DMS Cardiology News July 2021, is a curated collection of articles, posts & studies related to cardiovascular disease prevention, cardiovascular mortality, coronary artery procedures, aortic valve stenosis, chronic heart failure, myocarditis, cardiovascular risk.
All articles are published on reliable and respected sources cited with links to read the original full article.
Coronary Artery Calcium versus Biomarkers: Which Better Predicts Cardiovascular Events?
Coronary artery calcium (CAC) and biomarkers have been of interest in recent years as predictors of downstream cardiovascular events. While both certainly hold important roles, which of the two is a better predictor? At the American Society for Preventive Cardiology (ASPC), two giants of their respective fields took to the virtual stage to debate just this question.
The debate itself was moderated by ASPC board member Dr. Ann Marie Navar from the University of Texas – Southwestern. In defense of coronary artery calcium was Dr. Khurram Nasir from Houston Methodist Hospital, Chief of the Division of Cardiovascular Prevention and Wellness. Speaking for biomarkers was Dr. Christie Ballantyne of the Baylor College of Medicine, Chief of Cardiology and Cardiovascular Research.
International Consensus Statement on Nomenclature and Classification of the Congenital Bicuspid Aortic Valve and Its Aortopathy, for Clinical, Surgical, Interventional and Research Purposes
This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves:
1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes);
2. The 2-sinus type (latero-lateral and antero-posterior phenotypes);
3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy:
1. The ascending phenotype;
2. The root phenotype;
3. Extended phenotypes.
Novel Lipid-Lowering Therapies to Reduce Cardiovascular Risk
The ultimate goal of lipid-lowering therapy is to reduce the risk of atherosclerotic cardiovascular disease (ASCVD). Current cholesterol guidelines1 recommend comprehensive assessment of all ASCVD risk factors and a focus on lifestyle counseling.
Several patient groups also derive clear benefits from cholesterol-lowering drug therapy to reduce risk. Statins are first-line agents: initiation is recommended for all patients treated for secondary prevention, patients with familial hypercholesterolemia, and essentially all adults aged 40 to 75 years with diabetes.
Consideration of statin initiation is recommended in patients treated for primary prevention with an estimated 10-year ASCVD risk of 7.5% or more, or certain patients with an estimated risk of less than 7.5% and risk-enhancing factors (eg, chronic kidney disease, low-density lipoprotein cholesterol [LDL-C] level >160 mg/dL, family history of premature CVD, or a chronic inflammatory condition). In patients with familial hypercholesterolemia who cannot achieve LDL-C lower than 100 mg/dL, or patients treated for secondary prevention who cannot achieve LDL-C lower than 70 mg/dL, drugs like ezetimibe or proprotein convertase subtilisin/kexin type 9 (PCSK-9) inhibitors can be considered to reduce risk further.1
Myocarditis With COVID-19 mRNA Vaccines
Implantable Cardioverter-Defibrillator Eligibility After Initiation of Sacubitril/Valsartan in Chronic Heart Failure: Insights From PROVE-HF
Current guidelines recommend implantable cardioverter-defibrillator (ICD) implantation for prevention of sudden death in patients with heart failure (HF) and reduced ejection fraction (EF) and EF ≤35% after at least 3 months of optimized HF therapy.1 The angiotensin receptor–neprilysin inhibitor sacubitril/valsartan induces favorable ventricular remodeling2 and improves clinical outcomes in patients with HF with reduced EF (HFrEF) compared to enalapril.3 We investigated the impact of sacubitril/valsartan initiation on ICD eligibility in patients enrolled in the PROVE-HF study (Prospective Study of Biomarkers, Symptom Improvement, and Ventricular Remodeling During Sacubitril/Valsartan Therapy for Heart Failure) (URL: http://www.clinicaltrials.gov. Unique identifier: NCT02887183).
PROVE-HF was a 52-week, multicenter, open-label, single-arm study that enrolled 794 patients with chronic HFrEF and left ventricular ejection fraction ≤40% who were then initiated and titrated on sacubitril/valsartan.2 Echocardiographic assessments were performed at baseline and 6 and 12 months and were interpreted at a core laboratory that was blinded to the sequence of echocardiograms. The protocol was approved by the institutional review board at each participating center, and all participants provided informed consent before enrollment in the study. The data, analytic methods, and study materials will not be made available to other researchers for purposes of reproducing the results
Eight-year outcomes for patients with aortic valve stenosis at low surgical risk randomized to transcatheter vs. surgical aortic valve replacement
The aims of the study were to compare clinical outcomes and valve durability after 8 years of follow-up in patients with symptomatic severe aortic valve stenosis at low surgical risk treated with either transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR).
Methods and results
In the NOTION trial, patients with symptomatic severe aortic valve stenosis were randomized to TAVI or SAVR. Clinical status, echocardiography, structural valve deterioration, and failure were assessed using standardized definitions. In total, 280 patients were randomized to TAVI (n = 145) or SAVR (n = 135). Baseline characteristics were similar, including mean age of 79.1 ± 4.8 years and a mean STS score of 3.0 ± 1.7%. At 8-year follow-up, the estimated risk of the composite outcome of all-cause mortality, stroke, or myocardial infarction was 54.5% after TAVI and 54.8% after SAVR (P = 0.94). The estimated risks for all-cause mortality (51.8% vs. 52.6%; P = 0.90), stroke (8.3% vs. 9.1%; P = 0.90), or myocardial infarction (6.2% vs. 3.8%; P = 0.33) were similar after TAVI and SAVR. The risk of structural valve deterioration was lower after TAVI than after SAVR (13.9% vs. 28.3%; P = 0.0017), whereas the risk of bioprosthetic valve failure was similar (8.7% vs. 10.5%; P = 0.61).
In patients with severe aortic valve stenosis at low surgical risk randomized to TAVI or SAVR, there were no significant differences in the risk for all-cause mortality, stroke, or myocardial infarction, as well as the risk of bioprosthetic valve failure after 8 years of follow-up.
Improving Terminology to Describe Coronary Artery Procedures: JACC Review Topic of the Week
Coronary artery disease (CAD) is treated with medical therapy with or without percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The latter 2 options are commonly referred to as “myocardial revascularization” procedures.
We reason that this term is inappropriate because it is suggestive of a single treatment effect of PCI and CABG (ie, the reestablishment of blood flow to ischemic myocardium) and obscures key mechanisms, such as the improvement in coronary flow capability in the absence of ongoing ischemia, the reperfusion in the presence of ischemia, and the prevention of myocardial infarction from CAD progression.
We review the current evidence on the topic and suggest the use of a purely descriptive terminology (“invasive treatment by PCI or CABG”) which has the potential to improve clinical decision making and guide future trial design.
Download PDF: https://www.jacc.org/doi/pdf/10.1016/j.jacc.2021.05.010
Omega-3 fatty acids boost outcomes, reduce cardiovascular mortality
The effects of omega-3 fatty acids (FAs), such as eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids, on cardiovascular outcomes are uncertain. We aimed to determine the effectiveness of omega-3 FAs on fatal and non-fatal cardiovascular outcomes and examine the potential variability in EPA vs. EPA+DHA treatment effects.
We searched EMBASE, PubMed, ClinicalTrials.gov, and Cochrane library databases through June 7, 2021. We performed a meta-analysis of 38 randomized controlled trials of omega-3 FAs, stratified by EPA monotherapy and EPA+DHA therapy. We estimated random-effects rate ratios (RRs) with (95% confidence intervals) and rated the certainty of evidence using GRADE. The key outcomes of interest were cardiovascular mortality, non-fatal cardiovascular outcomes, bleeding, and atrial fibrillation (AF). The protocol was registered in PROSPERO (CRD42021227580).
The Precision of Cardiovascular Disease Prevention Begins With a Zip Code
Cardiovascular disease (CVD) remains the leading cause of death of men and women in the United States, with a continued rise in the prevalence and mortality of CVD (1).
With the awareness that more than 80% of CVD is preventable, and given that the U.S. trajectory has contrasted with that of other high-income countries, there have been calls to address the social causes that have placed “the USA last among comparable nations” (2).
CVD prevention measures have almost exclusively focused on identifying risk factors for atherosclerotic CVD (ASCVD). Despite great advancement in our understanding of the causes of ASCVD, there remain significant inequities regarding which groups shoulder the greatest burden of ASCVD and its risk factors, often affected by race and ethnicity, socioeconomic status, neighborhoods, and health care access. These “causes of the causes” are the social determinants of health and reflect the social environmental impact on cardiovascular health.
The World Health Organization defines the social determinants of health as “the circumstances in which people are born, grown, live, work, and age, and the systems put in place to deal with illness” (3). Understanding how these social processes affect ASCVD risk factors, and ultimately ASCVD, can help the preventive cardiology community create novel ways to address primary and secondary CVD prevention.
Rates of ASCVD mortality among minorities, particularly the Black population, have remained disproportionately high (1). Social determinants of health greatly affect the risk of developing ASCVD. In an editorial, Dr. Clyde Yancy stated that “the definition of a health care disparity is not simply a difference in health outcomes by race or ethnicity, but a disproportionate difference attributable to variables other than access to care” (4).
Under-represented minorities who live in poor areas and at-risk communities may have reduced access to healthy foods and may live in neighborhoods with higher crime rates and housing density, in addition to having reduced access to medical care (Figure 1). These factors put these populations at greater risk of developing obesity, hypertension, hyperlipidemia, type 2 diabetes, and other risk factors for ASCVD (4).