544 research outputs found
Cardiology News /Recent Literature Review / First Two Quarters 2014
No full textCARDIOLOGY NEWS(Reproduced with permission from A.S. Manolis et al. Cardiology News / Recent Literature Review, Rhythmos 2014; 9: 29-35, & 46-53) (www.rhythmos.gr)Cardiology News /Recent Literature Review / First Quarter 2014Konstantinos Vlachos, MD, Kostas Letsas, MD, Antonis S. Manolis, MD, Evagelismos Hospital, Athens, Greece Athens Cardiology Update 2014: Athens (Crown Plaza Hotel), 10-12/4/2014HRS Meeting: San Francisco, 7-10/5/2014EuroPCR: Paris, 20-23/5/2014CardioStim: Nice, 18-21/6/2014ESC Congress: Barcelona, 30/8-3/9/14TCT: Washington, 12-17/9/14HCS Annual Meeting: Athens, 23-25/10/2014AHA: Chicago, 15-19/11/14Cutting Inappropriate ICD Shocks: Long Arrhythmia-Detection Time Strategy ConfirmedProgramming implantable cardioverter defibrillators (ICDs) to delay the time they take to treat ventricular arrhythmias cuts mortality by 23% and inappropriate shocks by more than one-half in a meta-analysis encompassing ~4900 patients. The included studies were prospective and multicenter and covered both primary and secondary prevention and patients with either ischemic or nonischemic cardiomyopathy. The risk of syncope did not rise significantly with longer detection times, despite traditional concerns that lots of patients would not tolerate prolonged arrhythmia exposure before their ICD is allowed to deliver therapy, either shocks or antitachycardia pacing (ATP). Instead, the extra time frequently gave devices a better chance to exclude non–life-threatening arrhythmias like atrial fibrillation and to let otherwise self-terminating ventricular arrhythmias play out on their own. Current nominal settings used by some ICD manufacturers are likely to be too aggressive, with arrhythmia detection times that in some cases may be as short as 1-3 s. These results highlight the importance of setting longer default ICD detection times. The analysis included 4896 patients from the MADIT-RIT, ADVANCE 3, and PROVIDE randomized trials and the RELEVANT nonrandomized study. Overall, 264 patients received appropriate shocks and 253 experienced inappropriate shocks at follow-up (12 - 17 months). The relative risk (RR) of death from any cause was 0.77 (p=0.02) in the prolonged-detection-time groups compared with controls; the risks of inappropriate shocks and appropriate and inappropriate ATP also fell significantly. Why there were fewer deaths with longer detection times is unclear but it may derive from less exposure to potential hazards of shocks and ATP; inappropriate shocks may up mortality, and ATP poses a small risk of inducing ventricular fibrillation; or it may be due to some other factor, e.g. avoidance of treatment for multiple ICD therapies (e.g., prescription of antiarrhythmic drugs) (Scott PA et al, Heart Rhythm 2014; DOI:10.1016/j.hrthm.2014.02.009. Epub 2014 Feb 12)... (excerpt
Transcatheter aortic valve implantation in nonagenarians: selectively feasible or extravagantly futile?
No full textA growing number of nonagenarians is recorded as life expectancy increases. Unfortunately, this extreme-aged group is plagued by increased prevalence of aortic stenosis amidst a higher occurrence of comorbidities that pose dilemmas to cardiologists and cardiac surgeons when having to choose a conservative or interventional treatment modality, and a surgical or transcatheter aortic valve implantation (TAVI) approach. TAVI is an expensive procedure, which also confers a higher mortality and morbidity risk in nonagenarians, compared to younger patients. Considering the physiologic rather the chronologic age alone, and adopting a shared-decision making approach (participatory medicine), it may be more realistic to determine a patient's candidacy for this non-surgical therapeutic modality. Thus, it comes down to the patient selection process by having the heart team review each nonagenarian case individually and getting the patient and the family involved, always aiming to prolong and improve patient's quality of life (QoL), but also taking into consideration patient preferences and values, sharing and respecting goals, realistic expectations, and end-of-life views and ideas. One should keep in mind that there is always the possibility that TAVI may be clinically futile for patients who have a multitude of comorbidities and extreme frailty, for whom a transition to palliative care might be prudent. Selecting nonagenarian patients with low comorbidity index and with no extreme frailty, adopting a minimalistic approach and paying attention to vascular access hemostasis may provide the elements that may lead to a successful, desirable and hopefully cost-effective outcome
Current Status of Renal Artery Angioplasty and Stenting for Resistant Hypertension: A Case Series and Review of the Literature
No full textBackground: Renal artery stenosis (RAS) has a high prevalence in older patients, especially in the context of general atherosclerosis. It is frequently associated with resistant hypertension and impaired renal function and their attendant consequences. The issue whether revascularization via percutaneous renal angioplasty and stenting (PRA/S) can benefit these patients remains unsettled. Objective: To present a case series of patients with refractory hypertension and RAS undergoing PRA/S and also to provide an extensive review of the literature on the current status of PRA/S for resistant hypertension. Methods: Data of all consecutive patients undergoing PRA/S by a single operator over 1 year were prospectively collected. These were 9 patients with hypertension refractory to drug therapy who also had other clinical cardiac problems that led to their hospitalization, including flash pulmonary edema and coronary artery disease. They were all receiving >= 3 antihypertensive drugs and renal angiography revealed critical RAS (unilateral in 3 and bilateral in 6). In addition, an extensive literature review of the topic was carried out in PubMed, Scopus and Google Scholar. Results: PRS was successful in all 9 high-risk RAS patients with resistant hypertension (5 men, mean age 71 years) without complications and helped in bringing under control their elevated blood pressure (BP) and in maintaining their renal function over a mean of 21 months. Literature review of this controversial topic indicates that in carefully selected patients, PRA/S may play an important role in controlling BP, alleviating symptoms and perhaps preventing renal failure, albeit without concrete evidence of significantly affecting hard end-points of renal events, major cardiovascular events and death. Randomized controlled studies (RCTs), including a large one (CORAL trial), although heavily criticized, have not provided evidence in favor of revascularization. Although RCTs are rather neutral, a multitude of prospective, observational cohort studies, comparing the outcomes of patients after PRA/S have demonstrated significant improvement in systolic and diastolic BP in about two thirds and improvement and/or stabilization in renal function in 30-40% of patients undergoing PRA/S. Nevertheless, the issue remains unsolved and a subject of future studies for further more definitive settlement. Suggestions have been made to adopt physiological and functional renal lesion assessment that may enhance patient selection, at least for RAS cases of moderate lesion severity. Based on this small case series and on exhaustive literature review, an algorithm for approaching patients with significant RAS is herein proposed. Conclusion: In high-risk RAS patients with truly resistant hypertension, flash pulmonary edema, and/or rapid deterioration of renal function, PRA/S, a procedure with currently high technical success, may constitute the only viable option. Importantly, despite the unfavorable results of RCTs, current guidelines have not yet changed and clinicians should continue to abide by them. They recommend PRA/S as a reasonable option for patients with hemodynamically significant (especially ostial) RAS and uncontrolled, resistant or malignant hypertension, recurrent, unexplained congestive heart failure or pulmonary edema or unstable angina
Sudden death risk stratification in non-ischemic dilated cardiomyopathy using old and new tools: a clinical challenge
No full textIntroduction: Risk stratification for sudden cardiac death in non-ischemic dilated cardiomyopathy (NIDCM) remains a clinical challenge. Areas covered: Currently, left ventricular ejection fraction (LVEF), severity of heart failure symptoms according to NYHA classification, and morphology and duration of the QRS complex guide device management in these patients with implantation of a cardioverter defibrillator (ICD) and/or cardiac resynchronization therapy (CRT) devices. Recently, the results of a randomized trial stirred some controversy regarding the utility of ICD in NIDCM patients, however, a subsequent meta-analysis confirmed prior findings of the survival-prolonging benefit of device therapy. Newer risk markers, like late gadolinium enhancement in cardiac magnetic resonance imaging (CMR) detecting myocardial fibrosis, are encouraging in improving risk stratification in these patients. Furthermore, resurgence of an old tool, the electrophysiology study (EPS), and technical advances in genetics in identifying highrisk familial NIDCM, appear promising in this direction. Expert commentary: Based on old and new tools, a more individualized approach may be applied in NIDCM patients, whereby CMR, EPS and genetics may provide further guidance, particularly in patients with LVEF>35%. These issues are herein reviewed and a practical algorithm is proposed for risk stratification and device implantation in NIDCM patients with LVEF below and above 35%
Cardiology News / Recent Literature Review / Last Quarter 2017
No full textAF Symposium 2018: Orlando, FL, 11-13/1/208ACC.18 Congress: Orlando, FL, 10-12/3/2018EHRA Meeting: Barcelona, 18-20/3/2018HRS Meeting: Boston, 9-12/5/2018EuroPCR Meeting: Paris, 22-25/5/2018ESC Meeting: Munich, 25-29/8/2018SPAIN Study: Dual-Chamber Pacing With Closed Loop Stimulation (DDD-CLS) Reduced Syncope Burden and Time to First Recurrence by 7-Fold, and Prolonged Time to First Syncope Recurrence in Patients Age≥40 Years With Tilt-Induced Cardio-inhibitory Vasovagal SyncopeDDD-CLS pacing is a rate-responsive mode that uses intracardiac impedance as a surrogate of cardiac contractility to adapt heart rate to patient needs. Among 46 patients, aged 56.30 ± 10.63 years, with tilt-induced cardioinhiboitory vasovagal syncope, the proportion of patients with ≥50% reduction in the number of syncopal episodes was 72% with DDD-CLS compared with 28% with sham DDI mode (p=0.017). A total of 4 patients (8.7%) had events during DDD-CLS and 21 (45.7%) during sham DDI (hazard ratio: 6.7). Kaplan-Meier curve was significantly different between groups in time to first syncope: 29.2 months vs 9.3 months (p< 0.016); odds ratio: 0.11 (p< 0.0001) (Baron-Esquivias G et al, J Am Coll Cardiol 2017;70: 1720–28).PESA Study: Skipping Breakfast is Associated With an Increased Odds of Prevalent Noncoronary and Generalized Atherosclerosis Independently of the Presence of Conventional CV Risk Factors Three patterns of breakfast consumption were studied: high-energy breakfast, when contributing to >20% of total daily energy intake (27% of the population); low-energy breakfast, when contributing between 5% and 20% of total daily energy intake (70% of the population); and skipping breakfast, when consuming <5% of total daily energy (3% of the population). Independent of the presence of traditional and dietary CV risk factors, and compared with high-energy breakfast, habitual skipping breakfast was associated with a higher prevalence of noncoronary (odds ratio-OR: 1.55) and generalized (OR: 2.57) atherosclerosis (Uzhova I et al, J Am Coll Cardiol 2017;70: 1833-42)."Real life" Longevity of Implantable Cardioverter-Defibrillator Devices (ICDs) Much Shorter than Manufacturers’ Projected LongevityManufacturers of implantable cardioverter-defibrillators (ICDs) promise a 5- to 9-year projected longevity; however, real-life data indicate otherwise. Over 20 years, among 685 ICD patients (601 men; age, 63.1 ± 13.3 years) with coronary (n = 396) or valvular (n = 15) disease, cardiomyopathy (n = 220), or electrical disease (n = 54) (mean ejection fraction 35%) and devices implanted for secondary (n = 562) or primary (n = 123) prevention (292 single-, 269 dual-chamber and 124 CRT devices implanted in the abdomen in 17 or chest in 668), ICD pulse generator replacements were performed in 238 patients. These were 209 men and 29 women, aged 63.7 ± 13.9 years, with ejection fraction of 37.7% ± 14.0%, who had an ICD for secondary (n = 210) or primary (n = 28) prevention. The mean ICD longevity was 58.3 ± 18.7 months. In 20 (8.4%) patients, devices exhibited premature battery depletion within 36 months. Most (94%) patients had none, minor, or modest use of ICD therapy. Longevity was longest for single-chamber devices and shortest for CRT devices. Latest-generation devices replaced over the second decade lasted longer compared with devices replaced during the first decade. When analyzed by manufacturer, Medtronic devices appeared to have longer longevity by 13 to 18 months. The authors concluded that ICDs continue to have limited longevity of 4.9 ± 1.6 years, and 8% demonstrate premature battery depletion by 3 years. CRT devices have the shortest longevity (mean, 3.8 years) by 13 to 17 months, compared with other ICD devices (Manolis AS et al, Clin Cardiol 2017;40:759-764)... (excerpt
Cardiology News / Recent Literature Review / First Quarter 2018
No full textManolis AS, Anninos H. Cardiology News / Recent Literature Review / First Quarter 2018. Rhythmos 2018;13(2):38-43. HRS Meeting: Boston, 9-12/5/2018EuroPCR Meeting: Paris, 22-25/5/2018ESC Meeting: Munich, 25-29/8/2018ICD in Children & Adolescents with Brugada Syndrome: ~1 in 4 Patients Receive Appropriate Life-Saving Interventions Over a Period of 7 Years, Although Inappropriate Shocks and Other Adverse Events Occur Relatively Frequently Among 35 consecutive patients (aged 13.9±6.2 years). over a mean of 88 months, sustained ventricular arrhythmias were treated by the ICD in 9 patients (26%), including shocks in 8 (23%) and antitachycardia pacing in 1 patient (3%). Three patients (9%) died in an electrical storm. Seven patients (20%) experienced inappropriate shocks, and 5 (14%) had device-related complications. Aborted sudden cardiac death and spontaneous type I ECG were identified as independent predictors of appropriate shock occurrence (Gonzalez Corcia MC et al, J Am Coll Cardiol 2018;71: 148–57).Cardiomyopathy (CM) Patients With LVEF≤35% and LBBB Demonstrate Significantly Less LV Functional Recovery With Medical Therapy Than Do Those With a Narrow QRS / Thus, They Would Benefit From Earlier Implantation of a CRT DeviceAmong 659 patients with CM, 111 having LBBB (17%), 59 wide QRS duration ≥120 ms but not LBBB (9%), and 489 narrow QRS duration (74%), adjusted mean increase in LVEF over 3-6 months in the 3 groups was 2.03%, 5.28%, and 8%, respectively (p<0.0001), with no different results for interim revascularization and myocardial infarction. The combined endpoint of heart failure hospitalization or mortality was highest for patients with LBBB (Sze et al, J Am Coll Cardiol 2017;71: 306-17).1-Year Follow-Up of PRAGUE-18 Study: Among Patients With MI Undergoing Primary PCI, Antiplatelet Therapy With Prasugrel or Ticagrelor is Associated With Similar Outcomes / Economically Motivated, Early Post-Discharge Switch To Clopidogrel was not Associated With Increased Risk of Ischemic Events Among 1,230 patients with acute myocardial infarction (MI) treated with primary PCI and randomized to prasugrel or ticagrelor, the endpoint (cardiovascular death, MI, or stroke at 1 year) occurred in 6.6% of prasugrel patients and in 5.7% of ticagrelor patients (hazard ratio: 1.167; p = 0.503). No significant differences were found in: CV death (3.3% vs 3%), MI (3% vs. 2.5%), stroke (1.1% vs 0.7%), all-cause death (4.7% vs. 4.2%), definite stent thrombosis (1.1% vs. 1.5%), all bleeding (10.9% vs. 11.1%), and TIMI major bleeding (0.9% vs. 0.7%). The percentage of patients who switched to clopidogrel for economic reasons was 34.1% (n=216) for prasugrel and 44.4% (n=265) for ticagrelor (p=0.003). Patients who were economically motivated to switch to clopidogrel had (compared with patients who continued the study medications) a lower risk of major CV events; however, they also had lower ischemic risk (Motovska Z et al, J Am Coll Cardiol 2018;71:371-81)... (excerpt
Exercise and Arrhythmias: A Double-Edged Sword
No full textAmple evidence indicates that moderate regular exercise is beneficial for both normal individuals and patients with cardiovascular (CV) disease. However, intense and strenuous exercise in individuals with evident or occult underlying CV abnormalities may have adverse effects with provocation and exacerbation of arrhythmias that may lead to life-threatening situations. Both of these aspects of exercise-induced effects are herein reviewed
Use of Sodium–Glucose Cotransporter 2 (SGLT-2) Inhibitors Beyond Diabetes: On the Verge of a Paradigm Shift?
No full textThe sodium–glucose co-transporter 2 (SGLT2) inhibitors have proven effective in glycemia control in patients with type 2 diabetes (T2D) by increasing urinary glucose excretion. However, the beneficial effects of SGLT2 inhibition extend beyond glycemic control, with new studies demonstrating beneficial effects that lead to improved cardiovascular (CV) (cardioprotection) and renal outcomes (renoprotection) in patients with T2D. Pivotal CV outcomes trials have demonstrated a 27-35% reduction in heart failure (HF) hospitalizations in patients with T2D. Importantly, a variety of pleiotropic effects of these new agents have been identified that include, but are not limited to, anti-atherosclerotic, anti-inflammatory, and anti-oxidant effects, decreased vascular stiffness and improved endothelial function, weight loss, reduction in sympathetic activity and in cardiac arrhythmogenesis. Ongoing studies are investigating these actions in patients with and without diabetes. Such results, if positive, may lead to a paradigm shift in the management of CV, renal and even other diseases beyond diabetes. Rhythmos 2020;15(1):67-71
Editorial commentary: Premature heart disease mortality: A sobering reality calling for action
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