bluuebunny/crossref_metadata_2025 huggingface dataset:
Association of major adverse cardiovascular events and all-cause mortality with left ventricular geometry in elderly
Authors: Maimaitiaili R , Zhao S , Xu C , Meng W , Tang J , Yang H , Teliewubai J , Yu S , Chi C , Xiong J , Zhao Y , Xu Y , Zhang Y
Published: November 2023

Objective

To investigate the association of major adverse cardiovascular events and mortality with left ventricular geometry in elderly.

Methods

We prospectively recruited 3363 community-dwelling elderly (43.6% male, aged 71.1±5.9 years; 56.4% female, aged 71.1±6.1 years) from local community. Echocardiographic parameters were collected, left ventricular mass index (LVMi) above 115 g/m2 in male or 95 g/m2 in female, relative wall thickness (RWT) above 0.42 were considered as abnormal. Participants then were classified into 4 mutually exclusive groups as: normal geometry (normal LVMi and normal RWT), concentric remodeling (normal LVMi and increased RWT), eccentric hypertrophy (increased LVMi and normal RWT), concentric hypertrophy (increased LVMi and increased RWT). Cardiovascular death, non-fatal myocardial infarction including non-fatal ischemic stroke were recorded as incident MACE. Adjusted Cox regression models were used to evaluate the hazard ratios of MACE and all-cause mortality.

Results

Mean LVMi and RWT were 87.0 ± 28.4 g/m2 and 0.39 ± 0.08. During a median follow-up of 5.4 years, we identified 224 incident MACE cases and 233 deaths. All-cause mortality was significantly greater in participants with eccentric hypertrophy (adjusted hazard ratio [HR]: 1.649; 95% confidence interval [CI]: 1.143-2.379) compared with normal geometry in multivariate analyses after adjusting for baseline covariates. Incident MACE was significant both in concentric hypertrophy (HR:1.982; 95% CI: 1.239-3.170) and eccentric hypertrophy (HR:1.846; 95% CI: 1.266-2.692) but not in concentric remodeling (HR:1.101; 95% CI: 0.759-1.597). Baseline LVMi was a significant predictor of all-cause mortality (HR:1.047 per 10g/m2 increase in LVMi; 95% CI: 1.004-1.093). Similar results were observed with non-fatal myocardial infarction, non-fatal ischemic stroke and cardiovascular death.

Conclusion

Increased baseline LVMi and abnormal left ventricular geometry portend an increased risk for incident MACE and all-cause mortality in community dwelling elderly. From the pathophysiology point of view, per 10 g/m2 increase in LVMi add 5% risk for all-cause mortality.TablesFigures
Association between fasting glucose and cardiovascular disease mortality in cancer survivors: a population-based study
Authors: Jung M H , Jung M K , Lee H K , Lee S Y , Kim K A , An S J , Chung W B , Ihm S H , Jung H O , Youn H J
Published: November 2023

Background

Prevention of subsequent cardiovascular disease (CVD) is an essential part of care among cancer survivors.

Purpose

We investigated the association of fasting blood sugar (FBS) with the risk of CVD mortality in cancer survivors.

Methods

Using nationwide cohort data, we included cancer patients who underwent health examination during 2009-2010 and survived more than 5 years as of Dec 31, 2010. We excluded those with known CVD. Participants were categorized into 5 groups by FBS levels. Clinical endpoint was mortality due to CVD (ischemic heart disease, stroke, heart failure, or sudden cardiac death).

Results

Among 177,774 cancer survivors (mean age 59.9 ± 23.0 years, female 59.1%), a reverse L-shaped association was observed between FBS and overall CVD mortality (Figure 1). Adjusted hazard ratios (95% confidence intervals) were 1.14 (0.72-1.81), 1.00 (reference), 1.02 (0.94-1.11), 1.40 (1.24-1.58), and 2.28 (1.88-2.77) for FBS <70, 70-99, 100-125, 126-179, and 180mg/dL, respectively. When we stratified by age, the risk of hypoglycemia (FBS < 70mg/dL) for CVD mortality was evident in middle aged adults (<65 years), but not in older adults (≥65 years) (Figure 2). Among middle aged cancer survivors, the adjusted hazard ratio (95% confidence intervals) were 2.97 (1.32-6.69), 1.00 (reference), 0.95 (0.74-1.21), 1.58 (1.13-2.21), and 1.97 (1.19-3.26) for FBS <70, 70-99, 100-125, 126-179, and 180mg/dL, respectively.

Conclusion

The strict control of elevated FBS is essential to prevent CVD mortality even in cancer survivors. Meanwhile, the risk of hypoglycemia in middle-aged cancer survivors should not be overlooked either.Figure 1Figure 2
Diastolic function assessment with left atrial strain in long-term survivors of childhood acute lymphoblastic leukemia
Authors: Fernandez-Aviles Irache C , Gonzalez Manzanares R , Heredia Campos G , Resua Collazo A , Castillo Dominguez J C
Published: November 2023

Background

Survivors of childhood cancer might be at increased risk of diastolic dysfunction at follow-up due to cardiotoxic treatment exposure. Although diastolic function assessment is challenging in this relatively young population, left atrial strain might provide a novel insight into this evaluation.

Purpose

To examine diastolic function in a cohort of long-term survivors of childhood acute lymphoblastic leukemia survivors using left atrial strain and conventional echocardiographic parameters.

Methods

Long-term survivors who were diagnosed at a single center between 1985-2015 and a control group of healthy siblings were recruited. Conventional diastolic function parameters and strain were compared, the latter measured during the three atrial phases: reservoir (PALS), conduit (LACS) and contraction (PACS). Inverse probability of treatment weighting was used to account for differences between the groups.

Results

90 survivors (24.6±9.7 years, time since diagnosis 18 [11-26] years) and 58 controls were analyzed. PALS and LACS were significantly reduced compared to the control group: 46.4±11.2 vs 52.1±11.7 (p=0.003) and 32.5±8.8 vs 38.2±9.3 (p=0.003), respectively (figure 1B). Conventional diastolic parameters and PACS were similar between the groups (figure 1A). The reductions in PALS and LACS were associated to cardiotoxic treatment exposure in age and sex adjusted analysis (≥ moderate risk, low risk, controls): 45.4±10.5, 49.5±12.9, 52.1±11.7 (padj=0.003) and 31.7±9.0, 35.2±7.5, 38.2±9.3 (padj=0.001), respectively (figure 2).

Conclusions

Long-term childhood leukemia survivors showed a subtle impairment in diastolic function that was detected using atrial strain but not with conventional measurements. This impairment was more pronounced in those with higher cardiotoxic treatment exposure.Figure 1Figure 2
Characteristics and outcome of chest pain among patients with and without a history of cancer
Authors: Faierstein K , Tal-Ben Ishay R T B I , Raphael R R , Peretz Y P , Fourey D F , Shilo N S , Mayan H M , Maor E M
Published: November 2023

Background

Progress in medical oncology has led to remarkable contributions and prolonged life expectancy among cancer patients. Despite the improved prognosis, cancer treatment is associated with adverse cardiovascular outcomes in the oncologic population. This study aims to investigate the clinical characteristics and outcomes of cancer survivors presenting to the emergency department with chest pain.

Methods

We included consecutive adult patients (18 years and older) who presented at a large tertiary medical center, with chest pain between 2007 and 2022 and were hospitalized for further investigation. All-cause mortality and cancer data were available for all patients from national registries. Patients with active cancer were excluded. Patients were divided into two groups; (1) past cancer (defined as no oncologic therapy in the previous 6 months) and (2) no cancer history. A binary logistics regression model was used to identify patients diagnosed with non-ST-segment elevation myocardial infarction (NSTEMI), pulmonary embolism, new-onset atrial fibrillation, or death within 30 days of presentation.

Results

Final study population included 37,633 patients with a median age of 65 (IQR, 55-75), of whom 13,089 (34.8%) were women. There were 1807 (5%) patients with a history of cancer and 35,829 (95%) with no oncologic background. Patients with a cancer history were older (65 vs. 64, p<0.001) and were less likely to be men (50% vs. 66%, P<0.001). Univariate binary logistic regression demonstrated that cancer survivors were almost three times more likely to meet the study end-point and to have a cardiovascular diagnosis during hospitalization (OR 2.55, 95% CI 2.24-2.91, p<0.001). The association was consistent in a multivariate model (OR 1.7, 95% CI 1.46-1.96, p<0.001) and was more pronounced among females. During a median follow-up of 5.8 years (IQR, 2.4-8.1), 6,987 patients died. Kaplan-Meier survival analysis demonstrated that cancer survivors were more likely to die during follow-up (7.2% vs. 2.2%, respectively, log-rank P<0.001). A propensity score matching model demonstrated that cancer survivors were twice more likely to meet the study end-point of in-hospital cardiovascular diagnosis or mortality within 30 days (17% vs. 8%, p<0.001).

Conclusions

Among patients hospitalized with chest pain, those with an oncologic background are twice more likely to have a cardiovascular diagnosis that can explain their symptoms. In addition, these patients are at risk for short and long-term mortality. Our results support including a history of cancer in risk stratification models of patients presenting with chest pain.Kaplan-Meier curve by oncologic historyCardiovascular endpoints (log. scale)
Risk prediction model of cardiotoxicity in breast cancer patients; the multicenter prospective CHECK HEART-BC (comprehensive heart imaging to evaluate cardiac damage linked with chemotherapy in breast
Authors: Terui Y , Nochioka K , Ota H , Tada H , Sato H , Miyata S , Toyoda S , Shimojima M , Izumiya Y , Kitai T , Yasuda S , Sugimura K
Published: November 2023

Background

Cardiotoxicity due to cancer therapy has been emerging as an important issue along with the improvement in prognosis of breast cancer patients. Although the usefulness of global longitudinal strain and biomarker analysis was previously reported separately, there are few studies based on systematic evaluation of cardiotoxicity. Furthermore, large prospective cohort studies regarding cardiotoxicity and its prediction in breast cancer patients were also limited.

Purpose

Multicenter prospective study was performed to reveal the current characteristics of cardiotoxicity and develop a robust prediction model for cardiotoxicity using systematic evaluation of cardiac function.

Methods and results

Breast cancer patients who were scheduled for neoadjuvant and/or adjuvant chemotherapy were prospectively screened at the 25 participating institutions from August 2017 and March 2020. As a study protocol, follow-up visits were planned every 3 months from pre-treatment to 12 months after chemotherapy (median follow-up of 366 days). To evaluate their cardiac function, echocardiography, high-sensitive cardiac troponin, natriuretic peptide, and 12-lead ECG were acquired at every follow-up visit. cardiotoxicity was defined as a reduction in LVEF >10% point from baseline and to a value <53% in LVEF.

Results

542 chemotherapy-naïve patients were included for analysis from 25 institutions. cardiotoxicity developed in 46 (8.5%) during follow-up period. The HEART2 score based on pre-treatment data (model A) was composed of 6 variables including heart rate >64 bpm, LV end-systolic volume index >36.0 mL/m2, treatment with anthracycline, with radiation, with trastuzumab, and TAPSE <26 mm. The receiver-operating characteristic (ROC) curve showed acceptable accuracy (an area under curve (AUC) 0.74 [95%confidence interval 0.66-0.81], P<0.01). Furthermore, the ROC curve of the HEART2 score adding variables of 3 months after chemotherapy (model B) (difference in heart rate from pre-treatment, LV end-systolic volume index >42.0 mL/m2) showed a greater AUC than the model based on only pre-treatment data (AUC 0.81 [95%confidence interval 0.73-0.90], P<0.01). No patient with low-risk group in the HEART2 score based on variables of pre-treatment and 3 months after chemotherapy developed cardiotoxicity, while 28.1% developed cardiotoxicity in patients with high-risk group in both models.

Conclusions

CHECK HEART-BC study revealed current clinical characteristics of cardiotoxicity and developed the HEART2 score which showed good accuracy and consistency. The HEART2 score can provide an efficient and effective strategy for early detection of cardiotoxicity.The HEART2 scoreThe combination of model A and B
Long-term and real-life incidence of cancer therapy-related cardiovascular toxicity in patients with breast cancer: a swedish cohort study
Authors: Mallios P , Hubbert L , Karlstrom P , Papakonstantinou A , Bergh J , Hedayati E
Published: November 2023

Background

Cancer treatment and cancer itself increase the risk for cardiovascular disease (CVD) which in its turn contributes to cancer therapy-related cardiovascular toxicity (CTR-CVT). The aim of this study was to evaluate the long-term risk and predictors of CTR-CVT as well as all-cause mortality in women diagnosed with early breast cancer (BC) who were candidates for adjuvant chemotherapy.

Methods

Data from 433 women aged 18-60 years who were diagnosed with lymph node-positive BC between 1998-2002 and were eligible for adjuvant chemotherapy, were collected from Swedish health registers and medical records. For this study CTR-CVT was defined as hypertension (HT), coronary artery disease (CAD), heart failure (HF) or atrial fibrillation (AF) after the diagnosis of BC. Follow-up was from the date of BC diagnosis until November 30, 2021, or death. The incidence of CTR-CVT and all-cause mortality were calculated and hazard ratios (HR) for various factors associated with CTR-CVT were determined.

Results

The median age of the study population was 50 years (interquartile range (IQR) 32 years). A total of 910 CTR-CVT events were diagnosed in 311 women with a median of 19.3 years of follow-up (IQR 15.3 years). The proportions of CTR-CVT events were as follows: HT 281 (64%); CAD 198 (46%); HF 206 (47%); and AF 225 (51%). The cumulative incidence of CTR-CVT was 71.8% and 50% of all 433 patients developed CTR-CVT within 11.7 years of BC diagnosis (standard deviation (SD) 0.57, 95% confidence interval (CI) 10.6-12.9). Age was a risk factor for CTR-CVT. Treatment with anthracyclines increased the risk for HF (p=0.001; HR 2.0; 95%CI 1.4-2.8), CAD (p= 0.002; HR 1.7; 95% CI 1.2-2.4), and AF (p=0.013; HR 1.5; 95%CI 1.0-2.0). At the end of the 24-year study period, 227 of the 433 women were alive and the total cumulative mortality was 47.6%. Chemotherapy (anthracyclines or other agent) and older age at the time of BC diagnosis were associated with higher mortality rate.

Conclusions

In this cohort study the incidence of CTR-CVT and all-cause mortality after BC diagnosis and treatment was high, particularly in older patients and those receiving anthracyclines. This finding together with the time to onset of CTR-CVT, supports the current cardio-oncology guidelines recommending initial risk stratification, cardiovascular monitoring during treatment, followed by long-term annual screening for cardiovascular risk factors and CTR-CVT among BC survivors.Incidence CTR-CVTSurvival rate
The Dutch Cardio-Oncology cohort: Incidence of cardiovascular disease predisposes to a higher cancer mortality rate
Authors: Koop Y , Yousif L , De Boer R A , Bots M , Meijers W , Vaartjes C H
Published: November 2023

Background

Cardiovascular disease (CVD) and cancer are the two leading causes of death worldwide. The relationship between the two diseases is complex and multi-factorial, with both diseases sharing risk factors and influencing each other's pathogenesis and progression. Given this interaction and the high prevalence of both CVD and cancer, it is crucial to understand the impact of CVD incidence on cancer mortality and to evaluate which CVD patients are at highest risk. This study aims to evaluate which patients with incidence cardiovascular disease have a higher risk of malignancy-related mortality, stratified for type of cardiovascular disease and compared to the general population without cardiovascular diseases.

Methods

We performed a national population-based cohort study with incidence CVD patients, in the Netherlands between January 2000 and December 2005. A control group was selected from the entire Dutch population using a genetic matching algorithm, which consists of the closest match for age and sex, and a propensity scores for country of birth. Both CVD and control patients were older than 18 years and did not have current diagnosis or a history of CVD and malignancies in the 5 years before inclusion. Mortality data were evaluated after data linkage of national registries from Dutch Hospital Data and Statistics Netherlands until December 2020. Cox proportional hazard models were performed to evaluate mortality risk.

Results

A total of 2 240 879 participants were included with a mean follow-up of 12 years (sd 7.6), of which 738 666 developed CVD. Mean age was 70.5 years (sd 14.8) for CVD patients and 66.4 years (sd 15.9) for control patients. Amongst CVD patients, 492 551 (66.7%) died within follow-up, in 90 982 (12.3%) malignacies were the primary cause. For control patients, this was 641 117 (42.7%) and 169 180 (11.3%), respectively. Correcting for follow-up time, malignancy-related mortality incidence rates per 1000 person years were 118 for patients with CVD and 84 for control patients. The hazard of malignancy-related mortality was significantly higher in CVD patients compared to control patients (HR 1.42, 95% CI 1.41 – 1.43). The patients most at risk were those with venous diseases (i.e. phlebitis, venous embolism and thrombosis; HR 2.28 95% CI (2.20 – 2.36) and peripheral artery disease (HR 1.89, 95% CI 1.81 – 1.94). The incidence rate of malignancy related mortality was highest in patients with heart failure, with an incidence of 258 per 1000 person-years.

Conclusions

This is the first in depth study evaluating malignancy-related mortality in patients with newly developed CVD. Results show that CVD predisposes to a higher cancer mortality rate, especially in patients with venous and peripheral artery diseases. The interaction between CVD and cancer underlines the need to develop strategies for early detection and effective management of both diseases in this population.
Effects on reduction of morbidity and mortality in ACHD population of childbearing age as a result of ESC Guidelines
Authors: Metwaly S , Lennie V
Published: November 2023

Introduction

Cardiovascular disease remains the leading cause of maternal death during pregnancy and peripartum period. ACHD is a rising cause for maternal cardiovascular complications. Several studies demonstrated the beneficial role of systematic maternal cardiovascular risk assessment culminating in the European Society of Cardiology guidelines in 2018 endorsing the use of the modified World Health Organization (mWHO) classification to stratify maternal risk and further guide surveillance and management of women with underlying cardiac conditions.

Purpose

In this study we aim to reduce maternal cardiovascular morbidity risks by actively implementing recommendations from the 2018 ESC guidelines for the management of cardiovascular diseases in women with ACHD in childbearing age in Grampian region, Scotland.

Methods

We identified women of childbearing age (n = 204) in the ACHD population of NHS Grampian (n = 594). We initially calculated baseline percentage of ACHD women who had pre-pregnancy counselling, documented mWHO risk assessment and, if applicable, contraception advice and pregnancy rate. This population has been prospectively followed up during the period from 2020 to 2022 and ESC guidelines were implemented. By the end of the follow up period we assessed the changes in the pregnancy rate in ACHD women.

Results

Overall, the population of ACHD women of childbearing age in Grampian region has significantly grown (expanded) during the study period (from n = 204 to n = 230) and the vast majority (90.5%) of these patients are diagnosed with mWHO class I (38.3%, ESC mild ACHD) or mWHO class II / class II-III (52.2%, ESC moderate ACHD). There has been an increase in the percentage of women reviewed in Transition Clinic compared to baseline (44.7% versus 27.8%, respectively), a clearer documentation of mWHO pregnancy risk (31.6% versus 7.3%) and an increase in contraceptives use, especially in moderate and severe ACHD patients compared to baseline (65.2% versus 57.1%, respectively). This resulted in an overall reduction of the numbers of pregnancy in ACHD women compared to baseline (7.9% versus 40.1%, respectively), especially in women with ESC moderate and severe ACHD (Table 1) with consequent reduction in hospital admissions and morbidity.

Conclusions

Implementing risk stratification tools (mWHO pregnancy risk stratification) and systematic pre-pregnancy counselling with contraceptive advice (all key recommendations from the ESC guidelines) reduce the rate of high-risk pregnancy in ACHD women. This translates to an improvement in survival rates and lower morbidity in ACHD women. Further follow up is required to ensure the consistency of this finding.
Pregnancy and cardiac maternal outcomes in women with inherited cardiomyopathy: interest of the new CARPREG II risk score
Authors: Wallet T , Legrand L , Isnard R , Gandjbakhch E , Pousset F , Proukhnitzky J , Dommergues M , Nizard J , Charron P
Published: November 2023

Introduction

Inherited cardiomyopathies are rare but at high risk of cardiac maternal morbidity and mortality during pregnancy and post-partum. However data for risk stratification remains scarce. The new CARPREG II index score emerged to better predict prognosis in pregnancies with heart disease. Still, role of this score in inherited cardiomyopathies is unclear.

Objective

To describe characteristics and cardiac maternal outcomes in patients with inherited cardiomyopathy during pregnancy, and to evaluate the interest of the various index scores in this population.

Methods

In this retrospective monocentric study, 90 pregnancies of 74 patients were included (mean age 32 ± 5 years), with 28 dilated cardiomyopathies (DCM), 46 hypertrophic cardiomyopathies, 11 arrhythmogenic right ventricular cardiomyopathies and 5 left ventricular non compaction, excluding peri partum cardiomyopathies.

Results

A cardiac maternal complication was observed for 18 (20%) pregnancies, mainly driven by arrythmia and heart failure, and with 3 cardiovascular deaths. 43 (48 %) presented fetal or neo natal complications, with 18 premature delivery and 3 fetal or neonatal death. Median CARPREG II score was 2 [0;3], higher in the DCM subgroup. CARPREG II was significantly associated with the onset of cardiac maternal complication (p< 0.05 for all) and seemed to show a better performance for risk stratification than previous scores (Area under curve of ROC: 0.782 for CARPREG II, AUC 0.755 and 0.697 for CARPREG and mWHO respectively). Prior hospitalization for heart failure, left ventricular dysfunction, multiple line treatments, cardiac symptoms prior to pregnancy and late pregnancy assessment were associated with cardiac complications (p < 0.05 for all)

Conclusion

Pregnancy in women with inherited cardiomyopathy remains at high risk of maternal cardiovascular major events. Late pregnancy assessment and initial severity of cardiomyopathy were found associated with cardiac prognosis. The new CARPREG II score appeared as the most efficient for cardiac risk stratification in this population.
A non-coding SCN5A variant that reduces sodium channel function in hiPSC-derived cardiomyocytes is significantly enriched in Brugada syndrome patients from Thailand
Authors: Walsh R , Mauleekoonphairoj J , Mengarelli I , Verkerk A , Bosada F , Van Duijvenboden K , Poovorawan Y , Wongcharoen W , Sutjaporn B , Wandee P , Christoffels V , Wilde A , Nademanee K , Bezzina C , Khongphatthanayothin A
Published: November 2023

Background/Introduction

Brugada syndrome (BrS) is an inherited arrhythmia condition that can cause sudden cardiac death. Rare coding and common non-coding genetic variation in the Nav1.5 cardiac sodium channel-encoding SCN5A gene is robustly associated with BrS, but the role of rare and low frequency non-coding variants remains unexplored. BrS is several times more prevalent in Southeast Asia compared to other populations, indicating ancestry-specific genetic risk factors remain to be discovered.

Purpose

To identify and characterise novel genetic risk factors in BrS patients from Southeast Asia.

Methods

We performed genome sequencing in 231 BrS probands from Thailand and 500 population-matched controls to identify novel disease associated variants across the entire SCN5A locus. The candidate variant was engineered into human induced pluripotent stem cells (hiPSCs) by CRISPR-Cas9 and its effect was evaluated by single cell electrophysiology analysis on hiPSC-derived cardiomyocytes.

Results

We identified a rare (absent in gnomAD), non-coding variant in a regulatory element of the SCN5A gene (GRCh38:3-38580380-A-C) that was significantly enriched in cases (3.9%) vs controls (0.2%) (OR=20.2[2.5-160.6], p=2e-04). Transcription factor motif scanning analysis suggested the variant is likely to disrupt a Mef2 site that is conserved across species (Figure 1) – the MEF2 family of transcription factors play a critical role in cardiac transcriptional regulation. In hiPSC-derived cardiomyocytes, a significant reduction of peak Nav1.5-mediated sodium-current (INa) density (30% decrease at -20mV, p=8e-03), without changes in gating properties, was observed in cardiomyocytes carrying the variant in heterozygosity compared to isogenic controls (Figure 2). The variant also significantly reduced luciferase activity of the candidate regulatory element in HEK cells in the presence of cardiac transcription factors (Tbx5, Gata4, Mef2A, Mef2D).

Conclusion

A novel, non-coding variant in an SCN5A enhancer region is associated with BrS and was functionally validated using single cell electrophysiology in hiPSC-derived cardiomyocytes. This variant is found in ∼1 in every 25 BrS patients from Thailand and therefore may at least partially explain the increased prevalence of BrS in this region. Our study highlights the importance of research in understudied populations to understand the genetic aetiology of disease in diverse ancestries and to identify novel disease risk factors.
Etiology and predictors of heart failure in pregnancy. Newer Insights from the M-PAC registry
Authors: Anne Princy S , Justin Paul G , Anju Surendran S , Shoba S , Rani P R , Premakumari E , Meena T S , Thamizhselvi N , Suganthi S , Anandhi A
Published: November 2023

Background

Women with heart disease undergoing pregnancy is on the increase, along with an increasing cardiac contribution to maternal mortality.

Aim

To identify the proposition of pregnant women with heart disease, who develop heart failure as a complication and to identify the predictors of heart failure in pregnancy

Methods

The Madras medical college Pregnancy And Cardiac (M-PAC) registry (1) is a single-centre prospective observational registry conducted at a tertiary care public hospital in Tamil Nadu, India from July 2016 to December 2019. Patient with new or worsening heart failure during pregnancy and up to 1 week post-delivery were included in the present analysis. When heart failure was the presenting symptom, it was considered as the primary event and when patient presented with failure symptoms secondary to another inciting event, heart failure was considered as secondary event. This cohort of patient were evaluated for the aetiology, predictors and outcome of heart failure and were placed on extended follow up. The accuracy of mWHO and CARPREG I score to predict heart failure were assessed.

Results

1005 women with 1029 pregnancies were enrolled. Heart failure was observed in 127 (%) pregnancies, in 103 as primary event and in 24 as a secondary event. The common aetiologies of heart failure include rheumatic valvar heart diseases (n=45), peripartum cardiomyopathy (n=45) and congenital heart diseases (n=18). The univariable predictors of heart failure include, NYHA class at first visit, mWHO class of disease, first diagnosis of heart disease, during current pregnancy, pulmonary hypertension, left ventricular ejection fraction ≤ 45%, significant mitral stenosis, mechanical prosthetic heart valve and history of prior cardiac events. However, when peripartum cardiomyopathy was excluded from the analysis, current pregnancy diagnosis was no longer a predictor. Multivariable predictors of heart failure are shown in Figure-1. CARPREG-1 score was marginally more effective than modified World Health Organisation (mWHO) score (C-statistic of 0.820 vs 0.802) in predicting heart failure (Figure-2). Maternal death was 15.7% (20/127).

Caesarean delivery was more common in patients with heart failure (53/119; 44.5%; vs 318/838; 38%) Patients with heart failure had significantly higher proportion of composite adverse fetal outcome (46.5% vs 31.9%, P<0.001), preterm birth (9.2% vs 4.5%, P=0.029) and low birth weight (41.2% vs 26%, P <0.001)

Conclusion

Heart failure is the commonest complication of pregnant women with heart disease. Mortality is very high in patients presenting with heart failure. Modified WHO classification and CARPREG 1 score have moderate accuracy to predict heart failure in pregnancy.Fig-1: Predictors of Heart FailueFig-2: Prediction by CARPREG-1 and mWHO
Clinical outcomes and risk factors associated with drug-coated balloon treatment for femoropopliteal artery disease in patients on maintenance hemodialysis
Authors: Ito R , Oshima S , Kakuno M , Sakakibara T , Murohara T
Published: November 2023

Background

Hemodialysis (HD) patients, who are at high risk for atherosclerosis including peripheral artery disease, are associated with poor clinical outcomes after endovascular therapy. Although recent clinical trials have reported favorable outcomes after drug-coated balloon (DCB) treatment for femoropopliteal lesions, its usefulness and risk factors in HD patients have not been well elucidated.

Purpose

This study aimed to investigate clinical outcomes and the associated risk factors after DCB treatment in HD patients with femoropopliteal lesions.

Methods

This study included 140 HD patients with their 185 femoropopliteal lesions that underwent DCB treatment between September 2018 and January 2022. Non-HD patients and cases of acute limb ischemia were excluded. The endpoints were 1-year freedom from restenosis and clinically driven target lesion revascularization (CD-TLR). The risk factors were also evaluated.

Result

Duration of maintenance hemodialysis in all patients was 8.6 years. Mean lesion length was 11.0±6.9 cm, and rates of chronic total occlusion and severe calcification were 17.3% and 45.4%, respectively. Types of DCB were IN.PACT Admiral (22.9%), Lutonix (50.8%) and Ranger (24.3%). Bail-out stenting was performed in 1.1% of all lesions. The Kaplan-Meier estimate of freedom from restenosis and CD-TLR were 63.8% and 71.3% at 12 months, respectively. The freedom rates from CD-TLR after high-dose and low-dose DCB therapy were 79.4% and 66.4%, respectively (p=0.095). Risk factors independently associated with 1-year CD-TLR were diabetes [hazard ratio (HR) 2.30, 95% confidence interval (CI) 1.03-5.15, p=0.043], chronic limb-threatening ischemia (HR 1.93, 95%CI 1.05-3.53, p=0.035) and sever calcification (HR 2.42, 95%CI 1.39-4.21, p=0.0019). When patients were divided into groups according to number of these three risk factors, the rates of freedom from CD-TLR at 12 months were 100%, 94.8%, 76.7% and 30.3% among groups with no risk factor, any 1 risk factor, any 2 risk factors and all risk factors, respectively (p<0.0001).

Conclusion

The 1-year clinical outcomes after DCB treatment in HD patients with femoropopliteal lesions were unsatisfactory. Independent risk factors for 1-year CD-TLR were diabetes, chronic limb-threatening ischemia and severe calcification.
The impacts of the initiation of hemodialysis for patients with newly diagnosed end-stage renal disease and normal left ventricular systolic function
Authors: Fu Y , Sung S H
Published: November 2023

Background

Patients with end-stage renal disease (ESRD) are at increased risk of cardiovascular disease, left ventricular dysfunction, and subsequent morbidity and mortality. How the renal replacement therapy would affect the myocardial function and the clinical outcomes remains elucidated.

Methods

A total of 60 patients with newly diagnosed ESRD and then received hemodialysis were enrolled. The participants would undergo echocardiographic studies before and at 1 year after the initiation of hemodialysis. Left ventricular global longitudinal strain (GLS) was measured. Subjects with a reduced left ventricular ejection fraction (LVEF<50%) were excluded. The study population were stratified according to their post-hemodialytic GLS values. Clinical outcomes, including mortality and heart failure hospitalization were evaluated.

Result

A total of 47 patients (61.7% men, age 66.6±14.5 years) were included in this study. After hemodialysis, 27 (57.4%) patients had normal GLS, while 20 (42.6%) patients had reduced GLS. The baseline characteristics were similar in each group, except that coronary artery disease (CAD) was significantly more presented in subjects with reduced GLS (p=0.047). Moreover, LV end-systolic volume (LVESV) and right ventricular systolic pressure (RVSP), were significantly higher in those with reduced GLS than the counterpart. During a mean follow-up duration, the Kaplan-Meier survival analysis showed subjects with reduced GLS were associated with higher mortality (p=0.032). The logistic regression analysis, both LV end-systolic volume (LVESV) and right ventricular systolic pressure (RVSP) were identified as independent predictors of reduced LV GLS. After adjusting for age, sex and CAD, RVSP remained a significant predictor of reduced GLS (p=0.037).

Conclusion

In patients with ESRD, the study has demonstrated the baseline RVSP was associated with post-hemodialytic GLS, which was further correlated with long-term survival. The results may suggest RVSP could potentially reflect the impaired left ventricular systolic function. These findings may contribute to better risk stratification and clinical management in this population.
Impact of kidney function, ticagrelor and genetic polymorphism on high platelet reactivity
Authors: Kim W , Rhew J Y
Published: November 2023

Background

High platelet reactivity (HPR) is associated with worse clinical outcomes. Patients with chronic kidney disease (CKD) respond poorly to clopidogrel. The purpose was to investigate what is major determinant on HPR in CKD patients.

Methods

A total of 219 (139 normal kidney function, 80 CKD) patients who were treated with clopidogrel or ticagrlor were assessed platelet reactivity and genetic polymorphisms. Platelet function was evaluated by the VerifyNowTM P2Y12 assay. Genes tested were ABCB1, PON1, cytochrome P450 (CYP) 2C19, CYP2C9 and P2Y12. HPR was defined as P2Y12 reaction units ≥ 230.

Results

Platelet reactivity were significantly higher in patients with CKD compared to normal kidney function (288 ± 96 vs 223 ± 69, p < 0.01). But, there were no significant differences of genetic distribution between 2 groups. In patients with CKD and normal kidney function, CYP2C19 carriers had greater platelet reactivity during clopidogrel therapy but there were no differences during ticagrelor treatment regardless of CYP2C19 status (Figure). In multivariate analysis, CKD [hazard ratio (HR): 4.67 (2.27 – 9.78), p < 0.01], CYP2C19 carriers [HR: 2.81 (1.36 – 5.82), p < 0.01] and ticagrelor treatment [HR: 0.29 (0.18 – 0.48), p < 0.01] were significantly correlated with HPR.

Conclusion

Ticagrelor treatment achieved greater platelet inhibition in patients with CKD whereas CKD and CYP2C19 genotype were significantly correlated with HPR.
People with CKD in cardiovascular trials: a neglected population? A systematic review and evidence map
Authors: Colombijn J M T , Idema D L , Bots M L , Hooft L , Verhaar M C , Vernooij R W M
Published: November 2023

Background

People with chronic kidney disease (CKD) have a markedly higher risk for cardiovascular disease. Systematic underrepresentation of people with CKD in cardiovascular randomised controlled trials (RCTs) limits evidence to guide cardiovascular risk management (CVRM).

Purpose

In this systematic review we aimed to identify evidence gaps regarding CVRM medication for people with CKD and evaluated the prevalence of exclusion of people with CKD from cardiovascular RCTs.

Method

We searched Clinicaltrials.gov through the Cochrane Central Register of Controlled Trials from inception until October 2021. Eligible studies were randomised controlled trials (RCTs) that investigate the efficacy of guideline-recommended CVRM medications on (cardiovascular) mortality, cardiovascular morbidity, and end-stage kidney disease in adults with a history of cardiovascular disease or one or more major risk factors for cardiovascular disease. Two reviewers independently determined the eligibility of references and extracted data. Outcomes were an overview of studies that report results for people with CKD, evidence gaps in results, and the rate of exclusion of people with CKD.

Results

We included 1180 of the 2794 eligible RCTs involving 2,158,869 participants (mean age 63±6 years, 36% female). Overall, 841 (71%) RCTs excluded (subgroups of) people with CKD based on heterogenous exclusion criteria. Since 2000, this prevalence has increased from 70% to 75%. Of included RCTs, only 157 (13%) reported results for people with CKD (again in heterogenous subgroups). The prevalence of RCTs with results for people with CKD has increased since 2000 from 10% to 23%. Nevertheless, significant evidence gaps remain for most CVRM interventions, particularly for those with an eGFR <30 ml/min/1.73m2 (22 RCTs), and people who are treated with dialysis (14 RCTs) or received a kidney transplant (1 RCTs).

Conclusion(s)

The majority of cardiovascular RCTs continues to exclude (subgroups of) people with CKD and this has only increased over the years. Although more RCTs report results for people with CKD, evidence gaps for the efficacy most CVRM medications persist, particularly for those with severe CKD.Figure 1:Heat map (subgroup) analyses for MACE for people with different stages CKD. Panel A illustrates analyses for hypertension, panel B for antiplatelets and anticoagulants, panel C for cholesterol-lowering drugs, panel D for glucose-lowering drugs, and panel E for combinations of interventions.
Impact of mildly reduced kidney function on 5-year mortality in patients with STEMI treated with primary PCI
Authors: Popovic J , Milasinovic D , Mehmedbegovic Z , Jelic D , Zobenica V , Dukic D J , Radomirovic M , Klaric M , Mladenovic D J , Sarenac D , Travica L , Zejak N , Asanin M , Stankovic G
Published: November 2023

PURPOSE

Previous research associated renal failure (RF), as documented by estimated glomerular filtration rate (eGFR) <60 ml/min/1.73m2, with increased mortality risk following acute myocardial infarction. Our aim was to assess the impact of baseline mild RF (eGFR 60-89 ml/min/1.73m2) on mortality during 5-year follow-up after ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI).

Methods

The study included 8378 STEMI patients undergoing primary PCI in the period from 2009 until 2019 for whom baseline eGFR data were available, according to the Modification of Diet in Renal Disease (MDRD) study equation. Cox regression models were created to assess the effect of different stages of renal failure on 30-day and 5-year mortality. Follow-up data were available for 8202 patients at 30 days and 5650 patients at 5 years.

Results

Renal function was impaired in 49% of patients (eGFR <30 ml/min/1.73m2 in 2.5%, eGFR 30-59 ml/min/1.73m2 in 16.2% and eGFR 60-89 ml/min/1.73m2 in 30%). Patients with eGFR <90 ml/min/1.73m2 had higher mortality rates at 30 days (10.0% vs. 1.7%, p<0.001) and at 5 years (44.1% vs 13.5%, p<0.001). Mortality increase was synchronous with the degree of renal failure at both 30 days and 5 years (Figure, panel A and B, respectively). At 30-days, patients with mild RF had higher adjusted mortality compared to patients with eGFR>90 ml/min/1.73m2 (HR 1.6, CI95% 1.1-2.4, p 0.027). At 5 years, eGFR 60-89 ml/min/1.73m2 was also associated with the higher adjusted mortality (HR 1.4, CI95% 1.2-1.6, p<0,001). As expected, severe (eGFR <30 ml/min/1.73m2) and moderate (eGFR 30-59 ml/min/1.73m2) renal failure was associated with a higher risk of mortality (30 days: HR 4.4 and 2.6 respectively; 5 years: HR 3.7 and 2.2 respectively).

Conclusions

The risk of short- and long-term mortality after STEMI increases proportionally with the degree of baseline renal failure. Compared with patients with a normal renal function, even mild renal failure (eGFR 60-89 ml/min/1.73m2) is associated with higher mortality at both 30 days and 5 years.
The impact of pulmonary hypertension on early postoperative period after lung transplantation with particular emphasis on kidney function
Authors: Wajda-Pokrontka M , Nadziakiewicz P
Published: November 2023

Background

A special group of lung transplantation (LTx) recipients are patients diagnosed with pulmonary hypertension (PH) in the form of idiopathic pulmonary arterial hypertension (IPAH) or chronic lung diseases associated PH (CLD-PH). Acute left heart failure is a major complication observed in the early post-transplant period of patients with PH. To avoid post-transplant cardiac failure, the following measures may be implemented: use of intraoperative veno-arterial extracorporeal membrane oxygenation, administration of inotropic agents, a restrictive fluid management or use of continuous renal replacement therapy. Although, it remains unclear whether such a therapy affects long-term kidney function and patient survival.

Purpose

To analyze the influence of pulmonary hypertension diagnosis on early postoperative outcome including deterioration of renal function defined as the change in eGFR that occurred between baseline eGFR and the first and seventh day of observation post-LTx.

Methods

Retrospective data analysis of 79 patients undergoing lung transplantation in 2015-2018 in our institution with diagnosis of PH. Exclusion criterium was absence of 7 days observation post LTx or lack of PH diagnosis. The comparison of pre- and postoperative data was performed between IPAH (N=7) and CLD-PH (N=43) patients.

Results

We found differences in preoperative serum creatinine levels between IPAH and CLD-PH group (109,5 umol/l (70-126) vs 62,3 umol/l (49,3-73,4), respectively), p<0.05. The greatest decline of eGFR in the early postoperative period was demonstrated on day 7 in both groups (ΔeGFR=42,2±6,7 for CLD-PH group and 56,5±9,8 for IPAH group). Patients did not differ according to age, sex and BMI values. In IPAH group operation tend to last longer (657,9±78,2 min vs 539,6±111,6 min, p<0.05), all of them were performed with the use of cardiopulmonary bypass. All patients from IPAH group and 95,6% from CLD-PH group received inotropic support during LT procedure and early postoperative days. Duration of mechanical ventilation was statistically shorter among CLD-PH patients (2,9 days (0,8-1,4) vs 6,1 days (3,3-39), p<0.001).

Conclusion

It seems to be probable that pulmonary hypertension could be significant risk factor of kidney deterioration after lung transplantation. Identification of factors modifying renal insufficiency development in lung transplant recipients needs further investigations.
Postural orthostatic tachycardia syndrome (POTS) and other autonomic dysfunction following COVID-19 infection: incidence, characteristic and associating factors
Authors: Tanking C , Lakkananurak C , Srisakvarakul C , Panda S , Jitpreeda A , Leethananirawit N , Punprame P , Threechod K , Sukitpunyaroj D
Published: November 2023

Background

Long-COVID syndrome has become a new health concern. Many major clinical centers worldwide have experienced more patients with symptoms suggestive of autonomic dysfunction especially Postural Orthostatic Tachycardia syndrome (POTS). These patients were previously diagnosed with COVID19. However, there is lack of incidence and associating factors in Asian population.

Objective

This study investigated the incidence, associating factors and clinical features in patients with new-onset symptoms suggesting POTS or other autonomic disorders following COVID-19 infection.

Methods

We conducted a retro-prospective study to evaluate patients from COVID-19 outpatient clinic who have symptoms suggestive of POTs or other autonomic dysfunctions. These symptoms must last at least three months after PCR proven COVID 19 infections. Exclusion criteria were age < 18 years old, pregnancy and pre COVID-19 infection symptoms. Patients with symptoms severity score greater than two were assessed with blood tests, 24-hour Holter, 24-hour ambulatory blood pressure, echocardiogram and underwent head-up tilt table (HUTT).

Results

793 patients were interviewed at a mean of 146± 37 days after COVID-19 infection. Majority of patients are middle-aged female. 15 patients with symptoms severity score >2 were investigated. Out of those 15 patients, 12 have positive HUTT (1 demonstrating POTS, 10 neuro cardiogenic syncope, and 1 orthostatic hypotension). Among those positive HUTT patients, C-reactive protein (CRP) is significantly higher (OR 1.01; p-value 0.041). Fatigue and orthostatic intolerance are the two most complaint symptoms. All patients with positive HUTT have non dipping pattern on 24-hour ambulatory BP monitoring.

Conclusions

This study demonstrates incidence of 1.5% (12 out of 793) autonomic dysfunction and 0.1% POTS (1 out of 793) among post COVID-19 outpatient cases . Associating factor includes high CRP during infection. Most complaint symptoms are fatigue and orthostatic intolerance.Patient flow diagramType and severity of symptoms