Collagen Biomarker Associated With Atrial Fibrillation and Heart Failure Risk

MedicalResearch.com Interview with:
Susana Ravassa PhD

Program of Cardiovascular Diseases, CIMA
University of Navarra, and IdiSNA
Navarra Institute for Health Research
Pamplona, Spain 

MedicalResearch.com: What is the background for this study?

Response: Atrial fibrillation (AF) is an evolving epidemic responsible for substantial morbidity, mortality and health-care expenditure. In particular, when AF and heart failure (HF) occur in combination, clinical evolution is particularly poor. Left atrial (LA) myocardial interstitial fibrosis (MIF) is the main structural lesion in AF and considered as the main factor responsible for the perpetuation of this pathology. In addition, it is known that MIF is associated with a lower effectiveness of the treatment of AF by pulmonary vein isolation with catheter ablation. Therefore, the identification of biomarkers related to MIF, as an affordable and minimally invasive approach, is of great interest to detect patients at risk of AF, as well as to monitor their response to the LA ablation therapy.

We had previously demonstrated that the deleterious impact of MIF in the heart is due to alterations in both the quality (i.e., extent of cross-linking among collagen fibrils and type of collagen fibers that determine their rigidity and resistance to degradation [collagen cross-linking or CCL]) and the quantity (i.e., extent of collagen fibers that occupy the myocardial tissue [collagen deposition or CD]) of fibrotic tissue. We have shown that certain circulating biomarkers related to collagen type I metabolism are associated with CCL and CD. On the one hand, the serum carboxy-terminal propeptide of procollagen type I (PICP), released during the conversion of procollagen type I into fibril-forming mature collagen type I, is directly correlated with myocardial CD.

On the other hand, the ratio of serum carboxy-terminal telopeptide of collagen type I to serum matrix metalloproteinase-1 (serum CITP:MMP-1 ratio) is inversely correlated with myocardial CCL, as the higher is the cross-linking among collagen type I fibrils the lower will be the cleavage of CITP by MMP-1 during the process of degradation of the fiber. Interestingly, we have previously reported that the combination of these biomarkers identifies patients with heart failure presenting with a complex pattern of MIF characterized by both increased CCL and CD (CCL+CD+) showing a higher risk of adverse clinical evolution as compared with heart failure  patients without this combination of biomarkers. As both increased CCL and CD have been found in the left atrial myocardium in patients with AF, we designed this investigation to explore whether the CCL+CD+ combination of biomarkers is associated with AF. Continue reading

TAVRcathAID Mobile App Facilitates Coronary Access Education After TAVR

MedicalResearch.com Interview with:

Annapoorna Kini, MDZena and Michael A Wiener Professor of MedicineDirector of the Cardiac Catheterization LaboratoryMount Sinai Heart at Mount Sinai Hospital

Dr. Kini

Annapoorna Kini, MD
Zena and Michael A Wiener Professor of Medicine
Director of the Cardiac Catheterization Laboratory
Mount Sinai Heart at Mount Sinai Hospital

MedicalResearch.com: What is the background for this study?  

  • Expanding indication and use of Transcatheter aortic valve replacement (TAVR) poses a unique problem of coronary access after valve implantation.
  • Troubleshooting tools and techniques have been published but are not available at the fingertips of the user at all the times.
  • We tried to address this unique problem with an innovative educational mobile application (app) called “TAVRcathAID”.

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Even with Controlled LDL-Cholesterol, PCI Stent Patients Have Residual Inflammatory Risk

MedicalResearch.com Interview with:

Dr. George Dangas MD PhDProfessor of Medicine, CardiologyMount Sinai Health System

Dr. Dangas

Dr. George Dangas MD PhD
Professor of Medicine, Cardiology
Mount Sinai Health System

MedicalResearch.com: What is the background for this study?

Response: Widespread use of statins targeted to decrease levels of low density lipoprotein cholesterol (LDL-C) below 70mg/dL are recommended by guidelines. However, residual cholesterol risk may only be one part of the residual risk equation. Indeed, Biological inflammation has long been known as a pathophysiological mechanism of atherosclerosis and the recent CANTOS trial opened new therapeutic perspective by demonstrating that inflammation modulation via selective interleukin-1β inhibition could result in improved diagnosis in patients with coronary artery disease.

However, the prevalence and impact of a residual inflammatory biological syndrome in patients with controlled cholesterol risk is unclear. Continue reading

Multiple Modifiable Risk Factors in Young Adults with Heart Attack

MedicalResearch.com Interview with:

Srikanth Yandrapalli, MD Chief Resident in Internal Medicine at New York Medical College at  Westchester Medical Center Program 

Dr. Yandrapalli

Srikanth Yandrapalli, MD
Chief Resident in Internal Medicine at New York Medical College at
Westchester Medical Center Program 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Risk factors play an important role in the development of and progression of coronary heart disease, thus necessitating strategies to address the leading modifiable risk factors to reduce the burden of coronary heart disease. Data are lacking regarding therecent temporal trends in the prevalence of these risk factors during a first AMI in US young adults.

In our study, we report that among young adults in the US with a first acute myocardial infarction, the prevalence rates of major modifiable risk factors were very high with over 90% of patients having at least 1 such risk factor. Significant sex and racial disparities were observed. Sex differences in the rates of certain  risk factors were clearly evident with males having higher rates of smoking, dyslipidemia, and drug abuse, whereas females had higher rates metabolic risk factors like diabetes mellitus, hypertension, and obesity. Sex differences in the rates of certain risk factors narrowed with increasing age and over time. Blacks had higher rates of hypertension, obesity, and drug abuse, Whites had higher rates of smoking, Hispanics had higher rates of diabetes mellitus and patients of Asian/Pacific Islander race had higher rates of dyslipidemia. Prevalence rates progressively increased between 2005 and 2015 except for dyslipidemia for which a decreasing trend was noted more recently. Continue reading

Less Than Six Hours of Sleep May Raise Risk of Heart Disease

MedicalResearch.com Interview with:

José M. Ordovás, PhD Director Nutrition and Genomics Professor Nutrition and Genetics            JM-USDA-HNRCA at Tufts University Boston, MA 02111

Dr. Ordovás

José M. Ordovás, PhD
Director Nutrition and Genomics
Professor Nutrition and Genetics
JM-USDA-HNRCA at Tufts University
Boston, MA 02111

MedicalResearch.com: What is the background for this study?

Response: The current knowledge supports the notion that poor sleep is associated with cardiovascular risk factors such as obesity, hypertension, and diabetes. Besides, there is some proof that poor sleep might be related to the development of atherosclerosis; however, this evidence has been provided by studies including few participants and, in general, with sleep disorders, such as sleep apnea. Our research has used state-of-the-art imaging technology to measure plaque buildup in the arteries, and objective measures of sleep quantity and quality in about 4000 participants of the PESA CNIC- Santander Study. Moreover, this is the first study to look at the multiterritory development of plaques versus other studies that looked exclusively at the coronary arteries. Therefore, this combination provides stronger evidence than previous studies about the risk of poor sleep on the development of atherosclerosis.

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Maternal Obesity Raises Risk of Congenital Heart Defects

MedicalResearch.com Interview with:

Martina Persson, M.D, PhD Karolinska Institutet

Dr. Persson

Martina Persson, M.D, PhD
Karolinska Institute

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: It is well known that maternal obesity increases risks of adverse fetal outcomes, including congenital malformations of the heart. However, it is unclear if maternal overweight and obesity associate with risks of specific and more complex congenital heart defects. We conducted a population-based cohort study in Sweden using data from several health registries. The study included more than 2 million live, singletons born between 1992-2012. Risks (prevalence rate ratios) of complex heart defects (Tetralogy of Fallot, transposition of the great arteries (TGA), atrial septal defects (ASD), aortic arch defects, and single ventricle heart) and several specific heart defects were estimated in infants to mothers with overweight and increasing degree of obesity.

We found that risks of aortic arch defects, ASD and patent ductus arteriosus (in term infants) increased with maternal obesity severity. On the other hand, we found no clear associations between maternal BMI and risks of several other complex and specific heart defects.  Continue reading

Staged vs One-Time Multivessel Revascularization in Multivessel CAD

MedicalResearch.com Interview with:
Peter Hu MD Cleveland ClinicPeter T. Hu MD
Department of Cardiology
Cleveland Clinic

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Among patients with blockages in multiple coronary vessels, we studied predictors and outcomes of having a staged versus one-time multivessel percutaneous coronary intervention. By “staged” we mean performing coronary intervention only on one vessel, letting the patient recover, and fixing the other blockages at a later date. We know that multivessel coronary artery disease is very common – present in up to 2/3 of patients who require coronary interventions. Previous studies in patients with STEMI (ST-elevation myocardial infarction) suggested that staged multivessel PCI was associated with lower risk of death compared with one-time multivessel revascularization. Outside of STEMI patients, very little data exist in a broader group of patients who undergo coronary interventions to multiple vessels.

In our study, we found an association between doing a staged PCI and lower long-term mortality benefit compared with fixing multiple blockages at once. What was surprising was there seemed to be a correlation with the degree of benefit from staged PCI based on the symptoms and signs the patient presented with.

The association with improved outcomes was strongest in patients with STEMI, followed by those with NSTEMI, unstable angina, and stable angina, respectively. We also found that the decision to perform staged PCI was driven by patient and procedural characteristics, as well as other unmeasured site variation.  Continue reading

Comparison of the Evolut R™TAVR Valve with the Evolut PRO™

MedicalResearch.com Interview with:

Evolut TAVR PlatformDr. Shazia Afzal MD
University Hospital DüsseldorfMedical FacultyDivision of Cardiology, Pulmonology and Vascular Medicine, Düsseldorf, Germany

MedicalResearch.com: What is the background for this study?

Response: Since its introduction in 2002, transcatheter aortic valve replacement (TAVR) emerged to an increasingly important interventional procedure in the field of structural heart disease. Widespread use in Europe, the USA and Canada lead to continuous technological development and improved patient’s safety, procedural success and clinical outcome.

In 08/2017 one of the market leaders introduced its latest generation valve model -the CoreValve Evolut PROTM– which was especially designed to mitigate paravalvular leakage after valve deployment. We conducted the first prospective study which directly compares the Evolut PROTM with its direct predecessor the Evolut RTM as a head-to-head analysis especially focusing on hemodynamic performance and clinical outcome in a real-world setting. To ensure comparability between groups, we performed propensity score matching with special interest in CT-derived data to guarantee equitable anatomical conditions.

Since both valves are on the market but sold at different prices the pivotal question is whether the Evolut PROTM reaches its target. In a highly budget restricted health care system with limited refunding cost-effectiveness evolves to a substantial discussion point in daily clinical practice. Our results may not be marketing friendly but we think of relevance for the interventional community.  Continue reading

Study Finds Medicare Readmissions Penalties Have Not Increased Mortality from Heart Failure

MedicalResearch.com Interview with:

Teryl K. Nuckols, MD Vice Chair, Clinical Research Director, Division of General Internal Medicine Cedars Sinai Los Angeles, California

Dr. Nuckols

Teryl K. Nuckols, MD
Vice Chair, Clinical Research
Director, Division of General Internal Medicine
Cedars Sinai
Los Angeles, California

MedicalResearch.com: What is the background for this study?

Response: The Medicare Hospital Readmissions Reduction Program (HRRP) penalizes hospitals with increased 30-day readmission rates among seniors admitted with heart failure (HF).  Heart failure readmission rates declined markedly following the implementation of this policy. Two facts have raised concerns about whether the HRRP might have also inadvertently increased 30-day heart failure mortality rates.

First, before the policy was implemented, hospitals with higher heart failure readmission rates had lower 30-day HF mortality rates, suggesting that readmissions are often necessary and beneficial in this population. Second, 30-day HF mortality rose nationally after the HRRP was implemented, and the timing of the increase has suggested a possible link to the policy.

Are hospitals turning patients away, putting them at risk of death, or is the increase in heart failure mortality just a coincidence? To answer this question, we compared trends in 30-day HF mortality rates between penalized hospitals and non-penalized hospitals because 30-day HF readmissions declined much more at hospitals subject to penalties under this policy.

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Gene Variants Can Alter Glucose Absorption and Cardiometabolic Risks

MedicalResearch.com Interview with:

Scott David Solomon, MD Director, Noninvasive Cardiology Professor, Harvard Medical School Brigham and Women's Hospital

Dr. Solomon

Scott David Solomon, MD
Director, Noninvasive Cardiology
Professor, Harvard Medical School
Brigham and Women’s Hospital 

MedicalResearch.com: What is the background for this study? What are the main findings? 

Response: The sodium glucose transport proteins are known to be important in regulating uptake of glucose. SGLT-1 is predominantly located in the gut and is responsible for uptake of glucose and galactose in the small intestine. Individuals born with severe mutations of this gene have severe malabsorption syndrome.

We looked at genetic variants that lead to reduced function of the protein, but not complete loss of function, in a large cohort of individuals in the NIH funded Atherosclerosis Risk in Communities Study. We found that those with mutations in the gene had reduced glucose uptake, as measured by an oral glucose tolerance test, as well as less obesity, diabetes, heart failure and death.

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New Biomarkers Predictive of Atrial Fibrillation Outcome

MedicalResearch.com Interview with:

John D Horowitz, MBBS, PhD. Director of Cardiology/Clinical Pharmacology Queen Elizabeth Hospital University of Adelaide Australia

Dr. Horowitz

John D Horowitz, MBBS, PhD.
Director of Cardiology/Clinical Pharmacology
Queen Elizabeth Hospital
University of Adelaide
Australia 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response:  Atrial fibrillation (AF) describes intermittent or permanent episodes of irregular pulse, due to rapid electrical activity within the atria (filling chambers) of the heart. During AF, the atria quiver, rather than contract, and the response of the ventricles is often rapid, resulting in palpitations and an increased risk of development of heart failure. AF may occur at any age, but is most common in ageing patients (typically over 75 years). The primary importance of AF is that it markedly increases the risk of thrombus formation in the atrium, with the resultant problem that these thrombi may dislodge (embolise), and commonly block arteries in the brain, causing strokes. Hence patients with AF are usually treated with anticoagulants.

Although AF often occurs in patients with prior damage to their hearts and atrial distension, there has been evidence for about the past 8 years that AF also is caused, at least in part, by inflammatory changes: two components have been identified as possible causes for this inflammation: lack of nitric oxide (NO) effect[ NO is  an anti-inflammatory chemical formed by all tissues in the body],  and excess activity of the pro-inflammatory enzyme myeloperoxidase (MPO).  High concentrations of ADMA, which inhibits NO formation, may result from effects of MPO on tissues. SDMA, which is closely related to ADMA, also exerts pro-inflammatory effects and tends to suppress NO formation.

The currently reported study began with the design of the ARISTOTLE trial, an investigation of the (then) novel anticoagulant apixaban as an alternative to warfarin therapy, as a means of preventing strokes in patients with AF. It was elected to perform a substudy to investigate the potential role of ADMA and SDMA as modulators of risk in patients with atrial fibrillation.

This substudy, performed in just over 5000 patients from the ARISTOTLE trial, essentially asked two questions:

(1) There are several indices of stroke risk in patients with atrial fibrillation, such as the CHADS2 score. These all rely on patient characteristics (eg age, presence of diabetes) rather than chemical changes. We postulated that there would be a direct relationship between clinically based risk scores and ADMA/SDMA concentrations.

(2) More ambitiously, we postulated that ADMA and SDMA concentrations would represent INDEPENDENT risk markers for major adverse effects in atrial fibrillation patients on anticoagulant treatment, namely stroke, major bleeding and risk of mortality. 

ADMA/SDMA concentrations were determined in Adelaide, Australia, while statistical analyses were performed in Uppsala, Sweden.

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Heart Failure Medications Underutilized in Medical Practice

MedicalResearch.com Interview with:

Dr. Greene

Stephen J. Greene, MD
Fellow, Division of Cardiology
Duke University Medical Center
Durham, NC, USA

Stephen J. Greene, MD Fellow, Division of Cardiology Duke University Medical Center Durham, NC, USA

Dr. Fonarow

Gregg C. Fonarow, MD, FACC, FAHA, FHFSA
Eliot Corday Professor of Cardiovascular Medicine and Science
UCLA

 


MedicalResearch.com: What is the background for this study?

Response: Heart failure is a very common medical condition impacting roughly 6 million men and women in the United States, and associated with impaired quality of life, frequent hospitalizations, and high rates of death.

There are over 300,000 deaths each year in the US among patients with heart failure. Half of heart failure patients have heart failure because of a weak heart muscle where the heart cannot eject a normal amount of blood with each heartbeat, a term called “reduced ejection fraction.” Fortunately, there are multiple medications proven in large clinical trials to make people with heart failure with reduced ejection fraction live longer and feel better.

We also have target doses for these medications, which are the doses used in the trials where the medication proved its benefit. These medications and the target doses are strongly recommended in professional guidelines to improve patient outcomes.

To make sure patients have the best outcomes possible, it is important that we work to get patients on these proven medications if at all possible. Unfortunately, prior research has suggested that many patients eligible for these medications in regular outpatient practice do not receive them.

Most of this research is several years old, and there have been a lot of efforts to improve the quality of heart failure care in the meantime. In our study, we wanted to see if there have been improvements in the use and dosing of proven heart failure medications in modern-day practice. We also wanted to determine which patient factors were associated with not receiving a medication, or receiving the medication at a below target dose.

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Patients Who Discharge From Hospital Against Medical Advice Have Double Rate of Readmission

MedicalResearch.com Interview with:

Professor Mamas Mamas (BM BCh, MA, DPhil, MRCP) Professor of Cardiology at Keele University and an Honorary Professor of Cardiology at the University of Manchester

Prof. Mamas

Professor Mamas Mamas (BM BCh, MA, DPhil, MRCP)
Professor of Cardiology at Keele University and an
Honorary Professor of Cardiology at the University of Manchester

MedicalResearch.com: What is the background for this study?

Response: Discharge against medical advice occurs in 1 to 2% of all medical admissions but little / no data around how frequently this occurs in the context of PCI or the outcomes associated with such a course of action. We undertook this study to understand both how commonly discharge against medical advice occurs, the types of patients it occurs in and outcomes in terms of both readmission rates and causes of readmisison.   Continue reading

Stress Echocardiography vs Coronary CT To Evaluate Chest Pain in ER

MedicalResearch.com Interview with:

Jeffrey M. Levsky, M.D., Ph.D. Associate Professor, Department of Radiology Associate Professor, Department of Medicine (Cardiology) Albert Einstein College of Medicine Montefiore Medical Center 

Dr. Levsky

Jeffrey M. Levsky, M.D., Ph.D.
Associate Professor, Department of Radiology
Associate Professor, Department of Medicine (Cardiology)
Albert Einstein College of Medicine
Montefiore Medical Center

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Millions of Americans are evaluated each year for acute chest pain in the Emergency Department.  There are multiple modalities that can be used to triage these patients and there have only been a few studies comparing different imaging methods.

We chose to study Stress Echocardiography and Coronary CT Angiography, two exams that have not been compared directly in this population.  We found that Stress Echocardiography was able to discharge a higher proportion of patients in a shorter amount of time as compared to Coronary CTA.  Continue reading

Fewer Re-infarctions With hs Troponin To Assess Heart Attacks

MedicalResearch.com Interview with:

Martin J Holzmann MD, PhD

Dr. Holzmann

Martin J Holzmann MD, PhD
Functional Area of Emergency Medicine
Department of Internal Medicine,
Solna, Karolinska Institutet
Stockholm, Sweden

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We wanted to investigate how the introduction of the new high-sensitivity cardiac troponin T (hs-cTnT) assay affected incidence of myocardial infarction (MI) use of coronary angiography, cardiac revascularizations, and prognosis in patients with myocardial infarction.

We found that the incidence of MI increased by approximately 5%, with no change in mortality, but with an 11% reduced risk of reinfarctions, and a small increase in coronary angiographies, and cardiac revascularizations by 16%, and 13%, respectively.  Continue reading

Think Vitamin Supplements Improve Your Heart Health? Think Again!

MedicalResearch.com Interview with:
“Pills Vitamins Macro April 22, 2012 4” by Steven Depolo is licensed under CC BY 2.0David J.A. Jenkins, MD, PhD, DSc
Professor and Canada Research Chair in Nutrition and Metabolism
Department of Nutritional Sciences
University of Toronto 

MedicalResearch.com: What is the background for this study?

Response: The study was requested by the editor of JACC (Dr. Valentin Fuster) due to the widespread use of vitamin and mineral supplementation by the public and the requirement to know if there were any benefits or harms for cardiovascular disease.

Our study was a follow-up to the US Preventive Services Task Force 2013 recommendations.

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Silent MI Before Acute Heart Attack Can Be Poor Prognostic Indicator

MedicalResearch.com Interview with:

Robin Nijveldt  MD PhD FESC Radboudumc Department of Cardiology The Netherlands

Dr. Nijveldt

Robin Nijveldt  MD PhD FESC
Radboudumc, Department of Cardiology and
VU University Medical Center
Department of cardiology
the Netherlands

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We know from previous studies that patients with unrecognized myocardial infarcts have worse prognosis than people without infarcts.

It was currently unknown in how many patients presenting with a first acute myocardial infarction had previous unrecognized MI, and if so, if this is still a prognostic marker on long term follow-up.

In this paper we studied 405 patients from 2 academic hospitals in the Netherlands, with an average follow-up duration of 6.8 years. We found that silent MI was present in 8.2% of patients presenting with first acute MI, and that silent MI is a strong and independent predictor for adverse long-term clinical outcome such as death (HR 3.69) or the composite end point of death, reinfarction, ischemic stroke, or CABG (HR 3.05). Additionally, it appears that ECG is of limited value to detect silent MI, since our study did not reveal an association with long-term clinical outcome.

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Do Metabolically Healthy Obese Stay Healthy?

MedicalResearch.com Interview with:

Morgana Mongraw-Chaffin, PhD MPH Wake Forest School of Medicine North Carolina

Dr. Mongraw-Chaffin

Morgana Mongraw-Chaffin, PhD MPH
Wake Forest School of Medicine
North Carolina

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: While some large studies and meta-analyses of this topic suggest that metabolically healthy obesity (MHO) is not a benign condition, discrepancies persist in the results of individual studies. Lack of a clear explanation for these differences drives the continuing controversy over whether MHO is a useful tool for risk stratification or an intermediate condition on the pathway to cardiometabolic risk.

In the Multi-Ethnic Study of Atherosclerosis (MESA), we found that 48% of those with metabolically healthy obesity transitioned to unhealthy obesity by the end of follow-up. Those who transitioned had higher odds of developing cardiovascular disease compared to those who maintained normal weight. We further found that earlier transition from MHO to unhealthy obesity was associated with higher odds.

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How a PET Can Save Your Heart

MedicalResearch.com Interview with:

Dr-W-Robert-Taylor

Dr. Taylor

Robert Taylor, MD, PhD
Marcus Chair in Vascular Medicine
Executive Vice Chair, Medicine
Director, Division of Cardiology
Professor of Medicine and
Biomedical Engineering
Emory University School of Medicine

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The early identification and localization of bacterial infections is a critical step for initiating effective treatment.   This is particularly challenging in the setting of infections associated with implanted medical devices.  We have developed a highly specific probe for bacteria that is based on the fact that bacteria have a specific system for taking up maltodextrins which are polysaccharides that mammalian cells cannot take up directly.  We can label this probe with either a fluorescent of radioactive tag that allows visualization of the bacteria.

In the current article, we have used an animal model of implantable cardiac devices to demonstrate that our probe is very specific and sensitive for detecting bacterial infections.  It is worth noting that these are subclinical infections that could not be detected by any other means except for surgical removal.

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Medicaid Expansion Improved Access to Cardiac Care Without Diminishing Outcomes

MedicalResearch.com Interview with:

Donald Likosky, Ph.D., M.S. Associate Professor Head of the Section of Health Services Research and Quality Department of Cardiac Surgery. University of Michigan

Dr. Likosky

Donald Likosky, Ph.D., M.S.
Associate Professor
Head of the Section of Health Services Research and Quality
Department of Cardiac Surgery.
University of Michigan

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Michigan was one of several states to expand Medicaid. Current evaluations of the Michigan Medicaid expansion program have noted increases in primary care services and health risk assessments, but less work has evaluated its role within a specialty service line. There has been concern among some that Medicaid patients, who have traditionally lacked access to preventive services, may be at high risk for poor clinical outcomes if provided increased access to cardiovascular interventions.

Using data from two physician-led quality collaboratives, we evaluated the volume and outcomes of percutaneous coronary interventions and coronary artery bypass grafting 24mos before and 24mos after expansion. We noted large-scale increased access to both percutaneous coronary interventions (44.5% increase) and coronary artery bypass grafting (103.8% increase) among patients with Medicaid insurance. There was a decrease in access for patients with private insurance in both cohorts. Nonetheless, outcomes (clinical and resource utilization) were not adversely impacted by expansion.  Continue reading

Readmissions After Stent Surgery Common and Often Due to Co-Morbid Disease

MedicalResearch.com Interview with:

“Open Stent” by Lenore Edman is licensed under CC BY 2.0

Example of Open Cardiac Stent

Chun Shing Kwok, MBBS, MSc, BSc, MRCP(UK)
Clinical Lecturer in Cardiology and Specialist Registrar in Cardiology
Keele University & Royal Stoke University Hospital Guy Hilton Research 

MedicalResearch.com: What is the background for this study?

Response: Percutaneous coronary intervention (PCI) is a common revascularization modality in the treatment for coronary heart disease and the mortality rate after this procedure is low. Improved survival after PCI procedures has led to a growing population at risk of readmissions.  Early unplanned readmissions are important because they are a burden to patients, the local health care economy and it also serves as a quality of care indicator.

MedicalResearch.com: What are the main findings?

Response: Our analysis of 833,344 PCI procedures in the United States demonstrates that unplanned readmissions within 30 days of the index PCI are common (9.3%). The mean total hospital cost was higher for patients who were readmitted compared with those not readmitted ($37,524 vs $23,211). The majority of readmissions within 30 days are noncardiac (56%), with female sex, chronic kidney disease, liver failure, atrial fibrillation, increasing comorbidity burden, and discharge location among the strongest predictors of unplanned 30-day readmission. Patients who experienced an unplanned readmission for noncardiac reasons tended to be younger, with more comorbidities, including alcohol misuse, cancer, and dementia, whereas patients who are readmitted for cardiac reasons are more likely to have in-hospital complications at their index PCI event. 

MedicalResearch.com: What should readers take away from your report?

Response: Our results suggest that 30-day readmissions in the United States is common and comorbid illnesses and places of discharge are important factors that influence readmissions. There are important financial consequences of such readmissions, and further strategies to reduce the prevalence should be explored. 

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: Future work should explore if optimization of the management of any comorbid condition during a patient’s index admission for PCI and outreach programs to patients discharged to short-term hospitals, other institutions, and care homes may reduce early readmissions. 

Disclosures: Financial support was provided by the North Staffs Heart Committee. This work was conducted as a part of Dr. Kwok’s PhD research, which was supported by Biosensors International. 

Citations: 

Kwok CS, Rao SV, Potts JE, et al. Burden of 30-day readmissions after percutaneous coronary intervention in 833,344 patients in the United States: predictors, causes, and cost insights from the Nationwide Readmission Database. J Am Coll Cardiol Intv. 2018;Epub ahead of print.

Kalra A, Shishehbor MH, Simon DI. Percutaneous coronary intervention readmissions: where are the solutions? J Am Coll Cardiol Intv. 2018;Epub ahead of print.

 

 

 

 

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Should Digoxin Still Be Used in Patients With Atrial Fibrillation?

MedicalResearch.com Interview with:

Renato D. Lopes MD, MHS, PhD Duke University Medical Center Duke Clinical Research Institute Durham, NC 27705

Dr. Renato Lopes

Renato D. Lopes MD, MHS, PhD
Professor of Medicine, Division of Cardiology
Duke University Medical Center
Duke Clinical Research Institute
Terrace Level, Durham, NC 27705

MedicalResearch.com: What is the background for this study?

1-      Digoxin is used in ≈ 30% of patients with atrial fibrillation (AF) worldwide, despite the lack of randomized clinical trials to assess its efficacy and safety in this setting.
2-      Current AF guidelines recommend digoxin for rate control in patients with AF with and without heart failure (HF).
3-      There are no specific recommendations about serum digoxin concentration monitoring in the atrial fibrillation guidelines.

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Sustaining Physical Activity With Age Decreases All-Cause Mortality Risk

MedicalResearch.com Interview with:
“physical-activity-120112-M-2021D-019” by MilitaryHealth is licensed under CC BY 2.0
Trine Moholdt, PhD
Research Fellow
Department of Circulation and Medical Imaging | Exercise, Cardiometabolic Health and Reproduction
Norwegian University of Science and Technology

MedicalResearch.com: What is the background for this study?  

Response: Although obese individuals have an increased risk of cardiovascular disease, evidence from many observational studies shows that in those who already have cardiovascular disease, being overweight or obese is associated with lower risk of mortality compared to their normal weight counterparts.

This phenomenon is often called the “obesity paradox”. Recently we observed that in individuals who have a high physical activity level, there is no such obesity paradox and body mass index did not associate with survival time in those who with high physical activity (Moholdt et al, American Journal of Medicine, 2017).  Continue reading

Coronary Bypass Preferable To Stenting For Diabetes With LV Dysfunction

MedicalResearch.com 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

MedicalResearch.com: 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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Some Heart Attack Patients Without AFib Still at Increased Risk of Stroke

MedicalResearch.com 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

MedicalResearch.com: 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

MedicalResearch.com Interview with:
“Siren” by Michael Pereckas is licensed under CC BY 2.0Professor Dr. med. Thomas Muenzel

Universitätsmedizin Mainz
Zentrum für Kardiologie, Kardiologie I

MedicalResearch.com: 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

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

MedicalResearch.com 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

MedicalResearch.com: 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%.

MedicalResearch.com: 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. 

MedicalResearch.com: 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. 

Citations:

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

MedicalResearch.com Interview with:

The PlaqueTec Liquid Biopsy System™ (LBS)

The PlaqueTec Liquid Biopsy System™ (LBS)

Nick West MA MD FRCP FESC FACC
Chief Medical Officer
PlaqueTec Ltd

MedicalResearch.com: 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

Children with Heart Failure from Dilated Cardiomyopathy are Surviving Longer in the Most Recent Era

This file was derived from Blausen 0165 Cardiomyopathy Dilated.png

Structural categories of cardiomyopathy Wikipedia image

MedicalResearch.com Interview with:
Rakesh K. Singh MD, MS

Department of Pediatrics, University of California–San Diego and
Rady Children’s Hospital
San Diego, California

Steven E. Lipshultz MD
Department of Pediatrics
Wayne State University School of Medicine and
Children’s Hospital of Michigan
Detroit, Michigan 

MedicalResearch.com: What is the background for this study?

Response: Dilated cardiomyopathy (DCM) is a disease characterized by dilation and dysfunction of the left ventricle of the heart. While DCM is a relatively rare disease in children, nearly 40% of children with DCM require a heart transplant or die within 2 years of diagnosis. Heart transplantation has improved the outcomes of children with DCM over the last 3 decades, but is limited by donor heart availability. Newer therapies, including advanced ICU care and artificial heart machines, are now being used to treat children with DCM.

This study published in the November 28, 2017 issue of the Journal of American College of Cardiology (JACC) sought to determine whether more children with DCM were surviving longer in the more recent era. Specifically, it investigated whether children with DCM were surviving longer without the need for heart transplantation. Rakesh Singh, MD is the first author and an Associate Professor of Pediatrics at UC San Diego/Rady Children’s Hospital, while the senior author is Steven Lipshultz, MD, Professor at Wayne State University School of Medicine/Detroit Medical Center’s Children’s Hospital of Michigan and Director of Children’s Research Center of Michigan.

The Pediatric Cardiomyopathy Registry (PCMR) is a National Heart, Lung, and Blood Institute (NHLBI) sponsored registry from 98 pediatric centers in United States and Canada created to study the outcomes of children with various heart muscle disorders known as cardiomyopathies. For this study, outcomes of 1,199 children diagnosed with DCM from 1990-1999 were compared with 754 children diagnosed with DCM from 2000-2009.

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NOACs For Atrial Fib Anticoagulation May Have Lower Risk of Kidney Side Effects

Atrial Fibrillation - Wikipedia image

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

Interview with:
Dr Xiaoxi Yao PhD
Assistant Professor
Researcher
Mayo Clinic

What is the background for this study? What are the main findings?

Response: Lifelong oral anticoagulation, either with warfarin or a non-vitamin K antagonist oral anticoagulant (NOAC), is indicated for stroke prevention in most patients with atrial fibrillation (AF). Emerging evidence suggests that NOACs may be associated with better renal outcomes than warfarin.

The study found renal function decline is common among patients with atrial fibrillation treated with oral anticoagulants. NOACs, particularly dabigatran and rivaroxaban, may be associated with lower risks of adverse renal outcomes than warfarin.

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