American Radium Society™ Appropriate Use Criteria on Cardiac Toxicity Prevention and Management After Thoracic Radiotherapy.

PURPOSE: The multidisciplinary American Radium Society (ARS) Thoracic Committee was assigned to create Appropriate Use Criteria (AUC) on cardiac toxicity prevention and management for patients undergoing radiotherapy. METHODS AND MATERIALS: A systematic review of the current literature was conducted. Case variants of patients with thoracic malignancies undergoing radiation were created based on presence or absence cardiovascular risk factors and treatment-related risks assessed by dose exposure to the heart/cardiac substructures. Modified Delphi methodology was used by to evaluate the variants and procedures, with ≤3 rating points from median defining agreement/consensus. RESULTS: 6 variants were evaluated. The panel felt patients with cardiac comorbidities at high risk for radiation-related cardiac toxicity should undergo a prescreening cardiac focused history and physical (H&P) exam, electrocardiogram (EKG), cardiac imaging including an echocardiogram, and referral to a cardiologist/cardio-oncologist. Recommendations for those without cardiac comorbidities at low risk for cardiac toxicity were to undergo a baseline history and physical examination only. Conversely, those without cardiac comorbidities but at high risk for radiation-related cardiac toxicity were recommended to undergo a prescreening EKG, in addition to a H&P exam. For patients with cardiac comorbidities at low risk for cardiac toxicity, the panel felt prescreening and post-screening tests may be appropriate. CONCLUSIONS: The ARS Thoracic AUC panel has developed multidisciplinary consensus guidelines for cardiac toxicity prevention, surveillance, and management after thoracic radiotherapy based on cardiac comorbidities at presentation and risk of radiation-related cardiac toxicity.

A Review of Concurrent Chemo/Radiation, Immunotherapy, Radiation Planning, and Biomarkers for Locally Advanced Non-small Cell Lung Cancer and Their Role in the Development of ECOG-ACRIN EA5181.

ECOG-ACRIN EA5181 is a current prospective, randomized trial that is investigating whether the addition of concomitant durvalumab to standard chemo/radiation followed by 1 year of consolidative durvalumab results in an overall survival benefit over standard chemo/radiation alone followed by 1 year of consolidative durvalumab in patients with locally advanced, unresectable non-small cell lung cancer (NSCLC). Because multiple phase I/II trials have shown the relative safety of adding immunotherapy to chemo/radiation and due to the known synergism between chemotherapy and immunotherapy, it is hoped that concomitant durvalumab can reduce the relatively high incidence of local failure (38%-46%) as seen in recent prospective, randomized trials of standard chemo/radiation in this patient population. We will review the history of radiation for LA-NSCLC and discuss the role of induction, concurrent and consolidative chemotherapy as well as the concerns for late cardiac and pulmonary toxicities associated with treatment. Furthermore, we will review the potential role of next generation sequencing, PD-L1, ctDNA and tumor mutation burden and their possible impact on this trial.

A nested case-control study on radiation dose-response for cardiac events in breast cancer patients in Germany.

BACKGROUND: Previous studies with the majority of breast cancer (BC) patients treated up to 2000 provided evidence that radiation dose to the heart from radiotherapy (RT) was linearly associated with increasing risk for long-term cardiac disease. RT techniques changed substantially over time. This study aimed to investigate the dose-dependent cardiac risk in German BC patients treated with more contemporary RT. METHODS: In a cohort of 11,982 BC patients diagnosed in 1998-2008, we identified 494 women treated with 3D-conformal RT who subsequently developed a cardiac event. Within a nested case-control approach, these cases were matched to 988 controls. Controls were patients without a cardiac event after RT until the index date of the corresponding case. Separate multivariable conditional logistic regression models were used to assess the association of radiation to the complete heart and to the left anterior heart wall (LAHW) with cardiac events. RESULTS: Mean dose to the heart for cases with left-sided BC was 4.27 Gy and 1.64 Gy for cases with right-sided BC. For controls, corresponding values were 4.31 Gy and 1.66 Gy, respectively. The odds ratio (OR) per 1 Gy increase in dose to the complete heart was 0.99 (95% confidence interval (CI): 0.94-1.05, P = .72). The OR per 1 Gy increase in LAHW dose was 1.00 (95% CI: 0.98-1.01, P = .68). CONCLUSIONS: Contrary to previous studies, our study provided no evidence that radiation dose to the heart from 3D-conformal RT for BC patients treated between 1998 and 2008 was associated with risk of cardiac events.

Cardiac late effects after modern 3D-conformal radiotherapy in breast cancer patients: a retrospective cohort study in Germany (ESCaRa).

PURPOSE: Radiotherapy (RT) was identified as a risk factor for long-term cardiac effects in breast cancer patients treated until the 1990s. However, modern techniques reduce radiation exposure of the heart, but some exposure remains unavoidable. In a retrospective cohort study, we investigated cardiac mortality and morbidity of breast cancer survivors treated with recent RT in Germany. METHODS: A total of 11,982 breast cancer patients treated between 1998 and 2008 were included. A mortality follow-up was conducted until 06/2018. In order to assess cardiac morbidity occurring after breast cancer treatment, a questionnaire was sent out in 2014 and 2019. The effect of breast cancer laterality on cardiac mortality and morbidity was investigated as a proxy for radiation exposure. We used Cox Proportional Hazards regression analysis, taking potential confounders into account. RESULTS: After a median follow-up time of 11.1 years, there was no significant association of tumor laterality with cardiac mortality in irradiated patients (hazard ratio (HR) for left-sided versus right-sided tumor 1.09; 95% confidence interval (CI) 0.85-1.41). Furthermore, tumor laterality was not identified as a significant risk factor for cardiac morbidity (HR = 1.05; 95%CI 0.88-1.25). CONCLUSIONS: Even though RT for left-sided breast cancer on average incurs higher radiation dose to the heart than RT for right-sided tumors, we found no evidence that laterality is a strong risk factor for cardiac disease after contemporary RT. However, larger sample sizes, longer follow-up, detailed information on individual risk factors and heart dose are needed to assess clinically manifest late effects of current cancer therapy.

Velocity-pressure loops can estimate intrinsic and pharmacologically induced changes in cardiac afterload during non-cardiac surgery. An observational study.

PURPOSE: Continuous measurement of aortic pressure and aortic flow velocity signals in the operating theatre allows us to draw velocity-pressure (Vel-Pre) loops. The global afterload angle (GALA), derived from the Vel-Pre loops, has been linked to cardiac afterload indicators. As age is the major determinant of constitutive arterial stiffness, we aimed to describe (1) the evolution of the GALA according to age in a large cohort of anesthetized patients and (2) GALA variations induced by haemodynamic interventions. METHODS: We included patients for whom continuous monitoring of arterial pressure and cardiac output were indicated. Fluid challenges or vasopressors were administered to treat intra-operative hypotension. The primary endpoint was the comparison of the GALA values between young and old patients. The secondary endpoint was the difference in the GALA values before and after haemodynamic interventions. RESULTS: We included 133 anaesthetized patients: 66 old and 67 young patients. At baseline, the GALA was higher in the old patients than in young patients (38 ± 6 vs. 25 ± 4 degrees; p < 0.001). The GALA was positively associated with age (p < 0.001), but the mean arterial pressure (MAP) and cardiac output were not. The GALA did not change after volume expansion, regardless of the fluid response, but it did increase after vasopressor administration. Furthermore, while a vasopressor bolus led to a similar increase in MAP, phenylephrine induced a more substantial increase in the GALA than noradrenaline (+ 12 ± 5° vs. + 8 ± 5°; p = 0.01). CONCLUSION: In non-cardiac surgery, the GALA seems to be associated with both intrinsic rigidity (reflected by age) and pharmacologically induced vasoconstriction changes (by vasopressors). In addition, the GALA can discriminate the differential effects of phenylephrine and noradrenaline. These results should be confirmed in a prospective, ideally randomized, trial.

A Review of Immunotherapy for Stage III and Metastatic Non-Small Cell Lung Cancer and the Rationale for the ECOG-ACRIN EA5181 Study.

ECOG-ACRIN EA5181 is a phase III prospective, randomized trial that randomizes patients undergoing chemo/radiation for locally advanced non-small cell lung cancer (LA-NSCLC) to concomitant durvalumab or no additional therapy, with both arms receiving 1 year of consolidative durvalumab. Radiation dose escalation failed to improve overall survival in RTOG 0617. However, conventionally fractionated radiation to 60 Gy with concomitant chemotherapy is associated with a high risk of local failure (38%-46%). It is hoped that concomitant immunotherapy during chemo/radiation can help decrease the risk of local failure, thereby improving overall survival and progression-free survival with acceptable toxicity. In this article, we review conventional chemo/radiation therapy for LA-NSCLC, as well as the quickly evolving world of immunotherapy in the treatment of non-small cell lung cancer and discuss the rationale and study design of EA5181. IMPLICATIONS FOR PRACTICE: This article provides an up-to-date assessment of how immunotherapy is reshaping the landscape of metastatic non-small cell lung cancer (NSCLC) and how the impact of this therapy is now rapidly moving into the treatment of patients with locally advanced NSCLC who are presenting for curative treatment. This article reviews the recent publications of chemo/radiation as well as those combining immunotherapy with chemotherapy and chemo/radiation, and provides a strategy for improving overall survival of patients with locally advanced NSCLC by using concomitant immunotherapy with standard concurrent chemo/radiation.

Large branchial arch cyst excision using superficial and deep cervical plexus blocks in a patient with severe comorbidities.

Branchial arches are embryologic structures that develop between the fourth and seventh gestational week. Anomalies may form if these structures fail to develop. The majority of cases are diagnosed during childhood, with surgical excision recommended to prevent risk of infection, growth or malignancy. We report an unusual case of a 72-year-old man with severe cardiac comorbidities who presented with a large second branchial arch cyst extending into the oropharynx. General anaesthesia to facilitate surgical excision was deemed too risky. Therefore, we performed successful ultrasound-guided superficial and deep cervical plexus blocks as a sole mode of anaesthesia. This case highlights how regional anaesthesia can be utilised to facilitate surgery in high-risk patients, as well as presenting an alternative for general anaesthesia.

Atrial fibrillation and non-ischaemic cardiomyopathy in the peripartum period.

A 31-year-old primiparous woman with a history of bigeminy as a teenager developed atrial fibrillation with rapid ventricular response during elective caesarean section. Initial postoperative medical management was undertaken on the maternal high dependency unit and involved the administration of beta-blockers and digoxin. On postoperative day 1 the patient was transferred to the coronary care unit where she subsequently required synchronised direct current cardioversion to restore sinus rhythm. The patient remained on the coronary care unit for 5 days before discharge. Magnetic resonance imaging undertaken 6 weeks postpartum showed non-ischaemic cardiomyopathy. In this report, we discuss tachycardia-induced and peripartum cardiomyopathies, along with their potential underlying pathologies, incidence and associated morbidity. We describe potential pharmacological therapies including beta-blockers and angiotensin-converting enzyme inhibitors, as well as the implications of such medications for breastfeeding mothers. Patients presenting with palpitations in the antenatal period should receive prompt investigation including electrocardiography with ambulatory monitoring considered for those with persistent symptoms. Anyone with a proven cardiac arrhythmia should undergo echocardiography. This report illustrates the importance of the investigation of the symptoms of arrhythmia during pregnancy and emphasises the role of multidisciplinary working in the management of obstetric patients with complex medical comorbidity.

Natriuretic peptide-directed medical therapy: a systematic review.

Natriuretic peptides (NP) are strongly associated with perioperative cardiovascular events. However, in patients with raised NP, it remains unknown whether treatment to reduce NP levels prior to surgery results in better perioperative outcomes. In this systematic review and meta-analysis, we investigate NP-directed medical therapy in non-surgical patients to provide guidance for NP-directed medical therapy in surgical patients. The protocol was registered with PROSPERO (CRD42017051468). The database search included MEDLINE (PubMed), CINAHL (EBSCO host), EMBASE (EBSCO host), ProQuest, Web of Science, and Cochrane database. The primary outcome was to determine whether NP-directed medical therapy is effective in reducing NP levels within 6 months, compared to standard of care. The secondary outcome was to determine whether reducing NP levels is associated with decreased mortality. Full texts of 18 trials were reviewed. NP-directed medical therapy showed no significant difference compared to standard care in decreasing NP levels (standardized mean difference - 0.04 (- 0.16, 0.07)), but was associated with a 6-month (relative risk (RR) 0.82 (95% confidence interval (CI) 0.68-0.99)) reduction in mortality.

The role of cardiac rehabilitation using exercise to decrease natriuretic peptide levels in non-surgical patients: a systematic review.

Exercise is recommended in patients with cardiac failure. In the perioperative patient, exercise is also gaining popularity as a form of prehabilitation. In this meta-analysis, we examine if exercise is able to reduce natriuretic peptide levels. Natriuretic peptide (NP) has strong prognostic ability in identifying patients who will develop adverse postoperative cardiovascular outcomes. The protocol was registered with PROSPERO (CRD42017051468). The database search included MEDLINE (PubMed), CINAHL (EBSCO host), EMBASE (EBSCO host), ProQuest, Web of Science, and Cochrane database. The primary outcomes were to determine whether exercise therapy was effective in reducing NP levels as compared to control group, the shortest time period required to reduce NP levels after exercise therapy, and whether reducing NP levels decreased morbidity and mortality. Full texts of 16 trials were retrieved for this review. Exercise therapy showed a significant reduction in natriuretic peptide levels between the intervention and control groups (SMD - 0.45, 95% CI - 0.88 to - 0.03) with significant heterogeneity between the included trials. This was also shown in the within a 12-week period.

Influence of Mitroflow bioprosthesis structural valve deterioration on cardiac morbidity.

BACKGROUND: This study investigated the extent and nature of cardiac morbidity and cause of mortality in patients with Mitroflow structural valve deterioration (SVD). METHODS: A retrospective study was performed examining the medical records of patients who had received Mitroflow bioprosthesis between February 2001 and April 2014 and died during this period. A total of 211 patients were identified and included in the analyses. To determine the cause of mortality, cases were divided into three predefined groups: cardiovascular death due to SVD (group 1), cardiovascular death with no SVD (group 2) and non-cardiovascular death without SVD (group 3). RESULTS: Overall mortality in this study was 7.6% at 1 year, 46.4% at 5 years and 97.2% at 10 years. In group 1, 53 patients (25%) died; in group 2, 59 patients (28%) died; and in group 3, 99 patients (47%) died. Hospitalisation for congestive heart failure was observed in 49.1% in the SVD group vs. 10.2 and 13.1% in the two other groups, p < 0.001. Hospitalisation for endocarditis was also significantly higher in the SVD group (11.3%) than in the two other groups (6.8 and 0%), p < 0.05. Hospitalisation due to myocardial infarction, cerebral stroke, arrhythmia or other cardiac-related diseases was not significantly different between groups. CONCLUSION: Structural valve deterioration in Mitroflow bioprosthesis was associated with a high prevalence of hospital admissions due to congestive heart failure and endocarditis. Patients with Mitroflow bioprosthesis should be systematically and routinely followed with echocardiography, and reoperation should be considered if SVD has developed.

Pre-operative cardiac optimisation: a directed review.

Cardiac events remain the leading cause of peri-operative morbidity and mortality, and patients undergoing major surgery are exposed to significant risks which may be preventable and modifiable. Proper assessment and management of various cardiac conditions in the peri-operative period by anaesthetists can markedly improve patient safety, especially in high-risk patient populations. This involves understanding and applying current evidence-based practice and international guidelines on the main aspects of cardiac optimisation, including management of patients with hypertension, chronic heart failure, valvular heart diseases and cardiac implantable electronic devices. Peri-operative management of antihypertensive drugs in keeping with the current best evidence is discussed. Pre-operative cardiac risk assessment and cardiac biomarkers can be used to help predict and quantify peri-operative adverse cardiac events. There is an increasing need for anaesthetist-led services, including focused transthoracic echocardiography and management of implantable cardiac electronic devices. Anaesthetists should be encouraged to play a proactive role in pre-operative risk stratification and make timely multidisciplinary referrals if necessary. A personalised approach to pre-operative cardiac optimisation enables a safer peri-operative journey for at-risk patients undergoing major surgery.

Identifying the optimal regional predictor of right ventricular global function: a high-resolution three-dimensional cardiac magnetic resonance study.

Right ventricular (RV) function has prognostic value in acute, chronic and peri-operative disease, although the complex RV contractile pattern makes rapid assessment difficult. Several two-dimensional (2D) regional measures estimate RV function, however the optimal measure is not known. High-resolution three-dimensional (3D) cardiac magnetic resonance cine imaging was acquired in 300 healthy volunteers and a computational model of RV motion created. Points where regional function was significantly associated with global function were identified and a 2D, optimised single-point marker (SPM-O) of global function developed. This marker was prospectively compared with tricuspid annular plane systolic excursion (TAPSE), septum-freewall displacement (SFD) and their fractional change (TAPSE-F, SFD-F) in a test cohort of 300 patients in the prediction of RV ejection fraction. RV ejection fraction was significantly associated with systolic function in a contiguous 7.3 cm2 patch of the basal RV freewall combining transverse (38%), longitudinal (35%) and circumferential (27%) contraction and coinciding with the four-chamber view. In the test cohort, all single-point surrogates correlated with RV ejection fraction (p < 0.010), but correlation (R) was higher for SPM-O (R = 0.44, p < 0.001) than TAPSE (R = 0.24, p < 0.001) and SFD (R = 0.22, p < 0.001), and non-significantly higher than TAPSE-F (R = 0.40, p < 0.001) and SFD-F (R = 0.43, p < 0.001). SPM-O explained more of the observed variance in RV ejection fraction (19%) and predicted it more accurately than any other 2D marker (median error 2.8 ml vs 3.6 ml, p < 0.001). We conclude that systolic motion of the basal RV freewall predicts global function more accurately than other 2D estimators. However, no markers summarise 3D contractile patterns, limiting their predictive accuracy.

Clinical Utility of Survivin (BIRC5), Novel Cardiac Biomarker, as a Prognostic Tool Compared to High-sensitivity C-reactive Protein, Heart-type Fatty Acid Binding Protein and Revised Lee Score in Elderly Patients Scheduled for Major Non-cardiac Surgery: A Prospective Pilot Study.

BACKGROUND: Recent studies indicate that survivin (BIRC5) is sensitive to the existence of previous ischemic heart disease, since it is activated in the process of tissue repair and angiogenesis. The aim of this study was to determine the potential of survivin (BIRC5) as a new cardiac biomarker in the preoperative assessment of cardiovascular risk in comparison with clinically accepted cardiac biomarkers and one of the relevant clinical risk scores. METHODS: We included 79 patients, female (41) and male (38), with the mean age of 71.35±6.89. Inclusion criteria: extensive non-cardiac surgery, general anesthesia, age >55 and at least one of the selected cardiovascular risk factors (hypertension, diabetes mellitus, hyperlipidemia, smoking and positive family history). Exclusion criteria: emergency surgical procedures and inability to understand and sign an informed consent. Blood sampling was performed 7 days prior surgery and levels of survivin (BIRC5), hsCRP and H-FABP were measured. RESULTS: Revised Lee score was assessed based on data found in patients' history. Levels of survivin (BIRC5) were higher in deceased patients (P<0.05). It showed AUC=0.807 (95% CI, P<0.0005, 0.698-0.917), greater than both H-FABP and revised Lee index, and it increases the mortality prediction when used together with both biomarkers and revised Lee score. The determined cut-off value was 4 pg/mL and 92.86% of deceased patients had an increased level of survivin (BIRC5), (P=0.005). CONCLUSIONS: Survivin (BIRC5) is a potential cardiac biomarker even in elderly patients without tumor, but it cannot be used independently. Further studies with a greater number of patients are needed.

A pilot study of cardiopulmonary exercise testing and cardiac stress positron emission tomography before major non-cardiac surgery.

Cardiac events are a common cause of peri-operative morbidity. Cardiopulmonary exercise testing can objectively assess risk, but it does not quantify myocardial ischaemia. With appropriate dietary preparation to suppress basal myocardial glucose uptake, positron emission tomography with 18 F-fluorodeoxyglucose can identify post-ischaemic myocardium, providing an attractive complement to exercise testing. We aimed to investigate the feasibility of this diagnostic algorithm. Patients referred for cardiopulmonary exercise testing before major cancer surgery were prospectively recruited. Exercise testing and positron emission tomography imaging were performed after a high fat-low carbohydrate meal. Protocol feasibility (primary end-point) included compliance with pre-test diet instructions and the completion of tests. Stress myocardial perfusion imaging was performed if either exercise testing or positron emission tomography was equivocal or positive for ischaemia. We recorded cardiac complications for 30 postoperative days. We enrolled 26 participants, 20 of whom completed protocol. Twenty-one participants proceeded to surgery: myocardial injury or infarction was diagnosed in three participants, two of whom had positive or equivocal positron emission tomography but negative myocardial perfusion imaging. We have shown that pre-operative cardiac positron emission tomography after cardiopulmonary exercise testing is feasible; protocol deviations were minor and did not affect image quality. Our findings warrant further investigation to compare the diagnostic utility of cardiac positron emission tomography imaging with standard pre-operative stress tests.

T wave peak-to-end interval in COPD.

Introduction: The interval from the peak to the end of the electrocardiographic (ECG) T wave (Tp-Te) can estimate cardiovascular mortality and ventricular tachyarrhythmias. Objectives: In this study, we aimed to define a new ECG parameter in patients with COPD. Methods: This was a cross-sectional observational study that included COPD patients who were diagnosed previously and followed up in the outpatient clinic. All data of the patients' demographic features, history, spirometry, and electrocardiographs were analyzed. Results: We enrolled 134 patients with COPD and 40 healthy volunteers as controls in our study. Patients already known to be having COPD who were under follow-up for their COPD and diagnosed as having COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria were included. Men comprised 82.8% of the COPD group and 73.2% of controls. The mean age in the COPD and control group was 60.2±9.4 and 58.2±6.7 years, respectively. There was no significant difference between the groups for age or sex (p=0.207, p=0.267, respectively). There were 46 (34.3%) patients in group A, 23 (17.2%) patients in group B, 26 (19.4%) patients in group C, and 46 (29.1%) patients in group D as COPD group. There was a significant increase in Tp-Te results in all precordial leads in the COPD group compared with the control group (p<0.05). Precordial V4 lead has the most extensive area under the curve (0.831; sensitivity 76.5%, specificity 89.6%). Conclusion: We present strong evidence that Tp-Te intervals were increased in patients with COPD, which suggests that there may be an association between COPD and ventricular arrhythmias and cardiac morbidity.

The predictive value of risk indices for cardiac complications in living donor liver transplantation.

BACKGROUND AND AIMS: The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) risk tool and Revised Cardiac Risk Index (RCRI) are recommended tools for cardiovascular assessment before non-cardiac surgery to predict early postoperative cardiac morbidity and mortality. Their predictive value for postoperative cardiovascular morbidity and mortality after liver transplantation is unknown. We aimed to evaluate the validity of these two risk tools to predict early (30-day) cardiovascular complications and in-hospital all-cause mortality. METHODS: Patients who underwent living donor liver transplantation were retrospectively analyzed. Consecutive 278 adult patients were included and their NSQIP and RCRI scores were calculated. RESULTS: Cardiovascular morbidity occurred in 5 (1.8 %) patients. In-hospital all-cause mortality occurred in 18 (6.4 %) patients. None-of the patients died from cardiac complications. Causes of cardiac morbidity were as follows; acute coronary syndrome in 1 patient, intraoperative cardiac arrest with successful resuscitation in 1 patient, heart failure in 3 patients. Neither the NSQIP nor the RCRI score were associated with cardiovascular morbidity. Only RCRI medium-high score, DM and Nonalcoholic steatohepatitis as transplant indications were associated with in-hospital all-cause mortality (p = 0.001). CONCLUSIONS:  The NSQIP risk calculator and RCRI scores failed to accurately predict the risk of perioperative cardiac complications (Tab. 3, Ref. 30). Text in PDF www.elis.sk.

Psychological interventions for coronary heart disease: Cochrane systematic review and meta-analysis.

Background Although psychological interventions are recommended for the management of coronary heart disease (CHD), there remains considerable uncertainty regarding their effectiveness. Design Systematic review and meta-analysis of randomised controlled trials (RCTs) of psychological interventions for CHD. Methods The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL and PsycINFO were searched to April 2016. Retrieved papers, systematic reviews and trial registries were hand-searched. We included RCTs with at least 6 months of follow-up, comparing the direct effects of psychological interventions to usual care for patients following myocardial infarction or revascularisation or with a diagnosis of angina pectoris or CHD defined by angiography. Two authors screened titles for inclusion, extracted data and assessed risk of bias. Studies were pooled using random effects meta-analysis and meta-regression was used to explore study-level predictors. Results Thirty-five studies with 10,703 participants (median follow-up 12 months) were included. Psychological interventions led to a reduction in cardiovascular mortality (rfcelative risk 0.79, 95% confidence interval [CI] 0.63 to 0.98), although no effects were observed for total mortality, myocardial infarction or revascularisation. Psychological interventions improved depressive symptoms (standardised mean difference [SMD] -0.27, 95% CI -0.39 to -0.15), anxiety (SMD -0.24, 95% CI -0.38 to -0.09) and stress (SMD -0.56, 95% CI -0.88 to -0.24) compared with controls. Conclusions We found that psychological intervention improved psychological symptoms and reduced cardiac mortality for people with CHD. However, there remains considerable uncertainty regarding the magnitude of these effects and the specific techniques most likely to benefit people with different presentations of CHD.

[Control of cardiovascular risk factors in coronary patients one year after cardiac rehabilitation]. / Contrôle des facteurs de risque chez les patients coronariens un an après une réadaptation cardiaque.

OBJECTIVE: To assess risk factors monitoring in coronary patients one year after cardiac rehabilitation. METHOD: From 2015 to 2015, cardiac morbidity, total mortality and risk factors data were collected from a 4-week ambulatory cardiac rehabilitation program with a control one year later and were compared with the results of Euroaspire and Reach studies. RESULTS: Out of 1091 (87%) coronary patients, 746 (68%) were re-examined 12months later (aged 60years (ranging from 20 to 85years), 15% women, 44% hypertensive, 36% smokers, 17% diabetics, 74% with dyslipidemia). At the end of the program, management of CV risk factors was improved (BP ≤ 140/90mmHg and BMI > 30: 80 and 20% vs 65 and 25% at the beginning of the program; LDL < 0.7g/L: 42% and smoking: 4% vs 18% when hospitalized for their cardiac event). Unfortunately, this benefit decreased significantly at one year (BP ≤ 140/90mmHg: 63%, LDL < 0.7g/L: 27%; smoking: 6%) but it remains better than in Euroaspire IV study: 57, 20 et 16% respectively). While 54% had insufficient physical activity before cardiac rehabilitation, they were only 23% at 1-year vs 60% in Euroaspire study. We reported a total mortality of 0.6% vs 2.9% in Reach study and 12% cardiac hospitalization (53% for a new coronary event). CONCLUSION: Participation of coronary patients in a cardiac rehabilitation program significantly improves management of CV risk factors, morbidity and mortality. However, the control obtained at the end of the program decreases at one year.

Long-Term Cardiac Morbidity and Mortality in Patients With Aortic Valve Disease Following Liver Transplantation: A Case Matching Study.

INTRODUCTION: This retrospective study examined the role of aortic valve (AV) disease in patients who underwent orthotopic liver transplantation (OLT) to determine the incidence of postoperative cardiac morbidity and mortality when compared with a matched control group without AV disease. METHODS: Patients were included in the AV group if diagnosed with aortic stenosis (AS) or aortic regurgitation or had received AV replacement prior to OLT. The AV group (n = 53) was matched to a control group (n = 212) with the following preoperative variables: type of organ transplanted, age, gender, race, body mass index, MELD, redo-transplantation, preoperative renal replacement therapy, nonalcoholic steatohepatitis, viral hepatitis, diabetes, and coronary artery disease. A 1:4 ratio was utilized to improve the efficiency and power of the analysis. RESULTS: No significant difference in survival or posttransplant cardiac complications (acute coronary syndrome, heart failure, or dysrhythmia) was observed between groups. However, statistically significantly more patients-11% (6/53)-required coronary intervention following OLT in the AV group, whereas 3% (7/212) required coronary intervention (χ2 = 5.8; P = .0156) in the control group. Following OLT, 9% (5/53) in the AV group required surgical or nonsurgical AV intervention, whereas no valvular events were observed in the control group. Event-free survival in the AV group, with an end point defined as AV intervention (n = 5) and death (n = 10), was 92% (49/53) at 1 year, 83% (44/53) at 3 years, and 72% (38/53) at 5 years. CONCLUSIONS: Patients with pretransplant AV replacement or AS have significant cardiac complications (myocardial infarction, AV replacement, or cardiac death) in 1 to 3 years post-OLT.