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Results of a new study from the Mayo Clinic suggest an artificial intelligence-enabled electrocardiogram (ECG) could aid clinicians in emergency departments more accurately identify 

Findings from the study indicate the AI-enhanced ECG could improve identification of left ventricular systolic dysfunction in patients presenting the emergency departments with acute dyspnea.

"AI-enhanced ECGs are quicker and outperform current standard-of-care tests. Our results suggest that high-risk cardiac patients can be identified quicker in the emergency department and provides an opportunity to link them early to appropriate cardiovascular care," said lead investigator Demilade Adedinsewo, MD, MPH, chief fellow in the division of cardiovascular medicine at Mayo Clinic in Jacksonville, Florida, 

With the timely and accurate identification of systolic heart failure still posing a problem for emergency department clinicians, Adedinsewo and colleagues from various Mayo Clinic sites sought to determine whether incorporating an AI-ECG could improve identification of left ventricular systolic dysfunction. To do so, they designed a retrospective cohort study of all adult patients reporting dyspnea presenting to an emergency department at Mayo Clinic sites in Arizona, Florida, and Minnesota, as well as the Mayo Clinic Health Systems between May 2018-February 2019.

For inclusion in the analysis, patients needed to be at least 18 years of age and have at least 1 standard 10-second 12-lead ECG performed within 24 hours of the baseline visit. Patients were excluded if they had a known prior diagnosis of systolic, diastolic, or unspecified heart failure. Patients were also excluded if they did not undergo an echocardiogram within 30 days of the emergency department visit.

Initially, 21,309 patients were identified by investigators. Of these, 1606 were included in the current analysis. The median age of the population was 68 years, 47% were female, 91% were white.

The primary outcome of the study was the identification of new left ventricular systolic dysfunction, which was defined as a left ventricular ejection fraction of 35% or less, within 30 days of the initial visit through use of a deep learning network for ECGs. The secondary outcome of the study was identification of left ventricular ejection fraction less than 50% within 30 days using the same approach.

Investigators noted the algorithm used in the deep learning network employed a convolutional neural network (CNN) trained with Keras with a Tensorflow.

Upon analysis, the AI-ECG algorithm achieved an area under the receiver operating characteristic curve (AUC) of 0.89 (95% CI, 0.86-0.91) with an accuracy of 85.9% (95% CI, 84.1-87.6%) for detecting left ventricular ejection fraction of 35% or less. Results indicated the sensitivity, specificity, negative predictive value, and positive predictive value of the AI-ECG algorithm were 74%, 87%, 97%, and 40%, respectively.

For identifying left ventricular ejection fraction of less than 50%, the AI-ECG algorithm achieved an AUC of 0.85 (95% CI, 84.2-87.7%) with an accuracy of 86% (95% CI, 84.2-87.7%). Results indicated the sensitivity, specificity, negative predictive value, and positive predictive value of the AI-ECG algorithm were 63%, 91%, 92%, and 62%, respectively.

In a subgroup of patients who had NT-proBNP values, an NT-proBNP alone at a cutoff value of greater than 800 was able to identify new left ventricular systolic dysfunction with an AUC of 0.80 (95% CI, 0.76-0.84), which investigators suggest demonstrates the superior diagnostic value of the AI-ECG in this group of patients (

"Determining why someone has shortness of breath is challenging for emergency department physicians, and this AI-enabled ECG provides a rapid and effective method to screen these patients for left ventricular systolic dysfunction," added Adedinsewo, in the aforementioned statement.

An Artificial Intelligence-Enabled ECG Algorithm to Identify Patients with Left Ventricular Systolic Dysfunction Presenting to the Emergency Department with Dyspnea

Circulation: Arrhythmia and Electrophysiology.

An AI-enabled ECG algorithm could speed identification and treatment of heart failure among individuals presenting with shortness of breath. 

AI-Enabled ECG Improves Ability to Identify Heart Failure in Emergency Departments

This episode of the Practical Cardiology Podcast features an interview with Deepak Bhatt, MD, MPH, executive director of interventional cardiovascular programs at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, discussing clinical trials in cardiology during the ongoing pandemic.

The subject of the current interview is an article penned by Bhatt and other cardiologists addressing the impact the ongoing coronavirus disease 2019 (COVID-19) pandemic has had on cardiovascular trials in the United States, titled “

The Landscape of Cardiovascular Clinical Trials in the United States Initiated Before and During COVID-19


A leading trialist involved in major trials including REDUCE-IT and THEMIS, Bhatt offers perspective on data from a professional and personal perspective on how the pandemic has, is, and will continue to affect clinical trials, with the ripple causing disruptions in treatment pipelines and the treatment of patients.



Podcasts

Deepak Bhatt, MD, offers perspective on how the ongoing pandemic has impacted clinical trials in the cardiovascular space. 

Deepak Bhatt, MD: Impact of COVID-19 on Clinical Trials in Cardiology

A new systematic review and network meta-analysis from investigators at leading institutions across the US is providing clinicians with an updated overview of appropriate duration of 

 after percutaneous coronary intervention (PCI) with drug-eluting stents.

Led by Deepak Bhatt, MD, MPH, and a team of investigators representing institutions including the Cleveland Clinic, West Virginia University, and Johns Hopkins University, results of the network meta-analysis concluded short-term DAPT was associated with reductions in major bleeding compared to 12-month DAPT, but also found extended-term DAPT was associated with reductions of myocardial infarction.

“Compared with 12-month DAPT, the net clinical benefit appears to favor short-term DAPT followed by P2Y12 inhibitor monotherapy in patients similar to the ones included in these trials,” wrote study investigators. “However, extended-term DAPT in patients with ACS or at a higher risk of recurrent ischemic MACE is still warranted in patients selected to be at low bleeding risk.”

With no clear consensus among guidelines from major international organizations, investigators sought to provide a more definitive determination of outcomes associated with different durations of DAPT in patients undergoing PCI with drug-eluting stents. To do so, they designed the current study as using randomized clinical trials comparing durations of DAPT followed by aspirin or P2Y12 monotherapy in the aforementioned population published in the Medline, Embase, Cochrane library, and online databases through September 2019.

The co-primary end points for the study were myocardial infarction (MI) and major bleeding, which was used to calculate net clinical benefit for each respective approach. For the purpose of the analysis, short-term DAPT was defined as 6 months or less, mid-term DAPT was defined as 6 months, and extended-term DAPT was defined as more than 12 months. Outcomes for these respective durations were compared to 12-month DAPT using a random effects model.

Additional criteria for trials to be included study were having a sample size of 500 or more patients and follow-up of at least 6 months and reporting on cardiovascular and bleeding outcomes. Investigators noted pharmacokinetic and pharmacodynamic studies, those with a cross-over design, or those where a minority of patients included received PCI or drug-eluting stents.

In total, 24 trials with data related to 79,073 patients and 112,387 patient-years of follow-up were identified for inclusion in the network meta-analysis. Of the 24 included in the study, 95% had a low risk of bias for sequence generation and 75% had low risk of bias for allocation concealment. Additionally, 33% had a high risk of bias for blinding and 21% had high risk of detection bias.

For MI, results indicated extended-term DAPTwas associated with a reduction in risk of MI when compared to 12-month DAPT (absolute risk difference [ARD], -3.8 incident cases per 1000 person-years; relative risk [RR], 0.68; 95% CI, 0.54-0.87). Conversely, no significant difference was found when comparing mid-term DAPT (ARD, -4.6 incident cases per 1000 person-years; RR, 0.61; 0.45-0.83) and short-term DAPT followed by aspirin (ARD, -6.1 incident cases per 1000 person-years; RR, 0.55; 0.37-0.83) or P2Y12 monotherapy (ARD, -0.3 incident cases per 1000 person-years; RR, 0.97; 0.78-1.22) to 12-month DAPT for MI.

When compared against extended-term DAPT, 12-month DAPT, mid-term DAPT, and short-term DAPT followed by aspirin monotherapy or P2Y12 inhibitor monotherapy were associated with significantly higher risk of MI.

For major bleeding, results indicated extended-term DAPT was associated with an increased risk of major bleeding compared to 12-month DAPT (ARD, 4.9 incident cases per 1000 person-years; RR, 1.63; 1.15-2.30). Investigators highlighted short-term DAPT followed by P2Y12 inhibitor monotherapy was associated with a reduction in risk of major bleeding (ARD, -3.7 incident cases per 1000 person-years; RR, 0.69; 0.50-0.96).

Of note, the analysis indicated no significant differences in major bleeding when comparing mid-term DAPT and short-term DAPT followed by aspirin monotherapy to 12-month DAPT. Additionally, results of the analysis suggested all other approaches were associated with a reduced risk of major bleeding when compared to extended-term DAPT.

When assessing net clinical benefit, results of the analysis favored short-term APT followed by P2Y12 monotherapy in the entire cohort. However, the net clinical benefit favored extended-term DAPT for patients with acute coronary syndrome, which investigators attribute to a reduced risk of MI and a non-significant risk of major bleeding compared to a 12-month DAPT strategy.

Dual Antiplatelet Therapy After Percutaneous Coronary Intervention and Drug-Eluting Stents: A Systematic Review and Network Meta-Analysis

A new network meta-analysis offers an overview of the clinical benefit of less than 6 months, 6-month, 12-month, and extended periods of DAPT therapy after PCI with drug-eluting stents.

Meta-Analysis Compares Effects of DAPT Durations After PCI with DES

This episode of the Practical Cardiology Podcast features an interview with Dr. Hyung Chun, associate professor of medicine and pathology at Yale School of Medicine and director of Translational Research in the Yale Pulmonary Vascular Disease Program.

Chun recently led a study examining one of the most pressing issues in the treatment of COVID-19 patients: Blood clots. In the following interview, Chun discusses the potential mechanism behind blood clots in COVID-19 patients as well as the overall impact blood clots have on treatment course.

Director of Yale's Pulmonary Vascular Disease Program offers insight from a recent study he led attempting to determine the root cause of blood clots in COVID-19 patients.

Endotheliopathy of COVID-19 Blood Clots

Hear from Robert Busch, MD, as he offers his thoughts on the topline results of EMPEROR-REDUCED. Released on June 30, topline results of the study indicate use of empagliflozin (Jardiance) was associated with a reduction in the composite endpoint of death and worsening heart failure. 

Scheduled to be presented almost one year after the results of DAPA-HF, full results of EMPEROR-REDUCED could definitively prove the benefit seen on heart failure is truly a class effect of SGLT2 inhibitors. 

Videos

A practicing endocrinologist discusses his reaction to topline results from EMPEROR-REDUCED and what he hopes to see in the presentation at ESC 2020. 

Robert Busch, MD: EMPEROR-Reduced Topline Data and SGLT2 Class

This article originally appeared on Practical Cardiology's sister site, 

A national assessment of more than 1.5 million patients from the United Kingdom is quantifying the impact of bariatric surgery on cardiovascular mortality and the incidence of ischemic heart disease. 

A comparison between nearly 270,000 patients who underwent bariatric surgery to 1.27 million controls, results of the study indicate bariatric surgery was associated with significant decreases in rates of all-cause mortality and cardiovascular mortality as well as the incidence of 

“Healthcare providers may use the data on relative risk reduction as part of the discussion with patients considering bariatric surgery,” noted study investigators.

To provide clinicians with a more accurate overview of outcomes following bariatric surgery in obese individuals, a group of investigators from the Imperial College London and Musgrove Park Hospital designed their analysis using data from studies published within Medline, Embase, and Web of Science databases. For inclusion in the study, investigators required articles to be national or regional administrative database cohort studies comparing risk of long-term mortality or incident obesity-related diseases for patients who have undergone bariatric surgery versus appropriate control groups. Additionally, published articles needed to have a minimum follow-up period of 18 months and be published between January 1, 2000 and January 31, 2020.

The primary aim of the analysis was to assess the hazard ratios for all-cause mortality and the pooled odds ratios for incident disease. In total, investigators identified 18 studies with a median follow-up time of 55 months meeting their inclusion criteria.

From the 18 studies, investigators identified information related to 1,539,904 patients for the current study. Of these, 269,818 underwent bariatric surgery and 1,270,086 were included as controls subjects. Of the 269,818 who underwent bariatric surgery, 137,578 underwent gastric bypass, 58,916 underwent a sleeve gastrectomy, 52,973 underwent an adjustable gastric band, and 6397 underwent vertical banded gastroplasty, and 1002 underwent biliopancreatic diversion.

In 11 studies assessing all-cause mortality, investigators noted a significant reduction in relative risk of long-term all-cause mortality in patients who underwent bariatric surgery when compared with controls (POR, 0.62; 95% CI, 0.55-0.69; 

 <.001). In the 3 studies assessing cardiovascular mortality, those undergoing bariatric surgery had a significantly reduced relative risk of cardiovascular mortality compared to those in the control group (POR, 0.50; 95% CI, 0.35-0.71; 

Additionally, the analyses indicated bariatric surgery was strongly associated with reduced incidence of type 2 diabetes (POR, 0.39; 95% CI 0.18-0.83, 

=.010), hypertension (POR, 0.36; 95% CI, 0.32-0.40, 

 <.001), dyslipidemia (POR, 0.33; 95% CI 0.14-0.80, 

=.010), and ischemic heart disease (POR, 0.46; 95% CI, 0.29-0.73, 

=.001). Of note, 6, 5, 2, and 5 studies included in the analyses for each of these diseases, respectively.

Investigators cautioned against over-interpretation of study results without consideration of the possible limitations.

“Our results represent real-world data that may be generalizable to routine clinical practice. As further data accumulate, it may become clearer whether bariatric surgery reduces the incidence of new-onset obstructive sleep apnea or venous thromboembolism,” wrote investigators.

Association of bariatric surgery with all-cause mortality and incidence of obesity-related disease at a population level: A systematic review and meta-analysis

A systematic review and meta-analysis found bariatric surgery in obese patients was linked to decreases of more than 35% in risk of all-cause and cardiovascular mortality. 

Study Details Decreases in Death, Cardiovascular Disease from Bariatric Surgery

: A 52-year-old female with a history of asthma presents to the emergency department for cough, tactile fever, and dyspnea. She denies syncope, palpitations, chest pain or other complaints. She states it feels like she is having an asthma attack but she hasn’t had one in over a decade so she did not have medicine for it at home.

: Vital signs are notable for a pulse of 134, blood pressure of 113/62, temperature 98.6, and sat of 95% on RA. Exam is notable for obesity, tachycardia and mild wheezing but good air movement and no respiratory distress. There is no leg edema.

Bronchitis, Asthma, Tachydysrhythmia, Pulmonary Embolism, Acute Coronary Syndrome.

EKG ANALYSIS, CASE OUTCOME & 1-MINUTE CONSULT:

(Peer reviewed by Dr. Stephen W. Smith of 

The computer read is correct: the rate is >100; there is a left axis; the voltage is <10mm in all limb leads (just barely); and, there are significant Q waves in two inferior leads (III & aVF), which could, among other possibilities, represent a prior completed inferior MI. There are other possible explanations for these Q-waves of course, including a normal variant or a pulmonary embolism (incomplete S1Q3T3 without the inverted T in III). There is also fairly significant tachycardia that is not explained by pain, albuterol use, fever or other conditions, so PE, again, could be the cause. Finally, there are nonspecific T-wave changes not called by the computer.

: The chest x-ray was clear with no cardiomegaly or infiltrate. Another important consideration for the differential diagnosis of low voltage and tachycardia is pericardial tamponade. A bedside echo showed no pericardial effusion (her low voltage was likely from obesity) but a possibly enlarged RV. The patient’s SOB did not improve with a trial of albuterol though her tachycardia actually ironically did improve. The WBC count was elevated at 17 with 22% bands and D-dimer was also elevated. Antibiotics were started and a chest CT was ordered to rule out PE and look for an x-ray negative pneumonia (~30% of cases of pneumonia only show up on CT, often done to check for PE). The CT showed no pneumonia but did show a saddle pulmonary embolism. The patient received half-dose tPA, was admitted and did well. No other cause of bandemia was found.



1. Consider PE with otherwise unexplained tachycardia. Though this EKG is quite nonspecific it is consistent with large PE. There will usually be other clinical findings but remember that 20% of PE’s are painless (typically the LARGE ones), and cough is present in ~1/4 of PE’s. While we are on the topic of PE and tachycardia, remember that you shouldn’t rule out PE just because there is no tachycardia as 75% of PE patients have a pulse <100 and 40% have a pulse <90.

2. Consider PE with an S wave in lead 1, especially when it is new and is in the proper clinical setting.

3. Consider PE with nonspecific T-wave changes, such as flattening, especially when they are new and are in the proper clinical setting.

4. Elevated WBC counts and even bandemia are not specific for infection.WBC is probably around 70% specific and band count around 90% specific. Any severe stress can cause demargination and elevated WBC count, not infrequently to levels >14 and occasionally to levels >30. If the cause of leukocytosis is not thought to be infectious, ordering a CRP and/or sed rate may be helpful as they will typically both be normal or if elevated only slightly so in the abscess of severe infection.

5. Conditions sometime mimic other conditions. In this case the patient felt like she was having an asthma attack, but that was unusual in that she hadn’t had one in over a decade.

The latest case report from Dr. Brady Pregerson concerns a 52-year-old female with a history of asthma presenting with a cough, tactile fever, and dyspnea. 

Case Report: Asthma or Something More?

Data from a new study examining use of the SAPIEN 3 transcatheter heart valve from Edward Lifesciences demonstrate the high rate of success seen with the device during transcatheter mitral valve-in-valve replacement procedures.

Using data from more than 1500 patients undergoing transseptal or transapical mitral valve-in-valve replacements, investigators assessed the technical success of procedures as well as provide an overview of temporary outcomes trends, including 30-day and 1-year mortality rates.

“Transcatheter mitral valve-in-valve using the SAPIEN 3 is associated with high technical success, a low complication rate, and 30-day mortality rates lower than predicted by the STS score. Most patients experienced significant improvement of symptoms and quality of life that were maintained at 1 year,” wrote investigators.

With increasing evidence regarding their safety and efficacy and an equal increase in popularity, a team of investigators led by Mayra Guerrero, MD, of the Mayo Clinic, designed a registry-based prospective cohort study to further the evidence base surrounding mitral valve-in-valve replacement procedures. Using the Society of Thoracic Surgeons (STS)/American College of Cardiology (ACC) Transcatheter Valve Therapy Registry from June 2015-July 2019, investigators identified a total of 1529 patients for inclusion in the current study.

For inclusion in the study, patients needed to undergo a transseptal or transapical mitral valve-in-valve replacements between the aforementioned dates. Investigators pointed out 2144 patients were identified in their initial search, but patients undergoing mitral valve-in-ring, valve-in-mitral annular calcification, and transatrial mitral valve-in-valve implant procedures were excluded as well as those with insufficient data for classification.

The primary objective of the was to assess temporary outcomes of mitral valve-in-valve using the SAPIEN 3 transcatheter heart valve—with investigators using all-cause mortality at 1 -year as the primary efficacy end point and procedural technical success as per the Mitral Valve Academic Research Consortium as the primary safety end point.

Additionally, investigators included multiple secondary end points in their analysis. Specific secondary end points included procedural and in-hospital outcomes, New York Heart Association (NYHA) class, quality of life as defined by the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ), adverse events at 30 days and 1 year, and predictors of 1-year mortality.

Of the 1529 patients included in the study, 1326 underwent transseptal mitral valve-in-valve and 203 underwent transapical mitral valve-in-valve replacement procedures. For the overall study cohort, the mean age was 73.3 (SD, 11.84) years, 59.1% were women, and the mean STS predicted risk of mortality was 11.1% (SD, 8.7%).

Investigators determined the rate of procedural technical success was 96.8%, with success in 1480 of the 1529 patients included in the study. Results of the analysis indicated all0cause mortality among the overall study cohort was 5.4% at 30 days and 16.7% at 1 year. In analyses comparing outcomes and trends for transseptal and transapical procedures separately, investigators found transseptal access was associated with a lower 1-year all-cause mortality than transapical access (15.8% vs 21.7%; 

Additionally, investigators found transcatheter mitral valve-in-valve replacement contributed to early, sustained, and clinically meaningful improvements in heart failure—specifically improvements in NYHA class. Of note, the mean mitral valve gradient of patients included in the cohort was 7 (2.89) mmHg.

“Transseptal MViV should be considered an option for most patients with failed surgical bioprosthesis who have favorable anatomy electing bioprosthetic valve replacement,” investigators wrote in their conclusion.

One-Year Outcomes of Mitral Valve-in-Valve Using the SAPIEN 3 Transcatheter Heart Valve

An analysis of the STS/ACC Transcatheter Valve Therapy Registry reviews trends associated with use of the SAPIEN 3 transcatheter heart valve. 

Analysis of Outcomes, Trends with SAPIEN 3 Transcatheter Heart Valve

Results of a new systematic review and meta-analysis are offering updated insight on associations between diabetes mellitus and risk of new-onset and recurrent 

With more than 70 published articles assessing new-onset heart failure and more than 30 assessing recurrent heart failure, findings from the study provide an overview of the increased risk of heart failure associated with 

“These findings help to specify the populations that should be the focus of preventive strategies for diabetes mellitus-related heart failure. It is also indicated that diabetes mellitus is associated with future HFpEF and HFrEF to the same extent,” wrote study investigators.”

While mountains of data have established associations between diabetes mellitus and increased risk of heart failure, the exact magnitude of risk remains a topic of discussion among clinicians. To bring further clarity to this conversation, investigators designed the current meta-analysis to separately assess the risk of new-onset and recurrent heart failure depending on a patient’s diabetes status.

With this in mind, investigators designed their study to search the EMBASE and MEDLINE databases for cohort studies published up to July 28, 2019. Investigators established 4 main inclusion criteria for articles. From their search, investigators identified a total of 74 and 38 studies examining new-onset and recurrent heart failure, respectively.

To be included in the analysis, articles needed to be considered a cohort study, have information related to diabetes status of all participants, contain at least 6 months of follow-up data, and have diabetes mellitus as an exposure. Investigators planned to pool respective risk ratios for individuals with diabetes mellitus compared to those without diabetes mellitus through use of a random-effects model.

Among the studies examining new-onset heart failure, the pooled RR for heart failure as a whole was 2.14 (95% CI, 1.96-2.34). Investigators pointed a large between-study heterogeneity was significantly explained by mean age (

<.001). When examining studies detailing incidence of HFpEF, investigators found the pooled RR was 2.22 (95% CI, 2.02-2.43). In studies detailing the incidence of HFrEF, the pooled RR was 2.73 (95% CI, 2.71-2.75).

When assessing the 38 studies included in the recurrent heart failure analysis, investigators found the pooled RR was 1.39 (95% CI, 1.33-1.45). Investigators noted the large between-study heterogeneity seen in this group of studies was significantly explained by the proportion of men (

= 0.01) or the large pooled RR for studies of only participants with HFpEF (

Investigators purported the results of their analyses indicate diabetes mellitus is a significant risk of both new-onset and recurrent heart failure. Additionally, investigators pointed out the risk magnitude appeared to be large for new-onset heart failure in your populations.

“The present results indicate that diabetes mellitus is a significant risk factor for both new-onset and recurrent HF. It is suggested that the risk magnitude is large for new-onset HF especially in young populations and for recurrent HF especially in women or those with HFpEF,” wrote study investigators.

Diabetes mellitus and risk of new-onset and recurrent heart failure: a systematic review and meta-analysis

A review of published articles is detailing the risk of new-onset and recurrent heart failure, respectively, in patients with diabetes mellitus. 

Review Details Risk of Recurrent, New-Onset Heart Failure Associated with Diabetes

Data from a new study suggests certain reproductive factors could increase the risk of coronary artery disease in 

In what investigators call one of the largest study to examine these potential risk factors, results suggest having 3 or more pregnancies, early menopause, and having a shorter reproductive life were all independent risk factors for obstructive 

"This study expands our knowledge about the link between reproductive factors such as early menopause and shorter reproductive life span and increased cardiovascular risk. Indeed, there is a growing body of evidence suggesting that early loss of ovarian function results in accelerated aging. Future research should be directed toward identifying ways to delay ovarian aging," commented Stephanie Faubion, MD, clinician at Women's Health Clinic at Mayo Clinic and medical director of the North American Menopause Society, 

While previous research has suggested reproductive factors, there is much about the relationship between reproductive factors and subsequent cardiovascular risk. To learn more about how these factors may influence risk of coronary artery disease, a team of investigators from the Tongji Medical College designed the current study to compare reproductive factors among postmenopausal women with no apparent coronary artery disease, nonobstructive coronary artery disease, and obstructive coronary artery disease.

Using women admitted to the cardiovascular department of the Tongji Hospital from between April 2013 and October 2018, investigators were able to identify 2,511 postmenopausal women admitted for chest pain and referred for invasive coronary angiography for possible inclusion in the their study. Of these 974 were excluded due to prior coronary artery disease and 63 were excluded due to missing data. In total, 1474 women were included in the analysis.

Among the 1474 women included, coronary angiography resulted indicated 251 had no apparent coronary artery disease, 342 women had nonobstructive coronary artery disease, and 881 women had obstructive coronary artery disease. For the subsequent analyses, investigators used the those with no coronary artery disease and those with non obstructive coronary artery disease were used as controls.

In adjusted analyses, investigators identified multiple reproductive risk factors associated with an increased risk of obstructive coronary artery disease. Those who entered menopause at 40 years of age or younger were at an increased risk compared to those who entered menopause later in life (aOR, 1.77; 95% CI, 1.14-2.76; 

=.011), those with a reproductive life span of 30 or fewer years were at an increased risk compared to those with a reproductive life span of more than 30 years (aOR, 1.72; 95% CI, 1.26-2.35; 

=.011), and those with multigravidity, which was defined 3 pregnancies or more, were at an increased risk for obstructive coronary artery disease compared to those who were never pregnant (aOR, 1.81; 95% CI, 1.03-3.17; 

Further analysis indicated each additional year in age at menopause or reproductive life span was associated with a 4% reduction in obstructive coronary artery disease (OR, 0.96; 95% CI, 0.94-0.99; 

=.011). Factors not associated with increased risk of obstructive coronary artery disease included parity, age at first birth, spontaneous abortion, induced abortion, stillbirth, hypertensive disorders of pregnancy, gestational diabetes mellitus, and age at menarche.

“These results provide a new direction for the pathophysiological study of obstructive CAD. The prognosis of women with obstructive CAD is usually worse than that of women with no apparent CAD and nonobstructive CAD, and early intervention is necessary,” wrote study investigators. “Therefore, women with these reproductive risk factors should take precautions as early as possible.”

Reproductive risk factors for angiographic obstructive coronary artery disease among postmenopausal women

A new study is detailing the increased risk of coronary artery disease associated with certain reproductive factors in postmenopausal women. 

Study Details Reproductive Factors and Coronary Artery Disease Risk in Women

New data from an analysis of the OPTIMIZE-HF registry is underlining the importance of initiating therapy with loop diuretics in patients hospitalized for 

 decompensation not previously taking diuretics.

Results of the analysis, which was led by investigators from the Veterans Affairs Medical Center in Washington, DC, indicate initiating therapy with loop diuretics was associated with a 27% lower risk of 30-day all-cause mortality and a significantly lower risk of 30-day readmission, suggesting the effects of the therapy may go beyond symptom alleviation.

“Information provided by the current study has practical implications for clinicians involved in HF care,” wrote study investigators. “Despite the general impression that most clinicians would use loop diuretics to relieve symptoms in nearly all patients with HF, findings from our study suggest that many patients hospitalized for HF decompensation were not receiving diuretics before hospitalization.”

To further understand the associations between loop diuretic use and clinical outcomes among patients with heart failure, investigators designed a propensity-matched analysis to compare outcomes of patients from the Medicare-linked OPTIMIZE-HF registry. From the registry, which contains info on more than 25,000 older patients hospitalized for heart failure, a cohort of 9866 patients who were not receiving pre-admission diuretics were identified for the current study.

Of these 9866 patients, 1083 were excluded because they were receiving dialysis and 847 were excluded because they were discharged on thiazide diuretics. From the remaining 7936 patients, which included 5568 patients who were prescribed loop diuretics at discharge, investigators created 2 matched cohorts of 2191 patients based on 74 baseline characteristics.

After propensity matching, there was an absolute standardized difference of less than 5% for all 74 baseline characteristics. Investigators also pointed out 56 values had an absolute standardized difference of less than 2% and 41 values had an absolute standardized difference of less than 1%.

Among the 4382 propensity-matched patients, the mean age was 78±10 years, 54% were women, and 11% were African American. Outcomes of interest for the analysis included heart failure readmission, all-cause readmission, and all-cause mortality at 30 and 60 days. Investigators noted they also examined 2 combined endpoints of either readmission or mortality. All data on outcome events and time to events were obtained through Medicare data.

Upon analysis, results indicated 30-day all-cause mortality rates were 4.9% and 6.6% in the loop diuretics and no loop diuretics groups, respectively. Based on these results, investigators determined the hazard ratio with loop diuretic use versus nonuse was 0.73 (95% CI, 0.57-0.94; 

The analysis also indicated patients receiving loop diuretics had a significantly lower risk of 30-day heart failure readmission (HR, 0.79; 95% CI, 0.63-0.99; 

=.037) but not 30-day all-cause readmission (HR, 0.89; 95% CI, 0.79-1.01; 

=.081). Investigators pointed out none of these associations were statistically significant during analysis of 60-day follow-up data.

“The new message from our study is that prescription of loop diuretics at discharge may be associated with a lower risk of short-term rehospitalizations and mortality in these patients,” wrote investigators. “These findings are expected to clarify the role of loop diuretics in HF and strengthen the evidence for the guideline recommendation on loop diuretics.”

Investigators noted multiple limitations to consider when interpreting data from within the study. These limitations included basing the analysis on fee-for-service Medicare beneficiaries, which could limit generalizability, and not having access to data related to loop diuretic doses or start/restart/discontinuation after hospital discharge.

Loop Diuretic Prescription and 30-Day Outcomes in Older Patients With Heart Failure,

Journal of the American College of Cardiology.

A new analysis of a Medicare-linked database is detailing associations between loop diuretic use and nonuse after heart failure hospitalization with 30-day clinical outcomes.

Loop Diuretic Use Improves 30-Day Outcomes Following Heart Failure Hospitalization

New research indicates incorporating high-sensitivity troponin (hsTn) testing into an American Heart Association/American College of Cardiology (AHA/ACC) cholesterol management guideline-based algorithm for patients with 

atherosclerotic cardiovascular disease (ASCVD)

 could improve risk stratification and help optimize care.

When examining use of the biomarker-testing approach in patients from the PEGASUS-TIMI 54 trial, investigators determined incorporation of hsTn testing resulted in the reclassification of 11.9% of patients into a more appropriate risk group.

In an effort to understand whether addition of hsTn testing to guideline-derived ASCVD risk classification, a team led by investigators of the TIMI study group designed and conducted a prospective cohort biomarker substudy of patients from the PEGASUS-TIMI 54 trial. From the 21,162 patients included in the original trial, 8635 were included in the current substudy

The median age of the study cohort was 65 years (IQR, 58-71 years), 76.6% were men, and 96.6% were White individuals. All patients included in the study experienced myocardial infarction 1-3 years prior to enrollment, were at least 50 years of age, and had at least 1 high-risk feature.

For the analysis, patients were assigned to AHA/ACC guideline-derived risk groups classified as very-high risk ASCVD or a lower-risk ASCVD based on their cardiovascular history and comorbidity. Patients were also classified according to hsTnI levels, with threshold points of 2 ng/L and 6 ng/L, which was defined as an undetectable level and the increased risk threshold, respectively. This was followed by a joint classification on the basis of clinical features and hsTnI level.

The primary end point of the analysis was a composite of cardiovascular death, myocardial infarction, or stroke. Upon analysis, patients meeting the criteria for the very high-risk ASCVD group had a 3-year event rate of 8.8% when assessing for the primary end point. In comparison, the rate among patients in the lower-risk group was 5.0% (HR, 2.01; 95% CI, 1.58-2.57; 

When stratifying patients according to hsTnI level, 9.0% of patients in the very high-risk group had an undetectable hsTnI level and these patients had a corresponding 3-year event rate of 2.7%, which investigates noted was lower than the overall rate in the lower-risk group. Among patients in the lower-risk group, 22.6% had an hsTnI level exceeding the 6 ng/L risk threshold and these patients had a corresponding 3-year event rate of 9.1%, which investigators noted was comparable to the rate seen in the very high-risk group.

Based on these results, investigators determined the addition of hsTnI levels to guideline-derived ASCVD risk assessments led to a net reclassification index at event rate of 0.15 (95% CI, 0.10-0.21). Furthermore, results indicated use of hsTnI led to reclassification of 11.9% of patients in the substudy.

Harvey White, DSc, of the Auckland City Hospital and University of Auckland in New Zealand, highlights the potential of adding the biomarker to risk assessment algorithms but also warns against over-interpretation of results.

“It is not clear from the study by Marston and coworkers why increased hs-troponins within the normal range were associated with increased CVD risk. However, even without a complete understanding of the underlying mechanisms for the increased hs-troponin levels, the incremental information on CVD risk makes it very useful for improving risk assessment,” White wrote. “Troponin levels should not be viewed just as a marker for myocardial injury and diagnosis of MI in acute coronary syndrome but should be used more frequently for assessing CVD risk in stable patients with IHD.”

Clinical Application of High-Sensitivity Troponin Testing in the Atherosclerotic Cardiovascular Disease Framework of the Current Cholesterol Guidelines

Analysis of PEGASUS-TIMI 54 patients indicates incorporating the biomarker into guideline-based risk assessment could improve risk classification and care.

High-Sensitivity Troponin Testing Could Improve ASCVD Risk Stratification

This article was originally published on Practical Cardiology's sister site 

New research from the University of Cambridge in the United Kingdom has linked a diagnosis of common conditions among women in their 30s and 40s to an increase in risk of 

An analysis of more than 60,000 women from a Danish health registry, results of the study suggested polycystic ovary syndrome, which is common among women in their 30s and 40s, was associated with a 19% increase in risk of developing cardiovascular disease later in life.

"Heart health appears to be a particular problem for young women with PCOS,” said Clare Oliver-Williams, PhD, MPhil, a junior research fellow in the Cardiovascular Epidemiology Unit of the University of Cambridge, 

. “This may be because they are more likely to be overweight and have high blood pressure and diabetes compared to their peers.”

With previous studies establishing a link between presence of polycystic ovary syndrome and increased risk of cardiovascular risk factors such as obesity and hypertension, Oliver-Williams and a team of investigators sought to determine the specific risk of cardiovascular disease associated with polycystic ovary syndrome in age-adjusted analyses. With this in mind, they designed their study using data from women in the Danish National assisted reproductive technology-Couple II Cohort for a time frame ranging from 1994-2015.

From the registry, investigators identified a cohort of 60,574 women for inclusion in their study. Of these women, 6149 (10.2%) had polycystic ovary syndrome. The median follow-up range of the study population was 8.9 years and 2925 (4.8%) developed cardiovascular disease.

For the purpose of the analysis, investigators used ICD-10 codes to identify incident cardiovascular disease. Additionally, investigators noted the 2 models were used to calculate hazard ratio estimates for cardiovascular disease according to age.

The first model adjusted for age and the second model adjusted for age, year of first assisted reproductive technology treatment, baseline parity, gestational diabetes, relationship status, and education. Of note, specific age groups included in the analyses were defined as less than 30 years, 30-34 years, 35-39 years, 40-49 years, and 50 years and more. Investigators pointed out women with polycystic ovary syndrome were younger, more likely to develop gestational diabetes, and less likely to be single than the overall study cohort.

Results of the investigators’ age-adjusted analysis indicated women with polycystic ovary syndrome were at a greater risk of developing cardiovascular disease when compared to those without polycystic ovary syndrome (HR 1.20; 95% CI, 1.08–1.34). In further adjusted analyses, results indicated these women were at a 19% greater risk of developing cardiovascular disease (aHR 1.19, 95% CI 1.07–1.33).

Investigators highlighted results of the analyses also indicated there was no evidence of increased cardiovascular risk for women with polycystic ovary syndrome after the age of 50 years. In the aforementioned sensitivity analysis, adjustment for BMI, smoking, and alcohol yielded results indicating an increased risk of cardiovascular disease among women with polycystic ovary syndrome (HR, 1.49; 95% CI, 1.04-2.06).

In the aforementioned release, investigators noted the impact modifiable risk factors can have on the development of cardiovascular disease in these patient populations.

"Polycystic ovary syndrome isn't a life sentence—there are many ways to stay heart healthy," added Oliver-Williams. "Small changes add up, like eating more fruits and vegetables and doing more exercise."

Risk of cardiovascular disease for women with polycystic ovary syndrome: results from a national Danish registry cohort study

European Journal of Preventive Cardiology.

Research suggest polycystic ovary syndrome was tied to a 19% increase in risk of cardiovascular disease in women from a cohort within the UK. 

Research Links Polycystic Ovary Syndrome to Increased Cardiovascular Disease Risk

A recent analysis of Hispanic and Latino patients in the US is shedding new light on an unsettling trend in regard to cardiovascular health.

Results of the analysis indicated recommended medications for peripheral artery disease and 

, including antihypertensives, antiplatelet, and lipid-lowering therapies, were being severely underused in these populations.

“Heightened attention and more efforts to improve treatment are needed in the care of PAD patients to prevent future cardiovascular events and leg amputation,” said lead investigator Simin Hua, MHSc, an associate researcher in the department of epidemiology and population health at Albert Einstein College of Medicine in New York City, 

. “These efforts might include improving health care access, educating patients and advocating that physicians offer guideline-adherent treatment. This is especially important because many Hispanic/Latino individuals in the U.S. face issues such as lack of health insurance and high burden of cardiovascular risk factors.”

To further explore the underuse of cardiovascular medications for secondary prevention in Hispanic or Latin patients with peripheral artery disease, Hua and a team of investigators designed their study using data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). From the HCHS/SOL, which is an ongoing community-based study, investigators obtained information related to more than 16,000 patients from multiple sites across the US, including 1244 who were included in the current study.

The 1244 patients included in the current study were recruited from sites in Bronx, NY, Chicago, IL, Miami, FL, and San Diego, CA. Of the 1244 patients included in the study cohort, 826 reported a peripheral artery disease diagnosis at baseline and 418 reported coronary artery disease alone. During the baseline examination for the study, all participants were asked to bring in medication they had taken over the past 4 weeks.

Of note, multivariable regression models used in the analyses accounted for demographic and socioeconomic factors, acculturation, access to health care, and comorbidities.

Results of the investigators’ analyses indicated underuse of antiplatelet, lipid-lowering, and antihypertensive therapies among patients with peripheral artery disease. Specifically, 31% reported use of antiplatelet therapy, 26% reported use of lipid-lowering therapy, and 57% reported use of antihypertensive therapy.

Additionally, results suggested older age, increased number of doctor visits, and existing hypertension and diabetes were significantly associated with taking cardiovascular medications in adjusted models. Investigators noted those with concurrent coronary artery disease were 1.52-times (HR, 1.52; 95% CI, 1.20-1.93) more likely to report use of antiplatelet agents and 1.74-times (HR, 1.74; 95% CI, 1.30-2.32) more likely to report use of statins when compared to patients with peripheral artery disease alone.

Investigators highlighted there were significant differences found in use of antihypertensive mediation among patients with peripheral artery disease alone and those with concurrent coronary artery disease. Investigators also pointed out patients with a Mexican background reported lower rates of use across cardiovascular medications included in the study and an 11-18% higher rate of medication use, on average, among people with health insurance coverage compared to those without.

“The need for medications did not seem to receive the same level of attention for patients with PAD compared to those with coronary artery disease, even though both patient groups can benefit from these cardiovascular medications,” Hua added, in the aforementioned statement.

Underuse of Cardiovascular Medications in Individuals With Known Lower Extremity Peripheral Artery Disease: HCHS/SOL

Journal of the American Heart Association.

Among Hispanic and Latino patients with peripheral artery disease 31% reported use of antiplatelet therapy, 26% reported use of lipid-lowering therapy, and 57% reported use of antihypertensive therapy in a new study. 