Highlights of Cardiovascular Disease Prevention Studies Presented at the 2023 American College of Cardiology Conference.

PURPOSE OF REVIEW: To summarize selected late-breaking science on cardiovascular (CV) disease prevention presented at the 2023 American College of Cardiology (ACC) conference. RECENT FINDINGS: The CLEAR outcomes randomized control trial (RCT) compared bempedoic acid to placebo in patients at high-risk of cardiovascular disease (CVD) or prevalent CVD and statin intolerance for CV outcomes. The YELLOW III was a single-arm study that evaluated the effect of Evolocumab on coronary plaque characteristics in patients with stable coronary artery disease (CAD). A cohort evaluated the association between a self-reported low-carbohydrate high-fat (ketogenic) diet and serum lipid levels as compared to a standard diet. The LOADSTAR trial compared CV outcomes with targeted low-density lipoprotein cholesterol (LDL-C) approach vs. high-intensity statin in patients with CAD. The PCDS statin cluster randomized trial compared the effectiveness of an electronic reminder to the clinician on a high-intensity statin use among patients with a history of ASCVD as compared to no reminder. A prospective cohort study compared the extent of coronary atherosclerosis among lifelong endurance athletes and healthy non-athletes. A causal artificial intelligence study combined polygenic risk scores with data from large CV prevention RCTs to guide systolic blood pressure and LDL-C reduction targets to reach average CV risk. The ACCESS trial evaluated the impact of eliminating copayment for low-income older adults in Canada with chronic CV diseases on composite CV outcomes. A pooled analysis of 3 large RCTs evaluated the association between residual inflammatory risk and CV outcomes, as compared to residual elevated cholesterol risk in patients receiving statin therapy. A Phase 2B RCT compared the efficacy of an oral PCSK9i, MK-0616, in reducing LDL-C as compared to a placebo. The late-breaking clinical science presented at the 2023 conference of the ACC paves the way for an evidence-based alternative to statin therapy and provides data on several common clinical scenarios encountered in daily practice.

Mitral annular plane systolic excursion and tricuspid annular plane systolic excursion for risk stratification of acute pulmonary embolism.

INTRODUCTION: Risk stratification for acute pulmonary embolism (PE) incorporates metrics of right ventricle (RV) function. Significant RV dysfunction influences left ventricular (LV) function, though LV function metrics are not utilized for stratifying outcomes in patients with PE. Mitral annular plane systolic excursion (MAPSE) is a linear echocardiographic (TTE) measure that evaluates longitudinal LV function and may aid in risk stratification for acute PE. METHODS: Using a single-center database of patients with PE from 2007 to 2014, MAPSE was calculated for all TTE's available with sufficient quality (n = 362). A MAPSE of ≥11 mm was used as a normal reference. Thirty-day adverse outcomes were defined as administration of vasopressor, fibrinolytic therapy, open embolectomy, or 30-day PE-related mortality. Odds ratios (OR) and adjusted OR (AOR) were calculated using logistic regression analysis. Tricuspid annular plane systolic excursion (TAPSE) measurements were incorporated to determine the additive benefit of MAPSE. RESULTS: Compared with the reference MAPSE ≥ 11 mm and LVEF > 50%, patients with MAPSE < 11 mm and an LVEF > 50% had worse outcomes (AOR 2.94 [95% CI: 1.08-7.98], P = 0.035). Among patients with LVEF > 50%, the presence of both a MAPSE < 11 mm and TAPSE < 16 mm was associated with greater odds of adverse outcomes compared with isolated depressed TAPSE (AOR 10.75 [95% CI: 3.06-37.8], P < 0.01 vs AOR 1.68 [95% CI: 0.18-15.6], P = 0.65). CONCLUSION: A depressed MAPSE, in patients with preserved LVEF, is associated with worse outcomes in patients with acute PE. The addition of MAPSE to TAPSE appears to have a greater prognostic value than either alone and may further aid in risk stratification, but for confirmation further prospective data are needed.

Development of an impairment-based individualized treatment workflow using an iPad-based software platform.

Individuals with language and cognitive deficits following brain damage likely require long-term rehabilitation. Consequently, it is a huge practical problem to provide the continued communication therapy that these individuals require. The present project describes the development of an impairment-based individualized treatment workflow using a software platform called Constant Therapy. This article is organized into two sections. We will first describe the general methods of the treatment workflow for patients involved in this study. There are four steps in this process: (1) the patient's impairment is assessed using standardized tests, (2) the patient is assigned a specific and individualized treatment plan, (3) the patient practices the therapy at home and at the clinic, and (4) the clinician and the patient can analyze the results of the patient's performance remotely and monitor and alter the treatment plan accordingly. The second section provides four case studies that provide a representative sample of participants progressing through their individualized treatment plan. The preliminary results of the patient treatment provide encouraging evidence for the feasibility of a rehabilitation program for individuals with brain damage based on the iPad (Apple Inc., Cupertino, CA).

Impact of the 2018 UNOS Heart Transplant Policy Changes on Patient Outcomes.

In 2018, the United Network for Organ Sharing implemented a 6-tier allocation policy to replace the prior 3-tier system. Given increasing listings of critically ill candidates for heart transplantation and lengthening waitlist times, the new policy aimed to better stratify candidates by waitlist mortality, shorten waiting times for high priority candidates, add objective criteria for common cardiac conditions, and further broaden sharing of donor hearts. There have been significant shifts in cardiac transplantation practices and patient outcomes following the implementation of the new policy, including changes in listing practices, waitlist time and mortality, transplant donor characteristics, post-transplantation outcomes, and mechanical circulatory support use. This review aims to highlight emerging trends in United States heart transplantation practice and outcomes following the implementation of the 2018 United Network for Organ Sharing heart allocation policy and to address areas for future modification.

Changes in Care for Acute Pulmonary Embolism Through A Multidisciplinary Pulmonary Embolism Response Team.

BACKGROUND: Optimal management of acute pulmonary embolism requires expertise offered by multiple subspecialties. As such, pulmonary embolism response teams (PERTs) have increased in prevalence, but the institutional consequences of a PERT are unclear. METHODS: We compared all patients that presented to our institution with an acute pulmonary embolism in the 3 years prior to and 3 years after the formation of our PERT. The primary outcome was in-hospital pulmonary embolism-related mortality before and after the formation of the PERT. Sub-analyses were performed among patients with elevated-risk pulmonary embolism. RESULTS: Between August 2012 and August 2018, 2042 patients were hospitalized at our institution with acute pulmonary embolism, 884 (41.3%) pre-PERT implementation and 1158 (56.7%) post-PERT implementation, of which 165 (14.2%) were evaluated by the PERT. There was no difference in pulmonary embolism-related mortality between the two time periods (2.6% pre-PERT implementation vs 2.9% post-PERT implementation, P = .89). There was increased risk stratification assessment by measurement of cardiac biomarkers and echocardiograms post-PERT implementation. Overall utilization of advanced therapy was similar between groups (5.4% pre-PERT implementation vs 5.4% post-PERT implementation, P = 1.0), with decreased use of systemic thrombolysis (3.8% pre-PERT implementation vs 2.1% post-PERT implementation, P = 0.02) and increased catheter-directed therapy (1.3% pre-PERT implementation vs 3.3% post-PERT implementation, P = 0.05) post-PERT implementation. Inferior vena cava filter use decreased after PERT implementation (10.7% pre-PERT implementation vs 6.9% post-PERT implementation, P = 0.002). Findings were similar when analyzing elevated-risk patients. CONCLUSION: Pulmonary embolism response teams may increase risk stratification assessment and alter application of advanced therapies, but a mortality benefit was not identified.

The nature of lexical-semantic access in bilingual aphasia.

BACKGROUND: Despite a growing clinical need, there are no clear guidelines on assessment of lexical access in the two languages in individuals with bilingual aphasia. Objective. In this study, we examined the influence of language proficiency on three tasks requiring lexical access in English and Spanish bilingual normal controls and in bilingual individuals with aphasia. METHODS: 12 neurologically healthy Spanish-English bilinguals and 10 Spanish-English bilinguals with aphasia participated in the study. All participants completed three lexical retrieval tasks: two picture-naming tasks (BNT, BPNT) and a category generation (CG) task. RESULTS: This study found that across all tasks, the greatest predictors for performance were the effect of group and language ability rating (LAR). Bilingual controls had a greater score or produced more correct responses than participants with bilingual aphasia across all tasks. The results of our study also indicate that normal controls and bilinguals with aphasia make similar types of errors in both English and Spanish and develop similar clustering strategies despite significant performance differences between the groups. CONCLUSIONS: Differences between bilingual patients and controls demonstrate a fundamental lexical retrieval deficit in bilingual individuals with aphasia, but one that is further influenced by language proficiency in the two languages.

Effectiveness of an impairment-based individualized rehabilitation program using an iPad-based software platform.

The delivery of tablet-based rehabilitation for individuals with post-stroke aphasia is relatively new, therefore, this study examined the effectiveness of an iPad-based therapy to demonstrate improvement in specific therapy tasks and how the tasks affect overall language and cognitive skills. Fifty-one individuals with aphasia due to a stroke or traumatic brain injury (TBI) were recruited to use an iPad-based software platform, Constant Therapy, for a 10 week therapy program. Participants were split into an experimental (N = 42) and control (N = 9) group. Both experimental and control participants received a 1 h clinic session with a clinician once a week, the experimental participants additionally practiced the therapy at home. Participants did not differ in the duration of the therapy and both groups of participants showed improvement over time in the tasks used for the therapy. However, experimental participants used the application more often and showed greater changes in accuracy and latency on the tasks than the control participants; experimental participants' severity level at baseline as measured by standardized tests of language and cognitive skills were a factor in improvement on the tasks. Subgroups of task co-improvement appear to occur between different language tasks, between different cognitive tasks, and across both domains. Finally, experimental participants showed more significant and positive changes due to therapy in their standardized tests than control participants. These results provide preliminary evidence for the usefulness of a tablet-based platform to deliver tailored language and cognitive therapy to individuals with aphasia.