Coronary Bypass Preferable To Stenting For Diabetes With LV Dysfunction Interview with:

Dr. Jayan Nagendran MD, PhD, FRCSC Director of Research, Division of Cardiac Surgery Associate Professor, Department of Surgery Division of Cardiac Surgery University of Alberta

Dr. Nagendran

Dr. Jayan Nagendran MD, PhD, FRCSC
Director of Research, Division of Cardiac Surgery
Associate Professor, Department of Surgery
Division of Cardiac Surgery
University of Alberta What is the background for this study?

Response: The primary modalities of treatment of symptomatic coronary artery disease (coronary heart disease) are either percutaneous coronary intervention (coronary stunting) or coronary artery bypass grafting surgery. There are well designed clinical trials that guide clinical practice for the treatment of patients with diabetes requiring coronary revascularization and there are trials that examine the best modality of coronary revascularization in patients with left ventricular dysfunction. However, there is a lack of evidence for patients with both diabetes and left ventricular dysfunction. As such, we performed a propensity matched study of patients with diabetes and left ventricular dysfunction undergoing either percutaneous coronary intervention compared to coronary artery bypass grafting surgery. We used our provincial database that captures >100,000 patients undergoing coronary angiography to attain our two cohorts for comparison.

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Aggressive Systolic Blood Pressure Control In Older Patients With HFpEF Should Be Avoided

“Doctors” by Tele Jane is licensed under CC BY Interview with:
Dr. Apostolos Tsimploulis, Chief Medical Resident
Dr. Phillip H. Lam, Chief Cardiology Fellow
The Washington, DC Veterans Affairs Medical Center, Georgetown University, and
MedStar Washington Hospital Center, Washington, DC What is the background for this study? What are the main findings?

Response: Hypertension is a major risk factor for the development of new heart failure (HF). Findings from multiple randomized controlled trials in hypertension have consistently demonstrated that controlling systolic blood pressure (SBP) to normal levels such as to SBP <120 mm Hg reduces the risk of developing new HF.

However, interestingly, once patients develop heart failure, those with a normal SBP value such as SBP <120 mm Hg tend to have poor outcomes. This paradoxical association – also called reverse epidemiology – although poorly understood – has been described with other HF risk factors such as smoking and obesity. Regarding poor outcomes associated with lower SBP in HF patients with reduced ejection fraction (HFrEF – pronounced Hef-ref), it has been suggested that it may be a marker of weak heart muscle that is unable to pump enough blood. However, less is known about this association in patients with HF and preserved ejection fraction (HFpEF – pronounced Hef-pef) –– the heart muscle is not weak in the traditional sense.

This is an important question for a number of reasons: nearly half of all heart failure patients have HFpEF which accounts for about 2.5 to 3 million Americans. These patients have a high mortality similar to those with HFrEF – but unlike in HFrEF few drugs have been shown to improve their outcomes. Thus, there is a great deal of interest in improving their outcomes. One of those approaches is to control . systolic blood pressure and the 2017 ACC/AHA/HFSA Focused Update of the HF guidelines recommend that SBP “should be controlled in patients with HFpEF in accordance with published clinical practice guidelines to prevent morbidity.”

Thus, our study was designed to answer that simple question: do patients with HFpEF and SBP <120 mmHg, which is considered to be normal SBP, have better outcomes than those with SBP ≥120 mmHg.

Using a sophisticated approach called propensity score matching we assembled two groups of patients with HFpEF – one group with SBP <120 mmHg and the other groups had SBP ≥120 mmHg – and patients in both groups were similar in terms of 58 key baseline characteristics. In this population of balanced patients with HFpEF, those with a normal systolic blood pressure had a higher risk of mortality – starting 30 days post-discharge up to about 6 years. Finding from our restricted cubic spline plots suggest that compared with SBP <120 mm Hg, SBP values ≥120 mm Hg (up to 200 mm Hg) was not associated with a higher risk of death.

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Some Heart Attack Patients Without AFib Still at Increased Risk of Stroke Interview with:

Normal rhythm tracing (top) Atrial fibrillation (bottom) Wikipedia image

Normal rhythm tracing (top) Atrial fibrillation (bottom)
Wikipedia image

João Pedro Ferreira, MD, PhD &
Faiez Zannad, MD, PhD
National Institute of Health and Medical Research (INSERM)Center for Clinical Multidisciplinary Research 1433INSERM U1116University of LorraineRegional University Hospital of NancyFrench Clinical Research Infrastructure Network (F-CRIN) Investigation Network Initiative–Cardiovascular and Renal Clinical Trialists, Nancy, France
Department of Physiology and Cardiothoracic SurgeryCardiovascular Research and Development UnitFaculty of MedicineUniversity of Porto, Porto, Portugal What is the background for this study? What are the main findings?

Response: It is uncertain whether patients with a myocardial infarction with systolic dysfunction but without atrial fibrillation have increased risk for stroke.

In this study including >22,000 patients and 600 stroke events we found a subgroup of patients at high risk for stroke despite not having atrial fibrillation. These patients are older, have worse renal function, frank signs of pulmonary congestion, hypertension and previous stroke history. We created a simple and “ready to use” score that allows the identification of these patients in routine clinical practice.  Continue reading

Chronic NOISE Exposure Linked To Heart Disease Interview with:
“Siren” by Michael Pereckas is licensed under CC BY 2.0Professor Dr. med. Thomas Muenzel

Universitätsmedizin Mainz
Zentrum für Kardiologie, Kardiologie I What is the background for this study? What are the main findings? 

Response: The background for this review is that people more and more acknowledge that noise is not just annoying the people as reported for many years, evidence is growing that chronic noise can cause cardiovascular disease including metabolic disease such as diabetes type II and mental disease such as depression and anxiety disorders and noise impairs as well the cognitive development of children.

More recent studies also provided some insight into the mechanisms underlying noise-induced vascular damage. Noise interrupts communication or sleep and thus is causing annoyance. If this occurs chronically the people develop stress characterized by increased stress hormone levels. If this persists for a long time people develop cardiovascular risk factors on tis own such as diabetes, hypercholesterolemia, one measures an increase of the blood to coagulate and the blood pressure will increase. To this end people will develop cardiovascular disease including coronary artery disease, arterial hypertension, stroke, heart failure an arrhythmia such as atrial fibrillation.

So, there is no doubt that noise makes us sick !  Continue reading

Migraine Linked To Increased Risk of Stroke, AFib, PE and Cardiovascular Disease Interview with:
“Headache.” by Avenue G is licensed under CC BY 2.0
Kasper Adelborg, MD, PhD
Postdoctoral Fellow
Department of Clinical Epidemiology
Aarhus University Hospital What is the background for this study? What are the main findings? 

Response: Around one billion people worldwide are affected by migraine. Migraine has considerable impact on quality of life and imposes a substantial burden on society. Migraine is primarily a headache disorder, but previous studies have suggested a link between migraine and stroke and myocardial infarction, particularly among women, while the link between migraine and other heart problems are less well known.

In this large register-based Danish study published in the BMJ, we confirmed that migraine is associated with increased risks of stroke and myocardial infarction, but we also found that migraine was associated with increased risks of other cardiovascular diseases (specifically, venous thromboembolism and atrial fibrillation). Migraine was not associated with increased risks of heart failure or peripheral artery disease.

In contrast to most previous studies, our study had a very large sample size and an age- and sex- matched comparison cohort from the general population, which allowed us to put migraine in a population context and to perform several subgroup analyses. Here, we found several interesting findings.

  • In general, the associations were strongest in the first year after diagnosis but persisted in the long term (up to 19 years after diagnosis).
  • Most associations applied to both migraine patients with aura (warning signs before a migraine, such as seeing flashing lights) and in those without aura, and in both women and in men. 

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Survival From In-Hospital Cardiac Arrest Improves But Still Worse on Nights and Weekends Interview with:

Uchenna Ofoma, MD, MS Associate, Critical Care Medicine Assistant Professor of Medicine, Temple University Director of Critical Care Fellowship Research Geisinger Medical Center

Dr. Ofoma

Uchenna Ofoma, MD, MS
Associate, Critical Care Medicine
Assistant Professor of Medicine, Temple University
Director of Critical Care Fellowship Research
Geisinger Medical Center What is the background for this study? What are the main findings? 

Response: Patients who suffer in-hospital cardiac arrest at nights and during weekends (off-hours) are known to have lower rates of survival to hospital discharge, compared to their counterparts who have cardiac arrest during the daytime on weekdays (on-hours). Since overall survival to hospital discharge has improved over the past decade for the approximately 200,000 patients who experience in-hospital cardiac arrest annually, our study sought to determine whether survival differences between off-hours and on-hours arrest has changed over time.

On-hours was categorized as 7:00 a.m. to 10:59 p.m. Monday to Friday. Off-hours was categorized as 11:00 p.m. to 6:59 a.m. Monday to Friday or anytime on weekends. Among 151,071 adult patients in the GWTG-Resuscitation registry who experienced in-hospital cardiac arrest between January 2000 and December 2014, slightly over half (52%) suffered a cardiac arrest during off-hours. We found that survival to hospital discharge improved significantly in both groups over the study period — for on-hours: from 16.0% in 2000 to 25.2% in 2014; for off-hours: 11.9% in 2000 to 21.9% in 2014.

However, despite overall improvement in both groups, survival from in-hospital cardiac arrest at nights during off-hours remained significantly lower compared to on-hours by an absolute 3.8%. What should readers take away from your report? 

Response: Survival to hospital discharge has improved in both groups of patients. This is reassuring and suggests that health care providers and hospital systems must be doing something right. However, the persistent survival disparities between on-hours and off-hours arrests remains concerning. To ensure that improved survival trends are sustained over time, narrowing this gap must be made an area of focus for quality improvement efforts. Data regarding mediator variables, such as physician and nurse staffing patterns and how they changed over the course of the study was not available for this study. What recommendations do you have for future research as a result of this work? 

Response: Since timing of in-hospital cardiac arrest appears to impact survival outcomes, future research should aim at identifying factors that may be associated with these described survival discrepancies and care processes that mitigate against them.

Disclosures: The authors received research support from the Geisinger Health System Foundation and the National Institutes of Health. 


Journal of the American College of Cardiology
Volume 71, Issue 4, January 2018
DOI: 10.1016/j.jacc.2017.11.043
Trends in Survival After In-Hospital Cardiac Arrest During Nights and Weekends
Uchenna R. Ofoma, Suresh Basnet, Andrea Berger, H. Lester Kirchner, Saket Girotra, for the American Heart Association Get With the Guidelines – Resuscitation Investigators, Benjamin Abella, Monique L. Anderson, Steven M. Bradley, Paul S. Chan, Dana P. Edelson, Matthew M. Churpek, Romergryko Geocadin, Zachary D. Goldberger, Patricia K. Howard, Michael C. Kurz, Vincent N. Mosesso Jr., Boulos Nassar, Joseph P. Ornato, Mary Ann Peberdy and Sarah M. Perman

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Insufficient Evidence To Determine Cardiovascular Risks of Marijuana

Dr. Italia V. Rolle, PhD and Dr. Tim McAfee, MD Office on Smoking and Health National Center for Chronic Disease Prevention and Health Promotion CDC

Marijuana plant (Cannabis sativa) Interview with:
Divya Ravi, MD, MPH

The Wright Center for Graduate Medical Education
Scranton, PA What is the background for this study? What are the main findings?

Response: There is evidence to suggest that Marijuana can bring about changes at the tissue level and has the ability to potentiate vascular disease, in ways similar to tobacco.  With change in legalization and increase usage trends, we conducted this review to examine the known effects of marijuana on cardiovascular outcomes and risk factors, given that cardiovascular disease remains the greatest cause of morbidity and mortality worldwide.

Our review found insufficient evidence to draw meaningful conclusions that marijuana use is associated with cardiovascular risk factors and outcomes. The few studies that suggested a possible benefit from marijuana use, were cross-sectional, and were contradicted by more robust longitudinal studies that reported potential harmful effects.

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FFRct Technology Can Eliminate Need For Coronary Angiogram In Some Patients Interview with: Interview with: Cardiologist Mark Rabbat, MD, FSCCT

Dr. Rabbat

Cardiologist Mark Rabbat, MD, FSCCT
Who pioneered the use of FFRct at Loyola Medicine and was first author of an international expert panel of leading cardiologists and radiologists from centers in the United States, Canada, Denmark, Italy, Belgium and the Netherlands on how to interpret and report the tests published in the Journal of Cardiovascular Computed Tomography What is the scope of the problem?

Response: Coronary artery disease is a very large healthcare burden. Over sixteen million individuals in the United States have coronary artery disease.  Coronary artery disease may result in your heart not getting enough blood and increases your risk of a heart attack.

Historically, we have been faced with either using tests we knew were not always accurate or putting a patient through an invasive angiogram just to determine whether they would need another invasive procedure to restore blood flow.  The CT-derived fractional flow reserve (FFRct) analysis is the first technology that bridges the gap between the non-invasive and invasive tests within one platform.  Any patient with symptoms such as chest pain, chest tightness, fatigue, or shortness of breath without known coronary artery disease may be a candidate for the FFRct study.  Continue reading

The PlaqueTec Liquid Biopsy System™ Allows Detection of Predictive Intracoronary Artery Biomarkers Interview with:

The PlaqueTec Liquid Biopsy System™ (LBS)

The PlaqueTec Liquid Biopsy System™ (LBS)

Chief Medical Officer
PlaqueTec Ltd What is the background for the Liquid Biopsy System and this study?

Response: Despite huge advances in the diagnosis and treatment of coronary artery disease, this form of cardiovascular disease remains as the world’s number one cause of death. Although interventions such as coronary angioplasty and cholesterol lowering with statins have improved morbidity, patients still experience high rates of recurrent cardiovascular events. Various technologies have been applied to predict future patient events with limited success, such as ‘virtual histology’ intravascular ultrasound (VH-IVUS) in the PROSPECT study (Stone GW et al. N Engl J Med 2011; 364: 226-235). Many experts acknowledge that imaging alone may be insufficient to gauge risk, and that the utility of a more biological endpoint may be more appropriate. This supposition is supported by recent data that added endothelial shear stress estimation to the PROSPECT data and significantly improved subsequent event prediction (Stone PH et al. JACC Cardiovascular Imaging 2017; Sep 18 epub ahead of print).

Coronary artery disease has long been recognised to be underpinned by an inflammatory pathogenesis, and it is bioactive molecules (growth factors, cytokines etc) within the vasculature that affect plaque growth, transformation and vulnerability to rupture, resulting in myocardial infarction. Measuring these biomolecules in situ is challenging owing to an inability to reliably sample from the ‘boundary layer’ – a slower-moving circumferential stratum of blood adjacent to the endothelial surface that does not mix with the general bulk flow.

The PlaqueTec Liquid Biopsy System™ (LBS) was designed specifically to sample from the boundary layer at four sites simultaneously within the coronary artery, where biomolecules released from plaques are likely to be most concentrated. With the LBS, we can also detect small gradients of released molecules by simultaneously collecting blood both upstream and downstream of individual plaques.

The LBS has demonstrated safety and feasibility in preclinical and preliminary clinical studies, and was awarded a CE mark in Europe as a dedicated coronary blood sampling device in 2014. Continue reading

Statins: Large Disparity Between US/Canadian/UK and European Guidelines Interview with:

Borge G. Nordestgaard,

Borge G. Nordestgaard

Børge G. Nordestgaard, MD, DMSc
Department of Clinical Biochemistry
Herlev and Gentofte Hospital, Copenhagen University Hospital
Herlev, Denmark What is the background for this study?

Response: Five major organizations recently published guidelines for using statins to prevent atherosclerotic cardiovascular disease  — the American College of Cardiology/American Heart Association (ACC/AHA) in 2013, the United Kingdom’s National Institute for Health and Care Excellence (NICE) in 2014, and in 2016 the Canadian Cardiovascular Society (CCS), the US Preventive Services Task Force (USPSTF), and the European Society of Cardiology/European Atherosclerosis Society (ESC/EAS). We applied these five guidelines to a contemporary study cohort of 45,750 40-75 year olds from the Copenhagen General Population Study.

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