Journal: J Am Coll Cardiol

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Abstract

Preoperative Atrial Fibrillation and Cardiovascular Outcomes After Noncardiac Surgery.

Prasada S, Desai MY, Saad M, Smilowitz NR, ... Nakhla S, Mentias A
Background
The impact of pre-existing atrial fibrillation (AF) on outcomes after noncardiac surgery is not clear.
Objectives
We aimed to study the impact of AF on the risk of adverse outcomes after noncardiac surgery in a nationwide cohort.
Methods
We identified Medicare beneficiaries admitted for noncardiac surgery from 2015 to 2019 and divided the study cohort into 2 groups: with and without AF. Noncardiac surgery was classified into vascular, thoracic, general, genitourinary, gynecological, orthopedics and neurosurgery, breast, head and neck, and transplant. We used propensity score matching on exact age, sex, race, urgency and type of surgery, revised cardiac risk index (RCRI) and CHA2DS2-VASc score, and tight caliper on other comorbidities. The study outcomes were 30-day mortality, stroke, myocardial infarction, and heart failure. We examined the incremental utility of AF in addition to RCRI to predict adverse events after noncardiac surgery.
Results
The study cohort included 8,635,758 patients who underwent noncardiac surgery (16.4% with AF). Patients with AF were older, more likely to be men, and had higher prevalence of comorbidities. After propensity score matching, AF was associated with higher risk of mortality (OR: 1.31; 95% CI: 1.30-1.32), heart failure (OR: 1.31; 95% CI: 1.30-1.33), and stroke (OR: 1.40; 95% CI: 1.37-1.43) and lower risk of myocardial infarction (OR: 0.81; 95% CI: 0.79-0.82). Results were consistent in subgroup analysis by sex, race, type of surgery, and all strata of RCRI and CHA2DS2-VASc score. AF improved the discriminative ability of RCRI (C-statistic 0.73 to 0.76).
Conclusion
Pre-existing AF is independently associated with postoperative adverse outcomes after NCS.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 28 Jun 2022; 79:2471-2485
Prasada S, Desai MY, Saad M, Smilowitz NR, ... Nakhla S, Mentias A
J Am Coll Cardiol: 28 Jun 2022; 79:2471-2485 | PMID: 35738707
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Abstract

Long-Term Outcomes of Patients Requiring Unplanned Repeated Interventions After Surgery for Congenital Heart Disease.

Sengupta A, Gauvreau K, Kohlsaat K, Colan SD, ... Del Nido PJ, Nathan M
Background
Unplanned catheter-based or surgical reinterventions after congenital heart operations are independently associated with operative mortality and increased postoperative length of stay.
Objectives
This study assessed the long-term outcomes of transplant-free survivors of hospital discharge requiring predischarge reinterventions after congenital cardiac surgery.
Methods
Data from patients who required predischarge reinterventions in the anatomic area of repair after congenital cardiac surgery and survived to hospital discharge at a quaternary referral center from January 2011 to December 2019 were retrospectively reviewed. Previously published echocardiographic criteria were used to assess the severity of persistent residual lesions at discharge (Grade 1, no residua; Grade 2, minor residua; and Grade 3, major residua). Outcomes included postdischarge (late) mortality or transplant and unplanned reintervention. Associations between predischarge residual lesion severity and outcomes were assessed by using Cox or competing risk models, adjusting for baseline patient characteristics, case complexity, and preoperative risk factors.
Results
Among the 408 patients who met entry criteria, there were 58 (14.2%) postdischarge deaths or transplants and 208 (51.0%) late reinterventions at a median follow-up of 3.0 years (IQR: 1.1-6.8 years). Greater predischarge residual lesion severity was associated with worse transplant-free survival and freedom from reintervention (both, P < 0.05). On multivariable analyses, Grade 3 patients had an increased risk of postdischarge mortality or transplant (HR: 4.8; 95% CI: 2.0-11; P < 0.001) and late reintervention (subdistribution HR: 2.1; 95% CI: 1.4-3.1; P < 0.001) vs Grade 1 patients.
Conclusions
Among transplant-free survivors requiring predischarge reinterventions after congenital cardiac surgery, those with persistent major residua have significantly worse long-term outcomes. These high-risk patients warrant closer surveillance.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 28 Jun 2022; 79:2489-2499
Sengupta A, Gauvreau K, Kohlsaat K, Colan SD, ... Del Nido PJ, Nathan M
J Am Coll Cardiol: 28 Jun 2022; 79:2489-2499 | PMID: 35738709
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Abstract

Socioeconomic Status and Risk of Bleeding After Mechanical Aortic Valve Replacement.

Dalén M, Persson M, Glaser N, Sartipy U
Background
Whether low socioeconomic status (SES) is associated with increased risk of anticoagulation-related adverse events in patients with mechanical heart valves is unknown.
Objectives
This study sought to investigate the impact of patients\' SES on the risk of bleeding after mechanical aortic valve replacement (AVR).
Methods
This nationwide population-based cohort study included all patients aged 18-70 years who underwent mechanical AVR in Sweden from 1997 to 2018. Data were obtained from the SWEDEHEART register and other national health data registers. The exposure was quartiles of household disposable income. The primary outcome was hospitalization for a bleeding event.
Results
Among 5974 patients, the absolute risk for bleeding after 20 years of follow-up was 20% (95% CI: 17%-24%) in the lowest income quartile (Q1) and 16% (95% CI: 13%-20%) in the highest quartile (Q4). The risk of bleeding decreased with increasing income level and was significantly lower in patients in income level Q3 (HR: 0.77; 95% CI: 0.60-0.99) and Q4 (HR: 0.68; 95% CI: 0.50-0.92) than Q1. The risk of death from intracranial hemorrhage was five times higher in the lowest income quartile than the age- and sex-matched general Swedish population (standardized mortality ratio: 5.0; 95% CI: 3.3-7.4).
Conclusions
We observed a strong association between SES and risk of bleeding among patients who underwent mechanical AVR. These findings suggest suboptimal anticoagulation treatment in patients with lower SES and the need for strategies to optimize anticoagulation treatment in patients with a mechanical heart valve. (Health-Data Register Studies of Risk and Outcomes in Cardiac Surgery [HARTROCS]; NCT02276950).

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 28 Jun 2022; 79:2502-2513
Dalén M, Persson M, Glaser N, Sartipy U
J Am Coll Cardiol: 28 Jun 2022; 79:2502-2513 | PMID: 35738711
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Abstract

Medicare Coverage and Out-of-Pocket Costs of Quadruple Drug Therapy for Heart Failure.

Faridi KF, Dayoub EJ, Ross JS, Dhruva SS, Ahmad T, Desai NR
Background
Beta-blockers, angiotensin receptor-neprilysin inhibitor (ARNI), mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors (SGLT2i), known as quadruple therapy, are recommended for patients with heart failure with reduced ejection fraction (HFrEF).
Objectives
This study sought to determine Medicare coverage and out-of-pocket (OOP) costs of quadruple therapy and regimens excluding ARNI or SGLT2i.
Methods
This study assessed cost sharing, prior authorization, and step therapy in all 4,068 Medicare prescription drug plans in 2020. OOP costs were determined during the standard coverage period and annually based on the Medicare Part D standard benefit, inclusive of deductible, standard coverage, coverage gap, and catastrophic coverage.
Results
Tier ≥3 cost sharing was required by 99.1% of plans for ARNI and 98.5% for at least 1 SGLT2i. Only ARNI required prior authorization (24.3% of plans), and step therapy was required only for SGLT2is (5.4%) and eplerenone (0.8%). The median 30-day standard coverage OOP cost of quadruple therapy was $94 (IQR: $84-$100), including $47 (IQR: $40-$47) for ARNI and $45 (IQR: $40-$47) for SGLT2i. The median annual OOP cost of quadruple therapy was $2,217 (IQR: $1,956-$2,579) compared with $1,319 (IQR: $1,067-$1,675) when excluding SGLT2i and $1,322 (IQR: $1,025-$1,588) when including SGLT2i and substituting an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for ARNI. The median 30-day OOP cost of generic regimens was $3 (IQR: $0-$9).
Conclusions
Medicare drug plans restrict coverage of quadruple therapy through cost sharing, with OOP costs that are substantially higher than generic regimens. Quadruple therapy may be unaffordable for many Medicare patients with HFrEF unless medication prices and cost sharing are reduced.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 28 Jun 2022; 79:2516-2525
Faridi KF, Dayoub EJ, Ross JS, Dhruva SS, Ahmad T, Desai NR
J Am Coll Cardiol: 28 Jun 2022; 79:2516-2525 | PMID: 35738713
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Abstract

Pericardial Effusion Provoking Atrial Fibrillation After Cardiac Surgery: JACC Review Topic of the Week.

Gaudino M, Di Franco A, Rong LQ, Cao D, ... DiMaio JM, Girardi LN
Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery. Patients who develop POAF are more likely to experience adverse outcomes, including increased rates of death, stroke, heart failure, and hospitalizations, and higher hospital costs. Understanding the mechanisms underlying POAF is important to improve patients\' outcome and optimize health systems\' efficiency. Beyond classic pathogenic hypotheses, emerging evidence suggests that postoperative pericardial effusion and localized pericardial inflammation may trigger POAF. This hypothesis is supported by data from nonhuman animal models and a growing body of evidence showing that reducing postoperative pericardial effusion might reduce POAF incidence. In this review, we summarize the classic pathophysiology theories of POAF following cardiac surgery and discuss new etiologic mechanisms with a specific focus on the role of pericardial effusion and inflammation.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 28 Jun 2022; 79:2529-2539
Gaudino M, Di Franco A, Rong LQ, Cao D, ... DiMaio JM, Girardi LN
J Am Coll Cardiol: 28 Jun 2022; 79:2529-2539 | PMID: 35738715
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Abstract

Safety of Provocative Testing With Intracoronary Acetylcholine and Implications for Standard Protocols.

Takahashi T, Samuels BA, Li W, Parikh MA, ... Kobayashi Y, Microvascular Network
Background
Heterogeneity in diagnostic criteria and provocation protocols has posed challenges in understanding the safety of coronary provocation testing with intracoronary acetylcholine (ACh) for the contemporary diagnosis of epicardial and microvascular spasm.
Objectives
We examined the safety of testing and subgroup differences in procedural risks based on ethnicity, diagnostic criteria, and provocation protocols.
Methods
PubMed and Embase were searched in November 2021 to identify original articles reporting procedural complications associated with intracoronary ACh administration. The primary outcome was the pooled estimate of the incidence of major complications including death, myocardial infarction, ventricular tachycardia/fibrillation, and shock.
Results
A total of 16 studies with 12,585 patients were included in the meta-analysis. The overall pooled estimate of the incidence of major complications was 0.5% (95% CI: 0.0%-1.3%) without any reports of death. Exploratory subgroup analyses revealed that the pooled incidence of major complications was significantly higher in the studies that followed the contemporary diagnosis criteria for epicardial spasm defined as ≥90% diameter reduction (1.0%; 95% CI: 0.3%-2.0%) but significantly lower in Western populations (0.0%; 95% CI: 0.0%-0.45%). The rate of positive epicardial spasm and the incidence of major complications were similar between provocation protocols using the maximum ACh doses of 100 μg and 200 μg.
Conclusions
Intracoronary ACh administration for the contemporary diagnosis of epicardial and microvascular spasm is a safe procedure. Moreover, excellent safety records are observed in Western populations primarily presenting with myocardial ischemia and/or infarction with nonobstructive coronary arteries. This study will help standardize ACh testing to improve clinical diagnosis and ensure procedural safety.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 21 Jun 2022; 79:2367-2378
Takahashi T, Samuels BA, Li W, Parikh MA, ... Kobayashi Y, Microvascular Network
J Am Coll Cardiol: 21 Jun 2022; 79:2367-2378 | PMID: 35710187
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Abstract

Elevated Remnant Cholesterol Reclassifies Risk of Ischemic Heart Disease and Myocardial Infarction.

Doi T, Langsted A, Nordestgaard BG
Background
Elevated remnant cholesterol causes ischemic heart disease.
Objectives
We tested the hypothesis that the inclusion of elevated remnant cholesterol will lead to appropriate reclassification of individuals who later experience myocardial infarction and ischemic heart disease.
Methods
For >10 years we followed up 41,928 white Danish individuals from the Copenhagen General Population Study without a history of ischemic cardiovascular disease, diabetes, and statin use. Using predefined cut points for elevated remnant cholesterol, we calculated net reclassification index (NRI) from below to above 5%, 7.5%, and/or 10% 10-year occurrence of myocardial infarction and ischemic heart disease defined as a composite of death from ischemic heart disease, myocardial infarction, and coronary revascularization.
Results
For individuals with remnant cholesterol levels ≥95th percentile (≥1.6 mmol/L, 61 mg/dL), 23% (P < 0.001) of myocardial infarction and 21% (P < 0.001) of ischemic heart disease were reclassified correctly from below to above 5% for 10-year occurrence when remnant cholesterol levels were added to models based on conventional risk factors, whereas no events were reclassified incorrectly. Consequently, the addition of remnant cholesterol levels yielded NRI of 10% (95% CI: 1%-20%) for myocardial infarction and 5% (95% CI: -3% to 13%) for ischemic heart disease. Correspondingly, when reclassifications were combined from below to above 5%, 7.5%, and 10% risk of events, 42% (P < 0.001) of individuals with myocardial infarction and 41% (P < 0.001) with ischemic heart disease were reclassified appropriately, leading to NRI of respectively 20% (95% CI: 9%-31%) and 11% (95% CI: 2%-21%).
Conclusions
Elevated remnant cholesterol levels considerably improve myocardial infarction and ischemic heart disease risk prediction.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 21 Jun 2022; 79:2383-2397
Doi T, Langsted A, Nordestgaard BG
J Am Coll Cardiol: 21 Jun 2022; 79:2383-2397 | PMID: 35710189
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Abstract

Prospective Evaluation of Cardiovascular Risk 10 Years After a Hypertensive Disorder of Pregnancy.

Levine LD, Ky B, Chirinos JA, Koshinksi J, ... Koelper N, Lewey J
Background
Hypertensive disorders of pregnancy (HDP) are associated with increased risk of cardiovascular disease (CVD) 20-30 years later; however, cardiovascular (CV) risk in the decade after HDP is less studied.
Objectives
The purpose of this study was to evaluate differences in CV risk factors as well as subclinical CVD among a well-characterized group of racially diverse patients with and without a history of HDP 10 years earlier.
Methods
This is a prospective study of patients with and without a diagnosis of HDP ≥10 years earlier (2005-2007) who underwent in-person visits with echocardiography, arterial tonometry, and flow-mediated dilation of the brachial artery.
Results
A total of 135 patients completed assessments (84 with and 51 without a history of HDP); 85% self-identified as Black. Patients with a history of HDP had a 2.4-fold increased risk of new hypertension compared with those without HDP (56.0% vs. 23.5%; adjusted relative risk: 2.4; 95% CI: 1.39-4.14) with no differences in measures of left ventricular structure, global longitudinal strain, diastolic function, arterial stiffness, or endothelial function. Patients who developed hypertension, regardless of HDP history, had greater left ventricular remodeling, including greater relative wall thickness; worse diastolic function, including lower septal and lateral e\' and E/A ratio; more abnormal longitudinal strain; and higher effective arterial elastance than patients without hypertension.
Conclusions
We found a 2.4-fold increased risk of hypertension 10 years after HDP. Differences in noninvasive measures of CV risk were driven mostly by the hypertension diagnosis, regardless of HDP history, suggesting that the known long-term risk of CVD after HDP may primarily be a consequence of hypertension development.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 21 Jun 2022; 79:2401-2411
Levine LD, Ky B, Chirinos JA, Koshinksi J, ... Koelper N, Lewey J
J Am Coll Cardiol: 21 Jun 2022; 79:2401-2411 | PMID: 35710191
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Abstract

False Lumen Flow Assessment by Magnetic Resonance Imaging and Long-Term Outcomes in Uncomplicated Aortic Dissection.

Evangelista A, Pineda V, Guala A, Bijnens B, ... Ferreira I, Rodríguez-Palomares J
Background
Despite the absence of clinical complications after an acute aortic dissection (AD) with persistent patent false lumen (FL), a high risk for clinical events may persist.
Objectives
The aim of this study was to assess the natural evolution of noncomplicated AD and ascertain whether different FL flow patterns by magnetic resonance imaging (MRI) have independent prognostic value for AD-related events beyond established morphologic parameters.
Methods
One hundred thirty-one consecutive patients, 78 with surgically treated type A dissections and 53 with medically treated type B dissections, were followed up prospectively after acute AD with persistent patent FL in the descending aorta. Maximum aortic diameter, true lumen compression, entry tear, and partial FL thrombosis by computed tomography were assessed. Systolic antegrade true lumen and FL flow volumes and diastolic antegrade and retrograde flows were analyzed by MRI during the first year after AD.
Results
After a median follow-up period of 8.0 years (IQR: 4.6-10.9 years), 43 patients presented aorta-related events (25 died and 18 required endovascular treatment). FL systolic antegrade flow ≥30% with respect to total systolic antegrade flow and retrograde diastolic flow ≥80% with respect to total diastolic FL flow were predictors of aortic events. In multivariate analysis, aortic diameter >45 mm (HR: 2.91), type B dissection (HR: 2.44), and MRI flow pattern (HR: 16.87) were independent predictors of AD-related events.
Conclusions
High systolic antegrade flow volume in the FL with significant diastolic retrograde flow assessed by MRI and aortic diameter >45 mm identify patients with higher risk for complications in whom more aggressive management would be indicated.

Copyright © 2022. Published by Elsevier Inc.

J Am Coll Cardiol: 21 Jun 2022; 79:2415-2427
Evangelista A, Pineda V, Guala A, Bijnens B, ... Ferreira I, Rodríguez-Palomares J
J Am Coll Cardiol: 21 Jun 2022; 79:2415-2427 | PMID: 35710193
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Abstract

Causes, Angiographic Characteristics, and Management of Premature Myocardial Infarction: JACC State-of-the-Art Review.

Rallidis LS, Xenogiannis I, Brilakis ES, Bhatt DL
Among patients presenting with acute myocardial infarction (AMI), the proportion of young individuals has increased in recent years. Although coronary atherosclerosis is less extensive in young patients with AMI, with higher prevalence of single-vessel disease and rare left main involvement, the long-term prognosis is not benign. Young patients with AMI with obstructive coronary artery disease have similar risk factors as older patients except for higher prevalence of smoking, lipid disorders, and family history of premature coronary artery disease, and lower prevalence of diabetes mellitus and hypertension. Smoking cessation is by far the most effective secondary preventive measure. Myocardial infarction with nonobstructive coronary arteries is a relatively common clinical entity (10%-20%) among young patients with AMI, with intravascular and cardiac magnetic resonance imaging being key for diagnosis and potentially treatment. Spontaneous coronary artery dissection is a frequent pathogenetic mechanism of AMI among young women, requiring a high degree of suspicion, especially in the peripartum period.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 21 Jun 2022; 79:2431-2449
Rallidis LS, Xenogiannis I, Brilakis ES, Bhatt DL
J Am Coll Cardiol: 21 Jun 2022; 79:2431-2449 | PMID: 35710195
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Abstract

Inappropriate Sinus Tachycardia: Etiology, Pathophysiology, and Management: JACC Review Topic of the Week.

Ahmed A, Pothineni NVK, Charate R, Garg J, ... Gopinathannair R, Lakkireddy D
Inappropriate sinus tachycardia (IST) is a clinical syndrome that generally affects young patients and is associated with distressing symptoms. Although the most common symptom is palpitations, it can be accompanied by a myriad of symptoms, including anxiety, dizziness, presyncope, and syncope. The pathogenesis of IST is not well understood and considered multifactorial, with autonomic dysfunction being the central abnormality. IST is a diagnosis of exclusion. Management presents a clinical challenge. The overall efficacy of lifestyle modifications and medical therapy may be limited. Recent advances in catheter and surgical sinus node sparing ablation techniques have led to improvement in outcomes. In addition, increased focus has led to development of multimodality team-based interventions to improve outcomes in this group of patients. In this review, we discuss the mechanistic basis of IST, review current approaches to diagnosis, and outline contemporary therapeutic approaches.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 21 Jun 2022; 79:2450-2462
Ahmed A, Pothineni NVK, Charate R, Garg J, ... Gopinathannair R, Lakkireddy D
J Am Coll Cardiol: 21 Jun 2022; 79:2450-2462 | PMID: 35710196
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Abstract

Diabetes and Progression of Heart Failure: The Atherosclerosis Risk In Communities (ARIC) Study.

Echouffo-Tcheugui JB, Ndumele CE, Zhang S, Florido R, ... Shah AM, Selvin E
Background
The influence of diabetes on progression from preclinical heart failure (HF) stages to overt HF is poorly understood.
Objectives
The purpose of this study was to characterize the influence of diabetes on the progression from preclinical HF stages (A or B based on the 2021 Universal Definition) to overt HF.
Methods
We included 4,774 adults with preclinical HF (stage A [n = 1,551] or B [n = 3,223]) who attended the ARIC (Atherosclerosis Risk In Communities) study Visit 5 (2011-2013). Within each stage (A or B), we assessed the associations of diabetes and glycemic control (hemoglobin A1C [HbA1C] <7% vs ≥7%) with progression to HF, and of cross-categories of HF stages (A vs B), diabetes, and glycemic control with incident HF.
Results
Among the participants (mean age 75.4 years, 58% women, 20% Black), there were 470 HF events during 8.6 years of follow-up. Stage B participants with HbA1C ≥7% experienced clinical HF at a younger age than those with controlled diabetes or without diabetes (mean age 80 years vs 83 years vs 82 years; P < 0.001). HbA1C ≥7% was more strongly associated with HF in stage B (HR: 1.83; 95% CI: 1.33-2.51) compared with stage A (HR: 1.52; 95% CI: 0.53-4.38). In cross-categories of preclinical HF stage and HbA1C, participants with stage B and HbA1C ≥7% had increased risk of HF progression compared with stage A without diabetes (HR: 7.56; 95% CI: 4.68-12.20).
Conclusions
Among older adults with preclinical HF stages, uncontrolled diabetes was associated with substantial risk of HF progression. Our results suggest that targeting diabetes early in the HF process is critical.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 14 Jun 2022; 79:2285-2293
Echouffo-Tcheugui JB, Ndumele CE, Zhang S, Florido R, ... Shah AM, Selvin E
J Am Coll Cardiol: 14 Jun 2022; 79:2285-2293 | PMID: 35680178
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Abstract

Cigarette Smoking, Cessation, and Risk of Heart Failure With Preserved and Reduced Ejection Fraction.

Ding N, Shah AM, Blaha MJ, Chang PP, Rosamond WD, Matsushita K
Background
Smoking is well-recognized as a risk factor for heart failure (HF). However, few studies have evaluated the prospective association of cigarette smoking and smoking cessation with heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) as distinct phenotypes.
Objectives
The aim of this study was to quantify the association of cigarette smoking and smoking cessation with the incidence of HFpEF and HFrEF.
Methods
In 9,345 ARIC (Atherosclerosis Risk In Communities) study White and Black participants without history of HF at baseline in 2005 (age range 61-81 years), we quantified the associations of several established cigarette smoking parameters (smoking status, pack-years, intensity, duration, and years since cessation) with physician-adjudicated incident acute decompensated HF using multivariable Cox models.
Results
Over a median follow-up of 13.0 years, there were 1,215 incident HF cases. Compared with never smokers, current cigarette smoking was similarly associated with HFpEF and HFrEF, with adjusted HRs ∼2. There was a dose-response relationship for pack-years of smoking and HF. A more extended period of smoking cessation was associated with a lower risk of HF, but significantly elevated risk persisted up to a few decades for HFpEF and HFrEF.
Conclusions
All cigarette smoking parameters consistently showed significant and similar associations with HFpEF and HFrEF. Smoking cessation significantly reduced the risk of HF, but excess HF risk persisted for a few decades. Our results strengthened the evidence that smoking is an important modifiable risk factor for HF and highlighted the importance of smoking prevention and cessation for the prevention of HF, including HFpEF.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 14 Jun 2022; 79:2298-2305
Ding N, Shah AM, Blaha MJ, Chang PP, Rosamond WD, Matsushita K
J Am Coll Cardiol: 14 Jun 2022; 79:2298-2305 | PMID: 35680180
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Abstract

Early Coronary Atherosclerosis in Women With Previous Preeclampsia.

Hauge MG, Damm P, Kofoed KF, Ersbøll AS, ... Gustafsson F, Linde JJ
Background
Women with previous preeclampsia have an increased risk of coronary artery disease later in life.
Objectives
This study aimed to determine the prevalence of coronary atherosclerosis in younger women with previous preeclampsia in comparison with women from the general population.
Methods
Women aged 40-55 years with previous preeclampsia were matched 1:1 on age and parity with women from the general population. Participants completed an extensive questionnaire, a clinical examination, and a coronary computed tomography angiography (CTA). The main study outcome was the prevalence of any coronary atherosclerosis on coronary CTA or a calcium score >0 in case of a nondiagnostic coronary CTA.
Results
A total of 1,417 women, with a mean age of 47 years, were included (708 women with previous preeclampsia and 709 control subjects from the general population). Women with previous preeclampsia were more likely to have hypertension (284 [40.1%] vs 162 [22.8%]; P < 0.001), dyslipidemia (338 [47.7%] vs 296 [41.7%]; P = 0.023), diabetes mellitus (24 [3.4%] vs 8 [1.1%]; P = 0.004), and high body mass index (27.3 ± 5.7 kg/m2 vs 25.0 ± 4.2 kg/m2; P < 0.001). Cardiac computed tomography was performed in all women. The prevalence of any coronary atherosclerosis was higher in the preeclampsia group (193 [27.4%] vs 141 [20.0%]; P = 0.001) with an OR: 1.41 (95% CI: 1.08-1.85; P = 0.012) after adjustment for age, dyslipidemia, diabetes mellitus, smoking, body mass index, menopause, and parity.
Conclusions
Younger women with previous preeclampsia had a slightly higher prevalence of coronary atherosclerosis compared with age- and parity-matched women from the general population. Preeclampsia remained an independent risk factor after adjustment for traditional cardiovascular risk factors. (The CoPenHagen PREeClampsia and cardIOvascUlar diSease study [CPH-PRECIOUS]; NCT03949829).

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 14 Jun 2022; 79:2310-2321
Hauge MG, Damm P, Kofoed KF, Ersbøll AS, ... Gustafsson F, Linde JJ
J Am Coll Cardiol: 14 Jun 2022; 79:2310-2321 | PMID: 35680182
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Abstract

Care Models for Acute Chest Pain That Improve Outcomes and Efficiency: JACC State-of-the-Art Review.

Dawson LP, Smith K, Cullen L, Nehme Z, ... Taylor AJ, Stub D
Existing assessment pathways for acute chest pain are often resource-intensive, prolonged, and expensive. In this review, the authors describe existing chest pain pathways and current issues at the patient and system level, and provide an overview of recent advances in chest pain research that could inform improved outcomes for both patients and health systems. There are multiple avenues to improve existing models of chest pain care, including novel risk stratification pathways incorporating highly sensitive point-of-care troponin assays; new devices available before first medical contact that could allow clinicians to access vital signs and electrocardiogram data; artificial intelligence and precision medicine tools that may guide indications for further testing; and strategies to improve hospital benchmarking and performance monitoring to standardize care. Improving the speed and accuracy of chest pain diagnosis and management should be a priority for researchers and is likely to translate to substantive benefits for patients and health systems.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 14 Jun 2022; 79:2333-2348
Dawson LP, Smith K, Cullen L, Nehme Z, ... Taylor AJ, Stub D
J Am Coll Cardiol: 14 Jun 2022; 79:2333-2348 | PMID: 35680185
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Abstract

Inflammasome Signaling in Atrial Fibrillation: JACC State-of-the-Art Review.

Ajoolabady A, Nattel S, Lip GYH, Ren J
As the most prevalent form of arrhythmia, atrial fibrillation (AF) increases the risk of heart failure, thromboembolism, and stroke, contributing to the raising mortality and morbidity in patients with cardiovascular diseases. Despite the multifaceted nature of AF pathogenesis and complexity of AF pathophysiology, a growing body of evidence indicates that the NLRP3 inflammasome activation contributes to onset and progression of AF. Herein, the authors aim at reviewing the current literature on the role of inflammasome signaling in AF pathogenesis, and novel therapeutic options in the management of AF.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 14 Jun 2022; 79:2349-2366
Ajoolabady A, Nattel S, Lip GYH, Ren J
J Am Coll Cardiol: 14 Jun 2022; 79:2349-2366 | PMID: 35680186
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Abstract

Precision Phenotyping of Dilated Cardiomyopathy Using Multidimensional Data.

Tayal U, Verdonschot JAJ, Hazebroek MR, Howard J, ... Heymans SRB, Prasad SK
Background
Dilated cardiomyopathy (DCM) is a final common manifestation of heterogenous etiologies. Adverse outcomes highlight the need for disease stratification beyond ejection fraction.
Objectives
The purpose of this study was to identify novel, reproducible subphenotypes of DCM using multiparametric data for improved patient stratification.
Methods
Longitudinal, observational UK-derivation (n = 426; median age 54 years; 67% men) and Dutch-validation (n = 239; median age 56 years; 64% men) cohorts of DCM patients (enrolled 2009-2016) with clinical, genetic, cardiovascular magnetic resonance, and proteomic assessments. Machine learning with profile regression identified novel disease subtypes. Penalized multinomial logistic regression was used for validation. Nested Cox models compared novel groupings to conventional risk measures. Primary composite outcome was cardiovascular death, heart failure, or arrhythmia events (median follow-up 4 years).
Results
In total, 3 novel DCM subtypes were identified: profibrotic metabolic, mild nonfibrotic, and biventricular impairment. Prognosis differed between subtypes in both the derivation (P < 0.0001) and validation cohorts. The novel profibrotic metabolic subtype had more diabetes, universal myocardial fibrosis, preserved right ventricular function, and elevated creatinine. For clinical application, 5 variables were sufficient for classification (left and right ventricular end-systolic volumes, left atrial volume, myocardial fibrosis, and creatinine). Adding the novel DCM subtype improved the C-statistic from 0.60 to 0.76. Interleukin-4 receptor-alpha was identified as a novel prognostic biomarker in derivation (HR: 3.6; 95% CI: 1.9-6.5; P = 0.00002) and validation cohorts (HR: 1.94; 95% CI: 1.3-2.8; P = 0.00005).
Conclusions
Three reproducible, mechanistically distinct DCM subtypes were identified using widely available clinical and biological data, adding prognostic value to traditional risk models. They may improve patient selection for novel interventions, thereby enabling precision medicine.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 07 Jun 2022; 79:2219-2232
Tayal U, Verdonschot JAJ, Hazebroek MR, Howard J, ... Heymans SRB, Prasad SK
J Am Coll Cardiol: 07 Jun 2022; 79:2219-2232 | PMID: 35654493
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Abstract

Transcatheter Closure of Atrial and Ventricular Septal Defects: JACC Focus Seminar.

Turner ME, Bouhout I, Petit CJ, Kalfa D
The field of congenital interventional cardiology has experienced tremendous growth in recent years. Beginning with the development of early devices for transcatheter closure of septal defects in the 1970s and 1980s, such technologies have evolved to become a mainstay of treatment for many atrial septal defects (ASDs) and ventricular septal defects (VSDs). Percutaneous device closure is now the preferred approach for the majority of secundum ASDs. It is also a viable treatment option for selected VSDs, though limitations still exist. In this review, the authors describe the current state of transcatheter closure of ASDs and VSDs in children and adults, including patient selection, procedural approach, and outcomes. Potential areas for future evolution and innovation are also discussed.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 07 Jun 2022; 79:2247-2258
Turner ME, Bouhout I, Petit CJ, Kalfa D
J Am Coll Cardiol: 07 Jun 2022; 79:2247-2258 | PMID: 35654496
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Abstract

Interventions for Congenital Atrioventricular Valve Dysfunction: JACC Focus Seminar.

Barry OM, Bouhout I, Kodali SK, George I, ... Petit CJ, Kalfa D
Innovation and creativity have led to tremendous advancements in the care and management of patients with congenital heart disease (CHD) that have resulted in considerably increased survival. Catheter-based interventions have contributed significantly to these advancements. However, catheter-based interventions for congenital lesions of the atrioventricular (AV) valves have been limited in scope and effectiveness mainly because of patient size and anatomical challenges. Thus, surgical repair and replacement for congenital AV valve lesions have remained the preferred therapy. However, the ongoing transcatheter heart valve revolution has led to techniques and technologies that are changing the landscape, particularly for adult CHD patients. Many devices for AV valve repair and replacement are being studied in adult patients without CHD, and translation of select practices to CHD patients has begun, with many more to come. Transcatheter AV valve interventions represent exciting opportunities for the growing numbers of adult CHD patients.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 07 Jun 2022; 79:2259-2269
Barry OM, Bouhout I, Kodali SK, George I, ... Petit CJ, Kalfa D
J Am Coll Cardiol: 07 Jun 2022; 79:2259-2269 | PMID: 35654497
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Abstract

Transcatheter Cardiac Interventions in the Newborn: JACC Focus Seminar.

Barry OM, Bouhout I, Turner ME, Petit CJ, Kalfa DM
For neonates with critical congenital heart disease requiring intervention, transcatheter approaches for many conditions have been established over the past decades. These interventions may serve to stabilize or palliate to surgical next steps or effectively primarily treat the condition. Many transcatheter interventions have evidence-based records of effectiveness and safety, which have led to widespread acceptance as first-line therapies. Other techniques continue to innovatively push the envelope and challenge the optimal strategies for high-risk neonates with right ventricular outflow tract obstruction or ductal-dependent pulmonary blood flow. In this review, the most commonly performed neonatal transcatheter interventions will be described to illustrate the current state of the field and highlight areas of future opportunity.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 07 Jun 2022; 79:2270-2283
Barry OM, Bouhout I, Turner ME, Petit CJ, Kalfa DM
J Am Coll Cardiol: 07 Jun 2022; 79:2270-2283 | PMID: 35654498
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Abstract

Cardiovascular Outcomes in Aortopathy: GenTAC Registry of Genetically Triggered Aortic Aneurysms and Related Conditions.

Holmes KW, Markwardt S, Eagle KA, Devereux RB, ... Roman MJ, GenTAC Investigators
Background
The GenTAC (Genetically Triggered Thoracic Aortic Aneurysm and Cardiovascular Conditions) Registry enrolled patients with genetic aortopathies between 2007 and 2016.
Objectives
The purpose of this study was to compare age distribution and probability of elective surgery for proximal aortic aneurysm, any dissection surgery, and cardiovascular mortality among aortopathy etiologies.
Methods
The GenTAC study had a retrospective/prospective design. Participants with bicuspid aortic valve (BAV) with aneurysm (n = 879), Marfan syndrome (MFS) (n = 861), nonsyndromic heritable thoracic aortic disease (nsHTAD) (n = 378), Turner syndrome (TS) (n = 298), vascular Ehlers-Danlos syndrome (vEDS) (n = 149), and Loeys-Dietz syndrome (LDS) (n = 121) were analyzed.
Results
The 25% probability of elective proximal aortic aneurysm surgery was 30 years for LDS (95% CI: 18-37 years), followed by MFS (34 years; 95% CI: 32-36 years), nsHTAD (52 years; 95% CI: 48-56 years), and BAV (55 years; 95% CI: 53-58 years). Any dissection surgery 25% probability was highest in LDS (38 years; 95% CI: 33-53 years) followed by MFS (51 years; 95% CI: 46-57 years) and nsHTAD (54 years; 95% CI: 51-61 years). BAV experienced the largest relative frequency of elective surgery to any dissection surgery (254/33 = 7.7), compared with MFS (273/112 = 2.4), LDS (35/16 = 2.2), or nsHTAD (82/76 = 1.1). With MFS as the reference population, risk of any dissection surgery or cardiovascular mortality was lowest in BAV patients (HR: 0.13; 95% CI: 0.08-0.18; HR: 0.13; 95%: CI: 0.06-0.27, respectively). The greatest risk of mortality was seen in patients with vEDS.
Conclusions
Marfan and LDS cohorts demonstrate age and event profiles congruent with the current understanding of syndromic aortopathies. BAV events weigh toward elective replacement with relatively few dissection surgeries. Nonsyndromic HTAD patients experience near equal probability of dissection vs prophylactic surgery, possibly because of failure of early diagnosis.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 31 May 2022; 79:2069-2081
Holmes KW, Markwardt S, Eagle KA, Devereux RB, ... Roman MJ, GenTAC Investigators
J Am Coll Cardiol: 31 May 2022; 79:2069-2081 | PMID: 35618343
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Abstract

Gender Differences in Takotsubo Syndrome.

Arcari L, Núñez Gil IJ, Stiermaier T, El-Battrawy I, ... Eitel I, Santoro F
Background
Male sex in takotsubo syndrome (TTS) has a low incidence and it is still not well characterized.
Objectives
The aim of the present study is to describe TTS sex differences.
Methods
TTS patients enrolled in the international multicenter GEIST (GErman Italian Spanish Takotsubo) registry were analyzed. Comparisons between sexes were performed within the overall cohort and using an adjusted analysis with 1:1 propensity score matching for age, comorbidities, and kind of trigger.
Results
In total, 286 (11%) of 2,492 TTS patients were men. Male patients were younger (age 69 ± 13 years vs 71 ± 11 years; P = 0.005), with higher prevalence of comorbid conditions (diabetes mellitus 25% vs 19%; P = 0.01; pulmonary diseases 21% vs 15%; P = 0.006; malignancies 25% vs 13%; P < 0.001) and physical trigger (55 vs 32% P < 0.01). Propensity-score matching yielded 207 patients from each group. After 1:1 propensity matching, male patients had higher rates of cardiogenic shock and in-hospital mortality (16% vs 6% and 8% vs 3%, respectively; both P < 0.05). Long-term mortality rate was 4.3% per patient-year (men 10%, women 3.8%). Survival analysis showed higher mortality rate in men during the acute phase in both cohorts (overall: P < 0.001; matched: P = 0.001); mortality rate after 60 days was higher in men in the overall (P = 0.002) but not in the matched cohort (P = 0.541). Within the overall population, male sex remained independently associated with both in-hospital (OR: 2.26; 95% CI: 1.16-4.40) and long-term mortality (HR: 1.83; 95% CI: 1.32-2.52).
Conclusions
Male TTS is featured by a distinct high-risk phenotype requiring close in-hospital monitoring and long-term follow-up.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 31 May 2022; 79:2085-2093
Arcari L, Núñez Gil IJ, Stiermaier T, El-Battrawy I, ... Eitel I, Santoro F
J Am Coll Cardiol: 31 May 2022; 79:2085-2093 | PMID: 35618345
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Abstract

Disruption of Circadian Rhythms by Shift Work Exacerbates Reperfusion Injury in Myocardial Infarction.

Zhao Y, Lu X, Wan F, Gao L, ... Ji Y, Pu J
Background
Shift work is associated with increased risk of acute myocardial infarction (AMI) and worsened prognosis. However, the mechanisms linking shift work and worsened prognosis in AMI remain unclear.
Objectives
This study sought to investigate the impact of shift work on reperfusion injury, a major determinant of clinical outcomes in AMI.
Methods
Study patient data were obtained from the database of the EARLY-MYO-CMR (Early Assessment of Myocardial Tissue Characteristics by CMR in STEMI) registry, which was a prospective, multicenter registry of patients with ST-segment elevation myocardial infarction (STEMI) undergoing cardiac magnetic resonance (CMR) imaging after reperfusion therapy. The primary endpoint was CMR-defined post-reperfusion infarct size. A secondary clinical endpoint was the composite of major adverse cardiac events (MACE) during follow-up. Potential mechanisms were explored with the use of preclinical animal AMI models.
Results
Of 706 patients enrolled in the EARLY-MYO-CMR registry, 412 patients with STEMI were ultimately included. Shift work was associated with increased CMR-defined infarct size (β = 5.94%; 95% CI: 2.94-8.94; P < 0.0001). During a median follow-up of 5.0 years, shift work was associated with increased risks of MACE (adjusted HR: 1.92; 95% CI: 1.12-3.29; P = 0.017). Consistent with clinical findings, shift work simulation in mice and sheep significantly augmented reperfusion injury in AMI. Mechanism studies identified a novel nuclear receptor subfamily 1 group D member 1/cardiotrophin-like cytokine factor 1 axis in the heart that played a crucial role in mediating the detrimental effects of shift work on myocardial injury.
Conclusions
The current study provided novel findings that shift work increases myocardial infarction reperfusion injury. It identified a novel nuclear receptor subfamily 1 group D member 1/cardiotrophin-like cytokine factor 1 axis in the heart that might play a crucial role in mediating this process. (Early Assessment of Myocardial Tissue Characteristics by CMR in STEMI [EARLY-MYO-CMR] registry; NCT03768453).

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 31 May 2022; 79:2097-2115
Zhao Y, Lu X, Wan F, Gao L, ... Ji Y, Pu J
J Am Coll Cardiol: 31 May 2022; 79:2097-2115 | PMID: 35618347
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Abstract

Becoming a Parent During Cardiovascular Training.

Oliveros E, Burgess S, Nadella N, Davidson L, ... DeFaria Yeh D, Park K
Background
Specialty training in cardiovascular diseases is consistently perceived to have adverse job conditions and interfere with family life. There is a dearth of universal workforce support for trainees who become parents during training.
Objectives
This study sought to identify parental policies across cardiovascular training programs internationally.
Methods
An Internet-based international survey study available from August 2020 to October 2020 was sent via social media. The survey was administered 1 time and anonymously. Participants shared experiences regarding parental benefits/policies and perception of barriers for trainees. Participants were divided into 3 groups: training program directors, trainees pregnant during cardiology fellowship, and trainees not pregnant during training.
Results
A total of 417 replies were received from physicians, including 47 responses (11.3%) from training program directors, 146 responses (35%) from current or former trainees pregnant during cardiology training, and 224 responses (53.7%) from current or former trainees that were not pregnant during cardiology training. Among trainees, 280 (67.1%) were parents during training. Family benefits and policies were not uniformly available across institutions, and knowledge regarding the existence of such policies was low. Average parental leave ranged from 1 to 2 months in the United States compared with >4 months outside the United States, and in all countries, paternity leave was uncommon (only 11 participants [2.6%]). Coverage during family leave was primarily provided by peers (n = 184 [44.1%]), and 168 (91.3%) were without additional monetary or time compensation.
Conclusions
This is the first international survey evaluating and comparing parental benefits and policies among cardiovascular training programs. There is great variability among institutions, highlighting disparities in real-world experiences.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 31 May 2022; 79:2119-2126
Oliveros E, Burgess S, Nadella N, Davidson L, ... DeFaria Yeh D, Park K
J Am Coll Cardiol: 31 May 2022; 79:2119-2126 | PMID: 35618349
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Abstract

Call for Formalized Pathways in Vascular Medicine Training: JACC Review Topic of the Week.

Eberhardt RT, Bonaca MP, Abu Daya H, Garcia LA, ... Young MN, Piazza G
The burden of vascular diseases and complexity of their management have been growing. Vascular medicine specialists may help to bridge gaps in care, especially as part of multidisciplinary teams. However, there is a limited number of vascular medicine specialists because of constraints in training. Despite established pathways for training in vascular medicine, there are obstacles that restrict completion of training in dedicated programs. A key factor is lack of funding as a result of inadequate recognition by key national accrediting and credentialing organizations. A concerted effort is required to overcome the obstacles to expand vascular medicine training programs and ultimately the pool of vascular medicine specialists. Well-trained vascular medicine specialists will be well positioned to ease the burden of vascular disease and optimize patient outcomes.

Copyright © 2022 American College of Cardiology Foundation. All rights reserved.

J Am Coll Cardiol: 31 May 2022; 79:2129-2139
Eberhardt RT, Bonaca MP, Abu Daya H, Garcia LA, ... Young MN, Piazza G
J Am Coll Cardiol: 31 May 2022; 79:2129-2139 | PMID: 35618351
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Abstract

Association of Thromboxane Generation With Survival in Aspirin Users and Nonusers.

Rade JJ, Barton BA, Vasan RS, Kronsberg SS, ... Kakouros N, Kickler TA
Background
Persistent systemic thromboxane generation, predominantly from nonplatelet sources, in aspirin (ASA) users with cardiovascular disease (CVD) is a mortality risk factor.
Objectives
This study sought to determine the mortality risk associated with systemic thromboxane generation in an unselected population irrespective of ASA use.
Methods
Stable thromboxane B2 metabolites (TXB2-M) were measured by enzyme-linked immunosorbent assay in banked urine from 3,044 participants (mean age 66 ± 9 years, 53.8% women) in the Framingham Heart Study. The association of TXB2-M to survival over a median observation period of 11.9 years (IQR: 10.6-12.7 years) was determined by multivariable modeling.
Results
In 1,363 (44.8%) participants taking ASA at the index examination, median TXB2-M were lower than in ASA nonusers (1,147 pg/mg creatinine vs 4,179 pg/mg creatinine; P < 0.0001). TXB2-M were significantly associated with all-cause and cardiovascular mortality irrespective of ASA use (HR: 1.96 and 2.41, respectively; P < 0.0001 for both) for TXB2-M in the highest quartile based on ASA use compared with lower quartiles, and remained significant after adjustment for mortality risk factors for similarly aged individuals (HR: 1.49 and 1.82, respectively; P ≤ 0.005 for both). In 2,353 participants without CVD, TXB2-M were associated with cardiovascular mortality in ASA nonusers (adjusted HR: 3.04; 95% CI: 1.29-7.16) but not in ASA users, while ASA use was associated with all-cause mortality in those with low (adjusted HR: 1.46; 95% CI: 1.14-1.87) but not elevated TXB2-M.
Conclusions
Systemic thromboxane generation is an independent risk factor for all-cause and cardiovascular mortality irrespective of ASA use, and its measurement may be useful for therapy modification, particularly in those without CVD.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 24 May 2022; epub ahead of print
Rade JJ, Barton BA, Vasan RS, Kronsberg SS, ... Kakouros N, Kickler TA
J Am Coll Cardiol: 24 May 2022; epub ahead of print | PMID: 35660296
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Abstract

Arterial Ultrasound Testing to Predict Atherosclerotic Cardiovascular Events.

Nicolaides AN, Panayiotou AG, Griffin M, Tyllis T, ... Avraamides C, Martin RM
Background
Studies have indicated that the presence and size of subclinical atherosclerotic plaques improve the prediction of atherosclerotic cardiovascular events (ASCVE) over and above that provided by conventional risk factors alone. However, the relative contribution of different ultrasonographic measurements and sites of measurements on the 10-year ASCVD risk is largely unknown.
Objectives
Our aims were to determine the relative performance of carotid intima-media thickness, plaque thickness, and plaque area in 10-year ASCVD prediction when added to conventional risk factors as well as whether the vascular territory of these measurements, carotid or common femoral bifurcation, and the number of bifurcations with plaque (NBP) influence prediction.
Methods
We enrolled 985 adults (mean age: 58.1 ± 10.2 years) free of atherosclerotic cardiovascular disease. Conventional risk factors were recorded, and both carotid and common femoral bifurcations were scanned with ultrasonography. The primary endpoint was a composite of first-time fatal or nonfatal ASCVE.
Results
Over a mean ± SD follow-up of 13.2 ± 3.7 years, ASCVE occurred in 154 (15.6%) participants. By adding different plaque measurements to conventional risk factors in a Cox model, net reclassification improvement was 10.4% with maximum intima-media thickness, 9.5% with carotid plaque thickness, and 14.2% with carotid plaque area. It increased to 16.1%, 16.6%, and 16.6% (P < 0.0001) by adding measurements from 4 bifurcations: NBP, total plaque thickness, and total plaque area, respectively.
Conclusions
NBP, total plaque thickness, or total plaque area from both the carotid and common femoral bifurcations provides a better prediction of future ASCVE than measurements from a single site. The results need to be validated in an independent cohort.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 24 May 2022; 79:1969-1982
Nicolaides AN, Panayiotou AG, Griffin M, Tyllis T, ... Avraamides C, Martin RM
J Am Coll Cardiol: 24 May 2022; 79:1969-1982 | PMID: 35589158
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Abstract

Clinical Features and Natural History of Preadolescent Nonsyndromic Hypertrophic Cardiomyopathy.

Norrish G, Cleary A, Field E, Cervi E, ... Elliott PM, Kaski JP
Background
Up to one-half of childhood sarcomeric hypertrophic cardiomyopathy (HCM) presents before the age of 12 years, but this patient group has not been systematically characterized.
Objectives
The aim of this study was to describe the clinical presentation and natural history of patients presenting with nonsyndromic HCM before the age of 12 years.
Methods
Data from the International Paediatric Hypertrophic Cardiomyopathy Consortium on 639 children diagnosed with HCM younger than 12 years were collected and compared with those from 568 children diagnosed between 12 and 16 years.
Results
At baseline, 339 patients (53.6%) had family histories of HCM, 132 (20.9%) had heart failure symptoms, and 250 (39.2%) were prescribed cardiac medications. The median maximal left ventricular wall thickness z-score was 8.7 (IQR: 5.3-14.4), and 145 patients (27.2%) had left ventricular outflow tract obstruction. Over a median follow-up period of 5.6 years (IQR: 2.3-10.0 years), 42 patients (6.6%) died, 21 (3.3%) underwent cardiac transplantation, and 69 (10.8%) had life-threatening arrhythmic events. Compared with those presenting after 12 years, a higher proportion of younger patients underwent myectomy (10.5% vs 7.2%; P = 0.045), but fewer received primary prevention implantable cardioverter-defibrillators (18.9% vs 30.1%; P = 0.041). The incidence of mortality or life-threatening arrhythmic events did not differ, but events occurred at a younger age.
Conclusions
Early-onset childhood HCM is associated with a comparable symptom burden and cardiac phenotype as in patients presenting later in childhood. Long-term outcomes including mortality did not differ by age of presentation, but patients presenting at younger than 12 years experienced adverse events at younger ages.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 24 May 2022; 79:1986-1997
Norrish G, Cleary A, Field E, Cervi E, ... Elliott PM, Kaski JP
J Am Coll Cardiol: 24 May 2022; 79:1986-1997 | PMID: 35589160
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Impact:
Abstract

Worldwide Disparities in Recovery of Cardiac Testing 1 Year Into COVID-19.

Einstein AJ, Hirschfeld C, Williams MC, Vitola JV, ... Paez D, INCAPS COVID 2 Investigators Group
Background
The extent to which health care systems have adapted to the COVID-19 pandemic to provide necessary cardiac diagnostic services is unknown.
Objectives
The aim of this study was to determine the impact of the pandemic on cardiac testing practices, volumes and types of diagnostic services, and perceived psychological stress to health care providers worldwide.
Methods
The International Atomic Energy Agency conducted a worldwide survey assessing alterations from baseline in cardiovascular diagnostic care at the pandemic\'s onset and 1 year later. Multivariable regression was used to determine factors associated with procedure volume recovery.
Results
Surveys were submitted from 669 centers in 107 countries. Worldwide reduction in cardiac procedure volumes of 64% from March 2019 to April 2020 recovered by April 2021 in high- and upper middle-income countries (recovery rates of 108% and 99%) but remained depressed in lower middle- and low-income countries (46% and 30% recovery). Although stress testing was used 12% less frequently in 2021 than in 2019, coronary computed tomographic angiography was used 14% more, a trend also seen for other advanced cardiac imaging modalities (positron emission tomography and magnetic resonance; 22%-25% increases). Pandemic-related psychological stress was estimated to have affected nearly 40% of staff, impacting patient care at 78% of sites. In multivariable regression, only lower-income status and physicians\' psychological stress were significant in predicting recovery of cardiac testing.
Conclusions
Cardiac diagnostic testing has yet to recover to prepandemic levels in lower-income countries. Worldwide, the decrease in standard stress testing is offset by greater use of advanced cardiac imaging modalities. Pandemic-related psychological stress among providers is widespread and associated with poor recovery of cardiac testing.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 24 May 2022; 79:2001-2017
Einstein AJ, Hirschfeld C, Williams MC, Vitola JV, ... Paez D, INCAPS COVID 2 Investigators Group
J Am Coll Cardiol: 24 May 2022; 79:2001-2017 | PMID: 35589162
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Impact:
Abstract

Reduced Heart Failure and Mortality in Patients Receiving Statin Therapy Before Initial Acute Coronary Syndrome.

Bugiardini R, Yoon J, Mendieta G, Kedev S, ... Badimon L, Cenko E
Background
There is uncertainty regarding the impact of statins on the risk of atherosclerotic cardiovascular disease (ASCVD) and its major complication, acute heart failure (AHF).
Objectives
The aim of this study was to investigate whether previous statin therapy translates into lower AHF events and improved survival from AHF among patients presenting with an acute coronary syndrome (ACS) as a first manifestation of ASCVD.
Methods
Data were drawn from the International Survey of Acute Coronary Syndromes Archives. The study participants consisted of 14,542 Caucasian patients presenting with ACS without previous ASCVD events. Statin users before the index event were compared with nonusers by using inverse probability weighting models. Estimates were compared by test of interaction on the log scale. Main outcome measures were the incidence of AHF according to Killip class and the rate of 30-day all-cause mortality in patients presenting with AHF.
Results
Previous statin therapy was associated with a significantly decreased rate of AHF on admission (4.3% absolute risk reduction; risk ratio [RR]: 0.72; 95% CI: 0.62-0.83) regardless of younger (40-75 years) or older age (interaction P = 0.27) and sex (interaction P = 0.22). Moreover, previous statin therapy predicted a lower risk of 30-day mortality in the subset of patients presenting with AHF on admission (5.2 % absolute risk reduction; RR: 0.71; 95% CI: 0.50-0.99).
Conclusions
Among adults presenting with ACS as a first manifestation of ASCVD, previous statin therapy is associated with a reduced risk of AHF and improved survival from AHF. (International Survey of Acute Coronary Syndromes [ISACS] Archives; NCT04008173).

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 24 May 2022; 79:2021-2033
Bugiardini R, Yoon J, Mendieta G, Kedev S, ... Badimon L, Cenko E
J Am Coll Cardiol: 24 May 2022; 79:2021-2033 | PMID: 35589164
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Impact:
Abstract

Diagnosis and Management of Infective Endocarditis in People Who Inject Drugs: JACC State-of-the-Art Review.

Yucel E, Bearnot B, Paras ML, Zern EK, ... Wakeman SE, Sundt T
The incidence of injection drug use-associated infective endocarditis has been increasing rapidly over the last decade. Patients with drug use-associated infective endocarditis present an increasingly common clinical challenge with poor long-term outcomes and high reinfection and readmission rates. Their care raises issues unique to this population, including antibiotic selection and administration, indications for and ethical issues surrounding surgical intervention, and importantly management of the underlying substance use disorder to minimize the risk of reinfection. Successful treatment of these patients requires a broad understanding of these concerns. A multidisciplinary, collaborative approach providing a holistic approach to treating both the acute infection along with effectively addressing substance use disorder is needed to improve short-term and longer-term outcomes.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 24 May 2022; 79:2037-2057
Yucel E, Bearnot B, Paras ML, Zern EK, ... Wakeman SE, Sundt T
J Am Coll Cardiol: 24 May 2022; 79:2037-2057 | PMID: 35589166
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Impact:
Abstract

Sodium Glucose Cotransporter-2 Inhibition for Acute Myocardial Infarction: JACC Review Topic of the Week.

Udell JA, Jones WS, Petrie MC, Harrington J, ... Hernandez AF, Butler J
Sodium glucose cotransporter-2 (SGLT2) inhibitors improve cardiorenal outcomes in patients with type 2 diabetes mellitus, chronic kidney disease, and chronic heart failure. SGLT2 inhibitors also reduce the risk of cardiovascular mortality and hospitalization for heart failure among patients with type 2 diabetes mellitus and a remote history of myocardial infarction (MI). As a result of the growing body of evidence in diverse disease states, and the hypothesized mechanisms of action, it is reasonable to consider the potential of SGLT2 inhibition to improve outcomes in patients with acute MI as well if initiated early after presentation. Whether these therapies are efficacious and safe to use early in the course of acute coronary heart disease remains relatively unexplored. Here, we describe the contemporary data and continuing evidence gap for considering the use of SGLT2 inhibitors early following an acute MI to reduce cardiovascular morbidity and mortality.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 24 May 2022; 79:2058-2068
Udell JA, Jones WS, Petrie MC, Harrington J, ... Hernandez AF, Butler J
J Am Coll Cardiol: 24 May 2022; 79:2058-2068 | PMID: 35589167
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Impact:
Abstract

Distribution of Coronary Artery Calcium by Age, Sex, and Race Among Patients 30-45 Years Old.

Javaid A, Dardari ZA, Mitchell JD, Whelton SP, ... Villines TC, Blaha MJ
Background
Coronary artery calcium (CAC) is a measure of atherosclerotic burden and is well-validated for risk stratification in middle- to older-aged adults. Few studies have investigated CAC in younger adults, and there is no calculator for determining age-, sex-, and race-based percentiles among individuals aged <45 years.
Objectives
The purpose of this study was to determine the probability of CAC >0 and develop age-sex-race percentiles for U.S. adults aged 30-45 years.
Methods
We harmonized 3 datasets-CARDIA (Coronary Artery Risk Development in Young Adults), the CAC Consortium, and the Walter Reed Cohort-to study CAC in 19,725 asymptomatic Black and White individuals aged 30-45 years without known atherosclerotic cardiovascular disease. After weighting each cohort equally, the probability of CAC >0 and age-sex-race percentiles of CAC distributions were estimated using nonparametric techniques.
Results
The prevalence of CAC >0 was 26% among White males, 16% among Black males, 10% among White females, and 7% among Black females. CAC >0 automatically placed all females at >90th percentile. CAC >0 placed White males at the 90th percentile at age 34 years compared with Black males at age 37 years. An interactive webpage allows one to enter an age, sex, race, and CAC score to obtain the corresponding estimated percentile.
Conclusions
In a large cohort of U.S. adults aged 30-45 years without symptomatic atherosclerotic cardiovascular disease, the probability of CAC >0 varied by age, sex, and race. Estimated percentiles may help interpretation of CAC scores among young adults relative to their age-sex-race matched peers and can henceforth be included in CAC score reporting.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 17 May 2022; 79:1873-1886
Javaid A, Dardari ZA, Mitchell JD, Whelton SP, ... Villines TC, Blaha MJ
J Am Coll Cardiol: 17 May 2022; 79:1873-1886 | PMID: 35550683
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Abstract

Location of Aortic Enlargement and Risk of Type A Dissection at Smaller Diameters.

Ganapathi AM, Ranney DN, Peterson MD, Lindsay ME, ... Isselbacher EM, Hughes GC
Background
Previous work has demonstrated that more than one-half of acute type A aortic dissections (ATADs) occur at a maximal aortic diameter (MAD) of <5.5 cm. However, no analysis has investigated whether ATAD risk at smaller MADs is more common with modest dilation of the aortic root (AR) or supracoronary ascending aorta (AA) in patients without genetically triggered aortopathy.
Objectives
This study sought to determine if the segment of modest aortic dilation affects risk of ATAD.
Methods
Using the International Registry of Acute Aortic Dissection (IRAD) database from May 1996 to October 2016, we identified 667 ATAD patients with MAD <5.5 cm. Patients were stratified by location of the largest proximal aortic segment (AR or AA). Patients with known genetically triggered aortopathy were excluded. MADs at time of dissection were compared between AR and AA groups. Secondary outcomes included operation, postoperative outcomes, and long-term survival.
Results
Of patients with ATAD at an MAD <5.5 cm, 79.5% (n = 530) were in the AA group and 20.5% (n = 137) in the AR group. Modestly dilated ARs (median MAD 4.6 cm [IQR: 4.1-5.0 cm]) dissected at a significantly smaller diameter than modestly dilated AAs (median MAD 4.8 cm [IQR: 4.4-5.1 cm]) (P < 0.01). AR patients were significantly younger than AA patients (58.5 ± 13.0 years vs 63.2 ± 13.3 years; P < 0.01) and more commonly male (78% vs 65%; P < 0.01). Postoperative and long-term outcomes did not differ between groups.
Conclusions
ATAD appears to occur at smaller diameters in patients with modest dilation in the AR vs the AA (4.6 vs 4.8 cm). These findings may have implications for future consensus guidelines regarding the management of patients with aortic disease.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 17 May 2022; 79:1890-1897
Ganapathi AM, Ranney DN, Peterson MD, Lindsay ME, ... Isselbacher EM, Hughes GC
J Am Coll Cardiol: 17 May 2022; 79:1890-1897 | PMID: 35550685
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Impact:
Abstract

Cardiovascular Risk Factors Mediate the Long-Term Maternal Risk Associated With Hypertensive Disorders of Pregnancy.

Stuart JJ, Tanz LJ, Rimm EB, Spiegelman D, ... Rexrode KM, Rich-Edwards JW
Background
Hypertensive disorders of pregnancy (HDP), including gestational hypertension and preeclampsia, are associated with an increased risk of CVD.
Objectives
The purpose of this study was to evaluate associations between HDP and long-term CVD and identify the proportion of the association mediated by established CVD risk factors.
Methods
Parous participants without CVD in the Nurses\' Health Study II (n = 60,379) were followed for incident CVD from first birth through 2017. Cox proportional hazards models estimated HRs and 95% CIs for the relationship between HDP and CVD, adjusting for potential confounders, including prepregnancy body mass index, smoking, and parental history of CVD. To evaluate the proportion of the association jointly accounted for by chronic hypertension, hypercholesterolemia, type 2 diabetes, and changes in body mass index, we used the difference method.
Results
Women with HDP in first pregnancy had a 63% higher rate of CVD (95% CI: 1.37-1.94) compared with women with normotensive pregnancies. This association was mediated by established CVD risk factors (proportion mediated = 64%). The increased rate of CVD was higher for preeclampsia (HR: 1.72; 95% CI: 1.42-2.10) than gestational hypertension (HR: 1.41; 95% CI: 1.03-1.93). Established CVD risk factors accounted for 57% of the increased rate of CVD for preeclampsia but 84% for gestational hypertension (both P < 0.0001).
Conclusions
Established CVD risk factors arising after pregnancy explained most (84%) of the increased risk of CVD conferred by gestational hypertension and 57% of the risk among women with preeclampsia. Screening for chronic hypertension, hypercholesterolemia, type 2 diabetes, and overweight/obesity after pregnancy may be especially helpful in CVD prevention among women with a history of HDP.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 17 May 2022; 79:1901-1913
Stuart JJ, Tanz LJ, Rimm EB, Spiegelman D, ... Rexrode KM, Rich-Edwards JW
J Am Coll Cardiol: 17 May 2022; 79:1901-1913 | PMID: 35550687
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Abstract

Burden of Pediatric Heart Failure in the United States.

Amdani S, Marino BS, Rossano J, Lopez R, Schold JD, Tang WHW
Background
There are currently limited accurate national estimates for pediatric heart failure (HF).
Objectives
This study aims to describe the current burden of primary and comorbid pediatric HF in the United States.
Methods
International Classification of Diseases, Clinical Modification codes were used to identify HF cases and comorbidities from the Kids\' Inpatient Database, National Inpatient Sample, National Emergency Department (ED) Sample, and National Vital Statistics System for 2012 and 2016. To describe HF events, all visits/events among pediatric and adult subjects were included in the analysis. HF events were classified into 1 of 3 groups: 1) no HF; 2) primary HF; or 3) comorbid HF. We compared patients with and without HF and calculated unique event rates with age and sex standardization.
Results
Congenital heart disease, conduction disorders/arrhythmias, and cardiomyopathy were responsible for the majority of pediatric HF-related ED visits and hospitalizations. Compared to 2012, in 2016, there was an increase in comorbid HF ED visits (rate ratio: 1.93; P < 0.001) and primary HF hospitalizations (rate ratio: 1.14; P = 0.002). Pediatric HF burden was lower compared to adult HF; however, deaths in the ED and in-hospital were significantly more likely in children presenting with HF than adults.
Conclusions
The burden of pediatric HF continues to increase. Compared to adults with HF presenting to the ED and in-hospital, outcomes are inferior and per patient resource use is higher for children hospitalized with HF. National initiatives to understand risk factors for morbidity and mortality in pediatric HF and continued surveillance and mitigation of preventable risk factors may attenuate this uptrend.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 17 May 2022; 79:1917-1928
Amdani S, Marino BS, Rossano J, Lopez R, Schold JD, Tang WHW
J Am Coll Cardiol: 17 May 2022; 79:1917-1928 | PMID: 35550689
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Impact:
Abstract

The Increasing Role of Rhythm Control in Patients With Atrial Fibrillation: JACC State-of-the-Art Review.

Camm AJ, Naccarelli GV, Mittal S, Crijns HJGM, ... Turakhia MP, Kirchhof P
The considerable mortality and morbidity associated with atrial fibrillation (AF) pose a substantial burden on patients and health care services. Although the management of AF historically focused on decreasing AF recurrence, it evolved over time in favor of rate control. Recently, more emphasis has been placed on reducing adverse cardiovascular outcomes using rhythm control, generally by using safe and effective rhythm-control therapies (typically antiarrhythmic drugs and/or AF ablation). Evidence increasingly supports early rhythm control in patients with AF that has not become long-standing, but current clinical practice and guidelines do not yet fully reflect this change. Early rhythm control may effectively reduce irreversible atrial remodeling and prevent AF-related deaths, heart failure, and strokes in high-risk patients. It has the potential to halt progression and potentially save patients from years of symptomatic AF; therefore, it should be offered more widely.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 17 May 2022; 79:1932-1948
Camm AJ, Naccarelli GV, Mittal S, Crijns HJGM, ... Turakhia MP, Kirchhof P
J Am Coll Cardiol: 17 May 2022; 79:1932-1948 | PMID: 35550691
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Impact:
Abstract

Anticoagulation for Percutaneous Ventricular Assist Device-Supported Cardiogenic Shock: JACC Review Topic of the Week.

Vandenbriele C, Arachchillage DJ, Frederiks P, Giustino G, ... Price S, Chieffo A
Interest in the use of mechanical circulatory support for patients presenting with cardiogenic shock is growing rapidly. The Impella (Abiomed Inc), a microaxial, continuous-flow, short-term, ventricular assist device (VAD), requires meticulous postimplantation management. Because systemic anticoagulation is needed to prevent pump thrombosis, patients are exposed to increased bleeding risk, further aggravated by sepsis, thrombocytopenia, and high shear stress-induced acquired von Willebrand syndrome. The precarious balance between bleeding and thrombosis in percutaneous VAD-supported cardiogenic shock patients is often the main reason that patient outcomes are jeopardized, and there is a lack of data addressing optimal anticoagulation management strategies during percutaneous VAD support. Here, we present a parallel anti-Factor Xa/activated partial thromboplastin time-guided anticoagulation algorithm and discuss pitfalls of heparin monitoring in critically ill patients. This review will guide physicians toward a more standardized (anti)coagulation approach to tackle device-related morbidity and mortality in this critically ill patient group.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 17 May 2022; 79:1949-1962
Vandenbriele C, Arachchillage DJ, Frederiks P, Giustino G, ... Price S, Chieffo A
J Am Coll Cardiol: 17 May 2022; 79:1949-1962 | PMID: 35550692
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Abstract

Evolution and Prognostic Impact of Cardiac Damage After Aortic Valve Replacement.

Généreux P, Pibarot P, Redfors B, Bax JJ, ... Leon MB, Cohen DJ
Background
The impact of aortic valve replacement (AVR) on progression/regression of extra-valvular cardiac damage and its association with subsequent prognosis is unknown.
Objectives
To describe evolution of cardiac damage post-AVR and its association with outcomes.
Methods
Patients undergoing transcatheter or surgical AVR from the PARTNER 2 and 3 trials were pooled and classified by cardiac damage stage at baseline and 1-year (Stage 0, no damage; Stage 1, left ventricular damage; Stage 2, left atrial or mitral valve damage; Stage 3, pulmonary vasculature or tricuspid valve damage; Stage 4, right ventricular damage). Proportional hazards models determined association between change in cardiac damage post-AVR and 2-year outcomes.
Results
Among 1974 patients, 121 (6.1%) were Stage 0, 287 (14.5%) Stage 1, 1014 (51.4%) Stage 2, 412 (20.9%) Stage 3, and 140 (7.1%) Stage 4 pre-AVR. Two-year mortality was associated with extent of cardiac damage at baseline and 1-year. Compared with baseline, cardiac damage improved in ∼15%, remained unchanged in ∼60%, and worsened in ∼25% of patients at 1-year. One-year change in cardiac damage stage was independently associated with mortality (adjHR for improvement=0.49; no change=1.0; worsening=1.95; p=0.023) and composite of death or heart failure hospitalization (adjHR for improvement=0.60; no change=1.0; worsening=2.25; p<0.001) at 2 years.
Conclusion
In patients undergoing AVR, extent of extravalvular cardiac damage at baseline and its change at 1-year have important prognostic implications. These findings suggest that earlier detection of AS and intervention prior to development of irreversible cardiac damage may improve global cardiac function and prognosis.

Copyright © 2022. Published by Elsevier Inc.

J Am Coll Cardiol: 14 May 2022; epub ahead of print
Généreux P, Pibarot P, Redfors B, Bax JJ, ... Leon MB, Cohen DJ
J Am Coll Cardiol: 14 May 2022; epub ahead of print | PMID: 35595203
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Abstract

Balloon- Versus Self-Expanding Valve Systems for Treating Small Failed Surgical Aortic Bioprostheses: The LYTEN Trial.

Rodés-Cabau J, Abbas A, Serra V, Vilalta V, ... Pelletier-Beaumont E, Pibarot P
Background
Data comparing valve systems in the valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) field has been obtained from retrospective studies.
Objectives
To compare the hemodynamic results between the balloon-expandable SAPIEN (3/ULTRA) (BEV) and self-expanding Evolut (R/PRO/PRO+) (SEV) valves in ViV-TAVR.
Methods
Patients with a failed small (≤23 mm) surgical valve. were randomized to receive a BEV or a SEV. The primary endpoint was valve hemodynamics (maximal/mean residual gradients; severe prosthesis patient mismatch [PPM] or moderate-severe aortic regurgitation [AR]) at 30 days as evaluated by Doppler-echocardiography.
Results
A total of 102 patients were randomized, and of these, 98 patients finally underwent a ViV-TAVR procedure (BEV: 46, SEV: 52). The procedure was successful in all cases, with no differences in clinical outcomes at 30 days between groups (no death or stroke events). Patients in the SEV group exhibited lower mean and maximal transvalvular gradient values (15±8 vs 23±8 mmHg, p˂0.001; 28±16 vs 40±13 mmHg, p ˂0.001), and a tendency towards a lower rate of severe PPM (44% vs. 64%, p=0.07). There were no cases of moderate-severe AR. 55 consecutive patients (SEV: 27, BEV: 28) underwent invasive valve hemodynamic evaluation during the procedure, with no differences in mean and peak transvalvular gradients between both groups (p=0.41 and p=0.70, respectively).
Conclusions
In patients with small failed aortic bioprostheses, ViV-TAVR with a SEV was associated with improved valve hemodynamics as evaluated by echocardiography. There were no differences between groups in intra-procedural invasive valve hemodynamics and 30-day clinical outcomes (NCT03520101).

Copyright © 2022. Published by Elsevier Inc.

J Am Coll Cardiol: 13 May 2022; epub ahead of print
Rodés-Cabau J, Abbas A, Serra V, Vilalta V, ... Pelletier-Beaumont E, Pibarot P
J Am Coll Cardiol: 13 May 2022; epub ahead of print | PMID: 35597385
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Abstract

Definitions and Standardized Endpoints for Treatment of Coronary Bifurcations.

Lunardi M, Louvard Y, Lefèvre T, Stankovic G, ... Onuma Y, Bifurcation Academic Research Consortium and European Bifurcation Club
The Bifurcation Academic Research Consortium (Bif-ARC) project originated from the need to overcome the paucity of standardization and comparability between studies involving bifurcation coronary lesions. This document is the result of a collaborative effort between academic research organizations and the most renowned interventional cardiology societies focused on bifurcation lesions in Europe, the United States, and Asia. This consensus provides standardized definitions for bifurcation lesions; the criteria to judge the side branch relevance; the procedural, mechanistic, and clinical endpoints for every type of bifurcation study; and the follow-up methods. Considering the complexity of bifurcation lesions and their evaluation, detailed instructions and technical aspects for site and core laboratory analysis of bifurcation lesions are also reported. The recommendations included within this consensus will facilitate pooled analyses and the effective comparison of data in the future, improving the clinical relevance of trials in bifurcation lesions, and the quality of care in this subset of patients.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 13 May 2022; epub ahead of print
Lunardi M, Louvard Y, Lefèvre T, Stankovic G, ... Onuma Y, Bifurcation Academic Research Consortium and European Bifurcation Club
J Am Coll Cardiol: 13 May 2022; epub ahead of print | PMID: 35597684
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Impact:
Abstract

Antithrombotic Therapy After Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation.

Freeman JV, Higgins AY, Wang Y, Du C, ... Masoudi FA, Curtis JP
Background
Pivotal trials of percutaneous left atrial appendage occlusion (LAAO) used specific postprocedure treatment protocols.
Objectives
This study sought to evaluate patterns of postprocedure care after LAAO with the Watchman device in clinical practice and compare the risk of adverse events for different discharge antithrombotic strategies.
Methods
We evaluated patients in the LAAO Registry of the National Cardiovascular Data Registry who underwent LAAO with the Watchman device between 2016 and 2018. We assessed adherence to the full postprocedure trial protocol including standardized follow-up, imaging, and antithrombotic agents and then evaluated the most commonly used antithrombotic strategies and compared the rates and risk of adverse events at 45 days and 6 months by means of multivariable COX frailty regression.
Results
Among 31,994 patients undergoing successful LAAO, only 12.2% received the full postprocedure treatment protocol studied in pivotal trials; the most common protocol deviations were with discharge antithrombotic medications. The most common discharge medication strategies were warfarin and aspirin (36.9%), direct oral anticoagulant (DOAC) and aspirin (20.8%), warfarin only (13.5%), DOAC only (12.3%), and dual antiplatelet therapy (5.0%). In multivariable Cox frailty regression, the adjusted risk of any adverse event through the 45-day follow-up visit were significantly lower for discharge on warfarin alone (HR: 0.692; 95% CI: 0.569-0.841) and DOAC alone (HR: 0.731; 95% CI: 0.574-0.930) compared with warfarin and aspirin. Warfarin alone retained lower risk at the 6-month follow-up.
Conclusions
In contemporary U.S. practice, practitioners rarely used the full U.S. Food and Drug Administration-approved postprocedure treatment protocols studied in pivotal trials of the Watchman device. Discharge after implantation on warfarin or DOAC without concomitant aspirin was associated with lower risk of adverse outcomes.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 10 May 2022; 79:1785-1798
Freeman JV, Higgins AY, Wang Y, Du C, ... Masoudi FA, Curtis JP
J Am Coll Cardiol: 10 May 2022; 79:1785-1798 | PMID: 35512858
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Impact:
Abstract

High-Intensity Statin Use Among Patients With Atherosclerosis in the U.S.

Nelson AJ, Haynes K, Shambhu S, Eapen Z, ... Pagidipati NJ, Granger CB
Background
Preventive therapy among patients with established atherosclerotic cardiovascular disease (ASCVD) is generally underused. Whether new guideline recommendations and a focus on implementation have improved the use of high-intensity statins is unknown.
Objectives
This study sought to evaluate the patterns and predictors of statin use among patients with ASCVD.
Methods
In this retrospective cohort study, pharmacy and medical claims data from a commercial health plan were queried for patients with established ASCVD between January 31, 2018, and January 31, 2019. Statin use on an index date of January 31, 2019, was evaluated, as was 12-month adherence and discontinuation. Multivariable logistic regression was used to determine independent associations with statin use of varying intensities.
Results
Of the 601,934 patients with established ASCVD, 41.7% were female, and the mean age was 67.5 ± 13.3 years. Overall, 22.5% of the cohort were on a high-intensity statin, 27.6% were on a low- or moderate-intensity statin, and 49.9% were not on any statin. In multivariable analysis, younger patients, female patients, and those with higher Charlson comorbidity score were less likely to be prescribed any statin. Among statin users, female patients, older patients, and those with peripheral artery disease were less likely to be on a high-intensity formulation, whereas a cardiology encounter in the prior year increased the odds. The majority of high-intensity stain users achieved high levels of adherence.
Conclusions
Substantial underuse of statins persists in a large, insured, and contemporary cohort of patients with ASCVD from the United States. In particular, concerning gaps in appropriate statin use remain among younger patients, women, and those with noncoronary ASCVD.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 10 May 2022; 79:1802-1813
Nelson AJ, Haynes K, Shambhu S, Eapen Z, ... Pagidipati NJ, Granger CB
J Am Coll Cardiol: 10 May 2022; 79:1802-1813 | PMID: 35512860
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Impact:
Abstract

Incidence of Sudden Cardiac Death in the European Union.

Jean-Philippe E, Lerner I, Valentin E, Folke F, ... Jouven X, ESCAPE-NET Investigators
Background
Although sudden cardiac death (SCD) is recognized as a high-priority public health topic, reliable estimates of the incidence of SCD or, more broadly, out-of-hospital cardiac arrest (OHCA), in the population are scarce, especially in the European Union.
Objectives
The study objective was to determine the incidence of SCD and OHCA in the European Union.
Methods
The study examined 4 large (ie, >2 million inhabitants) European population-based prospective registries collecting emergency medical services (EMS)-attended (ie, with attempted resuscitation) OHCA and SCD (OHCA without obvious extracardiac causes) for >5 consecutive years from January 2012 to December 2017 in the Paris region (France), the North Holland region (the Netherlands), the Stockholm region (Sweden), and in all of Denmark.
Results
The average annual incidence of SCD in the 4 registries ranged from 36.8 per 100,000 (95% CI: 23.5-50.1 per 100,000) to 39.7 per 100,000 (95% CI: 32.6-46.8 per 100,000). When extrapolating to each European country and accounting for age and sex, this yields to 249,538 SCD cases per year (95% CI: 155,377-343,719 SCD cases per year). The average annual incidence of OHCA in the 4 registries ranged from 47.8 per 100,000 (95% CI: 21.2-74.4 per 100,000) to 57.9 per 100,000 (95% CI: 19.6-96.3 per 100,000), corresponding to 343,496 OHCA cases per year (95% CI: 216,472-464,922 OHCA cases per year) in the European Union. Incidence rates of SCD and OHCA increased with age and were systematically higher in men compared with women.
Conclusions
By combining data from 4 large, population-based registries with at least 5 years of data collection, this study provided an estimate of the incidence of SCD and OHCA in the European Union.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 10 May 2022; 79:1818-1827
Jean-Philippe E, Lerner I, Valentin E, Folke F, ... Jouven X, ESCAPE-NET Investigators
J Am Coll Cardiol: 10 May 2022; 79:1818-1827 | PMID: 35512862
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Impact:
Abstract

Guidelines for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes: JACC Guideline Comparison.

Kelsey MD, Nelson AJ, Green JB, Granger CB, ... McGuire DK, Pagidipati NJ
Cardiovascular disease is a leading cause of morbidity and mortality in individuals with type 2 diabetes mellitus. These high-risk patients benefit from aggressive risk factor management, with blood pressure and low-density lipoprotein-cholesterol treatment, glycemic control, kidney protection, and lifestyle intervention. There are several recommendation and guideline documents across cardiology, endocrinology, nephrology, and general medicine professional societies from the United States and Europe with recommendations for cardiovascular risk reduction in patients with type 2 diabetes mellitus. Although there are some noteworthy differences, particularly in risk stratification, low-density lipoprotein-cholesterol and blood pressure treatment targets, and the use of sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, overall there is considerable alignment across recommendations from different professional societies.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 10 May 2022; 79:1849-1857
Kelsey MD, Nelson AJ, Green JB, Granger CB, ... McGuire DK, Pagidipati NJ
J Am Coll Cardiol: 10 May 2022; 79:1849-1857 | PMID: 35512864
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Impact:
Abstract

Venous Tone and Stressed Blood Volume in Heart Failure: JACC Review Topic of the Week.

Fudim M, Kaye DM, Borlaug BA, Shah SJ, ... Sunagawa K, Burkhoff D
A number of pathologic processes contribute to the elevation in cardiac filling pressures in heart failure (HF), including myocardial dysfunction and primary volume overload. In this review, we discuss the important role of the venous system and the concepts of stressed blood volume and unstressed blood volume. We review how regulation of venous tone modifies the distribution of blood between these 2 functional compartments, the physical distribution of blood between the pulmonary and systemic circulations, and how these relate to the hemodynamic abnormalities observed in HF. Finally, we review recently applied methods for estimating stressed blood volume and how they are being applied to the results of clinical studies to provide new insights into resting and exercise hemodynamics and therapeutics for HF.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 10 May 2022; 79:1858-1869
Fudim M, Kaye DM, Borlaug BA, Shah SJ, ... Sunagawa K, Burkhoff D
J Am Coll Cardiol: 10 May 2022; 79:1858-1869 | PMID: 35512865
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Impact:
Abstract

Survival Following Alcohol Septal Ablation or Septal Myectomy for Patients With Obstructive Hypertrophic Cardiomyopathy.

Cui H, Schaff HV, Wang S, Lahr BD, ... Ommen SR, Maron MS
Background
There is little information regarding long-term mortality comparing the 2 most common procedures for septal reduction for obstructive hypertrophic cardiomyopathy (HCM), alcohol septal ablation (ASA), and septal myectomy.
Objectives
This study sought to compare the long-term mortality of patients with obstructive HCM following septal myectomy or ASA.
Methods
We evaluated outcomes of 3,859 patients who underwent ASA or septal myectomy in 3 specialized HCM centers. All-cause mortality was the primary endpoint of the study.
Results
In the study cohort, 585 (15.2%) patients underwent ASA, and 3,274 (84.8%) underwent septal myectomy. Patients undergoing ASA were significantly older (median age: 63.0 years [IQR: 52.7-72.8 years] vs 53.7 years [IQR: 44.9-62.8 years]; P < 0.001) and had smaller septal thickness (19.0 mm [IQR: 17.0-22.0 mm] vs 20.0 mm [IQR: 17.0-23.0 mm]; P = 0.007). Patients undergoing ASA also had more comorbidities, including renal failure, diabetes, hypertension, and coronary artery disease. There were 4 (0.7%) early deaths in the ASA group and 9 (0.3%) in the myectomy group. Over a median follow-up of 6.4 years (IQR: 3.6-10.2 years), the 10-year all-cause mortality rate was 26.1% in the ASA group and 8.2% in the myectomy group. After adjustment for age, sex, and comorbidities, the mortality remained greater in patients having septal reduction by ASA (HR: 1.68; 95% CI: 1.29-2.19; P < 0.001).
Conclusions
In patients with obstructive hypertrophic cardiomyopathy, ASA is associated with increased long-term all-cause mortality compared with septal myectomy. This impact on survival is independent of other known factors but may be influenced by unmeasured confounding patient characteristics.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 03 May 2022; 79:1647-1655
Cui H, Schaff HV, Wang S, Lahr BD, ... Ommen SR, Maron MS
J Am Coll Cardiol: 03 May 2022; 79:1647-1655 | PMID: 35483751
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Impact:
Abstract

Prevention of Cardiovascular Events and Mortality With Icosapent Ethyl in Patients With Prior Myocardial Infarction.

Gaba P, Bhatt DL, Steg PG, Miller M, ... Ballantyne CM, REDUCE-IT Investigators
Background
REDUCE-IT was a double-blind trial that randomized 8,179 statin-treated patients with controlled low-density lipoprotein cholesterol and moderately elevated triglycerides to icosapent ethyl (IPE) or placebo. There was a significant reduction in the primary endpoint, including death from cardiovascular (CV) causes. The specific impact of IPE among patients with prior myocardial infarction (MI) was unknown.
Objectives
Our goal was to examine the benefit of IPE on ischemic events among patients with prior MI in REDUCE-IT.
Methods
We performed post hoc analyses of patients with prior MI. The primary endpoint was CV death, MI, stroke, coronary revascularization, or hospitalization for unstable angina. The key secondary endpoint was CV death, MI, or stroke.
Results
A total of 3,693 patients had a history of prior MI. The primary endpoint was reduced from 26.1% to 20.2% with IPE vs placebo; HR: 0.74 (95% CI: 0.65-0.85; P = 0.00001). The key secondary endpoint was reduced from 18.0% to 13.3%; HR: 0.71 (95% CI: 0.61-0.84; P = 0.00006). There was also a significant 35% relative risk reduction in total ischemic events (P = 0.0000001), a 34% reduction in MI (P = 0.00009), a 30% reduction in CV death (P = 0.01), and a 20% lower rate of all-cause mortality (P = 0.054), although there was a slight increase in atrial fibrillation. Sudden cardiac death and cardiac arrest were also significantly reduced by 40% and 56%, respectively.
Conclusions
Patients with a history of prior MI in REDUCE-IT treated with IPE demonstrated large and significant relative and absolute risk reductions in ischemic events, including CV death. (A Study of AMR101 to Evaluate Its Ability to Reduce Cardiovascular Events in High Risk Patients With Hypertriglyceridemia and on Statin. The Primary Objective is to Evaluate the Effect of 4 g/Day AMR101 for Preventing the Occurrence of a First Major Cardiovascular Event. [REDUCE-IT]; NCT01492361).

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 03 May 2022; 79:1660-1671
Gaba P, Bhatt DL, Steg PG, Miller M, ... Ballantyne CM, REDUCE-IT Investigators
J Am Coll Cardiol: 03 May 2022; 79:1660-1671 | PMID: 35483753
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Abstract

Cardiovascular Implications of the 2021 KDIGO Blood Pressure Guideline for Adults With Chronic Kidney Disease.

Lee HH, Lee H, Townsend RR, Kim DW, Park S, Kim HC
Background
The 2021 Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommends a systolic blood pressure (BP) target of <120 mm Hg for nondialysis chronic kidney disease (CKD).
Objectives
We sought to examine the potential implications of the 2021 KDIGO BP target, compared with the 2012 KDIGO and 2017 American College of Cardiology (ACC)/American Heart Association (AHA) BP targets, as related to cardiovascular disease (CVD) outcomes.
Methods
From the cross-sectional Korea National Health and Nutrition Examination Survey (KNHANES) and longitudinal National Health Insurance Service (NHIS) data, adults with nondialysis CKD were identified and categorized into 4 groups based on concordance/discordance between guidelines: 1) above both targets; 2) above 2021 KDIGO only; 3) above 2012 KDIGO or 2017 ACC/AHA only; and 4) controlled within both targets. We determined the nationally representative proportion and CVD risk of each group.
Results
In KNHANES (n = 1,939), 50.2% had BP above both 2021 and 2012 KDIGO targets, 15.9% above the 2021 KDIGO target only, 3.5% above the 2012 KDIGO target only, and 30.4% controlled within both targets. In NHIS (n = 412,167; median follow-up: 10.0 years), multivariable-adjusted HRs for CVD events were 1.52 (95% CI: 1.47-1.58) among participants with BP above both targets, 1.28 (95% CI: 1.24-1.32) among those with BP above 2021 KDIGO only, and 1.07 (95% CI: 0.61-1.89) among those with BP above 2012 KDIGO only, compared to those with BP controlled within both targets. Results were similar for comparison between 2021 KDIGO and 2017 ACC/AHA BP targets.
Conclusions
New candidates for BP-lowering treatment per the 2021 KDIGO guideline account for a substantial proportion of the total CKD population and bear significantly high CVD risk.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 03 May 2022; 79:1675-1686
Lee HH, Lee H, Townsend RR, Kim DW, Park S, Kim HC
J Am Coll Cardiol: 03 May 2022; 79:1675-1686 | PMID: 35483755
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Abstract

Systematic Review of Physical Activity Trajectories and Mortality in Patients With Coronary Artery Disease.

Gonzalez-Jaramillo N, Wilhelm M, Arango-Rivas AM, Gonzalez-Jaramillo V, ... Franco OH, Bano A
Background
The role of lifestyle physical activity (PA) trajectories in the mortality risk of patients with coronary heart disease (CHD) remains unclear.
Objectives
The purpose of this study was to determine the association of longitudinal PA trajectories with all-cause and cardiovascular disease (CVD) mortality in patients with CHD.
Methods
Longitudinal cohorts reporting the association of PA trajectories with mortality in patients with CHD were identified in April 2021 by searching 5 databases without language restrictions. Published HRs and 95% CIs were pooled using random effects models and bias assessed by Egger regression.
Results
A total of 9 prospective cohorts included 33,576 patients. The mean age was 62.5 years. The maximum follow-up was 15.7 years. All of the studies assessed PA through validated questionnaires, and mortality was well documented. Changes in PA defined 4 nominal PA trajectories. Compared with always-inactive patients, the risk of all-cause mortality was 50% lower in those who remained active (HR: 0.50; 95% CI: 0.39-0.63); 45% lower in those who were inactive but became active (HR: 0.55; 95% CI: 0.44-0.7); and 20% lower in those who were active but became inactive (HR: 0.80; 95% CI: 0.64-0.99). Similar results were observed for CVD mortality, except for the category of decreased activity (HR: 0.91; 95% CI: 0.67-1.24). The overall risk of bias was low. No evidence of publication bias was found. Multiple sensitivity analyses provided consistent results.
Conclusions
This study illustrates how patients with CHD may benefit by preserving or adopting an active lifestyle. The observation that the benefits of past activity can be weakened or lost if PA is not maintained may be confounded by disease progression.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 03 May 2022; 79:1690-1700
Gonzalez-Jaramillo N, Wilhelm M, Arango-Rivas AM, Gonzalez-Jaramillo V, ... Franco OH, Bano A
J Am Coll Cardiol: 03 May 2022; 79:1690-1700 | PMID: 35483757
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Abstract

The National Cardiovascular Data Registry Data Quality Program 2020: JACC State-of-the-Art Review.

Malenka DJ, Bhatt DL, Bradley SM, Shahian DM, ... Roe M, Masoudi FA
The National Cardiovascular Data Registry is a group of registries maintained by the American College of Cardiology Foundation. These registries are used by a diverse constituency to improve the quality and outcomes of cardiovascular care, to assess the safety and effectiveness of new therapies, and for research. To achieve these goals, registry data must be complete and reliable. In this article, we review the process of National Cardiovascular Data Registry data collection, assess data completeness and integrity, and report on the current state of the data. Registry data are complete. Accuracy is very good but variable, and there is room for improvement. Knowledge of the quality of data is essential to ensuring its appropriate use.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 03 May 2022; 79:1704-1712
Malenka DJ, Bhatt DL, Bradley SM, Shahian DM, ... Roe M, Masoudi FA
J Am Coll Cardiol: 03 May 2022; 79:1704-1712 | PMID: 35483759
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Abstract

Complicated Carotid Artery Plaques and Risk of Recurrent Ischemic Stroke or TIA.

Kopczak A, Schindler A, Sepp D, Bayer-Karpinska A, ... Saam T, Dichgans M
Background
Complicated nonstenosing carotid artery plaques (CAPs) are an under-recognized cause of stroke.
Objectives
The purpose of this study was to determine whether complicated CAP ipsilateral to acute ischemic anterior circulation stroke (icCAP) are associated with recurrent ischemic stroke or transient ischemic attack (TIA).
Methods
The CAPIAS (Carotid Plaque Imaging in Acute Stroke) multicenter study prospectively recruited patients with ischemic stroke restricted to the territory of a single carotid artery. Complicated (AHA-lesion type VI) CAP were defined by multisequence, contrast-enhanced carotid magnetic resonance imaging obtained within 10 days from stroke onset. Recurrent events were assessed after 3, 12, 24, and 36 months. The primary outcome was recurrent ischemic stroke or TIA.
Results
Among 196 patients enrolled, 104 patients had cryptogenic stroke and nonstenosing CAP. During a mean follow-up of 30 months, recurrent ischemic stroke or TIA occurred in 21 patients. Recurrent events were significantly more frequent in patients with icCAP than in patients without icCAP, both in the overall cohort (incidence rate [3-year interval]: 9.50 vs 3.61 per 100 patient-years; P = 0.025, log-rank test) and in patients with cryptogenic stroke (10.92 vs 1.82 per 100 patient-years; P = 0.003). The results were driven by ipsilateral events. A ruptured fibrous cap (HR: 4.91; 95% CI: 1.31-18.45; P = 0.018) and intraplaque hemorrhage (HR: 4.37; 95% CI: 1.20-15.97; P = 0.026) were associated with a significantly increased risk of recurrent events in patients with cryptogenic stroke.
Conclusions
Complicated CAP ipsilateral to acute ischemic anterior circulation stroke are associated with an increased risk of recurrent ischemic stroke or TIA. Carotid plaque imaging identifies high-risk patients who might be suited for inclusion into future secondary prevention trials. (Carotid Plaque Imaging in Acute Stroke [CAPIAS]; NCT01284933).

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 27 Apr 2022; epub ahead of print
Kopczak A, Schindler A, Sepp D, Bayer-Karpinska A, ... Saam T, Dichgans M
J Am Coll Cardiol: 27 Apr 2022; epub ahead of print | PMID: 35523659
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Abstract

Association of Left Atrial Structure and Function With Heart Failure in Older Adults.

Inciardi RM, Claggett B, Minamisawa M, Shin SH, ... Chen LY, Solomon SD
Background
Limited data exist to characterize novel measures of left atrial (LA) structure and function in older adults without prevalent heart failure (HF).
Objectives
The aim was to assess reference range of LA measures, their associations with N-terminal pro-B-type natriuretic-peptide (NT-proBNP) and the related risk for incident HF or death.
Methods
We analyzed LA structure (LA maximal [LAViMax] and minimal volume indexed by body surface area) and function (LA emptying fraction, LA reservoir, conduit, and contraction strain) in 4,901 participants from the ARIC (Atherosclerosis Risk In Communities) study (mean age 75 ± 5 years, 40% male, and 19% Black) without prevalent HF. We assessed sex-specific 10th and 90th percentile ARIC-based reference limits in 301 participants free of prevalent cardiovascular disease, and related LA measures to NT-proBNP and incident HF or death (median follow-up of 5.5 years) in the whole ARIC cohort.
Results
Approximately 20% of the overall population had LA abnormalities according to the ARIC-based reference limit. Each LA measure was associated with NT-proBNP and, except for LAViMax, with incident HF or death after multivariable adjustment (including left ventricular function and NT-proBNP). Results were consistent in participants with normal LAViMax (P for interaction > 0.05). LA measures were prognostic for both incident HF with preserved ejection fraction or death and incident HF with reduced ejection fraction or death. When added to HF risk factors and NT-proBNP (baseline C-statistics = 0.74) all LA measures, except for LAViMax, significantly enhanced the prognostic accuracy.
Conclusions
Novel measures of LA structure and function, but not standard assessment by LAViMax, are associated with increased risk of incident HF or death regardless of measures of left ventricular function and NT-proBNP.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 26 Apr 2022; 79:1549-1561
Inciardi RM, Claggett B, Minamisawa M, Shin SH, ... Chen LY, Solomon SD
J Am Coll Cardiol: 26 Apr 2022; 79:1549-1561 | PMID: 35450571
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Abstract

Effects of Metoprolol on Exercise Hemodynamics in Patients With Obstructive Hypertrophic Cardiomyopathy.

Dybro AM, Rasmussen TB, Nielsen RR, Ladefoged BT, ... Jensen MK, Poulsen SH
Background
The relationship between exercise hemodynamics, loading conditions, and medical treatment in patients with obstructive hypertrophic cardiomyopathy (HCM) is incompletely understood.
Objectives
This study aimed to investigate the effect of metoprolol on invasive hemodynamic parameters at rest and during exercise in patients with obstructive HCM.
Methods
This randomized, double-blind, placebo-controlled crossover trial enrolled 28 patients with obstructive HCM and New York Heart Association functional class ≥II. Patients were randomized to initiate either metoprolol 150 mg or placebo for 2 consecutive 2-week periods. Right-heart catheterization and echocardiography were performed at rest and during exercise at the end of each treatment period. The primary outcome was the difference in pulmonary capillary wedge pressure (ΔPCWP) between peak exercise and rest.
Results
No treatment effect on ΔPCWP was observed between metoprolol and placebo treatment (21 ± 9 mm Hg vs 23 ± 9 mm Hg; P = 0.12). At rest, metoprolol lowered heart rate (P < 0.0001), left ventricular outflow tract (LVOT) gradient (P = 0.01), and increased left ventricular end-diastolic volume (P = 0.02) and stroke volume (SV) (+6.4; 95% CI: 0.02-17.7; P = 0.049). During peak exercise, metoprolol was associated with a lower heart rate (P < 0.0001), a lower LVOT gradient (P = 0.0005), lesser degree of mitral regurgitation (P = 0.004), and increased SV (+9 mL; 95% CI: 2-15 mL; P = 0.008).
Conclusions
In patients with obstructive HCM, exercise was associated with an abnormal rise in PCWP, which was unaffected by metoprolol. However, metoprolol increased SV at rest and peak exercise following changes in end-diastolic volume, LVOT gradient, and degree of mitral regurgitation. (The Effect of Metoprolol in Patients With Hypertrophic Obstructive Cardiomyopathy [TEMPO]; NCT03532802).

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 26 Apr 2022; 79:1565-1575
Dybro AM, Rasmussen TB, Nielsen RR, Ladefoged BT, ... Jensen MK, Poulsen SH
J Am Coll Cardiol: 26 Apr 2022; 79:1565-1575 | PMID: 35450573
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Abstract

Elevated Lipoprotein(a) and Risk of Atrial Fibrillation: An Observational and Mendelian Randomization Study.

Mohammadi-Shemirani P, Chong M, Narula S, Perrot N, ... Pigeyre M, Paré G
Background
Atrial fibrillation (AF) is a cardiac arrhythmia associated with an elevated risk of stroke, heart failure, and mortality. However, preventative therapies are needed with ancillary benefits on its cardiovascular comorbidities. Lipoprotein(a) (Lp[a]) is a recognized risk factor for atherosclerotic cardiovascular disease (ASCVD), which itself increases AF risk, but it remains unknown whether Lp(a) is a causal mediator of AF independent of ASCVD.
Objectives
This study investigated the role of Lp(a) in AF and whether it is independent of ASCVD.
Methods
Measured and genetically predicted Lp(a) levels were tested for association with 20,432 cases of incident AF in the UK Biobank (N = 435,579). Mendelian randomization analyses were performed by using summary-level data for AF from publicly available genome-wide association studies (N = 1,145,375).
Results
In the UK Biobank, each 50 nmol/L (23 mg/dL) increase in Lp(a) was associated with an increased risk of incident AF using measured Lp(a) (HR: 1.03; 95% CI: 1.02-1.04 ; P = 1.65 × 10-8) and genetically predicted Lp(a) (OR: 1.03; 95% CI: 1.02-1.05; P = 1.33 × 10-5). Mendelian randomization analyses using independent data replicated the effect (OR: 1.04 per 50 nmol/L Lp[a] increase; 95% CI: 1.03-1.05 per 50 nmol/L Lp[a] increase; P = 9.23 × 10-10). There was no evidence of risk-conferring effect from low-density lipoprotein cholesterol or triglycerides, and only 39% (95% CI: 27%-73%) of Lp(a) risk was mediated through ASCVD, suggesting that Lp(a) partly influences AF independent of its known effects on ASCVD.
Conclusions
Our findings implicate Lp(a) as a potential causal mediator in the development of AF which show that the effects of Lp(a) extend across myocardial tissues. Ongoing clinical trials for Lp(a)-lowering therapies should evaluate effects on AF prevention.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 26 Apr 2022; 79:1579-1590
Mohammadi-Shemirani P, Chong M, Narula S, Perrot N, ... Pigeyre M, Paré G
J Am Coll Cardiol: 26 Apr 2022; 79:1579-1590 | PMID: 35450575
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Abstract

Infertility and Risk of Heart Failure in the Women\'s Health Initiative.

Lau ES, Wang D, Roberts M, Taylor CN, ... Eaton CB, Ho JE
Background
There is growing recognition that reproductive factors are associated with increased risk of future cardiovascular disease. Infertility has been less well studied, although emerging data support its association with increased risk of cardiovascular disease. Whether infertility is associated with future risk of heart failure (HF) is not known.
Objectives
This study sought to examine the development of HF and HF subtypes in women with and without history of infertility.
Methods
We followed postmenopausal women from the Women\'s Health Initiative prospectively for the development of HF. Infertility was self-reported at study baseline. Multivariable cause-specific Cox models were used to evaluate the association of infertility with incident overall HF and HF subtypes (heart failure with preserved ejection fraction [HFpEF]: left ventricular ejection fraction of ≥50% vs heart failure with reduced ejection fraction [HFrEF]: left ventricular ejection fraction of <50%]).
Results
Among 38,528 postmenopausal women (mean age: 63 ± 7 years), 5,399 (14%) participants reported a history of infertility. Over a median follow-up of 15 years, 2,373 developed incident HF, including 807 with HFrEF and 1,133 with HFpEF. Infertility was independently associated with future risk of overall HF (HR: 1.16; 95% CI: 1.04-1.30; P = 0.006). Notably, when examining HF subtypes, infertility was associated with future risk of HFpEF (HR: 1.27; 95% CI: 1.09-1.48; P = 0.002) but not HFrEF (HR: 0.97; 95% CI: 0.80-1.18).
Conclusions
Infertility was significantly associated with incident HF. This was driven by increased risk of HFpEF, but not HFrEF, and appeared independent of traditional cardiovascular risk factors and other infertility-related conditions. Future research should investigate mechanisms that underlie the link between infertility and HFpEF.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 26 Apr 2022; 79:1594-1603
Lau ES, Wang D, Roberts M, Taylor CN, ... Eaton CB, Ho JE
J Am Coll Cardiol: 26 Apr 2022; 79:1594-1603 | PMID: 35450577
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Abstract

Origins and Evolution of Extracorporeal Circulation: JACC Historical Breakthroughs in Perspective.

Holman WL, Timpa J, Kirklin JK
Midway through the 20th century, direct open-heart operations were not yet a reality, awaiting safe methods to support the cardiopulmonary circulation during cardiac surgery. The scientific advancements collectively leading to safe cardiopulmonary bypass are considered some of the most impactful advances of modern medicine. Stimulated by the work of physiologists and engineers in the late 19th century, primitive pump and oxygenator designs were the forerunners of major work by DeBakey and others in roller pump design and by Gibbon in oxygenator development. Following Gibbon\'s historic successful closure of an atrial septal defect in 1953 with his heart-lung machine, it was left to Lillehei and Kirklin to first successfully repair large series of cardiac malformations. The history leading to these historic events and the subsequent evolution of cardiopulmonary bypass machines for short- and longer-term support is filled with engineering and surgical brilliance, daring innovations, and serendipity.

Copyright © 2022. Published by Elsevier Inc.

J Am Coll Cardiol: 26 Apr 2022; 79:1606-1622
Holman WL, Timpa J, Kirklin JK
J Am Coll Cardiol: 26 Apr 2022; 79:1606-1622 | PMID: 35450579
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Abstract

Nutrition Assessment and Dietary Interventions in Heart Failure: JACC Review Topic of the Week.

Driggin E, Cohen LP, Gallagher D, Karmally W, ... Carbone S, Maurer MS
Despite the high prevalence of nutrition disorders in patients with heart failure (HF), major HF guidelines lack specific nutrition recommendations. Because of the lack of standardized definitions and assessment tools to quantify nutritional status, nutrition disorders are often missed in patients with HF. Additionally, a wide range of dietary interventions and overall dietary patterns have been studied in this population. The resulting evidence of benefit is, however, conflicting, making it challenging to determine which strategies are the most beneficial. In this document, we review the available nutritional status assessment tools for patients with HF. In addition, we appraise the current evidence for dietary interventions in HF, including sodium restriction, obesity, malnutrition, dietary patterns, and specific macronutrient and micronutrient supplementation. Furthermore, we discuss the feasibility and challenges associated with the implementation of multimodal nutrition interventions and delineate potential solutions to facilitate addressing nutrition in patients with HF.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 26 Apr 2022; 79:1623-1635
Driggin E, Cohen LP, Gallagher D, Karmally W, ... Carbone S, Maurer MS
J Am Coll Cardiol: 26 Apr 2022; 79:1623-1635 | PMID: 35450580
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Abstract

Long-Term Cardiovascular Outcomes After Bariatric Surgery in the Medicare Population.

Mentias A, Aminian A, Youssef D, Pandey A, ... Nissen SE, Desai MY
Background
The long-term effect of bariatric surgery on cardiovascular outcomes in the elderly population is not well studied.
Objectives
The aim of this study was to evaluate the association between bariatric surgery and long-term cardiovascular outcomes in the Medicare population.
Methods
Medicare beneficiaries who underwent bariatric surgery from 2013 to 2019 were matched to a control group of patients with obesity with a 1:1 exact matching based on age, sex, body mass index, and propensity score matching on 87 clinical variables. The study outcomes included all-cause mortality, new-onset heart failure (HF), myocardial infarction (MI), and ischemic stroke. An instrumental variable analysis was performed as a sensitivity analysis.
Results
The study cohort included 189,770 patients (94,885 matched patients in each group). By study design, the 2 groups had similar age (mean: 62.33 ± 10.62 years), sex (70% female), and degree of obesity (mean body mass index: 44.7 ± 7.3 kg/m2) and were well balanced on all clinical variables. After a median follow-up of 4.0 years (IQR: 2.4-5.7 years), bariatric surgery was associated with a lower risk of mortality (9.2 vs 14.7 per 1,000 person-years; HR: 0.63; 95% CI: 0.60-0.66), new-onset HF (HR: 0.46; 95% CI: 0.44-0.49), MI (HR: 0.63; 95% CI: 0.59-0.68), and stroke (HR: 0.71; 95%: CI: 0.65-0.79) (P < 0.001). The benefit of bariatric surgery was evident in patients who were 65 years and older. Using instrumental variable analysis, bariatric surgery was associated with a lower risk of mortality, HF, and MI.
Conclusions
Among Medicare beneficiaries with obesity, bariatric surgery is associated with lower risk of mortality, new-onset HF, and MI.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 19 Apr 2022; 79:1429-1437
Mentias A, Aminian A, Youssef D, Pandey A, ... Nissen SE, Desai MY
J Am Coll Cardiol: 19 Apr 2022; 79:1429-1437 | PMID: 35422238
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Abstract

Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia.

Arenal Á, Ávila P, Jiménez-Candil J, Tercedor L, ... Fernández-Avilés FJ, Berruezo A
Background
In patients with ischemic cardiomyopathy and an implantable cardioverter-defibrillator (ICD), catheter ablation and antiarrhythmic drugs (AADs) reduce ICD shocks, but the most effective approach remains uncertain.
Objectives
This trial compares the efficacy and safety of catheter ablation vs AAD as first-line therapy in ICD patients with symptomatic ventricular tachycardias (VTs).
Methods
The SURVIVE-VT (Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia) is a prospective, multicenter, randomized trial including patients with ischemic cardiomyopathy and appropriated ICD shock. Patients were 1:1 randomized to complete endocardial substrate-based catheter ablation or antiarrhythmic therapy (amiodarone + beta-blockers, amiodarone alone, or sotalol ± beta-blockers). The primary outcome was a composite of cardiovascular death, appropriate ICD shock, unplanned hospitalization for worsening heart failure, or severe treatment-related complications.
Results
In this trial, 144 patients (median age, 70 years; 96% male) were randomized to catheter ablation (71 patients) or AAD (73 patients). After 24 months, the primary outcome occurred in 28.2% of patients in the ablation group and 46.6% of those in the AAD group (hazard ratio [HR]: 0.52; 95% CI: 0.30-0.90; P = 0.021). This difference was driven by a significant reduction in severe treatment-related complications (9.9% vs 28.8%, HR: 0.30; 95% CI: 0.13-0.71; P = 0.006). Eight patients were hospitalized for heart failure in the ablation group and 13 in the AAD group (HR: 0.56; 95% CI: 0.23-1.35; P = 0.198). There was no difference in cardiac mortality (HR: 0.93; 95% CI: 0.19-4.61; P = 0.929).
Conclusions
In ICD patients with ischemic cardiomyopathy and symptomatic VT, catheter ablation reduced the composite endpoint of cardiovascular death, appropriate ICD shock, hospitalization due to heart failure, or severe treatment-related complications compared to AAD. (Substrate Ablation vs Antiarrhythmic Drug Therapy for Symptomatic Ventricular Tachycardia [SURVIVE-VT]: NCT03734562).

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 19 Apr 2022; 79:1441-1453
Arenal Á, Ávila P, Jiménez-Candil J, Tercedor L, ... Fernández-Avilés FJ, Berruezo A
J Am Coll Cardiol: 19 Apr 2022; 79:1441-1453 | PMID: 35422240
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Abstract

External Validation of the FREEDOM Score for Individualized Decision Making Between CABG and PCI.

Takahashi K, Serruys PW, Fuster V, Farkouh ME, ... BEST, and FREEDOM Trial investigators
Background
Although randomized trials have established that coronary artery bypass grafting (CABG) is, on average, the most effective revascularization strategy compared with percutaneous coronary intervention (PCI) in patients with diabetes and multivessel disease (MVD), individual patients differ in many characteristics that can affect the benefits and harms of treatment. The FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus) score was developed to predict different outcomes with CABG vs PCI on the basis of 8 patient characteristics and the smoking-treatment interaction.
Objectives
This study aimed to assess the ability of the 5-year major adverse cardiovascular event (MACE) model to predict treatment benefit of CABG vs PCI in the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) and BEST (Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease) trials.
Methods
This study identified 702 patients with diabetes and MVD to mirror the FREEDOM participants. Discrimination was assessed by C-index, and calibration was assessed by calibration plots in the PCI and CABG arms, respectively. The ability of the FREEDOM score to predict treatment benefit of CABG vs PCI was assessed.
Results
Overall, CABG was associated with a lower rate of 5-year MACE compared with PCI (12.4% vs 20.3%; log-rank P = 0.021) irrespective of a history of smoking (Pinteraction = 0.975). Both discrimination and calibration were helpful in the PCI arm (C-index: 0.69; slope: 0.96, intercept: -0.24), but moderate in the CABG arm (C-index: 0.61; slope: 0.61; intercept: -0.53). The FREEDOM score showed some heterogeneity of treatment benefit.
Conclusions
The FREEDOM score could identify some heterogeneity of treatment benefit of CABG vs PCI for 5-year MACE. Until further prospective validations are performed, these results should be taken into consideration when using the FREEDOM score in patients with diabetes and MVD. (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery [SYNTAX]; NCT00114972) (Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease [BEST]; NCT00997828) (Future Revascularization Evaluation in Patients with Diabetes Mellitus [FREEDOM]; NCT00086450).

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 19 Apr 2022; 79:1458-1473
Takahashi K, Serruys PW, Fuster V, Farkouh ME, ... BEST, and FREEDOM Trial investigators
J Am Coll Cardiol: 19 Apr 2022; 79:1458-1473 | PMID: 35422242
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Abstract

Percutaneous Pulmonary Angioplasty for Patients With Takayasu Arteritis and Pulmonary Hypertension.

Zhou YP, Wei YP, Yang YJ, Xu XQ, ... Jiang X, Jing ZC
Background
Percutaneous transluminal pulmonary angioplasty (PTPA) is a treatment modality for chronic thromboembolic pulmonary hypertension, but whether it can be applied to Takayasu arteritis-associated pulmonary hypertension (TA-PH), another chronic obstructive pulmonary vascular disease, remains unclear.
Objectives
This study sought to investigate the efficacy and safety of PTPA for TA-PH.
Methods
Between January 1, 2016, and December 31, 2019, a total of 50 patients with TA-PH who completed the PTPA procedure (the PTPA group) and 21 patients who refused the PTPA procedure (the non-PTPA group) were prospectively enrolled in this cohort study. The primary outcome was all-cause mortality. The safety outcomes included PTPA procedure-related complications.
Results
Baseline characteristics and medical therapies were similar between the PTPA group and the non-PTPA group. During a mean follow-up time of 37 ± 14 months, deaths occurred in 3 patients (6.0%) in the PTPA group and 6 patients (28.6%) in the non-PTPA group, contributing to the 3-year survival rate of 93.7% in the PTPA group and 76.2% in the non-PTPA group (P = 0.0096 for log-rank test). The Cox regression model showed that PTPA was associated with a significantly reduced hazard of all-cause mortality in TA-PH patients (HR: 0.18; 95% CI: 0.05-0.73; P = 0.017). No periprocedural death occurred. Severe complications requiring noninvasive positive pressure ventilation occurred in only 1 of 150 total sessions (0.7%).
Conclusions
PTPA tended to be associated with a reduced risk of all-cause mortality with acceptable safety profiles and seemed to be a promising therapeutic option for TA-PH patients.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 19 Apr 2022; 79:1477-1488
Zhou YP, Wei YP, Yang YJ, Xu XQ, ... Jiang X, Jing ZC
J Am Coll Cardiol: 19 Apr 2022; 79:1477-1488 | PMID: 35422244
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Impact:
Abstract

Sex Differences in Cardiovascular Consequences of Hypertension, Obesity, and Diabetes: JACC Focus Seminar 4/7.

Regensteiner JG, Reusch JEB
It has long been recognized that there are significant differences between the sexes affecting prevalence, incidence, and severity over a broad range of diseases. Until the early 1990s, the limited research conducted on women\'s health focused primarily on diseases affecting fertility and reproduction, and women were excluded from most clinical trials. For these reasons, the prevention, diagnosis, and treatment of serious chronic diseases such as cardiovascular disease in women continue to be based primarily on findings in men, and sex-specific clinical guidelines are mostly lacking. Hypertension, obesity, and diabetes, interrelated risk factors for cardiovascular disease, differ by sex in terms of prevalence and adverse effects as well as by genetics and biology. Research is needed to understand sex differences in hypertension, obesity, and diabetes to optimally inform sex-specific prevention, diagnosis, and treatment strategies for women and men. In this way, sex-specific clinical guidelines can be developed where warranted.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 19 Apr 2022; 79:1492-1505
Regensteiner JG, Reusch JEB
J Am Coll Cardiol: 19 Apr 2022; 79:1492-1505 | PMID: 35422246
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Impact:
Abstract

Sex-Related Factors in Valvular Heart Disease: JACC Focus Seminar 5/7.

Hahn RT, Clavel MA, Mascherbauer J, Mick SL, Asgar AW, Douglas PS
Numerous sex-based differences are observed across the spectrum of valvular heart disease, starting with pathophysiology and progression of disease, moving on to compensation and comorbidities (both cardiovascular such as coronary artery disease and noncardiovascular such as frailty), assessment of severity and hemodynamics including timing of intervention, and procedural risks/benefits and outcomes. The aortic valve is perhaps best understood with sex differences in both pathologic changes and response to volume and pressure overload, yet large gaps in our understanding still exist. Studies of other valve diseases have focused on differences in prevalence, presentation, and outcomes for surgical or transcatheter therapies. Defining sex-specific responses to valvular heart disease may improve disease recognition, define treatment strategies, and improve outcomes.

Copyright © 2022. Published by Elsevier Inc.

J Am Coll Cardiol: 19 Apr 2022; 79:1506-1518
Hahn RT, Clavel MA, Mascherbauer J, Mick SL, Asgar AW, Douglas PS
J Am Coll Cardiol: 19 Apr 2022; 79:1506-1518 | PMID: 35422247
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Impact:
Abstract

Sex-Specific Considerations in Drug and Device Therapy of Cardiac Arrhythmias: JACC Focus Seminar 6/7.

Amuthan R, Curtis AB
Sex and gender are important factors influencing the epidemiology and outcomes of cardiovascular care in various cardiac arrhythmias. Observed sex-related differences are influenced by the effects of both biologically determined sex and culturally defined gender. Under-representation of women in clinical trials and incomplete understanding of the mechanisms behind sex differences have led to inadequate evidence to guide effective sex-specific treatment. This lack of information has contributed to disparities in clinical care. In this review, we examine the effect of sex and gender on the clinical presentation and outcomes with drug and device therapy in various arrhythmias, while acknowledging the paucity of data on the effect of gender. We evaluate the implications of sex on the clinical management of arrhythmias covered by guideline documents, highlight recent data that warrant consideration for additional sex-specific recommendations, and illustrate knowledge gaps that require further study.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 19 Apr 2022; 79:1519-1529
Amuthan R, Curtis AB
J Am Coll Cardiol: 19 Apr 2022; 79:1519-1529 | PMID: 35422248
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Impact:
Abstract

Sex-Based Differences in Heart Failure: JACC Focus Seminar 7/7.

Khan SS, Beach LB, Yancy CW
Sex-based differences exist in risk, symptoms, and management of heart failure (HF). Women have a higher incidence of HF with preserved ejection fraction compared with men. This may be partially caused by the cardiovascular effects of estrogen and sex-specific risk factors (eg, adverse pregnancy outcomes, premature menopause). Key gaps exist in understanding of gender-based differences in HF, which is a distinctly different concept than sex-based differences. Although evidence-based therapies for HF are available, only limited data address sex-specific efficacy, and no data address gender-based efficacy. Persistent shortcomings in representation of women and gender minority participants in clinical trials limit an actionable database. A comprehensive roadmap to close the sex/gender-based gap in HF includes the following: 1) sex/gender-specific personalized prevention; 2) sex/gender-neutral implementation of evidence-based therapies; and 3) sex/gender-appropriate policy-level initiatives to spur research assessing sex/gender-specific causes of HF; enhance sex/gender-specific subgroup reporting; and promote community engagement of these important patient cohorts.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 19 Apr 2022; 79:1530-1541
Khan SS, Beach LB, Yancy CW
J Am Coll Cardiol: 19 Apr 2022; 79:1530-1541 | PMID: 35422249
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Impact:
Abstract

Association of Cumulative Blood Pressure With Cognitive Decline, Dementia, and Mortality.

Li C, Zhu Y, Ma Y, Hua R, Zhong B, Xie W
Background
Elevated blood pressure (BP) has been linked to impaired cognition and dementia in older adults. However, few studies have accounted for long-term cumulative BP exposure.
Objectives
The aim of this study was to test whether long-term cumulative BP was independently associated with subsequent cognitive decline, incident dementia, and all-cause mortality among cognitively healthy adults.
Methods
This study used data from the HRS (Health and Retirement Study) and ELSA (English Longitudinal Study of Ageing). Cumulative BP was calculated as the area under the curve using measurements from wave 0 (1998-1999) to wave 4 (2008-2009) in ELSA and wave 8 (2006-2007) to wave 10 (2010-2011) in the HRS. Outcomes included cognitive decline, incident dementia, and all-cause mortality.
Results
A total of 7,566 and 9,294 participants from ELSA and the HRS were included (44.8% and 40.2% men and median age 62.0 years [IQR: 55.0-70.0 years] and 65.0 years [IQR: 58.0-72.0 years], respectively). The median follow-up duration was 8.0 years (IQR: 4.0-8.0 years) and 8.0 years (IQR: 6.0-8.0 years), respectively. Elevated cumulative systolic BP and pulse pressure were independently associated with accelerated cognitive decline (P < 0.001 for both), elevated dementia risk (P < 0.001 for both), and all-cause mortality (P < 0.001 for both), while a significant inverse association was observed for diastolic BP. Strong dose-response relationships were identified, with similar results for the 2 cohorts.
Conclusions
Long-term cumulative BP was associated with subsequent cognitive decline, dementia risk, and all-cause mortality in cognitively healthy adults aged ≥50 years. Efforts are required to control long-term systolic BP and pulse pressure and to maintain adequate diastolic BP.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 12 Apr 2022; 79:1321-1335
Li C, Zhu Y, Ma Y, Hua R, Zhong B, Xie W
J Am Coll Cardiol: 12 Apr 2022; 79:1321-1335 | PMID: 35393012
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Impact:
Abstract

Late Balloon Valvuloplasty for Transcatheter Heart Valve Dysfunction.

Akodad M, Blanke P, Chuang MA, Duchscherer J, ... Ye J, Webb JG
Background
Transcatheter heart valve (THV) dysfunction with an elevated gradient or paravalvular leak (PVL) may be documented late after THV implantation. Medical management, paravalvular plugs, redo THV replacement, or surgical valve replacement may be considered. However, late balloon dilatation is rarely utilized because of concerns about safety or lack of efficacy.
Objectives
We aimed to evaluate the safety and efficacy of late dilatation in the management of THV dysfunction.
Methods
All patients who underwent late dilatation for symptomatic THV dysfunction at 2 institutions between 2016 and 2021 were identified. Baseline, procedural characteristics, and clinical and echocardiographic outcomes were documented. THV frame expansion was assessed by multislice computed tomography before and after late dilatation.
Results
Late dilatation was performed in 30 patients a median of 4.6 months (IQR: 2.3-11.0 months) after THV implantation in the aortic (n = 25; 83.3%), mitral (n = 2; 6.7%), tricuspid (n = 2; 6.7%) and pulmonary (n = 1; 3.3%) position. THV underexpansion was documented at baseline, and frame expansion substantially improved after late dilatation. The mean transvalvular gradient fell in all patients. For aortic THVs specifically, mean transaortic gradient fell from 25.4 ± 13.9 mm Hg to 10.8 ± 4.1 mm Hg; P < 0.001. PVL was reduced to ≤mild in all 11 patients with a previous >mild PVL. Embolic events, stroke, annular injury, and bioprosthetic leaflet injury were not observed. Symptomatic benefit was durable at 19.6 months (IQR: 14.8-36.1 months) follow-up.
Conclusions
Balloon dilatation late after THV implantation appears feasible and safe in appropriately selected patients and may result in THV frame expansion resulting in improvements in hemodynamic performance and PVL.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 12 Apr 2022; 79:1340-1351
Akodad M, Blanke P, Chuang MA, Duchscherer J, ... Ye J, Webb JG
J Am Coll Cardiol: 12 Apr 2022; 79:1340-1351 | PMID: 35393014
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Impact:
Abstract

Prevalence and Prognostic Implications of Left Ventricular Systolic Dysfunction in Adults With Congenital Heart Disease.

Egbe AC, Miranda WR, Pellikka PA, DeSimone CV, Connolly HM
Background
Although the prevalence and prognostic implications of left ventricular systolic dysfunction (LVSD), and the effect of cardiac therapies on LVSD are well described in patients with acquired heart disease, such data are sparse in adults with congenital heart disease (CHD).
Objectives
The purpose of this study was to determine the prevalence, risk factors, and prognostic implications of LVSD, and the effect of cardiac therapies (guideline-directed medical therapy [GDMT] and cardiac resynchronization therapy [CRT]) on LVSD in adults with CHD.
Methods
This was a retrospective study of adults with CHD with systemic LV (2003-2019). LVSD was defined as left ventricular ejection fraction (LVEF) <52%/<54% (men/women). Cardiovascular event was defined as heart failure hospitalization, heart transplant, and cardiovascular death.
Results
Of 4,358 patients, 554 (12%) had LVSD, and the prevalence of LVSD was higher in right-sided lesions compared with left-sided lesions (15% vs 10%; P < 0.001). Cardiovascular events occurred in 312 (7%) patients. LVEF was independently associated with cardiovascular events (HR: 0.95; 95% CI: 0.93-0.97; P = 0.009). Of 544 patients with LVSD, 311 received GDMT and 48 patients received CRT. LVEF increased by 6% (95% CI: 2%-10%) and 11% (95% CI: 8%-14%), and N-terminal pro-hormone brain natriuretic peptide decreased by 151 pg/mL (95% CI: 62-289 pg/mL) and 201 pg/mL (95% CI: 119-321 pg/mL) in patients who received GDMT and CRT, respectively.
Conclusions
LVSD was present in 12% of adults with CHD, was more common in patients with right-sided lesions, and was associated with cardiovascular events. GDMT and CRT were associated with improvement in LVEF. These results provide a foundation for clinical trials to rigorously test the benefits of these therapies in CHD patients.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 12 Apr 2022; 79:1356-1365
Egbe AC, Miranda WR, Pellikka PA, DeSimone CV, Connolly HM
J Am Coll Cardiol: 12 Apr 2022; 79:1356-1365 | PMID: 35393016
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Abstract

Measurement of Midregional Pro-Atrial Natriuretic Peptide to Discover Atrial Fibrillation in Patients With Ischemic Stroke.

Schweizer J, Arnold M, König IR, Bicvic A, ... von Eckardstein A, Katan M
Background
Midregional pro-atrial natriuretic peptide (MR-proANP) is a promising biomarker to differentiate the underlying etiology of acute ischemic stroke (AIS).
Objectives
This study aimed to determine the role of MR-proANP for classification as cardioembolic (CE) stroke, identification of newly diagnosed atrial fibrillation (NDAF), and risk assessment for major adverse cardiovascular events (MACE).
Methods
This study measured MR-proANP prospectively collected within 24 hours after symptom-onset in patients with AIS from the multicenter BIOSIGNAL (Biomarker Signature of Stroke Aetiology) cohort study. Primary outcomes were CE stroke etiology and NDAF after prolonged cardiac monitoring, as well as a composite outcome of MACE (recurrent cerebrovascular events, myocardial infarction, or cardiovascular death) within 1 year. Logistic/Poisson and subproportional hazard regression were applied to evaluate the association between MR-proANP levels and outcomes. Additionally, a model for prediction of NDAF was derived and validated as a decision tool for immediate clinical application.
Results
Between October 1, 2014, and October 31, 2017, this study recruited 1,759 patients. Log10MR-proANP levels were associated with CE stroke (OR: 7.96; 95% CI: 4.82-13.14; risk ratio: 3.12; 95% CI: 2.23-4.37), as well as NDAF (OR: 35.3; 95% CI: 17.58-71.03; risk ratio: 11.47; 95% CI: 6.74-19.53), and MACE (subdistributional HR: 2.02; 95% CI: 1.32-3.08) during follow-up. The model to predict NDAF including only age and MR-proANP levels had a good discriminatory capacity with an area under the curve of 0.81 (95% CI: 0.76-0.86), was well calibrated (calibration in the large: -0.086; calibration slope 1.053), and yielded higher net-benefit compared with validated scores to predict NDAF (AS5F score, CHA2DS2-VASc [Congestive Heart Failure, Hypertension, Age ≥65 or ≥75, Diabetes, Prior Cardioembolic Event, (female) Sex, or Vascular Disease] score).
Conclusions
MR-proANP is a valid biomarker to determine risk of NDAF and MACE in patients with AIS and can be used as a decision tool to identify patients for prolonged cardiac monitoring. (Biomarker Signature of Stroke Aetiology Study: The BIOSIGNAL study [BIOSIGNAL]; NCT02274727).

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 12 Apr 2022; 79:1369-1381
Schweizer J, Arnold M, König IR, Bicvic A, ... von Eckardstein A, Katan M
J Am Coll Cardiol: 12 Apr 2022; 79:1369-1381 | PMID: 35393018
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Impact:
Abstract

Sex as a Biological Variable in Cardiovascular Diseases: JACC Focus Seminar 1/7.

Clayton JA, Gaugh MD
Sex and gender influence all aspects of cardiovascular health and disease-including epidemiology, pathophysiology, diagnosis, clinical manifestation, disease progression, and response to treatment-in complex and interrelated ways. Sex-based and gender-based differences have been identified in risk and presentation of cardiovascular diseases (CVDs); however, failure to address sex and gender as key variables in CVD research and reporting and limited understanding of differences have contributed to disparities in risk assessment, prevention, diagnosis, treatment, and outcomes. Improved consideration of both sex and gender in all phases of the biomedical research continuum, along with educational and training curricula focused on the role of sex and gender in CVD, are needed to provide targeted therapies and improve cardiovascular health outcomes for all.

Copyright © 2022. Published by Elsevier Inc.

J Am Coll Cardiol: 12 Apr 2022; 79:1388-1397
Clayton JA, Gaugh MD
J Am Coll Cardiol: 12 Apr 2022; 79:1388-1397 | PMID: 35393021
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Impact:
Abstract

Sex-Specific Considerations in the Presentation, Diagnosis, and Management of Ischemic Heart Disease: JACC Focus Seminar 2/7.

Solola Nussbaum S, Henry S, Yong CM, Daugherty SL, Mehran R, Poppas A
There are sex-related differences in the epidemiology, presentation, diagnostic testing, and management of ischemic heart disease in women compared with men. The adjusted morbidity and mortality are persistently higher, particularly in younger women and Blacks. Women have more angina but less obstructive coronary artery disease, which affects delays in presentation and diagnosis and testing accuracy. The nonbiological factors play a significant role in access to care, ischemic heart disease management, and guideline adherence. Future research focus includes sex-specific outcomes, characterization of the biological differences, and implementation science around quality of clinical care.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 12 Apr 2022; 79:1398-1406
Solola Nussbaum S, Henry S, Yong CM, Daugherty SL, Mehran R, Poppas A
J Am Coll Cardiol: 12 Apr 2022; 79:1398-1406 | PMID: 35393022
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Impact:
Abstract

Sex-Related Outcomes of Medical, Percutaneous, and Surgical Interventions for Coronary Artery Disease: JACC Focus Seminar 3/7.

Gaudino M, Di Franco A, Cao D, Giustino G, ... Dangas GD, Mehran R
Biological and sociocultural differences between men and women are complex and likely account for most of the variations in the epidemiology and treatment outcomes of coronary artery disease (CAD) between the 2 sexes. Worse outcomes in women have been described following both conservative and invasive treatments of CAD. For example, increased levels of residual platelet reactivity during treatment with antiplatelet drugs, higher rates of adverse cardiovascular outcomes following percutaneous coronary revascularization, and higher operative and long-term mortality after coronary bypass surgery have been reported in women compared with in men. Despite the growing recognition of sex-specific determinants of outcomes, representation of women in clinical studies remains low and sex-specific management strategies are generally not provided in guidelines. This review summarizes the current evidence on sex-related differences in patients with CAD, focusing on the differential outcomes following medical therapy, percutaneous coronary interventions, and coronary artery bypass surgery.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 12 Apr 2022; 79:1407-1425
Gaudino M, Di Franco A, Cao D, Giustino G, ... Dangas GD, Mehran R
J Am Coll Cardiol: 12 Apr 2022; 79:1407-1425 | PMID: 35393023
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Impact:
Abstract

Outcomes Associated With Peripheral Artery Disease in Myocardial Infarction With Cardiogenic Shock.

Mihatov N, Mosarla RC, Kirtane AJ, Parikh SA, ... Yeh RW, Secemsky EA
Background
Mortality rates for patients presenting with acute myocardial infarction (AMI) and cardiogenic shock (CS) remain high despite advances in revascularization strategies and mechanical circulatory support (MCS) devices.
Objectives
This study sought to elucidate the association between comorbid lower extremity peripheral artery disease (PAD) and outcomes in CS and AMI.
Methods
PAD status was defined in Medicare beneficiaries hospitalized with CS and AMI from October 1, 2015 to June 30, 2018. Primary outcomes ascertained through December 31, 2018 included in- and out-of-hospital mortality. Secondary outcomes included bleeding, amputation, stroke, and lower extremity revascularization. Multivariable regression models with adjustment for confounders were used to estimate risk. Subgroup analyses included patients treated with MCS and those who underwent coronary revascularization.
Results
Among 71,690 patients, 5.9% (N = 4,259) had PAD. Mean age was 77.8 ± 7.9 years, 58.7% were male, and 84.3% were White. Cumulative in-hospital mortality was 47.2%, with greater risk among those with PAD (56.3% vs 46.6% without PAD; adjusted OR: 1.50; 95% CI: 1.40-1.59). PAD patients also had greater risk of in-hospital amputation (1.6% vs 0.2%; adjusted OR: 7.0; 95% CI: 5.26-9.37) and out-of-hospital mortality (67.9% vs 40.7%; adjusted HR: 1.78; 95% CI: 1.67-1.90). MCS was less frequently utilized in PAD patients (21.5% vs 38.6% without PAD; P < 0.001) and was associated with higher mortality, need for lower extremity revascularization, and amputation risk. Findings were consistent in patients who underwent coronary revascularization.
Conclusions
Among patients presenting with AMI and CS, PAD was associated with worse limb outcomes and survival. In addition to lower MCS utilization rates, those with PAD who received MCS had increased mortality, lower extremity revascularization, and amputation rates.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 05 Apr 2022; 79:1223-1235
Mihatov N, Mosarla RC, Kirtane AJ, Parikh SA, ... Yeh RW, Secemsky EA
J Am Coll Cardiol: 05 Apr 2022; 79:1223-1235 | PMID: 35361344
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Impact:
Abstract

Mechanical Left Ventricular Unloading in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation.

Grandin EW, Nunez JI, Willar B, Kennedy K, ... Shaefi S, Garan AR
Background
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) increases left ventricular (LV) afterload, potentially provoking LV distention and impairing recovery. LV mechanical unloading (MU) with intra-aortic balloon pump (IABP) or percutaneous ventricular assist device (pVAD) can prevent LV distension, potentially at the risk of more complications, and net clinical benefit remains uncertain.
Objectives
This study aims to determine the association between MU and outcomes for patients undergoing VA-ECMO.
Methods
The authors queried the Extracorporeal Life Support Organization registry for adults receiving peripheral VA-ECMO from 2010 to 2019 and stratified them by MU with IABP or pVAD. The primary outcome was in-hospital mortality; secondary outcomes included on-support mortality and complications during VA-ECMO.
Results
Among 12,734 VA-ECMO patients, 3,399 (26.7%) received MU: 2,782 (82.9%) IABP and 580 (17.1%) pVAD. MU patients were older (age 56.3 vs 52.7 years) and, before extracorporeal membrane oxygenation, more often required >2 vasopressors (41.7% vs 27.2%) and had respiratory (21.1% vs 15.9%), renal (24.6% vs 15.8%), and liver failure (4.4% vs 3.1%) (all P < 0.001). MU patients had lower in-hospital mortality (56.6% vs 59.3%, P = 0.006), which persisted in multivariable modeling (adjusted OR [aOR]: 0.84; 95% CI: 0.77-0.92; P < 0.001). MU was associated with more cannula site bleeding (aOR: 1.25; 95% CI: 1.11-1.40; P < 0.001) and hemolysis (aOR: 1.27; 95% CI: 1.03-1.57; P = 0.02). Compared to pVAD, MU patients with IABP had similar mortality (aOR: 0.80; 95% CI: 0.64-1.01; P = 0.06) and less medical bleeding (aOR: 0.45; 95% CI: 0.31-0.64; P < 0.001), cannula site bleeding (aOR: 0.72; 95% CI: 0.54-0.96; P = 0.03), and renal injury (aOR: 0.78; 95% CI: 0.62-0.98; P = 0.03).
Conclusions
Among adults receiving VA-ECMO, MU was associated with lower in-hospital mortality despite increased complications including hemolysis and cannulation site bleeding. Compared to pVAD, MU with IABP was associated with similar mortality and lower complication rates.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 05 Apr 2022; 79:1239-1250
Grandin EW, Nunez JI, Willar B, Kennedy K, ... Shaefi S, Garan AR
J Am Coll Cardiol: 05 Apr 2022; 79:1239-1250 | PMID: 35361346
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Impact:
Abstract

Effects of Experimental Sleep Restriction on Energy Intake, Energy Expenditure, and Visceral Obesity.

Covassin N, Singh P, McCrady-Spitzer SK, St Louis EK, ... Levine JA, Somers VK
Background
Although the consequences of sleep deficiency for obesity risk are increasingly apparent, experimental evidence is limited and there are no studies on body fat distribution.
Objectives
The purpose of this study was to investigate the effects of experimentally-induced sleep curtailment in the setting of free access to food on energy intake, energy expenditure, and regional body composition.
Methods
Twelve healthy, nonobese individuals (9 males, age range 19 to 39 years) completed a randomized, controlled, crossover, 21-day inpatient study comprising 4 days of acclimation, 14 days of experimental sleep restriction (4 hour sleep opportunity) or control sleep (9 hour sleep opportunity), and a 3-day recovery segment. Repeated measures of energy intake, energy expenditure, body weight, body composition, fat distribution and circulating biomarkers were acquired.
Results
With sleep restriction vs control, participants consumed more calories (P = 0.015), increasing protein (P = 0.050) and fat intake (P = 0.046). Energy expenditure was unchanged (all P > 0.16). Participants gained significantly more weight when exposed to experimental sleep restriction than during control sleep (P = 0.008). While changes in total body fat did not differ between conditions (P = 0.710), total abdominal fat increased only during sleep restriction (P = 0.011), with significant increases evident in both subcutaneous and visceral abdominal fat depots (P = 0.047 and P = 0.042, respectively).
Conclusions
Sleep restriction combined with ad libitum food promotes excess energy intake without varying energy expenditure. Weight gain and particularly central accumulation of fat indicate that sleep loss predisposes to abdominal visceral obesity. (Sleep Restriction and Obesity; NCT01580761).

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 05 Apr 2022; 79:1254-1265
Covassin N, Singh P, McCrady-Spitzer SK, St Louis EK, ... Levine JA, Somers VK
J Am Coll Cardiol: 05 Apr 2022; 79:1254-1265 | PMID: 35361348
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Impact:
Abstract

Prognostic Impact of Mildly Impaired Renal Function in Patients Undergoing Multivessel Coronary Revascularization.

Kim TO, Kang DY, Ahn JM, Kim SO, ... Park DW, Asan Medical Center–Multivessel Revascularization Registry Investigators
Background
The long-term prognostic impact of mildly decreased renal function in patients undergoing coronary revascularization is still unknown.
Objectives
The goal of this study was to investigate the long-term prognostic impact of mildly decreased renal function and comparative outcomes after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in such a risk group of patients.
Methods
From the Asan Medical Center-Multivessel Revascularization registry, 10,354 eligible patients who underwent coronary revascularization were classified into 3 groups (stage I [n = 3,735]: normal renal function; stage II [n = 5,122]: mild dysfunction; and stage III [n = 1,497]: moderate dysfunction) according to estimated glomerular filtration rate. The primary outcome was the composite of death, spontaneous myocardial infarction, or stroke. Propensity score matching was used to assemble a cohort of patients with similar baseline characteristics.
Results
After propensity matching, the risk for primary composite outcome was not different between the stage I and the stage II group (HR: 1.12; 95% CI: 0.97-1.30). However, the risk of the primary outcome was significantly higher in the stage III group than in the stage I group (HR: 1.50; 95% CI: 1.22-1.84). The relative effect of PCI vs CABG for the primary outcome was similar in the matched cohort of each renal function group of stages I, II, and III.
Conclusions
In patients with multivessel disease after revascularization by PCI or CABG, the presence of mildly decreased renal function was not significantly associated with an increased risk of the primary composite outcome and mortality. Comparative outcomes after PCI and CABG were similar in the borderline-risk group. (Asan Medical Center-Multivessel Revascularization registry; NCT02039752).

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 05 Apr 2022; 79:1270-1284
Kim TO, Kang DY, Ahn JM, Kim SO, ... Park DW, Asan Medical Center–Multivessel Revascularization Registry Investigators
J Am Coll Cardiol: 05 Apr 2022; 79:1270-1284 | PMID: 35361350
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Impact:
Abstract

Critical Comparison of Documents From Scientific Societies on Cardiac Amyloidosis: JACC State-of-the-Art Review.

Rapezzi C, Aimo A, Serenelli M, Barison A, ... Garcia-Pavia P, Emdin M
Over the last year, 5 national or international scientific societies have issued documents regarding cardiac amyloidosis (CA) to highlight the emerging clinical science, raise awareness, and facilitate diagnosis and management of CA. These documents provide useful guidance for clinicians managing patients with CA, and all include: 1) an algorithm to establish a diagnosis; 2) an emphasis on noninvasive diagnosis with the combined use of bone scintigraphy and the exclusion of a monoclonal protein; and 3) indications for novel disease-modifying therapies for symptomatic CA, either with or without peripheral neuropathy. Nonetheless, the documents diverge on specific details of diagnosis, risk stratification, and treatment. Highlighting the similarities and differences of the documents by the 5 scientific societies with respect to diagnosis, risk stratification, and treatment offers useful insight into the knowledge gaps and unmet needs in the management of CA. An analysis of these documents, therefore, highlights \"gray zones\" requiring further investigation.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 05 Apr 2022; 79:1288-1303
Rapezzi C, Aimo A, Serenelli M, Barison A, ... Garcia-Pavia P, Emdin M
J Am Coll Cardiol: 05 Apr 2022; 79:1288-1303 | PMID: 35361352
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Abstract

Comparison of American and European Guidelines for Primary Prevention of Cardiovascular Disease: JACC Guideline Comparison.

Fegers-Wustrow I, Gianos E, Halle M, Yang E
This review compares the primary prevention recommendations of the recent 2021 European Society of Cardiology (ESC) and 2019 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines on cardiovascular disease (CVD) prevention. Although the 2019 ACC/AHA guideline represents its inaugural version, the ESC guideline is an update to its 2016 statement. Both guidelines address prevention using a holistic approach and agree on the importance of lifestyle optimization and intensified risk factor management. Cardiovascular (CV) risk assessment tools differ, reflecting the unique populations being screened as well as philosophical differences to their approach. Conventional risk factors are used to estimate CV risk, but each guideline acknowledges the role of risk modifiers to refine risk calculation. The ESC guideline recognizes the importance of nonclassical risk factors, including environmental issues, that impact CV health at the population level and calls for legislative action at the local, regional, and national levels.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 05 Apr 2022; 79:1304-1313
Fegers-Wustrow I, Gianos E, Halle M, Yang E
J Am Coll Cardiol: 05 Apr 2022; 79:1304-1313 | PMID: 35361353
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Abstract

Fulminant Myocarditis Following SARS-CoV-2 Infection: JACC Patient Care Pathways.

Rajpal S, Kahwash R, Tong MS, Paschke K, ... Gluckman TJ, Fuster V
A 60-year-old woman with a past medical history of asthma presented with fulminant myocarditis 9 days after testing positive for SARS-CoV-2 and 16 days after developing symptoms consistent with COVID-19. Her hospital course was complicated by the need for veno-arterial extracorporeal membrane oxygenation, ventricular arrhythmias, and pseudomonas bacteremia. She ultimately recovered and was discharged to home with normal left ventricular systolic function. Thereafter, she developed symptomatic ventricular tachycardia, for which she received an implantable cardioverter defibrillator and antiarrhythmic drug therapy.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 29 Mar 2022; epub ahead of print
Rajpal S, Kahwash R, Tong MS, Paschke K, ... Gluckman TJ, Fuster V
J Am Coll Cardiol: 29 Mar 2022; epub ahead of print | PMID: 35364210
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Abstract

Prospective Evaluation of Autonomic Dysfunction in Post-Acute Sequela of COVID-19.

Jamal SM, Landers DB, Hollenberg SM, Turi ZG, ... Tancredi J, Parrillo JE
Background
Patients with PASC often report symptoms of orthostatic intolerance and autonomic dysfunction. Numerous case reports link Postural Orthostatic Tachycardia Syndrome (POTS) to PASC. No prospective analysis has been performed.
Objective
We performed head-up tilt table (HUTT) testing in symptomatic Post-Acute Sequela of COVID-19 (PASC) patients to evaluate for orthostatic intolerance suggestive of autonomic dysfunction.
Methods
We performed a prospective, observational evaluation of patients with PASC complaining of poor exertional tolerance, tachycardia with minimal activity or positional change, and palpitations. Exclusion criteria included pregnancy, pre-PASC autonomic dysfunction or syncope, or another potential explanation of PASC symptoms. All subjects underwent HUTT.
Results
Twenty-four patients with the described PASC symptoms were included. HUTT was performed a mean of 5.8 ± 3.5 months after symptom onset. Twenty-three of the 24 had orthostatic intolerance on HUTT, with 4 demonstrating POTS, 15 provoked orthostatic intolerance (POI) after nitroglycerin, 3 neurocardiogenic syncope, and one orthostatic hypotension. Compared to those with POTS, patients with POI described significantly earlier improvement of symptoms.
Conclusions
This prospective evaluation of HUTT in PASC patients revealed orthostatic intolerance on HUTT suggestive of autonomic dysfunction in nearly all subjects. Those with POI may be further along the path of clinical recovery than those demonstrating POTS.

Copyright © 2022. Published by Elsevier Inc.

J Am Coll Cardiol: 28 Mar 2022; epub ahead of print
Jamal SM, Landers DB, Hollenberg SM, Turi ZG, ... Tancredi J, Parrillo JE
J Am Coll Cardiol: 28 Mar 2022; epub ahead of print | PMID: 35381331
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Abstract

Trends in Clinical Characteristics, Management Strategies and Outcomes of STEMI Patients with COVID-19.

Garcia S, Dehghani P, Stanberry L, Grines C, ... Yildiz M, Henry TD
Background
We previously reported high in-hospital mortality for STEMI patients with COVID-19 treated in the early phase of the pandemic.
Objectives
To describe trends of COVID-19 patients with STEMI during the course of the pandemic.
Methods
The North American COVID-19 STEMI (NACMI) registry is a prospective, investigator initiated, multi-center, observational registry of hospitalized STEMI patients with confirmed or suspected COVID-19 infection in North America. We compared trends in clinical characteristics, management and outcomes of patients treated in the first year of the pandemic (1/2020 to 12/2020) versus those treated in the second year (1/2021 to 12/2021).
Results
A total of 586 COVID positive (+) patients with STEMI were included in the present analysis; 227 treated in Y2020 and 359 treated in Y2021. Patients\' characteristics changed over time. Relative to Y2020, the proportion of Caucasian patients was higher (58% vs. 39%, p<0.001), patients presented more frequently with typical ischemic symptoms (59% vs 51%, p=0.04), were less likely to have shock pre-PCI (13% vs 18%, p=0.07) or pulmonary manifestations (33% vs. 47%, p=0.001) in Y2021. In-hospital mortality decreased from 33% (Y2020) to 23% (Y2021) (p=0.008). In Y2021, none of the 22 vaccinated patients expired in hospital, whereas in-hospital death was recorded in 37 (22%) of unvaccinated patients (p=0.009).
Conclusions
Significant changes have occurred in the clinical characteristics and outcomes of STEMI patients with COVID-19 infection during the course of the pandemic.

Copyright © 2022. Published by Elsevier Inc.

J Am Coll Cardiol: 25 Mar 2022; epub ahead of print
Garcia S, Dehghani P, Stanberry L, Grines C, ... Yildiz M, Henry TD
J Am Coll Cardiol: 25 Mar 2022; epub ahead of print | PMID: 35390486
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Abstract

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

Writing Committee Members, Heidenreich PA, Bozkurt B, Aguilar D, ... Vest AR, Yancy CW
Aim
The \"2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure\" replaces the \"2013 ACCF/AHA Guideline for the Management of Heart Failure\" and the \"2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure.\" The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.
Methods
A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.
Structure
Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients\' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Copyright © 2022 American Heart Association, Inc., the American College of Cardiology Foundation, and the Heart Failure Society of America. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 24 Mar 2022; epub ahead of print
Writing Committee Members, Heidenreich PA, Bozkurt B, Aguilar D, ... Vest AR, Yancy CW
J Am Coll Cardiol: 24 Mar 2022; epub ahead of print | PMID: 35379503
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Abstract

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

Writing Committee Members, Heidenreich PA, Bozkurt B, Aguilar D, ... Vest AR, Yancy CW
Aim
The \"2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure\" replaces the \"2013 ACCF/AHA Guideline for the Management of Heart Failure\" and the \"2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure.\" The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.
Methods
A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.
Structure
Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients\' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 24 Mar 2022; epub ahead of print
Writing Committee Members, Heidenreich PA, Bozkurt B, Aguilar D, ... Vest AR, Yancy CW
J Am Coll Cardiol: 24 Mar 2022; epub ahead of print | PMID: 35379504
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Abstract

Effect of Pelacarsen on Lipoprotein(a) Cholesterol and Corrected Low-Density Lipoprotein Cholesterol.

Yeang C, Karwatowska-Prokopczuk E, Su F, Dinh B, ... Witztum JL, Tsimikas S
Background
Laboratory methods that report low-density lipoprotein cholesterol (LDL-C) include both LDL-C and lipoprotein(a) cholesterol [Lp(a)-C] content.
Objectives
The purpose of this study was to assess the effect of pelacarsen on directly measured Lp(a)-C and LDL-C corrected for its Lp(a)-C content.
Methods
The authors evaluated subjects with a history of cardiovascular disease and elevated Lp(a) randomized to 5 groups of cumulative monthly doses of 20-80 mg pelacarsen vs placebo. Direct Lp(a)-C was measured on isolated Lp(a) using LPA4-magnetic beads directed to apolipoprotein(a). LDL-C was reported as: 1) LDL-C as reported by the clinical laboratory; 2) LDL-Ccorr = laboratory-reported LDL-C - direct Lp(a)-C; and 3) LDL-CcorrDahlén = laboratory LDL-C - [Lp(a) mass × 0.30] estimated by the Dahlén formula.
Results
The baseline median Lp(a)-C values in the groups ranged from 11.9 to 15.6 mg/dL. Compared with placebo, pelacarsen resulted in dose-dependent decreases in Lp(a)-C (2% vs -29% to -67%; P = 0.001-<0.0001). Baseline laboratory-reported mean LDL-C ranged from 68.5 to 89.5 mg/dL, whereas LDL-Ccorr ranged from 55 to 74 mg/dL. Pelacarsen resulted in mean percent/absolute changes of -2% to -19%/-0.7 to -8.0 mg/dL (P = 0.95-0.05) in LDL-Ccorr, -7% to -26%/-5.4 to -9.4 mg/dL (P = 0.44-<0.0001) in laboratory-reported LDL-C, and 3.1% to 28.3%/0.1 to 9.5 mg/dL (P = 0.006-0.50) increases in LDL-CcorrDahlén. Total apoB declined by 3%-16% (P = 0.40-<0.0001), but non-Lp(a) apoB was not significantly changed.
Conclusions
Pelacarsen significantly lowers direct Lp(a)-C and has neutral to mild lowering of LDL-Ccorr. In patients with elevated Lp(a), LDL-Ccorr provides a more accurate reflection of changes in LDL-C than either laboratory-reported LDL-C or the Dahlén formula.

Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 22 Mar 2022; 79:1035-1046
Yeang C, Karwatowska-Prokopczuk E, Su F, Dinh B, ... Witztum JL, Tsimikas S
J Am Coll Cardiol: 22 Mar 2022; 79:1035-1046 | PMID: 35300814
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Abstract

Electronic Alerts to Improve Heart Failure Therapy in Outpatient Practice: A Cluster Randomized Trial.

Ghazi L, Yamamoto Y, Riello RJ, Coronel-Moreno C, ... Desai NR, Ahmad T
Background
Use of GDMT is under-prescribed in patients with HFrEF.
Objectives
To examine whether targeted and tailored EHR alerts recommending GDMT in eligible patients with HFrEF improves utilization.
Methods
PROMPT-HF was a pragmatic, EHR-based, cluster-randomized comparative effectiveness trial. 100 providers caring for patients with HFrEF were randomized to either an alert or usual care. The alert notified providers of individualized GDMT recommendations along with patient characteristics. The primary outcome was an increase in the number of GDMT classes prescribed at 30 days post-randomization. Providers were surveyed on knowledge of guidelines and user experience.
Results
We enrolled 1,310 ambulatory HFrEF patients April-October 2021. Median age was 72 years; 31% were female; 18% were black; median LVEF was 32%. At baseline, 84% were receiving β-blockers, 71% RAASi, 29% MRA, and 11% SGLTi. The primary outcome occurred in 176/685 (26%) participants in the alert arm versus 117/625 (19%) in the usual care arm, increasing GDMT class prescription by >40% after alert exposure [adjusted RR: 1.41 (1.03, 1.93); P=0.03]. The number of patients needed to alert to result in an increase in addition of GDMT class was 14. 79% of alerted providers agreed that the alert was effective at enabling improved prescription of medical therapy for HF.
Conclusions
A real-time, targeted, and tailored EHR-based alerting system for outpatients with HFrEF led to significantly higher rates of GDMT at 30 days when compared with usual care. This low-cost intervention can be rapidly integrated into clinical care and accelerate adoption of high-value therapies in heart failure.

Copyright © 2022. Published by Elsevier Inc.

J Am Coll Cardiol: 19 Mar 2022; epub ahead of print
Ghazi L, Yamamoto Y, Riello RJ, Coronel-Moreno C, ... Desai NR, Ahmad T
J Am Coll Cardiol: 19 Mar 2022; epub ahead of print | PMID: 35385798
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Abstract

Left Ventricular Thrombus Following Acute Myocardial Infarction: JACC State-of-the-Art Review.

Camaj A, Fuster V, Giustino G, Bienstock SW, ... Dweck MR, Goldman ME
The incidence of left ventricular (LV) thrombus following acute myocardial infarction has markedly declined in recent decades caused by advancements in reperfusion and antithrombotic therapies. Despite this, embolic events remain the most feared complication of LV thrombus necessitating systemic anticoagulation. Mechanistically, LV thrombus development depends on Virchow\'s triad (ie, endothelial injury from myocardial infarction, blood stasis from LV dysfunction, and hypercoagulability triggered by inflammation, with each of these elements representing potential therapeutic targets). Diagnostic modalities include transthoracic echocardiography with or without ultrasound-enhancing agents and cardiac magnetic resonance. Most LV thrombi develop within the first 2 weeks post-acute myocardial infarction, and the role of surveillance imaging appears limited. Vitamin K antagonists remain the mainstay of therapy because the efficacy of direct oral anticoagulants is less well established. Only meager data support the routine use of prophylactic anticoagulation, even in high-risk patients.

Copyright © 2022. Published by Elsevier Inc.

J Am Coll Cardiol: 14 Mar 2022; 79:1010-1022
Camaj A, Fuster V, Giustino G, Bienstock SW, ... Dweck MR, Goldman ME
J Am Coll Cardiol: 14 Mar 2022; 79:1010-1022 | PMID: 35272796
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Abstract

Key Questions About Familial Hypercholesterolemia: JACC Review Topic of the Week.

Sniderman AD, Glavinovic T, Thanassoulis G
Familial hypercholesterolemia (FH) is characterized as a monogenic, autosomal dominant disorder, producing severe hypercholesterolemia within families due to causal variants within genes regulating the low-density lipoprotein receptor pathway. Demonstration of a causal variant is widely accepted as evidence of substantially higher cardiovascular risk. However, recent large-scale population studies challenge this characterization of FH, which appears to account for only a minor portion of those with severe hypercholesterolemia. Moreover, a substantial portion of FH variant positive patients do not have marked hypercholesterolemia. These discordances raise doubt as to how FH should be defined and how the concentration of low-density lipoprotein in plasma is regulated in individuals with and without FH. Moreover, review of the evidence suggests the impact of an FH causal variant on cardiovascular risk may be less than previously accepted and that all patients with severe hypercholesterolemia should be prioritized for therapy and family screening.

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 14 Mar 2022; 79:1023-1031
Sniderman AD, Glavinovic T, Thanassoulis G
J Am Coll Cardiol: 14 Mar 2022; 79:1023-1031 | PMID: 35272797
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Abstract

Restoring Sinus Rhythm Reverses Cardiac Remodeling and Reduces Valvular Regurgitation in Patients With Atrial Fibrillation.

Soulat-Dufour L, Lang S, Addetia K, Ederhy S, ... Lang RM, Cohen A
Background
Cardiac chamber remodeling in atrial fibrillation (AF) reflects the progression of cardiac rhythm and may affect functional regurgitation.
Objectives
The purpose of this study was to explore the 3-dimensional echocardiographic variables of cardiac cavity remodeling and the impact on functional regurgitation in patients with AF with/without sinus rhythm restoration at 12 months.
Methods
A total of 117 consecutive patients hospitalized for AF were examined using serial 3-dimensional transthoracic echocardiography at admission, at 6 months, and at 12 months (337 examinations).
Results
During follow-up, 47 patients with active restoration of sinus rhythm (SR) (through cardioversion and/or ablation) had a decrease in all atrial indexed volumes (Vi), end-systolic (ES) right ventricular (RV) Vi, an increase in end-diastolic (ED) left ventricular Vi, and an improvement in 4-chambers function (P < 0.05). Patients with absence/failure of restoration of SR (n = 39) had an increase in ED left atrial Vi and ED/ES RV Vi without modification of 4-chambers function, except for a decrease in left atrial emptying fraction (P < 0.05). Patients with spontaneous restoration of SR (n = 31) had no changes in Vi or function. The authors found an improvement vs baseline in severity of functional regurgitation in patients with active restoration of SR (tricuspid and mitral regurgitation) and in spontaneous restoration of SR (tricuspid regurgitation) (P < 0.05). In multivariable analysis, right atrial and/or left atrial reverse remodeling exclusively correlated with intervention (cardioversion and/or ablation) during 12-month follow-up.
Conclusions
Management of AF should focus on restoration of SR to induce anatomical (all atrial Vi, ES RV Vi) and/or functional (4 chambers) cardiac cavity reverse remodeling and reduce severity of functional regurgitation. (Thromboembolic and Bleeding Risk Stratification in Patients With Non-valvular Atrial Fibrillation [FASTRHAC]; NCT02741349).

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 14 Mar 2022; 79:951-961
Soulat-Dufour L, Lang S, Addetia K, Ederhy S, ... Lang RM, Cohen A
J Am Coll Cardiol: 14 Mar 2022; 79:951-961 | PMID: 35272799
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Abstract

5-Year Outcomes of PCI Guided by Measurement of Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve.

Götberg M, Berntorp K, Rylance R, Christiansen EH, ... Erlinge D, Fröbert O
Background
Instantaneous wave-free ratio (iFR) is a coronary physiology index used to assess the severity of coronary artery stenosis to guide revascularization. iFR has previously demonstrated noninferior short-term outcome compared to fractional flow reserve (FFR), but data on longer-term outcome have been lacking.
Objectives
The purpose of this study was to investigate the prespecified 5-year follow-up of the primary composite outcome of all-cause mortality, myocardial infarction, and unplanned revascularization of the iFR-SWEDEHEART trial comparing iFR vs FFR in patients with chronic and acute coronary syndromes.
Methods
iFR-SWEDEHEART was a multicenter, controlled, open-label, registry-based randomized clinical trial using the Swedish Coronary Angiography and Angioplasty Registry for enrollment. A total of 2,037 patients were randomized to undergo revascularization guided by iFR or FFR.
Results
No patients were lost to follow-up. At 5 years, the rate of the primary composite endpoint was 21.5% in the iFR group and 19.9% in the FFR group (HR: 1.09; 95% CI: 0.90-1.33). The rates of all-cause death (9.4% vs 7.9%; HR: 1.20; 95% CI: 0.89-1.62), nonfatal myocardial infarction (5.7% vs 5.8%; HR: 1.00; 95% CI: 0.70-1.44), and unplanned revascularization (11.6% vs 11.3%; HR: 1.02; 95% CI: 0.79-1.32) were also not different between the 2 groups. The outcomes were consistent across prespecified subgroups.
Conclusions
In patients with chronic or acute coronary syndromes, an iFR-guided revascularization strategy was associated with no difference in the 5-year composite outcome of death, myocardial infarction, and unplanned revascularization compared with an FFR-guided revascularization strategy. (Evaluation of iFR vs FFR in Stable Angina or Acute Coronary Syndrome [iFR SWEDEHEART]; NCT02166736).

Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 14 Mar 2022; 79:965-974
Götberg M, Berntorp K, Rylance R, Christiansen EH, ... Erlinge D, Fröbert O
J Am Coll Cardiol: 14 Mar 2022; 79:965-974 | PMID: 35272801
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Older ...

This program is still in alpha version.