Long-term outcomes following intravascular lithotripsy (IVL) for calcified coronary lesions: A Real-World Multicenter European Study.

OBJECTIVES: To explore the long-term clinical outcomes following intravascular lithotripsy (IVL) in calcified coronary lesions from a real-world population. BACKGROUND: IVL is a relatively new but promising modality for treating coronary calcified lesions, but there is a dearth of long-term outcome data from real-world patients. METHODS: This was a multicenter, observational study in which we enrolled all patients treated with IVL from November 2018 to February 2021 from eight centers in Europe and the United Kingdom. Procedural success, complications, and clinical outcomes (cardiac death, target vessel myocardial infarction [TVMI], target lesion revascularization [TLR], and MACE [major adverse cardiac events, the composite of cardiac death, TVMI, and TLR]) were assessed. RESULTS: In total, 273 patients with a mean age of 72 ± 9.1 years were treated with IVL. Major comorbidities included diabetes mellitus (n = 110, 40%) and chronic kidney disease (n = 45, 16%). Acute coronary syndrome accounted for 48% (n = 132) of patients, while 52% (n = 141) had stable angina. De novo lesions and in-stent restenosis accounted for 79% and 21% of cases, respectively. Intravascular imaging was used in 33% (n = 90) of patients. An upfront IVL strategy was adopted in 34% (n = 92), while the rest were bailout procedures. Adjuvant rotational atherectomy ("RotaTripsy") was required in 11% (n = 31) of cases. The procedural success was 99%. During a median follow-up of 687 days (interquartile range: 549-787), cardiac death occurred in 5% (n = 14), TVMI in 3% (n = 8), TLR in 6% (n = 16), and MACE rate was 11% (n = 30). CONCLUSION: This is the largest multicenter registry with a long-term follow-up showing the remarkably high procedural success of IVL use in calcified coronary lesions with low rates of hard endpoints and MACE.

Tissue doppler-derived contractile reserve is a simple and strong predictor of cardiopulmonary exercise performance across a range of cardiac diseases.

BACKGROUND: Resting echocardiographic measures of cardiac function such as left ventricular ejection fraction correlate poorly with exercise capacity. Assessment during exercise using measures less dependent on hemodynamic loading conditions, such as tissue Doppler imaging (TDI), may more accurately characterize the relationship between cardiac function and exercise capacity. METHODS AND RESULTS: One hundred one subjects with various cardiac diagnoses underwent exercise stress echocardiography with simultaneous cardiopulmonary gas exchange analysis. Standard two-dimensional, Doppler and spectral TDI parameters were assessed at both rest and peak exercise. Across all subjects the strongest relationship with peak oxygen uptake (pVO2 ) was with peak left ventricular systolic tissue velocity (S') during exercise (r = 0.84, P < 0.001). The strength of the relationship was greater than that observed with any other common echocardiographic measure of systolic or diastolic cardiac function. CONCLUSION: There is a very strong relationship between measurements of S' during exercise and exercise capacity. The previously observed poor correlation with standard measures of systolic and diastolic cardiac function may be explained both by the load dependence of parameters such as ejection fraction and by reliance on resting as opposed to exercise assessment.

Aortic valve calcification - a commonly observed but frequently ignored finding during CT scanning of the chest.

AIM: To describe the frequency and severity of Aortic valve calcification (AVC) in an unselected cohort of patients undergoing chest CT scanning and to assess the frequency with which AVC was being reported in the radiology reports. METHODS AND RESULTS: Consecutive CT scan images of the chest and the radiological reports (December 2009 to May 2010) were reviewed at the district general hospital (DGH). AVC on CT scan was visually graded on a scale ranging from 0 to IV (0 = no calcification, IV = severe calcification). Total of 416 (232 male; 184 female) CT chest scans [Contrast enhanced 302 (72%), unenhanced 114 (28%)] were reviewed. Mean age was 70.55 ± 11.48 years. AVC in CT scans was identified in 95 of the 416 patients (22.83%). AVC classification was as follows: Grade I: 60 (63.15%), Grade II: 22 (23.15%), Grade III: 9 (9.47%), Grade IV: 4 (4.21%). Only one CT report mentioned AVC. Only 31 of 95 AVC had Transthoracic echocardiogram (TTE). The interval time between CT scan and TTE was variable. CONCLUSION: Aortic valve calcification in CT chest scans is a common finding and studies have shown that it is strongly related to the presence and severity of aortic valve disease. As CT scans are considered as a valuable additional screening tool for detection of aortic stenosis, AVC should always be commented upon in the radiology reports. Furthermore, patients with at least Grade III and IV AVC should be sent for TTE.

Prognostic importance of tissue velocity imaging during exercise echocardiography in patients with systolic heart failure.

Resting echocardiography measurements are poor predictors of exercise capacity and symptoms in patients with heart failure (HF). Stress echocardiography may provide additional information and can be expressed using left ventricular ejection fraction (LVEF), or diastolic parameters (E/E'), but LVEF has some major limitations. Systolic annular velocity (S') provides a measure of longitudinal systolic function, which is relatively easy to obtain and shows a good relationship with exercise capacity. The objective of this study was to investigate the relationship among S', E/E' and LVEF obtained during stress echocardiography and both mortality and hospitalisation. A secondary objective was to compare S' measured using a simplified two-wall model. A total of 80 patients with stable HF underwent exercise stress echocardiography and simultaneous cardiopulmonary exercise testing. Volumetric and tissue velocity imaging (TVI) measurements were obtained, as was peak oxygen uptake (VO2 peak). Of the total number of patients, 11 died and 22 required cardiac hospitalisation. S' at peak exertion was a powerful predictor for death and hospitalisation. Cut-off points of 5.3 cm/s for death and 5.7 cm/s for hospitalisation provided optimum sensitivity and specificity. This study suggests that, in patients with systolic HF, S' at peak exertion calculated from the averaged spectral TVI systolic velocity of six myocardial segments, or using a simplified measure of two myocardial segments, is a powerful predictor of future events and stronger than LVEF, diastolic velocities at rest or exercise and VO2 peak. Results indicate that measuring S' during exercise echocardiography might play an important role in understanding the likelihood of adverse clinical outcomes in patients with HF.

Use of the Joint British Society cardiovascular risk calculator before initiating statins for primary prevention in hospital medicine: experience from a large university teaching hospital.

INTRODUCTION: Statin therapy is a well established treatment for hyperlipidemia. However, little is known about prescribing of statins for primary prevention in the real world, and even less about what happens to patients requiring primary prevention who are seen in a secondary care setting. The purpose of this research was to investigate the appropriateness of statin prescriptions by using the Joint British Society cardiovascular disease (JBS CVD) risk score for primary prevention in a large secondary care center. METHODS: We retrospectively analyzed 500 consecutive patients in whom a statin prescription was initiated over a four-month period. We excluded patients who met secondary prevention criteria. We used the JBS CVD risk prediction chart to calculate 10-year composite risk. We also studied which statins were prescribed and their starting doses. RESULTS: Of 500 patients consecutively started on statins in secondary care, 51 patients (10.2%) were treated for primary prevention. Of these, seven (14%) patients had a 10-year composite cardiovascular event risk of more than 20% (high-risk category), and were hence receiving appropriate therapy. Three main statins were prescribed for primary prevention, ie, atorvastatin (22 patients, 43%), simvastatin (25 patients, 49%), and pravastatin (four patients, 8%). The statins prescribed were initiated mainly at the 40 mg dose. CONCLUSIONS: Statin prescribing in secondary care for primary prevention is limited to about 10% of initiations. There is some overprescribing, because 86% of these patients did not require statins when risk-stratified appropriately. The majority of the prescriptions were for simvastatin 40 mg and atorvastatin 40 mg.