Use Of Cardiac Medications Research Articles

Aortic coarctation in pregnancy: outcomes and predictors for cardiovascular and hypertensive complications. Data from the ESC Registry of Pregnancy and Cardiac disease (ROPAC)

Abstract Background Pregnancy in women with repaired aortic coarctation (CoA) has a moderately increased risk (mWHO II-III) of an adverse cardiovascular, obstetric or fetal event, but prospective data to validate this estimated risk is scarce. Purpose We examined maternal and fetal outcomes in pregnant women with unrepaired and repaired CoA to identify predictors of adverse outcomes. Methods Pregnancies in women with CoA were selected from the worldwide prospective Registry of Pregnancy and Cardiac Disease (ROPAC, n=5739). The frequency and predictors of major adverse cardiac events (MACE, defined as maternal cardiac death, heart failure, atrial fibrillation/flutter, ventricular tachyarrhythmia, endocarditis, thromboembolic events, aortic dissection and acute coronary syndrome), and hypertensive complications (defined as pregnancy-induced hypertension, (pre)eclampsia or HELLP syndrome) were analyzed. Results Of 303 pregnancies in women with CoA (median age 30 years, median pregnancy duration 39 weeks), 10% were in women with unrepaired CoA and 27% in women with pre-existing hypertension. There were no maternal deaths. There were 4 neonatal deaths of which 3 occurred after a spontaneous extreme preterm birth. MACE occurred in 4.3% of pregnancies, predominantly involving heart failure (3.3%). MACE rate was similar in unrepaired vs repaired CoA (3.4% vs 4.4%, p=0.814). Predictors of MACE included pre-pregnancy clinical signs of heart failure (OR 31.8, 95% CI 6.8–147.7), LVEF <40% (OR 10.4, 95% CI 1.8–59.5), NYHA class >1 (OR 11.4, 95% CI 3.6–36.3), cardiac medication use (OR 4.9, 95% CI 1.3–18.3) and living in an emerging country (OR 4.88, 95% CI 1.58–15.07). Hypertensive complications occurred in 6.3%, more often in the subgroup with pre-existing hypertension (11% vs 5%, p=0.040). Pre-existing hypertension was the only predictor (OR 2.6, 95% CI 1.01–6.6). Caesarean section was performed in 50% of the total cohort. Conclusions Pregnancies in women with CoA are safe, well tolerated and MACE and hypertensive complication rates are low. These findings support mWHO risk score reevaluation to mWHO II for women with CoA without cardiac impairment. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): ESC EURObservational Research Programme (EORP)

Lower peak systolic blood pressure during exercise testing predicts higher risk of all-cause mortality even when accounting for exercise capacity and other confounders

Abstract Background The risk associated with an exaggerated systolic blood pressure (SBP) response during exercise testing is controversial. In part, this may be due to the confounding effect of exercise capacity, as achieving a high workload is related to both better survival and higher peak SBP. Purpose We aimed to determine the prognostic value of the SBP response at clinical exercise testing, with and without accounting for exercise capacity and other important confounders, for predicting all-cause mortality. Methods We analysed data from 10,245 subjects aged 18–85 years (54% male), referred for bicycle ergometer exercise testing at a single hospital between 2005 and 2015. Resting SBP, peak SBP, peak Watt as well as the first and last SBP and corresponding Watt during exercise were retrieved. The slope of the increase in SBP per increment in Watt between the first and last measurement during exercise (the SBP/Watt-slope) was calculated. Survival status was determined from the National Cause of Death register up until April 2019. Cox proportional hazard ratios for all-cause mortality were calculated in males and females for peak SBP and the SBP/Watt-slope, and natural cubic spline models (with three knots) were computed to explore the risk of death based on a continuum of each SBP measure. The models were adjusted for age, SBP at rest, a diagnosis of diabetes, hypertension, baseline cardiovascular disease (ICD10 Chapter IX) and the use of cardiac and/or antihypertensive medications. In additional analyses, peak SBP and the SBP/Watt-slope were adjusted for peak Watt or exercise capacity (% predicted), respectively. Results Over a median follow-up of 7.9 (IQR 5.7) years, 890 (8.7%) subjects died. Compared to survivors, subjects who died were older (69±10 vs 57±14 years, p<0.001), had lower age-adjusted exercise capacity (82±15 vs 92±17% pred. Watt, p<0.001), and had lower peak SBP (193±28 vs 196±26 mmHg, p=0.002). The SBP/Watt-slope was on average 21% higher in those who died (0.64±0.36 vs 0.53±0.27 mmHg/Watt, p<0.001). An exercise peak SBP <190 mmHg in females and <210 mmHg in males was associated with increased risk of all-cause death, after adjusting for age, prevalent comorbidities, cardiac medication and exercise capacity at baseline (Figure 1). After adjusting for maximal workload, higher peak SBP was associated with increased risk of dying in females, but not in males. An SBP/Watt-slope >0.5 mmHg/Watt was associated with higher risk of death in both sexes, although not when adjusting for exercise capacity. Conclusion Achieving a lower peak SBP was associated with increased risk of all-cause mortality in both sexes. This persisted after accounting for exercise capacity and other important confounders. In females, but not in males, there was also an increased risk of death associated with higher peak SBP. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): County Council of Ostergotland

Pregnancy outcomes in women with aortic coarctation

ObjectivePregnancy in women with aortic coarctation (CoA) has an estimated moderately increased risk (mWHO II–III) of adverse cardiovascular, obstetric or fetal events, but prospective data to validate this risk classification...

Gender Differences in Healthy Lifestyle Adherence Following Percutaneous Coronary Intervention for Coronary Artery Disease

Coronary artery disease (CAD) is the leading cause of mortality in Australian women. We identified gender differences in healthy lifestyle adherence in patients treated with percutaneous coronary intervention (PCI) for CAD. Consecutive patients were prospectively recruited from three Australian institutions (2016-2017). The primary endpoint at 1 year follow-up was healthy lifestyle adherence defined as 3/3 of: a heart-healthy diet, being physically active and not smoking. Secondary endpoints included cardiac rehabilitation attendance, medication use and lipid levels. From 729 participants (n=192, 26.3% women) 56% were adherent to all three lifestyle measures with no gender difference overall. Compared to men, women were less likely to smoke (7.7% versus 12.2%, p<0.001) to be physically active (61.5% versus 78.2%; p<0.0001), attend cardiac rehabilitation (58.2% versus 66.4%; p<0.045), and take statin therapy (85.4% versus 94.7%; p<0.0001). Female gender independently predicted physical inactivity (OR 2.41, 95% CI 1.57-3.68, p<0.001). Important gender differences exist in patients treated with PCI for CAD, namely, significant lower physical activity, cardiac rehabilitation attendance and statin use in women. These all represent key targets for gender-specific secondary prevention interventions.

Abstract 344: Circulating MicroRNA Signature as a Predictive Biomarker for Postoperative Heart Failure

Background: Advancements in cardiac surgical techniques have led to decreasing operative risk. However, postoperative heart failure (PoHF) continues to be a major risk factor for adverse cardiac events in 20-35% of patients after cardiac surgery, with a 10-fold increase in 30-day mortality. Prediction of PoHF is challenging, particularly in patients with preserved ventricular function. Circulating microRNAs (miRNAs) recently were identified to predict HF or AF after surgery, but their role in predicting PoHF is not known. This study aimed to find novel noninvasive circulating biomarkers along with clinical factors that can identify patients at risk of developing PoHF immediately after surgery. Methods: Patients undergoing CABG surgery with no previous history of HF, ventricular or supraventricular tachycardia were recruited, and preoperative blood assessed for circulating levels of protein biomarkers using ELISA. Differences in relative plasma levels of 13 miRNAs between the PoHF and no-PoHF groups were assessed by qPCR. Preoperative echocardiography was obtained. SAS was used for statistical analysis and ROC curve. Results: Out of 68 patients, 13 developed PoHF (19.1%, mean age 64.1±11.6y, 53.8% males), whereas 55 (mean age 68.3±12.4y) remained free of HF. Patients who developed PoHF had lower LVEF (51.4±13.7 vs 58.2±9.9, P&lt;0.05) with no differences in prevalence of hypertension, diabetes, hyperlipidemia, obesity, previous myocardial infarction, stroke, COPD, sleep apnea, or use of cardiac medications. The correlation matrix of all 13 miRNAs was transformed in a principal component (PC), resulting in 3 main clusters with eigenvalue &gt;1. PC cluster2 consisted of miR-23a, -23b, -25 and -26a2, principally involved in oxidatives stress, fibrosis and contractility, and had the strongest association (AUC=0.797; P&lt;0.01) with PoHF. A model combining PC cluster2 with age and LVEF improved sensitivity and specificity of the model to identify patients at risk of PoHF (AUC=0.880; 95% CL, 0.761-0.991; P&lt;0.001) Conclusion: Our study demonstrates that miR-23a, -23b, -25 and -26a2 may be useful predictors of PoHF. Circulating miRNA as biomarkers may have diagnostic potential to preoperatively, noninvasively identify patients at risk of developing PoHF.

Parameters of cardiac symptoms in young athletes using the Heartbytes database

ABSTRACT Introduction: To determine clinical parameters that are related to abnormal cardiac symptoms in physically active youth. Methods: We used Simon’s Heart Heartbytes National Youth Cardiac Registry to collect data from adolescent athletes in southeastern Pennsylvania. We collected age, race/ethnicity, abnormal cardiac symptoms, medical history, medication use, caffeine intake, and family history. We obtained height, weight, blood pressure, cardiac murmur findings, and ECGs. Echocardiogram was obtained if necessary. Binary logistic regression analysis was performed to identify independent associations between abnormal cardiac symptoms and collected variables. The odds ratio (OR), 95% confidence interval (95% CI), and p-values were used as statistical values. Results: Of the 887 athletes (543 males and 344 females, age = 16.9 ± 2.1 years, height = 166.9 ± 11.4 cm, weight = 62.0 ± 16.0 kg), 186 (21%) had abnormal cardiac symptoms including chest pain, passing out, difficulty breathing, extreme fatigue, and heart race. There was an independent association between abnormal symptoms and a past medical history (OR: 4.77, 95%CI: 3.18, 7.17, p = 0.001) and medication use (OR: 1.74, 95%CI: 1.08, 2.79, p = 0.022). In medical history, young athletes with asthma showed a greater propensity of abnormal cardiac symptoms (48.9%) compared to young athletes without (14.0%, p = 0.001). Additionally, young athletes with anxiety or depression demonstrated a higher proportion of abnormal cardiac symptoms (48.9%) than those without (19.5%, p = 0.001). Although the association between the presence of abnormal symptoms and African-American race (OR: 2.04, 95%CI: 0.96, 4.35, p = 0.065) and average daily consumption of at least 2 caffeine drinks (OR: 2.08, 95%CI: 0.86, 5.02, p = 0.103) were not significant, there was a trend to reach the a priori significance level. Conclusions: This study identified several clinical parameters that are associated with symptoms suggestive of abnormal cardiac conditions. Larger studies need to be done to better sort out the clinical history that may contribute to false positives to further reduce false positives at heart screenings.

Long-term effectiveness of catheter ablation in patients with atrial fibrillation and heart failure.

Randomized trials suggest reductions in all-cause mortality and heart failure (HF) rehospitalizations with catheter ablation (CA) in patients with atrial fibrillation (AF) and HF. Whether these results can be replicated in a real-world population with long-term follow-up or varies over time is unknown. We sought to evaluate the long-term effectiveness of CA in reducing the incidence of all-cause mortality, HF hospitalizations, stroke, and major bleeding in AF-HF patients. In a cohort of patients newly diagnosed with AF-HF in Quebec, Canada (2000-2017), CA patients were matched 1:2 to controls on time and frequency of hospitalizations. Confounders were controlled for using inverse probability of treatment weighting. Multivariable Cox models adjusted for the presence of cardiac electronic implantable devices and medication use during follow-up, and the effect of time since CA was modelled with B-splines. For non-fatal outcomes, the Lunn-McNeil approach was used to account for the competing risk of death. Among 101 933 AF-HF patients, 451 underwent CA and were matched to 899 controls. Over a median follow-up of 3.8 years, CA was associated with a statistically significant reduction in all-cause mortality [hazard ratio 0.4 (95% confidence interval 0.2-0.7)], but no difference in stroke or major bleeding. The hazard of HF rehospitalization for CA patients, relative to non-CA patients, varied with time since CA (P = 0.01), with a reduction in HF rehospitalizations until approximately 3 years post-CA. Compared with matched non-CA patients, CA was associated with a long-term reduction in all-cause mortality and a reduction in HF rehospitalizations until 3 years post-CA.

Abstract P5-14-14: A validated clinical risk prediction model for cardiac toxicity in patients treated with antiHER2 agents

Abstract Background: Cardiac toxicity (CT) in the form of left ventricular systolic dysfunction is a well-known complication of anti-HER2 therapy. Prior clinical trial data has suggested potential factors associated with increased risk for CT. We sought to develop a clinical risk prediction model from real world patients to better identify patients who may be at higher risk for CT. Methods: Patients treated with anti-HER2 agents at all Mayo Clinic sites from Jan 2008 to July 2015 were reviewed. Patient data including age, race, body mass index, comorbidities, smoking history, baseline ejection fraction (EF), presence of left ventricular hypertrophy (LVH), prior cancer treatments, number of anti-HER2 agents used, and cardiac medication use were recorded. Factors were compared in patients with and without development of CT. Cox regression models were used to identify univariate and multivariate predictors of CT. A risk score was then assigned based on the final multivariable model. Results: 604 patients were included in final analysis. Median follow-up 2.9 yrs; median age: 57 yr; baseline EF: 64%. One yr CT rate was 7%. Independent predictors of CT were age, baseline EF, LVH, and anthracycline use (C index=0.74). Based on model coefficient, scores of 1, 1, 2 and 3 were assigned to age&amp;gt;55, EF &amp;lt;60%, anthracycline exposure and LVH, respectively. Two random samples of 300 patients were created out of the original cohort for internal validation of the risk score model. In each, the risk score was found to be a highly significant predictor for CT with C index of 0.72 {HR 2.13 (95% CI 1.57-2.90), p &amp;lt;0.001} and 0.77 {HR 2.45 (95% CI 1.74-3.44), p &amp;lt;0.001}. Conclusions: Patients with risk factors of older age, lower baseline EF, anthracycline use and LVH are at increased risk for CT when treated with anti-HER2 agents. Using a risk prediction model at therapy initiation may enhance identification of patients who benefit from cardiology referral, closer cardiac monitoring, and/or prophylactic treatment while on anti-HER2 targeted therapy. Table 1. Multivariable Cox regression model predicting cardiac dysfunctionParameterParameter EstimateHR (95%CI)p valueScoreAge &amp;gt;550.909552.48(1.27, 4.84)0.00751EF&amp;lt;600.634361.89(1.01, 3.53)0.04751Anthracycline Exposure1.046132.85(1.48, 5.46)0.00162Baseline LVH1.633565.12(2.04,12.85)&amp;lt;0.0013 Citation Format: Pooja P Advani, Lauren Cornell, Zhuo Li, Jordan Ray, Catalina Sanchez, Armando Villanueva, Taryn Smith, Alvaro Moreno-Aspitia. A validated clinical risk prediction model for cardiac toxicity in patients treated with antiHER2 agents [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-14-14.

Pattern of Structural Heart Disease and Predictors of Mortality Among Affected Children Seen at the Niger Delta University Teaching Hospital Bayelsa State

Paediatric structural heart diseases are an important cause of morbidity and mortality especially in developing countries where late presentation and delayed diagnosis and treatment is common. The aim of this study was to describe the pattern of structural heart diseases in children seen in the Paediatric Cardiology Unit of a tertiary hospital in Bayelsa State Nigeria and identify the predictors of mortality among those who died over the study period. It was a retrospective review of cases seen in the paediatric cardiology unit and subsequently followed up over a 7-year period (1^st April 2013 to 31^st March 2020). Sociodemographic data, clinical features and echocardiographic findings as well as details of their outcome were documented. Data was imputed into an Excel spread sheet and analyzed using SPSS 22.0. Binary logistic regression was performed to determine the risk factors for mortality. Of the 175 children seen by the Cardiology Unit over the study period, 92 (52.6%) had structural heart diseases. The mean age of the children was 39.4±56.2 months with a male: female ratio of 1.6:1. Congenital heart diseases (CHD) were noted in 92% of cases with Atrial septal defects (ASD), followed by Ventricular Septal defects (VSD) and Patent Ductus Arteriosus (PDA) being the most prevalent CHD seen. The combination of ASD/VSD/PDA was the most common multiple structural defect noted. Acquired heart diseases including Rheumatic heart disease and Dilated cardiomyopathy were reported in 8% of cases. Mortalities were recorded in 20 children (21.7%) with most of the deaths occurring as a result of intractable heart failure. Mortality was significantly associated with the third birth order (OR-4.63; p-0.021), fast breathing (OR-2.15; p-0.006), presence of heart failure (OR-3.16; p-0.026), failure to thrive (OR-2.93; p-0.036), use of cardiac medications (OR-6.91; 0.0013) and CHD with multiple structural defects (OR-11.44; p-0.006).

Fractional Flow Reserve Derived from Computed Tomography Coronary Angiography in the Assessment and Management of Stable Chest Pain: Rationale and Design of the FORECAST Trial

BackgroundFractional flow reserve measurement based on computed tomography (FFRCT) is a novel, well validated, non-invasive method for determining the presence and extent of coronary artery disease (CAD) combined with a physiological assessment of vessel-specific ischemia in patients with chest pain. Previous studies indicate that FFRCT reduces the uptake of invasive angiography that shows no significant CAD, without compromising patient safety. The clinical effectiveness and economic impact of using FFRCT instead of other tests in the initial evaluation of patients with stable chest pain has not been tested in a randomized trial. MethodsThe FORECAST trial will randomise 1400 patients with stable chest pain to receive either FFRCT or routine clinical assessment as directed by the National Institute for Health and Care Excellence (NICE) CG95 guideline for Chest Pain of Recent Onset. The primary endpoint will be resource utilisation over the subsequent nine months, including non-invasive cardiac investigations, invasive coronary angiography, coronary revascularization, hospitalization for cardiac events, and the use of cardiac medications. Key pre-specified secondary endpoints will be major adverse cardiac events, angina severity, quality of life, patient satisfaction, time to definitive management plan, time to completion of initial evaluation, number of hospital attendances, and working days lost in patients who are in employment. ConclusionThe FORECAST randomized trial will assess the clinical and economic outcomes of using FFRCT as the primary test to evaluate patients presenting with stable chest pain.

Over-the-counter mouthwash use, nitric oxide and hypertension risk

Purpose: Mouthwash is used by a large population. Short-term clinical trials have shown that antibacterial mouthwash deplete oral nitrate-reducing bacteria, and decrease systemic nitric oxide bioavailability. Our previous publication from the San Juan Overweight Adults Longitudinal Study (SOALS) was the first to show frequent over-the-counter mouthwash use was independently associated with increased risk of prediabetes/diabetes. This manuscript evaluates whether over-the-counter mouthwash was associated with increased risk of hypertension.Materials and methods: SOALS recruited 40-65 year old overweight/obese individuals; baseline evaluations started in 2011 and the 3-year follow-up exam was completed by 2016. From the 1028 participants (76%) who completed follow-up, we excluded people with reported physician diagnosis of hypertension or systolic or diastolic BP at or above the hypertension cut-offs (n = 481), missing smoking (n = 1), missing physical activity (n = 1) and missing alcohol intake (n = 5) at baseline; 540 participants were included. The primary exposure was mouthwash use twice daily or more. The primary outcome for this manuscript is self-reported physician-diagnosed hypertension over the follow-up. We used Poisson regression controlling for age, sex, smoking, physical activity, waist circumference, alcohol intake, systolic blood pressure, pre-diabetes/diabetes status and cardiac medication use. We additionally evaluated other mouthwash use categorizations.Results: Twelve percent (66/540) developed hypertension over follow-up. People who used mouthwash twice/day or more had higher incidence of hypertension compared to less frequent users (Incidence Rate Ratio = 1.85; 95% Confidence Interval: 1.17, 2.94), and compared to non-users (IRR = 2.17; 95% CI: 1.27, 3.71). Several additional potential confounders evaluated did not impact these associations. Associations persisted among never smokers. Additional outcomes including BP assessed at a single study visit did not show associations.Conclusion: In this study, frequent regular use of over-the-counter mouthwash was associated with increased risk of hypertension, independent of major risk factors for hypertension and several other potential confounders.

Responses to Pirfenidone Treatment in Patients with Idiopathic Pulmonary Fibrosis is Not Associated with Changes in Echocardiographic Parameters of Left Ventricular Structure and Function

Background Pirfenidone, an FDA-approved novel anti-fibrotic agent used in the treatment of idiopathic pulmonary fibrosis (IPF), has been implicated in mitigating myocardial fibrosis, systolic and diastolic dysfunction in animal models (Kuwahara et al, Circulation 2002). However to date, the effect of Pirfenidone on left ventricular (LV) structure and function in humans with IPF has not been studied. Hypothesis We hypothesize that changes in echocardiographic parameters of LV structure and function would be more favorable in responders compared to non-responders of pirfenidone in patients with IPF. Methods We performed a retrospective review of 27 consecutive patients with IPF on pirfenidone between 2014-2018 with serial baseline and follow up echocardiograms and pulmonary function testing. Treatment failure (non-response) was defined as an absolute decline in forced vital capacity (FVC) of more than 10% whilst being on the medication. Comprehensive echocardiographic data extraction and analysis was performed in all patients. Changes in parameters of LV structure (LV mass, interventricular septal and posterior wall thickness, indexed end systolic and diastolic volumes), systolic function (LVEF), diastolic function (Indexed left atrial volume, trans-mitral Doppler flow patterns, tissue Doppler indices) and global LV longitudinal strain were compared between responders and non-responders. Results In our study cohort, 18 responders and 9 non-responders were identified. Responders were significantly older than non-responders, yet sex, history of CAD, hypertension, diabetes, atrial fibrillation, CKD and cardiac medication use were not significantly different. Baseline echocardiographic parameters were comparable, except for septal e/e’, which was higher in responders (11.68 vs 10.1; p Conclusion In contrary to our hypothesis, we observed that response to pirfenidone therapy in patients with IPF did not associate with echocardiographic changes of left ventricle structure and function.

Increased Blood Pressure and Body Mass Index as Potential Modifiable Factors in The Progression of Myocardial Dysfunction in Duchenne Muscular Dystrophy.

Duchenne muscular dystrophy (DMD) is characterized by progressive cardiomyopathy. Left ventricular (LV) function may worsen by factors increasing LV afterload such as hypertension and obesity. To identify potential modifiable risk factors for progression of cardiomyopathy in Duchenne muscular dystrophy (DMD). We retrospectively analysed systolic blood pressures (SBP) and body-mass indexes (BMI) from 273 visits of 65 DMD patients aged 4-18 years between 2003 and 2016, divided in 14 age groups. Values were normalized using Z-scores (Z-SBP and Z-BMI). A linear mixed model was used to analyse correlations between Z-SBP and BMI, steroid use, age, ambulatory status and cardiac medication (CM) use. To study the relationship between SBP and BMI and myocardial deformation prior to the onset of clinical cardiomyopathy, LV deformation, defined by global longitudinal strain (GLS), was quantified in a subset of 36 patients <11 years. Multiple linear regression was used to study the relation between GLS and clinical parameters. Median follow-up was 5 years. SBP was significantly elevated in all age groups under 14 years (p≤0.04) and 15-16 years (p = 0.033) and correlated positively with BMI (p = 0.001) and negatively with CM use over time (p = 0.018). Z-BMI followed a bell-shaped distribution and plotted approximately one standard deviation above the mean in patients between 7 and 15 years. In the subset of younger patients, reduced GLS was associated with higher BMI (β= 0.348, p = 0.004). SBP and BMI may be potentially modifiable factors to retard deterioration of LV function in DMD.

Risk Factors for Pulmonary Hypertension in Adults After Atrial Septal Defect Closure

Atrial septal defect (ASD) closure is performed to prevent pulmonary hypertension (PH), which is associated with poor outcome. This study investigated the prevalence of PH in adults before and after ASD closure and explored associations between patient characteristics and PH after ASD closure. Consecutive adult patients who underwent surgical or percutaneous ASD closure in the Erasmus MC, the Netherlands, were included (2000 to 2014). Echocardiograms before and after ASD closure were retrospectively assessed. Patients were categorized into 3 groups (no PH, possible PH, and PH) based on tricuspid regurgitation velocity (<2.9, 2.9 to 3.4, and ≥3.4 m/s) or mean pulmonary arterial pressure (<20, 20 to 24, and ≥25 mm Hg). Cox regression was performed to identify associations between patient characteristics and PH after ASD closure. Of the 244 eligible patients who underwent ASD closure, 198 (81%) had echocardiograms both before and median 15 (interquartile range 12 to 35) months after ASD closure (median age at closure 45 [interquartile range 30 to 57] years, 75% woman). The prevalence of PH was 13.1% (n = 26) before ASD closure and 5.0% (n = 10) after closure. New York Heart Association III to IV (hazard ratio [HR] 11.07, 95% confidence interval [CI] 3.12 to 39.29, p <0.001), pulmonary disease (HR 10.43, 95% CI 2.12 to 51.21, p = 0.004), cardiac medication use (HR 3.96, 95% CI 1.02 to 15.34, p = 0.047), right ventricular fractional area change (HR 0.87, 95% CI 0.81 to 0.93, p <0.001), and tricuspid annular plane systolic excursion (HR 0.75, 95% CI 0.59 to 0.95, p = 0.018) were significantly associated with PH. In conclusion, adult patients with low pulmonary pressures before ASD closure are not at risk of PH after closure. Nevertheless, PH remained prevalent in approximately 5% of patients. Especially those patients with high New York Heart Association functional class, presence of pulmonary disease, cardiac medication use and impaired RV function at baseline are at risk.

Emergency Department Volume and Outcomes for Patients After Chest Pain Assessment.

Chest pain is one of the most common reasons for emergency department (ED) visits in developed countries. Whether higher volume EDs have better outcomes, specifically for patients with chest pain, is unknown and pertinent. We conducted a study using population-based data on 498 291 patients ≥40 years old, presenting to ED in Ontario, Canada from 2008 to 2014, with chest pain and were discharged after assessment. We evaluated processes of care after discharge from ED. The primary outcome was a composite of all-cause death or hospitalization for acute coronary syndrome. Hierarchical logistic regression models adjusting for potential confounding variables were used to evaluate the association of annual ED chest pain volume and outcome. We also determined if there was a volume threshold above which an increased ED volume was not associated with a lower adverse outcome. The mean age of our patients was 59 years, 46.7% were men, and 20% had diabetes mellitus. Patients discharged from higher volume EDs had higher rates of cardiologist consultations, cardiac medication use, and cardiac testing within 30 days of ED assessment. Higher ED volume was associated with significantly lower adjusted odds ratio for mortality or acute coronary syndrome (odds ratio, 0.87; 95% CI, 0.82-0.92 per each unit increase in the log of volume) at 30 days and at 1 year (odds ratio, 0.92; 95% CI, 0.88-0.92). Once the annual ED chest pain volume reached 1400 cases (95% CI, 910-1900), an increase of annual chest pain volume of 100 was associated with relative decrease in the odds of the composite outcome at 30 days of <1%. Evaluations of chest pain in EDs with higher chest pain volume had lower rates of death or hospitalizations for acute coronary syndrome. There was a volume threshold above which an increase in volume was no longer associated with reduced outcomes.

Underutilization of antiplatelet and statin therapy after postoperative myocardial infarction following vascular surgery

ObjectiveThe objective of this study was to investigate adherence to practice guidelines for antiplatelet and statin use after postoperative myocardial infarction (POMI) and its effect on late mortality following vascular surgery in a multicenter registry. MethodsAntiplatelet and statin use was examined in 1749 vascular surgery procedures with POMI within the Vascular Quality Initiative (VQI) from 2005 to 2015. Our primary aim was to assess cardiac medication (CM) use at discharge, defined as (1) single antiplatelet therapy (SAPT; aspirin or P2Y12 inhibitor) or dual antiplatelet therapy (DAPT; aspirin and P2Y12 inhibitor) and (2) statin therapy. Long-term mortality in patients with POMI was analyzed on the basis of discharge CM. A proportional hazards model was developed to control for factors associated with mortality. Regional differences in CM use at discharge after POMI were compared. ResultsOverall discharge CM use after POMI included aspirin (81%), P2Y12 inhibitor (38%), statin therapy (76%), and combined antiplatelet and statin (74%). At discharge, 26% of patients were not receiving combined antiplatelet and statin therapy. SAPT (50%) was more common than DAPT (35%; P < .001). Patients with POMI undergoing carotid endarterectomy were more likely to be discharged on CM (80%) compared with patients undergoing infrainguinal bypass (78%), suprainguinal bypass (72%), endovascular aneurysm repair (71%), and open abdominal aortic aneurysm repair (59%; P < .001). Patients receiving SAPT or DAPT plus statin therapy had improved survival (79%) compared with those receiving noncombination or no therapy (69%) with mean follow-up of 5.5 years and 4.9 years, respectively (log-rank, P = .001). After adjustment for covariates including preoperative medications, treatment with SAPT or DAPT plus statin at discharge was associated with lower late mortality compared with noncombination or no therapy (hazard ratio, 0.72; 95% confidence interval, 0.56-0.93; P = .01). Regional variation in CM at discharge following POMI was also observed with a range of 33% to 100% (P = .05). ConclusionsWithin the VQI, regional and procedure-specific variation exists in CM regimen after POMI following vascular surgery. Absence of combined antiplatelet and statin therapy at discharge after POMI was associated with higher late mortality and represents an area for quality improvement in the care of these patients.

How Dangerous Is Hyperkalemia?

Hyperkalemia is a potentially life-threatening electrolyte disorder appreciated with greater frequency in patients with renal disease, heart failure, and with use of certain medications such as renin angiotensin aldosterone inhibitors. The traditional views that hyperkalemia can be reliably diagnosed by electrocardiogram and that particular levels of hyperkalemia confer cardiotoxic risk have been challenged by several reports of patients with atypic presentations. Epidemiologic data demonstrate strong associations of morbidity and mortality in patients with hyperkalemia but these associations appear disconnected in certain patient populations and in differing clinical presentations. Physiologic adaptation, structural cardiac disease, medication use, and degree of concurrent illness might predispose certain patients presenting with hyperkalemia to a lower or higher threshold for toxicity. These factors are often overlooked; yet data suggest that the clinical context in which hyperkalemia develops is at least as important as the degree of hyperkalemia is in determining patient outcome. This review summarizes the clinical data linking hyperkalemia with poor outcomes and discusses how the efficacy of certain treatments might depend on the clinical presentation.

Temporal stability and drivers of change in cardiac autonomic nervous system activity

This study determined temporal stability of ambulatory measured cardiac autonomic activity for different time periods and investigated potential drivers of changes in this activity. Data was drawn from baseline (n=2379), 2-year (n=2245), and 6-year (n=1876) follow-up from the Netherlands Study of Depression and Anxiety. Cardiac autonomic activity was measured with heart rate (HR), respiratory sinus arrhythmia (RSA) and pre-ejection period (PEP). Autonomic temporal stability was determined across 2, 4, and 6year intervals. We subsequently examined the association between sociodemographics, lifestyle, mental health, cardiometabolic health, and the use of antidepressant and cardiac medication with change in cardiac autonomic activity. Over 2years, stability was good for HR (ICC=0.703), excellent for RSA (ICC=0.792) and moderate for PEP (ICC=0.576). Stability decreased for a 4- (HR ICC=0.688, RSA ICC=0.652 and PEP ICC=0.387) and 6-year interval (HR ICC=0.633, RSA ICC=0.654 and PEP ICC=0.355). The most important determinants for increase in HR were (increase in) smoking, increase in body mass index (BMI) and (starting) the use of antidepressants. Beta-blocking/antiarrhythmic drug use led to a decrease in HR. Decrease in RSA was associated with age, smoking and (starting) antidepressant use. Decrease in PEP was associated with age and (increase in) BMI. Cardiac autonomic measures were rather stable over 2years, but stability decreased with increasing time span. Determinants contributing to cardiac autonomic deterioration were older age, (increase in) smoking and BMI, and (starting) the use of antidepressants. (Starting) the use of cardiac medication improved autonomic function.

Underuse of Effective Cardiac Medications Among Women, Middle-Aged Adults, and Racial/Ethnic Minorities With Coronary Artery Disease (from the National Health and Nutrition Examination Survey 2005 to 2014)

Given the proven effectiveness of several cardiac medications for patients with coronary artery disease (CAD), we examined the national use of 4 classes of effective medications, overall and by age, sex, and race/ethnicity in 2005 to 2014. We used data from the National Health and Nutrition Examination Survey, including a self-reported diagnosis of CAD and independently verified medication use. Weighting procedures extrapolated our data to the adult US population with CAD. Analyses included 1,789 US adults aged ≥45 years with a history of CAD. The average age of this population was 68 years; 40% were women and 79% were non-Hispanic whites. In 2005 to 2014, 53.2% (standard error [SE] = 1.5) reported use of angiotensin-converting enzyme inhibitor/angiotensin receptor blockers, 58.5% (SE = 1.5) β blockers, and 67.2% (SE = 1.4) statins. Two of these medications were used by 64.1% (SE = 1.5) of the study population and all 3 by 29.1% (SE = 1.3). In 2011 to 2014, 68.5% (SE = 2.4) of American adults with a history of CAD reported use of aspirin. The use of statins increased from 63.1% in 2005/2006 to 76.8% in 2013/2014. Adults aged 45 to 64 years old, women, and racial/ethnic minorities had lower use of effective cardiac medications compared with older adults, men, and non-Hispanic whites. In conclusion, the use of statins, but not other medications, has increased over the past 10 years among American adults with previously diagnosed CAD. Continued targeted efforts are needed to increase the receipt of effective cardiac medications among all US adults with CAD, especially those aged 45 to 64 years, women, and racial/ethnic minorities.

Interventions Supporting Long-term Adherence aNd Decreasing cardiovascular events (ISLAND): Pragmatic randomized trial protocol

Guidelines recommend cardiac rehabilitation and long-term use of cardiac medications for most patients who have had a myocardial infarction (MI), but adherence to these secondary prevention treatments is suboptimal. This is a multicenter, pragmatic, 3-arm randomized trial. Eligible patients (n = 2,742) with obstructive coronary artery disease are randomized post-MI to usual care or 1 of 2 intervention arms. Patients in the first intervention arm receive mail-outs sent on behalf of their cardiologist at 4, 8, 20, 32, and 44 weeks post-MI; content is designed to address determinants of adherence and facilitate discussion between the patient and their health care team. Patients in the second intervention arm receive mail-outs plus automated interactive voice response system telephone calls 2 weeks after each letter, as well as a telephone call by trained lay health workers if the interactive voice response system identifies challenges with adherence. Outcomes are assessed 12 months post-MI via patient self-report and administrative data sources. Co-primary outcomes are adherence to cardiac medications and completion of cardiac rehabilitation. Secondary outcomes include cardiovascular events and mortality. An embedded, theory-informed process evaluation will explore the mechanism of action; an economic evaluation is also planned. We describe a complete program evaluation of a highly pragmatic, health-system intervention to support adherence to recommended treatments. Research ethics boards approved waiver of consent for patients enrolled in the trial with provision of multiple opportunities to opt out and a debrief at the time of outcome assessment. The methods used here may provide a model for similar interventions.