Prior History Of Cardiac Disease Research Articles

382. CARDIAC REMODELING IN PATIENTS WITH ESOPHAGEAL CANCER-ASSOCIATED CACHEXIA

Abstract Background Cachexia is a debilitating wasting syndrome affecting 60% of patients with esophageal cancer, regardless of stage. While cachexia is usually characterized by skeletal muscle atrophy, systemic inflammation and aberrant endocrine signaling is thought to also precipitate cardiac atrophy and dysfunction. Indeed, cachectic patients often display clinical signs of heart failure. In this initial study, we sought to characterize the relationships between weight loss, body composition and parameters of cardiac structure and function. Methods We performed a retrospective review of patients that received esophagectomy between 2015 and 2020 at our facility. Male patients with pre-operative transthoracic echocardiogram studies and no prior history of cardiac disease were included. Body composition was measured using PET/CT scans. Patients were classified as having cachexia if having more than 8% loss in body mass in the six months before surgery. Appropriate t-tests and correlational analyses were performed after assessing normality. A p-value less than 0.05 was considered statistically significant. Results Mean age was 65.8 ± 7.54 years. Mean six-month weight loss was 13.2%, and 65.4% of patients were classified as having cachexia. Patients with cachexia tended to have lower left ventricular mass (135 ± 7.38 g v. 148 ± 7.53 g, p = 0.2) and significantly lower left atrial diameter (3.32 ± 0.441 cm v. 4.47 ± 0.515 cm, p = 0.0261). Curiously, pre-operative weight loss positively correlated with left ventricular internal diameter end systole (R = 0.4521, p = 0.0204) and negatively correlated with diastolic blood pressure (R = -0.4102, p = 0.0417). When compared to segmented PET/CT scans, patients with increased deposition of adipose to muscle—a sign of pathologic remodeling—also had decreased left atrial diameter (R = 0.6497, p = 0.0222). Conclusions Various measures of heart structure and function are altered in cachectic patients with esophageal cancer. Patients were more weight loss have reduced left atrial and increased left ventricular diameters. These findings suggest that cardiac structure may dynamically change in response to cachexia. In summary, there is a profound need to better characterize the pathology of cardiac atrophy and dysfunction in patients with cachexia.

Radiation Dose, Technique and Use of Brain Radiation on Overall Survival in Patients with Limited-Stage Small Cell Lung Cancer

<h3>Purpose/Objective(s)</h3> The standard of care for limited-stage small cell lung cancer (LS-SCLC) currently involves concurrent chemoradiation +/- prophylactic cranial irradiation (PCI). Previous research has presented conflicting data regarding the optimal radiation therapy (RT) technique, RT dosage, and impact of brain RT on long term overall survival (OS). This study aimed to explore prognostic factors of OS in LS-SCLC cancer patients using a population-based cohort. <h3>Materials/Methods</h3> Data on all patients diagnosed with LS-SCLC in Ontario, Canada from 2005-2017 was obtained using the Institute for Clinical Evaluative Sciences (IC/ES) Data and Analytic Services. Eligible patients received curative intent chemoradiation, and OS was estimated from a landmark date of 6 months post-diagnosis to avoid survivor bias. Kaplan-Meier methods and Cox regression were used to estimate OS and explore differences between RT dose (40-49, 50-59, 60+ Gy), RT technique (3DCRT, IMRT, VMAT), and use of brain RT (PCI – 25 Gy, whole brain RT – 20 or 30 Gy, other brain RT, no brain RT). Multivariate analyses adjusted for sex, age, income quintile, Charlson comorbidity index, disease stage, prior history of cardiac disease, brain RT dose, and laterality. <h3>Results</h3> A total of 1360 LS-SCLC patients who received chemoradiation were included. Median OS (95% CI) was 18.1 months (16.6-19.4). Higher RT dose had significantly improved OS when compared to 40-49 Gy on univariate analysis (HR=0.83, 0.71-0.95, 60+ Gy), however, this did not persist when adjusting for other prognostic factors on multivariate analysis (HR=0.90, 0.77-1.06, 60+ Gy). The use of whole brain RT was associated with worse OS on both univariate (HR=1.47, 1.24-1.74) and multivariate (HR=1.42, 1.18-1.70) analyses. OS (95% CI) at 5-years for RT dose were 40-49 Gy: 16% (13-19%), 50-59 Gy: 23% (18-29), and 60+ Gy: 20% (16-25). For RT technique, OS (95% CI) at 5-years were 3DCRT: 19% (13-22), IMRT: 18% (13-23), and VMAT: 12% (4-25). Multivariate analyses demonstrated that male sex (HR=1.36, 1.20-1.55), more advanced stage disease (HR=1.35/1.94/3.08/1.67 for stage 2/3/4/Unknown vs 1), and older age were prognostic for worse OS. <h3>Conclusion</h3> Analyses of population-based data demonstrated that male sex, older age, and more advanced disease stage were notable predictors of OS in LS-SCLC. RT dose, when adjusting for other important prognostic variables did not predict for improved OS. However, use of whole brain RT (versus PCI or no PCI) was associated with worse OS. Use of PCI versus no PCI did not influence survival in this cohort, nor did RT technique.

Massive Hemorrhage Due to Aortoesoghageal Fistula in an 11-Months-Old Infant: A Case Report

Aortoesophageal Fistula (AEF) with no prior history of cardiac disease or trauma is an uncommon but a mortal cause of Upper Gastro Intestinal Bleeding (UGIB) in children.&#x0D; In pediatric patients, AEF is mainly due to a congenital cardiac or vascular anomaly or foreign body ingestion. There are surgical, endoscopic, and interventional radiological treatment options; however, definitive treatment is surgical intervention. Because of the rapid and devastating course, diagnosis and treatment decision should be made quickly.&#x0D; In this article, we report a case of an 11-months-old infant who presented with hematemesis due to a primary aortoesophageal fistula. The patient was transported to the operating theater for an emergency endoscopy. He suffered massive hematemesis in the operating room and an emergency laparotomy was performed but no source of bleeding was detected. An undiagnosed AEF was found and repaired during a left thoracotomy. Despite massive volume resuscitation, the patient passed away four hours later in the PICU. The etiology of the fistula remains unknown.

Could Steroids Cause Dysrhythmia in COVID-19 Patients? A Case Report

Aim: Steroid-induced dysrhythmia is a rare but severe side effect.&#x0D; Presentation of Case: After 24-48 hours of corticosteroid administration, bradyarrhythmia was detected in our three COVID-19 patients (a 38 and 67-year-old female and a 57-year-old male) who had no prior medical history of cardiac disease. Bradyarrhythmia improved following discontinuation of corticosteroids.&#x0D; Discussion: Cardiac dysrhythmia is a rare side effect for steroids especially in Iranian patients. Our patients had no prior history of cardiac disease, and sinus bradycardia was observed while receiving intravenous methylprednisolone or dexamethasone&#x0D; Conclusion: This side effect can occur with any corticosteroid, and all patients receiving high doses of corticosteroids, even for a brief period, should be closely monitored.

C43 A CASE REPORT OF A GIANT RIGHT CORONARY ARTERY ANEURYSM: ROLE OF CONTRAST ECHOCARDIOGRAPHY

Abstract A giant coronary aneurysm is rare entity and it is defined if the diameter is 4–fold greater the reference vessel diameter or if it is &amp;gt; 20 mm in diameter. We report the case of a 73–years–old man without prior history of cardiac disease, admitted in Emergency Department for abdominal pain with normal ECG. Abdominal CT scan showed no pathological findings. At thoracic level it was reported a suspected pericardial cyst (75x80 mm), with partial compression of right chambers (Fig. 1). Echocardiography confirmed the presence of a giant round cystic–appearance lesion characterized by the presence of an anechoic space with internal echogenic swirling flow pattern at the level of right atrioventricular groove with mild compressive effect on right chambers. (Fig. 2). The color Doppler mode showed a faint signal, without a clear evidence of flow origin. A bubble test with agitated saline contrast medium injected through antecubital vein, shows no evidence of contrast uptake by the mass. In order to better characterize the lesion, we use echocardiographic contrast agent (SonoVue®), which showed a clear pattern of blood flow inside the mass with a probable origin at a very limited region (Fig. 2a–2b). At that level it was also possible to sample an ECG–synchronized systo–diastolic pulse–wave (PW)–Doppler pattern (peak velocity 125 cm/s), typical for a coronary artery flow. According to these echocardiographic findings, we supposed a giant right coronary aneurysm. Coronary Computed Tomography Angiography with 3D reconstruction showed a giant aneurysm of the right coronary artery at mid–level, preceded by a mild aneurysm of the proximal tract and two small aneurysms of the circumflex artery and diffuse atherosclerosis diseases with significant stenosis on mid left anterior descending artery (LAD). The coronary angiography confirmed the presence of the giant aneurysm in mild tract of right coronary artery preceded by a small one in the proximal tract andthe two small aneurysm of the circumflex artery and a critical stenosis of mid tract of LAD. The patient underwent surgical treatment of the aneurysm and coronary artery bypass graft (Fig. 3). Computed Tomography Coronary Angiography is the best method for coronary artery anatomy and coronary abnormalities. In case of giant coronary abnormalities, the use of echo contrast agent provides further important information about perfusion and/or flow assessment and it helped to clarify the diagnosis.

Long-Lasting Myocardial and Skeletal Muscle Damage Evidenced by Serial CMR During the First Year in COVID-19 Patients From the First Wave.

IntroductionThis observational CMR study aims to characterize left-ventricular (LV) damage, which may be specifically attributed to COVID-19 and is distant in time from the acute phase, through serial CMR performed during the first year in patients with no prior cardiac disease.MethodsThis study included consecutive patients without any prior history of cardiac disease but with a peak troponin-Ic > 50 ng/ml at the time of the first COVID-wave. All had a CMR in the first months after the acute phase, and some had an additional CMR at the end of the first year to monitor LV function, remodeling, and abnormalities evocative of myositis and myocarditis - i.e., increased T1/T2 relaxation times, increased extracellular volume (ECV), and delayed contrast enhancement.ResultsNineteen consecutively admitted COVID-19 patients (17 men, median age 66 [57–71] years) were included. Eight (42%) had hypertension, six (32%) were obese, and 16 (84%) had suffered an acute respiratory distress syndrome. The 1st CMR, recorded at a median 3.2 [interquartile range: 2.6–3.9] months from the troponin peak, showed (1) LV concentric remodeling in 12 patients (63%), (2) myocardial tissue abnormalities in 11 (58%), including 9 increased myocardial ECVs, and (3) 14 (74%) increased ECVs from shoulder skeletal muscles. The 2nd CMR, obtained at 11.1 [11.0–11.7] months from the troponin peak in 13 patients, showed unchanged LV function and remodeling but a return to normal or below the normal range for all ECVs of the myocardium and skeletal muscles.ConclusionMany patients with no history of cardiac disease but for whom an increase in blood troponin-Ic ascertained COVID-19 induced myocardial damage exhibited signs of persistent extracellular edema at a median 3-months from the troponin peak, affecting the myocardium and skeletal muscles, which resolved within a one-year time frame. Associations with long-COVID symptoms need to be investigated on a larger scale now.Clinical Trial RegistrationNCT04753762 on the ClinicalTrials.gov site.

Myocarditis as a rare, yet serious adverse event associated with immune checkpoint inhibitors in patients with non-small cell lung cancer: Case series from a large community-based cancer center.

e21047 Background: Patients (pts) with lung cancer and other cancers treated with immune checkpoint inhibitors (ICI) may experience immune related adverse events (irAE). These can present with variable severity and with single- or multi-organ involvement including pneumonitis, colitis, hepatitis, and myocarditis/pericarditis. The incidence of myocarditis has been reported between 0.06% and 2.4% and is associated with a high mortality (25% to 50%). This retrospective review of real-world data (RWD) investigates myocarditis as a high-grade adverse event in pts with lung cancer treated with ICIs. Methods: Pts were identified and characterized using RWD in the Syapse Learning Health Network platform from 2010 to 2020 at Advocate Aurora Health Care. Eligible pts included: ≥18 years old; histologically confirmed NSCLC; and myocarditis diagnosis by ICD codes. Additional chart review was performed to confirm timing of ICI treatment and myocarditis. All pts identification and review were performed after IRB review. Results: 12,686 pts with non-small cell lung cancer were eligible for review. The median age at diagnosis was 70; 54% were female; 86% were White and 12% were Black; 1,975 (15.6%) were treated with an ICI and of those 4 cases (0.2%) of myocarditis were identified. All 4 pts were White females, ages 46, 59, 65, and 74 years. Pathology included lung adenocarcinoma (3) and an undifferentiated lung carcinoma (1). All pts had metastatic disease, and none had a prior history of cardiac disease. ICIs were pembrolizumab (2), durvalumab (1), and nivolumab (1). Median time from initial dose of ICI to diagnosis of myocarditis was 62 days [range: 42-185]. All 4 pts presented with chest pain and elevated troponin T [median 0.07 ng/ml (range: 0.06-0.08)]. All pts had echocardiography at the time of diagnosis, and 2 pts had cardiac MRI that confirmed myocarditis. 3 pts were treated with a prednisone taper. 1 pt died of recurrent congestive heart failure and ventricular tachycardia despite rescue attempt with high dose corticosteroids. 2 pts had additional concomitant irAEs of hypothyroidism/colitis, and thyroiditis/pneumonitis, respectively. Conclusions: Many irAEs are reversible. This RWD analysis confirms that clinically evident myocarditis is a rare but serious adverse event of ICI therapy. Early consideration, diagnosis, and intervention may help prevent poor outcomes. Termination of ICI therapy along with initiation of corticosteroids constitute the current standard of management. Further research is warranted to better identify high risk groups, surveillance measures, and improved management of ICI associated myocarditis.

Indications for Maternal Echocardiography in Detecting Disease and the Impact on Pregnancy Management.

Few obstetric-specific guidelines detail the indications for screening echocardiography in pregnancy. The objective of the study is to examine the association of common indications for maternal echocardiography with the likelihood of abnormality identification, pregnancy management alteration, and conformity with current American College of Cardiology Foundation (ACCF) guidelines. This retrospective cohort analysis categorized all echocardiograms performed within pregnancy and the first month postpartum within a tertiary health system to correlate indications with abnormal findings. Data from 226 echocardiograms were analyzed from 205 women. The most common indication for initial echocardiography was cardiac symptoms (34.6%). History of cardiac disease was the only indication demonstrating a significant association with an abnormal finding on initial echocardiography (odds ratio [OR]: 2.6; p = 0.006). Postpartum status (OR: 4.9; p < 0.001), multiparity (p < 0.001), and tobacco use (OR: 2.2; p = 0.011) were demographic characteristics associated with the identification of abnormal findings on initial echocardiography. Abnormal echocardiographic findings were associated with changes in clinical management but did not correlate with adverse obstetric or neonatal outcomes, which may support the impact of a multidisciplinary programmatic approach. ACCF appropriateness criteria correlated well with identification of abnormal echocardiographic results (p = 0.034). Although the presence of cardiac symptoms or history of diabetes failed to demonstrate association with abnormal echocardiographic findings, a history of prior cardiac disease, tobacco use, multiparity, and postpartum status were factors associated with identification of abnormal findings on initial maternal echocardiography. The ACCF appropriateness criteria for obtaining echocardiography can be applied to pregnant women with consideration for these additional risk factors. · The ACCF criteria are applicable in pregnancy for appropriateness of echocardiography indications.. · Several clinical factors often prompt performance of echocardiography in pregnancy without merit.. · Consideration for multiparty, tobacco abuse, and postpartum state should coincide with ACCF criteria..

Application of the current HFA-ESC consensus guidelines on diagnosis of heart failure with preserved ejection fraction to a population referred for echocardiography

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND The recent Heart Failure Association (HFA) of the European Society of Cardiology (ESC) consensus guidelines on diagnosis of heart failure with preserved ejection fraction (HFpEF) have developed a simple diagnostic algorithm for clinical use. PURPOSE To assess whether echocardiogram (echo) parameters needed to assess diastolic function are routinely collected in patients referred for assessment of heart failure symptoms. METHODS Retrospective analysis of echo referrals in January 2020 were assessed for parameters of diastolic function as per step 2 of the HF-PEFF diagnostic algorithm. Echo images and clinical reports were reviewed. Electronic records were utilised to obtain clinical history, blood results (NT-proBNP) and demographic data. RESULTS 1330 patients underwent an echo in our department during January 2020. 83 patients were referred with symptoms of heart failure without prior history of cardiac disease; 20 patients found to have impaired left ventricular (LV) function were excluded from analysis. Of the 63 patients with possible HFpEF, HF-PEFF score was low in 18, intermediate in 33 and high in 12. Median age was 68 years (range 32 to 97 years); 25% had a BMI &amp;gt;30. There was a high prevalence of hypertension (52%), diabetes (19%) and atrial fibrillation (40%) (cf. Table 1). Body surface area (BSA) was documented in 65% of echo reports. Most echo parameters were recorded with the exception of global longitudinal strain (GLS) and indexed LV mass (cf. image 1). NT-proBNP was recorded in only 20 patients (31.7%). 12 patients with an intermediate HF-PEFF score could have been re-categorised to a high score depending on GLS and NT-proBNP (which were not recorded). CONCLUSION More than three quarters of echoes acquired in our department obtained the relevant parameters to assess diastolic function. The addition of BSA, and inclusion of NT-proBNP, and GLS would have been additive to a third of ‘intermediate’ patients to determine definite HFpEF. Our study demonstrates that the current HFA-ESC diagnostic algorithm and HF-PEFF scoring system are easy to use, highly relevant and applicable to current clinical practice. Age &amp;gt;70 years 29 (46.0%) Obesity (BMI &amp;gt;30) 16 (25.4%) Diabetes 12 (19%) Hypertension 33 (52.4%) Atrial Fibrillation 25 (39.7%) ECG abnormalities 18 (28.5%) Table 1. Prevalence of Clinical Risk Factors Abstract Figure. Image 1. HFPEFF score &amp; echo parameters

Lower Prevalence and Severity of Coronary Atherosclerosis in Chronic Chagas' Disease by Coronary Computed Tomography Angiography.

ResumoFundamento Em regiões endêmicas da doença de Chagas, por muitos anos, existe uma observação empírica recorrente de que a doença arterial coronariana (DAC) é incomum em pacientes com doença de Chagas. Estudos anteriores baseados em análise patológica ou angiografia coronária invasiva apresentam resultados controversos.Objetivo Investigar se a DAC é menos prevalente e menos grave em pacientes com doença de Chagas crônica em comparação a uma população pareada controle, com perfil de risco para DAC similar.Métodos Um total de 86 participantes, 43 pacientes com doença de Chagas crônica consecutivos e 43 indivíduos assintomáticos, sem qualquer história prévia de doença cardíaca ou doença DAC conhecida (grupo controle), foram incluídos no estudo. Pacientes e controles foram pareados quanto sexo, idade e escore de risco de Framingham. Todos os pacientes foram analisados quanto ao escore de cálcio coronário (ECC) e submetidos à angiotomografia coronária usando um tomógrafo de 320 detectores. O nível de significância estatística adotado foi de p < 0,05.Resultados O ECC foi significativamente mais baixo em pacientes com doença de Chagas em comparação aos controles (p<0,05). A presença de placas ateroscleróticas coronárias foi significativamente menos frequente em pacientes com doença de Chagas que nos controles (20,9% versus 41,9%, p=0,037). Após ajuste quanto ao escore de Framingham, o odds ratio para a presença de qualquer calcificação coronária foi de 0,26 (IC95%: 0,07-0,99, p=0,048). O padrão é similar para escore de cálcio coronário (ECC) > 10 (OR: 0,11, IC95%: 0,01-0,87, p=0,04), e para a presença de estenose (OR: 0,06, IC95%: 0,01-0,47, p=0,001). O pareamento por escore de propensão também mostrou um efeito da doença de Chagas no ECC (-21,6 pontos no escore absoluto e 25% menos pacientes com ECC > 10; p=0,015).Conclusões A prevalência e a gravidade da DAC são mais baixas nos pacientes com doença de Chagas crônica em comparação a uma população pareada e perfil de risco para DAC similar. (Arq Bras Cardiol. 2020; 115(6):1051-1060)

Genetic Factors Involved in Cardiomyopathies and in Cancer.

Cancer therapy-induced cardiomyopathy (CCM) manifests as left ventricular (LV) dysfunction and heart failure (HF). It is associated withparticular pharmacological agents and it is typically dose dependent, but significant individual variability has been observed. History of prior cardiac disease, abuse of toxics, cardiac overload conditions, age, and genetic predisposing factors modulate the degree of the cardiac reserve and the response to the injury. Genetic/familial cardiomyopathies (CMY) are increasingly recognized in general populations with an estimated prevalence of 1:250. Association between cardiac and oncologic diseases regarding genetics involves not only the toxicity process, but pathogenicity. Genetic variants in germinal cells that cause CMY (LMNA, RAS/MAPK) can increase susceptibility for certain types of cancer. The study of mutations found in cancer cells (somatic) has revealed the implication of genes commonly associated with the development of CMY. In particular, desmosomal mutations have been related to increased undifferentiation and invasiveness of cancer. In this article, the authors review the knowledge on the relevance of environmental and genetic background in CCM and give insights into the shared genetic role in the pathogenicity of the cancer process and development of CMY.

P3511Gender differences in electrocardiographic risk markers of heart failure

Abstract Background Heart failure (HF) is one the leading causes of hospitalization in the Western world. Women have a lower rate of HF hospitalization and mortality compared to men. Role of 12-lead electrocardiography (ECG) as a risk marker of future HF in women is not well known. Purpose We studied the association of standard 12-lead ECG and clinical risk factors to HF hospitalization in women and in men separately from a large middle aged general population sample with a long-term follow-up. Methods Standard 12-lead ECG markers were analyzed from 10,864 subjects (48.8% women, N=5,215) of the prospective Mobile Clinic Study, and their predictive value for HF hospitalization was analyzed. Results During the follow-up (29.6±11.2 yrs.), a total of 1,743 subjects had HF hospitalization; out of these, 861 were women (49.4%). Several baseline characteristics, such as age, body mass index, blood pressure, and history of prior cardiac disease predicted the occurrence of HF both in women and men (P&lt;0.001 for all). After adjusting for baseline variables, ECG sign of left ventricular hypertrophy (LVH) (P&lt;0.001), and atrial fibrillation (P&lt;0.001) were the only baseline ECG variables that predicted the future HF in women. In men, HF was predicted by fast heart rate (P=0.008), T wave inversions (P&lt;0.001), abnormal Q waves (P=0.002), and atrial fibrillation (P&lt;0.001). Statistically significant gender interactions in prediction of HF were observed in ECG sign of LVH (P&lt;0.001), inferolateral T wave inversions (P=0.005), and heart rate (P=0.012). Conclusions ECG sign of LVH predicts future HF in middle-aged women independently, and T wave inversions and elevated heart rate are associated with HF hospitalization in men in. Acknowledgement/Funding Finnish Cultural Foundation, The University of Oulu Scholarship Foundation, Juho Vainio Foundation

Invited commentary

This report represents a thorough analysis of the search for associations between plasma renin or aldosterone levels and excised carotid artery plaque characteristics and composition and includes evaluation of many important intraplaque inflammatory mediators. Because activation of the renin-angiotensin system has been previously described to be associated with an increase in coronary and cerebrovascular events, it seemed logical to assume that these levels should correlate with the atherosclerotic plaque. Failure to find such a relationship was unexpected, which implies that the mechanism for the clinical outcomes is unrelated to acceleration of plaque lesion growth or plaque destabilization. Interestingly, a higher incidence of the composite of subsequent major clinical cardiovascular events was noted to be associated with higher levels of renin and aldosterone, although a history of prior cardiac disease at baseline was also higher among these patients. Nonetheless, the association of subsequent cardiovascular events did reflect greater numbers of adverse cerebrovascular and peripheral vascular episodes in addition to cardiac events. In attempting to understand the findings presented, it must be noted that plasma samples were obtained at only one point during the lifetime of the atherosclerotic process. Were the mature plaques derived from arteries that may have long since become activated by the renin-angiotensin system and no longer were dependent on it for continued activity, with the effect of renin and aldosterone most critical in the early stages of lesion development? Alternatively, although exclusion of patients using angiotensin-converting enzyme inhibitors in this real-life population would have severely limited the sample set size available for analysis, such inhibition may still compromise the ability to interpret these results, even if use of this drug class did not appear to affect the results of preliminary Cox regression analysis. Certainly, use of these inhibitors has been associated with reductions in cardiovascular events.1Yusuf S. Sleight P. Pogue J. Bosch J. Davies R. Dagenais G. Heart Outcomes Prevention Evaluation Study InvestigatorsEffects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients.N Engl J Med. 2000; 342: 145-153Crossref PubMed Scopus (8167) Google Scholar Could it be that elevated renin and aldosterone levels have, in fact, no causal role, but rather serve merely as markers of an as yet undiscovered mechanism of plaque destabilization? Whatever the case, atherosclerosis remains a complex process, resistant to complete explanation despite the laudable efforts of committed researchers such as Dr Hillaert and her colleagues. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Renin and aldosterone are not associated with vulnerable plaque characteristics in patients with carotid artery diseaseJournal of Vascular SurgeryVol. 68Issue 1PreviewThe renin-angiotensin-aldosterone system is increasingly being recognized to play an important role in the development and clinical course of cardiovascular diseases. Renin-angiotensin-aldosterone system activation is associated with clinical outcome in various populations of cardiovascular patients, such as patients with coronary artery, peripheral artery, and cerebrovascular disease. In this study, we investigated the associations between plasma renin and aldosterone concentrations and atherosclerotic plaque characteristics and secondary vascular events in patients undergoing carotid endarterectomy. Full-Text PDF Open Archive

Cardiotoxicity of 5-fluorouracil and capecitabine in Chinese patients: a prospective study

Background5-Fluorouracil (5-FU) and capecitabine-associated cardiotoxicity ranging from asymptomatic electrocardiography (ECG) abnormalities to severe myocardial infarction has been reported in a number of studies, but such cardiotoxicity in Chinese patients with malignant diseases has not been investigated to date. In the present study, we aimed to prospectively evaluate the incidence rates and clinical manifestations of 5-FU- and capecitabine-associated cardiotoxicity in cancer patients recruited from multiple centers in China.MethodsAmong the 527 patients who completed the study, 196 received 5-FU-based chemotherapy and 331 received capecitabine-based chemotherapy as either first-line or adjuvant therapy. Adverse events were reported during the treatment and up to 28 days of follow-up. Outcome measures included ECG, myocardial enzymes, cardiac troponin, brain natriuretic peptide and echocardiography. Univariate analysis and logistic regression were performed for subgroup analysis and identification of significant independent variables that are associated with cardiotoxicity of both agents.ResultsIn total, 161 of 527 patients (30.6%) experienced cardiotoxicity. The incidence rate of cardiotoxicity was 33.8% (112/331) in the capecitabine group, which was significantly higher than the rate of 25% (49/196) in the 5-FU group (P = 0.0042). 110/527 patients (20.9%) suffered arrhythmia, 105/527 (19.9%) developed ischemic changes, while only 20/527 patients (3.8%) presented heart failure and 6/527 patients (1.1%) had myocardial infarction. Pre-existing cardiac disease, hypertension, capecitabine-based chemotherapy and duration of treatment were identified as significant risk factors associated with cardiotoxicity. The odds ratio were 15.7 (prior history of cardiac disease versus no history), 1.86 (capecitabine versus 5-FU), 1.06 (5–8 versus 1–4 chemotherapy cycles) and 1.58 (hypertension versus no hypertension), respectively.ConclusionsCardiotoxicity induced by fluoropyrimidines in the Chinese population may be underestimated in clinical practice. Close monitoring of patients is recommended, especially for those patients at high risk for cardiotoxicity. Possible risk factors are duration of treatment, capecitabine-based chemotherapy, pre-existing cardiac diseases and hypertension.Trial registration This study was initiated on January 22, 2014 and has been retrospectively registered with the registration number ChiCTR1800015434

Variant Angina and Aborted Sudden Cardiac Death.

Variant angina, which is characterized by recurrent chest pain and transient ECG changes along with angiographic evidence of coronary artery spasm, generally has a favorable prognosis. However, episodes of ischemia caused by vasospasm may lead to potentially life-threatening ventricular arrhythmias and cardiac arrest, even in patients with no history of prior cardiac disease. This review describes the epidemiology, pathogenesis, clinical spectrum, and management of variant angina, as well as outcomes in patients who present with aborted sudden cardiac death (ASCD). Contrary to prior opinions, evidence from recent observational studies indicate that patients with variant angina presenting with ASCD face a worse prognosis than those without this type of presentation. Predictors of ASCD include age, hypertension, hyperlipidemia, family history of sudden cardiac death, multi-vessel spasm, and left anterior descending artery spasm. Medical therapy alone with calcium channel blockers and nitrates may not be sufficiently protective in these patients and there is lack of concrete data on the optimal management strategy. Current guidelines recommend implantable cardiac defibrillator (ICD) therapy in patients who are survivors of cardiac arrest caused by ventricular fibrillation or unstable ventricular tachycardia after reversible causes are excluded, and should strongly be considered in these patients. Although medical therapy is absolutely imperative for patients with variant angina and a history of ASCD, ICD therapy in these patients is justified. Further large-scale studies are required to determine whether ICD therapy can improve survival in this high-risk group of patients.

Left Ventricular Functional Parameters and Geometric Patterns in Korean Adults on Coronary CT Angiography with a 320-Detector-Row CT Scanner.

ObjectiveTo assess the normal reference values of left ventricle (LV) functional parameters in Korean adults on coronary CT angiography (CCTA) with a 320-detector-row CT scanner, and to analyze sex-related differences and correlations with various clinical characteristics.Materials and MethodsThis study retrospectively enrolled 172 subjects (107 men and 65 women; age, 58 ± 10.9 years; body surface area [BSA], 1.75 ± 0.2 m2) who underwent CCTA without any prior history of cardiac disease. The following parameters were measured by post-processing the CT data: LV volume, LV functional parameters (ejection fraction, stroke volume, cardiac output, etc.), LV myocardial mass, LV inner diameter, and LV myocardial thickness (including septal wall thickness [SWT], posterior wall thickness [PWT], and relative wall thickness [RWT = 2 × PWT / LV inner diameter]). All of the functional or volumetric parameters were normalized using the BSA. The general characteristics and co-morbidities for the enrolled subjects were recorded, and the correlations between these factors and the LV parameters were then evaluated.ResultsThe LV myocardial thickness (SWT, 1.08 ± 0.18 cm vs. 0.90 ± 0.17 cm, p < 0.001; PWT, 0.91 ± 0.15 cm vs. 0.78 ± 0.10 cm, p < 0.001; RWT, 0.38 ± 0.08 cm vs. 0.33 ± 0.05 cm, p < 0.001), LV volume (LV end-diastolic volume, 112.9 ± 26.1 mL vs. 98.2 ± 21.0 mL, p < 0.001; LV end-systolic volume, 41.7 ± 14.7 mL vs. 33.7 ± 12.2 mL, p = 0.001) and mass (145.0 ± 29.1 g vs. 107.9 ± 20.0 g, p < 0.001) were significantly greater in men than in women. However, these differences were not significant after normalization using BSA, except for the LV mass (LV mass index, 79.6 ± 14.0 g/m2 vs. 66.2 ± 11.0 g/m2, p < 0.001). The cardiac output and ejection fraction were not significantly different between the men and women (cardiac output, 4.3 ± 1.0 L/min vs. 4.2 ± 0.9 L/min, p = 0.452; ejection fraction, 63.4 ± 7.7% vs. 66.4 ± 7.6%, p = 0.079). Most of the LV parameters were positively correlated with BSA, body weight, and total Agatston score.ConclusionThis study provides sex-related reference values and percentiles for LV on cardiac CT and should assist in interpreting results.

A Multicenter, Open Label Phase I/II Study of Carfilzomib, Pomalidomide and Dexamethasone in Relapsed and/or Refractory Multiple Myeloma (MM) Patients

A Multicenter, Open Label Phase I/II Study of Carfilzomib, Pomalidomide and Dexamethasone in Relapsed and/or Refractory Multiple Myeloma (MM) Patients

Abstract WP232: Prevalence of Positive Troponins and Association With Abnormal Echocardiograms in Acute Ischemic Stroke

Background and Purpose: Acute Ischemic Stroke (AIS) patients may have high sensitivity serum troponin (cTn) levels drawn upon admission, although it is unclear how frequently cTn levels are elevated, and whether these levels are associated with cardiac causes of stroke as seen on echocardiogram. We investigated the prevalence and positivity of cTn and echocardiogram testing within a large biracial population that is representative of the US. Methods: Within a catchment area of 1.3 million we screened local hospital admissions in 2010 using ICD-9 discharge codes 430-436 and ascertained all physician-confirmed AIS cases by standardized retrospective chart review, including diagnostic test results. Any positive cTn was defined by the standard 99 th percentile cutoff. Echocardiogram findings of interest were defined as in the table. Logistic regression was used for analyses, controlling for age, sex, race and prior history of cardiac disease. Results: Of the 1999 AIS cases that presented to an ED in the region 1706 (85.3%) had a cTn drawn and 1590 (79.5%) had an echocardiogram. A positive cTn was seen in 353/1706 (20.7%) and 160/1590 (10%) had an echocardiogram finding of interest. Of the 1377 that had both tests performed, a positive cTn was associated with an abnormal echocardiogram ( adjusted OR 2.9 95% CI 2-4.2 ). A negative cTn did not significantly alter the odds of having an abnormal echocardiogram ( Negative Likelihood Ratio=0.66 ). Conclusion: Testing with serum cTn and echocardiogram was common within our population. Troponinemia above the 99 th percentile was prevalent and was associated with clinically relevant structural cardiac disease on echocardiogram. However absence of troponinemia was not informative regarding the probability of a normal echocardiogram, and therefore does not obviate the need for echocardiography in this at risk population.

Caudate lobe resections: a single-center experience and evaluation of factors predictive of outcomes

BackgroundDespite the increasing frequency of liver resection for multiple types of disease, caudate lobe resection remains a rare surgical event. The goal of this study is to review our experience and evaluate possible predictors of adverse outcomes in patients undergoing caudate lobectomy.MethodsWe reviewed a 1,900-patient prospective hepato-pancreatico-biliary database from January 2000 to December 2011, identifying 36 hepatectomy patients undergoing caudate lobe resection. Clinicopathologic characteristic and outcome data were compared using chi-square, T-test, ANOVA, Kaplan-Meier, and Cox regression analysis. Primary endpoints were the incidence and severity of complications, and secondary endpoints were blood loss, hospital stay, and transfusion requirements. Patients were also divided in two groups with group A being patients operated on before December 2007 and group B after 2007. We compared the demographics, risk factors, complication rates, and operative details between the two groups.ResultsThirty-six patients underwent caudate lobe resection for cholangiocarcinoma (47.2%), metastatic colorectal cancer (36.1%), hepatocellular carcinoma (8.3%), or benign disease (8.3%). Nine patients (29%) had additional liver resection. Median overall survival (OS) was 21 months. Complications occurred in 52.7% (19/36) of patients with a median grade of 2. Tobacco abuse was associated with an increased risk of operative complications (73.3% vs. 38.9%, p = 0.03). Prior history of cardiac disease was associated with a higher complication rate (87% vs. 42%, p = 0.03). Neoadjuvant chemotherapy, biliary procedures, hepatitis, and prior major abdominal surgery were not predictive of complications. Major complication was also predicted by the volume of RBC transfusion (2.7 vs. 4.1 units, p = 0.003). In our subgroup analysis of the patients undergoing surgery before and after 2007, the two groups were well matched based on age, comorbidities, and risk factors. The complication rates and rates of high-grade complications were similar, but blood loss (600 ml vs. 400 ml, p = 0.03), inflow occlusion time (Pringle time 12.6 vs. 6, p = 0.00), and hospital stay (9.5 vs. 7 days, p = 0.01) were significantly lower in group B.ConclusionsWith appropriate patient selection, caudate lobe resection is an effective component of surgery for hepatic disease. Tobacco use and prior cardiac history increase the risk of complications.

Cardiac Toxicity After High-Dose Melphlan and Autologous Hematopoietic Stem Cell Transplantation for Multiple Myeloma

AbstractAbstract 2027▪▪This icon denotes a clinically relevant abstract Background:High-dose melphalan (HDM), 200 mg/m2, is the standard regimen for autologous hematopoietic stem cell transplant (auto-HCT) for multiple myeloma (MM). Although HDM-induced cardiotoxicity is reported, its incidence is not well known. In this retrospective analysis we evaluated the incidence of cardiotoxicity and its impact on outcome in patients undergoing auto-HCT for MM. Methods:Three-hundred and sixty-nine consecutive patients who received melphalan 200 mg/m2 for auto-HCT ASCT between January 2006 and December 2009 were included in these analyses. Cardiac toxicity was defined as any cardiac adverse event reported from the day of administration of melphalan to day+ 30 after auto-HCT. Results:Patient characteristics are summarized in Table 1. Median age at auto-HCT was 59 years (32–78 years). Median time from diagnosis to auto-HCT was 8.0 months (1.8–266.3). Patients undergoing auto-HCT had a left ventricular ejection fraction (LVEF) of >40%, and no symptomatic cardiac disease. Thirty-five patients had concurrent or AL amyloidosis, and 43 patients had a prior history of cardiac disease. By day +30 after auto-HCT, 34 patients (9.2%) developed one or more adverse cardiac adverse events (AE). Twenty-seven patients experienced a single cardiac AE: atrial fibrillation (a fib): 16, congestive heart failure (CHF): 3, supraventricular tachycardia (SVT): 3, ischemic chest pain: 2, ventricular bigeminy: 1, diastolic dysfunction: 1 and sudden cardiac death in a patient with AL amyloidosis: 1. Seven patients had a combination of 2 or more cardiac adverse events: CHF + a fib: 4, ischemic chest pain + QT prolongation: 1, ischemic chest pain + left bundle branch block (LBBB): 1, ischemic chest pain + premature ventricular contractions (PVCs): 1. Overall, supraventricular arrhythmias were responsible for cardiac AE in 6.2% (23/369) of the patients. Twenty-eight patients (82%) fully recovered from the cardiac AE. Four patients required long term pharmacologic treatment of a fib, and one patient with a fib developed a cerebellar infarct without residual neurologic deficits. Patients with cardiac AE were older (median age: 62 vs. 59, p=0.014) and had a prior history of cardiac disease (17/34 vs. 20/335, p=0.0001) compared to patients without cardiac AE. Gender, concurrent AL amyloidosis, interval between diagnosis and auto-HCT, or transplant before or after the year 2000 were not associated with cardiac AE. Median overall follow up was 28 months (1–369). 100-day non-relapse mortality (NRM) was 3% (1/34) vs. 0% (0/335) in patients with or without cardiac AEs (p=0.09). Kaplan-Meier estimates of 3-year OS were 70% vs. 84% in patients with or without cardiac AE (p=0.084). Conclusions:HDM and auto-HCT was associated with cardiac AEs in 9% of patients. A fib and CHF were the most common cardiac AEs, but >80% fully recovered without long-term sequelae. Patients with cardiac AE were relatively older and had a prior history of cardiac disease. There was no significant difference in NRM or OS in patients with or without melphalan-associated cardiac AEs.Table 1Patient CharacteristicsAll Patients (N=369)Patients With Cardiac Events (N=35)GenderMale15721Females21214RaceCaucasian24028African Americans644Mixed562Asian71unknown2Age (yrs)59 (32–78)62 (38–76)Durie SalmonI616215016313612unknown221Disease Status Before Transplant> VGPR1259PR16620<PR472Unknown314B2 microglobulin before transplant mg/dl4.45 (1.2–266.9)3.5 (0.6–36.2)Time for diagnosis to auto-HCT (months)8.0 (1.8–266.3)20.9 (32.5–168.6)<PR, includes Stable Disease, No Response, PD, Minimal Response; >=VGPR: includes Complete Remission (CR);, Very Good Partial Response and Partial Remission (VGPR), PR: Partial remission. RBBB (Right bundle branch block). Disclosures:No relevant conflicts of interest to declare.