Rhythmos (E-Journal - First Department of Cardiology / Evagelismos General Hospital of Athens)
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Cardiology News / Recent Literature Review / Third Quarter 2019: Cardiology News
No full textRhythmos 2019;14(4):80-86.
HCS 40th Cardiology Congress: Ioannina, 17-19/10/2019
AHA Meeting: Philadelphia, PA, USA, 16-18/11/2019
HCS Working Groups: Thessaloniki, 20-22/2/2020
ACC Meeting: Chicago, IL, USA, 28-30/3/2020
EHRA Meeting: Vienna, 29-31/3/2020
HRS Meeting: San Diego, 6-9/5/2020
EuroPCR: Paris, 19-22/5/2020
ESC Meeting: Amsterdam, 29/8-2/9/2020
Carpal Tunnel Syndrome (CTS) is Associated With Amyloidosis, Heart Failure (HF), and Adverse Cardiovascular (CV) Outcomes
Among 56,032 patients from the Danish registries who underwent surgical treatment for CTS, compared with a sex- and age-matched cohort, CTS was associated with a future diagnosis of amyloidosis (hazard ratio-HR: 12.12), and a higher incidence of HF, (HR 1.54). Risk of other adverse outcomes was also associated with CTS (p<0.0001 for AF, AV block, and pacemaker implantation) (Fosbel EL et al, J Am Coll Cardiol 2019; 74:15-23).
MI Risk Stratification with Single Measurement of High-Sensitivity Cardiac Troponin: an optimized threshold of <5 ng/l safely identified almost one-half of all patients as low risk at presentation, with hs-cTnI >120 ng/l identifying high-risk patients
Among 2,212 patients admitted for chest pain, acute MI occurred in 12%. Two assays of high-sensitivity cTnI had excellent sensitivities (98.6-99.6%) and negative predictive values (NPVs) (range 99.5-99.8%) for acute MI or death at 30 days across both assays. An optimized threshold of <5 ng/l identified almost one-half of all patients as low risk, with sensitivities of 98.6% and NPVs of 99.6% for acute MI or death at 30 days across both assays. For high-risk patients, hs-cTnI ≥120 ng/l resulted in positive predictive values for acute MI of ≥70% (Sandoval Y et al, J Am Coll Cardiol 2019; 74:271-82).
AG10, a Selective Transthyretin (TTR) Stabilizer, Appears a Safe and Effective Treatment for Patients With Amyloid TTR Cardiomyopathy (ATTR-CM)
Patients (n=49) with ATTR-CM (NYHA class II-III) were randomized 1:1:1 to AG10 400 mg, AG10 800 mg, or placebo bid for 28 days. AG10 is a selective, oral TTR stabilizer under development for ATTR-CM that mimics a protective TTR mutation. AG10 treatment was well-tolerated, achieved target plasma concentrations and achieved near-complete stabilization of TTR. TTR stabilization was more complete and less variable at the higher dose. Average serum TTR increased by 36 ± 21% and 51 ± 38% at 400 and 800 mg, respectively (both p<0.0001 vs placebo). Baseline serum TTR in treated subjects was below normal in 80% of mutant and 33% of wild-type subjects. AG10 treatment restored serum TTR to the normal range in all patients (Judge DP et al, J Am Coll Cardiol 2019; 74:285-95).
IMPULSE/PEFCAT: Pulsed Field Ablation (PFA) is a New Promising Mode Allowing Ultra-Rapid PV Isolation
During PFA, subsecond electric fields creating microscopic pores in cell membranes (electroporation) are particularly applicable to cardiomyocytes which have among the lowest thresholds to these fields, potentially permitting preferential myocardial ablation. Safety and effectiveness of catheter-PFA was assessed in 2 first-in-human trials in 81 patients with paroxysmal atrial fibrillation (AF). All PVs were acutely isolated by monophasic (n=15) or biphasic (n=66) PFA with ≤3 min elapsed delivery/patient, skin-to-skin procedure time of 92.2 ± 27.4 min, and fluoroscopy time of 13.1 ± 7.6 min. With successive waveform refinement, durability at 3 months improved from 18% to 100% of patients with all PVs isolated. There was only 1 procedure-related pericardial tamponade, with no additional adverse events over the 120-day median follow-up. The 12-month Kaplan-Meier estimate of freedom from arrhythmia was 87.4 ± 5.6% (Reddy VY et al, J Am Coll Cardiol 2019;74: 315-26)... (excerpt
No-Reflow Phenomenon: A Major Issue Concerning Revascularization in Acute Coronary Syndromes
Get PDFThe no-reflow phenomenon (NRp), a dreaded complication of primary and also of any complex percutaneous coronary intervention (PCI), is characterized by insufficient myocardial perfusion in a territory of a coronary artery without evidence of mechanical obstruction. Microvascular injury is the underlying mechanism of NRp and its manifestation is not only impaired TIMI flow (<3), but also impaired TIMI myocardial perfusion grade (TMPG) which should be assessed in case of chest pain, persistent ST segment elevation or hemodynamic compromise despite the presence of TIMI III flow. The NRp mechanism is multifaceted, the evidence base for its treatment is inconsistent and limited, but its predictors are well known. The armamentarium against NRp consists of preventive and therapeutic strategies, both mechanical and pharmacological. A brief overview of all the above issues concerning NRp is attempted herein. Rhythmos 2019;14(2):27-30
Programmed Ventricular Stimulation in Brugada Syndrome: An Irrefusable Offer or an Inaccurate Tool for Patients with Absent or Doubtful Symptoms?
Get PDFA case of a patient with Brugada pattern on ECG is presented with dubious symptoms whose management was guided by an electrophysiology (EP) study where programmed ventricular stimulation easily induced ventricular fibrillation with only two ventricular extrastimuli and facilitated a decision to implant a defibrillator for sudden death protection. Images of the EP tracings are provided that illustrate the findings and the pros and cons of such an approach are herein discussed. Rhythmos 2019;14(3):55-57
Cardiology News / Recent Literature Review / Second Quarter 2019
Get PDFESC Meeting: Paris, 31/8-4/9/2019TCT Meeting: San Francisco, 25-28/9/2019HCS 40th Congress: Ioannina, 17-19/10/2019AHA Meeting: Philadelphia, PA, USA, 16-18/11/2019ACC Meeting: Chicago, IL, USA, 28-30/3/2020EHRA Meeting: Vienna, 29-31/3/2020Rhythmos 2019;14(3):58-65. AUGUSTUS Trial: In Patients With Atrial Fibrillation (AF) and a Recent Acute Coronary Syndrome (ACS) or PCI Treated With a P2Y12 Inhibitor, an Antithrombotic Regimen Including Apixaban, Without Aspirin, Resulted in Less Bleeding and Fewer Hospitalizations Without Significant Differences in the Incidence of Ischemic Events Than Regimens that Included a Vitamin K Antagonist (VKA), Aspirin, or Both Among 4614 AF patients with ACS or PCI, major or clinically relevant nonmajor bleeding was noted in 10.5% of the patients receiving apixaban, as compared with 14.7% of those receiving a VKA (hazard ratio-HR, 0.69; P<0.001 for both noninferiority and superiority), and in 16.1% of the patients receiving aspirin, as compared with 9.0% of those receiving placebo (HR, 1.89; P<0.001). Patients in the apixaban group had a lower incidence of death or hospitalization than those in the VKA group (23.5% vs. 27.4%; HR, 0.83; P=0.002) and a similar incidence of ischemic events. Patients in the aspirin group had an incidence of death or hospitalization and of ischemic events that was similar to that in the placebo group (Lopes RD et al, N Engl J Med 2019; 380:1509-24).COAPT Trial: Among Patients Successfully Resuscitated After Out-Of-Hospital Cardiac Arrest with no Signs of STEMI, a Strategy of Immediate Angiography Was Not Found to be Better Than a Strategy of Delayed Angiography With Respect to Overall Survival at 90 DaysAt 90 days, 176 of 273 patients (64.5%) in the immediate angiography group and 178 of 265 patients (67.2%) in the delayed (delayed until after neurologic recovery) angiography group were alive (odds ratio, 0.89; P=NS). The median time to target temperature was 5.4 h in the immediate angiography group and 4.7 h in the delayed angiography group. No significant differences between the groups were found in the remaining secondary end points (Lemkers JS et al, N Engl J Med 2019; 380:1397-1407).ANNEXA-4: In Patients With Acute Major Bleeding Associated With Use of a Factor Xa Inhibitor, Treatment With Andexanet Markedly Reduced Anti–Factor Xa Activity, and 82% of Patients Had Excellent or Good Hemostatic Efficacy at 12 Hours Among 352 patients (mean age 77 years, most with CV disease) who had acute major bleeding (64% intracranial and 26% gastrointestinal) within 18 h after a factor Xa inhibitor and received a bolus of andexanet, followed by a 2-hour infusion, in patients who had received apixaban, the median anti–factor Xa activity decreased from 149.7 ng/ml at baseline to 11.1 ng/ml after the andexanet bolus (92% reduction); in patients who had received rivaroxaban, the median value decreased from 211.8 ng/ml to 14.2 ng/ml (92% reduction). Excellent or good hemostasis occurred in 204 of 249 patients (82%) who could be evaluated. Within 30 days, death occurred in 49 patients (14%) and a thrombotic event in 34 (10%). Reduction in anti–factor Xa activity was not predictive of hemostatic efficacy overall but was modestly predictive in patients with intracranial hemorrhage (Connolly SJ et al, N Engl J Med2019; 380:1326-35)... (excerpt). Rhythmos 2019;14(3):58-65
Cardiology News / Recent Literature Review / First Quarter 2019
Get PDFHRS Meeting: San Francisco, CA, USA, 8-11/5/2019EuroPCR: Paris, 21-24/5/2019ESC Meeting: Paris, 31/8-4/9/2019TCT Meeting: San Francisco, 25-28/9/2019HCS 40th Congress: Ioannina, 17-19/10/2019AHA Meeting: Philadelphia, PA, USA, 16-18/11/2019ACC Meeting: Chicago, IL, USA, 28-30/3/2020EHRA Meeting: Vienna, 29-31/3/2020SWEDEHEART Registry: Troponinemia is not Innocent and Demands Careful Workup Among 48,872 patients, a cardiac troponin (cTn) level >99th percentile was found in 9,800 (20.1%) patients. The prevalence of cardiovascular (CV) risk factors as well as CV and nonCV comorbidities increased across higher cTn strata. In total, 7,529 (15.4%) patients had a major adverse event (MAE), defined as the composite of all-cause mortality, MI, readmission for heart failure, or stroke over a median of 4.9 years). MAE risk was associated with higher cTn strata (hazard ratio–HR for highest assay-specific cTn tertile: 2.59; HR 3.57 in patients without CV comorbidities, renal dysfunction, LV dysfunction, or significant coronary stenosis) (Eggers KM et al, J Am Coll Cardiol 2019;73: 1–9).French SCAD Study: the rs9349379 Allele of the PHACTR1/EDN1 Genetic Locus Lying on Chromosome 6q24 is the First Generic Risk Locus for Spontaneous Coronary Artery DissectionThe previously reported risk allele for fibromuscular dysplasia (FMD) (rs9349379-A) was associated with a higher risk of SCAD in all studies. In a meta-analysis of 1,055 SCAD patients and 7,190 controls, the odds ratio (OR) was 1.67 per copy of rs9349379-A. In a subset of 491 SCAD patients, the OR estimate was higher for the association with SCAD in patients without FMD (OR: 1.89) than in SCAD cases with FMD (OR: 1.60). There was no effect of genotype on age at first event, pregnancy associated SCAD, or recurrence (Adlam D et al, J Am Coll Cardiol 2019;73:58-66). COMPASS-CABG Study: Compared With Aspirin or Rivaroxaban Alone, the Combination of Rivaroxaban and Aspirin Did Not Prevent Early Failure of CABGs but Reduced MACE, Consistent With Outcomes in the Overall COMPASS TrialAmong 1,448 COMPASS trial patients randomized 4-14 days after CABG surgery to receive the combination of rivaroxaban plus aspirin, rivaroxaban alone, or aspirin alone, the combination of rivaroxaban and aspirin and the regimen of rivaroxaban alone did not reduce the graft failure rates compared with aspirin alone (combination vs. aspirin: 9.1% vs 8% failed grafts; odds ratio - OR: 1.13; p=0.45; rivaroxaban alone vs aspirin: 7.8% vs 8% failed grafts; OR: 0.95; p=0.75). Compared with aspirin, the combination was associated with fewer MACE (2.4% vs. 3.5%; hazard ratio-HR: 0.69; p=0.34), whereas rivaroxaban alone was not (3.3% vs 3.5%; HR: 0.99; p=0.98). There was no fatal bleeding or tamponade within 30 days of randomization (Lamy A et al, J Am Coll Cardiol 2019;73:121-30)... (excerpt)
Twelve-Year Outcome of Multi-Lesion PCI with Coronary Stenting: Very Late Non-Target Lesion Progression Amidst Durable Patency of Multiple Stents : Very Late Non-Target Lesion Progression
No full textA case of a 72-year-old gentleman with very late non-target lesion revascularization is presented illustrating late atherosclerosis progression despite long-term statin therapy, while at the same time long-lasting patency of drug-eluting stents implanted 12 years earlier is pictorially exemplified. Rhythmos 2019;14(4):77-79
Successful Percutaneous Coronary Intervention in Tandem Coronary Lesions with Subtotal and Chronic Total Occlusion
Get PDFPercutaneous coronary intervention and stenting of tandem lesions of the left anterior descending coronary artery, one of which was a chronic total occlusion, was successfully performed in a symptomatic patient with extensive ischemia on myocardial scintigraphy with use of a standard antegrade approach and routine tools without the need to resort to elaborate techniques and sophisticated tools. Rhythmos 2018;14(1):10-12
Cardiology News / Recent Literature Review / Last Quarter 2018
Get PDFRhythmos 2019;14(1):13-21. ACC.19 Meeting: New Orleans, LA, USA, 16-18/3/2019 EHRA Congress: Lisbon, 17-19/3/2019HRS Meeting: San Francisco, CA, USA, 8-11/5/2019EuroPCR: Paris, 21-24/5/2019ESC Meeting: Paris, 31/8-4/9/2019TOTAL Trial: Although High Thrombus Burden Was an Important Predictor of Outcome in STEMI, Routine Thrombus Aspiration Did Not Improve Outcomes at 1 Year and Was Associated With an Increased Rate of Stroke Among 10,732 patients with STEMI randomized to routine manual thrombectomy versus PCI alone, the primary outcome of cardiovascular (CV) death, MI, cardiogenic shock, or heart failure at 1 year was similar with thrombus aspiration in patients with high (8.1% vs. 8.3% thrombus aspiration; hazard ratio - HR: 0.97) or low thrombus burden (% vs. 5% thrombus aspiration; HR: 1.22; interaction p=0.41). However, among patients with high thrombus burden, stroke at 1 month was more frequent with thrombus aspiration (31 / 0.7% thrombus aspiration vs 16 / 0.4% PCI alone, HR: 1.90). In the high thrombus burden group, thrombus aspiration did not improve 1-month (HR: 0.78; p=0.06) and 1-year CV mortality (HR: 0.88; p=0.25). Irrespective of treatment assignment, high thrombus burden was an independent predictor of death (HR: 1.78) (Jolly SS et al, J Am Coll Cardiol 2018;72: 1589–96).Meta-Analysis: Catheter Ablation of Atrial Fibrillation (AF) in Patients with Heart Failure (HF) was Superior to Conventional Drug Therapy in Improving All-Cause Mortality, HF Hospitalizations, LVEF, 6-Minute Walk Test Distance, VO2max, and Quality of Life, With an Increase, Albeit Non-Significant, in Adverse EventsMeta-analysis of 6 RCTs involving 775 patients indicated that compared with drug therapy, AF ablation reduced all-cause mortality (9% vs 17.6%; risk ratio -RR, 0.52) and HF hospitalizations (16.4% vs 27.6%; RR, 0.60). Ablation improved left ventricular ejection fraction (LVEF) (mean difference, 6.95%), 6-minute walk test distance (mean difference, 20.93 m), peak oxygen consumption (Vo2max) (mean difference, 3.17 mL/kg per minute), and quality of life (mean difference in Minnesota Living with Heart Failure Questionnaire score, −9.02 points). Serious adverse events were more common in the ablation groups (7.2% vs 3.8%; RR, 1.68) (Turagam MK et al, Ann Int Med 2018, Dec 25). The Mitral Annulus Disjunction (MAD) Arrhythmic SyndromeMitral annulus disjunction (MAD) is an abnormal atrial displacement of the mitral valve leaflet hinge point. MAD has been associated with mitral valve prolapse (MVP) and sudden cardiac death. Among 116 patients with MAD (age 49 ± 15 years; 60% female), palpitations were the most common symptom (71%), while severe arrhythmic events occurred in 14 (12%) patients. Patients with severe arrhythmic events were younger (age 37 ± 13 years vs 51 ± 14 years; p=0.001), had lower ejection fraction (51 ± 5% vs 57 ± 7%; p=0.002) and had more frequently papillary muscle fibrosis (4 or 36% vs 6 or 9%; p=0.03). MVP was evident in 90 (78%) patients and was not associated with ventricular arrhythmia (Dejgaard LA et al, J Am Coll Cardiol 2018;72:1600-9)... (excerpt
Idiopathic Premature Ventricular Contraction (PVC)-Induced Cardiomyopathy: The Role of Catheter Ablation
Get PDFPremature ventricular contractions (PVCs) are common and are considered benign in the absence of structural heart disease. However, high burden of PVCs potentially on 24-hour Holter monitoring, can potentially cause left ventricular dysfunction. In this case, catheter ablation has been demonstrated to be effective at PVC suppression and is associated with improvement or normalization of ventricular function. This form of reversible ventricular dysfunction termed as PVC cardiomyopathy and its pathogenesis is poorly understood at the current time. Rhythmos 2019;14(3):51-54
Diabetic Cardiomyopathy: Pathophysiology Considerations and Management: Diabetic Cardiomyopathy
No full textDiabetes mellitus (DM) is nowadays considered an epidemic in the industrialized world. Among other complications, it affects the heart and is accompanied by an increased cardiovascular mortality. The development of heart failure (HF) in DM occurs independently of any coronary artery disease or hypertension, and this entity is termed “diabetic cardiomyopathy”. Cardiac hypertrophy, abnormal ventricular strain features, diastolic dysfunction and subsequently systolic impairment are the cardinal imaging characteristics. The pathophysiology of the disease is complex and multifactorial and, as a consequence, the therapeutic options, on top of the conventional HF medications, should aim at reversing the pathophysiological processes. Hereby we briefly review the manifestations of diabetic cardiomyopathy, describe the pathogenetic mechanisms and discuss the potential therapeutic targets. Rhythmos 2019;14(4):71-76