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Peripartum Cardiomyopathy Registry

Silwa et al report a worldwide registry of peripartum cardiomyopathy (European Journal of Heart Failure (2017) 19, 1131–1141 doi:10.1002/ejhf.780).

ABSTRACT

Aims

The purpose of this study is to describe disease presentation, co-morbidities, diagnosis and initial therapeutic management of patients with peripartum cardiomyopathy (PPCM) living in countries belonging to the European Society of Cardiology (ESC) vs. non-ESC countries.

Methods and results

Out of 500 patients with PPCM entered by 31 March 2016, we report on data of the first 411 patients with completed case record forms (from 43 countries) entered into this ongoing registry. There were marked differences in socio-demographic parameters such as Human Development Index, GINI index on inequality, and Health Expenditure in PPCM patients from ESC vs. non-ESC countries (P < 0.001 each). Ethnicity was Caucasian (34%), Black African (25.8%), Asian (21.8%), and Middle Eastern backgrounds (16.4%). Despite the huge disparities in socio-demographic factors and ethnic backgrounds, baseline characteristics are remarkably similar. Drug therapy initiated post-partum included ACE inhibitors/ARBs and mineralocorticoid receptor antagonists with identical
frequencies in ESC vs. non-ESC countries. However, in non-ESC countries, there was significantly less use of beta-blockers (70.3% vs. 91.9%) and ivabradine (1.4% vs. 17.1%), but more use of diuretics (91.3% vs. 68.8%), digoxin (37.0% vs. 18.0%), and bromocriptine (32.6% vs. 7.1%) (P < 0.001). More patients in non-ESC vs. ESC countries continued to have symptomatic heart failure after 1 month (92.3% vs. 81.3%, P < 0.001). Venous thrombo-embolic events, arterial embolizations, and cerebrovascular accidents were documented in 28 of 411 patients (6.8%). Neonatal death rate was 3.1%.

Conclusion

PPCM occurs in women from different ethnic backgrounds globally. Despite marked differences in socio-economic background, mode of presentation was largely similar. Embolic events and persistent heart failure were common within 1 month post-diagnosis and required intensive, multidisciplinary management.

 

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Cardiac Arrest and Death in US Triathlon

Harris et al presents the characteristics including autopsy findings of US Triathlon participants (Ann Intern Med. doi:10.7326/M17-0847).

ABSTRACT

Background

Reports of race-related triathlon fatalities have
raised questions regarding athlete safety.
Objective: To describe death and cardiac arrest among triathlon
participants.

Design

Case series.

Setting

United States.

Participants

Participants in U.S. triathlon races from 1985 to
2016.

Measurements

Data on deaths and cardiac arrests were assembled
from such sources as the U.S. National Registry of Sudden
Death in Athletes (which uses news media, Internet
searches, LexisNexis archival databases, and news clipping services)
and USA Triathlon (USAT) records. Incidence of death or
cardiac arrest in USAT-sanctioned races from 2006 to 2016 was
calculated.

Results

A total of 135 sudden deaths, resuscitated cardiac arrests,
and trauma-related deaths were compiled; mean age of
victims was 46.7 ± 12.4 years, and 85% were male. Most sudden
deaths and cardiac arrests occurred in the swim segment (n =
90); the others occurred during bicycling (n = 7), running (n =
15), and postrace recovery (n = 8). Fifteen trauma-related deaths
occurred during the bike segment. Incidence of death or cardiac
arrest among USAT participants (n = 4 776 443) was 1.74 per
100 000 (2.40 in men and 0.74 in women per 100 000; P <
0.001). In men, risk increased substantially with age and was
much greater for those aged 60 years and older (18.6 per
100 000 participants). Death or cardiac arrest risk was similar for
short, intermediate, and long races (1.61 vs. 1.41 vs. 1.92 per
100 000 participants). At autopsy, 27 of 61 decedents (44%) had
clinically relevant cardiovascular abnormalities, most frequently
atherosclerotic coronary disease or cardiomyopathy.
Limitations: Case identification may be incomplete and may
underestimate events, particularly in the early study period. In
addition, prerace medical history is unknown in most cases.

Conclusion

Deaths and cardiac arrests during the triathlon are
not rare; most have occurred in middle-aged and older men.
Most sudden deaths in triathletes happened during the swim
segment, and clinically silent cardiovascular disease was present
in an unexpected proportion of decedents.

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Tachycardiomyopathy Educational Paper

Martin and Lambiase present an educational paper on tachycardiomyopathy (http:// dx. doi. org/ 10. 1136/heartjnl- 2016- 310391). See CASTLE AF at ESC 2017.

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Carcinoid Heart Disease Review

Hassan et al provide a useful review: (http:// dx. doi. org/ 10. 1136/
heartjnl- 2017- 311261).

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Thrombophilia Testing

September 28, 2017 Leave a comment

Connors provides an excellent review and guide to the use of thrombophilia testing (N Engl J Med 2017;377:1177-87. DOI: 10.1056/NEJMra1700365).

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Occult Cancer in Patients with Unprovoked Venous Thromboembolism

September 28, 2017 Leave a comment

van Es et al report a meta-analysis and systematic review examining the prevalence of occult cancer detection in the first year after unprovoked pulmonary thromboembolism (Ann Intern Med. 2017;167:410-417. doi:10.7326/M17-0868).

Abstract

Background

Screening for cancer in patients with unprovoked
venous thromboembolism (VTE) often is considered, but clinicians
need precise data on cancer prevalence, risk factors, and
the effect of different types of screening strategies.
Purpose: To estimate the prevalence of occult cancer in patients
with unprovoked VTE, including in subgroups of different ages
or those that have had different types of screening.

Data Sources

MEDLINE, EMBASE, and the Cochrane Central
Register of Controlled Trials up to 19 January 2016.
Study Selection: Prospective studies evaluating cancer screening
strategies in adults with unprovoked VTE that began enrolling
patients after 1 January 2000 and had at least 12 months of
follow-up.

Data Extraction

2 investigators independently reviewed abstracts
and full-text articles and independently assessed risk of
bias.

Data Synthesis

10 eligible studies were identified. Individual
data were obtained for all 2316 patients. Mean age was 60 years;
58% of patients received extensive screening. The 12-month period
prevalence of cancer after VTE diagnosis was 5.2% (95% CI,
4.1% to 6.5%). The point prevalence of cancer was higher in
patients who had extensive screening than in those who had
more limited screening initially (odds ratio [OR], 2.0 [CI, 1.2 to
3.4]) but not at 12 months (OR, 1.4 [CI, 0.89 to 2.1]). Cancer
prevalence increased linearly with age and was 7-fold higher in
patients aged 50 years or older than in younger patients (OR, 7.1
[CI, 3.1 to 16]).

Limitation

Variation in patient characteristics and extensive
screening strategies; unavailability of long-term mortality data.
Conclusion: Occult cancer is detected in 1 in 20 patients within
a year of receiving a diagnosis of unprovoked VTE. Older age is
associated with a higher cancer prevalence. Although an extensive
screening strategy initially may detect more cancer cases
than limited screening, whether this translates into improved patient
outcomes remains unclear.

Bromocriptine Peripartum Cardiomyopathy

September 28, 2017 Leave a comment

Hilfiker-Kleiner et al published a randomized clinical trial of 1 week versus 8 week bromocriptine in patients with peripartum cardiomyopathy (European Heart Journal (2017) 38, 2671–2679 doi:10.1093/eurheartj/ehx355). There is an accompanying editorial: European Heart Journal (2017) 38, 2680–2682 doi:10.1093/eurheartj/ehx428. Change in LVEF as assessed by cardiac magnetic resonance imaging was the primary endpoint.

Abstract

Aims

An anti-angiogenic cleaved prolactin fragment is considered causal for peripartum cardiomyopathy (PPCM). Experimental
and first clinical observations suggested beneficial effects of the prolactin release inhibitor bromocriptine in PPCM.

Methods and results

In this multicentre trial, 63 PPCM patients with left ventricular ejection raction (LVEF) _50%) was
present in 52% of the 1W- and in 68% of the 8W-groupwith no differences in secondary end points between both groups (hospitalizations for heart failure: 1W: 9.7% vs. 8W: 6.5%, P = 0.651). The risk within the 8W-group to fail full-recovery after 6months tended to be lower.No patient in the study needed heart transplantation, LV assist device or died.

Conclusion

Bromocriptine treatment was associated with high rate of full LV-recovery and low morbidity and mortality in PPCM patients compared with other PPCM cohorts not treated with bromocriptine. No significant differences were observed between 1W and 8W treatment suggesting that 1-week addition of bromocriptine to standard heart failure treatment is already beneficial with a trend for better full-recovery in the 8W group.