Tricuspid regurgitation is associated with increased mortality independent of pulmonary pressures and right heart failure: a systematic review and meta-analysis.

Aims: To undertake a systematic review and meta-analysis to determine the influence of tricuspid regurgitation (TR) severity on mortality. Methods and results: We performed a systematic search for studies reporting clinical outcomes of patients with TR. The primary endpoint was all-cause mortality and secondary endpoints were cardiac mortality and hospitalization for heart failure (HF). Overall risk ratios (RR) and 95% confidence intervals (CIs) were derived for each endpoint according to the severity of TR by meta-analysing the effect estimates of eligible studies. Seventy studies totalling 32 601 patients were included in the analysis, with a mean (±SD) follow-up of 3.2 ± 2.1 years. Moderate/severe TR was associated with a two-fold increased mortality risk compared to no/mild TR (RR 1.95, 95% CI 1.75-2.17). Moderate/severe TR remained associated with higher all-cause mortality among 13 studies which adjusted for systolic pulmonary arterial pressures (RR 1.85, 95% CI 1.44-2.39), and 15 studies, which adjusted for right ventricular (RV) dysfunction (RR 1.78, 95% CI 1.49-2.13). Moderate/severe TR was also associated with increased cardiac mortality (RR 2.56, 95% CI 1.84-3.55) and HF hospitalization (RR 1.73, 95% CI 1.14-2.62). Compared to patients with no TR, patients with mild, moderate, and severe TR had a progressively increased risk of all-cause mortality (RR 1.25, 1.61, and 3.44, respectively; P < 0.001 for trend). Conclusions: Moderate/severe TR is associated with an increased mortality risk, which appears to be independent of pulmonary pressures and RV dysfunction.

Testing the Effects of App-Based Motivational Messages on Physical Activity and Resting Heart Rate Through Smartphone App Compliance in Patients With Vulnerable Coronary Artery Plaques: Protocol for a Microrandomized Trial.

BACKGROUND: Achieving the weekly physical activity recommendations of at least 150-300 minutes of moderate-intensity or 75-150 minutes of vigorous-intensity aerobic exercise is important for reducing cardiometabolic risk, but evidence shows that most people struggle to meet these goals, particularly in the mid to long term. OBJECTIVE: The Messages Improving Resting Heart Health (MIRTH) study aims to determine if (1) sending daily motivational messages through a research app is effective in improving motivation and in promoting adherence to physical activity recommendations in men and women with coronary heart disease randomized to a 12-month intensive lifestyle intervention, and (2) the time of the day when the message is delivered impacts compliance with exercise training. METHODS: We will conduct a single-center, microrandomized trial. Participants will be randomized daily to either receive or not receive motivational messages over two 90-day periods at the beginning (phase 1: months 4-6) and at the end (phase 2: months 10-12) of the Lifestyle Vulnerable Plaque Study. Wrist-worn devices (Fitbit Inspire 2) and Bluetooth pairing with smartphones will be used to passively collect data for proximal (ie, physical activity duration, steps walked, and heart rate within 180 minutes of receiving messages) and distal (ie, change values for resting heart rate and total steps walked within and across both phases 1 and 2 of the trial) outcomes. Participants will be recruited from a large academic cardiology office practice (Central Sydney Cardiology) and the Royal Prince Alfred Hospital Departments of Cardiology and Radiology. All clinical investigations will be undertaken at the Charles Perkins Centre Royal Prince Alfred clinic. Individuals aged 18-80 years (n=58) with stable coronary heart disease who have low attenuation plaques based on a coronary computed tomography angiography within the past 3 months and have been randomized to an intensive lifestyle intervention program will be included in MIRTH. RESULTS: The Lifestyle Vulnerable Plaque Study was funded in 2020 and started enrolling participants in February 2022. Recruitment for MIRTH commenced in November 2022. As of September 2023, 2 participants were enrolled in the MIRTH study and provided baseline data. CONCLUSIONS: This MIRTH microrandomized trial will represent the single most detailed and integrated analysis of the effects of a comprehensive lifestyle intervention delivered through a customized mobile health app on smart devices on time-based motivational messaging for patients with coronary heart disease. This study will also help inform future studies optimizing for just-in-time adaptive interventions. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12622000731796; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382861. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/46082.

A case of ST elevation myocardial infarction secondary to heparin-induced thrombocytopaenia with thrombosis.

A 54 year-old woman with Noonan Syndrome presented with an acute anterolateral ST elevation myocardial infarction two weeks post septal myectomy and heparin exposure, on the background of known normal coronary arteries. Coronary angiography revealed acute thrombosis of the left main, left anterior descending and left circumflex arteries, which was successfully treated by percutaneous coronary intervention with overlapping bare metal stents. A positive heparin induced platelet antibody test and dramatic fall in platelet count confirmed the diagnosis of heparin induced thrombocytopaenia with thrombosis (HITTS) as the underlying diagnosis. This represents the first documented case of HITTS induced left main coronary artery thrombosis and occlusion.

Metabolite signatures of heart failure, sleep apnoea, their interaction, and outcomes in the community.

AIMS: Sleep apnoea and congestive heart failure (CHF) commonly co-exist, but their interaction is unclear. Metabolomics may clarify their interaction and relationships to outcome. METHODS AND RESULTS: We assayed 372 circulating metabolites and lipids in 1919 and 1524 participants of the Framingham Heart Study (FHS) (mean age 54 ± 10 years, 53% women) and Women's Health Initiative (WHI) (mean age 67 ± 7 years), respectively. We used linear and Cox regression to relate plasma concentrations of metabolites and lipids to echocardiographic parameters; CHF and its subtypes heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF); and sleep indices. Adenine dinucleotide phosphate (ADP) associated with left ventricular (LV) fractional shortening; phosphocreatine with LV wall thickness; lysosomal storage molecule sphingomyelin 18:2 with LV mass; and nicotine metabolite cotinine with time spent with an oxygen saturation less than 90% (ß = 2.3 min, P = 2.3 × 10-5 ). Pro-hypertrophic metabolite hydroxyglutarate partly mediated the association between LV wall thickness and HFpEF. Central sleep apnoea was significantly associated with HFpEF (P = 0.03) but not HFrEF (P = 0.5). There were three significant metabolite canonical variates, one of which conferred protection from cardiovascular death [hazard ratio = 0.3 (0.11, 0.81), P = 0.02]. CONCLUSIONS: Energetic metabolites were associated with cardiac function; energy- and lipid-storage metabolites with LV wall thickness and mass; plasma levels of nicotine metabolite cotinine were associated with increased time spent with a sleep oxygen saturation less than 90%, a clinically significant marker of outcome, indicating a significant hazard for smokers who have sleep apnoea.

Intensive LDL cholesterol-lowering treatment beyond current recommendations for the prevention of major vascular events: a systematic review and meta-analysis of randomised trials including 327 037 participants.

BACKGROUND: The benefits of LDL cholesterol-lowering treatment for the prevention of atherosclerotic cardiovascular disease are well established. However, the extent to which these effects differ by baseline LDL cholesterol, atherosclerotic cardiovascular disease risk, and the presence of comorbidities remains uncertain. METHODS: We did a systematic literature search (MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials, from inception up to June 15, 2019) for randomised controlled trials of statins, ezetimibe, and proprotein convertase subtilisin/kexin type 9 inhibitors with at least 1000 patient-years of follow-up. Random-effects meta-analysis and meta-regressions were done to assess for risk of major vascular events (a composite of cardiovascular mortality, non-fatal myocardial infarction, non-fatal ischaemic stroke, or coronary revascularisation) per 1 mmol/L (38·7 mg/dL) reduction in LDL cholesterol concentrations. FINDINGS: 327 037 patients from 52 studies were included in the meta-analysis. Each 1 mmol/L reduction in LDL cholesterol was associated with a 19% relative risk (RR) reduction for major vascular events (RR 0·81 [95% CI 0·78-0·84]; p<0·0001). Similar reductions (per 1 mmol/L reduction in LDL cholesterol) were found in trials with participants with LDL cholesterol 2·60 mmol/L or lower, 2·61-3·40 mmol/L, 3·41-4·10 mmol/L, and more than 4·1 mmol/L (p=0·232 for interaction); and in a subgroup of patients who all had a baseline LDL cholesterol less than 2·07 mmol/L (80 mg/dL; RR 0·83 [95% CI 0·75-0·92]; p=0·001). We found greater RR reductions in patients at lower 10-year atherosclerotic cardiovascular disease risk (change in RR per 10% lower 10-year atherosclerotic cardiovascular disease 0·97 [95% CI 0·95-0·98]; p<0·0001) and in patients at younger age across a mean age of 50-75 years (change in RR per 10 years younger age 0·92 [0·83-0·97]; p=0·015). We found no difference in RR reduction for participants with or without diabetes (p=0·878 for interaction) and chronic kidney disease (p=0·934 for interaction). INTERPRETATION: For each 1 mmol/L LDL cholesterol lowering, the risk reduction of major vascular events is independent of the starting LDL cholesterol or the presence of diabetes or chronic kidney disease. Patients at lower cardiovascular risk and younger age might have a similar relative reduction in risk with LDL-cholesterol lowering therapies and future studies should investigate the potential benefits of earlier intervention. FUNDING: None.

A case report: mechanical mitral valve thrombosis in pregnancy.

BACKGROUND: Pregnancy in women with mechanical valves has a high risk of both valve thrombosis and bleeding as well as adverse effects on the foetus. There is limited data on achieving optimal anticoagulation in pregnancy and management of valve thrombosis, to achieve a successful foetal outcome, while prioritizing the mother's health. While warfarin may carry a lower risk of valve thrombosis, warfarin is teratogenic in the first trimester and is associated with increased foetal loss throughout the pregnancy. Heparin does not cross the placenta but is associated with increased maternal morbidity and mortality. CASE SUMMARY: We describe the case of a pregnant patient with thrombosis of a mechanical mitral valve presenting with an embolic stroke at 22 weeks of pregnancy. The stroke was treated with clot retrieval and resulted in no residual neurological deficit. Two previous pregnancies had been managed with low molecular weight heparin, and both resulted in foetal loss. The patient was determined to continue this pregnancy. She was treated with intravenous unfractionated heparin during the remainder of the pregnancy. She developed worsening heart failure due to persisting valve thrombosis despite maintenance of therapeutic anticoagulation. The patient deteriorated rapidly prior to a planned early elective delivery. Emergency Caesarean section was required followed by valve replacement using extracorporeal membrane oxygenation support with an ultimately successful maternal and foetal outcome. Anticoagulation regimes and treatment of mechanical valve thrombosis in pregnancy are discussed. DISCUSSION: The management of pregnant patients with mechanical valves is complex, especially when valve thrombosis and other complications occur. A multidisciplinary approach is essential and in this case led to successful outcome.

Obstructive sleep apnea and cardiovascular disease.

Obstructive sleep apnea (OSA) is a common disorder associated with an increased risk of cardiovascular disease and stroke. As it is strongly associated with known cardiovascular risk factors, including obesity, insulin resistance, and dyslipidemia, OSA is an independent risk factor for hypertension and has also been implicated in the pathogenesis of congestive cardiac failure, pulmonary hypertension, arrhythmias, and atherosclerosis. Obesity is strongly linked to an increased risk of OSA, and weight loss can reduce the severity of OSA. The current standard treatment for OSA-nasal continuous positive airway pressure (CPAP)-eliminates apnea and the ensuing acute hemodynamic changes during sleep. Long-term CPAP treatment studies have shown a reduction in nocturnal cardiac ischemic episodes and improvements in daytime blood pressure levels and left ventricular function. Despite the availability of effective therapy, OSA remains an underdiagnosed and undertreated condition. A lack of physician awareness is one of the primary reasons for this deficit in diagnosis and treatment.

Repetitive hypoxia increases lipid loading in human macrophages-a potentially atherogenic effect.

Obstructive sleep apnea (OSA) is characterized by repetitive episodes of hypoxia and is associated with an increase in cardiovascular disease. We, therefore, investigated the effect of repetitive hypoxia on two key early events in atherogenesis; lipid loading in foam cells and monocyte adhesion to endothelial cells. Human macrophages were loaded with acetylated low-density lipoproteins. During lipid loading, the cells were exposed to 30 min cycles of 2%/21% oxygen or control (room air, 5% CO(2) incubator). Human umbilical vein endothelial cells (HUVECs) were also exposed to 30 min cycles of repetitive hypoxia or control conditions and monocyte adhesion measured. Cell adhesion molecules E-selectin, ICAM-1 and VCAM-1 were measured by ELISA. Repetitive hypoxia increased cholesteryl ester uptake by macrophages (127+/-5% compared to controls; p=0.003). By contrast, monocyte adhesion to HUVECs and cell adhesion molecule expression were unchanged by exposure to repetitive hypoxia, compared to controls (p >0.1). Repetitive hypoxia, at levels relevant to tissues such as the arterial wall, enhances lipid uptake into human macrophages. This may contribute to accelerated atherosclerosis in OSA patients.

Obstructive sleep apnea: novel trigger and potential therapeutic target for cardiac arrhythmias.

Obstructive sleep apnea (OSA), the most common form of sleep-disordered breathing, is prevalent and frequently underdiagnosed in our community. Although presenting with predominantly respiratory symptoms, the most serious complications from OSA are cardiovascular, including arrhythmias, disease of the sinus node and conducting system, and sudden cardiac death. The acute and chronic effects of OSA on the cardiovascular system, which include major effects on autonomic function during sleep and wakefulness, are potent contributors to the development and persistence of cardiac arrhythmias. Although large randomized studies are currently lacking, treatment of OSA may be an important primary or additional therapy to supplement the use of drugs or devices in the treatment of cardiac arrhythmias.

Treatment of obstructive sleep apnoea leads to enhanced pulmonary vascular nitric oxide release.

BACKGROUND: Obstructive sleep apnoea (OSA) is associated with pulmonary hypertension, however neither the pathogenesis of pulmonary vascular disease nor the effect of successful treatment of OSA on pulmonary vascular physiology has been characterised. METHODS: Seven subjects aged 52 (range 36-63) years with moderate to severe obstructive sleep apnoea (apnoea-hypopnoea index>15/h) had detailed pulmonary vascular reactivity studies, before and after 3 months of successful treatment with nasal continuous positive airways pressure (CPAP). On both occasions, we measured pulmonary pressure, flow velocity, flow and resistance, at baseline and in response to acetylcholine (an endothelium-dependent dilator), sodium nitroprusside (an endothelium-independent dilator), l-NMMA (an antagonist of nitric oxide synthesis) and l-Arginine (the substrate of nitric oxide). RESULTS: At baseline, pulmonary flow increased in response to acetylcholine and nitroprusside and fell in response to l-NMMA. Following CPAP treatment, the decrease in flow to l-NMMA was significantly greater (to 62+/-6% of control value vs 85+/-6% of pre-treatment; p=0.01), consistent with enhanced basal release of nitric oxide. The acetylcholine response tended to be greater after treatment (174+/-26% of control vs 147+/-12% of pre-CPAP, p=0.22), however the nitroprusside response was unchanged. CONCLUSION: Successful treatment of obstructive sleep apnoeic episodes in sleep results in enhanced nitric oxide release by the pulmonary microvascular circulation.

Electroencephalographic arousals during sleep do not alter the pressor response to Cheyne-Stokes respiration in subjects with chronic heart failure.

This study examined the influence of electroencephalographic (EEG) arousal on the magnitude and morphology of the pressor response to Cheyne-Stokes respiration (CSR) in subjects with congestive heart failure (CHF). Thirteen subjects with stable CHF (left ventricular ejection fraction, 26 +/- 7%) and CSR (apnea-hypopnea index 52 +/- 15 h(-1)) underwent overnight polysomnography with beat-to-beat measurement of systemic arterial blood pressure (BP). CSR events were divided into those with or without an EEG arousal defined according to the criteria of the American Sleep Disorders Association. The pressor response was quantified in terms of the delta BP change (difference between the minimum BP during apnea and maximum BP during hyperpnea). Changes in the morphology of the pressor response were assessed by subdividing individual respiratory events into six periods (three during apnea: A1, A2, A3; and three during hyperpnea: H1, H2, H3). Considerable fluctuations in BP and heart rate (HR) were observed across the CSR cycle (delta mean BP 20.2 +/- 6.5 mmHg). The presence of an EEG arousal did not alter the amplitude of fluctuations in BP. Mean blood pressure (MBP) increased 21.0 +/- 7.5 mmHg with arousal versus 19.3 +/- 5.8 mmHg without arousal (NS). A repeated measures ANOVA showed no significant interaction between the presence of arousal and the proportional change in mean BP across the six periods, indicating that an EEG arousal had no effect on the morphology of MBP change during CSR [F(5,60) = 1.44, P = 0.22]. This study showed that EEG-defined arousal does not amplify the pressor response to CSR in CHF.