Shared Lifestyle-Related Risk Factors of Cardiovascular Disease and Cancer: Evidence for Joint Prevention.

Cardiovascular disease (CVD) and cancer are leading causes of mortality and morbidity worldwide and are the major focus of the World Health Organization's joint prevention programs. While, diverse diseases, CVD and cancer, have many similarities. These include common lifestyle-related risk factors and shared environmental, metabolic, cellular, inflammatory, and genetic pathways. In this review, we will discuss the shared lifestyle-related and environmental risk factors central to both diseases and how the strategies commonly used to prevent atherosclerotic vascular disease can be applied to cancer prevention.

Regulatory T Cell Biomarkers Identify Patients at Risk of Developing Acute Cellular Rejection in the First Year Following Heart Transplantation.

BACKGROUND: Acute cellular rejection (ACR), an alloimmune response involving CD4+ and CD8+ T cells, occurs in up to 20% of patients within the first year following heart transplantation. The balance between a conventional versus regulatory CD4+ T cell alloimmune response is believed to contribute to developing ACR. Therefore, tracking these cells may elucidate whether changes in these cell populations could signal ACR risk. METHODS: We used a CD4+ T cell gene signature (TGS) panel that tracks CD4+ conventional T cells (Tconv) and regulatory T cells (Treg) on longitudinal samples from 94 adult heart transplant recipients. We evaluated combined diagnostic performance of the TGS panel with a previously developed biomarker panel for ACR diagnosis, HEARTBiT, while also investigating TGS' prognostic utility. RESULTS: Compared with nonrejection samples, rejection samples showed decreased Treg- and increased Tconv-gene expression. The TGS panel was able to discriminate between ACR and nonrejection samples and, when combined with HEARTBiT, showed improved specificity compared with either model alone. Furthermore, the increased risk of ACR in the TGS model was associated with lower expression of Treg genes in patients who later developed ACR. Reduced Treg gene expression was positively associated with younger recipient age and higher intrapatient tacrolimus variability. CONCLUSIONS: We demonstrated that expression of genes associated with CD4+ Tconv and Treg could identify patients at risk of ACR. In our post hoc analysis, complementing HEARTBiT with TGS resulted in an improved classification of ACR. Our study suggests that HEARTBiT and TGS may serve as useful tools for further research and test development.

Does Opium Consumption Have Shared Impact on Atherosclerotic Cardiovascular Disease and Cancer?

Although atherosclerotic cardiovascular disease (ASCVD) and cancer are seemingly different types of disease, they have multiple shared underlying mechanisms and lifestyle-related risk factors like smoking, unhealthy diet, excessive alcohol consumption, and inadequate physical activity. Opium abuse is prevalent in developing countries, especially the Middle East region and many Asian countries. Besides recreational purposes, many people use opium based on a traditional belief that opium consumption may confer protection against heart attack and improve the control of the risk factors of ASCVD such as diabetes mellitus, hypertension, and dyslipidemia. However, scientific reports indicate an increased risk of ASCVD and poor control of ASCVD risk factors among opium abusers compared with nonusers. Moreover, there is accumulating evidence that opium consumption exerts potential carcinogenic effects and increases the risk of developing various types of cancer. We conducted a review of the literature to review the current evidence on the relationship between opium consumption and ASCVD as well as various kinds of cancer. In addition, we will discuss the potential shared pathophysiologic mechanisms underlying the association between opium abuse and both ASCVD and cancer.

Health expenditures after first hospital admission for heart failure in Nova Scotia, Canada: a retrospective cohort study.

BACKGROUND: Although the frequency of heart failure makes it among the costliest of illnesses, there are scant Canadian data on annual costs of treatment or the costs as the condition advances. Our objective was to estimate mean prevalence- and incidence-based direct medical costs among older adults discharged alive after a first hospital admission for heart failure. METHODS: We conducted a retrospective cohort study using population-based administrative health databases for Nova Scotia. The cohort comprised persons 50 years of age or older with an incident hospital admission for heart failure between 2009 and 2012. We considered the costs (expressed as 2020 Canadian dollars) of hospital admissions, physician visits and, for patients 65 years of age or older, outpatient cardiac medications. We estimated costs for calendar years, longitudinally and in the last 2 years of life. We analyzed costs from the perspective of a third-party public payer. RESULTS: The cohort consisted of 3327 patients (mean age 77.6 yr; 1605 [48.2%] women). Median survival was 2.5 and 2.2 years among men and women, respectively. Annual prevalence-based costs were about $7100. Mean incidence-based costs ranged between $65 000 and $164 000 in the year after diagnosis and decreased by 90% subsequently. Costs were 4 to 7 times higher in the year before death than in the period from 1 to 2 years before death. INTERPRETATION: The direct medical costs of treating patients with heart failure in Nova Scotia displayed a reverse J shape, with costs highest after diagnosis, declining subsequently and then increasing during the final year of life. Strategies designed to improve the quality of care immediately after diagnosis and during more advanced stages of disease might reduce these costs.

Psychosocial and medical predictors of 14-year mortality and morbidity in male and female coronary artery bypass graft recipients: a prospective observational study.

BACKGROUND: Psychosocial factors may influence mortality and morbidity after coronary bypass surgery (CABG), but it is unclear when, post-surgery, they best predict the outcome, if they interact, or whether results differ for men and women. METHODS: This prospective, observational study assessed depression symptoms, social support, marital status, household responsibility, functional impairment, mortality and need for further coronary procedures over 14 years of follow-up. Data were collected in-hospital post-CABG and at home 1-year later. Mortality and subsequent cardiac procedure data were extracted from a Cardiac Registry. RESULTS: Of 296 baseline participants, 78% (43% were women) completed data at 1-year post-CABG. Long-term survival was shorter with 1-year depression and lower household responsibility but that was not true for the measures taken at baseline [HR for depression = 1.27; 95% CI 1.02-1.59 v. 0.99 (0.78-1.25), and HR = 0.71; 95% CI 0.52-0.97 v. 0.97 (0.80-1.16)] for household responsibility. An interaction between depression symptoms and social support at year 1 [χ2 (11) = 111.05, p < 0.001] revealed a greater hazard of mortality d with increased depression only at mean (HR = 1.67; 95% CI 1.21-2.26) and high social support (HR = 2.23; 95% CI 1.46-3.40). Depression also accounted for increased event recurrence. There were no significant interactions of sex with medical long-term outcomes. CONCLUSIONS: In a sex-balanced sample, depression and household responsibility measured at 1-year post-CABG were associated with significant variance in unadjusted and adjusted predictor models of long-term mortality whereas the same indices determined right after the procedure were not significant predictors.

High Intensity Interval Training Leads to Similar Inflammatory Activation as Seen With Traditional Training in Chronic Heart Failure.

BACKGROUND: Inflammatory activation has been associated with the severity and progression of chronic heart failure (CHF). Although cardiac rehabilitation is an important therapy, acute bouts of exercise may lead to increases in pro-inflammatory cytokines with exercise intensity mediating these changes. OBJECTIVE: To evaluate the acute inflammatory response in patients living with CHF during a randomized trial following Steady State (SS) or High Intensity Interval (HIIT) training. METHODS: Patients living with CHF (n = 14) were stratified (for body mass and aerobic power) and randomized into SS and HIIT cycle exercise. The HIIT exercise training involved 2 min work:recovery phases at 90:40% heart rate reserve. The SS exercise training involved continuous exercise at 65% of heart rate reserve (matched total work). Acute inflammatory markers were evaluated (via ELISA) at baseline, immediately following the bout, and at 6, 24, and 48 h post-exercise. RESULTS: There was limited differences in the changes in inflammatory biomarkers across time between the HIIT and SS groups. Both groups experienced a significant (p < 0.05) change in Interleukin-6 immediately post-exercise. CONCLUSIONS: A single bout of HIIT or SS does not result in excessive inflammatory activation in CHF patients. Acute HIIT and SS result in similar changes in inflammatory markers. These findings have important implications for exercise training and rehabilitation programs in persons living with CHF.

Canadian Real-World Experience of Using Sacubitril/Valsartan in Patients With Heart Failure With Reduced Ejection Fraction: Insight From the PARASAIL Study.

BACKGROUND: To determine the effectiveness of sacubitril/valsartan 97/103 mg twice daily (b.i.d.) on tolerability, safety, and quality of life (QoL) in Canadian patients with heart failure with reduced ejection fraction in a real-life setting. METHODS: In Prospective, Multicenter, Open Label, Post-Approval Study Aimed at Characterizing the Use of LCZ696 at 97 mg Sacubitril/103 mg Valsartan bid in Patients With HFrEF (PARASAIL), an open-label, prospective, phase IV, multicentre study, outpatients with heart failure with reduced ejection fraction and New York Heart Association functional class II-III were followed up for 12 months. The suggested starting dose of sacubitril/valsartan was 24/26 mg b.i.d. replacing angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, with an uptitration to 97/103 mg b.i.d. or as per clinical judgement. The primary endpoint was the proportion of patients achieving the target dose of sacubitril/valsartan 97/103 mg b.i.d. after 6 months of treatment. RESULTS: For the 302 patients included, the mean age was 64.47 years, and a majority of patients (82.8%) belonged to New York Heart Association class II. Overall, 195 (64.6%) patients were on maximum dose of sacubitril/valsartan 97/103 mg b.i.d. after 6 months and 62.3% remained on this dose at month 12. Using patient global assessment, patients experienced an improvement in QoL. For Minnesota Living with Heart Failure Questionnaire scores, a significant decrease from the baseline was observed at weeks 4, 12, and 24 (P < 0.0001 for all), which indicated an improvement in QoL. The patient global assessment and Minnesota Living with Heart Failure Questionnaire results correlate with moderate but significant changes in Euro quality of life-5D visual analogue scale scores. CONCLUSIONS: Results of the PARASAIL study in a real-life setting have shown that most patients were on sacubitril/valsartan 97/103 mg b.i.d. and the treatment was well tolerated. The patient-reported outcomes showed an overall improvement in patients' QoL.

CONTEXTE: L'objectif était de déterminer, en contexte réel, l'efficacité de l'association sacubitril à 97 mg/valsartan à 103 mg, deux fois par jour, sous l'angle de la tolérabilité, de l'innocuité et de la qualité de vie (QV) chez des patients canadiens atteints d'insuffisance cardiaque avec fraction d'éjection réduite. MÉTHODOLOGIE: Au cours de l'étude multicentrique et prospective sans insu de phase IV PARASAIL ( P rospective, Multicenter, Open L a bel, Post-App r ov a l S tudy Ai med at Characterizing the Use of L CZ696 at 97 mg Sacubitril/103 mg Valsartan bid in Patients With HFrEF), des patients externes atteints d'insuffisance cardiaque de classe fonctionnelle II ou III selon la NYHA (New York Heart Association) avec fraction d'éjection réduite ont été suivis durant 12 mois. La dose initiale recommandée était de 24 mg de sacubitril/26 mg de valsartan, deux fois par jour, à la place d'un inhibiteur de l'enzyme de conversion de l'angiotensine ou d'un antagoniste des récepteurs de l'angiotensine; la dose devait être augmentée à 97 mg de sacubitril/103 mg de valsartan, deux fois par jour, ou selon le jugement du clinicien. Le critère d'évaluation principal était la proportion de patients chez qui la dose cible de 97 mg de sacubitril/103 mg de valsartan, deux fois par jour, se trouvait atteinte après six mois de traitement. RÉSULTATS: L'âge moyen des 302 patients admis était de 64,47 ans. La majorité de ces patients (82,8 %) présentaient une insuffisance cardiaque de classe II selon la NYHA. Globalement, 195 (64,6 %) patients prenaient la dose maximale de 97 mg de sacubitril/103 mg de valsartan, deux fois par jour, après six mois de traitement; 62,3 % continuaient de prendre cette dose à 12 mois de traitement. L'évaluation globale des patients indique une amélioration de leur QV. Les scores au Minnesota Living With Heart Failure Questionnaire avaient significativement diminué par rapport aux scores de départ aux semaines 4, 12 et 24 (p < 0,0001 à tous les temps d'évaluation), ce qui indique une amélioration de la QV. L'évaluation globale des patients et les scores au Minnesota Living With Heart Failure Questionnaire sont corrélés avec des variations modérées, mais significatives des scores de QV à l'échelle visuelle analogique du questionnaire EQ-5D. CONCLUSIONS: Les résultats obtenus en contexte réel au cours de l'étude PARASAIL montrent que la plupart des patients prenaient la dose de 97 mg de sacubitril/103 mg de valsartan, deux fois par jour, et que le traitement était bien toléré. Les résultats rapportés par les patients témoignent d'une amélioration globale de la QV de ces derniers.

HEARTBiT: A Transcriptomic Signature for Excluding Acute Cellular Rejection in Adult Heart Allograft Patients.

BACKGROUND: Nine mRNA transcripts associated with acute cellular rejection (ACR) in previous microarray studies were ported to the clinically amenable NanoString nCounter platform. Here we report the diagnostic performance of the resulting blood test to exclude ACR in heart allograft recipients: HEARTBiT. METHODS: Blood samples for transcriptomic profiling were collected during routine post-transplantation monitoring in 8 Canadian transplant centres participating in the Biomarkers in Transplantation initiative, a large (n = 1622) prospective observational study conducted between 2009 and 2014. All adult cardiac transplant patients were invited to participate (median age = 56 [17 to 71]). The reference standard for rejection status was histopathology grading of tissue from endomyocardial biopsy (EMB). All locally graded ISHLT ≥ 2R rejection samples were selected for analysis (n = 36). ISHLT 1R (n = 38) and 0R (n = 86) samples were randomly selected to create a cohort approximately matched for site, age, sex, and days post-transplantation, with a focus on early time points (median days post-transplant = 42 [7 to 506]). RESULTS: ISHLT ≥ 2R rejection was confirmed by EMB in 18 and excluded in 92 samples in the test set. HEARTBiT achieved 47% specificity (95% confidence interval [CI], 36%-57%) given ≥ 90% sensitivity, with a corresponding area under the receiver operating characteristic curve of 0.69 (95% CI, 0.56-0.81). CONCLUSIONS: HEARTBiT's diagnostic performance compares favourably to the only currently approved minimally invasive diagnostic test to rule out ACR, AlloMap (CareDx, Brisbane, CA) and may be used to inform care decisions in the first 2 months post-transplantation, when AlloMap is not approved, and most ACR episodes occur.

Impact of Donor Origin on Survival After Orthotopic Heart Transplantation.

Heart transplantation is the definitive management for select patients with end-stage heart failure. Owing to an ongoing organ donor shortage, organs are sometimes allocated from distant locales. These organs may be perceived as less desirable because of donor risk factors and ischemic times. We compared survival after heart transplantation by donors originating from British Columbia (BC), other Canadian provinces, and the United States. This retrospective cohort analysis included all patients transplanted in BC between December 1, 1988, and October 21, 2014, and excluded those with missing data or retransplantation. Among 382 patients, 297 (77.7%) recipients and 238 (62.3%) donors were male. The median recipient age was 54.6 years (interquartile range, 46.0-61.0 years) and the median donor age was 33 years (interquartile range, 22-46 years). Overall 10-year survival was 62.1% (95% confidence interval, 56.3-67.4). There was no difference in 10-year survival when comparing donors from BC, other Canadian provinces, and the United States despite significantly lower median ischemic times in donors from BC. Donor location was not predictive of mortality after controlling for recipient age, donor age, and cold ischemic time. Donor origin did not impact 10-year survival after heart transplantation despite increased ischemic time, suggesting that distant donors result in similar outcomes in BC.

Medical therapy doses at hospital discharge in patients with existing and de novo heart failure.

AIMS: Uptitrating angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACE-I/ARBs), beta-blockers, and mineralocorticoid receptor antagonists (MRAs) to optimal doses in heart failure with reduced ejection fraction (HFrEF) is associated with improved outcomes and recommended in guidelines. Studies of ambulatory patients found that a minority are prescribed optimal doses. However, dose at hospital discharge has rarely been reported. This information may guide quality improvement initiatives during and following discharge. METHODS AND RESULTS: We assessed 370 consecutive patients with HFrEF hospitalized at two centres in Vancouver, Canada. Of those without contraindications, 86.4%, 93.4%, and 44.7% were prescribed an ACE-I/ARB/sacubitril-valsartan, beta-blocker, or MRA, respectively. The proportion of eligible patients prescribed target dose was respectively 28.6%, 31.7%, and 4.1%. Forty-two of 248 eligible patients (16.9%) were prescribed ≥50% of target dose, and only three patients received target dosing of all three medication classes. In multivariate regression models, cardiologist involvement in care was independently associated with increased dose and prescription of ≥50% of target dose for all medications, whereas a history of HF was only predictive for beta-blockers. CONCLUSIONS: In a single-region experience of hospitalized HFrEF patients, a high proportion of eligible patients were discharged on ACE-I/ARB or beta-blocker. Less than half were prescribed MRAs, and few were prescribed ≥50% or target dosing of all medications. Further exploration into barriers to medication uptitration, and improvement in processes of care, is needed.

Ensembling Electrical and Proteogenomics Biomarkers for Improved Prediction of Cardiac-Related 3-Month Hospitalizations: A Pilot Study.

BACKGROUND: Many risk models for predicting mortality, hospitalizations, or both in patients with heart failure have been developed but do not have sufficient discriminatory ability. The purpose of this study was to identify predictive biomarkers of hospitalizations in heart failure patients using omics-based technologies applied to blood and electrical monitoring of the heart. METHODS: Blood samples were collected from 58 heart failure patients during enrollment into this study. Each patient wore a 48-hour Holter monitor that recorded the electrical activity of their heart. The blood samples were profiled for gene expression using microarrays and protein levels using multiple reaction monitoring. Statistical deconvolution was used to estimate cellular frequencies of common blood cells. Classification models were developed using clinical variables, Holter variables, cell types, gene transcripts, and proteins to predict hospitalization status. RESULTS: Of the 58 patients recruited, 13 were hospitalized within 3 months after enrollment. These patients had lower diastolic and systolic blood pressures, higher brain natriuretic peptide levels, most had higher blood creatinine levels, and had been diagnosed with heart failure for a longer time period. The best-performing clinical model had an area under the receiver operating characteristic curve of 0.76. An ensemble biomarker panel consisting of Holter variables, cell types, gene transcripts, and proteins had an area under the receiver operating characteristic curve of 0.88. CONCLUSIONS: Molecular-based analyses as well as sensory data might provide sensitive biomarkers for the prediction of hospitalizations in heart failure patients. These approaches may be combined with traditional clinical models for the development of improved risk prediction models for heart failure.

Trace minerals intake: Risks and benefits for cardiovascular health.

Minerals play a major role in regulating cardiovascular function. Imbalances in electrolyte minerals are frequent and potentially hazardous occurrences that may lead to the development of cardiovascular diseases (CVDs). Transition metals, such as iron, zinc, copper and selenium, play a major role in cell metabolism. However, there is controversy over the effects of dietary and supplemental intake of these metals on cardiovascular risk factors and events. Since their pro-oxidant or antioxidant functions can have different effects on cardiovascular health. While deficiency of these trace elements can cause cardiovascular dysfunction, several studies have also shown a positive association between metal serum levels and cardiovascular risk factors and events. Thus, a J- or U-shaped relationship between the transition minerals and cardiovascular events has been proposed. Given the existing controversies, large, well-designed, long-term, randomized clinical trials are required to better examine the effects of trace mineral intake on cardiovascular events and all-cause mortality in the general population. In this review, we discuss the role of dietary and/or supplemental iron, copper, zinc, and selenium on cardiovascular health. We will also clarify their clinical applications, benefits, and harms in CVDs prevention.

What Do Patients Talk About? A Qualitative Analysis of Online Chat Sessions with Health Care Specialists During a "Virtual" Cardiac Rehabilitation Program.

INTRODUCTION: Cardiac rehabilitation programs (CRPs) are effective at reducing cardiovascular disease (CVD) risk, yet attendance in these programs remains low due to geographic constraints. In a previously conducted randomized trial we demonstrated that a virtual CRP (vCRP) delivered over the Internet reduced risk for CVD. The current investigation has reviewed the online chat sessions between participants and healthcare providers (HCP) to describe the content of discussions during the vCRP intervention. MATERIALS AND METHODS: Participants were recruited from two geographically isolated areas in British Columbia, Canada without in-person CRP or a cardiologist serving the area. The vCRP, among other elements, included scheduled one-on-one chat sessions with a dietician, exercise specialist, and nurse to mimic standard CRP consultations. The chat sessions were reviewed for content and themes. Multiple chat sessions between participants and a single care provider were also analyzed to describe how chat content progressed through multiple sessions. RESULTS: A total of 38 participants participated in the vCRP intervention. From the 122 chat sessions between participants and HCP during the vCRP, the main themes identified were Managing Health and Lifestyle, Continuity of Care, and Getting Care from a Distance. Within each theme, sub-themes were also identified. CONCLUSIONS: The vCRP chat sessions fulfilled the role of face-to-face consultations with HCP that are standard in hospital-based CRP and addressed patient concerns, facilitating remote patient-provider interaction and covering topics on exercise, diet, and positive behavior changes to limit risk factors for future heart problems.

Electrolyte minerals intake and cardiovascular health.

Appropriate intake of micronutrient, such as electrolyte minerals is critical for the well-being of the cardiovascular health system. However, there are some debates regarding the impacts of dietary and/or supplemental intake of these minerals, on the risk of cardiovascular events and associated risk factors. High sodium intake is adversely associated with the risk of hypertension. Although many reports refered to the positive association of Na intake and cardiovascular events and all-cause mortality, however, other studies indicated that low Na intake is related to higher risk of all-cause mortality and HF-related events. By contrast, dietary potassium, magnesium and calcium have an inverse correlation with cardiovascular events and risk factors, especially with blood pressure. There are some controversies about cardiovascular effects and all-cause mortality of high Ca intake, including no effect, preventive or adverse effect with or without vitamin D. Calcium supplementation might be beneficial for prevention of cardiovascular events and all-cause mortality only in individuals with low intake. Moreover, calcium intake showed a J- or U-shaped association with the risk of cardiovascular diseases. Due to the controversies of the effect of electrolyte minerals especially sodium and calcium intake on cardiovascular events, large scale, well-designed long-term randomized clinical trials are required to evaluate the effect of minerals intake on cardiovascular events and all-cause mortality. In this review, we discuss the role of dietary and or supplemental sodium, potassium, magnesium, calcium, in cardiovascular health, as well as their clinical applications, benefits, and risks for the primary prevention of cardiovascular disease, in general population.

Heart failure disease management program, its contribution to established pharmacotherapy and long-term prognosis in real clinical practice - retrospective data analysis.

BACKGROUND AND AIMS: The prognosis of patients with heart failure (HF) is still generally unfavorable. HF with reduced ejection fraction (HFrEF) patients reach target medication doses in very low percentages in daily clinical practice. HF disease management programs (DMP), including nurse and telemedicine support that facilitate achieving target medication doses, may improve the unfavorable prognosis. METHODS: We retrospectively analyzed the data of 738 patients with HFrEF who were followed in a single HF center during the years 1975-2011, for 6.4 (median) years. DMP, nurse and telemedicine support is established at this center. RESULTS: The group achieved left ventricle (LV) recovery after the HF treatment. The median LV ejection fraction improved from 25.0% at baseline to 50.0% at the time of the latest data collection. The proportion of NYHA II, III and IV classes decreased from 27.6%, 30.2% and 29.7% to 26.6%, 7.2% and 0.1%, respectively while the proportion of NYHA class I increased from 12.5% to 66.1%. Median NT-proBNP decreased from 975.0 to 324.0 pg/mL. The survival of the patient group was favorable; 79.7% survived 18.1 years after diagnosis of HF. A high percentage of the patients received recommended target or higher than target doses of angiotensin-converting enzyme inhibitors (82.0%) and beta-blockers (78.1%). CONCLUSION: The established pharmacotherapy resulted from an effective DMP and this contributed to the favorable prognosis.

Interdisciplinary Approach to an Unusual Case of Myocarditis in Pregnancy.

We present a case of myocarditis in a 26-year-old pregnant woman at 29 weeks gestation. Despite optimal medical therapy, she experienced a cardiac arrest 10 days postadmission. An interdisciplinary team facilitated emergency delivery of her baby by perimortem (ie, during maternal cardiac arrest) Caesarean section and initiation of emergency mechanical circulatory support. A cardiac biopsy revealed a mixed eosinophilic and histiocytic infiltrate. After a course of steroid therapy, she experienced full recovery. Both the patient and the infant are alive and well. The case highlights the success of modern interdisciplinary care, as well as ongoing gaps in our knowledge of myocarditis.

Nous présentons un cas de myocardite chez une femme de 26 ans enceinte de 29 semaines, qui a subi un arrêt cardiaque 10 jours après son admission. Une équipe interdisciplinaire a favorisé l'accouchement d'urgence par césarienne perimortem (c.-à-d. durant l'arrêt cardiaque de la mère), et la mise en place en urgence d'une assistance mécanique. Une biopsie cardiaque a révélé un infiltrat mixte d'éosinophiles et d'histiocytes. Il y a eu récupération complète de la fonction ventriculaire après un traitement aux stéroïdes. La patiente et l'enfant sont en vie et se portent bien. Le cas témoigne de la réussite de la pratique moderne des soins interdisciplinaires, et met en lumière les lacunes actuelles de nos connaissances sur la myocardite.

Coronary Vasospasm Following Heart Transplantation: Rapid Progression to Aggressive Cardiac Allograft Vasculopathy.

Coronary artery vasospasm (CVS) has been described in orthotopic heart transplant patients but is rare in the post-transplanted, denervated heart. Severe CVS has been associated with accelerated cardiac allograft vasculopathy (CAV) and allograft rejection. Allograft vasculopathy is the leading cause of decreased long-term survival in orthotopic heart transplant. The prognostic significance and relationship of the presence and severity of CVS with CAV are not well understood. We present a case of severe symptomatic CVS with rapid development of severe CAV. Our case emphasizes the need for close angiographic surveillance and intracoronary imaging for early detection of CAV in the presence of vasospasm.

Eligibility for cardiac resynchronization therapy in patients hospitalized with heart failure.

AIMS: Recent guidelines recommend cardiac resynchronization therapy (CRT) in mildly symptomatic heart failure (HF) but favour left bundle branch block (LBBB) morphology in patients with moderate QRS prolongation (120-150 ms). We defined how many patients hospitalized with HF fulfil these criteria. METHODS AND RESULTS: A single-centre retrospective cohort study of 363 consecutive patients hospitalized with HF (438 admissions) was performed. Electronic imaging, electrocardiograms, and records were reviewed. Overall, 153 patients (42%) had left ventricular ejection fraction (LVEF) ≤ 35%, and 34% of patients had QRS prolongation. Eighty patients (22%) were potentially eligible with LVEF ≤ 35% and QRS ≥ 120 ms or existing CRT. The majority (68 of 80) had a Class I or IIa recommendation according to international guidelines (LBBB or non-LBBB QRS ≥ 150 ms or right ventricular pacing). Only a minority (12 of 80) had moderate QRS prolongation of non-LBBB morphology. One-quarter (n = 22) of patients fulfilling criteria were ineligible for reasons including dementia, co-morbidities, or palliative care. A further eight patients required optimization of medical therapy. CRT was therefore immediately indicated in 50 patients. Of these, 29 were implanted or had existing CRT systems. Twenty-one of the 80 patients eligible for CRT were not identified or treated (6% of the total hospitalized cohort). CONCLUSIONS: Twenty-two per cent of elderly real-life patients hospitalized with HF fulfil LVEF and QRS criteria for CRT, most having a Class I or IIa indication. However, a large proportion is ineligible owing to co-morbidities or requires medical optimization. Although uptake of CRT was reasonable, there remain opportunities for improvement.

The Impact of Reduced Cardiac Rehabilitation on Maximal Treadmill Exercise Time: A RANDOMIZED CONTROLLED TRIAL.

PURPOSE: Cardiac rehabilitation programs (CRPs) remain underutilized partly because of access barriers. We therefore evaluated a CRP with fewer center-based sessions (rCRP) compared with standard CRP (sCRP) with respect to changes in exercise capacity and cardiac risk factors. METHODS: In this randomized controlled noninferiority trial, primary and secondary prevention patients at low and moderate risk were randomized to an sCRP (n = 60) or an rCRP (n = 61). Over 4 months, sCRP and rCRP participants attended 32 and 10 on-site cardiac rehabilitation sessions, respectively. The primary outcome was the difference in the change in exercise capacity from baseline at 4 and 16 months between the groups measured in seconds from a maximal treadmill exercise test. Noninferiority of the rCRP was tested with mixed-effects model analysis with a cut point of 60 seconds for the upper value of the group estimate. RESULTS: Attendance was higher for the rCRP group (97% ± 63% vs 71% ± 22%, P = .002). Over 16 months, exercise test time increased for the sCRP (524 ± 168 to 604 ± 172 seconds, P < .01) and the rCRP (565 ± 183 to 640 ± 192 seconds, P < .01). The rCRP was not inferior to the sCRP regarding changes in treadmill time (48.47 seconds, P = .454). The rCRP was not inferior to the sCRP regarding metabolic and anthropometric risk factors. CONCLUSION: Our findings suggest that, for a selected group of low-/moderate-risk patients, the number of center-based CRP exercise sessions can be decreased while maintaining reduced cardiovascular risk factors.

Differentiating heart failure phenotypes using sex-specific transcriptomic and proteomic biomarker panels.

AIMS: Heart failure with preserved ejection fraction (HFpEF) accounts for 30-50% of patients with heart failure (HF). A major obstacle in HF management is the difficulty in differentiating between HFpEF and heart failure with reduced ejection fraction (HFrEF) using conventional clinical and laboratory investigations. The aim of this study is to develop robust transcriptomic and proteomic biomarker signatures that can differentiate HFpEF from HFrEF. METHODS AND RESULTS: A total of 210 HF patients were recruited in participating institutions from the Alberta HEART study. An expert clinical adjudicating panel differentiated between patients with HFpEF and HFrEF. The discovery cohort consisted of 61 patients, and the replication cohort consisted of 70 patients. Transcriptomic and proteomic data were analysed to find panels of differentiating HFpEF from HFrEF. In the discovery cohort, a 22-transcript panel was found to differentiate HFpEF from HFrEF in male patients with a cross-validation AUC of 0.74, as compared with 0.70 for N-terminal pro-B-type natriuretic peptide (NT-proBNP) in those same patients. An ensemble of the transcript panel and NT-pro-BNP yielded a cross-validation AUC of 0.80. This performance improvement was also observed in the replication cohort. An ensemble of the transcriptomic panel with NT-proBNP produced a replication AUC of 0.90, as compared with 0.74 for NT-proBNP alone and 0.73 for the transcriptomic panel. CONCLUSIONS: We have identified a male-specific transcriptomic biomarker panel that can differentiate between HFpEF and HFrEF. These biosignatures could be further replicated on other patients and potentially be developed into a blood test for better management of HF patients.