bluuebunny/crossref_metadata_2025 huggingface dataset:
Sutureless and rapid-deployment versus conventional bioprosthetic aortic valve replacement in patients with aortic stenosis: a systematic review and meta-analysis of randomised controlled trials
Authors: Yadee J , Chotnoppharatphatthara P , Permsuwan U
Published: November 2023

Background

Sutureless aortic valve replacement (SUAVR) has become an alternative to conventional bioprosthetic aortic valve replacement (CAVR) for the treatment of aortic stenosis. This procedure was designed to shorten surgery time, enable optimal valve insertion, and improve surgical outcomes.

Purpose

This study aimed to compare the clinical outcomes between SUAVR and CAVR for treating patients with aortic stenosis.

Methods

Systematic searches were conducted from the inception to December 2022, using 4 databases: PubMed, Scopus, Embase, and Web of Sciences. Randomised controlled trials comparing SUAVR versus CAVR were included for analyses. Data were extracted and analysed using predefined clinical outcomes. The revised Cochrane risk-of-bias tool for randomized trials version 2.0 was used to assess the quality of included RCTs. A meta-analysis with risk ratio (RR) or mean difference (MD) was performed to compare clinical outcomes such as aortic cross-clamp (ACC) time, cardiopulmonary bypass (CPB) time, mortality, and complications at 30 days and 1 year.

Results

The study included 4 articles with a total of 478 SUAVR and 485 CAVR patients. Compared to CAVR, SUAVR had a significantly shorter ACC time (MD -25.1 minutes, 95%CI -44.5 to -5.8, I2 =97%, p 0.01) and CPB time (MD -22.8 minutes, 95% CI -42.4 to -3.2, I2 =93%, p 0.02). There was no significant difference in mortality at 30-day (RR 1.04, 95%CI 0.34-3.15, I2 =0%, p 0.952) and 1-year follow-up (RR 1.08, 95%CI 0.56-2.06, I2 =0%, p 0.822). Complications including myocardial infarction, stroke, major bleeding, renal failure, and endocarditis, did not significantly differ between the two groups. However, permanent pacemaker implantation was significantly higher after SUAVR at 30 days (RR 3.25, 95%CI 1.81-5.84, I2 =0%, p <0.01) and 1 year (RR 2.97, 95%CI 1.71-5.16, I2 =0%, p <0.01).

Conclusions

SUAVR had significantly shorter ACC and CPB times than CAVR. SUAVR required more permanent pacemaker implantation than CAVR. Mortality and other complications were comparable between the two groups.
Vascular closure after TAVI: assessing the safety and efficacy of a collagen-based device in a real-world population
Authors: Grine M , Borges-Rosa J , Martinho S , Morgado Gomes A R , Campos G M , Marinho A V , Oliveira-Santos M , Jorge E , Delgado Silva J , Leite L , Costa M , Goncalves L
Published: November 2023

Background

Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of symptomatic severe aortic stenosis. However, the high rates of vascular complications (5-20%) associated with the large-bore access hinder clinical outcomes. There are several options available for access site closure, including MANTA, a dedicated collagen plug-based device that showed promising results in recent trials.

Purpose

We sought to evaluate the safety and efficacy of large calibre arteriotomy closure with MANTA during transfemoral TAVI in a real-world cohort.

Methods

We retrospectively analysed all consecutive patients who underwent transfemoral TAVI access closure with the MANTA device in our centre between March 2020 and May 2022. The primary safety endpoints were the rates of closure device failure, and access-related vascular and bleeding complications. The secondary endpoint was periprocedural all-cause mortality. All endpoints were defined according to the Valve Academic Research Consortium (VARC) 3 criteria.

Results

A total of 299 patients were included, mean age of 81.09 ± 6.34 years, 50.5% females, median EuroSCORE II of 3.11% [IQR 2.08–4.75]. Approximately two-thirds were under antithrombotic treatment (36.4% on oral anticoagulation and 33.0% on antiplatelet therapy). Closure device failure occurred in 8.4% cases (n=25), nevertheless only one required bailout surgical closure. Vascular complications occurred in 11.4% (n=34), most minor and related to the access site (9.0%, n=27): arterial occlusion (5.0%, n=15), haematomas (3.0%, n=9) and pseudoaneurysms (1.0%, n=3). Bleeding complications occurred in 4.3% (n=13), most VARC type 1 (3.3%, n=10). Both smaller minimal femoral artery diameter (6.6 ± 1.1 mm vs 7.7 ± 1.4mm, p<0.001) and bigger sheath to femoral artery diameter ratio (0.76 ± 0.15 vs 0.68 ± 0.14, p=0.02) were associated with device failure. The secondary endpoint occurred in 7 patients (2.3%), both from cardiovascular (aortic dissection, n=3; ischemic stroke; n=2) and non-cardiovascular causes (sepsis, n=2). Device failure did not prolong the index hospitalization (4.00, IQR 3.00-5.00 days vs 4.00, IQR 3.00-5.00; p=0.36).

Conclusions

In a large real-world cohort, MANTA was a safe and effective solution for femoral arteriotomy closure after TAVI. Device failure was infrequent, rarely associated with severe complications and did not lengthen the hospital stay.
Characterizing patients ineligible for mitral valve intervention: Phenotypic clustering sub-analysis from the CHOICE-MI Registry
Authors: Ludwig S , Coisne A , Hamzi K , Ben Ali W , Duncan A , Makkar R , Webb J G , Rudolph T K , Nickenig G , Ruge H , Denti P , Conradi L , Modine T , Pezel T , Granada J F
Published: November 2023

Background/Introduction

Transcatheter mitral valve replacement (TMVR) is emerging as a therapeutic option for surgcal high-risk patients with mitral regurgitation (MR). However, a large proportion of these patients are still rejected due to clinical or anatomical reasons. The majority of these patients remain ineligible for any mitral valve (MV) intervention and continue medical treatment. Phenotypic characterization of these patients may assist in the identification of the anatomical challenges and drive future innovation efforts as well as assist in the risk stratification process of these patients.

Purpose

To characterize patients ineligible for TMVR and other MV interventions from a large international registry using an unsupervised phenotypic clustering approach integrating clinical, echocardiographic and computed tomography data to unveil differences between phenogroups.

Methods

Between 2014 and 2022, the CHOICE-MI registry included 984 patients undergoing screening for TMVR at 33 international sites. For this study, only patients with screening failure resulting in medical therapy alone were included. Patients receiving transcatheter or surgical treatment were excluded (Figure 1). A cluster analysis using K-means algorithm was performed on baseline clinical and imaging variables, and predictors of all-cause mortality within these clusters were assessed.

Results

Among 284 patients (77.4±8.82 years, 56.0% female, EuroSCORE II 6.6±5.8%) considered ineligible for any MV intervention, two clinically distinct phenogroups (PG) were identified using unsupervised hierarchical clustering of principal components (Figure 2): (PG1) Elderly women with primary MR, high left ventricular (LV) ejection fraction, and annular calcification (N=173, 60.9%); (PG2) Patients with secondary or mixed MR, LV and annular dilation, and high prevalence of comorbidities (N=111, 39.1%). There were no differences regarding Kaplan-Meier estimated 1-year all-cause mortality (PG1 vs. PG2, 21.4% vs. 23.4%, p=0.89) and 1-year cardiovascular mortality (10.4% vs. 13.5%, p=0.53). Predictors of mortality were albumin, renal function, extracardiac arteriopathy for PG1, and albumin, coronary artery disease, and prior myocardial infarction for PG2.

Conclusions

Using cluster analysis, this study identified two major subgroups among patients ineligible for mitral interventions with profound differences in clinical and anatomical profiles, and predictors of outcome. The combination of elderly women with primary MR, preserved LV ejection fraction and annular calcification was the most common phenogroup among patients rejected for mitral intervention. Identifying these factors may drive technological evolution to address unmet clinical and technical needs.
Patent foramen ovale closure reduces migraine burden: a meta-analysis
Authors: Beneki E , Dimitriadis K , Aznaouridis K , Soulaidopoulos S , Kostakis P , Sakalidis A , Mantzouranis M , Tsioufis P , Dri E , Aggeli K , Tsiamis E , Tsioufis K
Published: November 2023

Background

Patent foramen ovale (PFO) closure has been shown to reduce the risk of recurrent stroke in selected patients. On the other hand, the efficacy of PFO closure in reducing migraine attacks remains a matter of debate.

Purpose

We performed a systematic review and meta-analysis of randomized controlled trials that compared PFO closure plus medical therapy to medical therapy alone for the management of migraine.

Methods

A comprehensive search was conducted in PubMed through December 10, 2022. The main efficacy endpoints were the complete cessation of migraine, the mean reduction in monthly migraine days and the mean reduction in monthly migraine attacks. The main safety outcome was the occurrence of major procedure related adverse events.

Results

Our search retrieved 667 results. Three randomized controlled trials including 448 patients were included in the final analysis. Of these, 231 patients (mean age 43.4±10.5 years) underwent PFO closure, while 217 (43.7±10.6) were treated conservatively with medical therapy. In the medical treatment group, 190 patients underwent a sham procedure. The follow-up period ranged from 6 to 12 months. Overall, no significant association between PFO closure and complete migraine cessation was observed [Hazard Ration 3.31, 95% confidence intervals (CI): 0.72 – 15.17 – Figure 1). On the other hand, PFO closure was associated with a significant reduction in the mean number of migraine days per month [mean difference (MD): 1.23, 95% CI: 0.44-2.10, p=0.024, Figure 2A] as well as with a significant decrease in monthly migraine attacks (MD: 0.58, 95%CI : 0.25-0.91, p=0.017, Figure 2B). In respect of efficacy endpoint, a total of 9 transient, procedure related adverse events, including access-site bleeding, hematoma and tachycardia were reported in the implantation group.

Conclusions

PFO closure plus medical treatment compared to medical treatment alone was related with fewer and shorter migraine attacks. These results suggest clinical benefit of PFO closure in selected patients with migraine.Figure 1.Figure 2.
Population prevalence of ECG abnormalities and risk of incident CVD outcomes: 5-year follow-up of 25,000 Chinese adults
Authors: Turnbull I J , Camm C F , Halsey J , Du H , Chen Z , Clarke R
Published: November 2023

Background and purpose

Little is known about the utility of automated reporting of electrocardiograms (ECGs) for prediction of cardiovascular disease (CVD) types in low- and middle-income countries. We compared derived ECG phenotypes and a clinical risk score for prediction of incident major CVD types in a population study of Chinese adults.

Methods

CVD risk factors were collected and 12-lead ECGs performed with automated interpretation using Mortara’s VERITAS™ algorithm on 25,239 adults in the China Kadoorie Biobank resurvey in 2013-2014. Incident CVD outcomes were recorded prospectively over a median follow-up of 5 years. We examined the prevalence and prognosis of broad ECG phenotypes developed from automated outputs: (i) atrial fibrillation/flutter (AFib); (ii) ischaemia (possible/probable or definite); (iii) left ventricular hypertrophy (LVH); and (iv) normal ECG. Participants were stratified by modified CHA2DS2-VA score (<3 vs ≥3) and by age at resurvey. Kaplan-Meier curves were plotted to display cumulative CVD event rates during follow-up for ECG phenotypes.

Results

The mean (SD) age at resurvey was 59.5 (10.2) years, 62% were women and 57% were from rural areas. Overall, 44.3% had a normal ECG and 1.2% had AFib (0.4%, 0.9%, and 3.9% at ages <55, 55-69, and 70+). A total of 28.1% had ischaemia, and 13.6% had LVH (Table). The prevalence of all pathological ECG phenotypes increased with age and prior CVD. AFib was more common in individuals with CHA2DS2-VA ≥3 vs <3 (3.6% vs 0.8%). CHA2DS2-VA ≥3 was associated with higher HRs (95% CI) for stroke (1.91; 1.67-2.19), ischaemic heart disease (IHD) (1.79; 1.52-2.11), and heart failure (HF) (1.80; 1.23-2.62), respectively. Compared to CHA2DS2-VA ≥3, HRs for the AFib phenotype were greater for IHD (2.62; 1.97-3.50) and HF (3.79; 2.21-6.49) and similar for stroke (1.88; 1.44-2.77). LVH was most strongly associated with HF (1.83; 1.31-2.55) and positive associations with each CVD type were greater for definite vs probable/possible ischaemic phenotypes. After adjustment for age, 5-year cumulative incidence rates of CVD were 36.8% in individuals with AFib, 19.4% in those with ischaemia (all), 18.0% in those with LVH, and 14.1% in those with normal ECGs. Individuals with CHA2DS2-VA ≥3 had a 3-fold greater cumulative incidence of CVD than those with scores <3 (40.9% vs 13.9%).

Conclusions

All pathological ECG phenotypes were associated with higher risks of CVD outcomes, but AFib was most strongly predictive and comparable to moderate-high CHA2DS2-VA scores. However, absolute risks of subsequent CVD events were similar in those with ischaemia, LVH and a normal ECG. When combined with clinical risk scores, automated ECG interpretation is a useful adjunct in low-resource settings for CVD risk prediction in population studies and in clinical practice.
Association of extent and severity of coronary atheromatosis with clinically undetected depression
Authors: Babic R , Dimitrijevic S , Burazor I
Published: November 2023

Background

Comorbid depression is recognized among patients with cardiovascular diseases; however, it frequently remains clinically unrecognized. The reported prevalence of clinical depression among patients with cardiovascular diseases varies depending on the population characteristics and the clinical presentation of underlying cardiac disease. The association of comorbid depression with coronary artery disease is broadly reported; however, the causation is still putative. The data on the relation between the severity and extent of coronary atheromatosis versus the intensity of depressive symptoms are scarce.

Purpose of the study

Primary endpoint of this study was to determine the prevalence of previously undetected clinical depression among patients with chronic coronary syndromes referred for coronary angiography. The secondary endpoint was to assess the relationship between the extent and severity of coronary atheromatosis (evaluated by Gensini score) and the level of depression (assessed by Beck's Depression Inventory-II (BDI-II) questionnaire).

Methods

Single-center, cross-sectional observational study.

Results

Eighty-eight consecutive patients were enrolled in the study following signing the informed consent. The mean patient age was 63.8 ± 9.0 years, including 47 male and 41 female patients. Clinical depression (mild, moderate, or severe) was found in 20.5% of patients. The median value of BDI-II score was 6.5, with IQR of 8.25. The median value of Gensini score was 33.0, with IQR of 41.0. A strong positive linear correlation was found between BDI-II value and Gensini score (r=0.42, p<0.01). Significant differences in Gensini scores were found between 1st and 4th quartiles of BDI-II (p<0.01), and between the 1st and 2nd quartiles taken together and the 3rd and 4th taken together (p<0.05).

Conclusion

Unrecognized clinical depression (mild, moderate, and severe) is present to a sizable extent among patients with chronic coronary syndromes. Patients with chronic coronary syndromes and more pronounced depressive symptoms present with more severe and more extensive findings on coronary angiography compared to the patients with minimal depressive symptoms or without depression. These findings may be of significance for our future decision making in preventive cardiology.Correlation of BDI-II and Gensini scores
Association of red cell omega-3 fatty acids, particularly EPA, with cognitive performance in atrial fibrillation
Authors: Lee P , Bosshard L , Aeschbacher S , Springer A , Saeedi S , Allemann M , Bonati L , Kuhne M , Reichlin T , Moschovitis G , Muller A , Rodondi N , Conen D , Osswald S , Beer J H
Published: November 2023

Introduction

Atrial fibrillation (AF) is associated with cognitive impairment and dementia. Whether or not omega-3 Fatty Acids (n-3 FAs) have neuroprotective effects is controversial. We therefore aimed to determine the correlation of n-3 FAs with cognitive function in a large cohort of AF patients.

Methods

Red cell n-3 FAs levels were determined by gas chromatography and mass spectrometry in 2359 patients from the prospective ongoing multicenter Swiss Atrial Fibrillation study (Swiss-AF). To assess the overall cognitive performance of patients, we used several validated neurocognitive assessment tools, including the Montreal Cognitive Assessment (MoCA), Semantic Fluency Tests (SF), Trail Making Test (TMT A&B), and the Digit Symbol Substitution Test (DST). We also used a summary score that we have previously developed (the cognitive construct (CoCo) score). We performed mixed-effect linear regression analyses. Two adjustment models were applied; model 1 (adjusted for age, sex, and educational level) and model 2 (adjusted for age, sex, educational level, history of stroke/TIA, AF type, heart rate, arterial hypertension, diabetes, coronary artery disease, BMI, chronic kidney disease, smoking status, alcohol consumption, geriatric depression scale, use of oral anticoagulation and antiplatelet medication). We also included a random intercept to control for center-effect in both models.

Results

The mean age of our study population was 73 years (standard deviation [SD] 8.4), and 662 patients were females (28%), 318 had a history of stroke (13%), and 716 suffered from coronary artery disease (30%). We observed statistically significant associations of total n-3 FAs levels (EPA + DHA + DPA + ALA) with all neurocognitive assessments, as seen in figure a. Individual n-3 FAs levels (EPA and ALA) were positively associated with MoCA score in both models. EPA was significantly associated with multiple neurocognitive assessments including MoCA, SF, TMT-B, DST, and overall CoCo score in both models (figure b). We found that a 1% red cell EPA level increase was associated with 0.19 (Model 1, 95%CI 0.06-0.31, p=0.003) and 0.14 (Model 2, 95% CI 0.01-0.26, p=0.02) units increase in the standardized MoCA score.

Conclusions

Red cell n-3 FAs levels are associated with better cognitive performance in AF patients. We observed a particularly strong association of EPA levels with all neurocognitive assessments.
Exercise-based interventions for preventing and treating cancer therapy-related cardiovascular toxicity: a systematic review and meta-analysis
Authors: Huang Z , Chair S
Published: November 2023

Background

Cardiovascular toxicity is one of the most common side effects of cancer therapies. Physical exercise is regarded as a promising non-pharmacological therapy to prevent and mitigate cancer therapy-related cardiovascular toxicity (CTR-CVT) for cancer patients. Nevertheless, research evidence on its effects and optimal design remains unclear.

Purpose

This review aims to synthesize available data to evaluate the effects of exercise-based interventions on CTR-CVT in cancer patients and identify the potentially effective characteristics of exercise prescriptions.

Methods

Four databases (MEDLINE, Embase, Web of Science, and CENTRAL) were searched from the inception to October 2022 to identify eligible studies. Randomized controlled trials (RCTs) examining the effects of exercise-based interventions on CTR-CVT in cancer patients published in English were included. Risk of bias of included studies were assessed using the revised Cochrane "Risk of bias" tool for randomized trials (RoB 2.0). The meta-analysis was performed using statistical software R.

Results

Twenty studies with 1705 cancer patients were included. Our findings revealed that the VO2peak was significantly improved in the exercise-based intervention groups compared to the controls (standardized mean difference: 0.24, 95% confidence interval: 0.09 to 0.40). Evidence on other study outcomes remains unclear. The optimal characteristics of exercise programs could not be determined.

Conclusion

This review suggests that exercise-based interventions have the potential effects to prevent and treat CTR-CVT among cancer patients. Future well-designed RCTs are required to evaluate the impact of exercises on comprehensive CTR-CVT indicators.
Exercise-induced troponin I elevation is associated with alterations in regional longitudinal strain
Authors: Erevik C , Kleiven Ø , Froysa V , Bjorkavoll-Bergseth M , Chivulescu M , Klaebo L G , Dejgaard L , Auestad B , Skadberg Ø , Melberg T , Urheim S , Haugaa K , Edvardsen T , Orn S
Published: November 2023

Background

Mechanisms of exercise-induced troponin elevation in healthy individuals are unclear. This study aimed to determine if exercise-induced cardiac troponin elevation (cTn) is associated with alterations in the myocardial response to physical stress.

Methods

This study assessed regional and global myocardial function by strain echocardiography at rest and following exercise of increasing workloads in individuals with either a high- or a normal cTnI response to exercise. High-cTnI responders (n=34) were individuals with a previous exercise-induced cTnI level above the 92.5% limit (cTnI > 200 ng/L) in the NEEDED population (n= 1002). Normal-cTnI responders comprised 25 reference individuals with a post-exercise cTnI < 200 ng/L. All study participants were healthy individuals with normal CT coronary angiography. The first exercise was a cardiopulmonary exercise test (CPET) of 43 (40,45) minutes. The second exercise was a 91 km recreational mountain bike race of 230 (210, 245) minutes. Myocardial function was assessed by echocardiography before and within 10 minutes and 24 hours after both exercises.

Results

Study individuals were 51±10 years old, and 46 (74 %) were male. At baseline, there were no differences between the High- and Normal-cTnI responders regarding demographics, training condition, cardiac risk factors, peak oxygen consumption and conventional echocardiographic parameters. Maximal cTnI levels 3 hours after exercise were significantly higher in the High- compared with Normal-cTnI responders: CPET: cTnI 13 (9-32) vs 9 (5-17) ng/L (p 0.027) and Race: cTnI: 101 (76-198) vs 37 (25-69) ng/L (p <0.001). Following exercise, there were no differences in global ventricular function between the two groups, assessed as left ventricular (LV) global longitudinal strain (GLS) and right ventricular (RV) GLS. When comparing regional longitudinal strain between the two groups, High-cTnI responders had significantly lower regional strain values in the anteroseptal segments following both exercises (p-values 0.005-0.041, 8-14% relative difference, Figure 1 and 2). The changes were more profound after the most intensive exercise (the Race).

Conclusion

High-cTnI responders have larger reductions in post-exercise systolic longitudinal strain in anteroseptal segments than Normal -cTnI responders. The reduction in regional strain was most profound following the highest workload (the Race). These findings suggest that highly elevated exercise-induced cTnI levels may reflect vulnerable regional alterations in the myocardial response to increasing workloads.Figure 1CPETFigure 2Race
Physical activity and cause-specific mortality among 150,000 participants in the Mexico city prospective study
Authors: Gnatiuc Friedrichs L , Alegre-Diaz J , Ramirez-Reyes R , Trichia E , Aguilar-Ramirez D , Wade R , Collins R , Peto R , Berumen J , Emberson J , Kuri-Morales P , Tapia-Conyer R
Published: November 2023

Background

Previous studies of high-income populations have found that physical activity is associated with reduced mortality risk. We investigated the association of recreational physical activity intensity with cause-specific mortality at ages 35-74 in a Mexican population with high levels of adiposity and diabetes.

Methods

Between 1998 and 2004, 150,000 adults (age ≥35 years) were recruited into the Mexico City Prospective Study, and followed for median 19 years. Cox regression was used to assess the association of baseline-reported intensity of recreational physical activity (none, <30 minutes, ≥30 to <60 minutes, or ≥60 minutes per activity session) with death before age 75 years. Analyses were adjusted for age at risk, sex, residential district, education, smoking and alcohol consumption. They excluded those who at recruitment were aged ≥75 years, had incomplete data, or had vascular disease or any other chronic condition (except diabetes) recorded.

Results

Among the 45,291 men and 93,627 women aged 35-74 years, 70% of men and 81% of women reported taking no regular recreational physical activity, mean (SD) body mass index was 29.1 (4.9) kg/m2 and 13% had previously-diagnosed diabetes. There were 12,605 deaths from any cause at ages 35-74 years, including 3368 from vascular causes. Physical activity at recruitment was associated with lower all-cause mortality risk in a dose-dependent manner. Compared with those reporting no regular physical activity, those exercising ≥60 minutes per activity session had 28% lower all-cause mortality at ages 35-74 years (HR=0.72; 95% CI 0.67-0.78), including 22% lower vascular mortality (RR 0.78, 0.68-0.90). Associations were similar for the different types of vascular mortality and were similar in those with and without diabetes, so the absolute benefits of physical activity were larger in those with diabetes. Those who exercised for the longest durations per activity session had lower baseline blood pressure and a more favourable lipid profile than those who reported doing no regular recreational physical activity.

Conclusions

In this Mexican cohort, higher recreational physical activity was associated with a lower risk of premature death, with particularly high absolute benefits in those with diabetes.
Risk factor burden in familial hypercholesterolaemia with early onset coronary artery disease
Authors: Thein P M , Guerreiro C , Fhadil S , Hamedi N , Zalin A , Kapil V , Choudry F , Abhishek J , Siddiqi A , Patel R
Published: November 2023

Background

Familial hypercholesterolaemia (FH) is considered a causal risk factor for premature coronary artery disease (CAD) with a priority placed on identifying index cases and their relatives for preventative interventions. However recent population sequencing studies have identified that not all FH mutation carriers develop CAD. We hypothesised that a significant burden of traditional risk factors is required in addition to genetic risk to develop CAD.

Methods

We interrogated the clinical registry of patients attending the CVD risk and Lipids clinic at St Bartholomew’s Hospital in London which serves a large multi-ethnic population. Patients were prioritized for genetic testing based on Simon Broome and Dutch Lipid criteria. A second cohort of patients from the clinic consisted of premature CAD patients without phenotypic FH. CAD was defined as > 50% stenosis in an epicardial vessel by invasive or non-invasive imaging.

Results

We identified 40 patients with genetically confirmed FH and CAD (FH+/CAD+) and 116 people with FH and without CAD (FH+/CAD-). Of 10 traditional risk factors evaluated, prevalence of each was higher in FH +/CAD+ compared to FH+/CAD- patients.

Collectively, FH+/ CAD+ patients had a median number of risk factors of 5(4,6) compared to 4(3,5) for FH+/CAD- patients, (P<0.001). In non-FH patients, risk factors burden was higher in those with CAD (FH-/CAD+), compared to those without CAD: 5(4,6) V. 4(3,5) risk factors, respectively(P<0.001). Importantly, in patients who developed CAD, the traditional risk factor burden was greater in FH- patients than that of FH+ patients whereas, the genetic risk burden was greater in FH+ patients (Figure-1).

The mean age of onset of CAD in both FH+ and FH- patients was comparable: 43± 10 V. 43± 12years. Patients with FH+/CAD+ were older (53± 11 V 49± 13 years, P=0.276) but had an earlier onset of CAD, when risk burden was greater (43± 8 years if ≥ 5 risk factors v 49± 15 years if < 5 risk factors, P=0.192).

Conclusion

In a selected population from a large specialist lipid clinic, we demonstrate that traditional risk factor burden is additive to genetic risk for the development and age of onset of CAD, supporting a disease liability threshold model in FH.Figure-1.Risk Burden in FH with CAD
Ideal cardiovascular health metrics and cardiovascular mortality in patients with renal insufficiency
Authors: Huang R , Chen W H , Tu J B , Xiao G T , Li Z Y , Chen K L
Published: November 2023

Background

With high cardiovascular mortality, the benefits of cardiovascular health (CVH) metrics to renal insufficiency populations remain unclear.

Objectives

To investigate ideal cardiovascular health metrics (ICVHMs) associations with cardiovascular mortality in a renal insufficiency population compared to normal individuals.

Methods

We analyzed data from the National Health and Nutrition Examination (NHANES) 2007–2018 Survey, with mortality follow-up through December 31st, 2019. We divided 29,682 participants into three groups based on the estimated glomerular filtration rate. CVH was updated in the latest 2022 American Heart Association recommendations. Cox regression analyses based on NHANES data were used to determine associations between ICVHMs and cardiovascular mortality in patients with renal insufficiency.

Results

In 29,682 participants, the mean (standard error) age ranged from 40.2 (0.2) to 71.6 (0.4) years. When compared with participants with normal renal function, participants with mild renal insufficiency who had ideal CVH reduced their risk of cardiovascular mortality (Hazard Ratio (HR) = 0.34; 95% confidence interval (CI): 0.14–0.81), while the HR for cardiovascular mortality gradually decreased from 1.47 (95% CI: 0.85–2.52) in participants who had ≤ 1 ICVHMs, to 0.30 (95% CI: 0.12–0.77) in those who had ≥ 6 ICVHMs. In participants with renal insufficiency, for each ICVHMs increment, a 25% reduction in cardiovascular mortality risk was observed (95% CI: 0.69–0.82).

Conclusions

More ICVHMs counteracted renal impairment harm when compared with populations with normal functions, and cardiovascular benefits increased with ICVHMs in patients with renal insufficiency.
Prospective validation of a unique pretest probability score for preoperative deep vein thrombosis
Authors: Hamamoto Y , Tokushige A , Tajima A , Uchiyama Y , Horizoe Y , Yasuda H , Ohishi M
Published: November 2023

Background

Venous thromboembolism is a crucial perioperative complication. We developed a pretest probability score (KAGOSHIMA DVT score) for predicting deep vein thrombosis (DVT) before surgery. The purpose of our study was to validate KAGOSHIMA DVT score prospectively.

Methods

KAGOSHIMA DVT score was assigned 2 points to D-dimer ≥ 1.5 μg/mL and 1 point each to age ≥ 60 years, female, ongoing glucocorticoid therapy, cancer with high risk of DVT and prolonged immobility. KAGOSHIMA DVT score of 3 points or higher was defined as intermediate group, 5 or higher as high group. We included a total of 4051 patients planned surgery under general anesthesia between May 2022 and February 2023. 452 patients were performed whole leg ultrasonography suspected DVT using a cutoff point of D-dimer ≥ 1μg/ml, KAGOSHIMA DVT score of 3 points or higher. We excluded aneurysm, pregnancy, ongoing anticoagulant therapy, and other thrombosis. We validated 253 patients of the presence of DVT.

Results

DVT was detected in 93/253 (36.8%) patients, 64/200 (32%) in the intermediate probability group, and 29/53 (54.7%) in the high group, respectively. The prevalence of DVT increased with each increase in KAGOSHIMA DVT score. D-dimer ≥ 1.5 μg/mL (92% vs 100%, p=0.033), age ≥ 60 years (86.5% vs 96.2%, p=0.048), female (53% vs 96.2%, p<0.001), glucocorticoids (6.5% vs 22.6%, p=0.001), active cancer with high risk of DVT (23% vs 64.2%, p<0.001), and prolonged immobility (4.5% vs 22.6%, p<0.001) were significantly higher in the high probability group than the intermediate group.

The number of whole-leg ultrasonography decreased from 461 to 253(54.7%) during the same period. In the intermediate group, the detection rate of DVT was a significantly higher in the prospective study than in the retrospective study (21.4% vs 32%, p=0.012). In the high probability group, there was no significant difference (48.2% vs 54.7%, p=0.49).

Conclusion

KAGOSHIMA DVT score stratified perioperative DVT probability and was useful to detect DVT prospectively.rate of DVT
Insufficient long-term LDL-cholesterol management in patients with familial hypercholesterolemia 5 years after an acute coronary syndrome
Authors: Krasieva K , Gencer B , Carballo D , Muller O , Fournier S , Matter C , Luescher T , Raeber L , Rodondi N , Mach F , Nanchen D
Published: November 2023

Background

Long-term control of cardiovascular risk factors after an acute coronary syndrome (ACS) is a cornerstone in preventing cardiovascular event recurrence. In patients with familial hypercholesterolemia (FH) and ACS, long-term management of LDL-cholesterol has been poorly studied.

Purpose

To investigate the extent of LDL-c and other cardiovascular risk factor management 5 years after ACS in patients with and without FH.

Methods

We collected data from 3,201 patients with an ACS from a Swiss multicenter cohort study and with 5-years follow-up data. At hospital admission for ACS, clinical FH was defined based on personal and familial history of premature cardiovascular disease as well as LDL-c levels, using the Dutch Lipid Clinic and the Simon Broome definitions. At the 5-years follow-up visit after ACS, we assessed LDL-c levels, lipid-lowering drugs, and control of cardiovascular risk factors comparing patients with FH and without FH.

Results

At the time of ACS, mean age of the 3,201 patients was 61.6 years old (SD 12.2), 643 (20.1%) were female, and 740 (23.1%) were diagnosed with clinical FH. At 5-years follow-up post-ACS, mean age was 56.6 years for FH patients and 69.6 years for patients without FH. 5 years after ACS, 15.4% and 33.5% patients with FH had an LDL-cholesterol ≤ 1.4 mmol/l, respectively ≤ 1.8 mmol/l, compared with 21.0% and 44.3% of those without FH (p=0.01, respectively <0.001) (see Figure and Table). Use of statins was similar between groups, but patients with FH were more frequently using high-dose statins compared to patients without FH (51.0% vs 42.9%, p<0.001). Use of lipid-lowering therapy in general such as statins, ezetimibe, fibrates, or niacin was more frequent in patients with FH than in those without FH (91.0% vs 87.0%, p=0.01). Beside LDL-c management, 5-year control of other cardiovascular risk factors tended to be superior in FH patients as compared to patients without FH: 78.5% vs 69.0% p<0.001 for systolic blood pressure (BP) < 140 mmHg; 46.2% vs 38.9% p=0.4 for reaching HbA1c < 7% in patients with diabetes; 46.9% vs 42.7% p=0.27 for smoking cessation, and 28.2% vs 21.0% p=0.1 for reduction of alcohol consumption <14 units/week .

Conclusion

Five years after an ACS, patients with FH had less optimal control of LDL-c levels despite being younger and more frequently using high dose statins compared to patients without FH. Combination of lipid-lowering therapy needs to be studied for optimal long-term management of patients with ACS and FH.Figure:CVRF 5 years post-ACS FH/non-FHTable:CVRF 5 years post-ACS FH/non-FH
Early diagnosis and treatments in childhood are associated with better prognosis in patients with familial hypercholesterolemia
Authors: Tada H , Nomura A , Nohara A , Usui S , Sakata K , Takamura M , Kawashiri M
Published: November 2023

Objective

The early diagnosis and treatment initiation for children with familial hypercholesterolemia (FH) has been recommended in guidelines. However, there is limited data on the impact of early treatments on the prognosis of children with FH. To investigate if the early initiation of lipid-lowering therapies among Japanese pediatric patients with FH reduced the occurrence of cardiovascular disease (CVD) events in them.

Methods

We retrospectively investigated the occurrence of CVD events (myocardial infarction, unstable angina, or coronary artery revascularization) in patients with FH (N = 1050, male/female = 490/560), including 106 children below 20 years. We compared a variety of phenotypes, including genetic backgrounds, other complications, LDL cholesterol, medical therapies, and their prognoses between the patients’ diagnoses before the age of 20 years (children, mean age = 15 years) and after that age (adults, mean age = 52 years). Overall, 290 patients (27.6%) had a history of prior CVD events.

Results

The median follow-up duration was 12.6 [9.5–17.9] years. The baseline LDL cholesterol level, 239 mg/dL, dropped to 112 mg/dL with the treatments. The Achilles tendon thickness was significantly lower in children than that of adults (7.2 vs. 8.9 mm, P < 0.001). Over the follow-up duration, 119 CVD events were observed. Importantly, no CVD event was observed in children despite their median LDL cholesterol level at follow-up being significantly higher than that of adults (122 vs. 111 mg/dL, P < 0.001).

Conclusion

The likelihood of CVD events in those with FH diagnosed and treated in childhood is low.
Survey on lipid management in cardiovascular primary prevention: do physicians follow the guidelines?
Authors: Alami M , Mouine N , Iraqi H , Moustaghfir A
Published: November 2023

Background

Cardiovascular (CV) primary prevention (PP) is crucial at both the individual-level and community-level. Cholesterol "controversies" and misinformation may impact many physicians (and patients) in the implementation of the lipid management in CV primary prevention. Do most physicians follow the guidelines? Do they believe in the guidelines?

Purpose

The main aim of this survey is to assess physicians' level of implementation of the lipid guidelines in PP (ESC Guidelines of Cardiovascular Prevention 2021). The secondary aim of the survey is to evaluate physicians’ degree of agreement on recommended LDL targets in primary prevention. The third aim is to compare the results of the 3 physicians’ groups: cardiologists, endocrinologists, and General Practitioners (GPs).

Methods

The questionnaire was distributed electronically to approximately 2500 physicians (cardiologists, endocrinologists, and GPs) with a link to the hosting website. Data collected was anonymous. A chi-square statistical analysis was used to compare results among physicians’ groups.

Results

559 physicians answered the questionnaire (267 cardiologists, 90 endocrinologists, and 202 GPs). First session related to the everyday practice (4 out of 10 questions) showed that 49.9% of physicians are using the SCORE2 tool at least once a week. Significative differences were observed among physicians’ groups: 69.8% of endocrinologists vs 51.1% of cardiologists (p<0,02) are using the tool at least once a week. 38% of GPs are using the SCORE2 at least once a week (p<0,03 vs cardiologists and p<0,00001 vs endocrinologists). For the 3 questions related to 3 different pts profile who should be on statin (ESC Guidelines), 63.2% agree to prescribe the drug. There were no differences between the 3 physicians’ groups. The second session (6 questions), about physicians’ beliefs, 98.2% think that lowering LDL is a priority to avoid a Myocardial Infarction (MI) but only 54.9% believe that focusing on LDL is more important than A1c to reduce the risk of MI in diabetic pts. Statistical analysis showed no differences between the 3 physicians’ groups. 55.9% believe that LDL targets in the Guidelines for PP are too low and 72% think that an LDL target <1g/l (<2.6mmol/l) is enough in PP.

Conclusions

SCORE2 tool is more used by endocrinologists than cardiologists but it is still underused by both. In terms of lipids management, most of the surveyed physicians are following the guidelines. They are aware of the importance of lowering LDL, but the majority thinks that primary prevention’s guidelines targets are too low. An urgent awareness on the importance of risk calculation and reaching LDL targets is needed for many physicians that follow but do not believe.
Remnant cholesterol in atherosclerotic cardiovascular disease: a systematic review and meta-analysis
Authors: Delialis D D , Georgiopoulos G G , Aivalioti E A , Konstantaki C K , Oikonomou E O , Bampatsias D B , Mavraganis G M , Maneta E M , Patras R P , Papaioannou M P , Dimopoulou A M D , Angelidakis L A , Liberopoulos E L , Stellos K S , Stamatelopoulos K
Published: November 2023

Background

Accumulating evidence suggests a substantial contribution of remnant cholesterol (RC) to residual risk for the development or relapse of atherosclerotic cardiovascular disease (ASCVD).

Purpose

We aimed to evaluate the association of RC levels with ASCVD risk by different risk categories and method of RC assessment. We also assessed available evidence on the effect of lipid-lowering therapies (LLTs) on RC levels.

Data sources: English-language searches of Medline, Pubmed and Embase (inception to 31 January 2023); ClinicalTrials.gov (October 2021); and reference lists of studies and reviews.

Study selection: Studies reporting on the risk of the composite endpoint [all-cause mortality, cardiovascular mortality, and major adverse cardiac events (MACE)] by RC levels. Moreover, we searched for studies reporting differences in RC levels after administration of LLT(s).

Data extraction: Dual extraction and quality assessment of individual studies.

Data synthesis: Among n=29 studies with 257,387 participants, we found a pooled linear (pooled HR:1.27 per 1-SD increase,95% CI:1.12-1.43,P<0.001,I2=95%,n=15 studies) and non-linear association (pooled HR:1.59 per quartile increase,95% CI:1.35-1.85,P<0.001,I2=87.9%,n=15 studies) of RC levels and the risk of MACE both in patients with and without established ASCVD. Interestingly, the risk of MACE was higher in studies with directly measured vs. calculated RC levels. In a limited number of studies and participants, LLTs reduced RC levels.

Limitation: Publication bias and heterogeneity regarding the number of participants per study, follow-up duration, ASCVD prevalence, measurement of RC levels and endpoints.

Conclusion

RC levels are associated with ASCVD risk both in primary and secondary prevention. Directly measured RC levels are associated with ASCVD risk more evidently. Available LLTs tend to decrease RC levels, although the clinical relevance of RC decrease merits further investigation.
Attainment of LDL-cholesterol goals in patients with previous myocardial infarction: a real-world cross-sectional analysis
Authors: Gomes D , Sousa Paiva M , Freitas P , Albuquerque F , Lima R , Reis Santos R , Presume J , Bello R , Maltes S , Trabulo M , Aguiar C , Ferreira J , Ferreira A M , Mendes M
Published: November 2023

Background

ESC guidelines recommend an LDL-cholesterol (LDL-C) <55mg/dL for patients with established cardiovascular disease. While the Friedewald’s equation to estimate LDL-C is still widely used, the newer Martin-Hopkins’ formula has shown greater accuracy. The aims of this work were: 1) to assess the proportion of patients reaching their LDL-C goal and the therapies used, and 2) to assess the impact of using the Martin-Hopkins' method instead of Friedewald’s formula on the proportion of controlled patients.

Methods

Single-centre cross-sectional study including consecutive post-myocardial infarction patients followed by 20 different cardiologists in a tertiary hospital. Data were collected retrospectively from clinical appointments that took place after April 2022. Only those with an available ambulatory lipid profile were considered. For each patient, LDL-C levels and goal attainment were estimated by both Friedewald’s and Martin-Hopkins’ equations.

Results

A total of 400 patients were included (age 67±13 years, 77% male, 31% diabetics). The last myocardial infarction had occurred a median of 4,5 years before the appointment. Using Friedewald’s equation, median LDL-C under therapy was 64 mg/dL [IQR (50-81)]. Overall, 125 patients (31%) had LDL-C within target (Figure 1). High intensity statins were used in 256 patients (64%), 146 (37%) were under ezetimibe, and 2 (0.5%) were under PCSK9 inhibitors. Combination therapy of high intensity statin + ezetimibe was used in 102 patients (26%) (Figure 2). These patients had a median LDL-C of 61mg/dL [IQR (45-75)], with 35% attaining LDL-C levels <55 mg/dL, and 11% remaining above 100 mg/dL. Applying the Martin-Hopkins method would reclassify a total of 31 patients (7.8% of total). Among those deemed controlled by the Friedewald’s equation, 27 (21.6%) would have a Martin-Hopkins’ LDL-C above the target, while 4 (1.5%) of the uncontrolled patients would have a recalculated LDL-C <55mg/dL. The following medical appointment was scheduled a median of 8 months (IQR 6-11) later.

Conclusion

Less than one third of post-myocardial infarction patients followed in a tertiary hospital’s cardiology clinic had LDL-C values within the goal, with a prescription pattern suggesting a large underutilization of readily available therapies. Applying the Martin-Hopkins’ formula to calculate LDL-C would reclassify roughly one fifth of presumably controlled patients into the non-controlled group.Figure 1Figure 2
Cardiovascular outcomes in patients with coronary artery disease and elevated lipoprotein(a): Implications for the OCEAN(a)-Outcomes trial population
Authors: Shiyovich A , Berman A , Besser S , Biery D , Huck D , Weber B , Cannon C , Januzzi J , Booth J , Nasir K , Di Carli M , Lopez A , Kent S , Bhatt D , Blankstein R
Published: November 2023

Background

Lipoprotein(a) [Lp(a)] is associated with atherosclerotic cardiovascular (CV) disease. The ongoing Olpasiran Trials of Cardiovascular Events and Lipoprotein(a) Reduction [OCEAN(a)]-Outcomes trial is evaluating whether Lp(a) lowering can reduce the incidence of CV events among patients with prior myocardial infarction (MI) or percutaneous coronary intervention (PCI) and elevated Lp(a) (≥ 200 nmol/L).

Purpose

To evaluate the association of elevated Lp(a) with CV outcomes in an observational cohort resembling the OCEAN(a)-Outcomes trial main enrollment criteria.

Methods

This retrospective study leveraged a large Lp(a) registry derived from electronic health records at two large academic medical centers in the US. The registry included patients aged 18-85 years with Lp(a) measured as part of their clinical care between 2000 and 2019. While patients were required to have a history of MI, or PCI, those with severe kidney dysfunction or a malignant neoplasm were excluded. Elevated Lp(a) was defined as ≥ 200 nmol/L consistent with the OCEAN(a) -Outcomes trial. The primary outcome was a composite of coronary heart disease (CHD) death, MI, or coronary revascularization. A combination of natural language processing algorithms, billing and ICD codes, laboratory data, and the National Death Index were employed to identify outcomes and covariates.

Results

Among the 16,821 patients in the registry, 3,142 (18.7%) met the established inclusion and exclusion criteria. Among eligible patients, the median age was 61 (IQR: 52-73) years, 28.6% were women, and 12.3% had elevated Lp(a). Patients with elevated Lp(a), versus non-elevated Lp(a), were more likely to be women (37.6% vs. 27.3%, p<0.001) and to have hyperlipidemia (90.2% vs. 86.0%, p=0.024). Over a median follow-up of 12.2 years (IQR: 6.2-14.3), the primary composite outcome occurred more frequently in patients with versus without elevated Lp(a) (46.0% vs. 38.0%, HR=1.30 [95%CI: 1.09-1.53], p=0.003; Figure 1). Following adjustment for measured confounders, elevated Lp(a) remained independently associated with the primary outcome (adjHR=1.33 [95%CI: 1.12-1.58], p=0.001). Elevated Lp(a) was also associated with increased risk for most secondary outcomes (Table 1).

Conclusions

In an observational cohort resembling the main OCEAN(a)-Outcomes Trial enrollment criteria, patients with an Lp(a) ≥ 200 nmol/L had a higher risk of CV outcomes.