Low Serum Testosterone in Men with Newly Diagnosed Androgen-Deprivation Therapy-Naïve Prostate Cancer and Its Relationship to Cardiovascular Risk Factors: A RADICAL-PC Substudy.

PURPOSE: Cardiovascular disease is a common cause of death in prostate cancer patients. Low testosterone is associated with increased cardiovascular risk in the general male population. We investigated the relationship between serum testosterone, cardiovascular disease and risk factors in androgen-deprivation therapy-naïve prostate cancer patients. MATERIALS AND METHODS: We performed a cross-sectional analysis of a subgroup of 1,326 androgen-deprivation therapy-naïve men from RADICAL-PC (Role of Androgen-Deprivation Therapy In CArdiovascular Disease-A Longitudinal Prostate Cancer study) in whom serum testosterone was measured at baseline. RADICAL-PC is a prospective multicenter cohort study of men (2,565) enrolled within 1 year of prostate cancer diagnosis, or within 6 months of commencing androgen-deprivation therapy for the first time. Cardiovascular risk factors, cancer characteristics and total serum testosterone were collected at baseline. Low testosterone was defined as total serum testosterone <11 nmol/L (<320 ng/dL). A Framingham cardiovascular risk score ≥15 was considered high risk for future cardiovascular events. We performed logistic regression to calculate odds ratios for the association between testosterone and cardiovascular risk. RESULTS: Among 1,326 participants (median age 67 years, range 45-93), 553 (42%) had low testosterone. Low testosterone was associated with existing cardiovascular disease, diabetes, elevated hemoglobin A1c, obesity, hypertriglyceridemia, low high-density lipoprotein cholesterol, hypertension and Framingham score >15. Among patients with low testosterone, the odds ratio for high cardiovascular risk was 1.33 (1.02-1.73) after adjusting for ethnicity, education, alcohol use, cancer characteristics, physical activity and body mass index. CONCLUSIONS: Among androgen-deprivation therapy-naïve prostate cancer patients, low testosterone is common and associated with increased cardiovascular risk factors.

Percutaneous management of coronary bifurcation lesions: current perspective.

PURPOSE OF REVIEW: Coronary artery disease affecting bifurcations poses a challenge for percutaneous intervention. Several techniques and strategies for percutaneous management of bifurcation lesions have been described in the literature with variable data available for outcomes. In this review, we provide an overview of the strategies and techniques used for percutaneous intervention of bifurcation lesions with an update of recent technical developments and clinical evidence. RECENT FINDINGS: The coronary bifurcation lesions of both left main and other coronary segments are best treated with a provisional stenting strategy where main branch is treated with a stent placement and side branch intervention reserved for angiographically or physiologically determined hemodynamically significant residual stenosis despite application of a proximal stent optimization technique. When a provisional stent strategy is not likely to be successful due to anatomic or morphologic lesion characteristics and a large side branch or distal left main bifurcation is involved, an upfront bifurcation stenting strategy with double kissing crush technique may provide the optimum results. Coronary imaging and fractional flow determination may guide lesion specific management, facilitate device selection and improve clinical outcomes for percutaneous therapy for bifurcation lesions. SUMMARY: Despite advances in technology and procedural techniques, percutaneous intervention of coronary bifurcation lesions remains challenging and associated with higher adverse outcomes compared to non bifurcation lesions. Among the several bifurcation strategies, a provisional stenting approach is preferred for technical simplicity and better long term outcomes. Double kissing crush technique provides superior clinical results and should be preferred when a two stent strategy is indicated. Use of coronary imaging and physiology assessment should be incorporated in the algorithm of bifurcation interventions for greater technical and clinical success.

The Learning Curve and Annual Procedure Volume Standards for Optimum Outcomes of Transcatheter Aortic Valve Replacement: Findings From an International Registry.

OBJECTIVES: The authors aimed to determine the procedural learning curve and minimum annual institutional volumes associated with optimum clinical outcomes for transcatheter aortic valve replacement (TAVR). BACKGROUND: Transcatheter aortic valve replacement (TAVR) is a complex procedure requiring significant training and experience for successful outcome. Despite increasing use of TAVR across institutions, limited information is available for its learning curve characteristics and minimum annual volumes required to optimize clinical outcomes. METHODS: The study collected data for patients at 16 centers participating in the international TAVR registry since initiation of the respective TAVR program. All cases were chronologically ordered into initial (1 to 75), early (76 to 150), intermediate (151 to 225), high (226 to 300), and very high (>300) experience operators for TAVR learning curve characterization. In addition, participating institutions were stratified by annual TAVR case volume into low-volume (<50), moderate-volume (50 to 100), and high-volume (>100) groups for comparative analysis. Procedural and 30-day clinical outcomes were collected and multivariate regression analysis performed for 30-day mortality and the early safety endpoint. RESULTS: A total of 3,403 patients comprised the study population. On multivariate analysis, all-cause mortality was significantly higher for initial (odds ratio [OR]: 3.83; 95% confidence interval [CI]: 1.93 to 7.60), early (OR: 2.41; 95% CI: 1.51 to 5.03), and intermediate (OR: 2.53; 95% CI: 1.19 to 5.40) experience groups compared with the very high experience operators. In addition, the early safety endpoint was significantly worse for all experience groups compared with the very high experience operators. Low annual volume (<50) TAVR institutions had significantly higher all-cause 30-day mortality (OR: 2.70; 95% CI: 1.44 to 5.07) and worse early safety endpoint (OR: 1.60; 95% CI: 1.17 to 2.17) compared with the moderate- and high-volume groups. There was no difference in patient outcomes between intermediate and high annual volume groups. CONCLUSIONS: TAVR procedures display important learning curve characteristics with both greater procedural safety and a lower mortality when performed by experienced operators. In addition, TAVR performed at low annual volume (<50 procedures) institutions is associated with decreased procedural safety and higher patient mortality. These findings have important implications for operator training and patient care at centers performing TAVR.

Physician decision making in anticoagulating atrial fibrillation: a prospective survey of a physician notification system for atrial fibrillation detected on cardiac implantable electronic devices of patients at increased risk of stroke.

OBJECTIVES: The objectives of this study were to evaluate the effectiveness of a physician notification system for atrial fibrillation (AF) detected on cardiac devices, and to assess predictors of anticoagulation in patients with device-detected AF. METHODS: In 2013, a physician notification system for AF detected on a patient's CIED [including pacemakers, implantable cardioverter defibrillators (ICD) or cardiac resynchronization therapy (CRT) devices] was implemented, with a recommendation to consider oral anticoagulation in high-risk patients. We prospectively investigated the effectiveness of this system, and evaluated both patient and physician predictors of anticoagulation, as well as factors influencing physician decision making in prescribing anticoagulation. Both uni- and multivariable analysis as well as descriptive statistics were used in the analysis. RESULTS: We identified 177 patients with device-detected AF, 126 with a CHADS2 ⩾2. Only 41% were prescribed anticoagulation at any point within 12 months. On multivariable analysis, stroke risk as predicted by CHADS2 was not a predictor of anticoagulation. ASA use predicted a lower rate of anticoagulation (OR 0.39, 95% CI 0.16-0.97, p = 0.04); physicians in practice for <20 years were more likely to prescribe anticoagulation (OR 3.39, 95% CI 1.28-8.93, p = 0.01); and physicians who believed both cardiologist and family doctor should be involved in managing anticoagulation were more likely to prescribe anticoagulation (OR 3.28, 95% CI 1.02-10.5, p = 0.05). CONCLUSIONS: Patients on aspirin were less likely to be anticoagulated. Physicians in practice for <20 years and who believed that both the general practitioner and cardiologist should be involved in managing anticoagulants were more likely to prescribe anticoagulation.

Physician decision making in anticoagulating atrial fibrillation: a prospective survey of a physician notification system for atrial fibrillation detected on cardiac implantable electronic devices of patients at increased risk of stroke.

OBJECTIVES: The objectives of this study were to evaluate the effectiveness of a physician notification system for atrial fibrillation (AF) detected on cardiac devices, and to assess predictors of anticoagulation in patients with device-detected AF. METHODS: In 2013, a physician notification system for AF detected on a patient's CIED [including pacemakers, implantable cardioverter defibrillators (ICD) or cardiac resynchronization therapy (CRT) devices] was implemented, with a recommendation to consider oral anticoagulation in high-risk patients. We prospectively investigated the effectiveness of this system, and evaluated both patient and physician predictors of anticoagulation, as well as factors influencing physician decision making in prescribing anticoagulation. Both uni- and multivariable analysis as well as descriptive statistics were used in the analysis. RESULTS: We identified 177 patients with device-detected AF, 126 with a CHADS2 ⩾2. Only 41% were prescribed anticoagulation at any point within 12 months. On multivariable analysis, stroke risk as predicted by CHADS2 was not a predictor of anticoagulation. ASA use predicted a lower rate of anticoagulation (OR 0.39, 95% CI 0.16-0.97, p = 0.04); physicians in practice for <20 years were more likely to prescribe anticoagulation (OR 3.39, 95% CI 1.28-8.93, p = 0.01); and physicians who believed both cardiologist and family doctor should be involved in managing anticoagulation were more likely to prescribe anticoagulation (OR 3.28, 95% CI 1.02-10.5, p = 0.05). CONCLUSIONS: Patients on aspirin were less likely to be anticoagulated. Physicians in practice for <20 years and who believed that both the general practitioner and cardiologist should be involved in managing anticoagulants were more likely to prescribe anticoagulation.

Institutional experience and outcomes of transcatheter aortic valve replacement: Results from an international multicentre registry.

BACKGROUND: Despite rapidly increasing use of TAVR across institutions, limited data is available for the effect of procedural experience on TAVR outcomes. We investigate the relationship between institutional experience and TAVR outcomes. METHODS: 1953 patients undergoing TAVR at 8 international sites were grouped into chronological quantiles (Q) to assess temporal changes on procedural and clinical outcomes and multivariate logistic regression performed to determine predictors of device success, early safety and all-cause mortality. RESULTS: The mean age of patients was 81±7years and 991 (51%) were female. The quantiles comprised of first 62 cases for Q1, 63-133 for Q2, 134 to 242 for Q3 and 243 to 476 for Q4. Device success increased from Q1 to Q4 (78% vs 89%, p<0.001) with significant improvement in the early safety endpoint (19% vs 10%, p<0.001). All cause mortality reduced by half in Q4 compared to Q1 (8% vs 4%, p=0.01) and rates of major vascular complications, major bleeding and valve embolization decreased with increasing experience. The multivariate analysis identified TAVR in Q3 and Q4 to be independently associated with higher device success and lower risk of complications. TAVR in Q4 was independently associated with lower mortality (OR 0.36 95% CI 0.19-0.70, p=0.002). CONCLUSIONS: Greater institutional experience with TAVR procedures improves device success and clinical outcomes. An experience of >242 cases is independently associated with lower mortality. These findings have important implications for defining minimum volume criteria for institutions and training standards for TAVR procedure.

Transcatheter Tricuspid Repair With MitraClip for Severe Primary Tricuspid Regurgitation.

Severe tricuspid regurgitation is an independent predictor of adverse outcomes, yet few patients undergo surgery and treatment with medical therapy is often inadequate. Recent studies have reported the use of the MitraClip system (Abbott Vascular) to treat secondary tricuspid regurgitation. We describe the first use of MitraClip to treat severe primary tricuspid regurgitation and right heart failure in a patient with previous cardiac transplantation and high surgical risk.

Short Duration vs Standard Duration of Dual-Antiplatelet Therapy After Percutaneous Coronary Intervention With Second-Generation Drug-Eluting Stents - A Systematic Review, Meta-Analysis, and Meta-Regression Analysis of Randomized Controlled Trials.

BACKGROUND: Current guidelines recommend 12 months of dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation. Whether the duration of DAPT can be safely shortened with use of second-generation DESs is unclear. METHODS: We conducted a meta-analysis of randomized controlled trials comparing short duration (SD) (3-6 months) with standard longer duration (LD) (≥12 months) DAPT in patients treated with primarily second-generation DES implantation. Meta-regression was performed to explore the relationship between acute coronary syndrome (ACS) and the effect of DAPT duration. RESULTS: Six studies were included, with 12,752/13,928 (91.5%) patients receiving second-generation DESs. A total of 5367 patients (39%) had PCI in the setting of ACS. There was no difference in all-cause mortality (1.1% vs 1.2%; odds ratio [OR], 0.86; 95% confidence interval [CI], 0.63-1.18; P=.36) or cardiac mortality (0.9% vs 1.0%; OR, 0.92; 95% CI, 0.61-1.39; P=.69) with SD-DAPT vs LD-DAPT, respectively. Definite/probable stent thrombosis (0.5% vs 0.3%; OR, 1.33; 95% CI, 0.75-2.34; P=.51), myocardial infarction (1.5% vs 1.3%; OR, 1.17; 95% CI, 0.88-1.56; P=.29), and stroke (0.4% vs 0.4%; OR, 1.04; 95% CI, 0.60-1.81; P=.88) were similar between the groups. Compared with LD-DAPT, SD-DAPT was associated with lower clinically significant bleeding (0.9% vs 1.4%; OR, 0.64; 95% CI, 0.46-0.89; P=.01). Meta-regression analysis showed no significant association between the proportion of ACS patients in trials and duration of DAPT for the outcomes of mortality (P=.95), myocardial infarction (P=.98), or stent thrombosis (P=.89). CONCLUSION: In low-risk patients treated with contemporary second-generation DES implantation, SD-DAPT has similar rates of mortality, myocardial infarction, and stent thrombosis, with lower rates of bleeding compared with LD-DAPT.

The Utility of Systolic and Diastolic Echocardiographic Parameters for Predicting Coronary Artery Disease Burden as Defined by the SYNTAX Score.

BACKGROUND: Early identification of high-grade ischemia based on echocardiographic diastolic abnormalities may be clinically useful in the acute coronary syndrome (ACS) setting. This could provide the clinician with an awareness of the burden of coronary artery disease (CAD) before angiography is performed to allow for early intervention of suspected ischemic lesions. The objective of the study was to assess whether 2D transthoracic echocardiography (TTE)-derived tissue Doppler imaging parameters can predict the severity of CAD in comparison with the cardiac catheterization-derived SYNTAX score. METHODS: A retrospective study of 74 stable angina or patients with ACS was performed in 2012 at a single tertiary care center. In all study subjects, TTE and angiography were performed within 6 months of each other without revascularization in the interim. RESULTS: The study population included a total of 74 patients (mean age 67 ± 12 years) with 77% presenting with an ACS. The median SYNTAX score was 24.0 (6.0-35.0). The E-wave velocity was higher, and deceleration time (DT) was lower in the high SYNTAX group in comparison with the low/intermediate SYNTAX group (P = 0.045 and P = 0.001, respectively). Septal mitral annular S' was lower in the high SYNTAX group (P = 0.02). After multivariate analysis, E/A ratio (OR 0.03, 95% 0.00-0.36, P = 0.0067), DT (OR 0.93, 95% CI 0.89-0.97, P = 0.0001) and septal annular S'-wave velocity (OR 0.34, 95% CI 0.16-0.71, P = 0.0038) remained strong predictors of a high SYNTAX score. CONCLUSION: Early identification of systolic and diastolic dysfunction based on echocardiographic parameters may be of important clinical significance for predicting CAD burden prior to invasive angiography.

Novel high-sensitivity troponin assay requires higher cut-off value to separate acute myocardial infarction from non-acute myocardial infarction in a high-risk population.

PURPOSE: The novel high-sensitivity troponin T assay (hs-cTnT) has been validated for diagnosing AMI in the emergency room. However its utility in high-risk in-patient populations is unknown. METHODS: We retrospectively reviewed admissions to a general cardiology unit that had 2 hs-cTnT measurements in the first 12 h of presentation. We assessed 8 diagnostic algorithms that used hs-cTnT concentration and changes in concentration (including the 99th percentile cut-off of 14 ng/L) for their diagnostic utility in separating AMI patients from cardiac/nonACS and non-cardiac chest-pain patients. UA was excluded. RESULTS: There were 233 patients (mean age 67 years, 153 were males (66%)) admitted over a 2 month period, with AMI diagnosed in 118 of these patients (51%). The recommended 99th percentile cut-off had modest accuracy (65%), good sensitivity (88%), and poor specificity (25%); a higher cut-off of 75 ng/L had a better diagnostic accuracy of 73%, p < 0.05. While some hs-cTnT algorithms were either highly sensitive or specific, none were both. CONCLUSION: In high-risk cardiology in-patients, no hs-cTnT concentration cut-off or change more accurately diagnosed and excluded AMI, although higher cut-offs had better diagnostic utility.