Topic: General Cardiology

Abstract

Using Metabolic Equivalents in Clinical Practice.

Franklin BA, Brinks J, Berra K, Lavie CJ, Gordon NF, Sperling LS
Metabolic equivalents, or METs, are routinely employed as a guide to exercise training and activity prescription and to categorize cardiorespiratory fitness (CRF). There are, however, inherent limitations to the concept, as well as common misapplications. CRF and the patient\'s capacity for physical activity are often overestimated and underestimated, respectively. Moreover, frequently cited fitness thresholds associated with the highest and lowest mortality rates may be misleading, as these are influenced by several factors, including age and gender. The conventional assumption that 1 MET = 3.5 mL O2/kg/min has been challenged in numerous studies that indicate a significant overestimation of actual resting energy expenditure in some populations, including coronary patients, the morbidly obese, and individuals taking β-blockers. These data have implications for classifying relative energy expenditure at submaximal and peak exercise. Heart rate may be used to approximate activity METs, resulting in a promising new fitness metric termed the \"personal activity intelligence\" or PAI score. Despite some limitations, the MET concept provides a useful method to quantitate CRF and define a repertoire of physical activities that are likely to be safe and therapeutic. In conclusion, for previously inactive adults, moderate-to-vigorous physical activity, which corresponds to ≥3 METs, may increase MET capacity and decrease the risk of future cardiac events.

Am J Cardiol: 31 Jan 2018; 121:382-387
Franklin BA, Brinks J, Berra K, Lavie CJ, Gordon NF, Sperling LS
Am J Cardiol: 31 Jan 2018; 121:382-387 | PMID: 29229271
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Abstract

Meta-Analysis of the Safety and Efficacy of the Oral Anticoagulant Agents (Apixaban, Rivaroxaban, Dabigatran) in Patients With Acute Coronary Syndrome.

Khan SU, Arshad A, Riaz IB, Talluri S, Nasir F, Kaluski E
The significance of adding new oral anticoagulants (NOACs) to antiplatelet therapy in patients with acute coronary syndrome (ACS) is unclear. We conducted a meta-analysis to assess the safety and efficacy of adding NOACs (apixaban, rivaroxaban, and dabigatran) to single antiplatelet agent (SAP) or dual antiplatelet therapy (DAPT) in patients with ACS. Seven randomized controlled trials were selected using PubMed or MEDLINE, Scopus, and Cochrane library (inception to August 2017). The summary measure was random effects hazard ratio (HR) with 95% confidence interval (CI). The primary safety outcome was clinically significant bleeding. The secondary efficacy outcome was major adverse cardiovascular events (MACE; composite of myocardial infarction, stroke, and all-cause mortality). In 31,574 patients, addition of NOAC to SAP did not increase the risk of clinically significant bleeding (HR 0.82, 95% CI 0.56 to 1.20, p = 0.31); however, the risk of clinically significant bleeding was significantly increased with NOAC plus DAPT (HR 2.24, 95% CI 1.75 to 2.87, p < 0.001). NOACs had no statistically beneficial effect on MACE when used with SAP (HR 0.82, 95% CI 0.66 to 1.04, p = 0.10); however, a modest reduction in MACE was observed when NOACs were combined with DAPT (HR 0.86, 95% CI 0.78 to 0.93, p < 0.001). In conclusion, in patients with ACS, the addition of NOAC to DAPT resulted in increased risk of clinically significant bleeding, whereas only a modest reduction in MACE was achieved. The addition of NOACs to SAP did not result in significant reduction of MACE or increase in clinically significant bleeding.

Am J Cardiol: 31 Jan 2018; 121:301-307
Khan SU, Arshad A, Riaz IB, Talluri S, Nasir F, Kaluski E
Am J Cardiol: 31 Jan 2018; 121:301-307 | PMID: 29195825
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Abstract

Antithrombotic Therapy in Peripheral Artery Disease: Generating and Translating Evidence Into Practice.

Jones WS, Patel MR
Atherosclerotic cardiovascular (CV) disease remains a major health concern affecting more than 200 million adults worldwide, and lower extremity peripheral artery disease (PAD) is associated with significant morbidity and mortality. Treatment strategies to reduce the burden of major adverse CV events and limb events have mainly involved the use of antiplatelet and statin medications. Unlike other types of atherosclerotic CV disease, the evidence base is not well developed for therapies in patients with PAD. Recently, studies from subgroups of patients with PAD and a large clinical trial of PAD patients have been published, signaling a burgeoning interest in studying this higher risk population. This review outlines the inherent CV risks of patients with PAD, risk reduction strategies, emerging clinical trial data, and opportunities for the CV community to generate evidence in real-world settings and translate evidence into practice as new therapies become available.

J Am Coll Cardiol: 22 Jan 2018; 71:352-362
Jones WS, Patel MR
J Am Coll Cardiol: 22 Jan 2018; 71:352-362 | PMID: 29348028
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Abstract

Implications of Underlying Mechanisms for the Recognition and Management of Diabetic Cardiomyopathy.

Marwick TH, Ritchie R, Shaw JE, Kaye D
Heart failure is a complex clinical syndrome, the incidence and prevalence of which is increased in diabetes mellitus, pre-diabetes, and obesity. Although this may arise from underlying coronary artery disease, it often occurs in the absence of significant major epicardial coronary disease, and most commonly manifests as heart failure with preserved ejection fraction. Despite epidemiological evidence linking diabetes to heart failure incidence and outcome, the presence of a distinct primary \"diabetic\" cardiomyopathy has been difficult to prove, because the link between diabetes and heart failure is confounded by hypertension, microvascular dysfunction, and autonomic neuropathy. Nonetheless, several mechanistic associations at systemic, cardiac, and cellular/molecular levels explain different aspects of myocardial dysfunction, including impaired cardiac relaxation, compliance, and contractility. This review seeks to describe recent advances and limitations pertinent to integrating molecular mechanisms, clinical screening, and potential therapeutic avenues for this condition.

J Am Coll Cardiol: 22 Jan 2018; 71:339-351
Marwick TH, Ritchie R, Shaw JE, Kaye D
J Am Coll Cardiol: 22 Jan 2018; 71:339-351 | PMID: 29348027
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Abstract

Machine learning in cardiovascular medicine: are we there yet?

Shameer K, Johnson KW, Glicksberg BS, Dudley JT, Sengupta PP
Artificial intelligence (AI) broadly refers to analytical algorithms that iteratively learn from data, allowing computers to find hidden insights without being explicitly programmed where to look. These include a family of operations encompassing several terms like machine learning, cognitive learning, deep learning and reinforcement learning-based methods that can be used to integrate and interpret complex biomedical and healthcare data in scenarios where traditional statistical methods may not be able to perform. In this review article, we discuss the basics of machine learning algorithms and what potential data sources exist; evaluate the need for machine learning; and examine the potential limitations and challenges of implementing machine in the context of cardiovascular medicine. The most promising avenues for AI in medicine are the development of automated risk prediction algorithms which can be used to guide clinical care; use of unsupervised learning techniques to more precisely phenotype complex disease; and the implementation of reinforcement learning algorithms to intelligently augment healthcare providers. The utility of a machine learning-based predictive model will depend on factors including data heterogeneity, data depth, data breadth, nature of modelling task, choice of machine learning and feature selection algorithms, and orthogonal evidence. A critical understanding of the strength and limitations of various methods and tasks amenable to machine learning is vital. By leveraging the growing corpus of big data in medicine, we detail pathways by which machine learning may facilitate optimal development of patient-specific models for improving diagnoses, intervention and outcome in cardiovascular medicine.

Heart: 18 Jan 2018; epub ahead of print
Shameer K, Johnson KW, Glicksberg BS, Dudley JT, Sengupta PP
Heart: 18 Jan 2018; epub ahead of print | PMID: 29352006
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Abstract

Cardiopulmonary resuscitation: the science behind the hands.

Harris AW, Kudenchuk PJ
Sudden cardiac arrest is a leading cause of death worldwide. Despite significant advances in resuscitation science since the initial use of external chest compressions in humans nearly 60 years ago, there continues to be wide variability in rates of successful resuscitation across communities. The American Heart Association (AHA) and European Resuscitation Council emphasise the importance of high-quality chest compressions as the foundation of resuscitation care. We review the physiological basis for the association between chest compression quality and clinical outcomes and the scientific basis for the AHA\'s key metrics for high-quality cardiopulmonary resuscitation. Finally, we highlight that implementation of strategies that promote effective chest compressions can improve outcomes in all patients with cardiac arrest.

Heart: 19 Jan 2018; epub ahead of print
Harris AW, Kudenchuk PJ
Heart: 19 Jan 2018; epub ahead of print | PMID: 29353251
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Abstract

NHLBI Working Group Recommendations to Reduce Lipoprotein(a)-Mediated Risk of Cardiovascular Disease and Aortic Stenosis.

Tsimikas S, Fazio S, Ferdinand KC, Ginsberg HN, ... Olive M, Liu L
Pathophysiological, epidemiological, and genetic studies provide strong evidence that lipoprotein(a) [Lp(a)] is a causal mediator of cardiovascular disease (CVD) and calcific aortic valve disease (CAVD). Specific therapies to address Lp(a)-mediated CVD and CAVD are in clinical development. Due to knowledge gaps, the National Heart, Lung, and Blood Institute organized a working group that identified challenges in fully understanding the role of Lp(a) in CVD/CAVD. These included the lack of research funding, inadequate experimental models, lack of globally standardized Lp(a) assays, and inadequate understanding of the mechanisms underlying current drug therapies on Lp(a) levels. Specific recommendations were provided to facilitate basic, mechanistic, preclinical, and clinical research on Lp(a); foster collaborative research and resource sharing; leverage expertise of different groups and centers with complementary skills; and use existing National Heart, Lung, and Blood Institute resources. Concerted efforts to understand Lp(a) pathophysiology, together with diagnostic and therapeutic advances, are required to reduce Lp(a)-mediated risk of CVD and CAVD.

J Am Coll Cardiol: 15 Jan 2018; 71:177-192
Tsimikas S, Fazio S, Ferdinand KC, Ginsberg HN, ... Olive M, Liu L
J Am Coll Cardiol: 15 Jan 2018; 71:177-192 | PMID: 29325642
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Abstract

Role of Invasive Functional Assessment in Surgical Revascularization of Coronary Artery Disease.

Baibhav B, Gedela M, Moulton M, Pavlides G, ... Siddique A, Chatzizisis YS
In patients with stable coronary artery disease, percutaneous coronary intervention is associated with improved outcomes if the lesion is deemed significant by invasive functional assessment using fractional flow reserve. Recent studies have shown that a revascularization strategy using instantaneous wave-free ratio is noninferior to fractional flow reserve in patients with intermediate-grade stenoses. The decision to perform coronary artery bypass grafting surgery is usually based on anatomic assessment of stenosis severity by coronary angiography. The data on the role of invasive functional assessment in guiding surgical revascularization are limited. In this review, we discuss the diagnostic and prognostic significance of invasive functional assessment in patients considered for coronary artery bypass grafting. In addition, we critically discuss ongoing and future clinical trials on the role of invasive functional assessment in surgical revascularization.

Circulation: 16 Apr 2018; 137:1731-1739
Baibhav B, Gedela M, Moulton M, Pavlides G, ... Siddique A, Chatzizisis YS
Circulation: 16 Apr 2018; 137:1731-1739 | PMID: 29661951
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Abstract

Cardiovascular Magnetic Resonance in Acute ST-Segment-Elevation Myocardial Infarction: Recent Advances, Controversies, and Future Directions.

Bulluck H, Dharmakumar R, Arai AE, Berry C, Hausenloy DJ
Although mortality after ST-segment elevation myocardial infarction (MI) is on the decline, the number of patients developing heart failure as a result of MI is on the rise. Apart from timely reperfusion by primary percutaneous coronary intervention, there is currently no established therapy for reducing MI size. Thus, new cardioprotective therapies are required to improve clinical outcomes after ST-segment-elevation MI. Cardiovascular magnetic resonance has emerged as an important imaging modality for assessing the efficacy of novel therapies for reducing MI size and preventing subsequent adverse left ventricular remodeling. The recent availability of multiparametric mapping cardiovascular magnetic resonance imaging has provided new insights into the pathophysiology underlying myocardial edema, microvascular obstruction, intramyocardial hemorrhage, and changes in the remote myocardial interstitial space after ST-segment-elevation MI. In this article, we provide an overview of the recent advances in cardiovascular magnetic resonance imaging in reperfused patients with ST-segment-elevation MI, discuss the controversies surrounding its use, and explore future applications of cardiovascular magnetic resonance in this setting.

Circulation: 30 Apr 2018; 137:1949-1964
Bulluck H, Dharmakumar R, Arai AE, Berry C, Hausenloy DJ
Circulation: 30 Apr 2018; 137:1949-1964 | PMID: 29712696
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Abstract

Atrial Fibrillation Burden: Moving Beyond Atrial Fibrillation as a Binary Entity: A Scientific Statement From the American Heart Association.

Chen LY, Chung MK, Allen LA, Ezekowitz M, ... Turakhia MP,
Our understanding of the risk factors and complications of atrial fibrillation (AF) is based mostly on studies that have evaluated AF in a binary fashion (present or absent) and have not investigated AF burden. This scientific statement discusses the published literature and knowledge gaps related to methods of defining and measuring AF burden, the relationship of AF burden to cardiovascular and neurological outcomes, and the effect of lifestyle and risk factor modification on AF burden. Many studies examine outcomes by AF burden classified by AF type (paroxysmal versus nonparoxysmal); however, quantitatively, AF burden can be defined by longest duration, number of AF episodes during a monitoring period, and the proportion of time an individual is in AF during a monitoring period (expressed as a percentage). Current guidelines make identical recommendations for anticoagulation regardless of AF pattern or burden; however, a review of recent evidence suggests that higher AF burden is associated with higher risk of stroke. It is unclear whether the risk increases continuously or whether a threshold exists; if a threshold exists, it has not been defined. Higher burden of AF is also associated with higher prevalence and incidence of heart failure and higher risk of mortality, but not necessarily lower quality of life. A structured and comprehensive risk factor management program targeting risk factors, weight loss, and maintenance of a healthy weight appears to be effective in reducing AF burden. Despite this growing understanding of AF burden, research is needed into validation of definitions and measures of AF burden, determination of the threshold of AF burden that results in an increased risk of stroke that warrants anticoagulation, and discovery of the mechanisms underlying the weak temporal correlations of AF and stroke. Moreover, developments in monitoring technologies will likely change the landscape of long-term AF monitoring and could allow better definition of the significance of changes in AF burden over time.

Circulation: 15 Apr 2018; epub ahead of print
Chen LY, Chung MK, Allen LA, Ezekowitz M, ... Turakhia MP,
Circulation: 15 Apr 2018; epub ahead of print | PMID: 29661944
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Abstract

COSCA (Core Outcome Set for Cardiac Arrest) in Adults: An Advisory Statement From the International Liaison Committee on Resuscitation.

Haywood K, Whitehead L, Nadkarni VM, Achana F, ... Perkins GD,
Cardiac arrest effectiveness trials have traditionally reported outcomes that focus on survival. A lack of consistency in outcome reporting between trials limits the opportunities to pool results for meta-analysis. The COSCA initiative (Core Outcome Set for Cardiac Arrest), a partnership between patients, their partners, clinicians, research scientists, and the International Liaison Committee on Resuscitation, sought to develop a consensus core outcome set for cardiac arrest for effectiveness trials. Core outcome sets are primarily intended for large, randomized clinical effectiveness trials (sometimes referred to as or ) rather than for pilot or efficacy studies. A systematic review of the literature combined with qualitative interviews among cardiac arrest survivors was used to generate a list of potential outcome domains. This list was prioritized through a Delphi process, which involved clinicians, patients, and their relatives/partners. An international advisory panel narrowed these down to 3 core domains by debate that led to consensus. The writing group refined recommendations for when these outcomes should be measured and further characterized relevant measurement tools. Consensus emerged that a core outcome set for reporting on effectiveness studies of cardiac arrest (COSCA) in adults should include survival, neurological function, and health-related quality of life. This should be reported as survival status and modified Rankin scale score at hospital discharge, at 30 days, or both. Health-related quality of life should be measured with ≥1 tools from Health Utilities Index version 3, Short-Form 36-Item Health Survey, and EuroQol 5D-5L at 90 days and at periodic intervals up to 1 year after cardiac arrest, if resources allow.

Circulation: 25 Apr 2018; epub ahead of print
Haywood K, Whitehead L, Nadkarni VM, Achana F, ... Perkins GD,
Circulation: 25 Apr 2018; epub ahead of print | PMID: 29700122
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Abstract

Domain Management Approach to Heart Failure in the Geriatric Patient: Present and Future.

Gorodeski EZ, Goyal P, Hummel SL, Krishnaswami A, ... Alexander KP,
Heart failure (HF) is a quintessential geriatric cardiovascular condition, with more than 50% of hospitalizations occurring in adults age 75 years or older. In older patients, HF is closely linked to processes inherent to aging, which include cellular and structural changes to the myocardium, vasculature, and skeletal muscle. In addition, HF cannot be considered in isolation of physical functioning, or without the social, psychological, and behavioral dimensions of illness. The role of frailty, depression, cognitive impairment, nutrition, and goals of care are each uniquely relevant to the implementation and success of medical therapy. In this paper, we discuss a model of caring for older adults with HF through a 4-domain framework that can address the unique multidimensional needs and vulnerabilities of this population. We believe that clinicians who embrace this approach can improve health outcomes for older adults with HF.

J Am Coll Cardiol: 30 Apr 2018; 71:1921-1936
Gorodeski EZ, Goyal P, Hummel SL, Krishnaswami A, ... Alexander KP,
J Am Coll Cardiol: 30 Apr 2018; 71:1921-1936 | PMID: 29699619
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Abstract

Medical Nutrition Education, Training, and Competencies to Advance Guideline-Based Diet Counseling by Physicians: A Science Advisory From the American Heart Association.

Aspry KE, Van Horn L, Carson JAS, Wylie-Rosett J, ... Kris-Etherton P,
Growing scientific evidence of the benefits of heart-healthy dietary patterns and of the massive public health and economic burdens attributed to obesity and poor diet quality have triggered national calls to increase diet counseling in outpatients with atherosclerotic cardiovascular disease or risk factors. However, despite evidence that physicians are willing to undertake this task and are viewed as credible sources of diet information, they engage patients in diet counseling at less than desirable rates and cite insufficient knowledge and training as barriers. These data align with evidence of large and persistent gaps in medical nutrition education and training in the United States. Now, major reforms in undergraduate and graduate medical education designed to incorporate advances in the science of learning and to better prepare physicians for 21st century healthcare delivery are providing a new impetus and novel ways to expand medical nutrition education and training. This science advisory reviews gaps in undergraduate and graduate medical education in nutrition in the United States, summarizes reforms that support and facilitate more robust nutrition education and training, and outlines new opportunities for accomplishing this goal via multidimensional curricula, pedagogies, technologies, and competency-based assessments. Real-world examples of efforts to improve undergraduate and graduate medical education in nutrition by integrating formal learning with practical, experiential, inquiry-driven, interprofessional, and population health management activities are provided. The authors conclude that enhancing physician education and training in nutrition, as well as increasing collaborative nutrition care delivery by 21st century health systems, will reduce the health and economic burdens from atherosclerotic cardiovascular disease to a degree not previously realized.

Circulation: 29 Apr 2018; epub ahead of print
Aspry KE, Van Horn L, Carson JAS, Wylie-Rosett J, ... Kris-Etherton P,
Circulation: 29 Apr 2018; epub ahead of print | PMID: 29712711
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Abstract

Cerebrovascular Events After Cardiovascular Procedures: Risk Factors, Recognition, and Prevention Strategies.

Devgun JK, Gul S, Mohananey D, Jones BM, ... Tuzcu EM, Kapadia SR
Stroke has long been a devastating complication of any cardiovascular procedure that unfavorably affects survival and quality of life. Over time, strategies have been developed to substantially reduce the incidence of stroke after traditional cardiovascular procedures such as coronary artery bypass grafting, isolated valve surgery, and carotid endarterectomy. Subsequently, with the advent of minimally invasive technologies including percutaneous coronary intervention, carotid artery stenting, and transcatheter valve therapies, operators were faced with a new host of procedural risk factors, and efforts again turned toward identifying novel ways to reduce the risk of stroke. Fortunately, by understanding the procedural factors unique to these new techniques and applying many of the lessons learned from prior experiences, we are seeing significant improvements in the safety of these new technologies. In this review, the authors: 1) carefully analyze data from different cardiac procedural experiences ranging from traditional open heart surgery to percutaneous coronary intervention and transcatheter valve therapies; 2) explore the unique risk factors for stroke in each of these areas; and 3) describe how these risks can be mitigated with improved patient selection, adjuvant pharmacotherapy, procedural improvements, and novel technological advancements.

J Am Coll Cardiol: 30 Apr 2018; 71:1910-1920
Devgun JK, Gul S, Mohananey D, Jones BM, ... Tuzcu EM, Kapadia SR
J Am Coll Cardiol: 30 Apr 2018; 71:1910-1920 | PMID: 29699618
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Abstract

Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association.

Konstam MA, Kiernan MS, Bernstein D, Bozkurt B, ... Ward C,
The diverse causes of right-sided heart failure (RHF) include, among others, primary cardiomyopathies with right ventricular (RV) involvement, RV ischemia and infarction, volume loading caused by cardiac lesions associated with congenital heart disease and valvular pathologies, and pressure loading resulting from pulmonic stenosis or pulmonary hypertension from a variety of causes, including left-sided heart disease. Progressive RV dysfunction in these disease states is associated with increased morbidity and mortality. The purpose of this scientific statement is to provide guidance on the assessment and management of RHF.

Circulation: 11 Apr 2018; epub ahead of print
Konstam MA, Kiernan MS, Bernstein D, Bozkurt B, ... Ward C,
Circulation: 11 Apr 2018; epub ahead of print | PMID: 29650544
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Abstract

Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association.

Marino BS, Tabbutt S, MacLaren G, Hazinski MF, ... Laussen PC,
Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.

Circulation: 22 Apr 2018; epub ahead of print
Marino BS, Tabbutt S, MacLaren G, Hazinski MF, ... Laussen PC,
Circulation: 22 Apr 2018; epub ahead of print | PMID: 29685887
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Abstract

The Alchemist\'s Nightmare: Might Mesenchymal Stem Cells That Are Recruited to Repair the Injured Heart Be Transformed Into Fibroblasts Rather Than Cardiomyocytes?

Packer M
The injection of mesenchymal stem cells into the injured myocardium to induce cardiac regeneration has yielded disappointing results, conceivably because cells with cardioreparative potential must be supplied for long periods of time to produce a salutary effect. Accordingly, investigators have devised ways of directing such cells to the heart on an ongoing basis: by enhancing the action of endogenous peptides that function as cardiac homing signals (eg, stromal cell-derived factor-1). Stromal cell-derived factor-1 is released during acute cardiac injury and heart failure, but it has a short half-life because of degradation by dipeptidyl peptidase-4. Inhibition of dipeptidyl peptidase-4 potentiates the actions of stromal cell-derived factor-1 and, theoretically, could enhance cardiac recovery. However, in large-scale trials in patients with type 2 diabetes mellitus, dipeptidyl peptidase-4 inhibitors have not reduced the risk of atherosclerotic ischemic events, and they have unexpectedly increased the risk of heart failure, most probably heart failure with a preserved ejection fraction. Such an outcome might be explained if the channeling of mesenchymal stem cells to the heart by the actions of stromal cell-derived factor-1 (especially from nearby adipose tissue) were followed by the transformation of these cells into fibroblasts rather than cardiomyocytes. This concern has been supported by experimental studies; the resulting fibrosis would be expected to exacerbate the pathophysiological derangements that lead to heart failure with a preserved ejection fraction. Given the widespread use of dipeptidyl peptidase-4 inhibitors, the possibility that these drugs potentiate the cardiac homing of mesenchymal stem cells that cause myocardial fibrosis (rather than repair) warrants further study.

Circulation: 07 May 2018; 137:2068-2073
Packer M
Circulation: 07 May 2018; 137:2068-2073 | PMID: 29735591
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Abstract

Coronary Artery Disease in Patients ≥80 Years of Age.

Madhavan MV, Gersh BJ, Alexander KP, Granger CB, Stone GW
Coronary artery disease (CAD) is a major cause of morbidity and mortality in patients ≥80 years of age. Nonetheless, older patients have typically been under-represented in cardiovascular clinical trials. Understanding the pathophysiology, epidemiology, and optimal means of diagnosis and treatment of CAD in older adults is crucial to improving outcomes in this high-risk population. A patient-centered approach, taking into account health status, functional ability and frailty, cognitive skills, and patient preferences is essential when caring for older adults with CAD. The present systematic review focuses on the current knowledge base, gaps in understanding, and directions for future investigation pertaining to CAD in patients ≥80 years of age.

J Am Coll Cardiol: 07 May 2018; 71:2015-2040
Madhavan MV, Gersh BJ, Alexander KP, Granger CB, Stone GW
J Am Coll Cardiol: 07 May 2018; 71:2015-2040 | PMID: 29724356
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Abstract

Arrhythmias in Patients ≥80 Years of Age: Pathophysiology, Management, and Outcomes.

Curtis AB, Karki R, Hattoum A, Sharma UC
Advances in medical care have led to an increase in the number of octogenarians and even older patients, forming an important and unique patient subgroup. It is clear that advancing age is an independent risk factor for the development of most arrhythmias, causing substantial morbidity and mortality. Patients ≥80 years of age have significant structural and electrical remodeling of cardiac tissue; accrue competing comorbidities; react differently to drug therapy; and may experience falls, frailty, and cognitive impairment, presenting significant therapeutic challenges. Unfortunately, very old patients are under-represented in clinical trials, leading to critical gaps in evidence to guide effective and safe treatment of arrhythmias. In this state-of-the-art review, we examine the pathophysiology of aging and arrhythmias and then present the available evidence on age-specific management of the most common arrhythmias, including drugs, catheter ablation, and cardiac implantable electronic devices.

J Am Coll Cardiol: 07 May 2018; 71:2041-2057
Curtis AB, Karki R, Hattoum A, Sharma UC
J Am Coll Cardiol: 07 May 2018; 71:2041-2057 | PMID: 29724357
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Abstract

Contemporary management and outcomes in congenitally corrected transposition of the great arteries.

Kutty S, Danford DA, Diller GP, Tutarel O
Congenitally corrected transposition of the great arteries (ccTGA) can occur in isolation, or in combination with other structural cardiac anomalies, most commonly ventricular septal defect, pulmonary stenosis and tricuspid valve disease. Clinical recognition can be challenging, so echocardiography is often the means by which definitive diagnosis is made. The tricuspid valve and right ventricle are on the systemic arterial side of the ccTGA circulation, and are therefore subject to progressive functional deterioration. The natural history of ccTGA is also greatly influenced by the nature and severity of accompanying lesions, some of which require surgical repair. Some management strategies leave the right ventricle as the systemic arterial pump, but carry the risk of worsening heart failure. More complex \'double switch\' repairs establish the left ventricle as the systemic pump, and include an atrial baffle to redirect venous return in combination with either arterial switch or Rastelli operation (if a suitable ventricular septal defect permits). Occasionally, the anatomic peculiarities of ccTGA do not allow straightforward biventricular repair, and Fontan palliation is a reasonable option. Regardless of the approach selected, late cardiovascular complications are relatively common, so ongoing outpatient surveillance should be established in an age-appropriate facility with expertise in congenital heart disease care.

Heart: 10 Jan 2018; epub ahead of print
Kutty S, Danford DA, Diller GP, Tutarel O
Heart: 10 Jan 2018; epub ahead of print | PMID: 29326110
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Abstract

Valvular Heart Disease in Patients ≥80 Years of Age.

Kodali SK, Velagapudi P, Hahn RT, Abbott D, Leon MB
In the United States, the octogenarian population is projected to triple by 2050. With this aging population, the prevalence of valvular heart disease (VHD) is on the rise. The etiology, approach to treatment, and expected outcomes of VHD are different in the elderly compared with younger patients. Both stenotic and regurgitant lesions are associated with unfavorable outcomes if left untreated. Surgical mortality remains high due to multiple co-morbidities, and long-term survival benefit is dependent on many variables including valvular pathology. Quality of life is an important consideration in treatment decisions in this age group. Increasingly, octogenarian patients are receiving transcatheter therapies, with transcatheter aortic valve replacement having the greatest momentum. Numerous transcatheter devices for management of other valve lesions are currently in early clinical trials. This review will describe the epidemiology, etiology, diagnosis, and therapeutic options for VHD in the oldest old, with a focus on transcatheter technologies.

J Am Coll Cardiol: 07 May 2018; 71:2058-2072
Kodali SK, Velagapudi P, Hahn RT, Abbott D, Leon MB
J Am Coll Cardiol: 07 May 2018; 71:2058-2072 | PMID: 29724358
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Abstract

Socioeconomic Status and Cardiovascular Outcomes: Challenges and Interventions.

Schultz WM, Kelli HM, Lisko JC, Varghese T, ... Mensah GA, Sperling LS
Socioeconomic status (SES) has a measurable and significant effect on cardiovascular health. Biological, behavioral, and psychosocial risk factors prevalent in disadvantaged individuals accentuate the link between SES and cardiovascular disease (CVD). Four measures have been consistently associated with CVD in high-income countries: income level, educational attainment, employment status, and neighborhood socioeconomic factors. In addition, disparities based on sex have been shown in several studies. Interventions targeting patients with low SES have predominantly focused on modification of traditional CVD risk factors. Promising approaches are emerging that can be implemented on an individual, community, or population basis to reduce disparities in outcomes. Structured physical activity has demonstrated effectiveness in low-SES populations, and geomapping may be used to identify targets for large-scale programs. Task shifting, the redistribution of healthcare management from physician to nonphysician providers in an effort to improve access to health care, may have a role in select areas. Integration of SES into the traditional CVD risk prediction models may allow improved management of individuals with high risk, but cultural and regional differences in SES make generalized implementation challenging. Future research is required to better understand the underlying mechanisms of CVD risk that affect individuals of low SES and to determine effective interventions for patients with high risk. We review the current state of knowledge on the impact of SES on the incidence, treatment, and outcomes of CVD in high-income societies and suggest future research directions aimed at the elimination of these adverse factors, and the integration of measures of SES into the customization of cardiovascular treatment.

Circulation: 14 May 2018; 137:2166-2178
Schultz WM, Kelli HM, Lisko JC, Varghese T, ... Mensah GA, Sperling LS
Circulation: 14 May 2018; 137:2166-2178 | PMID: 29760227
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Abstract

Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association.

Cheng A, Nadkarni VM, Mancini MB, Hunt EA, ... Bhanji F,
The formula for survival in resuscitation describes educational efficiency and local implementation as key determinants in survival after cardiac arrest. Current educational offerings in the form of standardized online and face-to-face courses are falling short, with providers demonstrating a decay of skills over time. This translates to suboptimal clinical care and poor survival outcomes from cardiac arrest. In many institutions, guidelines taught in courses are not thoughtfully implemented in the clinical environment. A current synthesis of the evidence supporting best educational and knowledge translation strategies in resuscitation is lacking. In this American Heart Association scientific statement, we provide a review of the literature describing key elements of educational efficiency and local implementation, including mastery learning and deliberate practice, spaced practice, contextual learning, feedback and debriefing, assessment, innovative educational strategies, faculty development, and knowledge translation and implementation. For each topic, we provide suggestions for improving provider performance that may ultimately optimize patient outcomes from cardiac arrest.

Circulation: 20 Jun 2018; epub ahead of print
Cheng A, Nadkarni VM, Mancini MB, Hunt EA, ... Bhanji F,
Circulation: 20 Jun 2018; epub ahead of print | PMID: 29930020
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Abstract

Pulmonary arterial hypertension in adult congenital heart disease.

Brida M, Gatzoulis MA
Pulmonary arterial hypertension (PAH) is commonly associated with congenital heart disease (CHD) and relates to type of the underlying cardiac defects and repair history. Large systemic to pulmonary shunts may develop PAH if untreated or repaired late. PAH, when present, markedly increases morbidity and mortality in patients with CHD. Significant progress has been made for patients with Eisenmenger syndrome in pathophysiology, prognostication and disease-targeting therapy (DTT), which needs to be applied to routine patient care. Patients with PAH-CHD and systemic to pulmonary shunting may benefit from late defect closure if pulmonary vascular resistance (PVR) is still normal or near normal. Patients with PAH and coincidental defects, or previous repair of CHD should be managed as those with idiopathic PAH. Patients with a Fontan circulation, despite not strictly fulfilling criteria for PAH, may have elevated PVR; recent evidence suggests that they may also benefit from DTT, but more data are required before general recommendations can be made. CHD-PAH is a lifelong, progressive disease; patients should receive tertiary care and benefit from a proactive DTT approach. Novel biomarkers and genetic advances may identify patients with CHD who should be referred for late defect closure and/or patients at high risk of developing PAH despite early closure in childhood. Ongoing vigilance for PAH and further controlled studies are clearly warranted in CHD.

Heart: 01 May 2018; epub ahead of print
Brida M, Gatzoulis MA
Heart: 01 May 2018; epub ahead of print | PMID: 29720395
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Abstract

Leptin-Aldosterone-Neprilysin Axis: Identification of Its Distinctive Role in the Pathogenesis of the Three Phenotypes of Heart Failure in People With Obesity.

Packer M
Obesity (especially visceral adiposity) can be associated with 3 different phenotypes of heart failure: heart failure with a reduced ejection fraction, heart failure with a preserved ejection fraction, and high-output heart failure. All 3 phenotypes are characterized by an excessive secretion of aldosterone and sodium retention. In addition, obesity is accompanied by increased signaling through the leptin receptor, which can promote activation of both the sympathetic nervous system and the renin-angiotensin system and can directly stimulate the secretion of aldosterone. The deleterious interaction of leptin and aldosterone is potentiated by the simultaneous action of adiposity and the renal sympathetic nerves to cause overactivity of neprilysin; the loss of the counterbalancing effects of natriuretic peptides is exacerbated by an additional effect of both obesity and heart failure to interfere with adiponectin signaling. This intricate neurohormonal interplay leads to plasma volume expansion as well as to adverse ventricular remodeling and cardiac fibrosis. Furthermore, the activity of aldosterone and neprilysin is not only enhanced by obesity, but these mechanisms can also promote adipogenesis and adipocyte dysfunction, thereby enhancing the positive feedback loop. Last, in elderly obese women, changes in quantity and biology of epicardial adipose tissue further enhances the release of leptin and other proinflammatory adipokines, thereby leading to cardiac and systemic inflammation, end-organ fibrosis, and multiple comorbidities. Regardless of the phenotypic expression, activation of the leptin-aldosterone-neprilysin axis appears to contribute importantly to the evolution and progression of heart failure in people with obesity. Efforts to interfere with the detrimental interactions of this distinctive neurohormonal ecosystem with existing or novel therapeutic agents are likely to yield unique clinical benefits.

Circulation: 09 Apr 2018; 137:1614-1631
Packer M
Circulation: 09 Apr 2018; 137:1614-1631 | PMID: 29632154
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Abstract

Hyperpolarised magnetic resonance for in vivo real-time metabolic imaging.

Apps A, Lau J, Peterzan M, Neubauer S, Tyler D, Rider O
Although non-invasive perfusion and viability imaging often provide the gateway to coronary revascularisation, current non-invasive imaging methods only report the surrogate markers of inducible hypoperfusion and presence or absence of myocardial scar, rather than actually visualising areas of ischaemia and/or viable myocardium. This may lead to suboptimal revascularisation decisions. Normally respiring (viable) cardiomyocytes convert pyruvate to acetyl-CoA and CO/bicarbonate (via pyruvate dehydrogenase), but under ischaemic conditions characteristically shift this conversion to lactate (by lactate dehydrogenase). Imaging pyruvate metabolism thus has the potential to improve upon current imaging techniques. Using the novel hyperpolarisation technique of dynamic nuclear polarisation (DNP), the magnetic resonance signal of injected [1-C]pyruvate can be transiently magnified >10 000 times over that seen in conventional MR spectroscopy, allowing the characteristic metabolic signatures of ischaemia (lactate production) and viability (CO/bicarbonate production) to be directly imaged. As such DNP imaging of the downstream metabolism of [1-C]pyruvate could surpass the diagnostic capabilities of contemporary ischaemia and viability testing. Here we review the technique, and with brief reference to the salient biochemistry, discuss its potential applications within cardiology. These include ischaemia and viability testing, and further characterisation of the altered metabolism seen at different stages during the natural history of heart failure.

Heart: 26 Apr 2018; epub ahead of print
Apps A, Lau J, Peterzan M, Neubauer S, Tyler D, Rider O
Heart: 26 Apr 2018; epub ahead of print | PMID: 29703741
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Abstract

Thyroid Hormones and Cardiovascular Function and Diseases.

Razvi S, Jabbar A, Pingitore A, Danzi S, ... Zaman A, Iervasi G
Thyroid hormone (TH) receptors are present in the myocardium and vascular tissue, and minor alterations in TH concentration can affect cardiovascular (CV) physiology. The potential mechanisms that link CV disease with thyroid dysfunction are endothelial dysfunction, changes in blood pressure, myocardial systolic and diastolic dysfunction, and dyslipidemia. In addition, cardiac disease itself may lead to alterations in TH concentrations (notably, low triiodothyronine syndrome) that are associated with higher morbidity and mortality. Experimental data and small clinical trials have suggested a beneficial role of TH in ameliorating CV disease. The aim of this review is to provide clinicians dealing with CV conditions with an overview of the current knowledge of TH perturbations in CV disease.

J Am Coll Cardiol: 23 Apr 2018; 71:1781-1796
Razvi S, Jabbar A, Pingitore A, Danzi S, ... Zaman A, Iervasi G
J Am Coll Cardiol: 23 Apr 2018; 71:1781-1796 | PMID: 29673469
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Abstract

Standardized End Point Definitions for Coronary Intervention Trials: The Academic Research Consortium-2 Consensus Document.

Garcia-Garcia HM, McFadden EP, Farb A, Mehran R, ... Serruys PW,
The Academic Research Consortium (ARC)-2 initiative revisited the clinical and angiographic end point definitions in coronary device trials, proposed in 2007, to make them more suitable for use in clinical trials that include increasingly complex lesion and patient populations and incorporate novel devices such as bioresorbable vascular scaffolds. In addition, recommendations for the incorporation of patient-related outcomes in clinical trials are proposed. Academic Research Consortium-2 is a collaborative effort between academic research organizations in the United States and Europe, device manufacturers, and European, US, and Asian regulatory bodies. Several in-person meetings were held to discuss the changes that have occurred in the device landscape and in clinical trials and regulatory pathways in the last decade. The consensus-based end point definitions in this document are endorsed by the stakeholders of this document and strongly advocated for clinical trial purposes. This Academic Research Consortium-2 document provides further standardization of end point definitions for coronary device trials, incorporating advances in technology and knowledge. Their use will aid interpretation of trial outcomes and comparison among studies, thus facilitating the evaluation of the safety and effectiveness of these devices.

Circulation: 11 Jun 2018; 137:2635-2650
Garcia-Garcia HM, McFadden EP, Farb A, Mehran R, ... Serruys PW,
Circulation: 11 Jun 2018; 137:2635-2650 | PMID: 29891620
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Abstract

Hypertension Across a Woman\'s Life Cycle.

Wenger NK, Arnold A, Bairey Merz CN, Cooper-DeHoff RM, ... Walsh MN, Pepine CJ
Hypertension accounts for 1 in 5 deaths among American women, posing a greater burden for women than men, and is among their most important risk factors for death and development of cardiovascular and other diseases. Hypertension affects women in all phases of life, with specific characteristics relating to risk factors and management for primary prevention of hypertension in teenage and young adult women; hypertension in pregnancy; hypertension during use of oral contraceptives and assisted reproductive technologies, lactation, menopause, or hormone replacement; hypertension in elderly women; and issues of race and ethnicity. All are detailed in this review, as is information relative to women in clinical trials of hypertension and medication issues. The overarching message is that effective treatment and control of hypertension improves cardiovascular outcomes. But many knowledge gaps persist, including the contribution of hypertensive disorders of pregnancy to cardiovascular disease risk, the role of hormone replacement, blood pressure targets for elderly women, and so on.

J Am Coll Cardiol: 23 Apr 2018; 71:1797-1813
Wenger NK, Arnold A, Bairey Merz CN, Cooper-DeHoff RM, ... Walsh MN, Pepine CJ
J Am Coll Cardiol: 23 Apr 2018; 71:1797-1813 | PMID: 29673470
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Abstract

Projected Costs of Informal Caregiving for Cardiovascular Disease: 2015 to 2035: A Policy Statement From the American Heart Association.

Dunbar SB, Khavjou OA, Bakas T, Hunt G, ... Roger VL, Whitsel LP
In a recent report, the American Heart Association estimated that medical costs and productivity losses of cardiovascular disease (CVD) are expected to grow from $555 billion in 2015 to $1.1 trillion in 2035. Although the burden is significant, the estimate does not include the costs of family, informal, or unpaid caregiving provided to patients with CVD. In this analysis, we estimated projections of costs of informal caregiving attributable to CVD for 2015 to 2035.

Circulation: 08 Apr 2018; epub ahead of print
Dunbar SB, Khavjou OA, Bakas T, Hunt G, ... Roger VL, Whitsel LP
Circulation: 08 Apr 2018; epub ahead of print | PMID: 29632217
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Abstract

Risk Stratification of Genetic, Dilated Cardiomyopathies Associated With Neuromuscular Disorders: Role of Cardiac Imaging.

van der Bijl P, Delgado V, Bootsma M, Bax JJ
The etiology of dilated cardiomyopathy (DCM) can be grouped as either genetic or nongenetic. More than 50 pathogenic genes have been described, with sarcomeric and lamin A/C mutations being the most common. Mutation carriers for genetic DCM are often asymptomatic until cardiac disease manifests with heart failure, arrhythmias, or sudden cardiac death. Preventive strategies are promising but can only be applied and tested adequately if genetic DCM can be diagnosed at an early stage. Early diagnosis of mutation carriers that may develop overt DCM requires advanced imaging techniques that can detect subtle structural and functional abnormalities. Advanced echocardiographic techniques such as tissue Doppler imaging and speckle tracking strain analysis permit early detection of functional abnormalities, whereas cardiovascular magnetic resonance techniques provide information on tissue characterization and myocardial energetics that may be altered at an early stage. Furthermore, nuclear imaging techniques provide information on cellular function (metabolism, perfusion). Once the diagnosis of overt DCM has been established, various imaging parameters such as echocardiography-based myocardial mechanics and cardiovascular magnetic resonance-based tissue characterization have shown incremental benefit to left ventricular ejection fraction in risk stratification. Further research is required to understand how imaging techniques may help to choose management strategies that could delay progression when instituted early in the course of the disease. The present article reviews the role of imaging in the risk stratification of genetic DCM in general, with specific emphasis on DCM associated with neuromuscular disorders.

Circulation: 04 Jun 2018; 137:2514-2527
van der Bijl P, Delgado V, Bootsma M, Bax JJ
Circulation: 04 Jun 2018; 137:2514-2527 | PMID: 29866775
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Abstract

Multimorbidity in Older Adults With Cardiovascular Disease.

Forman DE, Maurer MS, Boyd C, Brindis R, ... Zieman S, Rich MW
Multimorbidity occurs in adults of all ages, but the number and complexity of comorbid conditions commonly increase with advancing age such that cardiovascular disease (CVD) in older adults typically occurs in a context of multimorbidity. Current clinical practice and research mainly target single disease-specific care that does not embrace the complexities imposed by concurrent conditions. In this paper, emerging concepts regarding CVD in combination with multimorbidity are reviewed, including recommendations for incorporating multimorbidity into clinical decision making, critical knowledge gaps, and research priorities to optimize care of complex older patients.

J Am Coll Cardiol: 14 May 2018; 71:2149-2161
Forman DE, Maurer MS, Boyd C, Brindis R, ... Zieman S, Rich MW
J Am Coll Cardiol: 14 May 2018; 71:2149-2161 | PMID: 29747836
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Abstract

Cardiovascular Diseases in India Compared With the United States.

Prabhakaran D, Singh K, Roth GA, Banerjee A, Pagidipati NJ, Huffman MD
This review describes trends in the burden of cardiovascular diseases (CVDs) and risk factors in India compared with the United States; provides potential explanations for these differences; and describes strategies to improve cardiovascular health behaviors, systems, and policies in India. The prevalence of CVD in India has risen over the past 2 decades due to population growth, aging, and a stable age-adjusted CVD mortality rate. Over the same time period, the United States has experienced an overall decline in age-adjusted CVD mortality, although the trend has begun to plateau. These improvements in CVD mortality in the United States are largely due to favorable population-level risk factor trends, specifically with regard to tobacco use, cholesterol, and blood pressure, although improvements in secondary prevention and acute care have also contributed. To realize similar gains in reducing premature death and disability from CVD, India needs to implement population-level policies while strengthening and integrating its local, regional, and national health systems. Achieving universal health coverage that includes financial risk protection should remain a goal to help all Indians realize their right to health.

J Am Coll Cardiol: 02 Jul 2018; 72:79-95
Prabhakaran D, Singh K, Roth GA, Banerjee A, Pagidipati NJ, Huffman MD
J Am Coll Cardiol: 02 Jul 2018; 72:79-95 | PMID: 29957235
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Abstract

Mobile Health Advances in Physical Activity, Fitness, and Atrial Fibrillation: Moving Hearts.

McConnell MV, Turakhia MP, Harrington RA, King AC, Ashley EA
The growing recognition that \"health\" takes place outside of the hospital and clinic, plus recent advances in mobile and wearable devices, have propelled the field of mobile health (mHealth). Cardiovascular disease and prevention are major opportunities for mHealth, as mobile devices can monitor key physiological signals (e.g., physical activity, heart rate and rhythm) for promoting healthy behaviors, detecting disease, and aid in ongoing care. In this review, the authors provide an update on cardiovascular mHealth by highlighting recent progress and challenges with mobile and wearable devices for assessing and promoting physical activity and fitness, and for monitoring heart rate and rhythm for the detection and management of atrial fibrillation.

J Am Coll Cardiol: 11 Jun 2018; 71:2691-2701
McConnell MV, Turakhia MP, Harrington RA, King AC, Ashley EA
J Am Coll Cardiol: 11 Jun 2018; 71:2691-2701 | PMID: 29880130
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Abstract

Cardiovascular Outcomes Reported in Hemodialysis Trials.

O\'Lone E, Viecelli AK, Craig JC, Tong A, ... Webster AC, Wheeler DC
Patients on long-term hemodialysis are at very high risk for cardiovascular disease but are usually excluded from clinical trials conducted in the general population or in at-risk populations. There are no universally agreed cardiovascular outcomes for trials conducted specifically in the hemodialysis population. In this review, we highlight that trials reporting cardiovascular outcomes in hemodialysis patients are usually of short duration (median 3 to 6 months) and are small (59% of trials have <100 participants). Overall, the cardiovascular outcomes are very heterogeneous and may not reflect outcomes that are meaningful to patients and clinicians in supporting decision making, as they are often surrogates of uncertain clinical importance. Composite outcomes used in different trials rarely share the same components. In a field in which a single trial is often insufficiently powered to fully assess the clinical and economic impact of interventions, differences in outcome reporting across trials make the task of meta-analysis and interpretation of all the available evidence challenging. Core outcome sets are now being established across many specialties in health care to prevent these problems. Through the global Standardized Outcomes in Nephrology-Hemodialysis initiative, cardiovascular disease was identified as a critically important core domain to be reported in all trials in hemodialysis. Informed by the current state of reporting of cardiovascular outcomes, a core outcome measure for cardiovascular disease is currently being established with involvement of patients, caregivers, and health professionals. Consistent reporting of cardiovascular outcomes that are critically important to hemodialysis patients and clinicians will strengthen the evidence base to inform care in this very high-risk population.

J Am Coll Cardiol: 18 Jun 2018; 71:2802-2810
O'Lone E, Viecelli AK, Craig JC, Tong A, ... Webster AC, Wheeler DC
J Am Coll Cardiol: 18 Jun 2018; 71:2802-2810 | PMID: 29903353
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Abstract

Artificial Intelligence in Cardiology.

Johnson KW, Torres Soto J, Glicksberg BS, Shameer K, ... Ashley E, Dudley JT
Artificial intelligence and machine learning are poised to influence nearly every aspect of the human condition, and cardiology is not an exception to this trend. This paper provides a guide for clinicians on relevant aspects of artificial intelligence and machine learning, reviews selected applications of these methods in cardiology to date, and identifies how cardiovascular medicine could incorporate artificial intelligence in the future. In particular, the paper first reviews predictive modeling concepts relevant to cardiology such as feature selection and frequent pitfalls such as improper dichotomization. Second, it discusses common algorithms used in supervised learning and reviews selected applications in cardiology and related disciplines. Third, it describes the advent of deep learning and related methods collectively called unsupervised learning, provides contextual examples both in general medicine and in cardiovascular medicine, and then explains how these methods could be applied to enable precision cardiology and improve patient outcomes.

J Am Coll Cardiol: 11 Jun 2018; 71:2668-2679
Johnson KW, Torres Soto J, Glicksberg BS, Shameer K, ... Ashley E, Dudley JT
J Am Coll Cardiol: 11 Jun 2018; 71:2668-2679 | PMID: 29880128
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Abstract

The Role of Nutraceuticals in Statin Intolerant Patients.

Banach M, Patti AM, Giglio RV, Cicero AFG, ... Rizzo M,
Statins are the most common drugs administered for patients with cardiovascular disease. However, due to statin-associated muscle symptoms, adherence to statin therapy is challenging in clinical practice. Certain nutraceuticals, such as red yeast rice, bergamot, berberine, artichoke, soluble fiber, and plant sterols and stanols alone or in combination with each other, as well as with ezetimibe, might be considered as an alternative or add-on therapy to statins, although there is still insufficient evidence available with respect to long-term safety and effectiveness on cardiovascular disease prevention and treatment. These nutraceuticals could exert significant lipid-lowering activity and might present multiple non-lipid-lowering actions, including improvement of endothelial dysfunction and arterial stiffness, as well as anti-inflammatory and antioxidative properties. The aim of this expert opinion paper is to provide the first attempt at recommendation on the management of statin intolerance through the use of nutraceuticals with particular attention on those with effective low-density lipoprotein cholesterol reduction.

J Am Coll Cardiol: 02 Jul 2018; 72:96-118
Banach M, Patti AM, Giglio RV, Cicero AFG, ... Rizzo M,
J Am Coll Cardiol: 02 Jul 2018; 72:96-118 | PMID: 29957236
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Abstract

Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention: A Scientific Statement From the American Heart Association.

Magnani JW, Mujahid MS, Aronow HD, Cené CW, ... Willey JZ,
Health literacy is the degree to which individuals are able to access and process basic health information and services and thereby participate in health-related decisions. Limited health literacy is highly prevalent in the United States and is strongly associated with patient morbidity, mortality, healthcare use, and costs. The objectives of this American Heart Association scientific statement are (1) to summarize the relevance of health literacy to cardiovascular health; (2) to present the adverse associations of health literacy with cardiovascular risk factors, conditions, and treatments; (3) to suggest strategies that address barriers imposed by limited health literacy on the management and prevention of cardiovascular disease; (4) to demonstrate the contributions of health literacy to health disparities, given its association with social determinants of health; and (5) to propose future directions for how health literacy can be integrated into the American Heart Association\'s mandate to advance cardiovascular treatment and research, thereby improving patient care and public health. Inadequate health literacy is a barrier to the American Heart Association meeting its 2020 Impact Goals, and this statement articulates the rationale to anticipate and address the adverse cardiovascular effects associated with health literacy.

Circulation: 03 Jun 2018; epub ahead of print
Magnani JW, Mujahid MS, Aronow HD, Cené CW, ... Willey JZ,
Circulation: 03 Jun 2018; epub ahead of print | PMID: 29866648
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Abstract

Anemia and Iron Deficiency in Heart Failure: Current Concepts and Emerging Therapies.

Anand IS, Gupta P
Anemia and iron deficiency are important and common comorbidities that often coexist in patients with heart failure. Both conditions, together or independently, are associated with poor clinical status and worse outcomes. Whether anemia and iron deficiency are just markers of heart failure severity or whether they mediate heart failure progression and outcomes and therefore should be treated is not entirely clear. Treatment of anemia in patients with heart failure with erythropoiesis-stimulating agents has been evaluated intensively during the past several years. Unfortunately, these agents did not improve outcomes but were associated with a higher risk of adverse events. Iron deficiency in patients with heart failure can be absolute, when total body iron is decreased, or functional, when total body iron is normal or increased but is inadequate to meet the needs of target tissues because of sequestration in the storage pool. Whereas iron replacement is appropriate in patients with anemia resulting from absolute iron deficiency, it has been unclear whether and how absolute or functional iron deficiency should be treated in nonanemic patients with heart failure. Recently, small studies found that administration of intravenous iron in patients with heart failure and absolute or functional iron deficiency with or without anemia improves symptoms and exercise capacity, but long-term outcomes and safety data are not yet available. In this review, we discuss the causes and pathogenesis of and treatment options for anemia and iron deficiency in patients with heart failure.

Circulation: 02 Jul 2018; 138:80-98
Anand IS, Gupta P
Circulation: 02 Jul 2018; 138:80-98 | PMID: 29967232
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Abstract

Validity of inducible ischaemia as a surrogate for adverse outcomes in stable coronary artery disease.

Timmis A, Raharja A, Archbold RA, Mathur A
Regional myocardial ischaemia is commonly expressed as exertional angina in patients with stable coronary artery disease (CAD). It also associates with prognosis, risk tending to increase with the severity of ischaemia. The validity of myocardial ischaemia as a surrogate for adverse clinical outcomes, however, has not been well established. Thus, in cohort studies, ischaemia testing has failed to influence rates of myocardial infarction and coronary death. Moreover, in clinical studies, pharmacological and interventional treatments that are effective in correcting ischaemia have rarely been shown to reduce cardiovascular (CV) risk. This contrasts with statins and other anti-inflammatory drugs that have no direct effect on ischaemia but improve CV outcomes by modifying the atherothrombotic disease process. Despite this, and with little evidence of patient benefit, stress testing is commonly used during the follow-up of patients with stable CAD when the demonstration of ischaemic change may be seen as a target for treatment, independently of symptomatic status. Substitution of a symptom-driven management strategy has the potential to reduce rates of non-invasive stress testing, unnecessary downstream revascularisation procedures and use of valuable resources in patients with stable CAD without adverse consequences for CV risk.

Heart: 30 Oct 2018; 104:1733-1738
Timmis A, Raharja A, Archbold RA, Mathur A
Heart: 30 Oct 2018; 104:1733-1738 | PMID: 29875140
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Abstract

Supplemental Vitamins and Minerals for CVD Prevention and Treatment.

Jenkins DJA, Spence JD, Giovannucci EL, Kim YI, ... Pichika SC, Sievenpiper JL
The authors identified individual randomized controlled trials from previous meta-analyses and additional searches, and then performed meta-analyses on cardiovascular disease outcomes and all-cause mortality. The authors assessed publications from 2012, both before and including the U.S. Preventive Service Task Force review. Their systematic reviews and meta-analyses showed generally moderate- or low-quality evidence for preventive benefits (folic acid for total cardiovascular disease, folic acid and B-vitamins for stroke), no effect (multivitamins, vitamins C, D, β-carotene, calcium, and selenium), or increased risk (antioxidant mixtures and niacin [with a statin] for all-cause mortality). Conclusive evidence for the benefit of any supplement across all dietary backgrounds (including deficiency and sufficiency) was not demonstrated; therefore, any benefits seen must be balanced against possible risks.

J Am Coll Cardiol: 04 Jun 2018; 71:2570-2584
Jenkins DJA, Spence JD, Giovannucci EL, Kim YI, ... Pichika SC, Sievenpiper JL
J Am Coll Cardiol: 04 Jun 2018; 71:2570-2584 | PMID: 29852980
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Abstract

Cardiovascular Disease and Homelessness.

Baggett TP, Liauw SS, Hwang SW
Cardiovascular disease (CVD) is a major cause of death among homeless adults, at rates that exceed those in nonhomeless individuals. A complex set of factors contributes to this disparity. In addition to a high prevalence of cigarette smoking and suboptimal control of traditional CVD risk factors such as hypertension and diabetes, a heavy burden of nontraditional psychosocial risk factors like chronic stress, depression, heavy alcohol use, and cocaine use may confer additional risk for adverse CVD outcomes beyond that predicted by conventional risk estimation methods. Poor health care access and logistical challenges to cardiac testing may lead to delays in presentation and diagnosis. The management of established CVD may be further challenged by barriers to medication adherence, communication, and timely follow-up. The authors present practical, patient-centered strategies for addressing these challenges, emphasizing the importance of multidisciplinary collaboration and partnership with homeless-tailored clinical programs to improve CVD outcomes in this population.

J Am Coll Cardiol: 04 Jun 2018; 71:2585-2597
Baggett TP, Liauw SS, Hwang SW
J Am Coll Cardiol: 04 Jun 2018; 71:2585-2597 | PMID: 29852981
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Abstract

Sex Differences in Cardiovascular Pathophysiology: Why Women Are Overrepresented in Heart Failure With Preserved Ejection Fraction.

Beale AL, Meyer P, Marwick TH, Lam CSP, Kaye DM
Consistent epidemiological data demonstrate that patients with heart failure with preserved ejection fraction (HFpEF) are more likely to be women than men. Exploring mechanisms behind this sex difference in heart failure epidemiology may enrich the understanding of underlying HFpEF pathophysiology and phenotypes, with the ultimate goal of identifying therapeutic approaches for the broader HFpEF population. In this review we evaluate the influence of sex on the key domains of cardiac structure and function, the systemic and pulmonary circulation, as well as extracardiac factors and comorbidities that may explain the predisposition of women to HFpEF. We highlight the potential role of factors exclusive to or more prevalent in women such as pregnancy, preeclampsia, and iron deficiency. Finally, we discuss existing controversies and gaps in knowledge, as well as the clinical importance of known sex differences in the context of the potential need for sex-specific diagnostic criteria, improved risk stratification models, and targeted therapies.

Circulation: 09 Jul 2018; 138:198-205
Beale AL, Meyer P, Marwick TH, Lam CSP, Kaye DM
Circulation: 09 Jul 2018; 138:198-205 | PMID: 29986961
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Abstract

Use of Intracardiac Echocardiography in Interventional Cardiology: Working With the Anatomy Rather Than Fighting It.

Enriquez A, Saenz LC, Rosso R, Silvestry FE, ... Marchlinski FE, Garcia F
The indications for catheter-based structural and electrophysiological procedures have recently expanded to more complex scenarios, in which an accurate definition of the variable individual cardiac anatomy is key to obtain optimal results. Intracardiac echocardiography (ICE) is a unique imaging modality able to provide high-resolution real-time visualization of cardiac structures, continuous monitoring of catheter location within the heart, and early recognition of procedural complications, such as pericardial effusion or thrombus formation. Additional benefits are excellent patient tolerance, reduction of fluoroscopy time, and lack of need for general anesthesia or a second operator. For these reasons, ICE has largely replaced transesophageal echocardiography as ideal imaging modality for guiding certain procedures, such as atrial septal defect closure and catheter ablation of cardiac arrhythmias, and has an emerging role in others, including mitral valvuloplasty, transcatheter aortic valve replacement, and left atrial appendage closure. In electrophysiology procedures, ICE allows integration of real-time images with electroanatomic maps; it has a role in assessment of arrhythmogenic substrate, and it is particularly useful for mapping structures that are not visualized by fluoroscopy, such as the interatrial or interventricular septum, papillary muscles, and intracavitary muscular ridges. Most recently, a three-dimensional (3D) volumetric ICE system has also been developed, with potential for greater anatomic information and a promising role in structural interventions. In this state-of-the-art review, we provide guidance on how to conduct a comprehensive ICE survey and summarize the main applications of ICE in a variety of structural and electrophysiology procedures.

Circulation: 21 May 2018; 137:2278-2294
Enriquez A, Saenz LC, Rosso R, Silvestry FE, ... Marchlinski FE, Garcia F
Circulation: 21 May 2018; 137:2278-2294 | PMID: 29784681
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Abstract

Seafood Long-Chain n-3 Polyunsaturated Fatty Acids and Cardiovascular Disease: A Science Advisory From the American Heart Association.

Rimm EB, Appel LJ, Chiuve SE, Djoussé L, ... Lichtenstein AH,
Since the 2002 American Heart Association scientific statement \"Fish Consumption, Fish Oil, Omega-3 Fatty Acids, and Cardiovascular Disease,\" evidence from observational and experimental studies and from randomized controlled trials continues to emerge to further substantiate the beneficial effects of seafood long-chain n-3 polyunsaturated fatty acids and cardiovascular disease. A recent American Heart Association science advisory addressed the specific effect of n-3 polyunsaturated fatty acid supplementation on clinical cardiovascular events. This American Heart Association science advisory extends that review and offers further support to include n-3 polyunsaturated fatty acids from seafood consumption. Several potential mechanisms have been investigated, including antiarrhythmic, anti-inflammatory, hematologic, and endothelial, although for most, longer-term dietary trials of seafood are warranted to substantiate the benefit of seafood as a replacement for other important sources of macronutrients. The present science advisory reviews this evidence and makes a suggestion in the context of the and in consideration of other constituents of seafood and the impact on sustainability. We conclude that 1 to 2 seafood meals per week be included to reduce the risk of congestive heart failure, coronary heart disease, ischemic stroke, and sudden cardiac death, especially when seafood replaces the intake of less healthy foods.

Circulation: 16 May 2018; epub ahead of print
Rimm EB, Appel LJ, Chiuve SE, Djoussé L, ... Lichtenstein AH,
Circulation: 16 May 2018; epub ahead of print | PMID: 29773586
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Abstract

Deciphering the Role of Lipid Droplets in Cardiovascular Disease: A Report From the 2017 National Heart, Lung, and Blood Institute Workshop.

Goldberg IJ, Reue K, Abumrad NA, Bickel PE, ... Walther TC, Chen J
Lipid droplets (LDs) are distinct and dynamic organelles that affect the health of cells and organs. Much progress has been made in understanding how these structures are formed, how they interact with other cellular organelles, how they are used for storage of triacylglycerol in adipose tissue, and how they regulate lipolysis. Our understanding of the biology of LDs in the heart and vascular tissue is relatively primitive in comparison with LDs in adipose tissue and liver. The National Heart, Lung, and Blood Institute convened a working group to discuss how LDs affect cardiovascular diseases. The goal of the working group was to examine the current state of knowledge on the cell biology of LDs, including current methods to study them in cells and organs and reflect on how LDs influence the development and progression of cardiovascular diseases. This review summarizes the working group discussion and recommendations on research areas ripe for future investigation that will likely improve our understanding of atherosclerosis and heart function.

Circulation: 16 Jul 2018; 138:305-315
Goldberg IJ, Reue K, Abumrad NA, Bickel PE, ... Walther TC, Chen J
Circulation: 16 Jul 2018; 138:305-315 | PMID: 30012703
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Abstract

Transcatheter Tricuspid Valve Interventions: Landscape, Challenges, and Future Directions.

Asmarats L, Puri R, Latib A, Navia JL, Rodés-Cabau J
Tricuspid regurgitation is a common finding in patients with left-sided valvular or myocardial disease, often being a marker for late-stage chronic heart failure with a grim prognosis. However, isolated tricuspid valve surgery remains infrequent and is associated with the highest mortality among all valve procedures. Hence, a largely unmet clinical need exists for less invasive therapeutic options in these patients. In recent times, multiple percutaneous therapies have been developed for treating severe tricuspid regurgitation, including tricuspid valve repair and, more recently replacement, opening an entirely new venue for managing tricuspid regurgitation. The aim of this review is to provide an updated overview and a clinical perspective on novel transcatheter tricuspid valve therapies, highlighting potential challenges and future directions.

J Am Coll Cardiol: 25 Jun 2018; 71:2935-2956
Asmarats L, Puri R, Latib A, Navia JL, Rodés-Cabau J
J Am Coll Cardiol: 25 Jun 2018; 71:2935-2956 | PMID: 29929618
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Abstract

Energetics of Blood Flow in Cardiovascular Disease: Concept and Clinical Implications of Adverse Energetics in Patients With a Fontan Circulation.

Rijnberg FM, Hazekamp MG, Wentzel JJ, de Koning PJH, ... Blom NA, Roest AAW
Visualization and quantification of the adverse effects of distorted blood flow are important emerging fields in cardiology. Abnormal blood flow patterns can be seen in various cardiovascular diseases and are associated with increased energy loss. These adverse energetics can be measured and quantified using 3-dimensional blood flow data, derived from computational fluid dynamics and 4-dimensional flow magnetic resonance imaging, and provide new, promising hemodynamic markers. In patients with palliated single-ventricular heart defects, the Fontan circulation passively directs systemic venous return to the pulmonary circulation in the absence of a functional subpulmonary ventricle. Therefore, the Fontan circulation is highly dependent on favorable flow and energetics, and minimal energy loss is of great importance. A focus on reducing energy loss led to the introduction of the total cavopulmonary connection (TCPC) as an alternative to the classical Fontan connection. Subsequently, many studies have investigated energy loss in the TCPC, and energy-saving geometric factors have been implemented in clinical care. Great advances have been made in computational fluid dynamics modeling and can now be done in 3-dimensional patient-specific models with increasingly accurate boundary conditions. Furthermore, the implementation of 4-dimensional flow magnetic resonance imaging is promising and can be of complementary value to these models. Recently, correlations between energy loss in the TCPC and cardiac parameters and exercise intolerance have been reported. Furthermore, efficiency of blood flow through the TCPC is highly variable, and inefficient blood flow is of clinical importance by reducing cardiac output and increasing central venous pressure, thereby increasing the risk of experiencing the well-known Fontan complications. Energy loss in the TCPC will be an important new hemodynamic parameter in addition to other well-known risk factors such as pulmonary vascular resistance and can possibly be improved by patient-specific surgical design. This article describes the theoretical background of mechanical energy of blood flow in the cardiovascular system and the methods of calculating energy loss, and it gives an overview of geometric factors associated with energy efficiency in the TCPC and its implications on clinical outcome. Furthermore, the role of 4-dimensional flow magnetic resonance imaging and areas of future research are discussed.

Circulation: 28 May 2018; 137:2393-2407
Rijnberg FM, Hazekamp MG, Wentzel JJ, de Koning PJH, ... Blom NA, Roest AAW
Circulation: 28 May 2018; 137:2393-2407 | PMID: 29844073
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Abstract

Epicardial Adipose Tissue May Mediate Deleterious Effects of Obesity and Inflammation on the Myocardium.

Packer M
Epicardial adipose tissue has unique properties that distinguish it from other depots of visceral fat. Rather than having distinct boundaries, the epicardium shares an unobstructed microcirculation with the underlying myocardium, and in healthy conditions, produces cytokines that nourish the heart. However, in chronic inflammatory disorders (especially those leading to heart failure with preserved ejection fraction), the epicardium becomes a site of deranged adipogenesis, leading to the secretion of proinflammatory adipokines that can cause atrial and ventricular fibrosis. Accordingly, in patients at risk of heart failure with preserved ejection fraction, drugs that promote the accumulation or inflammation of epicardial adipocytes may lead to heart failure, whereas treatments that ameliorate the proinflammatory characteristics of epicardial fat may reduce the risk of heart failure. These observations suggest that epicardial adipose tissue is a transducer of the adverse effects of systemic inflammation and metabolic disorders on the heart, and thus, represents an important target for therapeutic interventions.

J Am Coll Cardiol: 21 May 2018; 71:2360-2372
Packer M
J Am Coll Cardiol: 21 May 2018; 71:2360-2372 | PMID: 29773163
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Abstract

The Changing Landscape of Diabetes Therapy for Cardiovascular Risk Reduction: JACC State-of-the-Art Review.

Newman JD, Vani AK, Aleman JO, Weintraub HS, Berger JS, Schwartzbard AZ
Type 2 diabetes mellitus (T2D) is a major risk factor for cardiovascular disease (CVD), the most common cause of death in T2D. Despite improved risk factor control, however, adults with T2D continue to experience substantial excess CVD risk. Until recently, however, improved glycemic control has not been associated with robust macrovascular benefit. The advent of 2 new classes of antihyperglycemic agents, the sodium-glucose cotransporter-2 inhibitors and the glucagon-like peptide-1 receptor agonists, and their respective large cardiovascular outcome trials, has led to a paradigm shift in how cardiologists and heath care practitioners conceptualize T2D treatment. Herein, the authors review the recent trial evidence, the potential mechanisms of action of the sodium-glucose cotransporter-2 inhibitors and the glucagon-like peptide-1 receptor agonists, safety concerns, and their use for the primary prevention of CVD as well as in diabetic patients with impaired renal function and heart failure.

J Am Coll Cardiol: 08 Oct 2018; 72:1856-1869
Newman JD, Vani AK, Aleman JO, Weintraub HS, Berger JS, Schwartzbard AZ
J Am Coll Cardiol: 08 Oct 2018; 72:1856-1869 | PMID: 30286929
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Abstract

Psychopharmacology and Cardiovascular Disease.

Piña IL, Di Palo KE, Ventura HO
This review discusses common mental health disorders and their associations with cardiovascular disease risks. Commonly found mental health disorders include depression, anxiety, and personality types. The link between depression and cardiovascular disease mortality has been established. Depression is also common in patients with heart failure. In addition to discussing psychological disorders, a review of psychotropic drugs is also included. Drugs are described for therapy for depression and anxiety, as well as associations with cardiovascular drug-drug interactions. Drug-drug interactions are more common and potentially dangerous in elderly patients, in whom the conditions often coexist. The most common drug-drug interactions involve the P450 system of enzymes.

J Am Coll Cardiol: 21 May 2018; 71:2346-2359
Piña IL, Di Palo KE, Ventura HO
J Am Coll Cardiol: 21 May 2018; 71:2346-2359 | PMID: 29773162
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Abstract

Blood Sugar Regulation for Cardiovascular Health Promotion and Disease Prevention: JACC Health Promotion Series.

Schwarz PEH, Timpel P, Harst L, Greaves CJ, ... Almedawar MM, Morawietz H
The primary objective of this study was to analyze the most up-to-date evidence regarding whether and how blood sugar regulation influences cardiovascular health promotion and disease prevention by carrying out an umbrella review. Three separate, systematic literature searches identified 2,343 papers in total. Overall, 44 studies were included for data extraction and analysis. The included systematic reviews and meta-analyses published between January 1, 2016, and December 31, 2017, were of good to very good quality (median Overview Quality Assessment Questionnaire score = 17). Identified evidence suggests that cardiovascular disease (CVD) prevention services should consider regulation of blood glucose as a key target for intervention. Furthermore, the recommendations for effective intervention and service development/training described here for prevention of CVD should be adopted into evidence-based practice guidelines. Multidisciplinary teams should be formed to deliver multicomponent interventions in community-based settings. There may be substantial opportunities for integrating CVD and diabetes prevention services.

J Am Coll Cardiol: 08 Oct 2018; 72:1829-1844
Schwarz PEH, Timpel P, Harst L, Greaves CJ, ... Almedawar MM, Morawietz H
J Am Coll Cardiol: 08 Oct 2018; 72:1829-1844 | PMID: 30286928
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Abstract

Stress Cardiomyopathy Diagnosis and Treatment: JACC State-of-the-Art Review.

Medina de Chazal H, Del Buono MG, Keyser-Marcus L, Ma L, ... Berrocal D, Abbate A
Stress cardiomyopathy is an acute reversible heart failure syndrome initially believed to represent a benign condition due to its self-limiting clinical course, but now recognized to be associated with a non-negligible rate of serious complications such as ventricular arrhythmias, systemic thromboembolism, and cardiogenic shock. Due to an increased awareness and recognition, the incidence of stress cardiomyopathy has been rising (15-30 cases per 100,000 per year), although the true incidence is unknown as the condition is likely underdiagnosed. Stress cardiomyopathy represents a form of neurocardiogenic myocardial stunning, and while the link between the brain and the heart is established, the exact pathophysiological mechanisms remain unclear. We herein review the proposed risk factors and triggers for the syndrome and discuss a practical approach to diagnosis and treatment of the patients with stress cardiomyopathy, highlighting potential challenges and unresolved questions.

J Am Coll Cardiol: 15 Oct 2018; 72:1955-1971
Medina de Chazal H, Del Buono MG, Keyser-Marcus L, Ma L, ... Berrocal D, Abbate A
J Am Coll Cardiol: 15 Oct 2018; 72:1955-1971 | PMID: 30309474
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Abstract

Atherosclerotic Cardiovascular Disease in South Asians in the United States: Epidemiology, Risk Factors, and Treatments: A Scientific Statement From the American Heart Association.

Volgman AS, Palaniappan LS, Aggarwal NT, Gupta M, ... Watson KE,
South Asians (from Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka) make up one quarter of the world\'s population and are one of the fastest-growing ethnic groups in the United States. Although native South Asians share genetic and cultural risk factors with South Asians abroad, South Asians in the United States can differ in socioeconomic status, education, healthcare behaviors, attitudes, and health insurance, which can affect their risk and the treatment and outcomes of atherosclerotic cardiovascular disease (ASCVD). South Asians have higher proportional mortality rates from ASCVD compared with other Asian groups and non-Hispanic whites, in contrast to the finding that Asian Americans (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) aggregated as a group are at lower risk of ASCVD, largely because of the lower risk observed in East Asian populations. Literature relevant to South Asian populations regarding demographics and risk factors, health behaviors, and interventions, including physical activity, diet, medications, and community strategies, is summarized. The evidence to date is that the biology of ASCVD is complex but is no different in South Asians than in any other racial/ethnic group. A majority of the risk in South Asians can be explained by the increased prevalence of known risk factors, especially those related to insulin resistance, and no unique risk factors in this population have been found. This scientific statement focuses on how ASCVD risk factors affect the South Asian population in order to make recommendations for clinical strategies to reduce disease and for directions for future research to reduce ASCVD in this population.

Circulation: 23 May 2018; epub ahead of print
Volgman AS, Palaniappan LS, Aggarwal NT, Gupta M, ... Watson KE,
Circulation: 23 May 2018; epub ahead of print | PMID: 29794080
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Abstract

Cardiac Shock Care Centers: JACC Review Topic of the Week.

Rab T, Ratanapo S, Kern KB, Basir MB, ... King SB, O\'Neill W
Despite advances over the past decade, the incidence of cardiogenic shock secondary to acute myocardial infarction has increased, with an unchanged mortality near 50%. Recent trials have not clarified the best strategies in treatment. While dedicated cardiac shock centers are being established, there are no standardized agreements on the utilization of mechanical circulatory support and the timeliness of percutaneous coronary intervention strategies. In some centers and prospective registries, outcomes after placement of advanced mechanical circulatory support prior to reperfusion therapy with percutaneous coronary intervention have been encouraging with improved survival. Here, we suggest systems of care with a treatment pathway for patients with acute myocardial infarction complicated by cardiogenic shock.

J Am Coll Cardiol: 15 Oct 2018; 72:1972-1980
Rab T, Ratanapo S, Kern KB, Basir MB, ... King SB, O'Neill W
J Am Coll Cardiol: 15 Oct 2018; 72:1972-1980 | PMID: 30309475
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Abstract

Heart failure with preserved ejection fraction: controversies, challenges and future directions.

Zakeri R, Cowie MR
Heart failure with preserved ejection fraction (HFpEF) comprises almost half of the population burden of HF. Because HFpEF likely includes a range of cardiac and non-cardiac abnormalities, typically in elderly patients, obtaining an accurate diagnosis may be challenging, not least due to the existence of multiple HFpEF mimics and a newly identified subset of patients with HFpEF and normal plasma natriuretic peptide concentrations. The lack of effective treatment for these patients represents a major unmet clinical need. Heterogeneity within the patient population has triggered debate over the aetiology and pathophysiology of HFpEF, and the neutrality of randomised clinical trials suggests that we do not fully understand the syndrome(s). Dysregulated nitric oxide-cyclic guanosine monophosphate-protein kinase G signalling, driven by comorbidities and ageing, may be the fundamental abnormality in HFpEF, resulting in a systemic inflammatory state and microvascular endothelial dysfunction. Novel informatics platforms are also being used to classify HFpEF into subphenotypes, based on statistically clustered clinical and biological characteristics: whether such subclassification will lead to more targeted therapies remains to be seen. In this review, we summarise current concepts and controversies, and highlight the diagnostic and therapeutic challenges in clinical practice. Novel treatments and disease management strategies are discussed, and the large gaps in our knowledge identified.

Heart: 04 Jan 2018; epub ahead of print
Zakeri R, Cowie MR
Heart: 04 Jan 2018; epub ahead of print | PMID: 29305560
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Abstract

Coronary Calcium Score and Cardiovascular Risk.

Greenland P, Blaha MJ, Budoff MJ, Erbel R, Watson KE
Coronary artery calcium (CAC) is a highly specific feature of coronary atherosclerosis. On the basis of single-center and multicenter clinical and population-based studies with short-term and long-term outcomes data (up to 15-year follow-up), CAC scoring has emerged as a widely available, consistent, and reproducible means of assessing risk for major cardiovascular outcomes, especially useful in asymptomatic people for planning primary prevention interventions such as statins and aspirin. CAC testing in asymptomatic populations is cost effective across a broad range of baseline risk. This review summarizes evidence concerning CAC, including its pathobiology, modalities for detection, predictive role, use in prediction scoring algorithms, CAC progression, evidence that CAC changes the clinical approach to the patient and patient behavior, novel applications of CAC, future directions in scoring CAC scans, and new CAC guidelines.

J Am Coll Cardiol: 23 Jul 2018; 72:434-447
Greenland P, Blaha MJ, Budoff MJ, Erbel R, Watson KE
J Am Coll Cardiol: 23 Jul 2018; 72:434-447 | PMID: 30025580
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Abstract

Antithrombotic Therapy for Peripheral Artery Disease: Recent Advances.

Hussain MA, Al-Omran M, Creager MA, Anand SS, Verma S, Bhatt DL
Peripheral artery disease (PAD) affects over 200 million people globally and is a cause of significant morbidity, mortality, and disability due to limb loss. Although secondary prevention with antithrombotic therapy is a mainstay of treatment to prevent adverse cardiovascular events, PAD patients are often undertreated with antithrombotic agents. Furthermore, there is a paucity of high-quality data from randomized controlled trials of PAD patients, leading to wide variations in clinical practice and guideline recommendations. Recently, there have been important advances that have further increased the number of antiplatelet and anticoagulant choices potentially available for patients with PAD. In this context, this paper aims to summarize the current available evidence for the safety and efficacy of various antithrombotic agents in PAD, and discuss how to integrate this emerging evidence into actual clinical practice. An evidenced-based approach to PAD patients is essential to achieve optimal outcomes, weighing cardiovascular and limb benefits against bleeding risks.

J Am Coll Cardiol: 28 May 2018; 71:2450-2467
Hussain MA, Al-Omran M, Creager MA, Anand SS, Verma S, Bhatt DL
J Am Coll Cardiol: 28 May 2018; 71:2450-2467 | PMID: 29793635
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Abstract

Restenosis, Stent Thrombosis, and Bleeding Complications: Navigating Between Scylla and Charybdis.

Torrado J, Buckley L, Durán A, Trujillo P, ... Biondi-Zoccai G, Guzmán LA
The field of interventional cardiology has significantly evolved over 40 years by overcoming several challenges. The introduction of first-generation drug-eluting stents significantly reduced the rates of restenosis, but at the expense of an increase of late stent thrombosis. Prolonged antithrombotic therapy reduced rates of stent thrombosis, but at the cost of increased bleeding. Although the advent of second-generation drug-eluting stents subsequently reduced the incidence of late stent thrombosis, its permanent nature prevents full recovery of vascular structure and function with accordant risk of very late stent failure. In the present era of interventional cardiology, the tradeoff between stent thrombosis, restenosis, and bleeding presents as a particularly complex challenge. In this review, the authors highlight major contributors of late/very late stent thrombosis while targeting stent restenosis, and they discuss evolutionary advances in stent technology and antiplatelet therapy, to further improve upon the care of patients with coronary artery disease.

J Am Coll Cardiol: 16 Apr 2018; 71:1676-1695
Torrado J, Buckley L, Durán A, Trujillo P, ... Biondi-Zoccai G, Guzmán LA
J Am Coll Cardiol: 16 Apr 2018; 71:1676-1695 | PMID: 29650125
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Abstract

The Evolving Future of PCSK9 Inhibitors.

Rosenson RS, Hegele RA, Fazio S, Cannon CP
Variants in proprotein convertase subtilisin/kexin type 9 (PCSK9) provide insights into mechanisms regulating low-density lipoprotein (LDL) levels. Human monoclonal antibodies that target PCSK9 lower LDL cholesterol (LDL-C) levels by 55% to 72% in different high-risk patient groups. Clinical trials with PCSK9 inhibitors have demonstrated reductions in atherosclerotic cardiovascular disease events, particularly in patients with recent acute coronary syndrome, multivessel coronary artery disease, or peripheral arterial disease. Commonly observed profound reductions in LDL-C to levels <25 mg/dl have been accompanied by even lower rates of atherosclerotic cardiovascular disease events, thus supporting the concept that there may be no lower limit for LDL-C. Aggressive LDL-C lowering with fully human PCSK9 monoclonal antibodies has been accompanied by a safety profile that has been very favorable. On the basis of clinical trial evidence, LDL lowering with PCSK9 inhibitors is recommended for high-risk patients with LDL-C levels ≥70 mg/dl on maximally tolerated oral therapies including statins and/or ezetimibe.

J Am Coll Cardiol: 16 Jul 2018; 72:314-329
Rosenson RS, Hegele RA, Fazio S, Cannon CP
J Am Coll Cardiol: 16 Jul 2018; 72:314-329 | PMID: 30012326
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Abstract

Myocardial Interstitial Fibrosis in Heart Failure: Biological and Translational Perspectives.

González A, Schelbert EB, Díez J, Butler J
Myocardial interstitial fibrosis contributes to left ventricular dysfunction leading to the development of heart failure. Basic research has provided abundant evidence for the cellular and molecular mechanisms behind this lesion and the pathways by which it imparts a detrimental impact on cardiac function. Translation of this knowledge, however, to improved diagnostics and therapeutics for patients with heart failure has not been as robust. This is partly related to the paucity of biomarkers to accurately identify myocardial interstitial fibrosis and to the lack of personalized antifibrotic strategies to treat it in an effective manner. This paper summarizes current knowledge of the mechanisms and detrimental consequences of myocardial interstitial fibrosis, discusses the potential of circulating and imaging biomarkers available to recognize different phenotypes of this lesion and track their clinical evolution, and reviews the currently available and potential future therapies that allow its individualized management in heart failure patients.

J Am Coll Cardiol: 16 Apr 2018; 71:1696-1706
González A, Schelbert EB, Díez J, Butler J
J Am Coll Cardiol: 16 Apr 2018; 71:1696-1706 | PMID: 29650126
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Abstract

Rheumatic Heart Disease Worldwide: JACC Scientific Expert Panel.

Watkins DA, Beaton AZ, Carapetis JR, Karthikeyan G, ... Yacoub MH, Zühlke LJ
Rheumatic heart disease (RHD) is a preventable heart condition that remains endemic among vulnerable groups in many countries. After a period of relative neglect, there has been a resurging interest in RHD worldwide over the past decade. In this Scientific Expert Panel, the authors summarize recent advances in the science of RHD and sketch out priorities for current action and future research. Key questions for laboratory research into disease pathogenesis and epidemiological research on the burden of disease are identified. The authors present a variety of pressing clinical research questions on optimal RHD prevention and advanced care. In addition, they propose a policy and implementation research agenda that can help translate current evidence into tangible action. The authors maintain that, despite knowledge gaps, there is sufficient evidence for national and global action on RHD, and they argue that RHD is a model for strengthening health systems to address other cardiovascular diseases in limited-resource countries.

J Am Coll Cardiol: 17 Sep 2018; 72:1397-1416
Watkins DA, Beaton AZ, Carapetis JR, Karthikeyan G, ... Yacoub MH, Zühlke LJ
J Am Coll Cardiol: 17 Sep 2018; 72:1397-1416 | PMID: 30213333
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Abstract

A Clinician\'s Guide for Trending Cardiovascular Nutrition Controversies: Part II.

Freeman AM, Morris PB, Aspry K, Gordon NF, ... White B, Kris-Etherton P
The potential cardiovascular (CV) benefits of many trending foods and dietary patterns are still incompletely understood, and scientific inquiry continues to evolve. In the meantime, however, a number of controversial dietary patterns, foods, and nutrients have received significant media attention and are mired by \"hype.\" This second review addresses some of the more recent popular foods and dietary patterns that are recommended for CV health to provide clinicians with current information for patient discussions in the clinical setting. Specifically, this paper delves into dairy products, added sugars, legumes, coffee, tea, alcoholic beverages, energy drinks, mushrooms, fermented foods, seaweed, plant and marine-derived omega-3-fatty acids, and vitamin B12.

J Am Coll Cardiol: 30 Jul 2018; 72:553-568
Freeman AM, Morris PB, Aspry K, Gordon NF, ... White B, Kris-Etherton P
J Am Coll Cardiol: 30 Jul 2018; 72:553-568 | PMID: 30049315
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Abstract

Positive Psychological Well-Being and Cardiovascular Disease: JACC Health Promotion Series.

Kubzansky LD, Huffman JC, Boehm JK, Hernandez R, ... Seligman MEP, Labarthe DR
Facets of positive psychological well-being, such as optimism, have been identified as positive health assets because they are prospectively associated with the 7 metrics of cardiovascular health (CVH) and improved outcomes related to cardiovascular disease. Connections between psychological well-being and cardiovascular conditions may be mediated through biological, behavioral, and psychosocial pathways. Individual-level interventions, such as mindfulness-based programs and positive psychological interventions, have shown promise for modifying psychological well-being. Further, workplaces are using well-being-focused interventions to promote employee CVH, and these interventions represent a potential model for expanding psychological well-being programs to communities and societies. Given the relevance of psychological well-being to promoting CVH, this review outlines clinical recommendations to assess and promote well-being in encounters with patients. Finally, a research agenda is proposed. Additional prospective observational studies are needed to understand mechanisms underlying the connection between psychological well-being and cardiovascular outcomes. Moreover, rigorous intervention trials are needed to assess whether psychological well-being-promoting programs can improve cardiovascular outcomes.

J Am Coll Cardiol: 17 Sep 2018; 72:1382-1396
Kubzansky LD, Huffman JC, Boehm JK, Hernandez R, ... Seligman MEP, Labarthe DR
J Am Coll Cardiol: 17 Sep 2018; 72:1382-1396 | PMID: 30213332
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Abstract

The Macrophage in Cardiac Homeostasis and Disease: JACC Macrophage in CVD Series (Part 4).

Lavine KJ, Pinto AR, Epelman S, Kopecky BJ, ... Rosenthal N, Kovacic JC
Macrophages are integral components of cardiac tissue and exert profound effects on the healthy and diseased heart. Paradigm shifting studies using advanced molecular techniques have revealed significant complexity within these macrophage populations that reside in the heart. In this final of a 4-part review series covering the macrophage in cardiovascular disease, the authors review the origins, dynamics, cell surface markers, and respective functions of each cardiac macrophage subset identified to date, including in the specific scenarios of myocarditis and after myocardial infarction. Looking ahead, a deeper understanding of the diverse and often dichotomous functions of cardiac macrophages will be essential for the development of targeted therapies to mitigate injury and orchestrate recovery of the diseased heart. Moreover, as macrophages are critical for cardiac healing, they are an emerging focus for therapeutic strategies aimed at minimizing cardiomyocyte death, ameliorating pathological cardiac remodeling, and for treating heart failure and after myocardial infarction.

J Am Coll Cardiol: 29 Oct 2018; 72:2213-2230
Lavine KJ, Pinto AR, Epelman S, Kopecky BJ, ... Rosenthal N, Kovacic JC
J Am Coll Cardiol: 29 Oct 2018; 72:2213-2230 | PMID: 30360829
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Abstract

Macrophage Trafficking, Inflammatory Resolution, and Genomics in Atherosclerosis: JACC Macrophage in CVD Series (Part 2).

Moore KJ, Koplev S, Fisher EA, Tabas I, ... Doran AC, Kovacic JC
Atherosclerosis is characterized by the retention of modified lipoproteins in the arterial wall. These modified lipoproteins activate resident macrophages and the recruitment of monocyte-derived cells, which differentiate into mononuclear phagocytes that ingest the deposited lipoproteins to become \"foam cells\": a hallmark of this disease. In this Part 2 of a 4-part review series covering the macrophage in cardiovascular disease, we critically review the contributions and relevant pathobiology of monocytes, macrophages, and foam cells as relevant to atherosclerosis. We also review evidence that via various pathways, a failure of the resolution of inflammation is an additional key aspect of this disease process. Finally, we consider the likely role played by genomics and biological networks in controlling the macrophage phenotype in atherosclerosis. Collectively, these data provide substantial insights on the atherosclerotic process, while concurrently offering numerous molecular and genomic candidates that appear to hold great promise for selective targeting as clinical therapies.

J Am Coll Cardiol: 29 Oct 2018; 72:2181-2197
Moore KJ, Koplev S, Fisher EA, Tabas I, ... Doran AC, Kovacic JC
J Am Coll Cardiol: 29 Oct 2018; 72:2181-2197 | PMID: 30360827
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Abstract

Monocyte and Macrophage Dynamics in the Cardiovascular System: JACC Macrophage in CVD Series (Part 3).

Fayad ZA, Swirski FK, Calcagno C, Robbins CS, Mulder W, Kovacic JC
It has long been recognized that the bone marrow is the primary site of origin for circulating monocytes that may later become macrophages in atherosclerotic lesions. However, only in recent times has the complex relationship among the bone marrow, monocytes/macrophages, and atherosclerotic plaques begun to be understood. Moreover, the systemic nature of these interactions, which also involves additional compartments such as extramedullary hematopoietic sites (i.e., spleen), is only just becoming apparent. In parallel, progressive advances in imaging and cell labeling techniques have opened new opportunities for in vivo imaging of monocyte/macrophage trafficking in atherosclerotic lesions and at the systemic level. In this Part 3 of a 4-part review series covering the macrophage in cardiovascular disease, the authors intersect systemic biology with advanced imaging techniques to explore monocyte and macrophage dynamics in the cardiovascular system, with an emphasis on how events at the systemic level might affect local atherosclerotic plaque biology.

J Am Coll Cardiol: 29 Oct 2018; 72:2198-2212
Fayad ZA, Swirski FK, Calcagno C, Robbins CS, Mulder W, Kovacic JC
J Am Coll Cardiol: 29 Oct 2018; 72:2198-2212 | PMID: 30360828
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Abstract

Unmet Need for Adjunctive Dyslipidemia Therapy in Hypertriglyceridemia Management.

Ganda OP, Bhatt DL, Mason RP, Miller M, Boden WE
Despite the important role of high-intensity statins in reducing atherosclerotic cardiovascular disease events in secondary and primary prevention, substantial residual risk persists, particularly among high-risk patients with type 2 diabetes mellitus, metabolic syndrome, and obesity. Considerable attention is currently directed to the role that elevated triglycerides (TGs) and non-high-density lipoprotein cholesterol levels play as important mediators of residual atherosclerotic cardiovascular disease risk, which is further strongly supported by genetic linkage studies. Previous trials with fibrates, niacin, and most cholesterol ester transfer protein inhibitors that targeted high-density lipoprotein cholesterol raising, and/or TG lowering, have failed to show conclusive evidence of incremental event reduction after low-density lipoprotein cholesterol levels were \"optimally controlled\" with statins. Although omega-3 fatty acids are efficacious in lowering TG levels and may have pleiotropic effects such as reducing plaque instability and proinflammatory mediators of atherogenesis, clinical outcomes data are currently lacking. Several ongoing randomized controlled trials of TG-lowering strategies with an optimal dosage of omega-3 fatty acids are nearing completion.

J Am Coll Cardiol: 15 Jun 2018; epub ahead of print
Ganda OP, Bhatt DL, Mason RP, Miller M, Boden WE
J Am Coll Cardiol: 15 Jun 2018; epub ahead of print | PMID: 29935936
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Abstract

Macrophage Biology, Classification, and Phenotype in Cardiovascular Disease: JACC Macrophage in CVD Series (Part 1).

Williams JW, Giannarelli C, Rahman A, Randolph GJ, Kovacic JC
Macrophages represent one of the most numerous and diverse leukocyte types in the body. Furthermore, they are important regulators and promoters of many cardiovascular disease programs. Their functions range from sensing pathogens to digesting cell debris, modulating inflammation, and producing key cytokines and other regulatory factors throughout the body. Macrophage research has undergone a renaissance in recent years, which has propelled a newfound interest in their heterogeneity as well as a new understanding of ontological differences in their development. In addition, recent technological advances such as single-cell mass-cytometry by time-of-flight have enabled phenotype and functional analyses of individual immune myeloid cells, including macrophages, at unprecedented resolution. In this Part 1 of a 4-part review series covering the macrophage in cardiovascular disease, we focus on the basic principles of macrophage development, heterogeneity, phenotype, tissue-specific differentiation, and functionality as a basis to understand their role in cardiovascular disease.

J Am Coll Cardiol: 29 Oct 2018; 72:2166-2180
Williams JW, Giannarelli C, Rahman A, Randolph GJ, Kovacic JC
J Am Coll Cardiol: 29 Oct 2018; 72:2166-2180 | PMID: 30360826
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Abstract

Inflammation, Immunity, and Infection in Atherothrombosis: JACC Review Topic of the Week.

Libby P, Loscalzo J, Ridker PM, Farkouh ME, ... Hasan AA, Amar S
Observations on human and experimental atherosclerosis, biomarker studies, and now a large-scale clinical trial support the operation of immune and inflammatory pathways in this disease. The factors that incite innate and adaptive immune responses implicated in atherogenesis and in lesion complication include traditional risk factors such as protein and lipid components of native and modified low-density lipoprotein, angiotensin II, smoking, visceral adipose tissue, and dysmetabolism. Infectious processes and products of the endogenous microbiome might also modulate atherosclerosis and its complications either directly, or indirectly by eliciting local and systemic responses that potentiate disease expression. Trials with antibiotics have not reduced recurrent cardiovascular events, nor have vaccination strategies yet achieved clinical translation. However, anti-inflammatory interventions such as anticytokine therapy and colchicine have begun to show efficacy in this regard. Thus, inflammatory and immune mechanisms can link traditional and emerging risk factors to atherosclerosis, and offer novel avenues for therapeutic intervention.

J Am Coll Cardiol: 22 Oct 2018; 72:2071-2081
Libby P, Loscalzo J, Ridker PM, Farkouh ME, ... Hasan AA, Amar S
J Am Coll Cardiol: 22 Oct 2018; 72:2071-2081 | PMID: 30336831
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Abstract

Healthy Weight and Obesity Prevention: JACC Health Promotion Series.

Lavie CJ, Laddu D, Arena R, Ortega FB, Alpert MA, Kushner RF
Overweight and obesity have reached epidemic levels in the United States and worldwide, and this has contributed to substantial cardiovascular and other health risks. However, controversy exists concerning the causes of obesity and effective modalities for its prevention and treatment. There is also controversy related to the concept of metabolically healthy obesity phenotype, the \"obesity paradox,\" and on the importance of fitness to protect individuals who are overweight or obese from cardiovascular diseases. In this state-of-the-art review, the authors focus on \"healthy weight\" with the emphasis on the pathophysiologic effects of weight gain on the cardiovascular system; mechanistic/triggering factors; and the role of preventive actions through personal, education/environment, and societal/authoritative factors, as well as factors to provide guidance for caregivers of health promotion. Additionally, the authors briefly review metabolically healthy obesity, the obesity paradox, and issues beyond lifestyle consideration for weight loss with medications and bariatric surgery.

J Am Coll Cardiol: 24 Sep 2018; 72:1506-1531
Lavie CJ, Laddu D, Arena R, Ortega FB, Alpert MA, Kushner RF
J Am Coll Cardiol: 24 Sep 2018; 72:1506-1531 | PMID: 30236314
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Abstract

Positive Pressure Ventilation in the Cardiac Intensive Care Unit.

Alviar CL, Miller PE, McAreavey D, Katz JN, ... Morrow DA,
Contemporary cardiac intensive care units (CICUs) provide care for an aging and increasingly complex patient population. The medical complexity of this population is partly driven by an increased proportion of patients with respiratory failure needing noninvasive or invasive positive pressure ventilation (PPV). PPV often plays an important role in the management of patients with cardiogenic pulmonary edema, cardiogenic shock, or cardiac arrest, and those undergoing mechanical circulatory support. Noninvasive PPV, when appropriately applied to selected patients, may reduce the need for invasive mechanical PPV and improve survival. Invasive PPV can be lifesaving, but has both favorable and unfavorable interactions with left and right ventricular physiology and carries a risk of complications that influence CICU mortality. Effective implementation of PPV requires an understanding of the underlying cardiac and pulmonary pathophysiology. Cardiologists who practice in the CICU should be proficient with the indications, appropriate selection, potential cardiopulmonary interactions, and complications of PPV.

J Am Coll Cardiol: 24 Sep 2018; 72:1532-1553
Alviar CL, Miller PE, McAreavey D, Katz JN, ... Morrow DA,
J Am Coll Cardiol: 24 Sep 2018; 72:1532-1553 | PMID: 30236315
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Abstract

Air Pollution and Cardiovascular Disease: JACC State-of-the-Art Review.

Rajagopalan S, Al-Kindi SG, Brook RD
Fine particulate matter <2.5 μm (PM) air pollution is the most important environmental risk factor contributing to global cardiovascular (CV) mortality and disability. Short-term elevations in PM increase the relative risk of acute CV events by 1% to 3% within a few days. Longer-term exposures over several years increase this risk by a larger magnitude (∼10%), which is partially attributable to the development of cardiometabolic conditions (e.g., hypertension and diabetes mellitus). As such, ambient PM poses a major threat to global public health. In this review, the authors provide an overview of air pollution and health, including assessment of exposure, impact on CV outcomes, mechanistic underpinnings, and impact of air pollution reduction strategies to mitigate CV risk. The review concludes with future challenges, including the inextricable link between air pollution and climate change, and calls for large-scale trials to allow the promulgation of formal evidence-based recommendations to lower air pollution-induced health risks.

J Am Coll Cardiol: 22 Oct 2018; 72:2054-2070
Rajagopalan S, Al-Kindi SG, Brook RD
J Am Coll Cardiol: 22 Oct 2018; 72:2054-2070 | PMID: 30336830
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Abstract

Diastolic stress echocardiography: from basic principles to clinical applications.

Prasad SB, Holland DJ, Atherton JJ
Heart failure with preserved ejection fraction (HFpEF) looms as a major public heart challenge with increasing prevalence due to an ageing population. Diagnosis can be challenging due to non-specific symptomatology, low natriuretic peptide levels and equivocal diastology on resting echocardiography. Diastolic stress echocardiography represents a non-invasive option to refining the diagnosis in this subset of patients. Diastolic responses to exercise are most commonly measured with a non-invasive measure of left ventricular filling pressures (LVFP) estimated by the ratio of the early mitral inflow wave to early diastolic tissue velocity (E/e\' ratio). This is measured pre- and post-exercise , and is highly feasible. An elevation of exercise E/e\' >15 is classified as an abnormal response as per current guidelines. An alternative measure of exercise-related diastolic performance, the Diastolic Functional Reserve Index has also been proposed, but has not been as well studied as exercise E/e\'. A number of studies have validated exercise E/e\' as a measure of LVFP against invasively measured LVFP using simultaneous echocardiography-catheterisation studies. The independent prognostic value of exercise E/e\' has also been well delineated in a number of studies. While diastolic stress echocardiography can be considered for all patients with suspected HFpEF, it is of particular value in patients with normal or equivocal diastolic indices on resting echocardiography.

Heart: 19 Jul 2018; epub ahead of print
Prasad SB, Holland DJ, Atherton JJ
Heart: 19 Jul 2018; epub ahead of print | PMID: 30030333
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Abstract

Ejection Fraction Pros and Cons: JACC State-of-the-Art Review.

Marwick TH
Ejection fraction (EF) reflects both cardiac function and remodeling, and is widely recognized as a valuable diagnostic and prognostic tool. Its use in a variety of settings, ranging from heart failure and myocardial infarction to valvular heart disease, has made it a cornerstone of modern cardiology, pervading guidelines and practice. However, the development of the test was in another era, with younger patients and a lower prevalence of heart failure with preserved EF. The performance expectations of EF in the current era are also demanding-in relation to detection of subclinical LV dysfunction, and especially relating to recognition of changes in LV function on sequential testing-for example in patients taking cardiotoxic drugs. This review discusses whether the impressive evidence base for EF justifies its ongoing use in the context of newer markers of LV function, and the sophisticated questions posed by modern cardiology.

J Am Coll Cardiol: 05 Nov 2018; 72:2360-2379
Marwick TH
J Am Coll Cardiol: 05 Nov 2018; 72:2360-2379 | PMID: 30384893
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Impact:
Abstract

Lifestyle Modifications for Preventing and Treating Heart Failure.

Aggarwal M, Bozkurt B, Panjrath G, Aggarwal B, ... Litwin SE,
Continued improvement in medical and device therapy for heart failure (HF) has led to better survival with this disease. Longer survival and increasing numbers of unhealthy lifestyle factors and behaviors leading to occurrence of HF at younger ages are both contributors to an increase in the overall prevalence of HF. Clinicians treating this complex disease tend to focus on pharmacological and device therapies, but often fail to capitalize on the significant opportunities to prevent or treat HF through lifestyle modification. Herein, the authors review the evidence behind weight management, exercise, nutrition, dietary composition, supplements, and mindfulness and their potential to influence the epidemiology, pathophysiology, etiology, and management of stage A HF.

J Am Coll Cardiol: 05 Nov 2018; 72:2391-2405
Aggarwal M, Bozkurt B, Panjrath G, Aggarwal B, ... Litwin SE,
J Am Coll Cardiol: 05 Nov 2018; 72:2391-2405 | PMID: 30384895
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Impact:
Abstract

Artificial Lungs for Lung Failure: JACC Technology Corner.

Naito N, Cook K, Toyoda Y, Shigemura N
Although lung transplantation is an effective treatment for end-stage lung failure, its limitations have led to renewed interest in artificial lung support for patients with lung failure. The use of ventricular assist devices has significantly improved the quality of life and survival of patients with end-stage heart failure. In contrast, there are no devices that can be used long term as destination therapy for end-stage lung failure, and there is a strong need for them. Extracorporeal membrane oxygenation is widely used as a temporary treatment for acute lung failure and as a bridge to lung transplant. Many patients with advanced lung failure cannot return home with good quality of life once they are hospitalized. In this review, the authors discuss the history, status, and future of artificial lungs, focusing on long-term artificial respiratory support as a destination therapy. Respiratory assist devices, such as artificial lungs, could eventually become analogous to ventricular assist devices.

J Am Coll Cardiol: 01 Oct 2018; 72:1640-1652
Naito N, Cook K, Toyoda Y, Shigemura N
J Am Coll Cardiol: 01 Oct 2018; 72:1640-1652 | PMID: 30261966
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Abstract

Promoting Physical Activity and Exercise: JACC Health Promotion Series.

Fletcher GF, Landolfo C, Niebauer J, Ozemek C, Arena R, Lavie CJ
Physical inactivity is one of the leading modifiable risk factors for global mortality, with an estimated 20% to 30% increased risk of death compared with those who are physically active. The \"behavior\" of physical activity (PA) is multifactorial, including social, environmental, psychological, and genetic factors. Abundant scientific evidence has demonstrated that physically active people of all age groups and ethnicities have higher levels of cardiorespiratory fitness, health, and wellness, and a lower risk for developing several chronic medical illnesses, including cardiovascular disease, compared with those who are physically inactive. Although more intense and longer durations of PA correlate directly with improved outcomes, even small amounts of PA provide protective health benefits. In this state-of-the-art review, the authors focus on \"healthy PA\" with the emphasis on the pathophysiological effects of physical inactivity and PA on the cardiovascular system, mechanistic/triggering factors, the role of preventive actions through personal, education/environment, and societal/authoritative factors, as well as factors to provide guidance for caregivers of health promotion regarding PA. Sustainable and comprehensive programs to increase PA among all individuals need to be developed and implemented at local, regional, national, and international levels to effect positive changes and improve global health, especially the reduction of cardiovascular disease.

J Am Coll Cardiol: 01 Oct 2018; 72:1622-1639
Fletcher GF, Landolfo C, Niebauer J, Ozemek C, Arena R, Lavie CJ
J Am Coll Cardiol: 01 Oct 2018; 72:1622-1639 | PMID: 30261965
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Abstract

Long Noncoding RNAs in Atherosclerosis: JACC Review Topic of the Week.

Zhang Z, Salisbury D, Sallam T
Atherosclerosis is a complex and chronic disease characterized by lipid deposition in the vessel wall that leads to an inflammatory and proliferative cascade involving smooth muscle, endothelial, and immune cells. Despite substantial improvements in our understanding of mechanisms contributing to atherosclerosis and overall reduction in cardiovascular mortality, the absolute disease burden remains substantially high. The recent discovery of a new group of mediators known as long noncoding ribonucleic acids (lncRNAs) offers a unique opportunity for the development of novel diagnostic and therapeutic tools in atherothrombotic disease. A number of studies suggest that lncRNAs are important mediators in health and disease, and rapidly accumulating evidence implicates lncRNAs in regulatory circuits controlling atherosclerosis. In this review, the authors outline important contributions of lncRNAs to atherosclerosis and its associated risk factors, including hypercholesterolemia, diabetes, hypertension, and obesity.

J Am Coll Cardiol: 05 Nov 2018; 72:2380-2390
Zhang Z, Salisbury D, Sallam T
J Am Coll Cardiol: 05 Nov 2018; 72:2380-2390 | PMID: 30384894
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Abstract

Cost-effectiveness of cardiac rehabilitation: a systematic review.

Shields GE, Wells A, Doherty P, Heagerty A, Buck D, Davies LM
Patients may be offered cardiac rehabilitation (CR), a supervised programme often including exercises, education and psychological care, following a cardiac event, with the aim of reducing morbidity and mortality. Cost-constrained healthcare systems require information about the best use of budget and resources to maximise patient benefit. We aimed to systematically review and critically appraise economic studies of CR and its components. In January 2016, validated electronic searches of the National Health Service Economic Evaluation Database (NHS EED), Health Technology Assessment, PsycINFO, MEDLINE and Embase databases were run to identify full economic evaluations published since 2001. Two levels of screening were used and explicit inclusion criteria were applied. Prespecified data extraction and critical appraisal were performed using the NHS EED handbook and Drummond checklist. The majority of studies concluded that CR was cost-effective versus no CR (incremental cost-effectiveness ratios (ICERs) ranged from $1065 to $71 755 per quality-adjusted life-year (QALY)). Evidence for specific interventions within CR was varied; psychological intervention ranged from dominant (cost saving and more effective) to $226 128 per QALY, telehealth ranged from dominant to $588 734 per QALY and while exercise was cost-effective across all relevant studies, results were subject to uncertainty. Key drivers of cost-effectiveness were risk of subsequent events and hospitalisation, hospitalisation and intervention costs, and utilities. This systematic review of studies evaluates the cost-effectiveness of CR in the modern era, providing a fresh evidence base for policy-makers. Evidence suggests that CR is cost-effective, especially with exercise as a component. However, research is needed to determine the most cost-effective design of CR.

Heart: 12 Apr 2018; epub ahead of print
Shields GE, Wells A, Doherty P, Heagerty A, Buck D, Davies LM
Heart: 12 Apr 2018; epub ahead of print | PMID: 29654096
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Abstract

Cardiovascular imaging in Turner syndrome: state-of-the-art practice across the lifespan.

Mortensen KH, Young L, De Backer J, Silberbach M, ... Lopez L, Roos-Hesselink JW
Cardiovascular imaging is essential to providing excellent clinical care for girls and women with Turner syndrome (TS). Congenital and acquired cardiovascular diseases are leading causes of the lifelong increased risk of premature death in TS. Non-invasive cardiovascular imaging is crucial for timely diagnosis and treatment planning, and a systematic and targeted imaging approach should combine echocardiography, cardiovascular magnetic resonance and, in select cases, cardiac CT. In recent decades, evidence has mounted for the need to perform cardiovascular imaging in all females with TS irrespective of karyotype and phenotype. This is due to the high incidence of outcome-determining lesions that often remain subclinical and occur in patterns specific to TS. This review provides an overview of state-of-the-art cardiovascular imaging practice in TS, by means of a review of the most recent literature, in the context of a recent consensus statement that has highlighted the role of cardiovascular diseases in these females.

Heart: 17 Sep 2018; epub ahead of print
Mortensen KH, Young L, De Backer J, Silberbach M, ... Lopez L, Roos-Hesselink JW
Heart: 17 Sep 2018; epub ahead of print | PMID: 30228249
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Abstract

Mechanical Unloading in Heart Failure.

Uriel N, Sayer G, Annamalai S, Kapur NK, Burkhoff D
Myocardial injury induces significant changes in ventricular structure and function at both the cellular and anatomic level, leading to ventricular remodeling and subsequent heart failure. Unloading left ventricular pressure has been studied in both the short-term and long-term settings, as a means of preventing or reversing cardiac remodeling. In acute myocardial infarction, cardiac unloading is used to reduce oxygen demand and limit infarct size. Research has demonstrated the benefits of short-term unloading with mechanical circulatory support devices before reperfusion in the context of acute myocardial infarction with cardiogenic shock, and a confirmatory trial is ongoing. In chronic heart failure, ventricular unloading using mechanical circulatory support can reverse many of the cellular and anatomic changes that accompany ventricular remodeling. Ongoing research is evaluating the ability of left ventricular assist devices to promote myocardial recovery and remission from clinical heart failure.

J Am Coll Cardiol: 30 Jul 2018; 72:569-580
Uriel N, Sayer G, Annamalai S, Kapur NK, Burkhoff D
J Am Coll Cardiol: 30 Jul 2018; 72:569-580 | PMID: 30056830
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Abstract

Percutaneous coronary intervention for stable coronary artery disease.

Al-Lamee RK, Nowbar AN, Francis DP
The adverse consequences of stable coronary artery disease (CAD) are death, myocardial infarction (MI) and angina. Trials in stable CAD show that percutaneous coronary intervention (PCI) does not reduce mortality. PCI does appear to reduce spontaneous MI rates but at the expense of causing some periprocedural MI. Therefore, the main purpose of PCI is to relieve angina. Indeed, patients and physicians often choose PCI rather than first attempting to control symptoms with anti-anginal medications as recommended by guidelines. Nevertheless, it is unclear how effective PCI is at relieving angina. This is because, whereas anti-anginal medications are universally required to be tested against placebo, there is no such requirement for procedural interventions such as PCI. The first placebo-controlled trial of PCI showed a surprisingly small effect size. This may be because it is overly simplistic to assume that the presence of a stenosis and inducible ischaemia in a patient means that the clinical chest pain they report is caused by ischaemia. In this article, we review the evidence base and argue that if we as a medical specialty wish to lead the science of procedures for symptom control, we should recognise the special merit of placebo-controlled experiments.

Heart: 20 Sep 2018; epub ahead of print
Al-Lamee RK, Nowbar AN, Francis DP
Heart: 20 Sep 2018; epub ahead of print | PMID: 30242142
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Abstract

Primary Prevention With Statins in the Elderly.

Mortensen MB, Falk E
The burden of atherosclerotic cardiovascular disease (ASCVD) in high-income countries is mostly borne by the elderly. With increasing life expectancy, clear guidance on sensible use of statin therapy to prevent a first and potentially devastating ASCVD event is critically important to ensure a healthy aging population. Since 2013, 5 major North American and European guidelines on statin use in primary prevention of ASCVD have been released by the American College of Cardiology/American Heart Association, the UK National Institute for Health and Care Excellence, the Canadian Cardiovascular Society, U.S. Preventive Services Task Force, and the European Society of Cardiology/European Atherosclerosis Society. Guidance on using statin therapy in primary ASCVD prevention in the growing elderly population (>65 years of age) differs markedly. The authors discuss the discrepant recommendations, place them into the context of available evidence, and identify circumstances in which uncertainty may hamper the appropriate use of statins in the elderly.

J Am Coll Cardiol: 01 Jan 2018; 71:85-94
Mortensen MB, Falk E
J Am Coll Cardiol: 01 Jan 2018; 71:85-94 | PMID: 29301631
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Abstract

Obesity: Pathophysiology and Management.

Gadde KM, Martin CK, Berthoud HR, Heymsfield SB
Obesity continues to be among the top health concerns across the globe. Despite our failure to contain the high prevalence of obesity, we now have a better understanding of its pathophysiology, and how excess adiposity leads to type 2 diabetes, hypertension, and cardiovascular disease. Lifestyle modification is recommended as the cornerstone of obesity management, but many patients do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and neurohormonal adaptation of the body in response to weight loss. Fortunately, 5 drug therapies-orlistat, lorcaserin, liraglutide, phentermine/topiramate, and naltrexone/bupropion-are available for long-term weight management. Additionally, several medical devices are available for short-term and long-term use. Bariatric surgery yields substantial and sustained weight loss with resolution of type 2 diabetes, although due to the high cost and a small risk of serious complications, it is generally recommended for patients with severe obesity. Benefit-to-risk balance should guide treatment decisions.

J Am Coll Cardiol: 01 Jan 2018; 71:69-84
Gadde KM, Martin CK, Berthoud HR, Heymsfield SB
J Am Coll Cardiol: 01 Jan 2018; 71:69-84 | PMID: 29301630
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Abstract

Exercise recommendations in patients with valvular heart disease.

Gati S, Malhotra A, Sharma S
Valvular heart disease affects 1%-2% of young individuals, many of whom aspire to partake in competitive sport or high intensity recreational exercise. There are limited reports on the impact of intensive physical activity on the progression of valvular heart disease; therefore, current recommendations are based on consensus opinion. The management of exercising individuals with valvular heart disease requires a structured approach that incorporates several key factors including symptomatic status, functional capacity, type and nature of the valvular lesion, impact on ventricular structure and function and effect on pulmonary artery pressure. Asymptomatic individuals with minor valvular abnormalities may engage in all forms of competitive sport, whereas those with lesions of moderate severity may exercise intensively if an exercise stress test tailored to the relevant physical activity reveals good functional capacity without myocardial ischaemia, haemodynamic disturbances or arrhythmia. Symptomatic athletes and those with severe valvular heart disease, impaired ventricular function, pulmonary hypertension and arrhythmias should refrain from most competitive sports. Athletes with a bicuspid aortic valve and aortic root diameter >40 mm should avoid sport with a strong isometric component even with minimal valvular dysfunction. There is an association between mitral valve prolapse and sudden cardiac death in the general population; however, there is limited evidence of increased risk with competitive sport. Athletes undergoing corrective surgery may return to exercise after 3 months if ventricular function and exercise capacity are preserved. Individuals anticoagulated for mechanical bioprosthetic valves should avoid contact or collision sport to minimise the risk of bleeding.

Heart: 26 Sep 2018; epub ahead of print
Gati S, Malhotra A, Sharma S
Heart: 26 Sep 2018; epub ahead of print | PMID: 30262455
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Abstract

Anatomy, Function, and Dysfunction of the Right Ventricle: JACC State-of-the-Art Review.

Sanz J, Sánchez-Quintana D, Bossone E, Bogaard HJ, Naeije R
There is increasing recognition of the crucial role of the right ventricle (RV) in determining functional status and prognosis in multiple conditions. The normal RV is anatomically and functionally different from the left ventricle, which precludes direct extrapolation of our knowledge of left-sided physiopathology to the right heart. RV adaptation is largely determined by the level of exposure to hemodynamic overload (both preload and afterload) as well as its intrinsic contractile function. These 3 processes (pressure overload, volume overload, and RV cardiomyopathy) are associated with distinct clinical course and therapeutic approach, although in reality they often coexist in various degrees. The close relationship between the RV and left ventricle (ventricular interdependence) and its coupling to the pulmonary circulation further modulate RV behavior in different clinical scenarios. In this review, the authors summarize current knowledge of RV anatomic, structural, metabolic, functional, and hemodynamic characteristics in both health and disease.

J Am Coll Cardiol: 01 May 2019; 73:1463-1482
Sanz J, Sánchez-Quintana D, Bossone E, Bogaard HJ, Naeije R
J Am Coll Cardiol: 01 May 2019; 73:1463-1482 | PMID: 30922478
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Impact:
Abstract

Present Status of Brugada Syndrome: JACC State-of-the-Art Review.

Brugada J, Campuzano O, Arbelo E, Sarquella-Brugada G, Brugada R
The Brugada syndrome is an inherited disorder associated with risk of ventricular fibrillation and sudden cardiac death in a structurally normal heart. Diagnosis is based on a characteristic electrocardiographic pattern (coved type ST-segment elevation ≥2 mm followed by a negative T-wave in ≥1 of the right precordial leads V to V), observed either spontaneously or during a sodium-channel blocker test. The prevalence varies among regions and ethnicities, affecting mostly males. The risk stratification and management of patients, principally asymptomatic, still remains challenging. The current main therapy is an implantable cardioverter-defibrillator, but radiofrequency catheter ablation has been recently reported as an effective new treatment. Since its first description in 1992, continuous achievements have expanded our understanding of the genetics basis and electrophysiological mechanisms underlying the disease. Currently, despite several genes identified, SCN5A has attracted most attention, and in approximately 30% of patients, a genetic variant may be implicated in causation after a comprehensive analysis.

J Am Coll Cardiol: 27 Aug 2018; 72:1046-1059
Brugada J, Campuzano O, Arbelo E, Sarquella-Brugada G, Brugada R
J Am Coll Cardiol: 27 Aug 2018; 72:1046-1059 | PMID: 30139433
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Abstract

Clinical Diagnosis, Imaging, and Genetics of Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia: JACC State-of-the-Art Review.

Gandjbakhch E, Redheuil A, Pousset F, Charron P, Frank R
Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is an inherited cardiomyopathy that can lead to sudden cardiac death and heart failure. Our understanding of its pathophysiology and clinical expressivity is continuously evolving. The diagnosis of ARVC/D remains particularly challenging due to the absence of specific unique diagnostic criteria, its variable expressivity, and incomplete penetrance. Advances in genetics have enlarged the clinical spectrum of the disease, highlighting possible phenotypes that overlap with arrhythmogenic dilated cardiomyopathy and channelopathies. The principal challenges for ARVC/D diagnosis include the following: earlier detection of the disease, particularly in cases of focal right ventricular involvement; differential diagnosis from other arrhythmogenic diseases affecting the right ventricle; and the development of new objective electrocardiographic and imaging criteria for diagnosis. This review provides an update on the diagnosis of ARVC/D, focusing on the contribution of emerging imaging techniques, such as echocardiogram/magnetic resonance imaging strain measurements or computed tomography scanning, new electrocardiographic parameters, and high-throughput sequencing.

J Am Coll Cardiol: 13 Aug 2018; 72:784-804
Gandjbakhch E, Redheuil A, Pousset F, Charron P, Frank R
J Am Coll Cardiol: 13 Aug 2018; 72:784-804 | PMID: 30092956
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Abstract

Impact of Lipids on Cardiovascular Health: JACC Health Promotion Series.

Ference BA, Graham I, Tokgozoglu L, Catapano AL
People who maintain ideal cardiovascular heath have a low lifetime risk of cardiovascular disease. Therefore, encouraging people to achieve ideal cardiovascular health represents an important opportunity to improve the prevention of cardiovascular disease. However, preventing cardiovascular disease by promoting ideal cardiovascular health requires shifting the focus from treating disease after it develops to preventing cardiovascular events before they happen by slowing the progression of atherosclerosis. Because atherogenic lipoproteins play a central causal role in the initiation and progression of atherosclerosis, maintaining optimal lipid levels is necessary to achieve ideal cardiovascular health. This review describes the cumulative effect of lipid-carrying lipoproteins on the risk of cardiovascular disease, estimates the magnitude of the clinical benefit that can be achieved by maintaining optimal lipid levels, identifies the most effective timing for implementing strategies designed to achieve optimal lipid levels, and provides a clinical pathway to help people achieve the lipid levels necessary for ideal cardiovascular health.

J Am Coll Cardiol: 03 Sep 2018; 72:1141-1156
Ference BA, Graham I, Tokgozoglu L, Catapano AL
J Am Coll Cardiol: 03 Sep 2018; 72:1141-1156 | PMID: 30165986
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