Contemporary Review of Risk Scores in Prediction of Coronary and Cardiovascular Deaths.

PURPOSE OF REVIEW: Explore the current literature supporting risk stratification scores for prediction of coronary and cardiovascular disease deaths. RECENT FINDINGS: Accurate risk prediction remains the foundation of management choice in primary prevention. When applied to new populations, the calibration of a predictive model will deteriorate, although discrimination changes minimally. One of the approaches with better performance and validation is the initial use of pooled cohort equation to identify low and high-risk patients, followed by coronary artery calcium scoring in those with borderline to intermediate risk. It is important to utilize a risk stratification tool that has been validated in a patient population that resembles the one used to develop the original tool to maintain adequate calibration. It is likely that the future of mortality risk prediction will develop in combined clinical risk predictors and cardiovascular imaging, such coronary artery calcium (CAC) scoring that renders the highest predictive accuracy.

Cost-effectiveness of a Contact Intervention and a Psychotherapeutic Program for Post-discharge Suicide Prevention.

OBJECTIVE: To determine the cost-effectiveness of 2 strategies for post-discharge suicide prevention, an Enhanced Contact intervention based on repeated in-person and telephone contacts, and an individual 2-month long problem-solving Psychotherapy program, in comparison to facilitated access to outpatient care following a suicide attempt. METHODS: We conducted a cost-effectiveness analysis based on a decision tree between January and December 2019. Comparative effectiveness estimates were obtained from an observational study conducted between 2013 and 2017 in Madrid, Spain. Electronic health care records documented resource use (including extra-hospital emergency care, mortality, inpatient admission, and disability leave). Direct cost data were derived from Madrid's official list of public health care prices. Indirect cost data were derived from Spain's National Institute of Statistics. RESULTS: Both augmentation strategies were more cost-effective than a single priority outpatient appointment considering reasonable thresholds of willingness to pay. Under the base-case scenario, Enhanced Contact and Psychotherapy incurred, respectively, €2,340 and 6,260 per averted attempt, compared to a single priority appointment. Deterministic and probabilistic sensitivity analyses showed both augmentation strategies to remain cost-effective under several scenarios. Enhanced Contact was slightly cost minimizing in comparison to Psychotherapy (base-case scenario: €-196 per averted attempt). CONCLUSIONS: Two post-discharge suicide prevention strategies based on Enhanced Contact and Psychotherapy were cost-effective in comparison to a single priority appointment. Increasing contacts between suicide attempters and mental health-care providers was slightly cost minimizing compared to psychotherapy.

Clinical characteristics and outcomes of patients requiring prolonged inotropes after left ventricular assist device implantation.

Limited data exist regarding patients with continuous-flow left ventricular assist device (LVAD) support who require long-term inotropes. Our primary objective was to evaluate the clinical characteristics and all-cause mortality of LVAD recipients with prolonged inotrope use (PIU). Secondary endpoints were to compare predictors of PIU, mortality, risk of late re-initiation of inotropes, time to gastrointestinal bleed (GIB), infection, and arrhythmias. Retrospective cohort study was conducted on adult patients with primary continuous-flow LVADs implanted from January 2008 to February 2017 and the patients were followed up through February 2018. We defined PIU as ≥14 days of inotrope support. Kaplan-Meier method, competing risk models and Cox proportional hazard models were used. Final analytic sample was 203 patients, 58% required PIU, and 10% were discharged on inotropes. There was no difference in preimplant characteristics. One-year survival rate was 87% if no PIU required, 74% if PIU required, and 72% if discharged on inotropes. PIU was associated with longer length of stay and higher incidence of GIB. We found no association between PIU and late re-initiation of inotropes, infection or arrhythmias. Adjusted hazard risk of death was increased in patients with PIU (HR = 1.66, P = .046), older age (HR = 1.28, P = .031), and higher creatinine levels (HR = 1.60, P = .007). Prolonged inotrope use is frequently encountered following LVAD implantation and is associated with adverse prognosis but remains a therapeutic option. Inability to wean inotropes prior to hospital discharge is a marker of patients at particularly higher risk of mortality following LVAD implantation.

Management of Angina Post Percutaneous Coronary Intervention.

PURPOSE OF REVIEW: Our review discusses the management of post percutaneous coronary intervention angina (PPCIA) which negatively impacts 20-40% of patients and imposes a high burden on the healthcare system. RECENT FINDINGS: Mechanisms of PPCIA include microvascular dysfunction, distal coronary vasospasm or disease, microembolization, myocardial bridge, coronary artery disease (CAD) progression, and rarely stent thrombosis or in-stent restenosis. Nitrates, beta blockers (BB), calcium channel blockers, and ranolazine are the common medical management options. Only BB showed 1-year mortality benefit following myocardial infarction. Stress echocardiography and cardiac magnetic resonance are the best to detect CAD vs. microvascular dysfunction. Invasively, vasoprovocative testing and fractional flow reserve provide useful prognostic information. If the ischemia burden is ≤10%, conservative management should be considered based upon the individual patient scenario. The optimal management of PPCIA remains unclear and further research is necessary. Multiple treatment options exist, which should be implemented in an individualized fashion.

Beta-Blockers, Calcium Channel Blockers, and Mortality in Stable Coronary Artery Disease.

PURPOSE OF REVIEW: To examine the current clinical evidence behind the use of calcium channel blockers (CCB) and beta-blockers (BB) for the treatment of patients with stable coronary artery disease (SCAD) and their effect on mortality. RECENT FINDINGS: Current evidence suggests that BB use as a first line antianginal medication is associated with lower 5-year all-cause mortality only in patients who had MI within a year. This could be driven due to their effects reducing the sympathetic neuro-hormonal activation of more acutely ill patients. The use of CCB as an antianginal therapy, although proven effective in multiple trials both as monotherapy and combined with other agents, has not shown mortality benefit. Both BB and CCB are effective antianginals, and the selection among them depends on the patient clinical presentation and comorbidities. BB are the only ones that have shown survival benefit in SCAD, particularly the first year post-MI.

Dairy Intake and Risk of Cardiovascular Disease.

PURPOSE OF REVIEW: Due to inconsistent findings on dairy consumption and CVD and all-cause mortality, we performed a narrative literature review to the current literature on dairy and its association with CVD. RECENT FINDINGS: Due to their complex biochemistry, dairy consumption is a rather heterogeneous exposure. Multiple pathways have been proposed from dairy consumption and CVD. Current guidelines advocate for consumption of low-fat dairy products particularly milk, cheese, and yogurt, although the evidence for this is scant. Randomized clinical trials and large prospective studies on lipid-related cardiometabolic disease risk factors are consistent with results from most meta-analyses of prospective cohort studies, which suggest null or inverse relationship between CVD risk and mortality with dairy consumption although there is no clear dose response relationship. Most of current evidence suggests that dairy products are neutral or positive effect on human cardiovascular diseases.

Supplemental Vitamins and Minerals for Cardiovascular Disease Prevention and Treatment.

PURPOSE OF REVIEW: The objective of this study is to explore the current literature supporting the use oral multivitamins and multi/minerals (OMVMs) for cardiovascular diseases (CVD) treatment and prevention. RECENT FINDINGS: Data on multivitamins, vitamin C and D, coenzyme Q, calcium, and selenium, has showed no consistent benefit for the prevention of CVD, myocardial infarction, or stroke, nor was there a benefit for all-cause mortality to support their routine supplementation. Folic acid alone and B vitamins with folic acid, B6 and B12, reduce stroke, whereas niacin and antioxidants are associated with an increased risk of all-cause mortality. Iron deficiency should be avoided and treated if found, but routine supplementation to those without deficiency is not evidence based. Despite the high supplement use by the general public, there is no evidence to support the routine supplementation of oral multivitamins and multi/minerals (OVMN) for CVD prevention or treatment.

Risk Factors for 30-day Hospital Readmissions After Peripheral Vascular Interventions in Peripheral Artery Disease Patients at the US-Mexico Border.

Peripheral artery disease (PAD) is associated with high rates of readmission following endovascular interventions and contributes to a significant hospital readmission burden. Quality metrics like hospital readmissions affect hospital performance, but must adjust to local trends. Our primary goal was to evaluate risk factors and readmission rates post-percutaneous peripheral intervention in a US-Mexico border city, at a single tertiary university hospital. We performed a retrospective review of patients with PAD undergoing first time peripheral intervention from July 2015 to June 2020. Among 212 patients, 58% were readmitted with median 235-day follow-up (inter-quartile range (IQR) 42-924); 35.3% of readmissions occurred within 30 days, and 30.2% of those were within 7 days. Median time to readmission was 62 days. Active smokers had 84% higher risk of readmission (hazard ratio (HR) 1.84, 95% CI 1.23-2.74, P < .01). Other significant factors noted were insurance status-Medicaid or uninsured (HR 1.94, 95% CI 1.22-3.09), prior amputation (HR 1.69, 95% CI 1.13-2.54), heart failure, both preserved (HR 4.35, 95% CI 2.07-9.16) and reduced ejection fraction (HR 1.88, 95% CI 1.14-3.10). Below the knee, interventions were less likely to be readmitted (adjusted HR .64, 95% CI 0.42-.96). Readmission rates were unrelated to medication adherence.

Prognosis in Hispanic patient population with pulmonary arterial hypertension: An application of common risk stratification models.

Pulmonary arterial hypertension (PAH) is a cardiovascular disease with high mortality rate. Current guidelines propose initiation and escalation of PAH-targeted treatment based on a goal-directed approach targeting hemodynamic, functional, and biochemical variables. This approach has been successfully validated in large Caucasian cohorts. However, given the low number of Hispanic patients enrolled in large PAH trials and registries, it is unknown if the same prognostic tools can be applied to this patient population. We analyzed a single-center outpatient cohort that consisted of 135 Hispanic patients diagnosed with PAH. Baseline characteristics were calculated based on COMPERA, COMPERA 2.0 and REVEAL 2.0 risk scores before the initiation of PAH-targeted therapies. The survival rate at 1 year after diagnosis was 88% for the entire cohort. The three established risk scores to predict PAH outcomes yielded similar results with reasonable discrimination of mortality in the different risk strata (all p < 0.001). Hispanic patients with PAH have a high mortality rate. Our analysis suggests that guideline proposed risk assessment at baseline yields important prognostic information in this patient population.

Long-term efficacy and safety profiles of iris-fixated foldable anterior chamber phakic intraocular lens implantation in eyes with more than 10 years of follow-up.

PURPOSE: To evaluate the long-term efficacy, safety, predictability, and stability of a foldable anterior chamber phakic intraocular lens (pIOL) (Artiflex) implantation in eyes with more than 10 years of follow-up. SETTING: Instituto de Microcirugía Ocular, Barcelona, Spain. DESIGN: Retrospective study. METHODS: Patients who underwent Artiflex pIOL implantation during 2008 to 2011 and with more than 10 years of follow-up were included. Variables analyzed were as follows: uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction, spherical equivalent (SE), endothelial cell count (ECC), and intraocular pressure (IOP) preoperatively and at 1 month, 1 year, 5 years, and the final follow-up. Descriptive statistics were performed and results reported following the Standard for Reporting Refractive Surgery Outcomes. RESULTS: 76 eyes (40 patients) were analyzed, and the mean follow-up was 10.67 ± 0.64 years. The mean preoperative SE was -8.26 ± 2.47 diopters (D), and the mean preoperative cylinder was -0.95 ± 0.86 D. At the final follow-up, efficacy and safety indices were 0.82 and 1.11, respectively. In total, 58 eyes (76%) achieved a UDVA of ≥20/40. 30 eyes (39%) gained ≥1 line of CDVA, and no eye lost ≥2 lines of CDVA. At the final follow-up, 46 (61%) and 58 (76%) eyes were within ±0.50 D and ±1.00 D of attempted SE correction, respectively. 72 eyes (95%) had ≤1.00 D of postoperative astigmatism, and 46 eyes (61%) were within ±15 degrees from the intended correction axis. At the last visit, a statistically significant myopic progression of -0.56 ± 0.83 D was observed ( P = .01). The mean ECC loss at the final follow-up was 12.2 ± 12.5%. IOP remained stable. Two eyes (2.63%) developed cataract after 10.3 years. CONCLUSIONS: Long-term results demonstrated that Artiflex pIOL implantation was effective, predictable, stable, and safe.

Narrative review in the current role of angiotensin receptor-neprilysin inhibitors.

Heart failure (HF) accounts for a tremendous burden on health care systems and the society. Since the landmark PARADIGM-HF trial, sacubitril/valsartan, the first in the class of angiotensin receptor neprilysin inhibitor (ARNI) showed superiority to enalapril in patients with HF with reduced ejection fraction (HFrEF). We performed a narrative literature review, hand-searched the reference lists of included articles and relevant reviews. Inhibition of neprilysin increases bradykinin, natriuretic peptides and adrenomedullin levels counteract the neurohormal activation that leads to sodium retention, vasoconstriction, and cardiac remodeling. In PARADIGM-HF the primary outcome of CV death or HF hospitalization was reduced 20% in the ARNI group (HR 0.80, P<0.001) similar to mortality due to cardiovascular cause (HR 0.80, P<0.001) in patients with HFrEF, rendering a number needed to treat of 21 patients. This effect was consistent across subgroups. The safety of starting ARNI inpatient once the acute decompensation of HF is stabilized was demonstrated in PIONEER-HF trial. With willingness-to-pay thresholds commonly acceptable in the United States, sacubitril/valsartan is likely to be cost effective, which might not be in other health systems. Although its safety has been reassured in some clinical trials, common side effects are hypotension, worsening kidney function, hyperkalemia and angioedema. In HFpEF (PARAGON-HF), sacubitril/valsartan showed decrease in the level of the cardiac biomarkers, with improve functional NYHA and decrease in hospitalizations, predominately in women and patients with borderline ejection fraction. Some ongoing studies aim to demonstrate the effects of ARNI in acute coronary syndrome, stable ischemic heart disease, advanced HF, mitral regurgitation, aortic impedance and pulmonary hypertension. In conclusion, sacubitril/valsartan has proven to be an effective addition to the HFrEF arsenal, with safety comparable to current standard of care. In HFpEF, it improves quality of life, particularly in women and in patients with borderline ejection fraction, with no effect on mortality.

Narrative review of pharmacotherapy for transthyretin cardiac amyloid.

Treatment of cardiac amyloidosis is determined by the amyloid type and degree of involvement. Two types of amyloid commonly infiltrate the heart: immunoglobulin light-chain amyloid (AL), and transthyretin amyloid (ATTR), that encompasses other two forms, a hereditary form (hATTR), and a sporadic, age-related wild-type (wtATTR). The prevalence is expected to increase with aging population. The natural history of ATTR cardiomyopathy includes progressive heart failure (HF), complicated by arrhythmias and conduction system disease. New therapies options have been approved or are under investigation. We performed a narrative literature review, manually-searched the reference lists of included articles and relevant reviews. Treatment for cardiac ATTR should be directed towards alleviation of HF symptoms and to slow or stop progressive amyloid deposition. Conventional HF medications are poorly tolerated and may not alter the disease progression or symptoms, except perhaps with the administration of diuretics. There are three approaches of therapy for ATTR cardiomyopathy: tetramer stabilizers, inhibition of ATTR protein synthesis and clearance of deposited fibrils. Tafamidis diminishes the progression of cardiomyopathy, functional parameters, improves overall outcome in patients with early disease stages, irrespective of ATTR status and is well tolerated. Diflunisal has shown promising results in early studies, but at the expense of significant side effects. Two new agents, antisense oligonucleotides, patisiran and inotersen are under investigation in cardiac amyloidosis. Patisiran appears to be the most effective treatment for hATTR, although evidence is limited, with a relatively small cardiac subpopulation. Therapies considering clearance of amyloid fibrils from tissue remain experimental. In conclusion, tafamidis is the only approved agent for the treatment of ATTR cardiomyopathy although multiple other agents have shown promising early results and are undergoing clinical trials. Careful consideration of the type of ATTR, comorbidities and disease stage will be key in deciding the optimal therapy for ATTR patients.

Antithrombotic / Antiplatelet Therapy in Patients with Stable Coronary Artery Disease and After Acute Coronary Syndrome.

The major physiopathological mechanism underlying Acute Coronary Syndromes (ACS) is atherosclerotic plaque rupture with resultant coronary thrombosis, posing a big burden in health care systems. Dual anti-platelet therapy (DAPT) can improve CV outcome with a prolonged regimen, albeit at the cost of increased bleeding rates. We performed a narrative literature review on the topic, in which we explored databases through April 15th, 2020, with no restrictions on language. Keywords related to antiplatelet therapy, P2Y12 inhibitor, aspirin and DAPT were utilized. Randomized clinical trials, large prospective studies, systematic reviews and meta-analysis were included. We hand-searched the reference lists of included articles and relevant reviews. The review revealed that when choosing antiplatelet agents, the decision should be driven by pharmacodynamic properties as well as demonstrated efficacy and safety. Additionally, it was noted that in patients undergoing percutaneous coronary intervention, prasugrel and ticagrelor are preferred. In patients with a high risk of bleeds or receiving thrombolysis, or when cost or specific patient issues exist, clopidogrel is considered though it is a second-line therapy. Due to an elevated risk of bleeds, triple therapy should be avoided, as evidence shows effectiveness and safety with regimens without ASA. Furthermore, multiple studies have also shown that regimens shorter than 12 months of DAPT could be adequate for many patients, and newer guidelines are likely to reflect it. There are specific recommendations for switching among antiplatelets, mostly based on registries and pharmacodynamic studies.

Management of left ventricular thrombus: a narrative review.

Left ventricular thrombus (LVT) is a serious complication of acute myocardial infarction (MI) and also non-ischemic cardiomyopathies. We performed a narrative literature review, manual-search of reference lists of included articles and relevant reviews. Our literature review indicates that the incidence of LVT following acute MI has decreased, probably due to improvement in patient care as a result of better and earlier reperfusion techniques. Predictors of LVT include anterior MI, involvement of left ventricular (LV) apex (regardless of the coronary territory affected), LV akinesis or dyskinesis, reduced LV ejection fraction (LVEF), severe diastolic dysfunction and large infarct size. LVT is associated with increased risk of systemic embolism, stroke, cardiovascular events and death, and there is evidence that anticoagulant therapy for at least 3 months can reduce the risk of these events. Cardiac magnetic resonance (CMR) has the highest diagnostic accuracy for LVT, followed by echocardiography with the use of echocardiographic contrast agents (ECAs). Although current guidelines suggest use of vitamin K antagonist (VKA) for a minimum of 3 to 6 months, there is growing evidence of the benefits of direct acting oral anticoagulants in treatment of LVT. Embolic events appear to occur even after resolution of LVT suggesting that anticoagulant therapy needs to be considered for a longer period in some cases. Recommendations for the use of triple therapy in the presence of the LVT are mostly based on extrapolation from outcome data in patients with atrial fibrillation (AF) and MI. We conclude that the presence of LVT is more likely in patients with anterior ST-segment elevation MI (STEMI) (involving the apex) and reduced ejection fraction (EF). LVT should be considered a marker of increased long-term thrombotic risk that may persist even after thrombus resolution. Ongoing clinical trials are expected to elucidate the best management strategies for patients with LVT.

Persistent mitral regurgitation after left ventricular assist device: a clinical conundrum.

AIMS: Persistent mitral valve regurgitation (MR) after continuous flow left ventricular assist device implantation (cfLVAD) is associated with pulmonary hypertension and right ventricular failure with variable effects on survival across published studies. The aim of this study is to determine the incidence and predictors of persistent MR at 6-month follow-up after cfLVAD implantation and its impact on survival, haemodynamics, right ventricular function, and morbidity. METHODS AND RESULTS: We performed a retrospective review of all adult cfLVAD recipients from January 2012 to June 2017 at a single tertiary university hospital with follow-up until April 2019. Primary outcome was to compare survival between patients with no-to-mild compared with persistent moderate-to-severe MR at 6 months. Secondary outcomes included right heart failure (RHF), length of stay, re-hospitalizations, and composite of death, transplant, and pump exchange during the length of follow-up. Final analytic sample was 111 patients. The incidence of persistent moderate or severe MR at 6 months was 26%. Significant predictors of persistent MR at 6 months were left atrium dimension and volume. The group with persistent moderate-to-severe MR at 6 months had higher incidence of RHF at 6 months (45% vs. 25%, P = 0.04). There was no difference in survival at 1 year between the groups (no-to-mild MR 85.5%, moderate-to-severe MR 87.9%, Wilcoxon P-value = 0.63). There was no difference in re-hospitalizations, length of stay, composite of death, transplant, or pump exchange during the length of follow-up between the comparison groups. CONCLUSIONS: Persistent moderate-to-severe MR after cfLVAD implantation is present in one fourth of patients and is associated with increased incidence of RHF, higher mean pulmonary pressure, and pulmonary capillary wedge pressure with no effect on 1 year survival. Increased left atrium size was associated with persistent moderate-to-severe MR at 6 months.