Journal Scan

In this journal scan, articles published in various cardiovascular journals between April and June 2023 are being presented. The articles are ordered according to the subsets of cardiology (Coronary artery disease, Heart failure, Arrhythmias, Imaging, Pulmonary hypertension, and Valvular Heart Disease).

Coronary Artery Disease

In this subset, the positive results of a prospective, multicenter study to evaluate the safety and performance of the CAT RX aspiration catheter in patients with a high thrombus burden acute coronary vessel occlusion (CHEETAH) study proved the importance of thrombectomy in percutaneous coronary intervention (PCI). Despite the increased complexity of the disease, unprotected left main PCI is associated with improved outcomes when compared to an earlier decade. Improvement of left ventricular ejection fraction is an important factor to be addressed in patients with recurrent left ventricular thrombus. Common blood investigations like lactate, albumin, and bilirubin were found to be independently predictive of mortality in acute myocardial infarction .

Sustained Mechanical Aspiration Thrombectomy for High Thrombus Burden Coronary Vessel Occlusion: The Multicentre CHEETAH Study

Mathews SJ, Parikh SA, Wu W, Metzger DC, Chambers JW, Ghali MGH, et. al.

Circ Cardiovasc Interv. 2023 Feb;16(2): e012433. doi: 10.1161/CIRCINTERVENTIONS.122.012433. Epub 2023 Feb 21. PMID: 36802804

Abstract

Background: Poor myocardial reperfusion due to distal embolization and microvascular obstruction after percutaneous coronary intervention (PCI) is associated with an increased risk of morbidity and mortality. Prior trials have not shown a clear benefit of routine manual aspiration thrombectomy. Sustained mechanical aspiration may mitigate this risk and improve outcomes. The objective of this study is to evaluate sustained mechanical aspiration thrombectomy before PCI in high thrombus-burden acute coronary syndrome patients.

Methods: This prospective study evaluated the Indigo CAT RX Aspiration System (Penumbra Inc, Alameda, California, USA) for sustained mechanical aspiration thrombectomy before PCI at 25 hospitals across the USA. Adults presenting within 12 hours of symptom onset with high thrombus burden and target lesion(s) located in a native coronary artery were eligible. The primary endpoint was a composite of cardiovascular death, recurrent myocardial infarction (MI), cardiogenic shock, or new or worsening New York Heart Association class IV heart failure within 30 days. Secondary endpoints included thrombolysis in MI thrombus grade, thrombolysis in MI flow, myocardial blush grade, stroke, and device-related serious adverse events.

Results: From August 2019 to December 2020, a total of 400 patients were enrolled (mean age 60.4 years, 76.25% male). The primary composite endpoint rate was 3.60% (14/389 [95% confidence interval, 2.0–6.0%]). The rate of stroke within 30 days was 0.77%. Final rates of thrombolysis in MI thrombus grade 0, thrombolysis in MI flow 3, and myocardial blush grade 3 were 99.50%, 97.50%, and 99.75%, respectively. No device-related serious adverse events occurred.

Conclusions: Sustained mechanical aspiration before PCI in high thrombus burden acute coronary syndrome patients was safe and was associated with high rates of thrombus removal, flow restoration, and normal myocardial perfusion on final angiography.

Comments: Large intracoronary thrombus is associated with increased mortality and morbidity, distal embolization, and no-reflow phenomenon. Manual thrombectomy trials did not show any mortality benefit leading to class IIB indication. However, in patients with a high thrombus burden, it led to decreased cardiovascular death but increased stroke, and transient ischemic attacks. The main reason for the ineffective thrombus retrieval was decreasing aspiration force as the syringe gets filled. The embolization events were due to the requirement of the operator to exchange syringes during the procedure. A sustained mechanical aspiration and a dedicated vacuum pump with constant aspiration force were hypothesized to solve the drawbacks. The efficacy of this device was known in neuro vasculature. The achievement of 99.75% myocardial blush grade 3 and no device-related serious adverse events ascertains the efficacy of this device in thrombus retrieval and improved cardiac outcomes.

Temporal Trends in In-hospital Outcomes Following Unprotected Left-main Percutaneous Coronary Intervention: An Analysis of 14 522 Cases from British Cardiovascular Intervention Society Database 2009 to 2017

Kinnaird T, Gallagher S, Farooq V, Protty M, Back L, Devlin P et al.

Circ Cardiovasc Interv. 2023 Jan;16(1):e012350. doi: 10.1161/CIRCINTERVENTIONS.122.012350. Epub 2023 Jan 17. PMID: 36649390

Abstract

Background: Percutaneous coronary intervention (PCI) is increasingly used as a treatment option for unprotected left main stem (uLMS) artery (uLMS percutaneous intervention) disease. However, whether patient outcomes have improved over time is uncertain.

Methods: Using the United Kingdom national PCI database, we studied all patients undergoing uLMS percutaneous intervention between 2009 and 2017. We excluded patients who presented with ST-segment–elevation, cardiogenic shock, and an emergency indication for PCI.

Results: Between 2009 and 2017, in the study-indicated population, 14522 uLMS percutaneous intervention procedures were performed. Significant temporal changes in baseline demographics were observed with increasing patient age and comorbid burden. Procedural complexity increased over time, with the number of vessels treated, bifurcation PCI, the number of stents used, and the use of intravascular imaging and rotational atherectomy increased significantly through the study period. After adjustment for baseline differences, there were significant temporal reductions in the occurrence of peri-procedural myocardial infarction (p < .001 for trend), in-hospital major adverse cardiac or cerebrovascular events (p < .001 for trend), and acute procedural complications (p < .001 for trend). In multivariable analysis examining the associates of in-hospital major adverse cardiac or cerebrovascular events, while age per year (odds ratio, 1.02 [95% confidence interval, 1.01–1.03]), female sex (odds ratio, 1.47 [1.19–1.82]), three or more stents (odds ratio, 1.67 [05% [1.02–2.67]), and patient comorbidity were associated with higher rates of in-hospital major adverse cardiac or cerebrovascular events, by contrast, use of intravascular imaging (odds ratio, 0.56 [0.45–0.70]), and year of PCI (odds ratio, 0.63 [0.46–0.87]) were associated with lower rates of in-hospital major adverse cardiac or cerebrovascular events.

Conclusions: Despite trends for increased patient and procedural complexity, in-hospital patient outcomes have improved after uLMS percutaneous intervention over time.

Comments: The superiority of PCI vs coronary artery bypass graft (CABG) surgery in the left main disease revascularization is of debate over the decades. Although many studies are comparing uLMS-PCI and CABG, there are limited data on the temporal changes in patient outcomes after uLMS-PCI, and in the complex and high-risk coronary intervention (CHIP) population. The trial data favoring CABG (Nordic - Baltic - British left main revascularization (NOBEL)) and PCI (evaluation of XIENCE versus coronary artery bypass surgery for effectiveness of left main revascularization (EXCEL)) used different definitions and led to different conclusions. The CABG is beneficial in this subset compared to PCI as the non-flow limiting lesions are not addressed in the latter, the main cause of recurrent Mis at follow-up. It is the first study of analysis of uLMS-PCI in the CHIP population. Many previous studies have shown that left main stenting would often lead to distal bifurcation stenting. The advent of angled microcatheters has led to improvised access to angled circumflex. This study showed despite the increased patient and procedural complexity and severity of coronary artery disease, uLMS-PCI has improved patient outcomes over a decade. The improved outcomes were seen in centers with increased volumes. This volume-outcome effect is not seen with PCI in general. The other reason is a potent dual antiplatelet therapy. The location of the disease in the left main stem, the presence of calcium in the lesion, type of distal bifurcation disease was not assessed in this study. So, the relationship between disease and outcomes could not be evaluated.

Factors Influencing Left Ventricular Thrombus Resolution and its Significance on Clinical Outcomes

Kim SE, Lee CJ, Oh J, Kang SM.

ESC Heart Fail. 2023 Jun;10(3):1987–1995. doi: 10.1002/ehf2.14369. Epub 2023 Apr 3. PMID: 37009745

Abstract

Aims: A left ventricular thrombus (LVT) is not uncommon in patients with impaired LV systolic function. However, the treatment strategy for LVT has not yet been fully established. We aimed to identify the factors influencing LVT resolution and the significance of LVT resolution on clinical outcomes.

Methods: There were 212 patients diagnosed with LVT (mean age, 60.5 ± 14.0 years; male, 82.5%). The mean left ventricular ejection fraction (LVEF) was 33.1 ± 10.9%, and 71.7% of patients were diagnosed with ischemic cardiomyopathy. Most patients were treated with vitamin K antagonists (VKA) (86.7%), and 28 patients (13.2%) were treated with direct oral anticoagulants or low molecular weight heparin. LVT resolution was observed in 179 patients (84.4%). LVEF improvement failure within 6 months was a significant factor hindering LVT resolution (hazard ratio [HR]: 0.52, 95% confidence interval [CI]: 0.31–0.85, p = .010). During a median of 4.0 years of follow-up (interquartile range: 1.9 to 7.3 years), 32 patients (15.1%) experienced primary outcomes (18 all-cause deaths, 15 strokes, and 3 arterial thromboembolisms) and 20 patients (11.2%) experienced LVT recurrence after LVT resolution. LVT resolution was independently associated with a lower risk for primary outcomes (HR: 0.45, 95% CI: 0.21–0.98, p = .045). In the patients with resolved LVT, discontinuation or duration of anticoagulation after resolution were not significant predictors for LVT recurrence, but LVEF improvement failure at LVT resolution was associated with a significantly higher risk of LVT recurrence (HR: 3.10, 95% CI: 1.23–7.78, p = .016).

Conclusions: This study suggests that LVT resolution is an important predictor for favorable clinical outcomes. LVEF improvement failure interfered with LVT resolution and appeared to be a crucial factor for LVT recurrence. After LVT resolution, the continuation of anticoagulation did not seem to impact LVT recurrence and the prognosis.

Comments: The presence of LVT places the patient at risk of embolization. Managing these patients is a double edge sword. It includes the use of oral anticoagulants, with an increased risk of bleeding when combined with dual antiplatelet therapy. The non-Vitamin K antagonist s are as efficacious as the VKA. The triple therapy duration is for at least four weeks. Following four weeks a single antiplatelet preferably a P2Y12 antagonist is used. A patient with no improvement in LVEF despite the resolution of the thrombus, is prone to recurrent thrombi as shown in this study. The single denominator to be addressed in such patients is the improvement of LVEF more than the resolution of thrombus.

Association Between Lactate/Albumin Ratio And Mortality in Patients with Heart Failure after Myocardial Infarction

Chen Y, Yang K, Wu B, Lin W, Chen S, Xu X, et al.

ESC Heart Failure. 2023 Jun;10(3):1928–1936. doi: 10.1002/ehf2.14359. Epub 2023 Mar 28. PMID: 36987543

Abstract

Aims: Lactate/albumin ratio (L/A) is a recognized prognostic index of patients with heart failure (HF) after myocardial infarction (MI). We aim to evaluate the prognostic value of the L/A ratio in predicting in-hospital mortality for those patients.

Methods and Results: We enrolled qualified patients from Medical Information Mart for the Intensive Care IV database for a retrospective study. A receiver operating characteristic (ROC) curve of the subjects was applied to determine the predicted value and the best cut-off value of L/A on admission. Univariate/multivariate Cox regression analysis and restricted cubic splines (RCS) were performed to identify the association between hospital admission and hospital mortality. The Kaplan–Meier (KM) method was used to draw the survival curve of the two groups with different L/A levels at admission. L/A values at admission were significantly higher in the death groups than the survival groups [1.36 (1.20) vs. 0.62 (0.36), p < .05], and area under the ROC curve [0.780 (95% confidence interval, 0.772–0.827)] was better than other indicators, and the best the cut-off value was 0.671. Data from Cox regression analysis showed that a higher L/A value is supposed to be an independent risk factor for in-hospital mortality. RCS analysis showed evidence of an increasing trend and a non-linear relationship between L/A and in-hospital mortality (p value was non-linear <.05). KM survival curves were significantly lower in the high L/A group than in the low L/A group (p < .001), and the former group had an increased risk of in-hospital mortality compared with the latter one (log-rank p < .001).

Conclusions: Elevated L/A ratio on admission is an independent predictor of high in-hospital mortality in post-MI HF patients, which proved to be better than lactate, Sequential Organ Failure Assessment score, and other related indicators.

Comments: The incidence of MI is increasing year by year, and the number of patients with HF after MI is also gradually elevating. Elevated lactate levels are associated with mortality, which is widely used for early diagnosis, treatment, and risk stratification of patients with infectious shock. Serum lactate is a marker of hypoperfusion. It is elevated in liver and kidney dysfunction apart from HF. Similarly, albumin acts as a negative acute phase protein and is affected by various pathological conditions like lactate. The lactate-to-albumin ratio was a prognostic marker in severe sepsis. and HF patients. When assessed for the prognostic value regarding incident HF post-MI, the L/A ratio and sequential organ failure assessment (SOFA) were found to be more predictive than Troponin T and systemic inflammatory response syndrome (SIRS) score. The optimal cutoff value was 0.671 with a sensitivity and specificity of 76.1 % and 72.3% respectively. The higher the values, the higher the risk of death showing a linear relationship. It is an easily available test compared to other biomarkers.

Circulating Total Bilirubin and Long-Term Prognosis in Patients with Previous Myocardial Infarction

Cao YX, Liu HH, Li S, Zhang M, Guo YL, Wu NQ, et al.

JACC: Asia. 2023 Feb 7;3(2):242–251. doi: 10.1016/j.jacasi.2022.11.002. PMID: 37181387

Abstract

Background: Although experimental studies have demonstrated the protective role of total bilirubin (TBil) in cardiovascular diseases (CVDs), several previous clinical observations are controversial. More importantly, no data are currently available regarding the relation of TBil to major adverse cardiovascular events (MACE) in patients with previous myocardial infarction (MI).

Objectives : This study sought to explore the association between TBil and long-term clinical outcomes in patients with previous MI.

Methods : A total of 3,809 patients who are post-MI were consecutively enrolled in this prospective study. Cox regression models using hazard ratios (HRs) and confidence interval (Cis) were applied to investigate associations between the TBil concentration category (group 1: bottom to median tertiles within the reference range; group 2: top tertile; group 3: above reference range) and main outcome (recurrent MACE) as well as secondary outcomes (hard endpoints and all-cause mortality).

Results : During the 4-year follow-up period, 440 patients (11.6%) suffered from recurrent MACE. Kaplan-Meier survival analysis showed the lowest MACE incidence in group 2 (p < .001). When compared with the reference group (group 1) in multivariable analysis, a J-shaped association was apparent for MACE, with a decreased risk in group 2 (HR: 0.76; 95% CI: 0.59–0.96) and elevated risk in group 3 (HR: 1.29; 95% CI: 1.03–1.61). Similar associations were identified regarding hard endpoints and all-cause mortality. Moreover, TBil demonstrated incremental discriminatory strength when added to the predictive model.

Conclusions : In this prospective cohort study with long-term follow-up, higher TBil levels within the physiological range reduced the incidence of long-term cardiovascular events in patients who are post-MI.

Comments: Multiple biomarkers are used for the prediction of cardiovascular outcomes and risk stratification. Clinically, circulating TBil has been used for the diagnosis of liver diseases. The existing evidence supports that TBil within the normal physiologic range is a potent endogenous antioxidant with pleiotropic effects which may likely contribute to the protective effect on various oxidative stress diseases like diabetes, stroke, peripheral arterial disease, heart failure, and CVD. Increased levels can be due to congestion of the liver secondary to cardiac dysfunction. Trends of bilirubin levels, rather than single point measurement, and at discharge measurement of bilirubin is of value in predicting the long-term MACE. The association of bilirubin with cardiac events was not linear and had a J or U curve. Only the moderately elevated bilirubin levels in the physiological range contributed to the decreased risk of MACE. Higher bilirubin levels were found to be toxic. The various confounding factors that altered the values of bilirubin in this observational study must be addressed by the longitudinal measure of bilirubin and see the association in a randomized trial. An important practical implication is that TBil is a low-cost, non-invasive, and easily measured biomarker. It provides prognostic information that might help in risk stratifying post-MI.

Heart Failure

Relationship Between Hemodynamic Indicators and Haemogram in Patients with Heart Failure

Oh T, Ogawa K, Nagoshi T, Minai K, Ogawa T, Kawai M, et al.

ESC Heart Failure. 2023 Apr;10(2):955–964. doi: 10.1002/ehf2.14258. Epub 2022 Dec 7. PMID: 36478404

Abstract

Aims: Pulmonary congestion, reduced cardiac output, neurohumoral factor activation, and decreased renal function associated with decreased cardiac function may have various effects on hemograms. The relationship between these factors and haemograms in patients with heart failure has not been sufficiently investigated. Recently, it was suggested that the lungs are an important site for platelet (Plt) biosynthesis and that it is necessary to study the relationship between pulmonary congestion and Plt count in heart failure in detail. In this study, we examined the relationship between various hemodynamic indicators and hemograms in detail using statistical analyses.

Methods and Results: A total of 345 patients who underwent cardiac catheterization for the evaluation of cardiac function between January 1, 2015 and December 31, 2020 were included in the study. Hemodynamic indices, including left ventricular end-diastolic pressure (LVEDP) and cardiac index (CI), were measured. Plasma noradrenaline (nor) concentration, estimated glomerular filtration rate (eGFR), white blood cell (WBC) count, hemoglobin (Hb) level, and Plt count were measured using blood samples collected at the same time. Structural equation modeling (SEM) was used to examine the relationship between LVEDP, CI, plasma Nor concentration, eGFR, WBC count, Hb level, and Plt count. Bayesian inference using SEM was performed for Plt count. A total of 345 patients (mean age: 66.0 ± 13.2 years) were included in this study, and 251 (73%) patients were men. After simple and multiple regression analyses, path diagrams were drawn and analyzed using SEM. LVEDP showed a significant negative relationship with Plt count (standardized estimate: –0.129, p = .015), and CI showed a significant negative relationship with Hb level (standardized estimate: –0.263, p < .001). Plasma Nor concentration showed a significant positive relationship with WBC count (standardized estimate: 0.165, p = .003) and Plt count (standardized estimate: 0.198, p < .001). The eGFR had a significant positive relationship with Hb level (standardized estimate: 0.274, p < .001). Bayesian inference using SEM revealed no relationship between LVEDP and Hb level or WBC count but a significant negative relationship between LVEDP and Plt count.

Conclusions: LVEDP, CI, plasma Nor concentration, and eGFR were related to WBC count, Hb level, and Plt count in patients with heart failure. There was a strong relationship between elevated LVEDP and decreased Plt count, suggesting that pressure overload on the lungs may interfere with the function of the lung as a site of Plt biosynthesis.

Comments: The association of various hemogram parameters with left ventricular dysfunction was assessed in this study. There was a negative relationship between LVEDP and Plt count, CI and Hb level, and eGFR and Hb level, and there was a positive relationship between plasma Nor concentration and WBC count and plasma Nor concentration and Plt count. The relationship of LVEDP was specific to Plt count but not to Hb or WBC count. Platelet production is related to blood flow (which is decreased) and shear stress (which is increased) in cardiac dysfunction. An elevated LVEDP would lead to pulmonary congestion thereby shear stress and decreased Plt count. Association with other factors associated with declining cardiac function should be checked.

Clinical Significance of ST-Segment Depression During Atrial Fibrillation Rhythm for Subsequent Heart Failure Events

Kawaji T, Hamatani Y, Kato M, Yokomatsu T, Miki S, Abe M, et al.

Eur Heart J Open. 2023 Jun;3(3):oead060. doi: 10.1093/ehjopen/oead060. PMID: 37359320

Abstract

Aims: The clinical significance of ST-segment depression during atrial fibrillation (AF) rhythm has not been fully evaluated. The present study aimed to explore the association of ST-segment depression during AF rhythm with subsequent heart failure (HF) events.

Methods and Results: The study enrolled 2718 AF patients whose baseline electrocardiography (ECG) was available from a Japanese community-based prospective survey. We assessed the association of ST-segment depression in baseline ECG during AF rhythm with clinical outcomes. The primary endpoint was a composite HF endpoint: cardiac death or hospitalization due to HF. The prevalence of ST-segment depression was 25.4% (upsloping 6.6%, horizontal 18.8%, downsloping 10.1%). Patients with ST-segment depression were older and had more comorbidities than those without. During the median follow-up of 6.0 years, the incidence rate of the composite HF endpoint was significantly higher in patients with ST-segment depression than those without (5.3% vs. 3.6% per patient-year, log-rank p < .01). The higher risk was present in horizontal or downsloping ST-segment depression, but not in upsloping one. By multivariable analysis, ST-segment depression was an independent predictor for the composite HF endpoint (hazard ratio 1.23, 95% confidence interval 1.03–1.49, p = .03). In addition, ST-segment depression at anterior leads, unlike inferior or lateral leads, was not associated with a higher risk for the composite HF endpoint.

Conclusion: ST-segment depression during AF rhythm was associated with subsequent HF risk; however, the association was affected by the type and distribution of ST-segment depression.

Comments: Atrial fibrillation is a common arrhythmia seen in daily practice. The presence of AF is associated with an increased risk of HF, stroke, and all-cause mortality. The T wave inversion during an episode of AF was associated with increased cardiac events at follow-up. ST depression is also common along with T wave inversion which is associated with the presence of coronary artery disease (CAD). The association of different ST depressions (upsloping, downsloping and horizontal) with mortality and HF was assessed in this study. The ST depression was seen more in the lateral leads. Of the ST depressions seen, the horizontal depression was more common. The ST segment depression can be because of coronary microvascular dysfunction, impaired vasodilation of the arterioles, and can be seen in relative ischemic conditions such as left ventricular hypertrophy, severe aortic stenosis. The take-home message is the presence of ST depression, horizontal more in the lateral or inferior leads is suggestive of CAD, and risk of HF at follow-up. The major limitation of the study is the ST segment was assessed only during AF and not compared to the baseline ECG. Baseline comorbidities in both groups were different which might have affected the outcome, and propensity score matching was not done to overcome the difference. The study population is confined to Japan, and generalizing worldwide or globally should be cautious. The pathophysiological basis of ST depression was not supported by stress tests or nuclear imaging.

Hemodynamic Validation of the Three-step HFA-PEFF Algorithm to Diagnose Heart Failure with a Preserved Ejection Fraction

Lanzarone E, Baratto C, Vicenzi M, Villella F, Rota I, Dewachter C, et al.

ESC Heart Failure. 2023 Aug;10(4):2588–2595. doi: 10.1002/ehf2.14436. Epub 2023 Jun 15. PMID: 37321596

Abstract

Aims: The (Heart Failure Association-Pre-test assessment, Echocardiography, and natriuretic peptide score, Functional testing in cases of uncertainty, Final etiology) HFA-PEFF algorithm is a three-step algorithm to diagnose heart failure with preserved ejection fraction (HFpEF). It provides a three-level likelihood of HFpEF: low (score < 2), intermediate (score 2–4), or high (score > 4). HFpEF may be confirmed in individuals with a score > 4 (rule-in approach). The second step of the algorithm is based on echocardiographic features and natriuretic peptide levels. The third step implements diastolic stress echocardiography (DSE) for controversial diagnostic cases. We sought to validate the three-step HFA-PEFF algorithm against a hemodynamic diagnosis of HFpEF based on rest and exercise right heart catheterization (RHC).

Methods and Results: Seventy-three individuals with exertional dyspnoea underwent a full diagnostic work-up following the HFA-PEFF algorithm, including DSE and rest/exercise RHC. The association between the HFA-PEFF score and a hemodynamic diagnosis of HFpEF, as well as the diagnostic performance of the HFA-PEFF algorithm vs. RHC, was assessed. The diagnostic performance of left atrial (LA) strain < 24.5% and LA strain/E/E′ < 3% was also assessed. The probability of HFpEF was low/intermediate/high in 8%/52%/40% of individuals in the second step of the HFA-PEFF algorithm and 8%/49%/43% in the third step. After RHC, 89% of patients were diagnosed as HFpEF and 11% as non-cardiac dyspnoea. The HFA-PEFF score resulted associated with the invasive hemodynamic diagnosis of HFpEF (p < .001). The sensitivity and specificity of the HFA-PEFF score for the invasive hemodynamic diagnosis of HFpEF were 45% and 100% for the second step of the algorithm and 46% and 88% for the third step of the algorithm. Neither age, sex, body mass index, obesity, chronic obstructive pulmonary disease, or paroxysmal atrial fibrillation influenced the performance of the HFA-PEFF algorithm, as these characteristics were similarly distributed over the true positive, true negative, false positive, and false negative cases. The sensitivity of the second step of the HFA-PEFF score was non-significantly improved to 60% (p = .08) by lowering the rule-in threshold to >3. LA strain alone had a sensitivity and specificity of 39% and 14% for hemodynamic HFpEF, increasing to 55% and 22% when corrected for E/E′.

Conclusions: As compared with rest/exercise RHC, the HFA-PEFF score lacks sensitivity: Half of the patients were wrongly classified as non-cardiac dyspnoea after non-invasive tests, with a minimal impact of DSE in modifying HFpEF likelihood.

Comments: This is the first study reporting the performance of the three-step HFA-PEFF score against rest and exercise RHC in consecutive patients with unexplained dyspnoea. The results showed that compared with invasive rest and exercise hemodynamics, the HFA-PEFF score is characterized by good specificity but suboptimal sensitivity. The implementation of DSE did not seem to add significantly to the diagnostic performance of the score. Only 50% of cases were diagnosed to have HFPEF even when DSE was done. A simpler HF2PEF is of value in screening patients for HFPEF.

Arrhythmias

Predictors of Atrial Fibrillation Post Coronary Artery Bypass Graft Surgery: New Scoring System

Lotter K, Yadav S, Saxena P, Vangaveti V, John B.

Open Heart. 2023 Jun;10(1):e002284. doi: 10.1136/openhrt-2023-002284. PMID: 37316327

Abstract

Background: Atrial fibrillation (AF) following coronary artery bypass graft surgery (CABG) is common and results in significant increases in hospital stay and financial encumbrance.

Objective: Determine and use the predictors of postoperative AF (POAF) following CABG to develop a new predictive screening tool.

Method: A retrospective case–control study evaluated 388 patients (98 developed POAF and 290 remained in sinus rhythm) who undertook CABG surgery at Townsville University Hospital between 2016 and 2017. The demographic profile, and risk factors for AF including hypertension, age>75 years, transient ischemic attack, chronic obstructive pulmonary disease, heart failure (HATCH) score, electrocardiography features, and perioperative factors were determined.

Results: Patients who developed POAF were significantly older. On univariate analysis HATCH score, aortic regurgitation, increased p-wave duration and amplitude in lead II, and terminal p-wave amplitude in lead V1 were associated with POAF; as were increased cardiopulmonary bypass time (CBP) (103.5 ± 33.9 vs 90.6 ± 26.4 min, p = .001) and increased cross-clamp time. On multivariate analysis, age (p = .038), p-wave duration ≥100 ms (p = .005), HATCH score (p = .049), and CBP Time ≥100 min (p = .001) were associated with POAF. The receiver operating characteristic curve demonstrated that with a cut-off of ≥2 for the HATCH score, POAF could be predicted with a sensitivity (Sn) of 72.8% and a specificity (Sp) of 34.7%. Adding p-wave duration in lead II >100 ms and CBP time >100 min to the HATCH score increased the Sn to 83.7% with a Sp of 33.1%. This was termed the HATCH-PC score.

Conclusion: Patients with HATCH scores ≥2, and those with p-wave duration >100 ms, or CBP time >100 min were at greater risk of developing POAF following CABG.

Comments: The AF is the most common complication following CABG and is associated with increased hospital stay, morbidity, and mortality. The POAF like hypertension, age>75 years, chronic obstructive pulmonary disease, transient ischemic attack or stroke, and heart failure was identified and the HATCH score was formulated. The clinical utility of the score in identifying high-risk individuals has not been studied. The HATCH PC score helps in identifying high-risk individuals, prophylactic measures can be taken to prevent MACE. However, the evaluation of the utility of the score was done in a single center, by a single person where the error of p-wave measurement can affect the score. A HATCH score of ≥2 was associated with a 34.7% Sn and a 72.8% Sp for predicting POAF. Sensitivity was improved while Sp declined when p-wave ≥100 ms (Sn = 65.3%, Sp = 47.6) and CPB ≥100 min (Sn = 83.7%, Sp = 33.1%) were added successively.

Imaging

Epicardial Adipose Tissue and Obstructive Coronary Artery Disease in Acute Chest Pain: The EPIC-ACS Study

Jehn S, Roggel A, Dykun I, Balcer B, Al-Rashid F, Totzeck M, et al.

Eur Heart J Open. 2023 Apr 17;3(3):oead041. doi: 10.1093/ehjopen/oead041. PMID: 37143611

Abstract

Aims: We tested the hypothesis that epicardial adipose tissue (EAT) quantification improves the prediction of the presence of obstructive coronary artery disease (CAD) in patients presenting with acute chest pain in the emergency department.

Methods and Results: Within this prospective observational cohort study, we included 657 consecutive patients (mean age 58.06 ± 18.04 years, 53% male) presenting to the emergency department with acute chest pain suggestive of acute coronary syndrome between December 2018 and August 2020. Patients with ST-elevation myocardial infarction, hemodynamic instability, or known CAD were excluded. As part of the initial workup, we performed bedside echocardiography for quantification of EAT thickness by a dedicated study physician, blinded to all patient characteristics. Treating physicians remained unaware of the results of the EAT assessment. The primary endpoint was defined as the presence of obstructive CAD, as detected in subsequent invasive coronary angiography. Patients reaching the primary endpoint had significantly more EAT than patients without obstructive CAD (7.90 ± 2.56 mm vs. 3.96 ± 1.91 mm, p < .0001). In a multivariable regression analysis, a 1 mm increase in EAT thickness was associated with a nearby two-fold increased odds of the presence of obstructive CAD [1.87 (1.64–2.12), p < .0001]. Adding EAT to a multivariable model of the Global Registry of Acute Coronary Events score, cardiac biomarkers, and traditional risk factors significantly improved the area under the receiver operating characteristic curve (0.759–0.901, p < .0001).

Conclusion: Epicardial adipose tissue strongly and independently predicts the presence of obstructive CAD in patients presenting with acute chest pain to the emergency department. Our results suggest that the assessment of EAT may improve diagnostic algorithms for patients with acute chest pain.

Comments: Diagnostic evaluation of patients with chest pain is challenging in the emergency department. The use of electrocardiography and biomarkers is inconclusive in most patients, leading to further tests and increased cost burden. Non-invasive tests are done to further evaluate for which the currently recommended tests are computerized tomography coronary angiography and stress tests. These tests are not available all the time limiting their application during odd hours. Echocardiography is readily available however has a level C recommendation in the evaluation of chest pain. Epicardial adipose tissue can be quantified on echocardiography. Epicardial adipose tissue is an important active visceral adipose tissue metabolically. The increased amount is linked to augmented inflammatory activity and thereby severe CAD. EAT was found to be predictive of obstructive CAD, however, only 45% underwent angiogram in this study. The remaining persons cannot be definitively ruled out CAD without further investigation. It is a single-center observational study done in the Caucasian cohort. Generalizing the results remains uncertain.

Pulmonary Hypertension

Prognostic role of pulmonary impedance estimation to predict right ventricular dysfunction in pulmonary hypertension

Hungerford SL, Kearney K, Song N, Bart N, Kotlyar E, Lau E, et al.

ESC Heart Failure. 2023 Jun;10(3):1811–1821. doi: 10.1002/ehf2.14180. Epub 2023 Mar 10. PMID: 36896830

Abstract

Background: The effect of pulmonary hypertension (PH) on right ventricular (RV) afterload is commonly defined by the elevation of pulmonary artery (PA) pressure or pulmonary vascular resistance (PVR). In humans, however, one-third to half of the hydraulic power in the PA is contained in pulsatile components of flow. Pulmonary impedance (Zc) expresses opposition of the PA to pulsatile blood flow. We evaluate pulmonary Zc relationships according to PH classification using a cardiac magnetic resonance (CMR)/right heart catheterization (RHC) method.

Methods: Prospective study of 70 clinically indicated patients referred for same-day CMR and RHC [60 ± 16 years; 77% females, 16 mean pulmonary arterial pressure (mPAP) <25 mmHg (PVR <240 dynes.s.cm_5/mPCWP <15 mm Hg), 24 pre-capillary (PrecPH), 15 isolated post-capillary (IpcPH), 15 combined pre-capillary/post-capillary (CpcPH)]. CMR provided an assessment of PA flow, and RHC, central PA pressure. Pulmonary Zc was expressed as the relationship of PA pressure to flow in the frequency domain (dynes.s.cm_5).

Results: Baseline demographic characteristics were well matched. There was a significant difference in mPAP (p < .001), PVR (p = .001), and pulmonary Zc between mPAP<25 mmHg patients and those with PH (mPAP <25 mm Hg: 47 ± 19 dynes.s.cm_5; PrecPH 86 ± 20 dynes.s.cm_5; IpcPH 66 ± 30 dynes.s.cm_5; CpcPH 86 ± 39 dynes.s.cm_5; p = .05). For all patients with PH, elevated mPAP was found to be associated with raised PVR (p < .001) but not with pulmonary Zc (p = 0.87), except for those with PrecPH (p < .001). Elevated pulmonary Zc was associated with reduced RVSWI, RVEF, and CO (all p < .05), whereas PVR and mPAP were not.

Conclusions: Raised pulmonary Zc was independent of elevated mPAP in patients with PH and more strongly predictive of maladaptive RV remodeling than PVR and mPAP. The use of this straightforward method to determine pulmonary Zc may help to better characterize pulsatile components of RV afterload in patients with PH than mPAP or PVR alone.

Comments: It is of clinical importance to know how the right ventricle is affected by PH. The assessment can be made by steady state or pulsatile components. Commonly used parameters in the assessment of the right heart (PA pressures and vascular resistance) are of a steady state. About one-third to half of the hydraulic power in the PA is contained in a pulsatile component termed impedance. Zc is a frequency-dependent function that gives information on resistance, capacitance, inertial components of vascular hydraulic load, and pulse wave reflection. In simple terms, it denotes the relationship of pulsatile pressure to flow. This study emphasizes the importance of impedance over and above mPAP and PVR in predicting early RV functional impairment.

Valvular Heart Disease

Transcatheter Repair for Patients with Tricuspid Regurgitation

Sorajja P, Whisenant B, Hamid N, Naik H, Makkar R, Tadros P, et al., TRILUMINATE Pivotal Investigators

N Engl J Med. 2023 May 18;388(20):1833–1842. doi: 10.1056/NEJMoa2300525. Epub 2023 Mar 4. PMID: 36876753

Abstract

Background: Severe tricuspid regurgitation (TR) is a debilitating condition that is associated with substantial morbidity and often with poor quality of life. Decreasing TR may reduce symptoms and improve clinical outcomes in patients with this disease.

Methods: We conducted a prospective randomized trial of percutaneous tricuspid transcatheter edge-to-edge repair (TEER) for severe TR. Patients with symptomatic severe TR were enrolled at 65 centers in the United States, Canada, and Europe and were randomly assigned in a 1:1 ratio to receive either TEER or medical therapy (control). The primary endpoint was a hierarchical composite that included death from any cause or tricuspid-valve surgery; hospitalization for heart failure; and an improvement in quality of life as measured with the Kansas City Cardiomyopathy Questionnaire (KCCQ), with an improvement defined as an increase of at least 15 points in the KCCQ score (range, 0–100, with higher scores indicating better quality of life) at the 1-year follow-up. The severity of TR and safety were also assessed.

Results: A total of 350 patients were enrolled; 175 were assigned to each group. The mean age of the patients was 78 years, and 54.9% were women. The results for the primary endpoint favored the TEER group (win ratio, 1.48; 95% confidence interval, 1.06 to 2.13; p = .02). The incidence of death or tricuspid-valve surgery and the rate of hospitalization for heart failure did not appear to differ between the groups. The KCCQ quality-of-life score changed by a mean (±SD) of 12.3 ± 1.8 points in the TEER group, as compared with 0.6 ± 1.8 points in the control group (p < .001). At 30 days, 87.0% of the patients in the TEER group and 4.8% of those in the control group had TR of no greater than moderate severity (p < .001). TEER was found to be safe; 98.3% of the patients who underwent the procedure were free from major adverse events at 30 days.

Conclusions: Tricuspid TEER was safe for patients with severe TR, reduced the severity of TR, and was associated with an improvement in quality of life.

Comments: Tricuspid valve regurgitation is associated with poor outcomes. However, dealing with TR is associated with increased cardiac mortality. The use of percutaneous management is of increasing trends to address the issues. This trial has shown evidence that the management of TR by TTEER is beneficial in reducing events. However, in the single-center study, no device-related complications, and half of the patients being on diuretics with no change in their dose should be kept in mind. The time of intervention was not mentioned. Further trials are needed to further strengthen this treatment modality in valvular heart disease (VHD) management.