Archive

Archive for January, 2017

Very Late Scaffold Thrombosis of Bioresorbable Vascular Scaffold

bvsvees.png
Toyota et al report a systematic review and meta-analysis of scaffold/stent thrombosis bioresorbable vascular scaffold versus everolimus eluting stent. The editorial is available here.

Abstract

OBJECTIVES

This study sought to compare the 2-year outcomes between bioresorbable vascular scaffold (BVS) and everolimus-eluting metallic drug-eluting stent (EES).

BACKGROUND

The occurrence of very late stent/scaffold thrombosis (VLST) of BVS beyond 1 year after implantation is an increasing concern.

METHODS

We conducted a meta-analysis of 24 studies (BVS: n ¼ 2,567 and EES: n ¼ 19,806) reporting the 2-year outcomes of BVS and/or EES to compare the risk of BVS versus EES for stent/scaffold thrombosis (ST) and target lesion failure (TLF) in 7 comparative studies (3 randomized and 4 observational), and to estimate the pooled incidence rates of ST and TLF including additional 17 single-arm studies.

RESULTS

In the 7 comparative studies, the risk for VLST between 1 and 2 years was numerically higher in BVS than in EES (odds ratio [OR]: 2.03 [95% confidence interval (CI): 0.62 to 6.71]). The excess risk of BVS relative to EES for ST
through 2 years was significant (OR: 2.08 [95% CI: 1.02 to 4.26]). The risk for TLF was neutral between BVS and EES. In the 24 studies, the pooled estimated incidence rates of VLST, and ST through 2 years were higher in BVS than in EES
(0.240 [95% CI: 0.022 to 0.608]% vs. 0.003 [95% CI: 0.000 to 0.028]%, and 1.43 [95% CI: 0.67 to 2.41]% vs. 0.56[95% CI: 0.43 to 0.70]%, respectively). The corresponding rates for TLF were comparable between BVS and EES(1.88 [95% CI: 1.30 to 2.55]% and 1.78 [95% CI: 1.17 to 2.49]% and 7.90 [95% CI: 6.26 to 9.69]% and 7.49 [95% CI:5.86 to 9.29]%, respectively).

CONCLUSIONS

In this meta-analysis, BVS as compared with EES was associated with higher risk for VLST between 1 and 2 years and ST through 2 years.

bvsvees00bvsvees01bvsvees02bvsvees03

Tea Consumption and Ischemic Heart Disease

Kim et al report a retrospective cohort analysis assessing the relationship between tea consumption and ischemic heart disease.

Abstract

Objective

To prospectively examine the association between tea consumption and the risk of ischaemic heart disease (IHD).

Methods

Prospective study using the China Kadoorie Biobank; participants from 10 areas across China were enrolled during 2004–2008 and followed up until 31 December 2013. After excluding participants with cancer, heart disease and stroke at baseline, the present study included 199 293 men and 288 082 women aged 30–79 years at baseline. Information on IHD incidence was collected through disease registries and the new national health insurance databases.

Results

During a median follow-up of 7.2 years, we documented 24 665 (7.19 cases/1000 person-years) incident IHD cases and 3959 (1.13 cases/1000 person years)major coronary events (MCEs). Tea consumption was associated with reduced risk of IHD and MCE. In the whole cohort, compared with participants who never
consumed tea during the past 12 months, the multivariable-adjusted HRs and 95% CIs for less than daily and daily tea consumers were 0.97 (0.94 to 1.00) and 0.92 (0.88 to 0.95) for IHD, 0.92 (0.85 to 1.00)and 0.90 (0.82 to 0.99) for MCE. No linear trends in the HRs across the amount of tea were observed in daily
consumers for IHD and MCE (PLinear >0.05). The inverse association between tea consumption and IHD was stronger in rural (PInteraction 0.006 for IHD,

Conclusions

In this large prospective study, daily tea consumption was associated with a reduced risk of IHD.

 

 

tea02tea03tea01

Heart Failure and Systemic Lupus Erythematosus

sle02sle03sle04sle01

Kim et al report on the prevalence of heart failure in patients with systemic lupus erythematosus (SLE).

Abstract

Background

Although case series suggest a higher burden of cardiovascular risk factors in patients with systemic lupus erythematosus (SLE) compared with the
general population, the association between SLE and heart failure (HF) remains undefined. We sought to investigate the incidence and risk of HF in patients with SLE.

Methods

In April 2016, we performed a retrospective cohort analysis using the Explorys platform, which provides aggregated electronic medical record data from
26 major integrated healthcare systems across the USA from 1999 to present. Demographic and regression analyses were performed to assess the impact of SLE on HF incidence.

Results

Among 45 284 540 individuals in the database, we identified 95 400 (0.21%) with SLE and 98 900 (0.22%) with a new diagnosis of HF between May 2015 and April 2016. HF incidence was markedly higher in the SLE group compared with controls (0.97% vs 0.22%, relative risk (RR): 4.6 (95% CI 4.3 to 4.9)), as were other cardiovascular risk factors. In regression analysis, SLE was an independent predictor of HF (adjusted OR: 3.17 (2.63 to 3.83), p<0.0001). RR of HF
was highest in young males with SLE (65.2 (35.3 to 120.5) for age 20–24), with an overall trend of increasing absolute risk but decreasing RR with
advancing age in both sexes. Renal involvement in SLE correlated with earlier and higher incidence of HF.

Conclusions

The findings of this study suggest that patients with SLE have significantly higher risk of developing HF and a worse cardiovascular risk profile compared with the general population. These results need to be confirmed by prospective studies.

Quality of Warfarin Control and Events in Patients with Mechanical Heart Valves

Grzymala-Lubanski et al report a retrospective non-randomized multicenter cohort study of patients with mechanical heart valves to assess the relationship between the quality and intensity of warfarin therapy and outcomes (thrombosis/bleeding/death). Measures of better quality control were associated with a lower rate of adverse events. Higher intensity anticoagulation was associated with increased rates of bleeding and death.

Two editorials are available here and here.

Abstract

Objectives

To study the impact of time in therapeutic range (TTR) and international normalised ratio (INR)variability on the risk of thromboembolic events, major
bleeding complications and death after mechanical heart valve (MHV)implantation. Additionally, the importance of different target INR levels was elucidated.

Methods

A retrospective, non-randomised multicentre cohort study including all patients with mechanical heart valve (MVH) prosthesis registered in the Swedish
National Quality Registry Auricula from 2006 to 2011. Data were merged with the Swedish National Patient Registry, SWEDEHEART and Cause of Death Registry.

Results

In total 4687 ordination periods,corresponding to 18 022 patient-years on warfarin, were included. High INR variability (above mean ≥0.40) or lower TTR (≤70%) was associated with a higher risk of bleeding (rate per 100 years 4.33 (95% CI 3.87 to 4.82) vs 2.08 (1.78 to 2.41); HR 2.15 (1.75 to 2.61) and
5.13 (4.51 to 5.82) vs 2.30 (2.03 to 2.60); HR 2.43 (2.02 to 2.89)), espectively. High variability and low TTR combined was associated with an even higher risk of bleedings (rate per 100 years 4.12 (95% CI 3.68 to 4.51) vs 2.02 (1.71 to 2.30); HR 2.16 (1.71 to 2.58) and 4.99 (4.38 to 5.52) vs 2.36 (2.06 to 2.60); HR 2.38 (2.05 to 2.85)) compared with the best group. Higher treatment intensity (mean INR 2.8–3.2 vs 2.2–2.7) was associated with higher rate of bleedings (2.92 (2.39 to 3.47) vs 2.48 (2.21 to 2.77); HR 1.29 (1.06 to 1.58)), death (3.36 (2.79 to 4.02) vs 1.89 (1.64 to 2.17), HR 1.65 (1.31 to 2.06)) and
complications in total (6.61 (5.74 to 7.46) vs 5.65 (5.20to 6.06); HR 1.24 (1.06 to 1.41)) after adjustment for MHV position, age and comorbidity.

Conclusions

A high warfarin treatment quality improves outcome after MHV implantation, both
measured with TTR and INR variability. No benefit was found with higher treatment intensity (mean INR 2.8–3.2 vs 2.2–2.7).

wv01wv02wv03wv04wv05wv06wv07

Amygdalar Activity and Cardiovascular Events

Tawakol et al report a longitudinal study of amygdala activity (18 F-fluorodeoxyglucose PET/CT) and cardiovascular events in patients without known cardiovascular disease or cancer. The authors found an increased hazard of cardiovascular events in patients with increased amygdala activity. The authors examine bone marrow effects and markers of arterial inflammation to obtain mechanistic insights. The authors also assess the correlation between perceived stress and amygdala activity.

The editorial is available here.

Abstract

Background

Emotional stress is associated with increased risk of cardiovascular disease. We imaged the amygdala, a brain region involved in stress, to determine whether its resting metabolic activity predicts risk of subsequent cardiovascular events.

Methods

Individuals aged 30 years or older without known cardiovascular disease or active cancer disorders, who underwent ¹⁸F-fluorodexoyglucose PET/CT at Massachusetts General Hospital (Boston, MA, USA) between Jan 1, 2005, and Dec 31, 2008, were studied longitudinally. Amygdalar activity, bone-marrow activity, and arterial inflammation were assessed with validated methods. In a separate cross-sectional study we analysed the relation between perceived stress, amygdalar activity, arterial inflammation, and C-reactive protein. Image analyses and cardiovascular disease event adjudication were done by mutually blinded researchers. Relations between amygdalar activity and cardiovascular disease events were assessed with Cox models, log-rank tests, and mediation (path) analyses.

Findings

293 patients (median age 55 years [IQR 45·0–65·5]) were included in the longitudinal study, 22 of whom had a cardiovascular disease event during median follow-up of 3·7 years (IQR 2·7–4·8). Amygdalar activity was associated with increased bone-marrow activity (r=0·47; p<0·0001), arterial infl ammation (r=0·49; p<0·0001), and risk of cardiovascular disease events (standardised hazard ratio 1·59, 95% CI 1·27–1·98; p<0·0001), a finding that remained signifi cant after multivariate adjustments. The association between amygdalar activity and cardiovascular disease events seemed to be mediated by increased bone-marrow activity and arterial inflammation in series. In the separate cross-sectional study of patients who underwent psychometric analysis (n=13), amygdalar activity was significantly associated with arterial inflammation (r=0·70; p=0·0083). Perceived stress was associated with amygdalar activity (r=0·56; p=0·0485), arterial inflammation (r=0·59; p=0·0345), and C-reactive protein (r=0·83;p=0·0210).

Interpretation

In this first study to link regional brain activity to subsequent cardiovascular disease, amygdalar activity independently and robustly predicted cardiovascular disease events. Amygdalar activity is involved partly via a path that includes increased bone-marrow activity and arterial inflammation. These findings provide novel insights into the mechanism through which emotional stressors can lead to cardiovascular disease in human beings.

amy01amy02amy03amy04amy05amy06

“Weekend Warrors”, cardiovascular disease and cancer

O’Donovan et al report a pooled analysis of cohort studies to assess the relationship between various levels of exercise and risk of all cause cardiovascular disease and cancer mortality. The authors found a reduced rates of both end-points in “weekend warriors” and similar “insufficient” exercise levels compared to sedentary participants.

Abstract

IMPORTANCE

More research is required to clarify the association between physical activity
and health in “weekend warriors” who perform all their exercise in 1 or 2 sessions per week.

OBJECTIVE

To investigate associations between the weekend warrior and other physical
activity patterns and the risks for all-cause, cardiovascular disease (CVD), and cancer
mortality.

DESIGN, SETTING, AND PARTICIPANTS

This pooled analysis of household-based surveillance
studies included 11 cohorts of respondents to the Health Survey for England and Scottish
Health Survey with prospective linkage to mortality records. Respondents 40 years or older
were included in the analysis. Data were collected from 1994 to 2012 and analyzed in 2016.

EXPOSURES

Self-reported leisure time physical activity, with activity patterns defined as
inactive (reporting no moderate- or vigorous-intensity activities), insufficiently active
(reporting activities), weekend warrior (reporting150 min/wk in moderate-intensity or75 min/wk
in vigorous-intensity activities from 1 or 2 sessions), and regularly active (reporting150
min/wk in moderate-intensity or75 min/wk in vigorous-intensity activities from3
sessions). The insufficiently active participants were also characterized by physical activity
frequency.

MAIN OUTCOMES AND MEASURES

All-cause, CVD, and cancer mortality ascertained from
death certificates.

RESULTS

Among the 63 591 adult respondents (45.9% male; 44.1%female; mean [SD] age,
58.6 [11.9] years), 8802 deaths from all causes, 2780 deaths from CVD, and 2526 from cancer occurred during 561 159 person-years of follow-up. Compared with the inactive participants, the hazard ratio (HR) for all-cause mortality was 0.66 (95%CI, 0.62-0.72) in insufficiently active participants who reported 1 to 2 sessions per week, 0.70 (95%CI, 0.60-0.82) in weekend warrior participants, and 0.65 (95%CI, 0.58-0.73) in regularly active participants. Compared with the inactive participants, the HR for CVD mortality was 0.60 (95%CI, 0.52-0.69) in insufficiently active participants who reported 1 or 2 sessions per week, 0.60 (95%CI, 0.45-0.82) in weekend warrior participants, and 0.59 (95%CI, 0.48-0.73) in regularly active participants. Compared with the inactive participants, the HR for cancer mortality was 0.83 (95%CI, 0.73-0.94) in insufficiently active participants who reported 1 or 2 sessions per week, 0.82 (95%CI, 0.63-1.06) in weekend warrior participants, and 0.79 (95%CI, 0.66-0.94) in regularly active participants.

CONCLUSIONS AND RELEVANCE

Weekend warrior and other leisure time physical activity patterns characterized by 1 or 2 sessions per week may be sufficient to reduce all-cause, CVD, and cancer mortality risks regardless of adherence to prevailing physical activity guidelines.

 

ww00ww01

Late Gadolinium Enhancement in Dilated Cardiomyopathy and SCD risk

lgedcm02lgedcm01

Di Marco et al report a systematic review and meta-analysis of the relationship between late gadolinium enhancement on cardiac MRI in patients with dilated cardiomyopathy and ventricular arrhythmias. The authors suggest that the evidence for independent prognostic value has implications for primary prevention ICD’s.

Abstract

OBJECTIVES

The aim of this study was to evaluate the association between late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging and ventricular arrhythmias or sudden cardiac death (SCD) in patients with dilated
cardiomyopathy (DCM).

BACKGROUND

Risk stratification for SCD in DCM needs to be improved.

METHODS

A systematic review and meta-analysis were conducted. A systematic search of PubMed and Ovid was performed, and observational studies that analyzed the arrhythmic endpoint (sustained ventricular arrhythmia, appropriate implantable cardioverter-defibrillator [ICD] therapy, or SCD) in patients with DCM, stratified by the presence or absence of LGE, were included.

RESULTS

Twenty-nine studies were included, accounting for 2,948 patients. The studies covered a wide spectrum of DCM, with a mean left ventricular ejection fraction between 20% and 43%. LGE was significantly associated with the arrhythmic endpoint both in the overall population (odds ratio: 4.3; p < 0.001) and when including only those studies that performed multivariate analysis (hazard ratio: 6.7; p < 0.001). The association between LGE and the arrhythmic endpoint remained significant among studies with mean left ventricular ejection fractions >35% (odds ratio: 5.2; p < 0.001) and was maximal in studies that included only patients with primary prevention ICDs (odds ratio: 7.8;
p ¼ 0.008).

CONCLUSIONS

Across a wide spectrum of patients with DCM, LGE is strongly and independently associated with ventricular arrhythmia or SCD. LGE could be a powerful tool to improve risk stratification for SCD in patients with DCM. These results raise 2 major questions to be addressed in future studies: whether patients with LGE could benefit from primary prevention ICDs irrespective of their left ventricular ejection fractions, while patients without LGE might not need
preventive ICDs despite having severe left ventricular dysfunction.