Annals Internal Medicine, Author Interviews, Biomarkers, Heart Disease / 19.04.2017 Interview with: Martin P. Than, MBBS Emergency Department, Christchurch Hospital and Dr John W Pickering, PhD Associate Professor Senior Research Fellow in Acute Care Emergency Care Foundation, Canterbury Medical Research Foundation, Canterbury District Health Board | Christchurch Hospital Research Associate Professor | Department of Medicine | University of Otago Christchurch New Zealand What is the background for this study? Response: Patients being investigated for possible acute coronary syndrome comprise one of the largest groups of patients presenting to emergency rooms. Troponin assays have developed such that they can now measure with greater accuracy much lower concentrations of troponin. A large retrospective registry based study and a couple of smaller prospective studies suggested that patients with a very low concentrations of troponin T (below the current limit of detection of 5 ng/L) measured with Roche Diagnostic’s high-sensitivity troponin T (hsTnT) assay on presentation to the emergency department (ie single blood draw) are very unlikely to be having a myocardial infarction (MI). Our study gathers the current best evidence for using concentrations below the limit of detection in conjunction with no evidence of new ischaemia on ECG to safely risk stratify patients to a very low-risk group for MI and, therefore, potentially identify patients safe for early discharge. (more…)
Author Interviews, Heart Disease, JACC, Medical Imaging, MRI / 19.04.2017 Interview with: Pr. Juerg Schwitter MD Médecin Chef Cardiologie Directeur du Centre de la RM Cardiaque du CHUV Centre Hospitalier Universitaire Vaudois - CHUV Suisse What is the background for this study? What are the main findings? Response: Coronary artery disease (CAD) is still one of the leading causes of death in the industrialized world and as such, it is also an important cost driver in the health care systems of most countries. For the European Union, the estimated costs for CAD management were 60 billion Euros in 2009, of which approximately 20 billion Euros were attributed to direct health care costs (1). In 2015, the total costs of CAD management in the United States were estimated to be 47 billion dollars (2). Substantial progress has been achieved regarding the treatment of CAD including drug treatment but also revascularizations procedures. There exists a large body of evidence demonstrating myocardial ischemia as one of the most important factors determining the patient’s prognosis and reduction of ischemia has been shown to improve outcome. On the other hand, techniques to detect CAD, i.e. relevant myocardial ischemia, were insufficient in the past. Evaluation of myocardial perfusion by first-pass perfusion cardiac magnetic resonance (CMR) is now closing this gap (3) and CMR is recommended by most international guidelines for the work-up of known or suspected CAD (4,5). Still, a major issue was not clarified until now, i.e. “how much ischemia is required to trigger revascularization procedures”. Thus, this large study was undertaken to assess at which level of ischemia burden, patients can be safely deferred from revascularization and can be managed by risk factor treatment only. Of note, this crucial question was addressed in both, patients with suspected CAD but also in patients with known (and sometimes already advanced) CAD, thereby answering this question in the setting of daily clinical practice. (more…)
Author Interviews, Heart Disease, Inflammation, Nature / 18.04.2017 Interview with: Borja Ibáñez MD Spanish National Centre for Cardiovascular Research Madrid What is the background for this study? What are the main findings? Response: Acute myocardial infarction (heart attack) is a severe condition responsible for thousands of deaths every year and with important long-term consequences for survivors. Best treatment for acute myocardial infarction is a rapid coronary reperfusion. Upon reperfusion, all inflammatory cells and mediators accumulated in the circulation during the infarction process, enter into the myocardium and causes an extra damage to the heart. Activated neutrophils play a critical role in this damage occurring upon reperfusion. The final size of infarction is the main determinant for mortality and long-term morbidity. The possibility of limiting the extent of infarcted tissue is of paramount importance. Betablockers have been used in patients for more than 4 decades, mainly to treat arrhythmias and high blood pressure. Recently the same group of investigators demonstrated that the very early administration (i.e. during ambulance transfer to the hospital) of the betablocker “metoprolol” was able to reduce the size of infarction in patients. The mechanism by which metoprolol was protective in patients suffering a myocardial infarction was unknown. (more…)
Author Interviews, Heart Disease, HIV, JAMA, Vanderbilt / 18.04.2017 Interview with: Matthew S Freiberg, MD, MSc Associate Professor of Medicine, Division of Cardiovascular Medicine Vanderbilt Translational and Clinical Cardiovascular Research Center What is the background for this study? Response:  HIV infected people are living longer and are at risk for cardiovascular diseases. While acute myocardial infarction has been studied and the increased risk of Acute Myocardial Infarction (AMI) among HIV+ people compared to uninfected people is well documented, there are less data describing the risk of HIV and different types of heart failure, including reduced and preserved ejection fraction heart failure. Understanding more about the link between HIV and different types of HF is important because reduced and preserved ejection fraction heart failure differ with respect to underlying mechanism, treatment, and prognosis. Moreover, as cardiovascular care has improved, HIV infected people who experience an AMI are likely to survive but may live with a damaged heart. Understanding more about the link between HIV and heart failure may help providers and their patients prevent or reduce the impact of HF on the HIV community. (more…)
Author Interviews, Heart Disease, Stem Cells / 17.04.2017 Interview with: Jalees Rehman, MD Director of Research, Division of Cardiology Associate Professor of Medicine and Pharmacology University of Illinois at Chicago College of Medicine Chicago, IL 60612 What is the background for this study? Response: Converting skin fibroblasts into regenerative blood vessel endothelial cells could be a valuable approach to repair diseased blood vessels in patients with cardiovascular disease and also to build new blood vessels in order to supply engineered tissues and organs. Using skin fibroblasts is very well suited for personalized therapies because they can be obtained from a skin biopsy in an outpatient setting. The biopsied skin sample is used to extract the skin fibroblasts, which are then expanded in cell culture dishes before they are converted to endothelial cells. This allows for the generation of tens or hundreds of millions of cells that will likely be needed for blood vessel repair and regeneration. By converting skin fibroblasts of a patient, we can generate personalized endothelial cells with the same genetic signature as the patient so that they are less likely to be rejected if implanted back into the same patient after the conversion. (more…)
Author Interviews, Heart Disease / 17.04.2017 Interview with: Roberta Gottlieb, MD Director of Molecular Cardiobiology Professor of Medicine Cedars-Sinai Heart Institute Cedars-Sinai Los Angeles, California What is the background for this study? Response: Most heart surgeries involve stopping the heart and relying upon a machine to oxygenate the blood and pump it to the rest of the body, a procedure called cardiopulmonary bypass. The heart is typically cooled, which further reduces metabolic demand. During this time, the heart is without a blood supply to provide oxygen and nutrients, but near the end of the procedure, the heart is re-started and blood flow is restored. This period of ischemia followed by reperfusion can injure the heart muscle, much like what happens during a myocardial infarction, or heart attack. It has been shown that the degree of injury at the time of surgery (measured by the release of cardiac enzymes) is associated with mortality at 30 days and risk of heart failure within 3 years. For that reason, it is important to understand the cellular and molecular events that occur in the heart muscle during cardiac surgery so that we can decrease ischemia/reperfusion injury. (more…)
Author Interviews, Heart Disease, JAMA, Vitamin D / 13.04.2017 Interview with: Robert Scragg, MBBS, PhD School of Population Health The University of Auckland Auckland New Zealand What is the background for this study? What are the main findings? Response: Interest in a possible role for vitamin D deficiency as a risk factor for cardiovascular disease was stimulated by studies showing a seasonal variation in cardiovascular disease, which is much higher in winter, when body levels of vitamin D are low, than in summer. Main findings are that bolus monthly doses of vitamin D supplementation do not prevent against cardiovascular disease, even in people with low levels of vitamin D. (more…)
Author Interviews, Diabetes, Heart Disease, NEJM / 13.04.2017 Interview with: Aidin Rawshani, MD, PhD student Sahlgrenska Academy University of Gothenburg What is the background for this study? What are the main findings? Response: Management of diabetes has improved in the past decades, studies have shown that mortality and cardiovascular disease among patients with diabetes has decreased, but these studies have not compared the trends among persons with type 1 diabetes and type 2 diabetes to those of the general population, where there have also been reductions in cardiovascular morbidity and mortality. We observed marked reductions in incidence for cardiovascular disease and mortality among individuals with diabetes, however, similar trends were observed for the general population. We observed a 43% (HR 1.43, 95% CI 1.25–1.62) greater event rate reduction for cardiovascular disease among individuals with type 1 diabetes compared to matched controls. The reduction in the rate of fatal outcomes did not differ significantly between patients with type 1 diabetes and controls, whereas patients with type 2 diabetes had a 13% (HR 0.87, 95% CI 0.85–0.89) lesser event rate reduction compared with matched controls. There was a 27% (HR 1.27, 95% CI 1.22–1.32) greater event rate reduction for cardiovascular disease among individuals with type 2 diabetes, compared with matched controls. Nevertheless, there remains a substantial excess overall rate of all outcomes analysed among persons with type 1 diabetes and type 2 diabetes, as compared with the general population. (more…)
Author Interviews, Heart Disease, JAMA, Lipids, Nutrition, Stroke, Yale / 13.04.2017 Interview with: Eric J. Brandt, MD Yale University Cardiovascular Disease Fellow What is the background for this study? What are the main findings? Response: From previous studies we know that industrial trans fatty acid (trans fat) consumption is linked to elevated risk for cardiovascular disease. Even small amounts of consumption can be deleterious to cardiovascular health. In New York state, there were 11 counties that restricted the use of trans fatty acids in eateries. We compared hospitalization for heart attacks and stroke from 2002 through 2013 in counties that did and did not have restrictions. Our study found that when comparing populations within New York state that restricted the use of trans fat, compared to those that did not, there was an associated additional decline beyond temporal trends for heart attacks and stroke events combined by 6.2%. (more…)
Author Interviews, Dental Research, Heart Disease / 13.04.2017 Interview with: Bradley F. Bale, M.D. Texas Tech Health Science Center School of Nursing, Lubbock, Texas 1002 Montrose Drive Gallatin, TN 37066 What is the background for this study? What are the main findings? Response: It has been known for some time that periodontal disease is associated with higher risk for arterial disease.  It was shown decades ago that the germs in the mouth frequently seed into our blood stream with simple activities such as chewing and brushing our teeth.  During the last decade, it was discovered certain high risk periodontal pathogens are associated with various cardiovascular (CV) risk factors such as blood pressure, lipid levels, insulin resistance and endothelial dysfunction.  These studies elucidated that the CV risk stems from the bacteria involved in the periodontal disease and not the clinical signs such as pocket depth, bleeding of gums and loose teeth. The above knowledge demonstrated that high risk periodontal pathogens can adversely influence two of the three elements in the atherogenic triad.  Those factors are concentration of apoB and endothelial inflammation and dysfunction.  Then approximately two years ago it was published that the high risk pathogen Porphyromonas  gingivalis (P.g.) can enhance the third element.  This portion is the transformation of contractile smooth muscle cells (SMCs) in the medial layer of artery into migratory secretory SMCs.  These morphed cells enter the deep layer of the intima and enrich it with proteoglycans which are the ‘velcro’ that traps cholesterol particles in the arterial wall and initiates the formation of arterial disease.  At that point, there was solid evidence that the high risk pathogens boost every element in the triad to create atherosclerosis.  With that knowledge these pathogens must be considered a contributory cause of arterial disease.  When a condition is causal it demands diagnosis and management to reduce the disease risk. (more…)
Author Interviews, Endocrinology, Heart Disease, Thyroid Disease / 09.04.2017 Interview with: Arjola Bano, MD, DSc PhD candidate Departments of Internal Medicine and Epidemiology Erasmus Medical Center, Rotterdam, The Netherlands What is the background for this study? What are the main findings? Response: Atherosclerosis is a chronic condition, characterized by the accumulation of lipids and fibrous elements in the arterial walls. It can progress insidiously from an asymptomatic narrowing of the arterial lumen (subclinical phase) to the clinical onset of vascular events (as coronary heart disease or stroke) and death. Despite advances in prevention and treatment, atherosclerotic diseases remain a leading cause of mortality worldwide. Therefore, identifying additional modifiable risk factors for atherosclerosis is of major importance. So far, the role of thyroid hormone on atherosclerosis remains unclear. Moreover, a comprehensive investigation exploring the link of thyroid function with the wide spectrum of atherosclerosis, including subclinical atherosclerosis, clinical atherosclerosis and atherosclerotic mortality, within the same population is lacking. Therefore, in a prospective study of 9231 middle-aged and elderly people, we explored the association of thyroid function with subclinical atherosclerosis (coronary artery calcification), atherosclerotic events (fatal and nonfatal coronary heart disease or stroke) and atherosclerotic mortality (death from coronary heart disease, cerebrovascular or other atherosclerotic disease). Higher free thyroxine (FT4) levels were associated with higher risk of subclinical atherosclerosis, atherosclerotic events and atherosclerotic mortality, independently of cardiovascular risk factors. The risk of atherosclerotic mortality increased with higher FT4 levels (HR; CI: 2.35; 1.61-3.41 per 1 ng/dl) and lower thyroid-stimulating hormone (TSH) levels (HR; CI: 0.92; 0.84-1.00 per 1 logTSH), with stronger estimates among participants with a history of atherosclerotic disease (HR; CI: 5.76; 2.79-11.89 for FT4 and 0.81; 0.69-0.95 for TSH). (more…)
AHA Journals, Author Interviews, Heart Disease, Mental Health Research / 04.04.2017 Interview with: Alessandro Paoletti Perini, MD, PhD and Valentina Kutyifa MD, PhD University of Rochester Medical Center Heart Research Follow-Up Program Rochester, New York, 14642 What is the background for this study? What are the main findings? Response: The present study is a pre-specified sub-study of the Multicenter Automatic Defibrillator Implantation Trial – Reduce Inappropriate Therapy (MADIT-RIT), which was published on the New England Journal of Medicine in 2012. The main trial showed that innovative ICD programming was associated with reduction in inappropriate ICD therapy and mortality. In the present investigation we focused on the detrimental effects that ICD firings, either appropriate or inappropriate, may have on patients’ psychological well-being. We observed that multiple appropriate and inappropriate shocks are associated with increased levels of ICD-related anxiety, a specific kind of psychological disorder which affects patients implanted with an ICD. Multiple appropriate ATP were also proved associated with higher anxiety, although not as much as shocks. On the other hand, we did not find a significant association with anxiety for multiple inappropriate ATP. (more…)
Author Interviews, Biomarkers, Heart Disease / 31.03.2017 Interview with: Szilard Voros, MD, FACC, FSCCT, FAHA CEO of Global Genomics Group What is the background for this study? What are the main findings? Response: Atherosclerotic coronary artery disease (ASCAD) is the leading cause of death and morbidity in the United States and worldwide, despite relatively successful medical therapies such as statins, like Zocor or Lipitor. A significant majority of patients with ASCAD present with sudden cardiac arrest, and the clinical evaluation of those patients who present with chest pain to their physicians is very inefficient. Based on current clinical guidelines, patients who present to their physician with complaints of new onset chest pain or its equivalent, such as exertional dyspnea should be assessed for the probability of the presence of significant ASCAD based on simple clinical predictors. Approximately 60% of such patients have an intermediate probability, and they are typically referred for initial non-invasive evaluation, such as a stress test with cardiac imaging, or for some other type of non-invasive test. Strikingly, no more that 5% of such stress tests performed in the United States are actually positive, and even when patients with positive stress test are taken for invasive coronary angiography, no more than 40% have significant ASCAD. A blood test that could serve as first step, as a “gatekeeper”, to non-invasive evaluation, would be highly desirable. Global Genomics Group, or G3, has performed one of the largest, unbiased, mass-spectrometry-based discovery studies in over 1,000 patients who underwent detailed cardiac CT to assess the presence or absence of ASCAD, by measuring over 1,000 metabolites from the blood. Using sophisticated bioinformatics tools, the researchers identified 8 important metabolites that were significantly abnormal in patients with ASCAD, and generated a biomarker signature for the detection of ASCAD based on those analytes, called “knowPLAQUETM”. The biomarker signature was generated in approximately 800 subjects, and was validated in an independent set of approximately 400 subjects, showing an area under the curve (“AUC”) of 0.82 for the diagnosis of Atherosclerotic coronary artery disease. This biomarker signature can be adapted relatively easily on commercial mass spectrometry platforms, and the researchers anticipate that this signature may be available for physicians to use by 2018. In addition to its diagnostic power, this biomarker signature also has uncovered important biological insights for the development of ASCAD, which can be leveraged for therapeutic purposes. (more…)
Author Interviews, Heart Disease, Insomnia / 31.03.2017 Interview with: Qiao He Master’s degree student China Medical University Shenyang, China What is the background for this study? Response: Sleep is an important factor for biological recovery functions, but in modern society, more and more people have complained having sleep problems like insomnia, one of the main sleep disorders. It is reported that approximately one-third of the German general population has been suffering from insomnia symptoms. In decades, many researchers have found associations between insomnia and bad health outcomes. Insomnia seems to be a big health issue. However, the results from previous studies regarding the association of insomnia and cardiovascular or cerebrovascular events were inconsistent. Therefore, we conducted this study. (more…)
Author Interviews, Biomarkers, Heart Disease, JAMA / 30.03.2017 Interview with: Stefan Kiechl, MD and Karin Willeit, MD Department of Neurology Medical University Innsbruck Innsbruck, Austria What is the background for this study? Response: Atrial fibrillation (AF) is the most common cardiac arrhythmia and a major contributor to thromboembolic stroke and population morbidity and mortality. Aside from well-established risk factors such as age, heart failure, and hypertension, inflammation has been suggested to play a significant role in the pathogenesis of AF. This is evidenced by histologic studies that found marked inflammatory infiltrates in atrial biopsies of AF patients and by epidemiological studies demonstrating an association of circulatory inflammation markers with incident AF. Of note, an increased endocardial expression of vascular intercellular adhesion molecule 1 (VCAM-1), a mediator of leukocyte trafficking, during rapid atrial pacing was demonstrated which was shown to contribute to an inflammatory and prothrombotic environment within atrial tissue. Because it is still unclear whether inflammation related to AF is primarily a systemic or localized phenomenon, we sought to examine the association of 13 baseline inflammation markers with incident atrial fibrillation in the prospective population-based Bruneck Study and to replicate key findings in a second cohort, the SAPHIR Study. (more…)
Author Interviews, Clots - Coagulation, Heart Disease, Thromboembolism / 29.03.2017 Interview with: Paul Burton, MD, PhD, FACC Vice President, Medical Affairs Janssen What is the background for this study? What are the main findings? Response: Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), affects more than 900,000 Americans each year; one-third of these occurrences are fatal. Once a person experiences a VTE, they are at risk of having another occurrence. Guidelines currently recommend anticoagulant therapy with a non-vitamin K antagonist oral anticoagulant (NOAC), like XARELTO® (rivaroxaban), for three months or longer. Once anticoagulant therapy is stopped, up to 10 percent of people will experience a recurrence during the first year and up to 20 percent within three years. In people who decide to stop anticoagulant therapy, guidelines currently suggest using aspirin for long-term prevention of recurrent VTE rather than no aspirin at all. The Phase 3 EINSTEIN CHOICE study was designed to compare the efficacy and safety of XARELTO® to aspirin for continued VTE management in people who experienced an initial VTE. The study met its primary endpoint, finding both XARELTO® doses (10 mg or 20 mg once daily) to be superior to aspirin 100 mg once daily in preventing recurrent VTE, with no significant impact on safety. Specifically, XARELTO® 10 mg reduced the risk of recurrent VTE by 74 percent and XARELTO® 20 mg by 66 percent. Rates of major bleeding were comparable and low across all treatment groups. These results were presented at the American College of Cardiology's 64th Annual Scientific Session (ACC.17) during a Joint ACC/Journal of American Medical Association Late-Breaking Clinical Trials session and published simultaneously in The New England Journal of Medicine. (more…)
Author Interviews, Heart Disease, JAMA, Osteoporosis / 27.03.2017 Interview with: Wallis CY Lau BSc Centre for Safe Medication Practice and Research Department of Pharmacology and Pharmacy Li Ka Shing Faculty of Medicine The University of Hong Kong What is the background for this study? What are the main findings? Response: Warfarin is a vitamin K antagonist (VKA) oral anticoagulant used for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF), a common heart rhythm disorder. It works by interfering with vitamin K-dependent reactions in the process of blood clot formation. As these reactions also play a role in bone mineralization, there is concern that warfarin use may be linked with osteoporotic fracture. Despite the concerns for fracture risk, warfarin had been an inevitable treatment choice for over 50 years as there were no other alternatives available. Dabigatran is the first non-VKA oral anticoagulant (NOAC) approved for use in patients with NVAF. Recently, an animal study reported that use of dabigatran is associated with a better bone safety profile compared to warfarin in rats, suggesting a potential for a lower risk of osteoporotic fractures over warfarin. However, the actual risk of osteoporotic fractures with dabigatran use in human remains unclear. Therefore, we conducted a population-based cohort study to compare the risk of osteoporotic fractures in patients with NVAF treated with dabigatran and warfarin. (more…)
Author Interviews, Heart Disease, JACC, Sleep Disorders / 24.03.2017 Interview with: Christopher M. O’Connor, MD FACC  CEO and Executive Director, Inova Heart & Vascular Institute IHVI Administration Falls Church, Virginia 22042 What is the background for this study? What are the main findings? Response: Sleep apnea is a very common comorbidity of patients with heart failure (both reduced ejection fraction and preserved ejection fraction). Early evidence from observational and small studies suggested that treating sleep apnea with adaptive servo-ventilation (ASV) therapy may improve patient outcomes. There is minimal clinical evidence about identifying and treating sleep apnea in those who’ve been hospitalized with acute decompensated heart failure. The CAT-HF study was designed to help address this, with the primary endpoint being cardiovascular outcomes measured as a Global Rank Score that included survival free from cardiovascular hospitalization and change in functional capacity as measured by the six-minute walk distance. It was also planned to expand on the SERVE-HF study that was investigating the use of ASV therapy to treat central sleep apnea (CSA) in chronic stable heart failure patients with reduced ejection fraction patients (HFrEF). (more…)
Author Interviews, Heart Disease / 23.03.2017 Interview with: Christopher L.F. Sun MIE PhD candidate Department of Mechanical and Industrial Engineering University of Toronto, ON, Canada What is the background for this study? What are the main findings? Response: Strategic automated external defibrillator (AED) placement is critical for reducing the time to treatment and improving survival outcomes of public out-of-hospital cardiac arrest (OHCA). Many previous studies have focused on examining broad location categories without considering temporal availability (i.e. hours of operation). These broad location categories are often composed of many individual businesses, each with their own unique properties including varying accessibility. Examining specific businesses and locations while incorporating hours of operations and time of OHCA occurrence can improve AED placements in respect to where and when they are needed. Our goal was to examine individual businesses and municipal locations that maximize spatiotemporal OHCA coverage, the number of OHCAs that occurred within 100 m of each location when it was open. We identified a total of 41 businesses and municipal locations with 20 or more locations in Toronto to include the study. We proceeded to rank these businesses and municipal locations by spatiotemporal coverage. We found that coffee shops and bank automated teller machines (ATMs) were the best places to put public AEDs, corresponding to 8 of the "Top 10" ranking stop in Toronto. Specifically, the Canadian coffee shop chain Tim Hortons ranked first of all 41 businesses considered. (more…)
Author Interviews, Heart Disease, JACC, Lifestyle & Health / 23.03.2017 Interview with: Andrew T. Yan, MD Terrence Donnelly Heart Centre St Michael's Hospital University of Toronto Toronto, Ontario, Canada What is the background for this study? What are the main findings? Response: The pathogenesis of aortic stenosis is complex and incompletely understood. Previous experimental data and epidemiologic studies (mostly cross-sectional) have demonstrated an association between conventional cardiovascular risk factors such as hypertension, diabetes, and dyslipidemia, and aortic sclerosis or stenosis. However, there is a paucity of longitudinal data from large population studies. Therefore, we sought to examine the relationship between conventional cardiovascular risk factors and incident severe aortic stenosis during extended follow-up in a large unselected elderly population in Ontario, Canada. In over 1 million individuals older than 65 who were followed for a median of 13 years, hypertension, diabetes and dyslipidemia were all significantly and independently associated with development of severe aortic stenosis requiring hospitalization or intervention. Furthermore, we observed a positive dose-response relationship between the number and duration of cardiac risk factors, and the risk of aortic stenosis. Together, these risk factors accounted for approximately one third of the incidence of severe aortic stenosis at a population level. (more…)
Author Interviews, Heart Disease / 22.03.2017 Interview with: Alec Vishnevsky, MD Cardiology Fellow and First Author Thomas Jefferson University Hospital Michael P. Savage, MD FACC FSCAI FACP Ralph J. Roberts Professor of Cardiology Sidney Kimmel Medical College at Thomas Jefferson University Director, Cardiac Catheterization Laboratory What is the background for this study? What are the main findings? Response: Percutaneous coronary intervention (PCI) has been a mainstay treatment for patients with symptomatic coronary artery disease. While current guidelines emphasize the importance of periprocedural antithrombotic medications, they fail to mention the use of nitroglycerin prior to PCI to rule out coronary artery spasm as the etiology of a stenosis seen on coronary angiography. This distinction is paramount as it can avoid unnecessary stenting procedures. In this case series, we described a series of patients presenting with chest pain and angiographically significant stenoses that resolved with administration of intracoronary nitroglycerin (IC NTG) prior to planned PCI. The study group consisted of 6 patients with a mean age of 52, all of whom had anginal symptoms and significant stenoses seen on coronary angiogram.  In each case, giving intracoronary nitroglycerin resulted in resolution of the stenosis, and all 6 patients were successfully managed medically without stenting. (more…)
Author Interviews, Heart Disease, JAMA / 21.03.2017 Interview with: Eric A. Secemsky, MD, MSc Interventional Cardiology Fellow Massachusetts General Hospital Harvard Medical School Baim Institute for Clinical Research What is the background for this study?  What are the main findings? Response: We know from previous trials that continuing dual antiplatelet therapy longer than 12 months after coronary stenting decreases ischemic events, including spontaneous myocardial infarction and stent thrombosis. However, extending dual antiplatelet therapy is also associated with some increase in bleeding risk. For instance, in the DAPT Study, more than 25,600 patients were enrolled and received both aspirin and a thienopyridine antiplatelet drug (clopidogrel or prasugrel) for one year after stenting. Of these patients, 11,648 participants who had followed the study protocol and had no serious cardiovascular or bleeding events during that first year were then randomized to either continue with dual therapy or to receive aspirin plus a placebo for another 18 months. The overall findings of the DAPT study were that, compared with switching to aspirin only after one year, continuing dual antiplatelet therapy for a total of 30 months led to a 1.6 percent reduction in major adverse cardiovascular and cerebrovascular events – a composite of death, myocardial infarction, stent thrombosis and ischemic stroke – and a 0.9 percent increase in moderate to severe bleeding events. The prognosis following early ischemic and bleeding events has previously been well described. However, data for events occurring beyond 1 year after PCI are limited. As such, we sought to assess the cumulative incidence of death following ischemic and bleeding events occurring among patients in the DAPT Study beyond 1 year after coronary stenting. (more…)
AHA Journals, Author Interviews, Genetic Research, Heart Disease / 21.03.2017 Interview with: Lia Crotti, MD, PhD Department of Cardiovascular, Neural and Metabolic Sciences San Luca Hospital IRCCS Istituto Auxologico Italiano What is the background for this study? Response: Sudden cardiac death in one of the major cause of death in Western Countries and among the causes of these deaths in young people under the age of 35, inherited forms of cardiomyopathy have a prominent role. Among these cardiomyopathies, Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) plays a major role. In ARVC, the heart tissue is replaced by fatty and fibrous tissue. This process encourages the development of life-threatening arrhythmias, such as ventricular fibrillation, that causes a cardiac arrest and sudden death in few minutes without a ready device to shock the heart. Intense physical activity favors the progression of the disease and arrhythmias are frequently triggered by adrenergic activation: those are the reason why young athletes with this disease are at high risk. (more…)
Author Interviews, Heart Disease, Pharmacology / 20.03.2017 Interview with: Kathrine Bach Søndergaard MD, Research Fellow Gentofte University Hospital Department of Cardiology Hellerup What is the background for this study? Response: Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used and have in previous studies been associated with an increased risk of cardiovascular adverse events, such as myocardial infarction and heart failure. Cardiac arrest is the ultimate adverse event; however, no research exists of the association between cardiac arrest and use of NSAIDs, which we aimed to assess in this study. (more…)
Author Interviews, Heart Disease, Medical Imaging / 20.03.2017 Interview with: Matthias Götberg, MD, PhD Director Cardiac Cath Lab Department of Coronary Heart Disease Skane University Hospital- Lund Lund, Sweden What is the background for this study? Response: Cardiologists encounter patients with narrowing of the coronary arteries on a daily basis. They typically use visual estimation of the severity of narrowing when performing coronary angiography, but it is difficult to accurately assess, based on a visual estimation alone, whether a stent is needed to widen the artery and allow the blood to more freely. FFR (Fractional Flow Reserve) is more precise tool and results in better outcomes than using angiography alone to assess narrowing of the coronary arteries. With FFR, the doctor threads a thin wire through the coronary artery and measures the loss of blood pressure across the narrowed area. To acquire an accurate measurement, the patient must be given adenosine, which is a drug that dilates the blood vessels during the procedure. This drug causes discomfort; patients describe having difficulty breathing or feeling as if someone is sitting on their chest. The drug also adds to the cost of the procedure and can have other rare but serious side effects. iFR (Instantaneous Wave-Free Ratio) is also based on coronary blood pressure measurements using a thin wire, but unlike FFR, it uses a mathematical algorithm to measure the pressure in the coronary artery only when the heart is relaxed and the coronary blood flow is high. As a result, a vasodilator drug is not needed. iFR has been validated in smaller trials and have been found to be equally good as FFR to detect ischemia, but larger randomized outcome trials are lacking. iFR-Swedeheart is a Scandinavian Registry-based Randomized Clinical Trial (RRCT) in which 2000 patients were randomized between iFR and FFR as strategies for performing assessment of narrowed coronary vessels. The primary composite endpoint at 12 months was all-cause death, non-fatal myocardial infarction, and unplanned revascularization. RRCT is a new trial design originating from Scandinavia using existing web-based national quality registries for online data entry, randomization and tracking of events. This allows for a very high inclusion rate and low costs to run clinical trials while ensuring robust data quality. (more…)
Author Interviews, Heart Disease, JACC / 19.03.2017 Interview with: Raffaele De Caterina MD, PhD Professor of Cardiology and Director of the University Cardiology Division 'G d'Annunzio' University in Chieti What is the background for this study? What are the main findings? Response: The widely used term “valvular atrial fibrillation” encompasses a variety of conditions in which atrial fibrillation and valvular heart disease coexist. Since most trials of the non-vitamin K antagonist oral anticoagulants (NOACs) have variably excluded “valvular atrial fibrillation”, in more or less restrictive terms, there has been uncertainty whether NOACs can be used in such varied conditions. While atrial fibrillation in the presence of a mechanical valve or rheumatic mitral stenosis has to be a true contraindication (unfavorable data with one NOAC in the former setting; no data in the latter setting), patients with valvular diseases such as mitral insufficiency, aortic stenosis, aortic insufficiency, or with the presence of a bioprosthesis, have been variably included in the phase III trials of NOACs, but had not been extensively and conclusively studied before. (more…)
Author Interviews, Heart Disease, Surgical Research / 19.03.2017 Interview with: Sung-Han Yoon MD Clinical Trials, Cardiology, Developmental Biology Cedars-Sinai Medical Center, Los Angeles What is the background for this study? What are the main findings? Response: Transcatheter aortic valve replacement (TAVR) has become the standard treatment in inoperable patients in high surgical risk patients with symptomatic severe aortic stenosis (AS). However, major randomized trials excluded congenital bicuspid AS due to its unique morphological features. The indication of TAVR is expanding into a younger population, in which the frequency of bicuspid AS is higher. Therefore, we will encounter TAVR for bicuspid AS more frequently. However, the experience of TAVR in bicuspid AS is limited to small series. Therefore, we aim to evaluate the clinical outcomes of TAVR in bicuspid AS and compare them to tricuspid AS. (more…)
Author Interviews, Heart Disease, Imperial College, Medical Imaging, Surgical Research / 19.03.2017 Interview with: Dr. Justin Davies PhD Senior Reserch Fellow and Hononary Consultant Cardiologist National Heart and Lung Institute, Imperial College London What is the background for this study? Response: We know from the FAME study that compared to angiography alone, FFR guided revascularization improves long-term clinical outcomes for our patients. Despite this, adoption of FFR into everyday clinical practice remains stubbornly low. One major factor for this is the need for adenosine (or other potent vasodilator medications) in order to perform an FFR measurement. Adenosine is expensive, unpleasant for the patient, time consuming and even potentially harmful. iFR is a newer coronary physiology index that does not require adenosine for its measurement. In the prospective, multi center, blinded DEFINE FLAIR study, 2492 patients were randomly assigned to either FFR guided revascularisation or iFR guided revascularization and followed up for a period of 1 year. (more…)
Author Interviews, Cannabis, Heart Disease, Stroke / 19.03.2017 Interview with: Aditi Kalla, MD Cardiology Research Fellow Einstein Medical Center Philadelphia What is the background for this study? Response: As of the recent 2016 election, decriminalization of cannabis passed in several states bringing the total count up to 28 states and D.C. where cannabis is now legal for medicinal and/or recreational purposes. From a physician’s perspective, it is rare that a drug has “hit the market” so to speak without undergoing clinical trials to determine safety and efficacy. Hence, we sought out to study if cannabis had any effects (positive or negative) on the cardiovascular system. (more…)
Author Interviews, Environmental Risks, Heart Disease, Medical Imaging / 19.03.2017 Interview with: Dr. Marco Valgimigli, MD, PhD Interventional Cardiology Sandro Pertini Hospital, ASL RM2, Rome, Italy What is the background for this study? What are the main findings? Response: Every year millions of people with coronary artery disease are treated worldwide with percutaneous coronary intervention (PCI). Radial access as compared to femoral access reduces bleeding and mortality in patients with acute coronary syndrome (ACS) undergoing invasive management. However, prior studies have raised concerns over the increased risk of radiation exposure for both patients and operators with radial instead of femoral access and it remains still unclear whether radial access increases the risk of operator or patient radiation exposure in contemporary practice when performed by expert operators. The MATRIX (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of angioX) trial is the largest randomized trial comparing radial versus femoral access in ACS patients undergoing invasive management. In this radiation sub-study (RAD-MATRIX), we collected fluoroscopy time and dose area product (DAP) and equipped radial operators consenting to participate with dedicated dosimeters, each wearing a thorax (primary endpoint), wrist and head (secondary endpoints) lithium fluoride thermo luminescent dosimeter, during study conduct to establish non-inferiority of radial versus femoral access. Among eighteen operators, performing 777 procedures in 767 patients, the non-inferiority primary endpoint was not achieved. Operator equivalent dose at the thorax was significantly higher with radial than femoral access. After normalization of operator radiation dose by fluoroscopy time or DAP, the difference remained significant. Radiation dose at wrist or head did not differ between radial and femoral access. Thorax operator dose did not differ in the right radial compared to the left radial access. In the overall MATRIX population, fluoroscopy time and DAP were higher with radial as compared to femoral access. (more…)