Coverage of the annual AHA Scientific Sessions

AHA Scientific Sessions 2020

Top Advances in Cardiology in 21st Century

Slideshows

Dr. Gregory Weiss reflects on what he believes are the 6 most significant advances to occur in cardiovascular medicine since 2000. His picks included statins, public awareness campaigns, and transcatheter aortic valve replacement. 

Cardiology's Top Advances in the 21st Century with Gregory Weiss, MD

A new study from Thomas Jefferson University is providing evidence in support of their prediction model for determining risk of stroke and other cardiovascular complications in patients undergoing non-cardiac surgery.

Results of the study indicate the web-based model could help identify patients at high-risk for these events and allow clinicians the ability to circumvent this risk when possible.

"Often times we do the research and publish a research paper that is too complex to translate to the bedside," said lead investigator Sang Woo, MD, director of the Division of Hospital Medicine at Thomas Jefferson University, 

. "My goal from the beginning was to come up with a new model that is very practical and useful and that can be incorporated into routine patient care."

Despite advances in technology and monitoring, cardiovascular complications following non-cardiac surgery remain a significant risk for many. With this in mind, the current study was designed as a way to validate a prediction model developed by Woo and a team of colleagues from Thomas Jefferson to assess risk for these events.

Woo and team designed their model using data from the Universal American College of Surgeons National Surgical Quality Improvement Program (ACS‐NSQIP). Specifically, the model was developed based on a cohort of 809,880 patients treated between 2007-2009. The model was created using information related to the age, history of coronary artery disease, history of stroke, emergency surgery, preoperative serum sodium, creatinine, hematocrit, American Society of Anesthesiologists physical status class, and type of surgery. This model was subsequently tested using ACS-NSQIP data from 2010.

The primary outcomes of interest for the study were postoperative 30-day stroke, major cardiovascular events, and 30-day mortality. For the purpose of analysis, major cardiovascular events included myocardial infarction, cardiac arrest, or stroke.

In the cohort of 355,870 patients from 2010 used to test the model, major cardiac complications occurred in 0.66% (n=5332) of patients (myocardial infarction, 0.28%; cardiac arrest, 0.41%), postoperative stroke occurred in in 0.25% (n=2005), and 30‐day mortality was 1.66% (n=13,484). Upon analysis, result indicated the risk prediction model had high predictive accuracy with area under the receiver operating characteristic curve for stroke (training cohort=0.869, validation cohort=0.876), major cardiovascular events (training cohort=0.871, validation cohort=0.868), and 30‐day mortality (training cohort=0.922, validation cohort=0.925).

Further analysis indicated surgery types, history of stroke, and coronary artery disease appeared to be significant risk factors for stroke and major cardiac complications. The surgery types associated with highest risk of stroke were vascular (thoracic‐EVAR), brain surgery, and carotid endarterectomy. For cardiac complications, procedures associated with greatest risk were open aorta surgery, thoracic‐EVAR, suprainguinal bypass, intestinal surgery, and liver/pancreas/spleen surgery.

“Using 9 clinical variables in a national cohort of patient data from the robust ACS‐NSQIP database collected over 4 years, we developed and validated a clinically useful risk assessment model for stroke, cardiac, and mortality risk,” wrote investigators in their conclusion.

Development and Validation of a Prediction Model for Stroke, Cardiac, and Mortality Risk After Non‐Cardiac Surgery,

Journal of the American Heart Association.

Articles

A web-based model developed by a team at Thomas Jefferson University appeared to accurately predict risk of stroke and adverse cardiovascular events following non-cardiac surgery. 

Web-Based Model Shows Promise for Predicting Stroke, Cardiac Events after Non-Cardiac Surgery

Results of a modeling study by investigators at Tufts University suggest nearly two-thirds of all COVID-19 hospitalizations can be attributed to the presence of four specific preexisting conditions.

An analysis that included data from more than 900,000 COVID-19 hospitalizations, results indicate 64% of hospitalizations were attributable to obesity, hypertension, diabetes, and 

—with more than 30% of all hospitalizations attributable to obesity alone.

"While newly authorized COVID-19 vaccines will eventually reduce infections, we have a long way to go to get to that point. Our findings call for interventions to determine whether improving cardiometabolic health will reduce hospitalizations, morbidity, and health care strains from COVID-19," said Dariush Mozaffarian, MD, DrPH, lead investigator and dean of the Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy at Tufts University, 

. "We know that changes in diet quality alone, even without weight loss, rapidly improve metabolic health within just six to eight weeks. It's crucial to test such lifestyle approaches for reducing severe COVID-19 infections, both for this pandemic and future pandemics likely to come."

With previous observational studies linking the aforementioned cardiometabolic conditions to increased risk of severe outcomes with COVID-19, Mozaffarian and colleagues from the Friedman School sought to assess absolute and proportional COVID-19 hospitalizations attributable to each condition, jointly and separately, and according to race/ethnicity, age, and sex. Designed as a comparative risk assessment, investigators chose the NHANES 2015-2018 for cardiometabolic conditions and Centers for Disease Control and Prevention’s Coronavirus Disease 2019–Associated Hospitalization Surveillance Network (COVID-NET) database and from the COVID Tracking Project for COVID-19 hospitalizations as data sources for their study.

Investigators identified a total of 906,849 hospitalizations for COVID-19 among US adults that had occurred as of November 18, 2020. When assessing the proportion of hospitalizations attributable to each disease separately, results of the model indicated 274,322 (30.2%) were attributable to obesity, 237,738 (26.2%) were attributable to 

, 185,678 (20.5%) were attributable to diabetes, and 106,139 (11.7.%) were attributable to heart failure. When assessing the conditions jointly, results indicated the four conditions accounted for 575,419 (63.5%) of the 906,849 hospitalizations. Investigators pointed out further analysis suggested 10% reductions in national prevalence rates of each condition could have prevented approximately 11% of COVID-19 hospitalizations.

Like many previous studies, the investigators’ analysis also revealed disparities in COVID-19 attributable to these conditions based age and race/ethnicity. Specific disparities highlighted within the study included age-based disparities in hospitalizations attributable to diabetes and increased attributability to all four conditions among Black adults than White adults. Investigators also noted some disparities appeared to become greater when combing age and race/ethnicity into comparative models.

"Medical providers should educate patients who may be at risk for severe COVID-19 and consider promoting preventive lifestyle measures, such as improved dietary quality and physical activity, to improve overall cardiometabolic health. It's also important for providers to be aware of the health disparities people with these conditions often face," said first investigator Meghan O'Hearn, a doctoral candidate at the Friedman School, in the aforementioned statement.

Investigators cautioned clinicians to consider limitations within their study before overinterpreting the results. These limitations included inability to prove causation and the inability to prove improvements will reduce risk of COVID-19 hospitalization.

Coronavirus Disease 2019 Hospitalizations Attributable to Cardiometabolic Conditions in the United States: A Comparative Risk Assessment Analysis

An analysis using data from the CDC, COVID-NET, and the COVID Tracking Project suggests nearly 2 out of 3 COVID-19 hospitalizations in the US were attributable to obesity, hypertension, diabetes, and heart failure. 

AHA Study Links 4 Major Conditions to More than 60% of COVID-19 Hospitalizations

This article was originally published on 

New research from the University of Pittsburgh suggests women with hypertensive disorders of pregnancy should undergo regular cardiovascular screenings, even if they are not showing symptoms of cardiovascular disease.

An analysis of data from 132 women suggests women with a history of hypertensive disorders of pregnancy had notable differences in left ventricular structure and function a decade after pregnancy.

"Hypertension is a silent killer," said lead investigator Malamo Countouris, MD, a clinical instructor in cardiology at Pitt's Department of Medicine and a co-director of the UPMC Magee-Womens Hospital Postpartum Hypertension Clinic, 

 "None of the women in our study had clinical symptoms of heart disease—they are young and probably feel well and healthy, and may not be seeing a health care provider regularly—but it's important to start screening them for high blood pressure early."

Led by Countouris, a team from the University of Pittsburgh sought to examine the long-term effects of hypertensive disorders of pregnancy on cardiac remodeling. To do so, investigators designed their study as an analysis of data from women identified within the Magee Obstetric Maternal and Infant database from the University of Pittsburgh. From the database, investigators obtained information related to medical history of women with pregnancies delivered from 2008-2009. These women were then asked to take part in an additional; visit between 2017-2019 where they underwent transthoracic echocardiograms and assessments ofheight, weight, and blood pressure by standardized methods.

In total, investigators identified 132 women for inclusion in their study. Of these, 102 had normotensive pregnancies and 30 had hypertensive digs-orders of pregnancy, including 21 with pre-eclampsia and 9 with gestational hypertension. The overall cohort was 10±1 years removed from delivery and had a mean age of 39±6 years. Of the women with pre-eclampisa, 6 had severe pre-eclampsia and 7 experienced a pre-term delivery.

Upon analysis, those with hypertensive disorders of pregnancy during their index pregnancy were more likely to have current hypertension at 8-10 years after delivery compared to their counterparts without hypertensive disorders of pregnancy when measured according to visit blood pressure or antihypertensive medication use (63.3% vs 25.5%; 

<.0001). Additionally, women with hypertensive disorders of pregnancy were more likely to have diabetes (20.7% vs 7.0%; 

=.03), higher systolic blood pressure (125±12 mmHg vs 114±13 mmHg; 

 <.0001), higher diastolic blood pressure (82 ±10 mmHg vs 74±9 mmHg; 

 <.0001), and there appeared to be a trend toward a higher proportion of placental maternal vascular malperfusion (MVM) lesions (63.3% vs 45.1%; 

After adjustment for race, age, MVM lesions, BMI, current hypertension, and HbA1c, women with a history of hypertensive disorders of pregnancy had greater inter ventricular septal thickness and relative wall thickness then those with normotensive pregnancies. Further analysis indicated both a history of hypertensive disorders of pregnancy and current hypertension had greater portions of left ventricular remodeling compared to all other groups. Additionally, investigators noted these patients also had lower mitral inflow E/A ratio and annular e’.

"Identifying women at high risk can provide a window of opportunity for targeted interventions to prevent heart disease," said Countouris. "Suggesting simple changes in lifestyle or diet, including regular exercise and better management of other cardiovascular risk factors, can prevent adverse changes in the heart and lower the risk of heart disease later in life."

Association of Hypertensive Disorders of Pregnancy With Left Ventricular Remodeling Later in Life

Journal of the American College of Cardiology.

An analysis of data from 130 women suggests those with hypertensive disorders of pregnancy were at an increased risk of cardiovascular disease later in life, even if they had no baseline history of cardiovascular disease.

Hypertension in Pregnancy Predicts Cardiovascular Disease Risk A Decade After Birth

An analysis of data from a major women’s health study is underlining the impact of increased consumption of plant protein on risk of death, 

, and dementia-related death among older women.

Funded by the National Institutes of Health and National Heart, Lung, and Blood Institute, results of the study provide valuable insight to clinicians and add to the ongoing conversations surrounding dietary science and nutrition.

"Our findings support the need to consider dietary protein sources in future dietary guidelines," said study lead investigator Wei Bao, MD, PhD, an assistant professor of epidemiology at the University of Iowa in Iowa City, in a 

statement from the American Heart Association

. "Current dietary guidelines mainly focus on the total amount of protein, and our findings show that there may be different health influences associated with different types of protein foods."

Despite an almost innumerable number of studies examining plant versus animal protein and other sources of nutrition, debate still exists surrounding the effectiveness of increased protein from either source on overall, but particularly, cardiovascular health. For the purpose of their study, investigators designed their analysis to use data from postmenopausal women enrolled in the Women’s Health Initiative from 1993-1998 and followed through February 2017.

Of the 142,267 women considered eligible for inclusion in the current study, 137,481 had information related to a valid food frequency questionnaire. From this group, investigators excluded 137 with missing data on postmenopausal hormone therapy use, 24,427 who had a history of cardiovascular disease at baseline, and 10,366 women with a history of cancer at baseline. In total, 102,521 women were selected for inclusion.

During 1,876,205 person-years of follow-up, a total of 25,976 deaths occurred, including 6993 from cardiovascular disease, 7516 from cancer, and 2734 from dementia. Specific causes of cardiovascular disease included 776 from definite coronary heart disease, 1808 from cerebrovascular disease, 140 from pulmonary embolism, 2120 from possible coronary heart disease and 2149 from other or unknown cardiovascular diseases. The most common form of cancer among those who died included lung cancer, breast cancer, and pancreatic cancer. Based on results of validated FFQ responses, investigators categorized patients into quintiles based on the consumption of various forms of protein reported.

When comparing the highest quintile of plant protein consumption to the lowest, consumption of plant protein was inversely associated with all-cause mortality (HR, 0.91; 95% CI, 0.86-0.96), cardiovascular disease mortality (HR, 0.88; 95% CI, 0.79-0.97), and dementia mortality (HR, 0.79; 95% CI, 0.67-0.94).

When assessing other major protein sources, those in the highest quintile of consuming processed red meat (HR, 1.06; 95% CI, 1.01-1.10) and consuming eggs (HR, 1.14; 95% CI, 1.10-1.19) was associated with increased risk of all-cause mortality. Additionally, analyses indicated being in the highest quintile for consumption unprocessed red meat(HR, 1.12; 95% CI, 1.02-1.23), eggs (HR, 1.24; 95% CI, 1.4-1.34), or dairy products (HR, 1.11; 95% CI, 1.02-1.22) was associated with greater risk of cardiovascular disease mortality. Further analysis also revealed egg consumption was associated with a higher risk of cancer mortality (HR, 1.10; 95% CI, 1.02-1.19).

When evaluating dementia mortality, investigators found processed red meat was associated with a greater risk of dementia mortality while consumption of poultry was associated with a lower risk. Investigators also highlighted a substitution analysis suggested substituting animal protein with plant protein was associated with a lower risk of all‐cause mortality, cardiovascular disease mortality, and dementia mortality. Furthermore, this same analysis suggested substitution of total red meat, eggs, or dairy products with nuts was associated with a lower risk of all‐cause mortality.

“It is important to note that dietary proteins are not consumed in isolation, so the interpretation of these findings could be challenging and should be based on consideration of the overall diet including different cooking methods,” said study investigator Yangbo Sun, MD, PhD, a postdoctoral research scholar at the University of Iowa in Iowa City and assistant professor of epidemiology at the University of Tennessee Health Science Center, in the aforementioned statement.

Association of Major Dietary Protein Sources With All‐Cause and Cause‐Specific Mortality: Prospective Cohort Study

Using data from the Women's Health Initiative, a new analysis found increased intake of plant protein was linked to lower risk of all-cause mortality, as well as deaths related to cardiovascular disease and dementia, in postmenopausal women. 

Plant Protein Intake Linked to Lower Risk of All-Cause, Cardiovascular Death Among Aging Women

New research from an analysis of data within the STS/ACC Transcatheter Valve Therapy (TVT) Registry is questioning the effectiveness of cerebral embolic protection devices (EPDs) for mitigating stroke risk during transcatheter aortic valve replacement (TAVR).

While a secondary, propensity-matched analysis indicated an 18% lower odds of in-hospital stroke with EPD use, results of the primary analysis suggested EPD use resulted in an absolute difference of -0.15%, which led investigators to call for larger, randomized trials to assess safety and efficacy of use in TAVR patients.

“These findings provide a strong basis for large-scale randomized controlled trials to test whether EPDs provide meaningful clinical benefit for patients undergoing TAVR,” wrote investigators. “More definitive data from ongoing randomized trials powered to detect differences in clinically-important endpoints are necessary to support use of EPDs in TAVR.”

Despite advances in techniques and technology, stroke remains a serious and persistent risk following TAVR. With this in mind, a team led by David Cohen, MD, director of Clinical and Outcomes Research of the Cardiovascular Research Foundation, sought to assess how use of EPDs might influence in-hospital stroke risk using data from the STS/ACC TVT Registry.

For the purpose of analysis, investigators included adults aged 18 years and older who underwent elective or urgent TAVR from January 2018-December 2019 for native aortic valve disease or a degenerated surgical bioprosthesis. Exclusion criteria for the study included undergoing TAVR at a surgery performing 20 or fewer procedures annually, repeat TAVR procedures, undergoing TAVR via non-transfemoral access, and missing data, among others.

In total, investigators identified 123,186 patients from 599 sites for inclusion in their study. Overall, use of EPD during TAVR increased over time, with rates of usage peaking in 2019 with use at 28% of sites and 13% of TAVR procedures. Investigators noted wide variation in EPD use across the sites included in the study with 8% of sites representing more than 50% of EPD use and 72% of sites reporting no EPD use.

The primary outcome of the analysis was in-hospital stroke. Investigators also included other events such as in-hospital stroke or death, 30-day stroke, and 30-day mortality. For the purpose of analysis, stroke was defined as an acute episode of focal or global neurological dysfunction caused by brain, spinal cord, or retinal vascular injury as a result of hemorrhage or infarction. Of note, investigators designed their study to include an instrumental variable analysis, which was used as the primary analysis, and a propensity scored-based secondary analysis using overlap weighting.

In their primary analysis, which used an instrumental variable model, there was no association between EPD use and in-hospital stroke ([adjusted relative risk, 0.90 [95% CI, 0.68-1.13], absolute risk difference: -0.15% [95% CI, -0.49 to 0.20]). In a secondary analysis using a propensity-score based model results suggested EPD use was associated with 18% lower odds of in-hospital stroke (adjusted OR 0.82 [95% CI, 0.69-0.97], absolute risk difference -0.28% [95% CI: -0.52 to -0.03]). This secondary analysis also suggested EPD use was associated with a lower risk of in-hospital stroke or death, 30-day stroke, and 30-day mortality.

Cerebral Embolic Protection and Outcomes of Transcatheter Aortic Valve Replacement: Results from the TVT Registry,

An observational analysis of data from more than 120k patients provides an overview of cerebral embolic protection devices and risk of in-hospital stroke among patients undergoing TAVR. 

Analysis of STS/ACC TVT Registry Indicate EPD Use May Not Protect Against Stroke 

Reflecting on a Year of COVID-19 in Critical Care Cardiology

Dr. Gregory Weiss offers his thoughts on the most clinically impactful studies related to COVID-19 and cardiology released in the past year from his perspective as a critical care cardiologist. 

One Year of COVID-19: A Critical Care Cardiologist's Review

New insights from a 12-week trial of middle-aged and older men on testosterone therapy suggest testosterone therapy has no beneficial effect on vascular health or function.

While some have theorized testosterone therapy could counteract the effects of aging on arteries, results of the trial indicate improvements in artery health and function were linked to increased physical activity and not testosterone therapy.

"The global increase in testosterone use has been very large, particularly among middle-aged and older men who might see it as a restorative hormone to increase energy and vitality," said lead investigator Daniel J. Green, PhD, Winthrop Professor and cardiovascular exercise physiology researcher in the School of Human Sciences at The University of Western Australia in Perth, 

. "However, previous studies are mixed as to whether replacement testosterone is beneficial or not, or whether it provides additional benefit over and above the effects of an exercise program."

With an interest in further understanding the effects of testosterone therapy in aging men, Green and a team of colleagues designed the current study to assess the impact of testosterone versus exercise training on endothelium-dependent flow-mediated dilation percentage and endothelium-independent glyceryl trinitrate percent responses. Designed as a 2x2 factorial randomized controlled trial, the 12-week study enrolled 80 men between 50-70 years of age with a waist girth of 95 centimeters or more and low to normal serum testosterone levels.

In total, 78 patients were included in the final analysis and underwent randomization. Of these 78, 21 were randomized to topical testosterone and a strutted exercise program, 18 were randomized to testosterone with no exercise, 20 were randomized to placebo therapy and no exercise, and 19 were randomized to placebo therapy with exercise. Of note, those randomized to testosterone therapy received 5% testosterone cream.

Investigators pointed out prescreening questionnaires allowed for the exclusion of patients based on smoking status, history of cardiovascular disease, and other factors. Additional inclusion criteria included having a fasting serum total testosterone of 6-14 nmol/L, a total cholesterol of 7 mmol/L or more, and a minimum eGFR of 45 ml/min.

Upon analysis, results indicated serum testosterone levels increased beyond 14 nmol/L among 62% of those randomized to testosterone therapy. Results also indicated exercise training was associated with increased flow-mediated dilation percent (

=.033; testosterone and exercise: +0.5, placebo and exercise: +1.0 versus testosterone and no additional exercise: −0.7, placebo and no additional exercise: +0.2%), while this effect was not apparent among those receiving testosterone therapy and it was not additive to exercise (

Additionally, there were no significant exercise or drug main effects on glyceryl trinitrate responses (

 >.05). Further analysis suggested exercise training was associated with improved endothelium-dependent vasodilator function, but testosterone therapy did not appear to influence flow-mediated dilation percent or add to the benefit of exercise. Investigators highlighted vascular smooth muscle sensitivity to nitric oxide was not modified by exercise, testosterone, or their combination.

“The results of our study suggest that if you are a healthy but relatively inactive middle-aged or older man with increased abdominal girth, and you are worried about your risk of heart attack, stroke or diabetes, then an exercise program with some support and supervision can help to improve the function and health of your arteries,” Green said. “Testosterone therapy may have some benefits, for example in increasing muscle mass in the legs, however, we didn’t find any benefits in terms of artery function, which is a determinant of future cardiovascular risk.”

Testosterone and Exercise in Middle-to-Older Aged Men

Analysis of data from a 12-week study by investigators in Australia suggests testosterone therapy was not associated with improvements in arterial health or function. 

Exercise, Not Testosterone Therapy Can Improve Vascular Function in Aging Men 

New research from Northwestern Medicine suggests the cardiovascular health of a mother during her first pregnancy could offer insight into the long-term health of her children.

An analysis of more than 2000 mother-child pairs indicates 

 at 28 weeks’ gestation, which was assessed based on BMI, blood pressure, and other factors, can help predict offspring 

"Our new findings suggest that the children of this large group of mothers with suboptimal cardiovascular health may be at higher risk for early declines in their own cardiovascular health during childhood," said lead investigator Amanda Perak, MD, assistant professor of pediatrics and preventive medicine at Lurie Children's Hospital and Northwestern University Feinberg School of Medicine, 

. "If we can address these underlying causes of children's poor heart health, we can hopefully help them avoid future heart attacks, strokes and premature deaths as they grow up."

Using data from the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study and HAPO Follow-up study, Perak and a team of colleagues from Northwestern and Lurie Children’s Hospital designed their study with the hope of assessing how maternal cardiovascular health during pregnancy might be associated with offspring cardiovascular health in adolescence. From the studies, investigators identified a cohort of 2302 mother-child dyads from 9 centers in multiple countries for inclusion. Of note, this represents 48% of the HAPO Follow-up study population.

For the purpose of analysis, cardiovascular health was assessed according to 5 metrics: BMI, blood pressure, total cholesterol levels, glucose level, and smoking status. Mothers underwent assessments of each of these metrics at 28 weeks’ gestation. For their offspring, investigators assessed cardiovascular health using 4 metrics: BMI, blood pressure, total cholesterol levels, and glucose level, which were assessed between the ages of 10-14 years. Scores for mothers ranged from 0-10 and scores for offspring ranged from 0-8.

From the HAPO studies, investigators obtained disinformation related to maternal demographics, parity, and alcohol use through patient questionnaires. Additionally, maternal gestational age was determined by last menstrual period or an ultrasound. All of these factors were used as covariates in fully-adjusted analysis.

Among the dyads included in the study, mothers had a mean age of 29.6 (SD, 2.7) years and children had a mean age of 11.3 (SD, 1.1) years. During pregnancy, mothers had a mean maternal cardiovascular health score of 8.6 out of 10.

Upon analysis, 32.8% of pregnant mothers had metrics considered ideal, but 6.0% had 2 or more poor metrics and the distribution of cardiovascular health categories among offspring varied according to maternal cardiovascular health category. In adjusted models, results indicated women with worse maternal cardiovascular health, which was defined as having 2 or more poor metrics, had a greater relative risk of having offspring with 1 (RR, 2.02; 95% CI, 1.55-2.64) and 2 or more (RR, 7.82; 95% CI, 4.12-14.85) poor metrics when compared to mothers with ideal metrics.

In fully-adjusted models, which accounted for birth factors including preeclampsia, did not fully explain significant associations observed in the other analyses. Specifically, results indicated children born to mothers with 2 or more poor metrics during pregnancy were at a 6.23-fold increase in risk of having 2 or more poor metrics at follow-up (RR, 6.23; 95% CI, 3.03-12.82).

"Our study combined multiple factors across a range of levels, and found that the associations of maternal cardiovascular health with offspring cardiovascular health were not driven by any one metric (such as obesity)," Perak added. "Instead, all metrics were related to the offspring's later health."

Associations of Maternal Cardiovascular Health in Pregnancy With Offspring Cardiovascular Health in Early Adolescence

An analysis of more than 2k mother-child dyads suggests assessments of cardiovascular health could provide insight into the health of offspring during adolescence. 

Mother's Heart Health Sheds Light on Offspring Health in Adolescence 

A new observational study is challenging the results of the ISCHEMIA trial after returning results suggests an invasive approach may be more effective for patient patients with anatomically high‐risk stable ischemic heart disease.

While ISCHEMIA concluded an early invasive approach did not provide substantial benefit in patients with stable ischemic heart disease, investigators noted the study did not address the effect of left main disease and high-risk coronary anatomy, which was the aim of the current study.

"What our results are saying is that medical management is important, but there might be a small group that would benefit from revascularization, and we need to find ways to identify that group of patients," said lead investigator Kevin Bainey, MD, director of the Adult Cardiac Catheterization and Interventional Cardiology Laboratory and the Interventional Cardiology Fellowship Program, 

. "The main message I want clinicians to know is that it's important to know the anatomy.”

To fill the apparent gap in knowledge related to effectiveness of optimal medical therapy compared to early invasive intervention in patients at a high anatomical risk coronary anatomy, Bainey and a team of colleagues designed their current study as an observational analysis using data from the APPROACH registry. From this cohort, investigators identified 9016 patients with stable ischemic heart disease and high-risk coronary anatomy.

For inclusion in the current study, patients were required to have 3 vessel disease with 70% or greater stenosis in all 3 epicardial vessels or left main disease with 50% or greater stenosis. Investigators noted these patients were all treated between April 1, 2002 and March 31, 2016. Investigators also created subgroups of interest for angiographic risk, which were defined as 3 vessel disease with 1 vessel stenosis of 95% or greater, 3 vessel disease with proximal left anterior descending coronary artery (pLAD) with 70% or greater stenosis, 3 vessel disease with pLAD and 95% or greater stenosis, left main disease with 50% or greater stenosis, and severe left main with 70% or greater stenosis.

For the purpose of analysis, investigators established a primary composite outcome of all-cause death or myocardial infarction in patients receiving revascularization versus conservative management with optimal medical therapy.

Upon analysis, investigators found 61% (n=5487) of patients received revascularization with either coronary artery bypass graft surgery (n=3312) or percutaneous coronary intervention (n=2175) and 39% (n=3529) were managed conservatively. Results indicated undergoing coronary revascularization was associated with a reduction in the study’s primary composite outcomewhen compared with section for conservative management (Inverse Probability Weighted hazard ratio [IPW‐HR]; 0.62; 95% CI, 0.58-0.66; 

<0.001; IPW‐HR 0.57; 95% CI 0.53-0.61; 

<.001, respectively). Further analysis suggested a similar risk reduction occurred when examining percutaneous coronary intervention (IPW‐HR, 0.64; 95% CI, 0.59-0.70, 

<.001) and coronary artery bypass grafting (IPW‐HR, 0.61; 95% CI, 0.57-0.66; 

"We strongly believe coronary anatomy is an important prognostic indicator of health outcomes," added Bainey. “In a patient who has a higher-risk stress test and is showing symptoms, we think it's valuable to perform a coronary angiogram to get a complete picture, rather than just managing them with medications."

Long‐Term Clinical Outcomes Following Revascularization in High‐Risk Coronary Anatomy Patients With Stable Ischemic Heart Disease

An analysis of data from the APPROACH registry suggest early revascularization with CABG or PCI may be a more effective approach than medical therapy in patients with stable ischemic heart disease and high-risk cardiac anatomy.