Diagnostic Cardiovascular Imaging and Therapeutic Strategies in Pregnancy: JACC Focus Seminar 4/5.

The prevalence of cardiovascular disease (CVD) in pregnancy, both diagnosed and previously unknown, is rising, and CVD is a leading cause of maternal morbidity and mortality. Historically, women of child-bearing potential have been underrepresented in research, leading to lasting knowledge gaps in the cardiovascular care of pregnant and lactating women. Despite these limitations, clinicians should be familiar with the safety of frequently used diagnostic and therapeutic interventions to adequately care for this at-risk population. This review, the fourth of a 5-part series, provides evidence-based recommendations regarding the use of common cardiovascular diagnostic tests and medications in pregnant and lactating women.

Transitional changes of acetylcholine spasm provocation test procedures.

Intracoronary acetylcholine (ACh) testing has become popular in the world as a spasm provocation test as well as an ergonovine test. Intracoronary ACh test based on the Japanese Circulation Society guidelines is necessary to insert a temporary pace maker (PM). We analyzed the ACh spasm provocation test procedures retrospectively. We performed 1829 ACh spasm provocation testing during 28 years. We investigated the procedural approach sites of artery and vein. Femoral artery and vein approach, brachial artery and femoral vein approach, brachial artery and vein approach, radial artery and brachial vein approach, radial artery and femoral vein approach were performed in 292 patients (16.0%), 498 patients (27.2%), 589 patients (32.2%), 252 patients (13.8%), and 175 patients (9.6%), respectively. We could perform the ACh testing by the femoral artery and brachial artery in all patients, while the success rate of radial artery approach was 97.1%. We could also insert the temporary PM by the brachial vein in 94.8% (841/887) of the study patients, whereas we could insert the temporary PM in all femoral vein approach [100% (965/965)]. We experienced the pulmonary embolism by the femoral artery and vein approach in two patients, while we also had the arterio-venous fistula necessary for surgical repair in two patients by the brachial artery and vein approach. Although there was no difference about the procedure-related major complications among the various procedures, we had no pulmonary embolism or arterio-venous fistula by the radial artery and brachial vein approach. Considering the disinfection with povidone iodine, procedural performance or procedure-related complications by the ACh testing, we recommend that radial artery and brachial vein approach is more comfortable method of the future ACh testing not only for patients but also for operators.

Individual preferences on the balancing of good and harm of cardiovascular disease screening.

OBJECTIVE: Transition towards value-based healthcare requires insight into what makes value to the individual. The aim was to elicit individual preferences for cardiovascular disease screening with respect to the difficult balancing of good and harm as well as mode of delivery. METHODS: A discrete choice experiment was conducted as a cross-sectional survey among 1231 male screening participants at three Danish hospitals between June and December 2017. Participants chose between hypothetical screening programmes characterised by varying levels of mortality risk reduction, avoidance of overtreatment, avoidance of regretting participation, screening duration and location. A multinomial mixed logit model was used to model the preferences and the willingness to trade mortality risk reduction for improvements on other characteristics. RESULTS: Respondents expressed preferences for improvements on all programme characteristics. They were willing to give up 0.09 (95% CI 0.08 to 0.09) lives saved per 1000 screened to avoid one individual being over treated. Similarly, respondents were willing to give up 1.22 (95% CI 0.90 to 1.55) or 5.21 (95% CI 4.78 to 5.67) lives saved per 1000 screened to upgrade the location from general practice to a hospital or to a high-tech hospital, respectively. Subgroup analysis revealed important preference heterogeneity with respect to smoking status, level of health literacy and self-perceived risk of cardiovascular disease. CONCLUSIONS: Individuals are able to express clear preferences about what makes value to them. Not only health benefit but also time with health professionals and access to specialised facilities were important. This information could guide the optimal programme design in search of value-based healthcare.

Painless local pressure application to test microvascular reactivity to ischemia.

BACKGROUND: Forearm cutaneous blood flux (CBF) measurement with post-occlusive reactive hyperemia (PORH) is uncomfortable and may not be devoid of risks. We aimed to investigate post-compression reactive hyperemia (PCRH) with a custom-made indenter that was designed to be easily used routinely by inexperienced observers. METHODS: Medical students evaluated PCRH with 1- to 4-min pressure applications of 16 to 34 kPa and PORH with 3-min forearm cuff occlusion using laser speckle contrast imaging in 15 healthy volunteers. Participants were asked to quantify their discomfort with a visual analogue scale (VAS) of 10 cm. Total ischemia (ISCH) was quantified by the product of CBF during ischemia and ischemia duration (min). We subtracted the CBF changes in the skin from a reference ipsilateral (PCRH) or contralateral (PORH) non-stimulated area. RESULTS: The average VAS was 1.0 for PCRH vs. 6.0 for PORH (p < 0.001). A strong linear relationship between ISCH and peak PCRH (r2 = 0.915, p < 0.001) was noted. Peak PORH values (63.9 laser perfusion units (LPU)) were significantly lower than all values of the 3-min PCRH (72.6 LPU), including the one obtained with 16 kPa. CONCLUSION: Inexperienced observers could test microvascular reactivity with PCRH without inducing the discomfort that is typically experienced with PORH. Further, PCRH elicits a higher peak response to ischemia compared with PORH. This extremely simple method could influence a broad spectrum of routine cutaneous microcirculation investigations, especially when a painful approach is particularly inadequate or if the patient is fragile. CLINICAL TRIAL REGISTRATION: NCT02861924.

Optimizing Risk Stratification and Noninvasive Diagnosis of Ischemic Heart Disease in Women.

Ischemic heart disease (IHD) is an important and previously underappreciated cause of significant morbidity and mortality in women. Key differences exist in the pathophysiology, sex-specific risk factors, and clinical presentation in women compared with men, which influence diagnostic accuracy and utility of pretest risk assessments and noninvasive testing. Women are disproportionately affected by ischemia from microvascular dysfunction as evidenced by having less obstructive coronary artery disease on angiography, contributing to the challenge in diagnosis and prognosis of IHD in women via conventional methods, which tend to emphasize detection of epicardial stenoses. In this article, we review the utility, evidence for, and challenges of currently available risk assessments and noninvasive cardiac diagnostic tests in women. We propose an approach to investigation of the symptomatic woman with suspected IHD and selection of the appropriate testing modality. Finally, we explore opportunities for future research and highlight the urgent need for updated, evidence-based, Canadian guidelines specific to women with IHD.

Feasibility, symptoms, adverse effects, and complications associated with noninvasive assessment of coronary flow velocity reserve in women with suspected or known coronary artery disease.

BACKGROUND: Microvascular coronary impairment, defined as reduced coronary flow reserve, represents the predominant etiologic mechanism of ischemia in women with chest pain and no obstructive coronary artery disease. Transthoracic echocardiography (TTE) is a noninvasive method for assessing coronary flow velocity reserve (CFVR) in the left anterior descending coronary artery (LAD). The purpose of this investigation was to define the safety profile, feasibility, adverse events, and rate of complications of the test in women with suspected CAD. METHODS: We evaluated CFVR in LAD with TTE during adenosine infusion in 1455 women aged 66.4±11.9 years. RESULTS: A complete CFVR study was achieved in 1429 pts (feasibility 98.2%), the test being performed also in the early phase of acute coronary syndrome and on obese patients. Minor symptoms or adverse effects occurred in 43.7% of patients not requiring test termination: hyperpnea (16.7%), flushing (9.4%), atypical chest pain (9.9%), headache (6.6%), minor arrhythmias (2.9%), chest pain with EKG changes (1.5%) were the symptoms reported. No major complications were observed. CONCLUSIONS: Noninvasive assessment of CFVR in LAD by TTE is a very feasible method with very low incidence of adverse events and complications in women with suspected or known CAD. It is safe and can be used when evaluating female patients with atherosclerotic LAD disease or with coronary microvascular impairment.

Índice de conicidad y su utilidad para detectar riesgo cardiovascular y metabólico / Conicity index and its usefulness for detection of cardiovascular and metabolic risk

Antecedentes: desarrollar formas diagnósticas de fácil aplicación, buena precisión y bajo costo, con la finalidad de predecir el riesgo cardiometabólico en nuestros pacientes, nos lleva a la necesidad de identificar medidas y relaciones antropométricas que nos resulten de utilidad en su detección. Objetivo: describir la utilidad del índice de conicidad, como predictor de riesgo cardiovascular y metabólico, y compararlo con algunas de las medidas y relaciones antropométricas utilizadas con este fin. Métodos: se revisaron 80 artículos, de los cuales 51 cumplieron con los criterios de calidad esperados por los autores. La búsqueda se realizó a través de algunas de las bases de datos y de los buscadores habituales. Resultados: las características fisiológicas del tejido adiposo abdominal son significativas, e incluso, posibles determinantes del aumento de riesgo cardiometabólico asociado a la obesidad visceral. El índice de conicidad es una relación que involucra varias medidas antropométricas, como la circunferencia de la cintura, la talla y el peso corporal. Este índice ha sido utilizado para indicar el aumento de la grasa abdominal, y en la predicción del riesgo cardiovascular y metabólico. Entre los resultados de los diferentes estudios realizados, se han observado diversos criterios con respecto a su utilidad y empleo, en comparación con otras medidas e índices antropométricos, que en el mejor de los casos, en un futuro, debemos intentar esclarecer, a través de investigaciones diseñadas con este objetivo. Conclusiones: el índice de conicidad es una relación útil, para determinar la existencia de obesidad abdominal, aunque no parece ser el mejor predictor de riesgo cardiovascular y/o metabólico, al compararlo con el resto de las medidas y relaciones antropométricas utilizadas con este fin(AU)

Background: developing diagnosing forms of easy use, good precisión and low cost, with the objective of predicting the cardiometabolic risk in our patients, leads us to the task of identifying anthropometric measurements and ratios that may be useful for the risk detection. Objective: to describe the usefulness of the conicity index as a predictor of cardiovascular and metabolaic risk and compare it with some of the anthropometric measurements and ratios used to this end. Methods: eighty aritcles, 51 of which met the expected quality criteria of the authors, were reviewed. The search was made in some of the regular databases and searchers. Results: the physiological characteristics of the abdominal fatty tissue were significant and even they may be possible determinants of the increased cardiometabolic risk associated to visceral obesity. The conicity index is a ratio that involves several anthropometric measurements such as waist circumference, height and body weight. This index has been used to show increase of abdominal fat and in prediction of the cardiovascular and the metabolic risk. Among the results of the different studies, there have been observed various criteria about the usefulness and applications of the index in comparison with other anthropometric measurements and indexes; something that at the very best should be clarified in the future through research studies designed for this end. Conclusions: the conicity index is a useful ratio to determine the existence of abdominal obesity, although it does not seem to be the best predictor of the cardiovascular and/or metabolic risk when making a comparison with the rest of the anthropometric measurements and ratios that have been so far used(AU)

Índice de conicidad y su utilidad para detectar riesgo cardiovascular y metabólico / Conicity index and its usefulness for detection of cardiovascular and metabolic risk

Antecedentes: desarrollar formas diagnósticas de fácil aplicación, buena precisión y bajo costo, con la finalidad de predecir el riesgo cardiometabólico en nuestros pacientes, nos lleva a la necesidad de identificar medidas y relaciones antropométricas que nos resulten de utilidad en su detección. Objetivo: describir la utilidad del índice de conicidad, como predictor de riesgo cardiovascular y metabólico, y compararlo con algunas de las medidas y relaciones antropométricas utilizadas con este fin. Métodos: se revisaron 80 artículos, de los cuales 51 cumplieron con los criterios de calidad esperados por los autores. La búsqueda se realizó a través de algunas de las bases de datos y de los buscadores habituales. Resultados: las características fisiológicas del tejido adiposo abdominal son significativas, e incluso, posibles determinantes del aumento de riesgo cardiometabólico asociado a la obesidad visceral. El índice de conicidad es una relación que involucra varias medidas antropométricas, como la circunferencia de la cintura, la talla y el peso corporal. Este índice ha sido utilizado para indicar el aumento de la grasa abdominal, y en la predicción del riesgo cardiovascular y metabólico. Entre los resultados de los diferentes estudios realizados, se han observado diversos criterios con respecto a su utilidad y empleo, en comparación con otras medidas e índices antropométricos, que en el mejor de los casos, en un futuro, debemos intentar esclarecer, a través de investigaciones diseñadas con este objetivo. Conclusiones: el índice de conicidad es una relación útil, para determinar la existencia de obesidad abdominal, aunque no parece ser el mejor predictor de riesgo cardiovascular y/o metabólico, al compararlo con el resto de las medidas y relaciones antropométricas utilizadas con este fin(AU)

Background: developing diagnosing forms of easy use, good precisión and low cost, with the objective of predicting the cardiometabolic risk in our patients, leads us to the task of identifying anthropometric measurements and ratios that may be useful for the risk detection. Objective: to describe the usefulness of the conicity index as a predictor of cardiovascular and metabolaic risk and compare it with some of the anthropometric measurements and ratios used to this end. Methods: eighty aritcles, 51 of which met the expected quality criteria of the authors, were reviewed. The search was made in some of the regular databases and searchers. Results: the physiological characteristics of the abdominal fatty tissue were significant and even they may be possible determinants of the increased cardiometabolic risk associated to visceral obesity. The conicity index is a ratio that involves several anthropometric measurements such as waist circumference, height and body weight. This index has been used to show increase of abdominal fat and in prediction of the cardiovascular and the metabolic risk. Among the results of the different studies, there have been observed various criteria about the usefulness and applications of the index in comparison with other anthropometric measurements and indexes; something that at the very best should be clarified in the future through research studies designed for this end. Conclusions: the conicity index is a useful ratio to determine the existence of abdominal obesity, although it does not seem to be the best predictor of the cardiovascular and/or metabolic risk when making a comparison with the rest of the anthropometric measurements and ratios that have been so far used(AU)

Prevention of contrast-induced acute kidney injury in patients undergoing cardiovascular procedures-a systematic review and network meta-analysis.

BACKGROUND: Interventional diagnostic and therapeutic procedures requiring intravascular iodinated contrast steadily increase patient exposure to the risks of contrast-induced acute kidney injury (CIAKI), which is associated with death, nonfatal cardiovascular events, and prolonged hospitalization. The aim of this study was to investigate the efficacy of pharmacological and non-pharmacological treatments for CIAKI prevention in patients undergoing cardiovascular invasive procedures with iodinated contrast. METHODS AND FINDINGS: MEDLINE, Google Scholar, EMBASE and Cochrane databases as well as abstracts and presentations from major cardiovascular and nephrology meetings were searched, up to 22 April 2016. Eligible studies were randomized trials comparing strategies to prevent CIAKI (alone or in combination) when added to saline versus each other, saline, placebo, or no treatment in patients undergoing cardiovascular invasive procedures with administration of iodinated contrast. Two reviewers independently extracted trial-level data including number of patients, duration of follow-up, and outcomes. Eighteen strategies aimed at CIAKI prevention were identified. The primary outcome was the occurrence of CIAKI. Secondary outcomes were mortality, myocardial infarction, dialysis and heart failure. The data were pooled using network meta-analysis. Treatment estimates were calculated as odds ratios (ORs) with 95% credible intervals (CrI). 147 RCTs involving 33,463 patients were eligible. Saline plus N-acetylcysteine (OR 0.72, 95%CrI 0.57-0.88), ascorbic acid (0.59, 0.34-0.95), sodium bicarbonate plus N-acetylcysteine (0.59, 0.36-0.89), probucol (0.42, 0.15-0.91), methylxanthines (0.39, 0.20-0.66), statin (0.36, 0.21-0.59), device-guided matched hydration (0.35, 0.12-0.79), prostaglandins (0.26, 0.08-0.62) and trimetazidine (0.26, 0.09-0.59) were associated with lower odds of CIAKI compared to saline. Methylxanthines (0.12, 0.01-0.94) or left ventricular end-diastolic pressure-guided hydration (0.09, 0.01-0.59) were associated with lower mortality compared to saline. CONCLUSIONS: Currently recommended treatment with saline as the only measure to prevent CIAKI during cardiovascular procedures may not represent the optimal strategy. Vasodilators, when added to saline, may significantly reduce the odds of CIAKI following cardiovascular procedures.

High mortality rate in hemodialysis patients who undergo invasive cardiovascular procedures related to peripheral artery disease - community-based observational study in Kumamoto Prefecture - .

BACKGROUND: Cardiovascular disease is a major cause of mortality in hemodialysis patients. The aim was to assess the relationship of various invasive cardiovascular procedures (ICP) to clinical outcome in hemodialysis patients. METHODS AND RESULTS: A total of 5,813 patients at 76 facilities were on maintenance hemodialysis in Kumamoto Prefecture. Of these, 4,807 patients at 58 institutions were enrolled. Of 4,807 patients, 212 ICP (4.4%) were performed for various cardiovascular diseases in 189 patients (3.9%). ICP included PCI (n=80), endovascular treatment (n=59), radiofrequency catheter ablation (n=8), implantation of permanent pacemaker (n=15) and ICD (n=5), thoracotomy for valvular diseases (n=16), CABG (n=14), bypass surgery for peripheral artery disease (PAD; n=8), and artificial vessel replacement for aneurysm or aortic dissection (n=7). The overall mortality rate was 10.1% (19/189 patients). The mortality rate was highest in patients who underwent ICP for PAD, compared with other ICP (PAD, 18.2%; non-PAD, 6.7%, P=0.017). Infection and PAD were significant predictors of mortality (infection: OR, 8.30; 95% CI: 1.29-65.13, P=0.027; PAD: OR, 3.76; 95% CI: 1.35-10.48, P=0.012). The presence of inflammation/malnutrition factors was associated with high mortality (OR, 15.49; 95% CI: 3.22-74.12, P=0.0006). CONCLUSIONS: In this community-based registry study of 4,807 hemodialysis patients, the mortality rate of PAD patients was high despite ICP.

Is defibrillation testing necessary?

With advancements in implantable cardioverter defibrillator (ICD) technology, the practice of performing defibrillation threshold (DFT) testing at the time of implantation has been questioned. With availability of biphasic waveforms, active cans, and high-output devices, opponents claim that DFT testing is no longer necessary. Clinical trials demonstrating the efficacy of ICDs in prevention of sudden cardiac death have, however, all used some form of defibrillation testing. This debate is fueled by the absence of data from randomized prospective trials evaluating the role of DFT testing in predicting clinical shock efficacy or survival. This review discusses both sides of the argument.

[Appropriateness of diagnostic tests in cardiovascular prevention: what can we skip?]. / Appropriatezza delle procedure diagnostiche in prevenzione cardiovascolare: di che cosa possiamo fare a meno?

In recent years, a huge increase in the use of cardiac procedures, both invasive and non-invasive, was observed. Diagnostic tests, mainly non-invasive tests, are often prescribed inappropriately, in most cases replacing the clinical evaluation. The rate of inappropriate tests in cardiology is largely variable, depending on regional issues and different medical approach. When the test entails radiation exposure, the biological risk for both the patient and the environment must be taken into account. For this reason, the test that results in less biological risk should always be preferred as a first step.Moreover, it has not been clearly demonstrated that some diagnostic tests help to improve the outcome, that is to prevent cardiovascular events. As many as one sixth of the patients who undergo stress imaging are not taking proper medication, and very frequently no change in therapy is made after the test, regardless of the outcome. Since the appropriateness of diagnostic evaluation requests is mandatory, we focused on the diagnostic tests usually performed in primary and secondary prevention that carry no contribution to the clinical management of patients. This review addresses the need to optimize available resources, reduce costs and avoid unnecessary cardiovascular assessments, thereby enhancing the more efficient care delivery models.

Non-invasive endothelial function testing and the risk of adverse outcomes: a systematic review and meta-analysis.

OBJECTIVES: We performed a systematic review and meta-analysis to understand the role of flow-mediated dilatation (FMD) of the brachial artery (BA) and peripheral arterial tonometry (PAT) in predicting adverse events, including cardiovascular (CV) events and all-cause mortality. BACKGROUND: FMD of the BA and PAT are non-invasive measures of endothelial function. Impairment of endothelial function is associated with increased CV events. While FMD is the more widely used and studied technique, PAT offers several advantages. The purpose of this systematic review and meta-analysis is to determine whether brachial FMD and PAT are independent risk factors for future CV events and mortality. METHODS: Multiple electronic databases were searched for articles relating FMD or PAT to CV events. Data were extracted on study characteristics, study quality, and study outcomes. Relative risks (RRs) from individual studies were combined and a pooled multivariate RR was calculated. RESULTS: Thirty-six studies for FMD were included in the systematic review, of which 32 studies consisting of 15, 191 individuals were meta-analysed. The pooled RR of CV events and all-cause mortality per 1% increase in brachial FMD, adjusting for potential confounders, was 0.90 (0.88-0.92). In contrast, only three studies evaluated the prognostic value of PAT for CV events, and the pooled RR per 0.1 increase in reactive hyperaemia index was 0.85 (0.78-0.93). CONCLUSION: Brachial FMD and PAT are independent predictors of CV events and all-cause mortality. Further research to evaluate the prognostic utility of PAT is necessary to compare it with FMD as a non-invasive endothelial function test in clinical practice.

Defibrillation threshold testing fails to show clinical benefit during long-term follow-up of patients undergoing cardiac resynchronization therapy defibrillator implantation.

BACKGROUND: The utility of defibrillation threshold testing in patients undergoing implantable cardioverter-defibrillator (ICD) implantation is controversial. Higher defibrillation thresholds have been noted in patients undergoing implantation of cardiac resynchronization therapy defibrillators (CRT-D). Since the risks and potential benefits of testing may be higher in this population, we sought to assess the impact of defibrillation safety margin or vulnerability safety margin testing in CRT-D recipients. METHODS AND RESULTS: A total of 256 consecutive subjects who underwent CRT-D implantation between January 2003 and December 2007 were retrospectively reviewed. Subjects were divided into two groups based on whether (n= 204) or not (n= 52) safety margin testing was performed. Patient characteristics, tachyarrhythmia therapies, procedural results, and clinical outcomes were recorded. Baseline characteristics, including heart failure (HF) severity, were comparable between the groups. Four cases of HF exacerbation (2%), including one leading to one death, were recorded in the tested group immediately post-implantation. No complications were observed in the untested group. After a mean follow-up of 32 ± 20 months, the proportion of appropriate shocks in the two groups was similar (31 vs. 25%, P = 0.49). There were three cases of failed appropriate shocks in the tested group, despite adequate safety margins at implantation, whereas no failed shocks were noted in the untested group. Survival was similar in the two groups. CONCLUSION: Defibrillation efficacy testing during implant of CRT-D was associated with increased morbidity and did not predict the success of future device therapy or improve survival during long-term follow-up.