Integrating Advanced Lipid Testing and Biomarkers in Assessment and Treatment.

PURPOSE OF REVIEW: Our ability to assess and stratify atherosclerotic disease risk in patients is evolving. Recent advances in advanced lipid testing have created opportunities for clinical application of novel biomarkers. RECENT FINDINGS: Until recently, LDL-C has served largely as the singular biomarker of ASCVD and guide for decisions in treatment for high-risk groups. There are important evolutions in the measurement of LDL-C but even still, the pathogenesis of atherosclerosis and ASCVD is not solely driven by LDL-C. As atherosclerosis is driven by multiple complex pathways including inflammation, it is important to expand our focus beyond LDL-C and utilize multiple biomarkers in the assessment of this disease process. Non-HDL, ApoB, LDL-P, Lp(a), and hsCRP are unique tools to aid in cardiac risk evaluation, especially in higher risk patients, though not limited to this population. A multifaceted approach to advanced lipid testing with novel biomarkers will enhance comprehensive ASCVD risk assessments.

The Impact of Underlying Obstructive Sleep Apnea Treatment on Exercise Capacity in Patients With Pulmonary Hypertension Undergoing a Cardiac Rehabilitation Program.

PURPOSE: Obstructive sleep apnea (OSA)-related pulmonary hypertension (PH) can often be reversed with treatment of OSA via continuous positive airway pressure. We hypothesized that treatment of OSA would be associated with a greater improvement in exercise capacity (EC) with cardiac rehabilitation (CR), especially in patients with PH as compared with those who are untreated. METHODS: We reviewed medical records of 315 consecutive patients who participated in CR. Pulmonary hypertension status was assessed on the basis of peak tricuspid regurgitant velocity (>2.8 m/sec) on pre-CR echocardiograms. The OSA status (no, untreated, or treated OSA) was determined on the basis of results from sleep studies, continuous positive airway pressure device data, and physician notes. Exercise capacity was assessed by measuring metabolic equivalents (METs) using a treadmill stress test before and after CR. RESULTS: We included 290 patients who participated in CR with available echocardiographic data: 44 (15%) had PH, and 102 (35%) had known OSA (30 treated and 72 untreated). Patients with OSA versus those with no OSA were more likely to have PH ( P = .06). Patients with PH versus no-PH were associated with significantly lower baseline METs in crude and adjusted analyses ( P ≤. 004). The PH and OSA status in isolation were not associated with changes in METs ( P > .2) with CR. There was a significant interaction between OSA treatment and PH in crude and adjusted analyses ( P ≤.01): treatment vs no treatment of OSA was associated with a clinically and statistically greater improvement in METs in patients who participated in CR with but not without PH. CONCLUSION: Baseline PH was associated with decreased baseline EC but did not attenuate CR-related improvements in METs. However, in the subset of OSA patients with PH, OSA therapy was associated with improved EC after CR.

2 Cases of Elusive Left Ventricular Outflow Tract Gradient.

Patients with hypertrophic cardiomyopathy (HCM) typically have septal hypertrophy and left ventricular outflow tract gradient, usually present at rest with increase under certain hemodynamic conditions. We report 2 cases of HCM in which there was subtle septal hypertrophy; the gradient was detected only postprandially, highlighting the importance of considering postprandial imaging in patients with suspected HCM. (Level of Difficulty: Intermediate.).

Association Between Acute Kidney Injury During Invasive Mechanical Ventilation and ICU Outcomes and Respiratory System Mechanics.

Compare ICU outcomes and respiratory system mechanics in patients with and without acute kidney injury during invasive mechanical ventilation. DESIGNS: Retrospective cohort study. SETTINGS: ICUs of the University of California, San Diego, from January 1, 2014, to November 30, 2016. PATIENTS: Five groups of patients were compared based on the need for invasive mechanical ventilation, presence or absence of acute kidney injury per the Kidney Disease: Improving Global Outcomes criteria, and the temporal relationship between the development of acute kidney injury and initiation of invasive mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 9,704 patients were included and 4,484 (46%) required invasive mechanical ventilation; 2,009 patients (45%) had acute kidney injury while being treated with invasive mechanical ventilation, and the mortality rate for these patients was 22.4% compared with 5% in those treated with invasive mechanical ventilation without acute kidney injury (p < 0.01). Adjusted hazard of mortality accounting for baseline disease severity was 1.58 (95% CI, 1.22-2.03; p < 0.001]. Patients with acute kidney injury during invasive mechanical ventilation had a significant increase in total ventilator days and length of ICU stay with the same comparison (both p < 0.01). Acute kidney injury during mechanical ventilation was also associated with significantly higher plateau pressures, lower respiratory system compliance, and higher driving pressures (all p < 0.01). These differences remained significant in patients with net negative cumulative fluid balance. CONCLUSIONS: Acute kidney injury during invasive mechanical ventilation is associated with increased ICU mortality, increased ventilator days, increased length of ICU stay, and impaired respiratory system mechanics. These results emphasize the need for investigations of ventilatory strategies in the setting of acute kidney injury, as well as mechanistic studies of crosstalk between the lung and kidney in the critically ill.

Association between implantable cardioverter-defibrillator and survival in patients awaiting heart transplantation: A meta-analysis and systematic review.

BACKGROUND: Patients with end-stage heart failure are at high risk for sudden cardiac death. However, implantable cardioverter-defibrillator (ICD) is not routinely implanted given the high competing risk of pump failure. A unique population worth separate consideration are patients with end-stage heart failure awaiting heart transplantation, as prolonged survival improves the chances of receiving transplant. OBJECTIVE: To compare clinical outcomes of heart failure patients with and without an ICD awaiting heart transplant. METHODS: We performed an extensive literature search and systematic review of studies that compared end-stage heart failure patients with and without an ICD awaiting heart transplantation. We separately assessed the rates of total mortality, sudden cardiac death, nonsudden cardiac death, and heart transplantation. Risk ratio (RR) and 95% confidence intervals were measured using the Mantel-Haenszel method. The random effects model was used owing to heterogeneity across study cohorts. RESULTS: Ten studies with a total of 36,112 patients were included. A total of 62.5% of patients had an ICD implanted. Patients with an ICD had decreased total mortality (RR 0.60, 95% CI 0.51-0.71, P < .00001) and sudden cardiac death (RR 0.27, 95% CI 0.11-0.66, P = .004) and increased rates of heart transplantation (RR 1.09, 95% CI 1.05-1.14, P < .0001). There was no difference in prevalence of nonsudden cardiac death (RR 0.68, 95% CI 0.44-1.04, P = .07). CONCLUSION: ICD implantation is associated with improved outcomes in patients awaiting heart transplant, characterized by decreased total mortality and sudden cardiac death as well as higher rates of heart transplantation.