You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

Heart’s Twitter Journal Club

6 Oct, 16 | by James Rudd

TwitterLogo_#55aceeJoin in our Journal Club on Twitter and engage with readers from across the world!

Each month we will discuss a paper from Heart.

We will select a recent paper ahead of time and then discuss four different aspects of it for about 15 minutes each.

The paper under discussion will be free to access for a week prior to the Journal Club.

Feel free to join the next journal club – they happen monthly, on the first Thursday of each month at 8PM GMT. All Welcome!


To join in you will need to have a Twitter account. To sign up to Twitter, click here (it doesn’t take long and make sure you follow us –@Heart_BMJ).

When it comes to the tweet chat itself, we suggest you use tchat.io. This is a specific site used for tweetchats as it cuts out all the other distractions on Twitter. Log into tchat.io using your Twitter details, then type #HeartJC into the search bar. This pulls up all the tweets using the hashtag. You can tweet from here and it will automatically add the correct hashtag at the end of each tweet for those overexcited tweeps!

You can otherwise tweet using Twitter, but you need to make sure you add the hashtag to each tweet otherwise we won’t see it.

Follow Heart (@Heart_BMJ) for all the latest updates on Twitter. The Journal Club tweets can be identified by the hashtag #HeartJC


The following links take you to transcripts of the discussions and related Analytics, for those interested.

2016

May 5th – Transcript: Chocolate and MI risk and Analytics: Symplur

June 2nd – Transcript: Exercise and Heart Disease and Analytics: Symplur

July 7th – Transcript: Gender differences in CAD and Analytics: Symplur

August 4th – Transcript:Loneliness and social isolation as risk factors for CHD and stroke and Analytics: Symplur

September 1st – Transcript: Troponins for MI diagnosis and Analytics: Symplur

October 6th – Transcript: Beta-blockers, COPD and Heart Failure and Analytics: Symplur

November 3rd – Transcript: Cardiac CT and Analytics: Symplur

December 1st – Transcript: Athletes and cardiac screening and Analytics: Symplur

Von Willebrand Factor Multimers during Transcatheter Aortic-Valve Replacement

20 Sep, 16 | by flee

Patients with stenotic or regurgitant aortic valve disease appear to cleave multimers of Von Willebrand factor (HMW-multimer), presumably due to high-shear stresses and non-laminar flow. Van Belle and colleagues hypothesized that transcatheter aortic valve replacement (TAVR) would correct this process, but that significant residual paravalvular leak (PVL) following TAVR would abrogate this corrective effect. Moderate to severe PVL has been associated with increased rates of hospitalization, and death compared to mild PVL. Thus, immediate characterization of the degree of PVL post TAVR using echocardiographic, hemodynamic and/or angiographic data is important, though occasionally challenging, particularly if discrepant. In this study, ratios of HMW-multimers and platelet reactivity (CT-ADP) were assessed pre- and post-TAVR in 183 patients receiving the Sapien XT valve at a single center. Among the 137 patients with no regurgitation following TAVR, HMW-multimer ratios and CT-ADP values changed significantly within 15 minutes of the TAVR using point of care testing. Among those with significant PVL, these assays only changed following effective correction of the PVL. These results were unaffected by concomitant use of clopidogrel or pre-existing mitral regurgitation. Using TEE as a reference standard, ROC curves identified a CT-ADP result of ≥180 seconds (AUC = 0.93) and HMW-multimer ratio of ≤ 0.8 (AUC = 0.94) as providing optimal discrimination for significant PVL. In multivariate models, an HMW-ratio < 0.8 or CT-ADP value > 180 seconds at the end of the procedure were both significantly associated with ≥3-fold higher one-year mortality rates.

more…

Genetic analysis of sudden cardiac death in the young

20 Sep, 16 | by flee

Sudden cardiac death (SCD) is a rare but devastating event among children and young adults. SCD in which no obvious cause is apparent despite comprehensive toxicological and histological autopsy analysis is particularly vexing.  The role of genetic testing in unexplained SCD is studied in this prospective analysis of  Australians and New Zealanders 1 to 35 years old.  Between 2010 and 2012 a total of 490 SCDs were identified across the population of 26.7 million (1.3 per 100,000). Seventy-two percent were boys or men. The highest overall incidence was in persons aged 31-35, in whom coronary artery disease was the commonest cause, and the lowest incidence was in children aged 6-10.  Inherited cardiomyopathies were found in 16% of all cases.  Most deaths (65%) occurred either at rest or during sleep, whereas sudden death during or after exercise was relatively uncommon (15%). Following post-mortem, 40% of cases were classified as unexplained. Female sex, younger age and death at night particularly common in this sub-group.  Subsequent genetic analysis was performed in these individuals using commercial panels of 59 cardiac genes including genes for long QT and catecholamine polymorphic ventricular tachycardia. As an alternative, 72 epilepsy genes were also investigated. Among analyzed individuals, 27% were found to have a clinically relevant cardiac gene disorder considered the probable cause of death (only 6% were found to carry an epilepsy gene).

more…

Long-term survival benefit for coronary artery bypass grafting surgery in ischemic cardiomyopathy

20 Sep, 16 | by flee

The Surgical Treatment for Ischemic Heart Failure (STICH) trial asked the important question whether coronary artery bypass grafting surgery (CABG) in patients with severe ischemic cardiomyopathy would provide a survival advantage over contemporary medical therapy alone. Reporting 5-year data in 2011, the study reported no significant difference but did demonstrate a tantalizing divergence in survival graphs between 2 and 5 years, which appeared to be increasing with time.  In an extension to the study, 10 year follow-up data is reported.  Out of the original 1212 patients in the study, data was available on 98% of the cohort at long-term follow-up.  Over this long time period the primary outcome of death from any cause occurred in 58.9% in the CABG group and in 66.1% in the medical-therapy group (HR with CABG vs. medical therapy, 0.84; 95% CI, 0.73 to 0.97; P=0.02).  Significant reductions were also seen in cardiovascular death (P=0.006) and hospitalizations for cardiovascular causes (P<0.001) in the CABG group. The overall number needed to treat to prevent 1 death was 14, equating to an overall 16% lower chance of cardiovascular death during the study period and an increase in longevity of approximately 18 months. The effect was consistent across all important sub-group analyses.

more…

Ablation superior to drugs in recurrent ventricular tachycardia

20 Sep, 16 | by flee

Nearly 100, 000 implantable cardiac defibrillators (ICDs) are implanted every year in N. America to treat patients at risk of ventricular tachycardia (VT)  following myocardial infarction.  ICD activation for VT is relatively common and associated with recurrent hospitalizations, reductions in quality of life and mortality. It is therefore important to understand the best course of action to suppress recurrent VT, either through intensifying antiarrhythmic therapy or catheter ablation.  In this multicenter trial of patients with ischemic cardiomyopathy and an ICD, subjects who presented with VT despite anti-arrhythmic therapy were randomized 1:1 in an open-label fashion to either catheter ablation or an escalated antiarrhythmic drug regimen. In the medical therapy arm, amiodarone was initiated or the dose was escalated as appropriate; mexiletine was added if they were already on at least 300 mg per day of amiodarone. The primary outcome was a composite of death, three or more documented episodes of ventricular tachycardia within 24 hours (ventricular tachycardia storm), or appropriate ICD shock based on an intention-to-treat strategy.  In total, 259 patients were enrolled with a median follow-up of 27.9±17.1 months.  Catheter ablation significantly reduced the primary end-point from 68.5% to 59.1% (HR 0.72; 95% CI, 0.53 to 0.98; P=0.04) primarily driven by a reduction in recurrent VT with no discernable effect on mortality.

more…

Cholesterol Lowering in Intermediate-risk Persons without Cardiovascular Disease.

11 Jul, 16 | by flee

Implementation of statin therapy in practice for primary prevention of cardiovascular disease is controversial due to concerns over costs and side-effects with broader use and uncertainty regarding LDL goals in the primary prevention population. Previous primary prevention trials suggest a reduction in cardiovascular outcomes in largely white patients with significant risk factors for coronary disease. The HOPE-3 trial randomized a diverse population of 12,000 individuals over 55 years of age (women over 60) with 1-2 relatively modest risk factors for cardiovascular disease (annual risk ~1%) but otherwise no indication for statin therapy to 10 mg of rosuvastatin daily vs placebo. The composite primary outcome was death from cardiovascular causes, non- fatal MI or stroke. Nearly 13% of patients were excluded following roll-in based on side-effects or lab abnormalities. For remaining patients, over median follow of 5.6 years there was a significant reduction in the primary endpoint: 3.7% vs 4.8% favoring treatment (HR 0.76 [CI 0.64-0.91]) with a NNT of 91. An expanded ‘co-primary’ outcome which also included heart failure, revascularization and resuscitated cardiac arrest resulted in a NNT of 73. Of note, there was a significant increase in muscle aches and weakness in the rosuvastatin group (5.8% vs 4.7%) but this did not clearly impact drug discontinuation, which was common at 23.7%. In fact, therapy discontinuation was 2.5% higher in the placebo group. Myopathy or rhabdomyolysis events were very rare, but there was a significant increase in cataracts in the rosuvastin group.

more…

Genetic variant protects against coronary disease

11 Jul, 16 | by flee

The links between cholesterol and coronary artery disease are well established and incontrovertible, with modification of serum LDL cholesterol levels repeatedly shown to reduce risk of myocardial infarction and cardiovascular death. But total non-HDL cholesterol levels, encompassing multiple other lipid fractions including Lp(a) and chylomicrons, have the strongest overall association with the risk of incipient coronary artery disease. In this large genome-wide association study, the authors identify a novel noncoding 12-base-pair deletion in intron 4 of the ASGR1 gene that appears to be associated with lower levels of non-HDL cholesterol.  In an initial discovery cohort of 2636 Icelanders, the polymorphism was associated with a reduced risk of atherosclerotic coronary disease. Further testing in a cohort of 398,000 Icelanders demonstrated a prevalence of heterozygous carriers of approximately 1 in 120. These carriers had lower levels of non-HDL cholesterol and a significant 34% reduction in rates of coronary artery disease (95% CI, 21 to 45; P=4.0×10(-6)).  To further validate these associations, five other large European cohorts containing a total of 42,524 case patients and 249,414 controls were analyzed with results consistent to those seen in the Icelandic cohort.  Finally, the authors describe a second loss of function polymorphism in the same ASGR1 gene that again leads to significantly reduced levels of non-HDL cholesterol in carriers, validating their initial hypothesis that ASGR1 is directly implicated in non-HDL cholesterol homeostasis.

more…

Diabetes drug Liraglutide reduces cardiovascular events and mortality

11 Jul, 16 | by flee

Type II diabetes, an epidemic fuelled by an unrelenting rise in obesity and sedentary behaviors, is a major risk factor for both micro- and macrovascular disease. An array of new treatments have recently come to trial with the aim of improving glycemic control and reducing disease complications. But lingering doubts remain regarding the cardiovascular implications of several of these agents, with FDA mandated studies now taking place to establish their safety.  Injectable liraglutide, a glucagon-like peptide 1 analogue,  improves HbA1c levels and also leads to weight loss but its cardiovascular effects are unknown.  In this post-approval double-blind study, 9340 patients with type 2 diabetes and at least one other major cardiovascular risk factor, were randomly allocated 1:1 to liraglutide or matching placebo, as well as usual care.  Patients were followed up for a median of 3.8 years with a primary composite study end-point of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke.  Designed as a non-inferiority study, liraglutide demonstrated statistically significant and clinically meaningful reductions in the primary end-point (13.0% vs. 14.9%, HR, 0.87; 95% CI, 0.78 to 0.97; P<0.001 for noninferiority; P=0.01 for superiority) with reductions in both cardiovascular death (P=0.007) and all cause mortality (P=0.02).  Liraglutide also demonstrated a good safety profile with numerically lower rates of heart failure hospitalisations and no increase in rates of pancreatitis, a previous concern.  At 36 months HbA1c was 0.4 lower in the liraglutide group. Of note, significant differences in blood pressure (1.2 mmHg lower) and weight reduction (2.3 kg better) were observed in the trial group.  The NNT to prevent one primary end-point event was 66 and the NNT for all cause mortality 98.

 

more…

Long-term survival benefit for CABG in ischemic cardiomyopathy

23 Jun, 16 | by flee

The STICH trial asked the important question whether CABG in patients with severe ischemic cardiomyopathy would provide a survival advantage over contemporary medical therapy alone. Reporting 5-year data in 2011, the study reported no significant difference but did demonstrate a tantalizing divergence in survival graphs between 2 and 5 years, which appeared to be increasing with time.  In an extension to the study, 10 year follow-up data is reported.  Out of the original 1212 patients in the study, data was available on 98% of the cohort at long-term follow-up.  Over this long time period the primary outcome of death from any cause occurred in 58.9% in the CABG group and in 66.1% in the medical-therapy group (HR with CABG vs. medical therapy, 0.84; 95% CI, 0.73 to 0.97; P=0.02).  Significant reductions were also seen in cardiovascular death (P=0.006) and hospitalizations for cardiovascular causes (P<0.001) in the CABG group. The overall number needed to treat to prevent 1 death was 14, equating to an overall 16% lower chance of cardiovascular death during the study period and an increase in longevity of approximately 18 months. The effect was consistent across all important sub-group analyses.

Conclusions: In patients with an ischemic cardiomyopathy, revascularization with CABG, when combined with optimal medical therapy confers a long-term survival benefit and a reduction in hospital admissions for cardiovascular causes.  These advantages are not realized immediately, perhaps due to countervailing perioperative risk, but appear sustained to 10 years.

Summarized by James M. McCabe, MD and Steven M. Bradley

Velazquez EJ, Lee KL, Jones RH, Al-Khalidi HR, Hill JA, Panza JA, Michler RE, Bonow RO, Doenst T, Petrie MC, Oh JK, She L, Moore VL, Desvigne-Nickens P, Sopko G, Rouleau JL; STICHES Investigators. Coronary-Artery Bypass Surgery in Patients with Ischemic Cardiomyopathy. N Engl J Med. 2016 Apr 3. [Epub ahead of print]

Transcatheter aortic valve implantation in intermediate risk patients

17 Jun, 16 | by flee

Transcatheter aortic valve implantation (TAVI) has had a major impact on both morbidity and mortality in high-risk and inoperable patients with severe aortic stenosis. Robust evidence has supported widespread adoption in this patient group but uncertainty exists as to whether TAVI may also achieve clinical equipoise with surgical aortic valve replacement (AVR)  in lower risk groups.  In the industry sponsored PARTNER 2 trial, patients deemed at intermediate surgical risk (generally with an STS score between 4 and 8) were randomized to either TAVI with the SAPIEN XT valve or conventional surgery (bioprosthetic valve of operative choice).  In a study powered for non-inferiority, a total of 2032 patients at 57 North American centers were recruited with a primary end-point of all cause mortality and disabling stroke measured at 24 months.  TAVI was found to be none-inferior to surgical AVR at 2 years with respective event rates of 19.3% and 21.1% (HR, 0.89; 95% CI, 0.73 to 1.09; P=0.25). The rates of stroke (6%) and death (17-18%) were very similar between groups. When analyzing only those patients whom underwent TAVI via transfemoral access (76% of the total population), there was a signal that TAVI resulted in a lower incidence of the primary end-point of death or stroke (P=0.05). The non-transfermoral (alternative) access cohort had similar outcomes to the surgical AVR group.  TAVI patients were found to have a lower incidence of major bleeding, kidney failure and new onset atrial fibrillation as well as having larger aortic valve areas.  In the surgical AVR group patients had less paravalvular leak and fewer vascular complications.  Interestingly, the rate of permanent pacemaker implantation was similar between the two groups at less than 10% (P=0.17)

Conclusions

In this landmark study, patients with intermediate surgical risk had similar, and in some instances, superior outcomes with TAVI as compared to conventional surgical AVR.  As with PCI before it, the rise of minimally invasive valve replacement appears inexorable and is likely to change the landscape of cardiac intervention over the coming years as both technology and operator experience improves.  In fact, these data reflect a TAVI technology that has already been supplanted in clinical practice by a next generation technology in most countries.

 

Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK, Thourani VH, Tuzcu EM, Miller DC, Herrmann HC, Doshi D, Cohen DJ, Pichard AD, Kapadia S, Dewey T, Babaliaros V, Szeto WY, Williams MR, Kereiakes D, Zajarias A, Greason KL, Whisenant BK, Hodson RW, Moses JW, Trento A, Brown DL, Fearon WF, Pibarot P, Hahn RT, Jaber WA, Anderson WN, Alu MC, Webb JG; PARTNER 2 Investigators. Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients. N Engl J Med. 2016 374(17)1609-20

 

Summarized by  James McCabe, MD

Latest from Heart

Latest from Heart

Cardiology Masterclasses

Cardiology Masterclasses