788 patients (64.5%) had AF recurrence under AAD. Although the rhythm outcome of a de novo AFCA was worse (log-rank p=0.041, HR 1.28, 95% CI 1.02 to 1.59), p=0.031) in women, AAD response after postprocedural recurrences was better in women than in men (log-rank p=0.003, HR 0.75, 95% CI 0.59 to 0.95, p=0.022), especially in women older than 60 years old (log-rank p=0.003). In 249 patients who underwent repeat procedure after AAD use, the pulmonary vein (PV) reconnection rate (62.7% vs 76.8%, p=0.048) was lower in women than in men but not the existence of extra-PV trigger (37.8% vs 25.4%, p=0.169).
Conclusions
Although women showed worse rhythm outcomes than men after AFCA, the post-AFCA AAD response was better in elderly women than in men.
Trial registration number
NCT02138695.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 24 Mar 2022; epub ahead of print
Park YJ, Park JW, Yu HT, Kim TH, ... Lee MH, Pak HN
Heart: 24 Mar 2022; epub ahead of print | PMID: 35332048
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Impact:
Abstract

Novel predictive role for mid-regional proadrenomedullin in moderate to severe aortic stenosis.

Tan ESJ, Oon YY, Chan SP, Liew OW, ... Richards AM, Ling LH
Objective
We investigated the prognostic significance of selected known and novel circulating biomarkers in aortic stenosis (AS).
Methods
N-terminal pro-BNP (NT-proBNP), high-sensitivity troponin-T (hsTnT), growth differentiation factor-15 (GDF-15), suppression of tumorigenicity-2 (ST2), mid-regional proadrenomedullin (MR-proADM) and mid-regional proatrial natriuretic peptide (MR-proANP) were measured in patients with moderate to severe AS, New York Heart Association (NYHA) class I-II and left ventricular ejection fraction ≥50%, recruited consecutively across five centres from 2011 to 2018. Their ability to predict both primary (all-cause mortality, heart failure hospitalisation or progression to NYHA class III-IV) and secondary (additionally incorporating syncope and acute coronary syndrome) outcomes was determined by competing risk analyses.
Results
Among 173 patients with AS (age 69±11 years, 55% male, peak transaortic velocity (Vmax) 4.0±0.8 m/s), the primary and secondary outcomes occurred in 59 (34%) and 66 (38%), respectively. With aortic valve replacement as a competing risk, the primary outcome was determined consistently by the comorbidity index and each selected biomarker except ST2 (p<0.05), independent of NYHA class, Vmax, LV-global longitudinal strain and serum creatinine. MR-proADM had the highest discriminative value for both primary (subdistribution HR (SHR) 11.3, 95% CI 3.9 to 32.7) and secondary outcomes (SHR 12.6, 95% CI 4.7 to 33.5). Prognostic assessment of dual-biomarker combinations identified MR-proADM plus either hsTnT or NT-proBNP as the best predictive model for both clinical outcomes. Paired biomarker models were not superior to those including MR-proADM as the sole circulating biomarker.
Conclusion
MR-proADM most powerfully portended worse prognosis and should be further assessed as possibly the biomarker of choice for risk stratification in AS.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 24 Mar 2022; epub ahead of print
Tan ESJ, Oon YY, Chan SP, Liew OW, ... Richards AM, Ling LH
Heart: 24 Mar 2022; epub ahead of print | PMID: 35332049
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Impact:
Abstract

Imaging surveillance for complications after primary surgery for type A aortic dissection.

Heuts S, Schalla S, Ramaekers MJFG, Bidar E, ... Wildberger JE, Adriaans BP
Acute type A aortic dissection (ATAAD) is a life-threatening condition that requires emergency surgery to avert fatal outcome. Conventional surgical procedures comprise excision of the entry tear and replacement of the proximal aorta with a synthetic vascular graft. In patients with DeBakey type I dissection, this approach leaves a chronically dissected distal aorta, putting them at risk for progressive dilatation, dissection propagation and aortic rupture. Therefore, ATAAD survivors should undergo serial imaging for evaluation of the aortic valve, proximal and distal anastomoses, and the aortic segments beyond the distal anastomosis. The current narrative review aims to describe potential complications in the early and late phases after ATAAD surgery, with focus on their specific imaging findings.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 23 Mar 2022; epub ahead of print
Heuts S, Schalla S, Ramaekers MJFG, Bidar E, ... Wildberger JE, Adriaans BP
Heart: 23 Mar 2022; epub ahead of print | PMID: 35321890
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Impact:
Abstract

Percutaneous coronary intervention in patients with documented coronary vasospasm during long-term follow-up.

Kim JH, Park J, Yang Y, Lee S, ... Park SJ, Song JK
Objective
Although recurring coronary artery spasm (CAS) may lead to the development of fixed atherosclerotic coronary stenosis (FS), the relationship between coronary atherosclerosis and CAS is still speculative. We evaluated the incidence of FS requiring percutaneous coronary intervention (PCI) in patients with documented CAS during long-term follow-up and analysed their clinical features.
Methods
Clinical data of 3556 patients during a median follow-up of 9.4 years after non-invasive ergonovine spasm provocation testing with echocardiographic monitoring of left ventricular wall motion (erg echo) were analysed.
Results
Erg echo documented CAS in 830 (23.3%) patients, who had higher frequencies of coronary risk factors than those without CAS. Patients with documented CAS on erg echo showed significantly lower 10-year overall (90.5% vs 94.2%, p<0.001) and PCI-free (97.4% vs 98.4%, p=0.002) survival rates than those without CAS. Documented CAS was an independent factor associated with later PCI after adjustment by either Cox regression model or Fine-Gray competing risk model. There was no significant difference in baseline clinical characteristics between patients who needed later PCI and those who did not. Among 28 patients who needed later PCI after documentation of CAS, the original CAS and later PCI territory were concordant in 25 (89.3%), while 3 (10.7%) showed discordance.
Conclusions
CAS is a risk factor for the development of FS requiring PCI during long-term follow-up, and warrants physicians\' vigilance and careful follow-up of patients with documented CAS and insignificant stenosis of major epicardial coronary arteries at the time of initial diagnosis.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 22 Mar 2022; epub ahead of print
Kim JH, Park J, Yang Y, Lee S, ... Park SJ, Song JK
Heart: 22 Mar 2022; epub ahead of print | PMID: 35318253
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Impact:
Abstract

Invasive coronary physiology in patients with angina and non-obstructive coronary artery disease: a consensus document from the coronary microvascular dysfunction workstream of the British Heart Foundation/National Institute for Health Research Partnership.

Perera D, Berry C, Hoole SP, Sinha A, ... Channon K, UK Coronary Microvascular Dysfunction Working Group
Nearly half of all patients with angina have non-obstructive coronary artery disease (ANOCA); this is an umbrella term comprising heterogeneous vascular disorders, each with disparate pathophysiology and prognosis. Approximately two-thirds of patients with ANOCA have coronary microvascular disease (CMD). CMD can be secondary to architectural changes within the microcirculation or secondary to vasomotor dysfunction. An inability of the coronary vasculature to augment blood flow in response to heightened myocardial demand is defined as an impaired coronary flow reserve (CFR), which can be measured non-invasively, using imaging, or invasively during cardiac catheterisation. Impaired CFR is associated with myocardial ischaemia and adverse cardiovascular outcomes.The CMD workstream is part of the cardiovascular partnership between the British Heart Foundation and The National Institute for Health Research in the UK and comprises specialist cardiac centres with expertise in coronary physiology assessment. This document outlines the two main modalities (thermodilution and Doppler techniques) for estimation of coronary flow, vasomotor testing using acetylcholine, and outlines a standard operating procedure that could be considered for adoption by national networks. Accurate and timely disease characterisation of patients with ANOCA will enable clinicians to tailor therapy according to their patients\' coronary physiology. This has been shown to improve patients\' quality of life and may lead to improved cardiovascular outcomes in the long term.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.

Heart: 22 Mar 2022; epub ahead of print
Perera D, Berry C, Hoole SP, Sinha A, ... Channon K, UK Coronary Microvascular Dysfunction Working Group
Heart: 22 Mar 2022; epub ahead of print | PMID: 35318254
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Impact:
Abstract

Clinical and economic impact of extracardiac lesions on coronary CT angiography.

Kelion A, Sabharwal N, Holdsworth D, Dawkins S, ... Sykes A, Bashir Y
Objective
When reporting coronary CT angiography (CCTA), extracardiac structures are routinely assessed, usually on a wide field-of-view (FOV) reconstruction. We performed a retrospective observational cross-sectional study to investigate the impact of incidental extracardiac abnormalities on resource utilisation and treatment, and cost-effectiveness.
Methods
All patients undergoing CCTA at a single institution between January 2012 and March 2020 were identified. The indication for CCTA was chest pain or dyspnoea in >90%. Patients with ≥1 significant extracardiac findings were selected. Clinical follow-up, investigations and treatment were documented, and costs were calculated.
Results
4340 patients underwent CCTA; 717 extracardiac abnormalities were identified in 687 individuals (15.8%; age 62±12 years; male 336, 49%). The abnormality was already known in 162 (23.6%). Lung nodules and cysts were the most common abnormalities (296, 43.1%). Clinical and/or imaging follow-up was pursued in 292 patients (42.5%). Treatment was required by 14 patients (0.3% of the entire population), including lung resection for adenocarcinoma in six (0.1%). All but two abnormalities (both adenocarcinomas) were identifiable on the limited cardiac FOV. The cost of reporting (£20) and follow-up (£33) of extracardiac abnormalities was £53 per patient. The cost per discounted quality-adjusted life year was £23 930, increasing to £46 674 for reporting the wide FOV rather than the cardiac FOV alone.
Conclusions
Extracardiac abnormalities are common on CCTA, but identification and follow-up are costly. The few requiring treatment are usually identifiable without review of the wide FOV. The way in which CCTAs are scrutinised for extracardiac abnormalities in a resource-limited healthcare system should be questioned.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 22 Mar 2022; epub ahead of print
Kelion A, Sabharwal N, Holdsworth D, Dawkins S, ... Sykes A, Bashir Y
Heart: 22 Mar 2022; epub ahead of print | PMID: 35318255
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Impact:
Abstract

Evolution of the burden of aortic stenosis by sex in the province of Quebec between 2006 and 2018.

Frieden P, Blais C, Hamel D, Gamache P, Pibarot P, Clavel MA
Objectives
To evaluate the evolution of the burden of aortic stenosis (AS) by sex in the province of Quebec from 2006-2007 to 2018-2019 and compare the percentage of mortality between people who underwent aortic valve intervention and those who did not.
Methods
Persons aged ≥20 years were identified from the Quebec Integrated Chronic Disease Surveillance System using International Classification of Diseases and intervention codes in the hospital files.
Results
In 2018, the crude prevalence and incidence of AS were 0.89% (99% CI 0.89 to 0.90) (n=59 025) and 1.39 per 1000 (1.35 to 1.43) (n=9105), respectively. Age-standardised prevalence and incidence of AS diagnosis increased between 2006 and 2018 from 0.67% (0.66 to 0.68) to 0.75% (0.74 to 0.76) and from 0.91 per 1000 (0.88 to 0.95) to 1.20 per 1000 (1.17 to 1.23), respectively. Among incident AS, the age-standardised percentage of valve interventions increased from 11.7% (10.9 to 12.6) to 14.5% (13.9 to 15.3). This increase was only observed in men. The 30-day mortality was stable among patients with incident AS treated conservatively, from 6.9% (6.5 to 7.4) to 7.3% (6.9 to 7.6), and decreased from 7.6% (6.1 to 9.3) to 3.8% (3.1 to 4.7) among operated patients with incident AS. This decrease was only observed in women. However, from 2010, the age-adjusted mortality among prevalent AS tended to be higher in women.
Conclusions
In the province of Quebec, age-standardised prevalence and incidence of AS diagnosis increased between 2006 and 2018. Among incident AS, there was an increase in valve intervention in men and a decrease in 30-day mortality in women who underwent valve intervention. Overall and age-standardised mortality remained higher in women.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 21 Mar 2022; epub ahead of print
Frieden P, Blais C, Hamel D, Gamache P, Pibarot P, Clavel MA
Heart: 21 Mar 2022; epub ahead of print | PMID: 35314452
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Impact:
Abstract

Echo-guided left ventricular assist device speed optimisation for exercise maximisation.

Stapor M, Pilat A, Gackowski A, Misiuda A, ... Kapelak B, Wierzbicki K
Objective
Current generation left ventricular assist devices (LVADs) operate with a fixed rotation speed and no automated speed adjustment function. This study evaluates the concept of physiological pump speed optimisation based on aortic valve opening (AVO) imaging during a cardiopulmonary exercise test (CPET).
Methods
This prospective crossover study (NCT05063006) enrolled patients with implanted third-generation LVADs with hydrodynamic bearing. After resting speed optimisation, patients were randomised to a fixed-modified speed or modified-fixed speed CPET sequence. Fixed speed CPET maintained baseline pump settings. During the modified speed CPET, the LVAD speed was continuously altered to preserve periodic AVO.
Results
We included 22 patients, the mean age was 58.4±7 years, 4.5% were women and 54.5% had ischaemic cardiomyopathy. Exertional AVO assessment was feasible in all subjects. Maintaining periodic AVO allowed to safely raise the pump speed from 2900 (IQR 2640-3000) to 3440 revolutions per minute (RPM) (IQR 3100-3700; p<0.001). As a result, peak oxygen consumption increased from 11.1±2.4 to 12.8±2.8 mL/kg/min (p<0.001) and maximum workload from 1.1 (IQR 0.9-1.5) to 1.2 W/kg (IQR 0.9-1.7; p=0.028). The Borg scale exertion level decreased from 15.2±1.5 to 13.5±1.2 (p=0.005).
Conclusions
Transthoracic AVO imaging is possible during CPETs in patients with LVAD. Dynamic echo-guided pump speed adjustment based on the AVO improves exercise tolerance and augments peak oxygen consumption and maximum workload.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 21 Mar 2022; epub ahead of print
Stapor M, Pilat A, Gackowski A, Misiuda A, ... Kapelak B, Wierzbicki K
Heart: 21 Mar 2022; epub ahead of print | PMID: 35314453
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Impact:
Abstract

Lipoprotein(a): a risk factor for atherosclerosis and an emerging therapeutic target.

Di Fusco SA, Arca M, Scicchitano P, Alonzo A, ... Imperoli G, Colivicchi F
Lipoprotein(a) (Lp(a)) is a complex circulating lipoprotein, and increasing evidence has demonstrated its role as a risk factor for atherosclerotic cardiovascular disease (ASCVD) and as a possible therapeutic target. Lp(a) atherogenic effects are attributed to several potential mechanisms in addition to cholesterol accumulation in the arterial wall, including proinflammatory effects mainly mediated by oxidised phospholipids. Several studies have found a causal and independent relationship between Lp(a) levels and cardiovascular risk. Furthermore, several studies also suggest a causal association between Lp(a) levels and calcific aortic valve stenosis. Available lipid-lowering agents have at best moderate impact on Lp(a) levels. Among available therapies, antibody proprotein convertase subtilisin/kexin type 9 inhibitors are the most effective in reducing Lp(a). Potent Lp(a)-lowering treatments that target LPA expression are under development. Lp(a) level measurement poses some challenges due to the absence of a definitive reference method and the reporting of Lp(a) values as molar (nanomoles per litre (nmol/L)) or mass concentrations (milligrams per decilitre (mg/dL)) by different assays. Currently, Lp(a) measurement is recommended to refine cardiovascular risk in specific clinical settings, that is, in individuals with a family history of premature ASCVD, in patients with ASCVD not explained by standard risk factors or in those with recurrent events despite optimal management of traditional risk factors. Patients with high Lp(a) levels should be managed with more intensive approaches to treat other modifiable cardiovascular risk factors. Overall, this review focuses on Lp(a) as an ASCVD risk factor and therapeutic target. Furthermore, it reports practical recommendations for Lp(a) measurement and interpretation and updated evidence on Lp(a)-lowering approaches.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 13 Mar 2022; epub ahead of print
Di Fusco SA, Arca M, Scicchitano P, Alonzo A, ... Imperoli G, Colivicchi F
Heart: 13 Mar 2022; epub ahead of print | PMID: 35288443
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Abstract

Contribution of NOTCH1 genetic variants to bicuspid aortic valve and other congenital lesions.

Debiec RM, Hamby SE, Jones PD, Safwan K, ... Webb TR, Bolger AP
Introduction
Bicuspid aortic valve (BAV) affects 1% of the general population. NOTCH1 was the first gene associated with BAV. The proportion of familial and sporadic BAV disease attributed to NOTCH1 mutations has not been estimated.
Aim
The aim of our study was to provide an estimate of familial and sporadic BAV disease attributable to NOTCH1 mutations.
Methods
The population of our study consisted of participants of the University of Leicester Bicuspid aoRtic vAlVe gEnetic research-8 pedigrees with multiple affected family members and 381 sporadic patients. All subjects underwent NOTCH1 sequencing. A systematic literature search was performed in the NCBI PubMed database to identify publications reporting NOTCH1 sequencing in context of congenital heart disease.
Results
NOTCH1 sequencing in 36 subjects from 8 pedigrees identified one variant c.873C>G/p.Tyr291* meeting the American College of Medical Genetics and Genomics criteria for pathogenicity. No pathogenic or likely pathogenic NOTCH1 variants were identified in 381 sporadic patients. Literature review identified 64 relevant publication reporting NOTCH1 sequencing in 528 pedigrees and 9449 sporadic subjects. After excluding families with syndromic disease pathogenic and likely pathogenic NOTCH1 variants were detected in 9/435 (2.1%; 95% CI: 0.7% to 3.4%) of pedigrees and between 0.05% (95% CI: 0.005% to 0.10%) and 0.08% (95% CI: 0.02% to 0.13%) of sporadic patients. Incomplete penetrance of definitely pathogenic NOTCH1 mutations was observed in almost half of reported pedigrees.
Conclusions
Pathogenic and likely pathogenic NOTCH1 genetic variants explain 2% of familial and <0.1% of sporadic BAV disease and are more likely to associate with tetralogy of Fallot and hypoplastic left heart.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.

Heart: 13 Mar 2022; epub ahead of print
Debiec RM, Hamby SE, Jones PD, Safwan K, ... Webb TR, Bolger AP
Heart: 13 Mar 2022; epub ahead of print | PMID: 35288444
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Abstract

Smartphone detection of atrial fibrillation using photoplethysmography: a systematic review and meta-analysis.

Gill S, Bunting KV, Sartini C, Cardoso VR, ... Gkoutos GV, Kotecha D
Objectives
Timely diagnosis of atrial fibrillation (AF) is essential to reduce complications from this increasingly common condition. We sought to assess the diagnostic accuracy of smartphone camera photoplethysmography (PPG) compared with conventional electrocardiogram (ECG) for AF detection.
Methods
This is a systematic review of MEDLINE, EMBASE and Cochrane (1980-December 2020), including any study or abstract, where smartphone PPG was compared with a reference ECG (1, 3 or 12-lead). Random effects meta-analysis was performed to pool sensitivity/specificity and identify publication bias, with study quality assessed using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) risk of bias tool.
Results
28 studies were included (10 full-text publications and 18 abstracts), providing 31 comparisons of smartphone PPG versus ECG for AF detection. 11 404 participants were included (2950 in AF), with most studies being small and based in secondary care. Sensitivity and specificity for AF detection were high, ranging from 81% to 100%, and from 85% to 100%, respectively. 20 comparisons from 17 studies were meta-analysed, including 6891 participants (2299 with AF); the pooled sensitivity was 94% (95% CI 92% to 95%) and specificity 97% (96%-98%), with substantial heterogeneity (p<0.01). Studies were of poor quality overall and none met all the QUADAS-2 criteria, with particular issues regarding selection bias and the potential for publication bias.
Conclusion
PPG provides a non-invasive, patient-led screening tool for AF. However, current evidence is limited to small, biased, low-quality studies with unrealistically high sensitivity and specificity. Further studies are needed, preferably independent from manufacturers, in order to advise clinicians on the true value of PPG technology for AF detection.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 10 Mar 2022; epub ahead of print
Gill S, Bunting KV, Sartini C, Cardoso VR, ... Gkoutos GV, Kotecha D
Heart: 10 Mar 2022; epub ahead of print | PMID: 35277454
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Abstract

Sex differences in sudden cardiac death in a nationwide study of 54 028 deaths.

Skjelbred T, Rajan D, Svane J, Lynge TH, Tfelt-Hansen J
Objective
Sudden cardiac death (SCD) is a leading cause of death and is more common among males than females. Epidemiological studies of sex differences in SCD cases of all ages are sparse. The aim of this study was to examine differences in incidence rates, clinical characteristics, comorbidities and autopsy findings between male and female SCD cases.
Methods
All deaths in Denmark in 2010 (54 028) were reviewed. Autopsy reports, death certificates, discharge summaries and nationwide health registries were reviewed to identify cases of SCD. Based on the available information, all deaths were subcategorised into definite, probable and possible SCD.
Results
A total of 6867 SCD cases were identified, of which 3859 (56%) were males and 3008 (44%) were females. Incidence rates increased with age and were higher for male population across all age groups in the adult population. Average age at time of SCD was 71 years among males compared with 79 among females (p<0.01). The greatest difference in SCD incidence between males and females was found among the 35-50 years group with an incidence rate ratio of 3.7 (95% CI: 2.8 to 4.8). Compared with female SCD victims, male SCD victims more often had cardiovascular diseases and diabetes mellitus (p<0.01).
Conclusion
This is the first nationwide study of sex differences in SCD across all ages. Differences in incidence rates between males and females were greatest among young adults and the middle-aged. Incidence rates of SCD among older female population approached that of the male population, despite having significantly more cardiovascular disease and diabetes in male SCD cases.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 10 Mar 2022; epub ahead of print
Skjelbred T, Rajan D, Svane J, Lynge TH, Tfelt-Hansen J
Heart: 10 Mar 2022; epub ahead of print | PMID: 35277455
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Abstract

Evaluation of antithrombotic use and COVID-19 outcomes in a nationwide atrial fibrillation cohort.

Handy A, Banerjee A, Wood AM, Dale C, ... Sofat R, CVD-COVID-UK Consortium
Objective
To evaluate antithrombotic (AT) use in individuals with atrial fibrillation (AF) and at high risk of stroke (CHA2DS2-VASc score ≥2) and investigate whether pre-existing AT use may improve COVID-19 outcomes.
Methods
Individuals with AF and CHA2DS2-VASc score ≥2 on 1 January 2020 were identified using electronic health records for 56 million people in England and were followed up until 1 May 2021. Factors associated with pre-existing AT use were analysed using logistic regression. Differences in COVID-19-related hospitalisation and death were analysed using logistic and Cox regression in individuals with pre-existing AT use versus no AT use, anticoagulants (AC) versus antiplatelets (AP), and direct oral anticoagulants (DOACs) versus warfarin.
Results
From 972 971 individuals with AF (age 79 (±9.3), female 46.2%) and CHA2DS2-VASc score ≥2, 88.0% (n=856 336) had pre-existing AT use, 3.8% (n=37 418) had a COVID-19 hospitalisation and 2.2% (n=21 116) died, followed up to 1 May 2021. Factors associated with no AT use included comorbidities that may contraindicate AT use (liver disease and history of falls) and demographics (socioeconomic status and ethnicity). Pre-existing AT use was associated with lower odds of death (OR=0.92, 95% CI 0.87 to 0.96), but higher odds of hospitalisation (OR=1.20, 95% CI 1.15 to 1.26). AC versus AP was associated with lower odds of death (OR=0.93, 95% CI 0.87 to 0.98) and higher hospitalisation (OR=1.17, 95% CI 1.11 to 1.24). For DOACs versus warfarin, lower odds were observed for hospitalisation (OR=0.86, 95% CI 0.82 to 0.89) but not for death (OR=1.00, 95% CI 0.95 to 1.05).
Conclusions
Pre-existing AT use may be associated with lower odds of COVID-19 death and, while not evidence of causality, provides further incentive to improve AT coverage for eligible individuals with AF.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 09 Mar 2022; epub ahead of print
Handy A, Banerjee A, Wood AM, Dale C, ... Sofat R, CVD-COVID-UK Consortium
Heart: 09 Mar 2022; epub ahead of print | PMID: 35273122
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Abstract

Exercise oxygen pulse kinetics in patients with hypertrophic cardiomyopathy.

Mapelli M, Romani S, Magrì D, Merlo M, ... Sinagra G, Agostoni P
Objectives
Reduced cardiac output (CO) has been considered crucial in symptoms\' genesis in hypertrophic cardiomyopathy (HCM). Absolute value and temporal behaviour of O2-pulse (oxygen uptake/heart rate (VO2/HR)), and the VO2/work relationship during exercise reflect closely stroke volume (SV) and CO changes, respectively. We hypothesise that adding O2-pulse absolute value and kinetics, and VO2/work relationship to standard cardiopulmonary exercise testing (CPET) could help identify more exercise-limited patients with HCM.
Methods
CPETs were performed in 3 HCM dedicated clinical units. We retrospectively enrolled non-end-stage consecutive patients with HCM, grouped according to left ventricle outflow tract obstruction (LVOTO) at rest or during Valsalva manoeuvre (72% of patients with LVOTO <30; 10% between 30 and 49 and 18% ≥50 mm Hg). We evaluated the CPET response in HCM focusing on parameters strongly associated with SV and CO, such as O2-pulse and VO2, respectively, considering their absolute values and temporal behaviour during exercise.
Results
We included 312 patients (70% males, age 49±18 years). Peak VO2 (percentage of predicted), O2-pulse and ventilation to carbon dioxide production (VE/VCO2) slope did not change across LVOTO groups. Ninety-six (31%) patients with HCM presented an abnormal O2-pulse temporal behaviour, irrespective of LVOTO values. These patients showed lower peak systolic pressure, workload (106±45 vs 130±49 W), VO2 (21.3±6.6 vs 24.1±7.7 mL/min/kg; 74%±17% vs 80%±20%) and O2-pulse (12 (9-14) vs 14 (11-17) mL/beat), with higher VE/VCO2 slope (28 (25-31) vs 27 (24-31)) (p<0.005 for all). Only 2 patients had an abnormal VO2/work slope.
Conclusion
None of the frequently used CPET parameters, either as absolute values or dynamic relationships, were associated with LVOTO. Differently, an abnormal temporal behaviour of O2-pulse during exercise, which is strongly related to inadequate SV increase, correlates with reduced functional capacity (peak and anaerobic threshold VO2 and workload) and increased VE/VCO2 slope, identifying more advanced disease irrespectively of LVOTO.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 09 Mar 2022; epub ahead of print
Mapelli M, Romani S, Magrì D, Merlo M, ... Sinagra G, Agostoni P
Heart: 09 Mar 2022; epub ahead of print | PMID: 35273123
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Abstract

Bicuspid aortic valve: evolving knowledge and new questions.

Sun BJ, Song JK
Bicuspid aortic valve (BAV), a common congenital anomaly with various morphological phenotypes, is also characterised by marked heterogeneity in clinical presentations including clinically silent condition with mild valvulo-aortopathy, progressive valvulopathy and complex valvulo-aortopathy with shorter life expectancy. The clinical importance of using a general and unified nosology for BAV is well-accepted by opinion leaders and an international consensus statement has been recently published, which will serve as an important scientific platform for BAV. This review describes the current knowledge of BAV based on clinical studies, addresses several unresolved issues requiring investigators\' attention and highlights the necessity of prospective studies with a very long follow-up duration for better appreciation of BAV-associated valvulo-aortopathy. In addition, the progression of valvular calcification in patients with BAV and its potential contribution to development of valvulopathy will be discussed.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 08 Mar 2022; epub ahead of print
Sun BJ, Song JK
Heart: 08 Mar 2022; epub ahead of print | PMID: 35264416
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Abstract

Familial risk of atrioventricular block in first-degree relatives.

Dyssekilde JR, Christiansen MK, Johansen JB, Nielsen JC, Bundgaard H, Jensen HK
Objective
Rare cases of genetically inherited atrioventricular block (AVB) have been reported; however, the heredity of AVB remains unknown. We aimed to assess the heredity of AVB.
Design, setting and participants
Using data from the Danish Civil Registration Registry, we established a nationwide cohort of individuals with parental links. Data were merged with information from the Danish Pacemaker and Implantable Cardioverter Defibrillator Registry, containing information on all pacemaker implantations performed in Denmark during the study period, to identify patients who received a first-time pacemaker because of AVB.
Results
A total of 4 648 204 individuals had parental links and a total of 26 880 consecutive patients received a first-time pacemaker due to AVB. Overall, the adjusted rate ratio (RR) of pacemaker implantation due to AVB was 2.1 (95% CI 1.8 to 2.5) if a father, mother or sibling had AVB compared with the risk in the general population. The adjusted RR was 2.2 (1.7-2.9) for offspring of mothers with AVB, 1.9 (1.5-2.4) for offspring of fathers with AVB and 3.5 (2.3-5.4) for siblings to a patient with AVB. The risk increased inversely proportionally with the age of the index case at the time of pacemaker implantation. The corresponding adjusted RRs were 15.8 (4.8-52.3) and 10.0 (3.3-30.4) if a mother or father, respectively, had a pacemaker implantation before 50 years.

Conclusion:
and relevance
First-degree relatives to a patient with AVB carry an increased risk of AVB with the risk being strongly inversely associated with the age of the index case at pacemaker implantation. These findings indicate a genetic component in the development of AVB in families with an early-onset disease.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 03 Mar 2022; epub ahead of print
Dyssekilde JR, Christiansen MK, Johansen JB, Nielsen JC, Bundgaard H, Jensen HK
Heart: 03 Mar 2022; epub ahead of print | PMID: 35246466
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Abstract

Outpatient cardiac rehabilitation dose after acute coronary syndrome in a nationwide cohort.

Kanaoka K, Iwanaga Y, Nakai M, Nishioka Y, ... Saito Y, Imamura T
Objective
Cardiac rehabilitation (CR) is effective in patients with acute coronary syndrome (ACS); however, CR programmes have not been fully implemented. This study aimed to reveal the current practice of outpatient CR and the dose-effect relationship of CR in real-world settings.
Methods
We performed a nationwide retrospective cohort study using the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Patients with ACS who underwent percutaneous coronary intervention between April 2014 and March 2018 were included. We analysed the implementation rate and dose of outpatient CR and the association between dose and outcomes.
Results
Out of 202 320 patients who underwent percutaneous coronary intervention for ACS, a total of 20 444 (10%) underwent outpatient CR. The median (IQR) number of total CR sessions was 9 (3-17), and the median (IQR) duration for each session was 60 (42-60) min. Patients were divided into four groups according to the total number of sessions (≤9 times or ≥10 times) and the duration per session (<50 min or ≥50 min). Compared with the low-number/short-duration group, the adjusted HR for all-cause mortality was 1.00 (95% CI 0.80 to 1.24, p=0.97) in the low-number/long-duration group, 0.63 (95% CI 0.46 to 0.87, p=0.005) in the high-number/short-duration group and 0.74 (95% CI 0.60 to 0.92, p=0.008) in the high-number/long-duration group, respectively.
Conclusion
We found that the participation rate for outpatient CR after ACS was low and the doses of sessions vary in real-world settings. A higher number of total sessions of outpatient CR is associated with a better prognosis irrespective of the session\'s duration.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 02 Mar 2022; epub ahead of print
Kanaoka K, Iwanaga Y, Nakai M, Nishioka Y, ... Saito Y, Imamura T
Heart: 02 Mar 2022; epub ahead of print | PMID: 35241624
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Abstract

Bayesian analysis of amiodarone or lidocaine versus placebo for out-of-hospital cardiac arrest.

Lane DJ, Grunau B, Kudenchuk P, Dorian P, ... Christenson J, Scheuermeyer F
Objective
Clinical trials for patients with shock-refractory out-of-hospital cardiac arrest (OHCA), including the Amiodarone, Lidocaine or Placebo (ALPS) trial, have been unable to demonstrate definitive benefit after treatment with antiarrhythmic drugs. A Bayesian approach, combining the available evidence, may yield additional insights.
Methods
We conducted a reanalysis of the ALPS trial comparing treatment with amiodarone or lidocaine with placebo in patients with OHCA following shock-refractory ventricular fibrillation or ventricular tachycardia (VF/VT). We used Bayesian regression to assess the probability of improved survival or improved neurological outcome on the 7-point modified Rankin Scale. We derived weak, moderate and strong priors from a previous clinical trial.
Results
The original ALPS trial randomised 3026 adult patients with OHCA to amiodarone (n=974, survival to hospital discharge 24.4%), lidocaine, (n=993, survival 23.7%) or placebo (n=1059, survival 21.0%). In our reanalysis the probability of improved survival from amiodarone ranged from 83% (strong prior) to 95% (weak prior) compared with placebo and from 78% (strong) to 90% (weak) for lidocaine-an estimated improvement in survival of 2.9% (IQR 1.4%-3.8%) for amiodarone and 1.7% (IQR 0.84%-3.2%) for lidocaine over placebo (moderate prior). The probability of improved neurological outcome from amiodarone ranged from 96% (weak) to 99% (strong) compared with placebo and from 88% (weak) to 96% (strong) for lidocaine.
Conclusions
In a Bayesian reanalysis of patients with shock-resistant VF/VT OHCA, treatment with amiodarone had high probabilities of improved survival and neurological outcome, while treatment with lidocaine had a more modest benefit.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 01 Mar 2022; epub ahead of print
Lane DJ, Grunau B, Kudenchuk P, Dorian P, ... Christenson J, Scheuermeyer F
Heart: 01 Mar 2022; epub ahead of print | PMID: 35236764
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Abstract

Physical activity and exercise recommendations for patients with valvular heart disease.

Chatrath N, Papadakis M
There is a paucity of studies looking at the natural history of valvular heart disease (VHD) in exercising individuals, and exercise recommendations are largely based on expert consensus. All individuals with VHD should be encouraged to avoid sedentary behaviour by engaging in at least 150 min of physical activity every week, including strength training. There are generally no exercise restrictions to individuals with mild VHD. Regurgitant lesions are better tolerated compared with stenotic lesions and as such the recommendations are more permissive for moderate-to-severe regurgitant VHD. Individuals with severe aortic regurgitation can still partake in moderate-intensity exercise provided the left ventricle (LV) and aorta are not significantly dilated and the ejection fraction (EF) remains >50%. Similarly, individuals with severe mitral regurgitation can partake in moderate-intensity exercise if the LV end-diastolic diameter <60 mm, the EF ≥60%, resting pulmonary artery pressure <50 mm Hg and there is an absence of arrhythmias on exercise testing. Conversely, individuals with severe aortic or mitral stenosis are advised to partake in low-intensity exercise. For individuals with bicuspid aortic valve, in the absence of aortopathy, the guidance for tricuspid aortic valve dysfunction applies. Mitral valve prolapse has several clinical, ECG and cardiac imaging markers of increased arrhythmic risk; and if any are present, individuals should refrain from high-intensity exercise.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 01 Mar 2022; epub ahead of print
Chatrath N, Papadakis M
Heart: 01 Mar 2022; epub ahead of print | PMID: 35236765
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Abstract

Single direct oral anticoagulant therapy in stable patients with atrial fibrillation beyond 1 year after coronary stent implantation.

Choi Y, Lee Y, Kim SH, Kim S, ... Lee MY, Oh YS
Objective
Optimal antithrombotic therapy in patients with atrial fibrillation (AF) beyond 1 year after coronary stent implantation has not been well established in the era of direct oral anticoagulant (DOAC).
Methods
Using Korean National Health Insurance Service data, we analysed 4294 patients with AF who were prescribed DOAC beyond 1 year after coronary stent implantation. Subjects were classified into the monotherapy group (DOAC single therapy, n=1221) or the combination therapy group (DOAC with an antiplatelet agent, n=3073). The primary ischaemic endpoint was defined as a composite of cardiovascular death, myocardial infarction, stroke or systemic thromboembolism. The secondary endpoints were all-cause death, major bleeding defined as a bleeding event requiring hospitalisation and net adverse clinical events. Propensity score matching was performed to balance baseline covariates.
Results
Among included patients, 94% had drug-eluting coronary stents. During a median follow-up of 19 (7-32) months, the monotherapy group had a similar risk of the primary ischaemic endpoint (HR 0.828, 95% CI 0.660 to 1.038) and all-cause death (HR 1.076, 95% CI 0.895 to 1.294) compared with the combination therapy group. Risk of major bleeding was lower in the monotherapy group (HR 0.690, 95% CI 0.481 to 0.989), which was mostly driven by reduced gastrointestinal bleeding (HR 0.562, 95% CI 0.358 to 0.883). There was no significant difference in net adverse clinical events between the two groups.
Conclusions
DOAC monotherapy showed similar efficacy in preventing ischaemic events and was associated with lower major bleeding events compared with combination therapy in patients with AF beyond 1 year after coronary stent implantation.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:285-291
Choi Y, Lee Y, Kim SH, Kim S, ... Lee MY, Oh YS
Heart: 27 Feb 2022; 108:285-291 | PMID: 33990409
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Impact:
Abstract

Change in N-terminal pro-B-type natriuretic peptide at 1 year predicts mortality in wild-type transthyretin amyloid cardiomyopathy.

Law S, Petrie A, Chacko L, Cohen OC, ... Fontana M, Gillmore JD
Objectives
Wild-type transthyretin amyloid cardiomyopathy (wtATTR-CM) is a progressive and fatal condition. Although prognosis can be determined at the time of diagnosis according to National Amyloidosis Centre (NAC) transthyretin amyloidosis (ATTR) stage, the clinical course varies substantially between individuals. There are currently no established measures of rate of disease progression. Through systematic analysis of functional, biochemical and echocardiographic disease-related variables we aimed to identify prognostic markers of disease progression in wtATTR-CM.
Methods
This is a retrospective observational study of 432 patients with wtATTR-CM diagnosed at the UK NAC, none of whom received disease-modifying therapy. The association between mortality from the 12-month timepoint and change from diagnosis to 12 months in a variety of disease-related variables was explored using Cox regression.
Results
Change in N-terminal pro-B-type natriuretic peptide concentration (∆ NT-proBNP) at 12 months from diagnosis was the strongest predictor of ongoing mortality and was independent of both change in other disease-related variables (HR 1.04 per 500 ng/L increase (95% CI 1.01 to 1.07); p=0.003) and a range of known prognostic variables at the time of diagnosis (HR 1.07 per 500 ng/L increase (95% CI 1.02 to 1.13); p=0.007). An increase in NT-proBNP of >500 ng/L, >1000 ng/L and >2000 ng/L during the first year of follow-up occurred in 45%, 35% and 16% of patients, respectively.
Conclusion
Change in NT-proBNP concentration during the first year of follow-up is a powerful independent predictor of mortality in wtATTR-CM.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:474-478
Law S, Petrie A, Chacko L, Cohen OC, ... Fontana M, Gillmore JD
Heart: 27 Feb 2022; 108:474-478 | PMID: 33990410
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Impact:
Abstract

Ramadan fasting: recommendations for patients with cardiovascular disease.

Akhtar AM, Ghouri N, Chahal CAA, Patel R, ... Waqar S, Khanji MY
Ramadan fasting is observed by most of the 1.8 billion Muslims around the world. It lasts for 1 month per the lunar calendar year and is the abstention from any food and drink from dawn to sunset. While recommendations on \'safe\' fasting exist for patients with some chronic conditions, such as diabetes mellitus, guidance for patients with cardiovascular disease is lacking. We reviewed the literature to help healthcare professionals educate, discuss and manage patients with cardiovascular conditions, who are considering fasting. Studies on the safety of Ramadan fasting in patients with cardiac disease are sparse, observational, of small sample size and have short follow-up. Using expert consensus and a recognised framework, we risk stratified patients into \'low or moderate risk\', for example, stable angina or non-severe heart failure; \'high risk\', for example, poorly controlled arrhythmias or recent myocardial infarction; and \'very high risk\', for example, advanced heart failure. The \'low-moderate risk\' group may fast, provided their medications and clinical conditions allow. The \'high\' or \'very high risk\' groups should not fast and may consider safe alternatives such as non-consecutive fasts or fasting shorter days, for example, during winter. All patients who are fasting should be educated before Ramadan on their risk and management (including the risk of dehydration, fluid overload and terminating the fast if they become unwell) and reviewed after Ramadan to reassess their risk status and condition. Further studies to clarify the benefits and risks of fasting on the cardiovascular system in patients with different cardiovascular conditions should help refine these recommendations.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:258-265
Akhtar AM, Ghouri N, Chahal CAA, Patel R, ... Waqar S, Khanji MY
Heart: 27 Feb 2022; 108:258-265 | PMID: 33990414
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Impact:
Abstract

Refined atrial fibrillation screening and cost-effectiveness in the German population.

Schnabel RB, Wallenhorst C, Engler D, Blankenberg S, ... Freedman B, Gutenberg Health Study investigators
Objective
Little is known on optimal screening population for detecting new atrial fibrillation (AF) in the community. We describe characteristics and estimate cost-effectiveness for a single timepoint electrocardiographic screening.
Methods
We performed a 12-lead ECG in the German population-based Gutenberg Health Study between 2007 and 2012 (n=15 010), mean age 55±11 years, 51% men and collected more than 120 clinical and biomarker variables, including N-terminal pro B-type natriuretic peptide (Nt-proBNP), risk factors, disease symptoms and echocardiographic variables.
Results
Of 15 010 individuals, 466 (3.1%) had AF. New AF was found in 32 individuals, 0.2% of the total sample, 0.5% of individuals aged 65-74 years and predominantly men (86%). The classical risk factor burden was high in individuals with new AF. The median estimated stroke risk was 2.2%/year, while risk of developing heart failure was 21% over 10 years. In the 65-74 year age group, the cost per quality-adjusted life-year gained resulting from a single timepoint screening was €30 361. In simulations, the costs were highly sensitive to AF detection rates, proportion of treatment and type of oral anticoagulant. Prescreening by Nt-proBNP measurements was not cost-effective in the current setting.
Conclusions
In our middle-aged population cohort, we identified 0.2% new AF by single timepoint screening. There was a significant estimated risk of stroke and heart failure in these individuals. Cost-effectiveness for screening may be reached in individuals aged 65 years and older. The simple age cut-off is not improved by using Nt-proBNP as a biomarker to guide a screening programme.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:451-457
Schnabel RB, Wallenhorst C, Engler D, Blankenberg S, ... Freedman B, Gutenberg Health Study investigators
Heart: 27 Feb 2022; 108:451-457 | PMID: 34376487
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Abstract

Addition of cystatin C predicts cardiovascular death better than creatinine in intensive care.

Helmersson-Karlqvist J, Lipcsey M, Ärnlöv J, Bell M, ... Dardashti A, Larsson A
Objective
Decreased kidney function increases cardiovascular risk and predicts poor survival. Estimated glomerular filtration rate (eGFR) by creatinine may theoretically be less accurate in the critically ill. This observational study compares long-term cardiovascular mortality risk by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation; Caucasian, Asian, paediatric and adult cohort (CAPA) cystatin C equation and the CKD-EPI combined creatinine/cystatin C equation.
Methods
The nationwide study includes 22 488 intensive care patients in Uppsala, Karolinska and Lund University Hospitals, Sweden, between 2004 and 2015. Creatinine and cystatin C were analysed with accredited methods at admission. Reclassification and model discrimination with C-statistics was used to compare creatinine and cystatin C for cardiovascular mortality prediction.
Results
During 5 years of follow-up, 2960 (13 %) of the patients died of cardiovascular causes. Reduced eGFR was significantly associated with cardiovascular death by all eGFR equations in Cox regression models. In each creatinine-based GFR category, 17%, 19% and 31% reclassified to a lower GFR category by cystatin C. These patients had significantly higher cardiovascular mortality risk, adjusted HR (95% CI), 1.55 (1.38 to 1.74), 1.76 (1.53 to 2.03) and 1.44 (1.11 to 1.86), respectively, compared with patients not reclassified. Harrell\'s C-statistic for cardiovascular death for cystatin C, alone or combined with creatinine, was 0.73, significantly higher than for creatinine (0.71), p<0.001.
Conclusions
A single cystatin C at admission to the intensive care unit added significant predictive value to creatinine for long-term cardiovascular death risk assessment. Cystatin C, alone or in combination with creatinine, should be used for estimating GFR for long-term risk prediction in critically ill.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:279-284
Helmersson-Karlqvist J, Lipcsey M, Ärnlöv J, Bell M, ... Dardashti A, Larsson A
Heart: 27 Feb 2022; 108:279-284 | PMID: 33795382
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Abstract

Atrial fibrillation and risk of incident heart failure with reduced versus preserved ejection fraction.

Nicoli CD, O\'Neal WT, Levitan EB, Singleton MJ, ... Safford MM, Soliman EZ
Objective
Associations between atrial fibrillation (AF) and heart failure (HF) have been established. We compared the extent to which AF is associated with each primary subtype of HF, with reduced (HFrEF) versus preserved ejection fraction (HFpEF).
Methods
We included 25 787 participants free of baseline HF from the REGARDS (REasons for Geographic And Racial Differences in Stroke) cohort. Baseline AF was ascertained from ECG and self-reported history of physician diagnosis. Incident HF events were determined from physician-adjudicated review of hospitalisation medical records and HF deaths. Based on left ventricular ejection fraction (LVEF) at the time of HF event, HFrEF, HFpEF, and mid-range HF were defined as LVEF <40%, ≥50% and 40%-49%, respectively. Multivariable Cox proportional-hazards models examined the association between AF and HF. The Lunn-McNeil method was used to compare associations of AF with incident HFrEF versus HFpEF.
Results
Over a median of 9 years of follow-up, 1109 HF events occurred (356 HFpEF, 388 HFrEF, 77 mid-range and 288 unclassified). In a model adjusted for sociodemographics, cardiovascular risk factors, and incident coronary heart disease, AF was associated with increased risk of all HF events (HR 1.67, 95% CI 1.38 to 2.01). The associations of AF with HFrEF versus HFpEF events did not differ significantly (HR 1.87 (95% CI 1.38 to 2.54) and HR 1.65 (95% CI 1.20 to 2.28), respectively; p value for difference=0.581). These associations were consistent in sex and race subgroups.
Conclusions
AF is associated with both HFrEF and HFpEF events, with no significant difference in the strength of association among these subtypes.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:353-359
Nicoli CD, O'Neal WT, Levitan EB, Singleton MJ, ... Safford MM, Soliman EZ
Heart: 27 Feb 2022; 108:353-359 | PMID: 34031160
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Abstract

Associations of atrial fibrillation with renal function decline in patients with chronic kidney disease.

Chen TH, Chu YC, Ou SM, Tarng DC
Background
Chronic kidney disease (CKD) is known to increase the risk of atrial fibrillation (AF) development, but the relationship between AF and subsequent renal function decline in patients with CKD is not well understood. In this study, we explored the role of AF on renal outcomes among patients with CKD.
Methods
In a retrospective hospital-based cohort study, we identified patients with CKD aged ≥20 years from 1 January 2008 to 31 December 2018. The patients were divided into AF and non-AF groups. We matched each patient with CKD and AF to two non-AF CKD controls according to propensity scores. The outcomes of interest included estimated glomerular filtration rate (eGFR) decline of ≥20%, ≥30%, ≥40% and ≥50%, and end-stage renal disease (ESRD).
Results
After propensity score matching, 6731 patients with AF and 13 462 matched controls were included in the analyses. Compared with the non-AF group, the AF group exhibited greater risks of eGFR decline ≥20% (HR 1.43; 95% CI 1.33 to 1.53), ≥30% (HR 1.50; 95% CI 1.36 to 1.66), ≥40% (HR 1.62; 95% CI 1.41 to 1.85) and ≥50% (HR 1.82; 95% CI 1.50 to 2.20), and ESRD (HR 1.22; 95% CI 1.12 to 1.34). Higher CHA2DS2-VASc scores were associated with greater risks of eGFR decline and ESRD.
Conclusions
In patients with CKD, AF was associated with greater risks of subsequent renal function decline. CHA2DS2-VASc scores may be a useful risk stratification scheme for predicting the risk of renal function decline.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:438-444
Chen TH, Chu YC, Ou SM, Tarng DC
Heart: 27 Feb 2022; 108:438-444 | PMID: 34193464
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Abstract

Update on management of atrial fibrillation in heart failure: a focus on ablation.

Mulder BA, Rienstra M, Van Gelder IC, Blaauw Y
Atrial fibrillation is increasingly encountered in patients with heart failure. Both diseases have seen tremendous rises in incidence in recent years. In general, the treatment of atrial fibrillation is focused on relieving patients from atrial fibrillation-related symptoms and risk reduction for thromboembolism and the occurrence or worsening of heart failure. Symptomatic relief may be accomplished by either (non-)pharmacological rate or rhythm control in combination with optimal therapy of underlying cardiovascular morbidities and risk factors. Atrial fibrillation ablation has been performed in patients without overt heart failure successfully for many years. However, in recent years, attempts have been made for patients with heart failure as well. In this review, we discuss the current literature describing the treatment of atrial fibrillation in heart failure. We highlight the early rate versus rhythm control studies, the importance of addressing underlying conditions and treatment of risk factors. A critical evaluation will be performed of the catheter ablation studies that have been performed so far in light of larger (post-hoc) ablation studies. Furthermore, we will hypothesise the role of patient selection as next step in optimising outcome for patient with atrial fibrillation and heart failure.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:422-428
Mulder BA, Rienstra M, Van Gelder IC, Blaauw Y
Heart: 27 Feb 2022; 108:422-428 | PMID: 34088767
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Impact:
Abstract

Effectiveness and safety of oral anticoagulants in elderly patients with atrial fibrillation.

Rutherford OW, Jonasson C, Ghanima W, Söderdahl F, Halvorsen S
Objectives
To assess the risk of stroke/systemic embolism (SE) and major bleeding associated with the use of oral anticoagulants in elderly patients with atrial fibrillation (AF) in a real-world population.
Methods
We identified all anticoagulant-naive initiators of warfarin, dabigatran, rivaroxaban and apixaban for the indication AF in Norway between January 2013 and December 2017. Multivariate competing risk regression was used to calculate subhazard ratios (SHRs) describing associations between non-vitamin K antagonist oral anticoagulants (NOACs) compared with warfarin for risk of stroke/SE and major bleeding.
Results
Among 30 401 patients ≥75 years identified (median age 82 years, 53% women, mean CHA2DS2-VaSc score 4.5), 3857 initiated dabigatran, 6108 rivaroxaban, 13 786 apixaban and 6650 warfarin. Reduced dose was initiated in 11 559 (49%) of the NOAC-treated patients. For stroke, the SHRs for standard dose NOAC against warfarin were 0.80 (95% CI 0.57 to 1.13) for dabigatran; 1.07 (95% CI 0.89 to 1.30) for rivaroxaban and 0.95 (95% CI 0.78 to 1.15) for apixaban. For major bleeding, the SHRs against warfarin were 0.75 (95% CI 0.52 to 1.08) for dabigatran; 0.96 (95% CI 0.78 to 1.16) for rivaroxaban and 0.74 (95% CI 0.60 to 0.91) for apixaban. Comparing reduced doses of NOACs with warfarin yielded similar results. Sensitivity analyses were in accordance with the main results.
Conclusion
In this nationwide cohort study of patients ≥75 years initiating oral anticoagulation for AF, standard and reduced dose NOACs were associated with similar risks of stroke/SE as warfarin and lower or similar risks of bleeding. The NOACs seem to be a safe option also in elderly patients.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:345-352
Rutherford OW, Jonasson C, Ghanima W, Söderdahl F, Halvorsen S
Heart: 27 Feb 2022; 108:345-352 | PMID: 33975877
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Impact:
Abstract

Smoking cessation, weight gain and risk of cardiovascular disease.

Wang X, Dong JY, Cui R, Muraki I, ... Tsugane S, Japan Public Health Center-based Prospective Study Group
Objective
To examine whether the relationship between smoking cessation and risk of cardiovascular disease (CVD) was modified by weight gain.
Methods
A total of 69 910 participants (29 650 men and 46 260 women) aged 45-74 years were grouped into six groups by smoking status in the first and 5-year surveys: sustained smokers, recent quitters according to postcessation weight gain (no weight gain, 0.1-5.0 kg, >5.0 kg), long-term quitters and never smokers. Quitting smoking within and longer than 5 years were defined as recent and long-term quitters, respectively. We used Cox proportional hazard models to estimate the HR for incident CVD, coronary heart disease (CHD) and stroke.
Results
We identified 4023 CVDs (889 CHDs and 3217 strokes) during a median of 14.8 years of follow-up. Compared with sustained smokers, the multivariable HR (95% CI) for CVD was 0.66 (0.52 to 0.83) for recent quitters without weight gain, 0.71 (0.55 to 0.90) for recent quitters with weight gain of 0.1-5.0 kg, 0.70 (0.44 to 1.10) for recent quitters with weight gain of >5.0 kg, 0.56 (0.49 to 0.64) for long-term quitters, and 0.60 (0.55 to 0.66) for never smokers. The analysis restricted to men showed a similar association. Prespecified analysis by age suggested that recent quitters overall had a lower HR for CVD among those aged <60 years vs ≥60 years. Similar patterns of association were observed in CHD and stroke.
Conclusions
Postcessation weight gain did not attenuate the protective association between smoking cessation and risk of CVD.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:375-381
Wang X, Dong JY, Cui R, Muraki I, ... Tsugane S, Japan Public Health Center-based Prospective Study Group
Heart: 27 Feb 2022; 108:375-381 | PMID: 34083407
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Abstract

Gender differences in use of invasive diagnostic and therapeutic procedures for acute ischaemic heart disease in Chinese adults.

Levy M, Chen Y, Clarke R, Guo Y, ... Chen Z, Mihaylova B
Objective
To investigate gender differences in the use of diagnostic and therapeutic procedures for acute ischaemic heart disease (IHD) in Chinese adults and assess whether socioeconomic or health system factors contribute to such differences.
Methods
In 2004-2008, the China Kadoorie Biobank recruited 512 726 adults from 10 diverse areas in China. Data for 38 928 first hospitalisations with IHD (2911 acute myocardial infarction (AMI), 9817 angina and 26 200 other IHD) were obtained by electronic linkage to health insurance records until 31 December 2016. Multivariate Poisson regression models were used to estimate women-to-men rate ratios (RRs) of having cardiac enzyme tests, coronary angiography and coronary revascularisation.
Results
Among the 38 928 individuals (61% women) with IHD admissions, women were less likely to have AMI (5% vs 12%), but more likely to have angina (26% vs 24%) or other IHD (69% vs 64%). For admissions with AMI, there were no differences in the use of cardiac enzymes between women and men (RR=1.00; 95% CI, 0.97 to 1.03), but women had lower use of coronary angiography (0.80, 0.68 to 0.93) and coronary revascularisation (0.85, 0.74 to 0.99). For angina, the corresponding RRs were: 0.97 (0.94 to 1.00), 0.66 (0.59 to 0.74) and 0.56 (0.47 to 0.67), respectively; while for other IHD, they were 0.97 (0.94 to 1.00), 0.87 (0.76 to 0.99) and 0.61 (0.51 to 0.73), respectively. Adjusting for socioeconomic and health system factors did not significantly alter the women-to-men RRs.
Conclusions
Among Chinese adults hospitalised with acute IHD, women were less likely than men to have coronary angiography and revascularisation, but socioeconomic and health system factors did not contribute to these differences.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.

Heart: 27 Feb 2022; 108:292-299
Levy M, Chen Y, Clarke R, Guo Y, ... Chen Z, Mihaylova B
Heart: 27 Feb 2022; 108:292-299 | PMID: 34045308
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Impact:
Abstract

Diagnosis, management and therapeutic strategies for congenital long QT syndrome.

Wilde AAM, Amin AS, Postema PG
Congenital long QT syndrome (LQTS) is characterised by heart rate corrected QT interval prolongation and life-threatening arrhythmias, leading to syncope and sudden death. Variations in genes encoding for cardiac ion channels, accessory ion channel subunits or proteins modulating the function of the ion channel have been identified as disease-causing mutations in up to 75% of all LQTS cases. Based on the underlying genetic defect, LQTS has been subdivided into different subtypes. Growing insights into the genetic background and pathophysiology of LQTS has led to the identification of genotype-phenotype relationships for the most common genetic subtypes, the recognition of genetic and non-genetic modifiers of phenotype, optimisation of risk stratification algorithms and the discovery of gene-specific therapies in LQTS. Nevertheless, despite these great advancements in the LQTS field, large gaps in knowledge still exist. For example, up to 25% of LQTS cases still remain genotype elusive, which hampers proper identification of family members at risk, and it is still largely unknown what determines the large variability in disease severity, where even within one family an identical mutation causes malignant arrhythmias in some carriers, while in other carriers, the disease is clinically silent. In this review, we summarise the current evidence available on the diagnosis, clinical management and therapeutic strategies in LQTS. We also discuss new scientific developments and areas of research, which are expected to increase our understanding of the complex genetic architecture in genotype-negative patients, lead to improved risk stratification in asymptomatic mutation carriers and more targeted (gene-specific and even mutation-specific) therapies.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.

Heart: 27 Feb 2022; 108:332-338
Wilde AAM, Amin AS, Postema PG
Heart: 27 Feb 2022; 108:332-338 | PMID: 34039680
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Impact:
Abstract

Association between combat-related traumatic injury and cardiovascular risk.

Boos CJ, Schofield S, Cullinan P, Dyball D, ... Bennett AN, ADVANCE study
Objective
The association between combat-related traumatic injury (CRTI) and cardiovascular risk is uncertain. This study aimed to investigate the association between CRTI and both metabolic syndrome (MetS) and arterial stiffness.
Methods
This was a prospective observational cohort study consisting of 579 male adult UK combat veterans (UK-Afghanistan War 2003-2014) with CRTI who were frequency-matched to 565 uninjured men by age, service, rank, regiment, deployment period and role-in-theatre. Measures included quantification of injury severity (New Injury Severity Score (NISS)), visceral fat area (dual-energy X-ray absorptiometry), arterial stiffness (heart rate-adjusted central augmentation index (cAIx) and pulse wave velocity (PWV)), fasting venous blood glucose, lipids and high-sensitivity C reactive protein (hs-CRP).
Results
Overall the participants were 34.1±5.4 years, with a mean (±SD) time from injury/deployment of 8.3±2.1 years. The prevalence of MetS (18.0% vs 11.8%; adjusted risk ratio 1.46, 95% CI 1.10 to 1.94, p<0.0001) and the mean cAIx (17.61%±8.79% vs 15.23%±8.19%, p<0.0001) were higher among the CRTI versus the uninjured group, respectively. Abdominal waist circumference, visceral fat area, triglycerides, estimated insulin resistance and hs-CRP levels were greater and physical activity and high-density lipoprotein-cholesterol lower with CRTI. There were no significant between-group differences in blood glucose, blood pressure or PWV. CRTI, injury severity (↑NISS), age, socioeconomic status (SEC) and physical activity were independently associated with both MetS and cAIx.
Conclusions
CRTI is associated with an increased prevalence of MetS and arterial stiffness, which are also influenced by age, injury severity, physical activity and SEC. The longitudinal impact of CRTI on clinical cardiovascular events needs further examination.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:367-374
Boos CJ, Schofield S, Cullinan P, Dyball D, ... Bennett AN, ADVANCE study
Heart: 27 Feb 2022; 108:367-374 | PMID: 34824088
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Impact:
Abstract

Dengue virus infection induces inflammation and oxidative stress on the heart.

Kangussu LM, Costa VV, Olivon VC, Queiroz-Junior CM, ... Souza DDG, Bonaventura D
Objective
Dengue fever is one of the most important arboviral diseases in the world, and its severe forms are characterised by a broad spectrum of systemic and cardiovascular hallmarks. However, much remains to be elucidated regarding the pathogenesis triggered by Dengue virus (DENV) in the heart. Herein, we evaluated the cardiac outcomes unleashed by DENV infection and the possible mechanisms associated with these effects.
Methods
A model of an adapted DENV-3 strain was used to infect male BALB/c mice to assess haemodynamic measurements and the functional, electrophysiological, inflammatory and oxidative parameters in the heart.
Results
DENV-3 infection resulted in increased systemic inflammation and vascular permeability with consequent reduction of systolic blood pressure and increase in heart rate. These changes were accompanied by a decrease in the cardiac output and stroke volume, with a reduction trend in the left ventricular end-systolic and end-diastolic diameters and volumes. Also, there was a reduction trend in the calcium current density in the ventricular cardiomyocytes of DENV-3 infected mice. Indeed, DENV-3 infection led to leucocyte infiltration and production of inflammatory mediators in the heart, causing pericarditis and myocarditis. Moreover, increased reactive oxygen species generation and lipoperoxidation were also verified in the cardiac tissue of DENV-3 infected mice.
Conclusions
DENV-3 infection induced a marked cardiac dysfunction, which may be associated with inflammation, oxidative stress and electrophysiological changes in the heart. These findings provide new cardiac insights into the mechanisms involved in the pathogenesis triggered by DENV, contributing to the research of new therapeutic targets for clinical practice.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:388-396
Kangussu LM, Costa VV, Olivon VC, Queiroz-Junior CM, ... Souza DDG, Bonaventura D
Heart: 27 Feb 2022; 108:388-396 | PMID: 34049953
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Abstract

Risk and predictors of heart failure in sarcoidosis in a population-based cohort study from Sweden.

Rossides M, Kullberg S, Grunewald J, Eklund A, ... Askling J, Arkema EV
Objectives
Previous studies showed a strong association between sarcoidosis and heart failure (HF) but did not consider risk stratification or risk factors to identify useful aetiological insights. We estimated overall and stratified HRs and identified risk factors for HF in sarcoidosis.
Methods
Sarcoidosis cases were identified from the Swedish National Patient Register (NPR; ≥2 International Classification of Diseases-coded visits, 2003-2013) and matched to general population comparators. They were followed for HF in the NPR. Treated were cases who were dispensed ≥1 immunosuppressant ±3 months from the first sarcoidosis visit (2006-2013). Using Cox models, we estimated HRs adjusted for demographics and comorbidity and identified independent risk factors of HF together with their attributable fractions (AFs).
Results
During follow-up, 204 of 8574 sarcoidosis cases and 721 of 84 192 comparators were diagnosed with HF (rate 2.2 vs 0.7/1000 person-years, respectively). The HR associated with sarcoidosis was 2.43 (95% CI 2.06 to 2.86) and did not vary by age, sex or treatment status. It was higher during the first 2 years after diagnosis (HR 3.7 vs 1.9) and in individuals without a history of ischaemic heart disease (IHD; HR 2.7 vs 1.7). Diabetes, atrial fibrillation and other arrhythmias were the strongest independent clinical predictors of HF (HR 2.5 each, 2-year AF 20%, 16% and 12%, respectively).
Conclusions
Although low, the HF rate was more than twofold increased in sarcoidosis compared with the general population, particularly right after diagnosis. IHD history cannot solely explain these risks, whereas ventricular arrhythmias indicating cardiac sarcoidosis appear to be a strong predictor of HF in sarcoidosis.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:467-473
Rossides M, Kullberg S, Grunewald J, Eklund A, ... Askling J, Arkema EV
Heart: 27 Feb 2022; 108:467-473 | PMID: 34021039
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Impact:
Abstract

Implications of cancer prior to and after heart transplantation.

Mudigonda P, Berardi C, Chetram V, Barac A, Cheng R
Cancer and cardiovascular disease share many risk factors. Due to improved survival of patients with cancer, the cohort of cancer survivors with heart failure referred for heart transplantation (HT) is growing. Specific considerations include time interval between cancer treatment and HT, risk for recurrence and risk for de novo malignancy (dnM). dnM is an important cause of post-HT morbidity and mortality, with nearly a third diagnosed with malignancy by 10 years post-HT. Compared with the age-matched general population, HT recipients have an approximately 2.5-fold to 4-fold increased risk of developing cancer. HT recipients with prior malignancy show variable cancer recurrence rates, depending on years in remission before HT: 5% recurrence if >5 years in remission, 26% recurrence if 1-5 years in remission and 63% recurrence if <1 year in remission. A myriad of mechanisms influence oncogenesis following HT, including reduced host immunosurveillance from chronic immunosuppression, influence of oncogenic viruses, and the cumulative intensity and duration of immunosuppression. Conversely, protective factors include acyclovir prophylaxis, use of proliferation signal inhibitors (PSI) and female gender. Management involves reducing immunosuppression, incorporating a PSI for immunosuppression and heightened surveillance for allograft rejection. Cancer treatment, including immunotherapy, may be cardiotoxic and lead to graft failure or rejection. Additionally, there exists a competing risk to reduce immunosuppression to improve cancer outcomes, which may increase risk for rejection. A multidisciplinary cardio-oncology team approach is recommended to optimise care and should include an oncologist, transplant cardiologist, transplant pharmacist, palliative care, transplant coordinator and cardio-oncologist.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:414-421
Mudigonda P, Berardi C, Chetram V, Barac A, Cheng R
Heart: 27 Feb 2022; 108:414-421 | PMID: 34210749
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Impact:
Abstract

Association between ibrutinib treatment and hypertension.

Lee DH, Hawk F, Seok K, Gliksman M, ... Schabath MB, Fradley M
Background
Ibrutinib is a tyrosine kinase inhibitor most commonly associated with atrial fibrillation. However, additional cardiotoxicities have been identified, including accelerated hypertension. The incidence and risk factors of new or worsening hypertension following ibrutinib treatment are not as well known.
Methods
We conducted a retrospective study of 144 patients diagnosed with B cell malignancies treated with ibrutinib (n=93) versus conventional chemoimmunotherapy (n=51) and evaluated their effects on blood pressure at 1, 2, 3 and 6 months after treatment initiation. Descriptive statistics were used to compare baseline characteristics for each treatment group. Fisher\'s exact test was used to identify covariates significantly associated with the development of hypertension. Repeated measures analyses were conducted to analyse longitudinal blood pressure changes.
Results
Both treatments had similar prevalence of baseline hypertension at 63.4% and 66.7%, respectively. There were no differences between treatments by age, sex and baseline cardiac comorbidities. Both systolic and diastolic blood pressure significantly increased over time with ibrutinib compared with baseline, whereas conventional chemoimmunotherapy was not associated with significant changes in blood pressure. Baseline hypertensive status did not affect the degree of blood pressure change over time. A significant increase in systolic blood pressure (defined as more than 10 mm Hg) was noted for ibrutinib (36.6%) compared with conventional chemoimmunotherapy (7.9%) at 1 month after treatment initiation. Despite being hypertensive at follow-up, 61.2% of patients who were treated with ibrutinib did not receive adequate blood pressure management (increase or addition of blood pressure medications). Within the ibrutinib group, of patients who developed more than 20 mm Hg increase in systolic blood pressure, only 52.9% had hypertension management changes.
Conclusions
Ibrutinib is associated with the development of hypertension and worsening of blood pressure. Cardiologists and oncologists must be aware of this cardiotoxicity to allow timely management of blood pressure elevations.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:445-450
Lee DH, Hawk F, Seok K, Gliksman M, ... Schabath MB, Fradley M
Heart: 27 Feb 2022; 108:445-450 | PMID: 34210750
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Impact:
Abstract

Epicardial adipose tissue in obesity-related cardiac dysfunction.

Ayton SL, Gulsin GS, McCann GP, Moss AJ
Obesity is associated with the development of heart failure and is a major risk factor for heart failure with preserved ejection fraction (HFpEF). Epicardial adipose tissue (EAT) is a unique visceral fat in close proximity to the heart and is of particular interest to the study of cardiac disease. Small poorly differentiated adipocytes with altered lipid:water content are associated with a proinflammatory secretome and may contribute to the pathophysiology observed in HFpEF. Multimodality imaging approaches can be used to quantify EAT volume and characterise EAT composition. Current research studies remain unclear as to the magnitude of effect that EAT plays on myocardial dysfunction and further work using multimodality imaging techniques is ongoing. Pharmacological interventions, including glucagon-like peptide 1 receptor agonists and sodium-dependent glucose linked transporter 2 inhibitors have shown promise in attenuating the deleterious metabolic and inflammatory changes seen in EAT. Clinical studies are ongoing to explore whether these therapies exert their beneficial effects by modifying this unique adipose deposit.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:339-344
Ayton SL, Gulsin GS, McCann GP, Moss AJ
Heart: 27 Feb 2022; 108:339-344 | PMID: 33985985
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Impact:
Abstract

Coronary artery disease in East and South Asians: differences observed on cardiac CT.

Chua A, Adams D, Dey D, Blankstein R, ... Ihdayhid AR, Ko B
Epidemiological studies have observed East Asians (EAs) are significantly less likely to develop or die from coronary artery disease (CAD) compared with Caucasians. Conversely South Asians (SAs) develop CAD at higher rate and earlier age. Recently, a range of features derived from cardiac CT have been identified which may further characterise ethnic differences in CAD. Emerging data suggest EAs exhibit less coronary calcification and high-risk, non-calcified plaque compared with Caucasians on CT, with no difference in luminal stenosis. In contrast, SAs exhibit similar to higher coronary calcification and luminal stenosis, smaller luminal dimensions and more high-risk, non-calcified plaque than Caucasians. Beyond demonstrating ethnic differences in CAD, cardiac CT may enhance and individualise cardiovascular risk stratification in EAs and SAs. While data thus far in EAs have demonstrated calcium score and CT-derived luminal stenosis may incrementally predict cardiovascular risk beyond traditional risk scores, there remains a paucity of data assessing its use in SAs. Future studies may clarify the prognostic value of cardiac CT in SAs and investigate how this modality may guide preventative therapy and coronary intervention of CAD in EAs and SAs.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:251-257
Chua A, Adams D, Dey D, Blankstein R, ... Ihdayhid AR, Ko B
Heart: 27 Feb 2022; 108:251-257 | PMID: 33985989
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Impact:
Abstract

Enhanced oxidative stress and presence of ventricular aneurysm for risk prediction in cardiac sarcoidosis.

Yoshitomi R, Kobayashi S, Yano Y, Nakashima Y, ... Kawano R, Yano M
Objective
Sudden cardiac death (SCD) is the major cause of death in cardiac sarcoidosis (CS). We aimed to identify the prognostic markers for sustained ventricular tachycardia (sVT) and SCD in patients with CS.
Methods
We performed a prospective observational cohort study for patients with CS diagnosed according to the Japanese or Heart Rhythm Society guidelines between June 2008 and March 2020 in our hospital. The primary endpoint was a composite of the first sVT and SCD. The levels of urinary 8-hydroxy-2\'-deoxyguanosine (U-8-OHdG), a marker of oxidative DNA damage that reflects the inflammatory activity of CS, other biomarkers, and indices of cardiac function and renal function were measured on admission.
Results
Eighty-nine consecutive patients with CS were enrolled; 28 patients with no abnormal 18F-fluorodeoxyglucose (18F-FDG) accumulation in the heart were excluded and 61 patients with abnormal 18F-FDG accumulation were followed up for a median of 46 months (IQR: 20-84). During the follow-up period, 15 of 61 patients showed sVT (n=12) or SCD (n=3). A Cox proportional hazard model showed that U-8-OHdG concentration and presence of ventricular aneurysm (VA) were independent predictors of first sVT/SCD. The cut-off U-8-OHdG concentration for predicting first sVT/SCD was 14.9 ng/mg·Cr. Patients with U-8-OHdG concentration ≥14.9 ng/mg·Cr and VA showed a significantly increased risk of sVT/SCD.
Conclusions
U-8-OHdG and presence of VA were powerful predictors of first sVT/SCD in patients with CS, facilitating the stratification of cardiac events and providing relevant information about the substrates of ventricular tachycardia.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:429-437
Yoshitomi R, Kobayashi S, Yano Y, Nakashima Y, ... Kawano R, Yano M
Heart: 27 Feb 2022; 108:429-437 | PMID: 35078868
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Abstract

Efficacy of treat-and-repair strategy for atrial septal defect with pulmonary arterial hypertension.

Takaya Y, Akagi T, Sakamoto I, Kanazawa H, ... Nakagawa K, Ito H
Objective
Therapeutic strategies for atrial septal defect (ASD) with severe pulmonary arterial hypertension (PAH) are controversial. This study aimed to evaluate the efficacy of PAH-specific medications and subsequent transcatheter closure (ie, treat-and-repair strategy) on clinical outcomes.
Methods
We enrolled 42 patients who were referred to 13 institutions for consideration of ASD closure with concomitant PAH and underwent the treat-and-repair strategy. The endpoint was cardiovascular death or hospitalisation due to heart failure or exacerbated PAH.
Results
At baseline prior to PAH-specific medications, pulmonary to systemic blood flow ratio (Qp:Qs), pulmonary vascular resistance (PVR), and mean pulmonary artery pressure (PAP) were 1.9±0.8, 6.9±3.2 Wood units and 45±15 mm Hg. Qp:Qs was increased to 2.4±1.2, and PVR and mean PAP were decreased to 4.0±1.5 Wood units and 35±9 mm Hg at the time of transcatheter ASD closure after PAH-specific medications. Transcatheter ASD closure was performed without any complications. During a median follow-up period of 33 months (1-126 months) after transcatheter ASD closure, one older patient died and one patient was hospitalised due to heart failure, but the other patients survived with an improvement in WHO functional class. PAP was further decreased after transcatheter ASD closure.
Conclusions
The treat-and-repair strategy results in low complication and mortality rates with a reduction in PAP in selected patients with ASD complicated with PAH who have a favourable response of medical therapy.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 27 Feb 2022; 108:382-387
Takaya Y, Akagi T, Sakamoto I, Kanazawa H, ... Nakagawa K, Ito H
Heart: 27 Feb 2022; 108:382-387 | PMID: 34415851
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Abstract

Exercise prescription in individuals with hypertrophic cardiomyopathy: what clinicians need to know.

Gati S, Sharma S
Hypertrophic cardiomyopathy (HCM) is the most frequently cited cause of exercise-related sudden cardiac death (SCD) in young individuals and has claimed the lives of some high-profile athletes. The circumstantial link between exercise and SCD from HCM has resulted in conservative exercise recommendations which focus on activities that should be avoided rather than the minimal amount of physical activity required to reap the multiple rewards of exercise. Consequently, most patients with HCM are confined to a sedentary lifestyle through fear of SCD, with accruing risk factors such as obesity and low cardiorespiratory fitness that confer a worse prognosis. Recent exercise programmes in asymptomatic and symptomatic individuals with HCM have shown that mild and moderate exercise is safe and accompanied by increased functional capacity and improved quality of life. Population studies also reveal that individuals with HCM in the higher quartiles of self-reported physical activity have lower total cardiovascular mortality compared with those in the lower quartiles. The impact of vigorous exercise on the natural history of HCM is unknown, although current experience suggests that affected adults with mild morphology and absence of high-risk factors may partake in such activity without adverse events. This review highlights the evidence base that has resulted in a paradigm shift in the approach to exercise in HCM and liberalised recent international exercise guidelines in HCM. Practical tips for prescribing exercise in symptomatic patients and relevant precautions are provided to aid clinicians when recommending exercise as part of the management plan for all patients with HCM.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 22 Feb 2022; epub ahead of print
Gati S, Sharma S
Heart: 22 Feb 2022; epub ahead of print | PMID: 35197306
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Abstract

Prospective analysis of gender-related characteristics in relation to cardiovascular disease.

Bolijn R, Kunst AE, Appelman Y, Galenkamp H, ... Tan HL, van Valkengoed IG
Objective
Differences in cardiovascular disease (CVD) incidence between men and women have been widely reported. Next to sex-related (biological) characteristics, gender-related (sociocultural) characteristics may partly explain how these differences arise. In this exploratory study, we examined the associations between selected gender-related characteristics and CVD incidence.
Methods
We linked baseline data of 18 058 participants without CVD from the population-based, multiethnic HEalthy LIfe in an Urban Setting study (Amsterdam, the Netherlands) to CVD incidence data, based on hospital admission and death records from Statistics Netherlands in 2013-2018. Using Cox regression analyses, we studied associations of time spent on household work, doing home repairs, primary earner status, type of employment, working in a male-dominated or female-dominated occupation and desire for emotional support with CVD incidence, stratified by sex. Analyses were adjusted for age, ethnicity and socioeconomic status.
Results
In men, gender-related characteristics were not associated with higher CVD incidence. In women, homemakers had a higher hazard for CVD compared with full-time workers (HR 2.34, 95% CI 1.35 to 4.04), whereas those spending a moderate amount of time on household work had a lower hazard for CVD than those spending little time (HR 0.56, 95% CI 0.34 to 0.95).
Conclusion
Although we found no evidence for associations between gender-related characteristics and CVD incidence in men, being the homemaker and moderate time spent on household work appeared to be associated with CVD incidence in women. Thus, attention to gender-related characteristics might in future help to identify subgroups that may benefit from additional prevention strategies.

© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 22 Feb 2022; epub ahead of print
Bolijn R, Kunst AE, Appelman Y, Galenkamp H, ... Tan HL, van Valkengoed IG
Heart: 22 Feb 2022; epub ahead of print | PMID: 35197307
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This program is still in alpha version.