Impact of empagliflozin on right ventricular parameters and function among patients with type 2 diabetes.

BACKGROUND: Sodium-glucose cotransporter 2 (SGLT2) inhibition reduces cardiovascular events in type 2 diabetes (T2DM) and is associated with a reduction in left ventricular (LV) mass index. However, the impact on right ventricular (RV) remodeling is unknown. Accordingly, the objective of this study was to assess the impact of SGLT2 inhibition on RV parameters and function in T2DM and coronary artery disease (CAD). METHODS: In EMPA-HEART CardioLink-6, 97 patients with T2DM and CAD were randomly assigned to empagliflozin 10 mg (n = 49) once daily or placebo (n = 48). Cardiac magnetic resonance imaging was performed at baseline and after 6 months. RV mass index (RVMi), RV end-diastolic and end-systolic volume index (RVEDVi, RVESVi) and RV ejection fraction (RVEF) were assessed in blinded fashion. RESULTS: At baseline, mean RVMi (± SD) (11.8 ± 2.4 g/m2), RVEF (53.5 ± 4.8%), RVEDVi (64.3 ± 13.2 mL/m2) and RVESVi (29.9 ± 6.9 mL/m2) were within normal limits and were similar between the empagliflozin and placebo groups. Over 6 months, there were no significant differences in RVMi (- 0.11 g/m2, [95% CI - 0.81 to 0.60], p = 0.76), RVEF (0.54%, [95% CI - 1.4 to 2.4], p = 0.58), RVEDVi (- 1.2 mL/m2, [95% CI - 4.1 to 1.7], p = 0.41) and RVESVi (- 0.81 mL/m2, [95% CI - 2.5 to 0.90], p = 0.35) in the empaglifozin group as compared with the placebo group. In both groups, there was no significant correlation between RVMi and LVMi changes from baseline to 6 months. CONCLUSIONS: In this post-hoc analysis, SGLT2 inhibition with empagliflozin had no impact on RVMi and RV volumes in patients with T2DM and CAD. The potentially differential effect of empagliflozin on the LV and RV warrants further investigation. CLINICAL TRIAL REGISTRATION: URL:  https://www.clinicaltrials.gov/ct2/show/NCT02998970?cond=NCT02998970&draw=2&rank=1 . Unique identifier: NCT02998970.

Knowledge and Attitudes of Canadian Cardiac Surgeons Regarding Patients With Human Immunodeficiency Virus.

BACKGROUND: Current data on cardiac surgical practices for people living with human immunodeficiency virus (HIV) are lacking. We hypothesized that cardiac surgeons would consider people living with HIV as candidates for the full scope of cardiac surgery, including heart transplant for these patients. METHODS: We conducted a prospective survey of 155 cardiac surgeons across Canada to evaluate their current clinical perceptions regarding cardiac surgery in people living with HIV. Specifically, we evaluated their assessment of eligibility toward a wide scope of cardiac surgeries by using representative clinical scenarios. RESULTS: A total of 63 surgeon responses (40.6%) were completed. The majority of surgeons agreed that a 50-year-old man with HIV and no other comorbidities, who had been receiving combination antiretroviral therapy for 5 years with an undetectable viral load since starting therapy and a CD4 count greater than 350 cells/µL, would be a candidate for valve replacement (73%), valve repair surgery (74.6%), or coronary artery bypass graft surgery (79.4%). Few surgeons believed that this patient would be eligible for cardiac transplantation (7.9%) or could be a cardiac transplant donor (1.6%). There was clinical equipoise over the eligibility for ventricular assist device surgery. CONCLUSIONS: A majority of cardiac surgeons would perform coronary artery bypass graft surgery or valve surgery on patients with controlled HIV, but most consider HIV status as a prohibitive risk factor for cardiac transplantation. Although this may represent an opportunity for continuing medical education for cardiac surgeons, it also highlights the need for contemporary, high-quality evidence in this patient population.

Prognostic utility of splenic response ratio in dipyridamole PET myocardial perfusion imaging.

BACKGROUND: Cardiac magnetic resonance perfusion studies with adenosine stress have shown that splenic response can identify patients with inadequate pharmacologic stress. We investigate the incremental prognostic impact of splenic response ratio (SRR) in patients with normal Rubidium (Rb)-82 PET myocardial perfusion imaging (MPI). METHODS: Consecutive patients undergoing dipyridamole Rb-82 PET MPI for the evaluation of coronary artery disease were screened. Spleen and liver Rb-82 activity was measured and the SRR was calculated: SRR = (Spleen stress/Liver stress)/(Spleen rest/Liver rest). Major adverse cardiac events (MACE) were determined at 1 year of follow-up in patients with normal summed stress score and normal summed difference score. RESULTS: Of the 839 patients screened, the spleen was visualized in 703 (84%) of scans. There was significantly higher MACE observed in splenic non-responders vs splenic responders in both the normal SSS (7.8% vs 2.9%, P = .027) and the normal SDS groups (7.4% vs 2.2%, P = .014). In multivariate analysis in patients with normal SDS, splenic response was a significant, independent predictor of MACE (HR 2.97, 95% CI 1.10 to 8.04, P = .033). CONCLUSIONS: SRR is a novel imaging metric to identify patients with sub-maximal vasodilator stress and an incremental prognostic marker in patients with normal SDS and SSS (Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT01128023).

Appropriate Use Criteria for Cardiac Computed Tomography: Impact on Diagnostic Utility.

BACKGROUND: Appropriate Use Criteria (AUC) guidelines for cardiac computed tomography (CCT) were developed to limit testing to reasonable clinical settings. However, significant testing is still done for inappropriate indications. This study investigates the impact of AUC on evaluability of CCT to determine if inappropriate tests result in a greater proportion of nondiagnostic results. METHODS: Investigators reviewed the medical records of 2417 consecutive patients who underwent CCT at the University of Ottawa Heart Institute. We applied the 2010 AUC and classified them as appropriate, inappropriate, or uncertain. Unclassifiable tests, as well as those with uncertain appropriateness, were excluded from the final analysis. Cardiac computed tomography results were classified as diagnostic if (1) all coronary segments were visualized, evaluable, and without obstructive stenosis; or (2) obstructive coronary artery disease with greater than 50% diameter stenosis in at least 1 coronary artery. All other test results were considered nondiagnostic. RESULTS: Of the 1984 patients included in the final analysis, 1522 patients (76.7%) had indications that were appropriate, whereas the remaining 462 (23.3%) were inappropriate. Inappropriate tests resulted in a higher rate of nondiagnostic results compared with appropriate CCT (9.0% vs 6.2%, P = 0.034). Inappropriate tests also had significantly more studies with nonevaluable segments than appropriate tests (24.5% vs 16.4%, P < 0.001) and were more likely to reveal obstructive coronary disease than appropriate CCT (50.5% vs 32.7%, P < 0.001). CONCLUSIONS: Cardiac computed tomography done for inappropriate indications may be associated with lower diagnostic yield and could impact future downstream resource utilization and health care costs.

Efficacy of adjunctive measures used to assist pulmonary vein isolation for atrial fibrillation: a systematic review.

PURPOSE OF REVIEW: Pulmonary vein reconnection leading to recurrence of atrial arrhythmias after pulmonary vein isolation (PVI) for atrial fibrillation remains a significant challenge. A number of adjunctive measures during PVI have been used to attempt to reduce pulmonary vein reconnection and recurrence of atrial arrhythmias. We performed a systematic review of the literature and meta-analysis of studies evaluating the efficacy of adjunctive measures used during PVI in reducing recurrent atrial arrhythmias. RECENT FINDINGS: Our literature search found four interventions that met the prespecified definition of adjunctive measure: adenosine testing post-PVI, contact force-guided PVI, pacing inexcitability of the ablation line during PVI and additional ablation based on the computed tomography thickness of the pulmonary vein-left atrial appendage ridge. Sixteen studies enrolling 3507 patients met all inclusion and exclusion criteria. PVI performed with adjunctive measures was shown to reduce the 1-year recurrence rate of atrial arrhythmias. The point estimate for the combined relative risk of atrial arrhythmia recurrence was 0.56 [95% confidence interval (CI): 0.43-0.73; P value <0.001] in the PVI with adjunctive measures group. SUMMARY: PVI for atrial fibrillation assisted by adjunctive measures results in clinically significant reduction of recurrent atrial arrhythmias. Additional research is required to assess the relative efficacy of individual or combined adjunctive strategies used during PVI for atrial fibrillation.

Noninvasive imaging in acute myocarditis.

PURPOSE OF REVIEW: The gold standard for diagnosing acute myocarditis is endomyocardial biopsy, but it is highly invasive and can result in serious complications. Noninvasive imaging has an essential role in the management of suspected acute myocarditis. In this article, we aim to review the role of various imaging techniques in acute myocarditis. RECENT FINDINGS: Newer methods such as strain and strain rate imaging using speckle tracking have emerged as an adjunctive echocardiographic parameter of myocardial dysfunction. The latest advancements in cardiovascular magnetic resonance (CMR) techniques have allowed quantitative T1 and T2 mappings that aim to quantify the areas of edematous myocardium and also address some of the limitations of traditional techniques as viable tools. An automated method for calculating late gadolinium enhancement by CMR has been developed in recent years. 18-Fluorodeoxyglucose PET is increasingly being used to assist in the diagnosis of myocarditis associated with cardiac sarcoidosis. SUMMARY: Echocardiography remains an essential and most commonly used initial investigation in suspected myocarditis. Due to the recent technological hardware and software advancements in CMR technology, CMR continues to occupy a pole position amongst all the other imaging modalities. The utility of cardiac computed tomography is less clear.

Conceptual framework for health-related quality of life assessment in acute gastroenteritis.

BACKGROUND AND OBJECTIVES: To date, most trials in pediatric acute gastroenteritis have evaluated short-term clinical disease activity (eg, duration of diarrhea or vomiting, level of dehydration), laboratory outcomes (eg, rotavirus, norovirus), or a composite of these outcomes. Measuring health-related quality of life may also be important in evaluating the effect of interventions for acute gastroenteritis in children. The objectives of this study were to conduct individual interviews and, when possible, focus group discussions, with parents of children with acute gastroenteritis; to determine how parent and child quality of life is negatively affected by acute gastroenteritis; and, from the perspective of parents and children, to develop a conceptual framework for quality of life instrument specific to pediatric acute gastroenteritis. METHODS: We conducted interviews and focus groups with parents of children (3 months-5 years of age) given a diagnosis of gastroenteritis in a hospital emergency department. Interviews and focus groups were conducted to determine the effect of gastroenteritis on quality of life in parents and children (as perceived by the parents). RESULTS: Interviews and focus groups involving 25 parents suggested a conceptual framework that, for children, includes 2 domains (physical and emotional function) and 14 subdomains. For parents, our framework includes 3 domains (physical, emotional, and social function) with physical function including 4 subdomains, emotional function including 7 subdomains, and social function including 2 subdomains. The framework has been used to develop a preliminary quality of life questionnaire for parents and children. CONCLUSIONS: Acute gastroenteritis has an important adverse effect on health-related quality in both children and parents involving physical symptoms and restrictions in physical function and disturbed emotional function. Upon further research on the psychometric properties of the proposed questionnaires, future trials of effectiveness should consider measuring patient important outcomes such as health-related quality of life.