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Showing 1 - 200 of 3120 Journals sorted alphabetically
A Practical Logic of Cognitive Systems     Full-text available via subscription   (Followers: 8)
AASRI Procedia     Open Access   (Followers: 14)
Academic Pediatrics     Hybrid Journal   (Followers: 26, SJR: 1.402, h-index: 51)
Academic Radiology     Hybrid Journal   (Followers: 22, SJR: 1.008, h-index: 75)
Accident Analysis & Prevention     Partially Free   (Followers: 90, SJR: 1.109, h-index: 94)
Accounting Forum     Hybrid Journal   (Followers: 25, SJR: 0.612, h-index: 27)
Accounting, Organizations and Society     Hybrid Journal   (Followers: 30, SJR: 2.515, h-index: 90)
Achievements in the Life Sciences     Open Access   (Followers: 4)
Acta Anaesthesiologica Taiwanica     Open Access   (Followers: 5, SJR: 0.338, h-index: 19)
Acta Astronautica     Hybrid Journal   (Followers: 382, SJR: 0.726, h-index: 43)
Acta Automatica Sinica     Full-text available via subscription   (Followers: 3)
Acta Biomaterialia     Hybrid Journal   (Followers: 26, SJR: 2.02, h-index: 104)
Acta Colombiana de Cuidado Intensivo     Full-text available via subscription   (Followers: 1)
Acta de Investigación Psicológica     Open Access   (Followers: 2)
Acta Ecologica Sinica     Open Access   (Followers: 8, SJR: 0.172, h-index: 29)
Acta Haematologica Polonica     Free   (Followers: 1, SJR: 0.123, h-index: 8)
Acta Histochemica     Hybrid Journal   (Followers: 3, SJR: 0.604, h-index: 38)
Acta Materialia     Hybrid Journal   (Followers: 239, SJR: 3.683, h-index: 202)
Acta Mathematica Scientia     Full-text available via subscription   (Followers: 5, SJR: 0.615, h-index: 21)
Acta Mechanica Solida Sinica     Full-text available via subscription   (Followers: 9, SJR: 0.442, h-index: 21)
Acta Oecologica     Hybrid Journal   (Followers: 10, SJR: 0.915, h-index: 53)
Acta Otorrinolaringologica (English Edition)     Full-text available via subscription   (Followers: 1)
Acta Otorrinolaringológica Española     Full-text available via subscription   (Followers: 3, SJR: 0.311, h-index: 16)
Acta Pharmaceutica Sinica B     Open Access   (Followers: 2)
Acta Poética     Open Access   (Followers: 4)
Acta Psychologica     Hybrid Journal   (Followers: 25, SJR: 1.365, h-index: 73)
Acta Sociológica     Open Access  
Acta Tropica     Hybrid Journal   (Followers: 6, SJR: 1.059, h-index: 77)
Acta Urológica Portuguesa     Open Access  
Actas Dermo-Sifiliograficas     Full-text available via subscription   (Followers: 4)
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Actas Urológicas Españolas     Full-text available via subscription   (Followers: 4, SJR: 0.383, h-index: 19)
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Actualites Pharmaceutiques     Full-text available via subscription   (Followers: 5, SJR: 0.141, h-index: 3)
Actualites Pharmaceutiques Hospitalieres     Full-text available via subscription   (Followers: 4, SJR: 0.112, h-index: 2)
Acupuncture and Related Therapies     Hybrid Journal   (Followers: 6)
Acute Pain     Full-text available via subscription   (Followers: 13)
Ad Hoc Networks     Hybrid Journal   (Followers: 11, SJR: 0.967, h-index: 57)
Addictive Behaviors     Hybrid Journal   (Followers: 15, SJR: 1.514, h-index: 92)
Addictive Behaviors Reports     Open Access   (Followers: 7)
Additive Manufacturing     Hybrid Journal   (Followers: 7, SJR: 1.039, h-index: 5)
Additives for Polymers     Full-text available via subscription   (Followers: 22)
Advanced Cement Based Materials     Full-text available via subscription   (Followers: 3)
Advanced Drug Delivery Reviews     Hybrid Journal   (Followers: 141, SJR: 5.2, h-index: 222)
Advanced Engineering Informatics     Hybrid Journal   (Followers: 11, SJR: 1.265, h-index: 53)
Advanced Powder Technology     Hybrid Journal   (Followers: 17, SJR: 0.739, h-index: 33)
Advances in Accounting     Hybrid Journal   (Followers: 9, SJR: 0.299, h-index: 15)
Advances in Agronomy     Full-text available via subscription   (Followers: 15, SJR: 2.071, h-index: 82)
Advances in Anesthesia     Full-text available via subscription   (Followers: 27, SJR: 0.169, h-index: 4)
Advances in Antiviral Drug Design     Full-text available via subscription   (Followers: 4)
Advances in Applied Mathematics     Full-text available via subscription   (Followers: 9, SJR: 1.054, h-index: 35)
Advances in Applied Mechanics     Full-text available via subscription   (Followers: 12, SJR: 0.801, h-index: 26)
Advances in Applied Microbiology     Full-text available via subscription   (Followers: 23, SJR: 1.286, h-index: 49)
Advances In Atomic, Molecular, and Optical Physics     Full-text available via subscription   (Followers: 16, SJR: 3.31, h-index: 42)
Advances in Biological Regulation     Hybrid Journal   (Followers: 4, SJR: 2.277, h-index: 43)
Advances in Botanical Research     Full-text available via subscription   (Followers: 3, SJR: 0.619, h-index: 48)
Advances in Cancer Research     Full-text available via subscription   (Followers: 26, SJR: 2.215, h-index: 78)
Advances in Carbohydrate Chemistry and Biochemistry     Full-text available via subscription   (Followers: 9, SJR: 0.9, h-index: 30)
Advances in Catalysis     Full-text available via subscription   (Followers: 6, SJR: 2.139, h-index: 42)
Advances in Cell Aging and Gerontology     Full-text available via subscription   (Followers: 4)
Advances in Cellular and Molecular Biology of Membranes and Organelles     Full-text available via subscription   (Followers: 13)
Advances in Chemical Engineering     Full-text available via subscription   (Followers: 26, SJR: 0.183, h-index: 23)
Advances in Child Development and Behavior     Full-text available via subscription   (Followers: 10, SJR: 0.665, h-index: 29)
Advances in Chronic Kidney Disease     Full-text available via subscription   (Followers: 9, SJR: 1.268, h-index: 45)
Advances in Clinical Chemistry     Full-text available via subscription   (Followers: 29, SJR: 0.938, h-index: 33)
Advances in Colloid and Interface Science     Full-text available via subscription   (Followers: 18, SJR: 2.314, h-index: 130)
Advances in Computers     Full-text available via subscription   (Followers: 16, SJR: 0.223, h-index: 22)
Advances in Dermatology     Full-text available via subscription   (Followers: 12)
Advances in Developmental Biology     Full-text available via subscription   (Followers: 12)
Advances in Digestive Medicine     Open Access   (Followers: 7)
Advances in DNA Sequence-Specific Agents     Full-text available via subscription   (Followers: 6)
Advances in Drug Research     Full-text available via subscription   (Followers: 23)
Advances in Ecological Research     Full-text available via subscription   (Followers: 47, SJR: 3.25, h-index: 43)
Advances in Engineering Software     Hybrid Journal   (Followers: 27, SJR: 0.486, h-index: 10)
Advances in Experimental Biology     Full-text available via subscription   (Followers: 9)
Advances in Experimental Social Psychology     Full-text available via subscription   (Followers: 46, SJR: 5.465, h-index: 64)
Advances in Exploration Geophysics     Full-text available via subscription   (Followers: 3)
Advances in Food and Nutrition Research     Full-text available via subscription   (Followers: 52, SJR: 0.674, h-index: 38)
Advances in Fuel Cells     Full-text available via subscription   (Followers: 16)
Advances in Genetics     Full-text available via subscription   (Followers: 17, SJR: 2.558, h-index: 54)
Advances in Genome Biology     Full-text available via subscription   (Followers: 11)
Advances in Geophysics     Full-text available via subscription   (Followers: 6, SJR: 2.325, h-index: 20)
Advances in Heat Transfer     Full-text available via subscription   (Followers: 22, SJR: 0.906, h-index: 24)
Advances in Heterocyclic Chemistry     Full-text available via subscription   (Followers: 9, SJR: 0.497, h-index: 31)
Advances in Human Factors/Ergonomics     Full-text available via subscription   (Followers: 27)
Advances in Imaging and Electron Physics     Full-text available via subscription   (Followers: 2, SJR: 0.396, h-index: 27)
Advances in Immunology     Full-text available via subscription   (Followers: 36, SJR: 4.152, h-index: 85)
Advances in Inorganic Chemistry     Full-text available via subscription   (Followers: 9, SJR: 1.132, h-index: 42)
Advances in Insect Physiology     Full-text available via subscription   (Followers: 3, SJR: 1.274, h-index: 27)
Advances in Integrative Medicine     Hybrid Journal   (Followers: 6)
Advances in Intl. Accounting     Full-text available via subscription   (Followers: 4)
Advances in Life Course Research     Hybrid Journal   (Followers: 8, SJR: 0.764, h-index: 15)
Advances in Lipobiology     Full-text available via subscription   (Followers: 2)
Advances in Magnetic and Optical Resonance     Full-text available via subscription   (Followers: 10)
Advances in Marine Biology     Full-text available via subscription   (Followers: 16, SJR: 1.645, h-index: 45)
Advances in Mathematics     Full-text available via subscription   (Followers: 10, SJR: 3.261, h-index: 65)
Advances in Medical Sciences     Hybrid Journal   (Followers: 6, SJR: 0.489, h-index: 25)
Advances in Medicinal Chemistry     Full-text available via subscription   (Followers: 6)
Advances in Microbial Physiology     Full-text available via subscription   (Followers: 5, SJR: 1.44, h-index: 51)
Advances in Molecular and Cell Biology     Full-text available via subscription   (Followers: 23)
Advances in Molecular and Cellular Endocrinology     Full-text available via subscription   (Followers: 10)
Advances in Molecular Toxicology     Full-text available via subscription   (Followers: 9, SJR: 0.324, h-index: 8)
Advances in Nanoporous Materials     Full-text available via subscription   (Followers: 4)
Advances in Oncobiology     Full-text available via subscription   (Followers: 2)
Advances in Organ Biology     Full-text available via subscription   (Followers: 2)
Advances in Organometallic Chemistry     Full-text available via subscription   (Followers: 15, SJR: 2.885, h-index: 45)
Advances in Parallel Computing     Full-text available via subscription   (Followers: 7, SJR: 0.148, h-index: 11)
Advances in Parasitology     Full-text available via subscription   (Followers: 7, SJR: 2.37, h-index: 73)
Advances in Pediatrics     Full-text available via subscription   (Followers: 24, SJR: 0.4, h-index: 28)
Advances in Pharmaceutical Sciences     Full-text available via subscription   (Followers: 13)
Advances in Pharmacology     Full-text available via subscription   (Followers: 16, SJR: 1.718, h-index: 58)
Advances in Physical Organic Chemistry     Full-text available via subscription   (Followers: 8, SJR: 0.384, h-index: 26)
Advances in Phytomedicine     Full-text available via subscription  
Advances in Planar Lipid Bilayers and Liposomes     Full-text available via subscription   (Followers: 3, SJR: 0.248, h-index: 11)
Advances in Plant Biochemistry and Molecular Biology     Full-text available via subscription   (Followers: 7)
Advances in Plant Pathology     Full-text available via subscription   (Followers: 5)
Advances in Porous Media     Full-text available via subscription   (Followers: 5)
Advances in Protein Chemistry     Full-text available via subscription   (Followers: 18)
Advances in Protein Chemistry and Structural Biology     Full-text available via subscription   (Followers: 20, SJR: 1.5, h-index: 62)
Advances in Quantum Chemistry     Full-text available via subscription   (Followers: 6, SJR: 0.478, h-index: 32)
Advances in Radiation Oncology     Open Access  
Advances in Small Animal Medicine and Surgery     Hybrid Journal   (Followers: 3, SJR: 0.1, h-index: 2)
Advances in Space Biology and Medicine     Full-text available via subscription   (Followers: 5)
Advances in Space Research     Full-text available via subscription   (Followers: 372, SJR: 0.606, h-index: 65)
Advances in Structural Biology     Full-text available via subscription   (Followers: 8)
Advances in Surgery     Full-text available via subscription   (Followers: 9, SJR: 0.823, h-index: 27)
Advances in the Study of Behavior     Full-text available via subscription   (Followers: 31, SJR: 1.321, h-index: 56)
Advances in Veterinary Medicine     Full-text available via subscription   (Followers: 16)
Advances in Veterinary Science and Comparative Medicine     Full-text available via subscription   (Followers: 13)
Advances in Virus Research     Full-text available via subscription   (Followers: 6, SJR: 1.878, h-index: 68)
Advances in Water Resources     Hybrid Journal   (Followers: 45, SJR: 2.408, h-index: 94)
Aeolian Research     Hybrid Journal   (Followers: 5, SJR: 0.973, h-index: 22)
Aerospace Science and Technology     Hybrid Journal   (Followers: 340, SJR: 0.816, h-index: 49)
AEU - Intl. J. of Electronics and Communications     Hybrid Journal   (Followers: 8, SJR: 0.318, h-index: 36)
African J. of Emergency Medicine     Open Access   (Followers: 6, SJR: 0.344, h-index: 6)
Ageing Research Reviews     Hybrid Journal   (Followers: 9, SJR: 3.289, h-index: 78)
Aggression and Violent Behavior     Hybrid Journal   (Followers: 434, SJR: 1.385, h-index: 72)
Agri Gene     Hybrid Journal  
Agricultural and Forest Meteorology     Hybrid Journal   (Followers: 15, SJR: 2.18, h-index: 116)
Agricultural Systems     Hybrid Journal   (Followers: 31, SJR: 1.275, h-index: 74)
Agricultural Water Management     Hybrid Journal   (Followers: 42, SJR: 1.546, h-index: 79)
Agriculture and Agricultural Science Procedia     Open Access  
Agriculture and Natural Resources     Open Access   (Followers: 3)
Agriculture, Ecosystems & Environment     Hybrid Journal   (Followers: 56, SJR: 1.879, h-index: 120)
Ain Shams Engineering J.     Open Access   (Followers: 5, SJR: 0.434, h-index: 14)
Air Medical J.     Hybrid Journal   (Followers: 5, SJR: 0.234, h-index: 18)
AKCE Intl. J. of Graphs and Combinatorics     Open Access   (SJR: 0.285, h-index: 3)
Alcohol     Hybrid Journal   (Followers: 11, SJR: 0.922, h-index: 66)
Alcoholism and Drug Addiction     Open Access   (Followers: 8)
Alergologia Polska : Polish J. of Allergology     Full-text available via subscription   (Followers: 1)
Alexandria Engineering J.     Open Access   (Followers: 1, SJR: 0.436, h-index: 12)
Alexandria J. of Medicine     Open Access   (Followers: 1)
Algal Research     Partially Free   (Followers: 9, SJR: 2.05, h-index: 20)
Alkaloids: Chemical and Biological Perspectives     Full-text available via subscription   (Followers: 3)
Allergologia et Immunopathologia     Full-text available via subscription   (Followers: 1, SJR: 0.46, h-index: 29)
Allergology Intl.     Open Access   (Followers: 4, SJR: 0.776, h-index: 35)
Alpha Omegan     Full-text available via subscription   (SJR: 0.121, h-index: 9)
ALTER - European J. of Disability Research / Revue Européenne de Recherche sur le Handicap     Full-text available via subscription   (Followers: 9, SJR: 0.158, h-index: 9)
Alzheimer's & Dementia     Hybrid Journal   (Followers: 49, SJR: 4.289, h-index: 64)
Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring     Open Access   (Followers: 4)
Alzheimer's & Dementia: Translational Research & Clinical Interventions     Open Access   (Followers: 4)
Ambulatory Pediatrics     Hybrid Journal   (Followers: 5)
American Heart J.     Hybrid Journal   (Followers: 48, SJR: 3.157, h-index: 153)
American J. of Cardiology     Hybrid Journal   (Followers: 48, SJR: 2.063, h-index: 186)
American J. of Emergency Medicine     Hybrid Journal   (Followers: 42, SJR: 0.574, h-index: 65)
American J. of Geriatric Pharmacotherapy     Full-text available via subscription   (Followers: 9, SJR: 1.091, h-index: 45)
American J. of Geriatric Psychiatry     Hybrid Journal   (Followers: 14, SJR: 1.653, h-index: 93)
American J. of Human Genetics     Hybrid Journal   (Followers: 32, SJR: 8.769, h-index: 256)
American J. of Infection Control     Hybrid Journal   (Followers: 26, SJR: 1.259, h-index: 81)
American J. of Kidney Diseases     Hybrid Journal   (Followers: 31, SJR: 2.313, h-index: 172)
American J. of Medicine     Hybrid Journal   (Followers: 45, SJR: 2.023, h-index: 189)
American J. of Medicine Supplements     Full-text available via subscription   (Followers: 3)
American J. of Obstetrics and Gynecology     Hybrid Journal   (Followers: 209, SJR: 2.255, h-index: 171)
American J. of Ophthalmology     Hybrid Journal   (Followers: 61, SJR: 2.803, h-index: 148)
American J. of Ophthalmology Case Reports     Open Access   (Followers: 6)
American J. of Orthodontics and Dentofacial Orthopedics     Full-text available via subscription   (Followers: 6, SJR: 1.249, h-index: 88)
American J. of Otolaryngology     Hybrid Journal   (Followers: 24, SJR: 0.59, h-index: 45)
American J. of Pathology     Hybrid Journal   (Followers: 27, SJR: 2.653, h-index: 228)
American J. of Preventive Medicine     Hybrid Journal   (Followers: 26, SJR: 2.764, h-index: 154)
American J. of Surgery     Hybrid Journal   (Followers: 36, SJR: 1.286, h-index: 125)
American J. of the Medical Sciences     Hybrid Journal   (Followers: 12, SJR: 0.653, h-index: 70)
Ampersand : An Intl. J. of General and Applied Linguistics     Open Access   (Followers: 6)
Anaerobe     Hybrid Journal   (Followers: 4, SJR: 1.066, h-index: 51)
Anaesthesia & Intensive Care Medicine     Full-text available via subscription   (Followers: 60, SJR: 0.124, h-index: 9)
Anaesthesia Critical Care & Pain Medicine     Full-text available via subscription   (Followers: 14)
Anales de Cirugia Vascular     Full-text available via subscription  
Anales de Pediatría     Full-text available via subscription   (Followers: 2, SJR: 0.209, h-index: 27)
Anales de Pediatría (English Edition)     Full-text available via subscription  
Anales de Pediatría Continuada     Full-text available via subscription   (SJR: 0.104, h-index: 3)
Analytic Methods in Accident Research     Hybrid Journal   (Followers: 4, SJR: 2.577, h-index: 7)
Analytica Chimica Acta     Hybrid Journal   (Followers: 36, SJR: 1.548, h-index: 152)
Analytical Biochemistry     Hybrid Journal   (Followers: 172, SJR: 0.725, h-index: 154)
Analytical Chemistry Research     Open Access   (Followers: 8, SJR: 0.18, h-index: 2)
Analytical Spectroscopy Library     Full-text available via subscription   (Followers: 12)
Anesthésie & Réanimation     Full-text available via subscription   (Followers: 1)
Anesthesiology Clinics     Full-text available via subscription   (Followers: 22, SJR: 0.421, h-index: 40)
Angiología     Full-text available via subscription   (SJR: 0.124, h-index: 9)
Angiologia e Cirurgia Vascular     Open Access  
Animal Behaviour     Hybrid Journal   (Followers: 177, SJR: 1.907, h-index: 126)
Animal Feed Science and Technology     Hybrid Journal   (Followers: 5, SJR: 1.151, h-index: 83)

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Journal Cover American Heart Journal
  [SJR: 3.157]   [H-I: 153]   [48 followers]  Follow
   Hybrid Journal Hybrid journal (It can contain Open Access articles)
   ISSN (Print) 0002-8703 - ISSN (Online) 1097-6744
   Published by Elsevier Homepage  [3123 journals]
  • Effect of carvedilol vs metoprolol succinate on mortality in heart failure
           with reduced ejection fraction
    • Authors: Tarek Ajam; Samer Ajam; Srikant Devaraj; Kahee Mohammed; Stephen Sawada; Masoor Kamalesh
      Pages: 1 - 6
      Abstract: Publication date: May 2018
      Source:American Heart Journal, Volume 199
      Author(s): Tarek Ajam, Samer Ajam, Srikant Devaraj, Kahee Mohammed, Stephen Sawada, Masoor Kamalesh
      Background Beta blocker therapy is indicated in all patients with heart failure with reduced ejection fraction (HFrEF) as per current guidelines. The relative benefit of carvedilol to metoprolol succinate remains unknown. This study aimed to compare survival benefit of carvedilol to metoprolol succinate. Methods The VA’s databases were queried to identify 114,745 patients diagnosed with HFrEF from 2007 to 2015 who were prescribed carvedilol and metoprolol succinate. The study estimated the survival probability and hazard ratio by comparing the carvedilol and metoprolol patients using propensity score matching with replacement techniques on observed covariates. Sub-group analyses were performed separately for men, women, elderly, duration of therapy of more than 3 months, and diabetic patients. Results A total of 43,941 metoprolol patients were matched with as many carvedilol patients. The adjusted hazard ratio of mortality for metoprolol succinate compared to carvedilol was 1.069 (95% CI: 1.046-1.092, P value: < .001). At six years, the survival probability was higher in the carvedilol group compared to the metoprolol succinate group (55.6% vs 49.2%, P value < .001). The sub-group analyses show that the results hold true separately for male, over or under 65 years old, therapy duration more than three months and non-diabetic patients. Conclusion Patients with HFrEF taking carvedilol had improved survival as compared to metoprolol succinate. The data supports the need for furthering testing to determine optimal choice of beta blockers in patients with heart failure with reduced ejection fraction.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2018.01.005
      Issue No: Vol. 199 (2018)
  • Comparison of Fractional FLow Reserve And Intravascular ultrasound-guided
           Intervention Strategy for Clinical OUtcomes in Patients with InteRmediate
           Stenosis (FLAVOUR): Rationale and design of a randomized clinical trial
    • Authors: Jeehoon Kang; Bon-Kwon Koo; Xinyang Hu; Joo Myung Lee; Joo-Yong Hahn; Hyoung-Mo Yang; Eun-Seok Shin; Chang-Wook Nam; Joon-Hyung Doh; Bong-Ki Lee; Chul Ahn; JianAn Wang; Seung-Jae Tahk
      Pages: 7 - 12
      Abstract: Publication date: May 2018
      Source:American Heart Journal, Volume 199
      Author(s): Jeehoon Kang, Bon-Kwon Koo, Xinyang Hu, Joo Myung Lee, Joo-Yong Hahn, Hyoung-Mo Yang, Eun-Seok Shin, Chang-Wook Nam, Joon-Hyung Doh, Bong-Ki Lee, Chul Ahn, JianAn Wang, Seung-Jae Tahk
      Background Coronary angiography has limitations in defining the ischemia-causing stenotic lesion, especially in cases with intermediate coronary stenosis. Fractional flow reserve (FFR) is a current standard method to define the presence of ischemia, and intravascular ultrasound (IVUS) is the most commonly used invasive imaging tool that can provide the lesion geometry and can provide the information on plaque vulnerability. The primary aim of this study is to compare the safety and efficacy of FFR-guided and IVUS-guided percutaneous coronary intervention (PCI) strategies in patients with intermediate coronary stenosis. Trial design Comparison of Fractional FLow Reserve And Intravascular ultrasound-guided Intervention Strategy for Clinical OUtcomes in Patients with InteRmediate Stenosis (FLAVOUR) trial is an international, multicenter, prospective, randomized clinical trial. A total of 1,700 consecutive patients with intermediate stenosis (40%-70% by visual estimation) in a major epicardial coronary artery will be randomized 1:1 to receive either FFR-guided or IVUS-guided PCI strategy. Patients will be treated with PCI according to the predefined criteria for revascularization; FFR ≤ 0.80 in the FFR-guided group and Minimal Lumen Area (MLA) ≤3 mm2 (or 3 mm2 <MLA ≤4 mm2 and plaque burden >70%) in the IVUS-guided group. The primary end point is the patient-oriented composite outcome, which is a composite of all-cause death, myocardial infarction, and any repeat revascularization at 24months after randomization. We will test noninferiority of current standard FFR-guided PCI strategy compared with IVUS-guided decision for PCI and stent optimization strategy. Conclusion The FLAVOUR trial will compare the safety and efficacy of FFR- and IVUS-guided PCI strategies in patients with intermediate coronary stenosis. This study will provide an insight on optimal evaluation and treatment strategy for patients with intermediate coronary stenosis.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.11.001
      Issue No: Vol. 199 (2018)
  • Shared decision-making tool for thromboprophylaxis in atrial fibrillation
           – A feasibility study
    • Authors: Mark H. Eckman; Alexandru Costea; Mehran Attari; Jitender Munjal; Ruth E. Wise; Carol Knochelmann; Matthew L. Flaherty; Pete Baker; Robert Ireton; Brett M. Harnett; Anthony C. Leonard; Dylan Steen; Adam Rose; John Kues
      Pages: 13 - 21
      Abstract: Publication date: May 2018
      Source:American Heart Journal, Volume 199
      Author(s): Mark H. Eckman, Alexandru Costea, Mehran Attari, Jitender Munjal, Ruth E. Wise, Carol Knochelmann, Matthew L. Flaherty, Pete Baker, Robert Ireton, Brett M. Harnett, Anthony C. Leonard, Dylan Steen, Adam Rose, John Kues
      Background Appropriate thromboprophylaxis for patients with atrial fibrillation or atrial flutter (AF) remains a national challenge. Methods We hypothesized that a shared decision-making interaction facilitated by an A trial F ibrillation S hared D ecision M aking Tool (AFSDM) would improve patient knowledge about atrial fibrillation, and the risks and benefits of various treatment options for stroke prevention; increase satisfaction with the decision-making process; improve the therapeutic alliance between patient and the clinical care team; and increase medication adherence. Using a pre- and post-visit study design, we enrolled 76 patients and completed 2 office visits and 1-month telephone follow-up for 65 patients being seen in our Arrhythmia Clinic over the 1-year period (July 2016 through June 2017). Our primary outcome measure was change in decisional conflict between the first and second clinical visit. Results Decisional conflict decreased from an average of 31 to 9. Mean change was 22.3 (95% CI, 25.7 - 37.1), corresponding to an effect size of 0.94 standard deviations. Satisfaction with decision increased from 4.0 to 4.5, measures of therapeutic alliance with the care team (Kim Alliance scale) increased from 100.1 to 103.1, and satisfaction with provider increased from 4.2 to 4.5 (P < .0001 for all measures). AF knowledge assessment scores increased from 8.4 to 9.1, and knowledge about personal stroke and bleeding risk increased from 1 to 1.5 (P < .0001). Finally, medication adherence improved as reflected by an increase in the Morisky Medication Adherence scale from 5.9 to 6.4 (P < .0001). Conclusions A shared decision-making interaction, facilitated by an AFSDM can significantly improve multiple measures of decision-making quality, leading to improved medication adherence and patient satisfaction.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2018.01.003
      Issue No: Vol. 199 (2018)
  • Prognostic value of viral eradication for major adverse cardiovascular
           events in hepatitis C cirrhotic patients
    • Authors: Patrice Cacoub; Pierre Nahon; Richard Layese; Lorraine Blaise; Anne Claire Desbois; Valérie Bourcier; Carole Cagnot; Patrick Marcellin; Dominique Guyader; Stanislas Pol; Dominique Larrey; Victor De Lédinghen; Denis Ouzan; Fabien Zoulim; Dominique Roulot; Albert Tran; Jean-Pierre Bronowicki; Jean-Pierre Zarski; Ghassan Riachi; Paul Calès; Jean-Marie Péron; Laurent Alric; Marc Bourlière; Philippe Mathurin; Jean-Frédéric Blanc; Armand Abergel; Lawrence Serfaty; Ariane Mallat; Jean-Didier Grangé; Pierre Attali; Yannick Bacq; Claire Wartelle; Thông Dao; Dominique Thabut; Christophe Pilette; Christine Silvain; Christos Christidis; Dominique Capron; Gérard Thiefin; David Zucman; Vincent Di Martino; Corinne Isnard Bagnis; Marianne Ziol; Angela Sutton; Eric Letouze; Françoise Roudot-Thoraval; Etienne Audureau; Pierre Nahon; Patrick Marcellin; Dominique Guyader; Stanislas Pol; Hélène Fontaine; Dominique Larrey; Victor De Lédinghen; Denis Ouzan; Fabien Zoulim; Dominique Roulot; Albert Tran; Jean-Pierre Bronowicki; Jean-Pierre Zarski; Vincent Leroy; Ghassan Riachi; Paul Calès; Jean-Marie Péron; Laurent Alric; Marc Bourlière; Philippe Mathurin; Sebastien Dharancy; Jean-Frédéric Blanc; Armand Abergel; Lawrence Serfaty; Ariane Mallat; Jean-Didier Grangé; Pierre Attali; Yannick Bacq; Claire Wartelle; Thông Dao; Yves Benhamou; Christophe Pilette; Christine Silvain; Christos Christidis; Dominique Capron; Gérard Thiefin; Sophie Hillaire; Vincent Di Martino
      Pages: 4 - 17
      Abstract: Publication date: April 2018
      Source:American Heart Journal, Volume 198
      Author(s): Patrice Cacoub, Pierre Nahon, Richard Layese, Lorraine Blaise, Anne Claire Desbois, Valérie Bourcier, Carole Cagnot, Patrick Marcellin, Dominique Guyader, Stanislas Pol, Dominique Larrey, Victor De Lédinghen, Denis Ouzan, Fabien Zoulim, Dominique Roulot, Albert Tran, Jean-Pierre Bronowicki, Jean-Pierre Zarski, Ghassan Riachi, Paul Calès, Jean-Marie Péron, Laurent Alric, Marc Bourlière, Philippe Mathurin, Jean-Frédéric Blanc, Armand Abergel, Lawrence Serfaty, Ariane Mallat, Jean-Didier Grangé, Pierre Attali, Yannick Bacq, Claire Wartelle, Thông Dao, Dominique Thabut, Christophe Pilette, Christine Silvain, Christos Christidis, Dominique Capron, Gérard Thiefin, David Zucman, Vincent Di Martino, Corinne Isnard Bagnis, Marianne Ziol, Angela Sutton, Eric Letouze, Françoise Roudot-Thoraval, Etienne Audureau
      Background The objective was to examine the role of a sustained virological response (SVR) on major adverse cardiovascular events (MACEs) in patients with compensated hepatitis C virus (HCV) cirrhosis. Methods Patients with the following criteria were enrolled in 35 French centers: (1) biopsy-proven HCV cirrhosis; (2) Child-Pugh A; (3) positive viremia; and (4) no prior liver complication, and then prospectively followed. All patients received HCV treatment after inclusion. MACEs included stroke, myocardial infarction, ischemic heart disease, heart failure, peripheral arterial disease, cardiac arrest, and cardiovascular death. SVR, defined as negative viremia 12 weeks posttreatment, was considered as a time-dependent covariate, and its effect on MACE occurrence was assessed. The median follow up was 57.5 months, ending in December 2015. Results Sixty-two of 878 (7.1%) patients presented a total of 79 MACEs. The main predictive baseline factors of MACEs were Asian ethnic origin, history of MACEs, arterial hypertension, diabetes mellitus, current smoking, low serum albumin level, high total bilirubin level, and low platelet count. In multivariate analysis, SVR was associated with a decreased risk of MACEs (hazard ratio=0.35, 95% CI 0.09-0.97, P =.044), whereas Asian ethnic origin, arterial hypertension, smoking, and low serum albumin level remained predictive of MACE occurrence. The 5-year survival rate was 60.1% versus 87.5% in patients who did versus those who did not present a MACE (P <.001). Conclusions In patients with compensated HCV-related cirrhosis, Asian ethnic origin, arterial hypertension, smoking, and low serum albumin are independent predictive factors of cardiovascular events, whereas an SVR is associated with a decreased rate of cardiovascular events.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.10.024
      Issue No: Vol. 198 (2018)
  • Improving patient risk communication: Translating cardiovascular risk into
           standardized risk percentiles
    • Authors: Ann Marie Navar; Michael J. Pencina; Hillary Mulder; Pierre Elias; Eric D. Peterson
      Pages: 18 - 24
      Abstract: Publication date: April 2018
      Source:American Heart Journal, Volume 198
      Author(s): Ann Marie Navar, Michael J. Pencina, Hillary Mulder, Pierre Elias, Eric D. Peterson
      Background Current cholesterol guidelines recommend using 10-year risk of atherosclerotic cardiovascular disease (ASCVD) to guide informed decisions regarding statin therapy, yet patients may have difficulty conceptualizing absolute risk estimates. Peer comparisons may provide an improved tool for patient risk comprehension. Methods Using data from the 2009–2014 National Health and Nutrition Examination Survey (NHANES), we estimated standardized risk percentiles for various age-, sex-, and race-specific subgroups based on their 10-year ASCVD risks using the Pooled Cohort Equations. Results We examined 9160 adults in NHANES who were free of cardiovascular disease and had complete clinical data. Among specific age, sex, and race groups, we estimated the distribution of 10-year risk, calculating the 10-year risk corresponding to each percentile in order to generate standardized cardiovascular risk percentiles. Estimated 10-year ASCVD absolute risk varied markedly by age, sex, and race subgroups. A 10-year risk of 7.0% would put a 55 year-old black male in the 20th percentile relative to his peers (ie, at lower risk than 80% of his peers), whereas a 10-year risk of 7.0% would put a 55 year-old white female in the 95th percentile (i.e., only 5% of her peers would have higher risk). Standardized cardiovascular risk percentiles by age, race, and sex are available online at Conclusion Cardiovascular risk varies substantially by age, sex, and race. These data allow for 10-year absolute risks of ASCVD to be translated into a standardized cardiovascular risk percentile, providing patients with information that is easy to understanding regarding how their personal risk of cardiovascular disease compares with their age-, sex-, and race-matched peers.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.12.005
      Issue No: Vol. 198 (2018)
  • Bioresorbable Polymer-Coated Orsiro Versus Durable Polymer-Coated Resolute
           Onyx Stents (BIONYX): Rationale and design of the randomized TWENTE IV
           multicenter trial
    • Authors: Liefke C. van der Heijden; Marlies M. Kok; Paolo Zocca; Gillian A.J. Jessurun; Carl E. Schotborgh; Ariel Roguin; Edouard Benit; Adel Aminian; Peter W. Danse; Marije M. Löwik; Gerard C.M. Linssen; Job van der Palen; Carine J.M. Doggen; Clemens von Birgelen
      Pages: 25 - 32
      Abstract: Publication date: April 2018
      Source:American Heart Journal, Volume 198
      Author(s): Liefke C. van der Heijden, Marlies M. Kok, Paolo Zocca, Gillian A.J. Jessurun, Carl E. Schotborgh, Ariel Roguin, Edouard Benit, Adel Aminian, Peter W. Danse, Marije M. Löwik, Gerard C.M. Linssen, Job van der Palen, Carine J.M. Doggen, Clemens von Birgelen
      Aim The aim was to compare in a noninferiority trial the efficacy and safety of 2 contemporary drug-eluting stents (DESs): a novel, durable polymer-coated stent versus an established bioabsorbable polymer-coated stent. Methods and results The BIONYX trial ( is an investigator-initiated, prospective, randomized, patient- and assessor-blinded, international, multicenter study in all-comer patients with all types of clinical syndromes and lesions who require percutaneous coronary interventions with DES. Patients at 7 study sites in the Netherlands, Belgium, and Israel were randomly assigned (1:1, stratified for gender and diabetes mellitus) to treatment with the novel, zotarolimus-eluting, durable polymer-coated Resolute Onyx stent that has a radiopaque, thin-strut, CoreWire stent platform versus the sirolimus-eluting, bioresorbable polymer-coated Orsiro stent (reference device) that has a very thin-strut, cobalt-chromium stent backbone. The primary end point is the 1-year incidence of the composite clinical end point target vessel failure consisting of cardiac death, target vessel–related myocardial infarction, or clinically indicated target vessel revascularization. A power calculation, assuming a target vessel failure rate of 6.0% (noninferiority margin 2.5%), revealed that 2,470 study patients would give the study 80% power (α level 5%), allowing for up to 3% loss to follow-up. The first patient was enrolled on October 7, 2015; on December 23, 2016, the last patient entered the study. Conclusions BIONYX is a large-scale, prospective, randomized, international, multicenter trial comparing a novel DES with durable coating versus a reference DES with biodegradable coating in all-comers. The study is the first randomized assessment of the Resolute Onyx stent, which is an often-used DES outside the United States.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.12.011
      Issue No: Vol. 198 (2018)
  • Preoperative factors associated with worsening in health-related quality
           of life following coronary artery bypass grafting in the Randomized On/Off
           Bypass (ROOBY) trial
    • Authors: Muath Bishawi; Brack Hattler; G. Hossein Almassi; John A. Spertus; Jacquelyn A. Quin; Joseph F. Collins; Frederick L. Grover; Annie Laurie Shroyer
      Pages: 33 - 38
      Abstract: Publication date: April 2018
      Source:American Heart Journal, Volume 198
      Author(s): Muath Bishawi, Brack Hattler, G. Hossein Almassi, John A. Spertus, Jacquelyn A. Quin, Joseph F. Collins, Frederick L. Grover, Annie Laurie Shroyer
      For advanced coronary disease, coronary artery bypass graft (CABG) surgery generally improves patients' symptoms and long-term survival. Unfortunately, some patients experience worse health-related quality of life (HRQL) after CABG. The objective of this study is to report the frequency and risk factors associated with 1-year post-CABG HRQL deterioration. Methods From 2002 to 2007, 2203 “Randomized On/Off Bypass” (ROOBY) trial patients randomly received either off-pump or on-pump CABG at 18 VA medical centers. Subjects completed both baseline and 1-year Seattle Angina Questionnaire (SAQ) and the Veterans Rand 36 (VR-36) questionnaires to assess HRQL. Using previously published criteria, the rates of clinically significant changes were determined for the SAQ [angina frequency (AF), physical limitation (PL), and quality of life (QoL)] and VR36 [mental component score (MCS) and physical component score (PCS)] subscales. Multivariate regression models were then used to identify pre-CABG patient characteristics associated with worsened 1-year HRQL status for each subscale. Results Over 80% of patients had an improvement or no change in SAQ and VR-36 subscale scores 1 year after CABG. The HRQL scale-specific deterioration rates were 4.5% SAQ-AF, 16.8% SAQ-PL, 4.9% SAQ-QoL, 19.4% VR36-MCS, and 13.5% VR36-PCS. Predictors of 1-year HRQL deterioration were diabetes and smoking for the SAQ-AF; diabetes, chronic obstructive pulmonary disease (COPD), and peripheral vascular disease (PVD) for SAQ-PL; COPD and depression for the SAQ-QoL; diabetes for VR36-PCS, and history of stroke and depression for VR36-MCS. The baseline score was an independent predictor for worsening in all the subscales studied. Conclusions Among VA patients, less than 20% experienced worse HRQL 1 year after CABG. For patients with low symptom burden at baseline, diabetes, smoking, depression, PVD, COPD, and a prior stroke, clinicians should be more cautious in pre-CABG counseling as to their anticipated HRQL improvements.

      PubDate: 2018-02-03T09:39:09Z
      DOI: 10.1016/j.ahj.2017.12.014
      Issue No: Vol. 198 (2018)
  • Changes in glomerular filtration rate and outcomes in patients with atrial
    • Authors: Laurent Fauchier; Arnaud Bisson; Nicolas Clementy; Patrick Vourc'h; Denis Angoulvant; Dominique Babuty; Jean Michel Halimi; Gregory Y.H. Lip
      Pages: 39 - 45
      Abstract: Publication date: April 2018
      Source:American Heart Journal, Volume 198
      Author(s): Laurent Fauchier, Arnaud Bisson, Nicolas Clementy, Patrick Vourc'h, Denis Angoulvant, Dominique Babuty, Jean Michel Halimi, Gregory Y.H. Lip
      Background Patients with kidney disease are more likely to develop atrial fibrillation (AF) than individuals with normal renal function, and more likely to suffer ischemic stroke (IS)/thromboembolism (TE). We investigated the relationship of kidney function evolution to IS/TE, mortality and bleeding in AF patients. Methods In a cohort of 8962 AF patients, 2653 had serum creatinine data, with 10894 patient-years of follow-up. Patients were stratified into quartiles of estimated glomerular filtration rate (eGFR) evolution (in mL/min per 1.73 m2/year). Results Rates of events (IS/TE, bleeding, mortality) increased with worsening eGFR by quartiles. The risk of events was particularly increased when patients in the 4th quartile were compared to others. Renal impairment per se was not an independent predictor of IS/TE but was an independent predictor of bleeding, whilst eGFR worsening was an independent predictor both for IS/TE (Hazard Ratio [HR] 1.573, 95%CI 1.160-2.134 for patients in the last quartile) and for bleeding events (HR 1.543, 95%CI 1.157-2.004). Worsening eGFR did not improve the predictive ability of the CHA2DS2VASc and HAS-BLED scores for identifying a higher risk of IS/TE or bleeding events, respectively. When the benefit of IS reduction was balanced against the increased risk of bleeding events, the net clinical benefit was positive in favor of OAC use (vs non-use) in patients with worsening eGFR. Conclusions Rates of IS/TE, mortality and bleeding increased with worsening eGFR >4.81 mL/min per 1.73 m2. Worsening eGFR was an independent predictor of IS/TE and of bleeding, and a better predictor of IS/TE than renal impairment in AF.

      PubDate: 2018-02-05T09:43:19Z
      DOI: 10.1016/j.ahj.2017.12.017
      Issue No: Vol. 198 (2018)
  • Temporal changes in radial access use, associates and outcomes in patients
           undergoing PCI using rotational atherectomy between 2007 and 2014: results
           from the British Cardiovascular Intervention Society national database
    • Authors: Tim Kinnaird; James Cockburn; Sean Gallagher; Anirban Choudhury; Alex Sirker; Peter Ludman; Mark de Belder; Samuel Copt; Mamas Mamas; Adam de Belder
      Pages: 46 - 54
      Abstract: Publication date: April 2018
      Source:American Heart Journal, Volume 198
      Author(s): Tim Kinnaird, James Cockburn, Sean Gallagher, Anirban Choudhury, Alex Sirker, Peter Ludman, Mark de Belder, Samuel Copt, Mamas Mamas, Adam de Belder
      Aims Access site choice for cases requiring rotational atherectomy (PCI-ROTA) is poorly defined. Using the British Cardiovascular Intervention Society PCI database, temporal changes and contemporary associates/outcomes of access site choice for PCI-ROTA were studied. Methods and Results Data were analysed from 11,444 PCI-ROTA procedures performed in England and Wales between 2007 and 2014. Multivariate logistic regression was used to identify predictors of access site choice and its association with outcomes. Results For PCI-ROTA, radial access increased from 19.6% in 2007 to 58.6% in 2014. Adoption of radial access was slower in females, those with prior CABG, and in patients with chronic occlusive (CTO) or left main disease. In 2013/14, the strongest predictors of femoral artery use were age (OR 1.02, [1.005-1.036], P = .008), CTO intervention (OR 1.95, [1.209-3.314], P = .006), and history of previous CABG (OR 1.68, [1.124-2.515], P = .010). Radial access was associated with reductions in overall length of stay, and increased rates of same-day discharge. Procedural success rates were similar although femoral access use was associated with increased access site complications (2.4 vs. 0.1%, P < .001). After adjustment for baseline differences, arterial complications (OR 15.6, P < .001), transfusion (OR 12.5, P = .023) and major bleeding OR 6.0, P < .001) remained more common with FA use. Adjusted mortality and MACE rates were similar in both groups. Conclusions In contemporary practice, radial access for PCI-ROTA results in similar procedural success when compared to femoral access but is associated with shorter length of stay, and lower rates of vascular complication, major bleeding and transfusion.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2018.01.001
      Issue No: Vol. 198 (2018)
  • Two-year follow-up of patients treated with dabigatran for stroke
           prevention in atrial fibrillation: Global Registry on Long-Term
           Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF)
    • Authors: Menno V. Huisman; Kenneth J. Rothman; Miney Paquette; Christine Teutsch; Hans-Christoph Diener; Sergio J. Dubner; Jonathan L. Halperin; Chang Sheng Ma; Kristina Zint; Amelie Elsaesser; Shihai Lu; Dorothee B. Bartels; Gregory Y.H. Lip
      Pages: 55 - 63
      Abstract: Publication date: April 2018
      Source:American Heart Journal, Volume 198
      Author(s): Menno V. Huisman, Kenneth J. Rothman, Miney Paquette, Christine Teutsch, Hans-Christoph Diener, Sergio J. Dubner, Jonathan L. Halperin, Chang Sheng Ma, Kristina Zint, Amelie Elsaesser, Shihai Lu, Dorothee B. Bartels, Gregory Y.H. Lip
      Background and purpose GLORIA-AF is a large, global, prospective registry program of newly diagnosed atrial fibrillation (AF) patients with ≥1 stroke risk factors. We describe the effectiveness and safety of dabigatran etexilate over 2 years from routine clinical practice in nearly 3000 patients from GLORIA-AF who are newly diagnosed with non-valvular AF and at risk of stroke. Methods Consecutive enrollment into phase II of GLORIA-AF was initiated following approval of dabigatran for stroke prevention in non-valvular AF. Within this Phase II, 2937 dabigatran patients completed 2-year follow-up by May 2016 and were eligible for analysis. Patients who took at least 1 dose of dabigatran (n=2932) were used to estimate incidence rates. Results Overall incidence rates per 100 person-years of 0.63 (95% confidence interval [CI], 0.42-0.92) for stroke, 1.12 (0.83-1.49) for major bleeding, 0.47 (0.29-0.72) for myocardial infarction, and 2.69 (2.22-3.23) for all-cause death were observed. For patients taking 150 mg dabigatran twice daily (BID), corresponding rates (95% CI) were 0.56 (0.30-0.94), 1.00 (0.64-1.47), 0.48 (0.25-0.83), and 2.07 (1.55-2.72), respectively. For patients taking 110 mg dabigatran BID, event rates (95% CI) were 0.67 (0.33-1.20), 1.16 (0.70-1.80), 0.43 (0.17-0.88), and 3.16 (2.36-4.15). Conclusions These global data confirm the sustained safety and effectiveness of dabigatran over 2 years of follow-up, consistent with the results from clinical trials as well as contemporary real-world studies. What is known • Non–vitamin K antagonist (VKA) anticoagulants (NOACs) are the preferred therapy for prevention of ischemic stroke based on phase 3 trials, but there is insufficient information on their efficacy and safety in daily practice, based on prospectively collected data What is new • This study shows that in non-valvular AF patient population, with up to 2 years of follow-up, the use of dabigatran led to a low incidence of ischemic stroke, major bleeding, and myocardial infarction in routine clinical care, confirming the sustained safety and effectiveness of dabigatran in clinical practice over 2 years of follow-up

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.08.018
      Issue No: Vol. 198 (2018)
  • Comparison of adverse event and device problem rates for transcatheter
           aortic valve replacement and Mitraclip procedures as reported by the
           Transcatheter Valve Therapy Registry and the Food and Drug Administration
           postmarket surveillance data
    • Authors: Benjamin Z. Galper; David E. Beery; Gregory Leighton; Libbe L. Englander
      Pages: 64 - 74
      Abstract: Publication date: April 2018
      Source:American Heart Journal, Volume 198
      Author(s): Benjamin Z. Galper, David E. Beery, Gregory Leighton, Libbe L. Englander
      Background Although outcomes data on transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve repair (Mitraclip) are available via the Transcatheter Valve Therapy (TVT) registry, dissemination of TVT data is often delayed. The Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) system collects postmarket outcomes data in public medical device reports. We used natural language processing to compare the event rates for TAVR and Mitraclip in the TVT registry and from MAUDE data. Methods We identified all medical device reports related to TAVR and Mitraclip from December 2011 through December 2014. Our primary objective was to demonstrate that event rates in TVT and MAUDE were not significantly different. We also compared TVT event rates for TAVRs performed in 2014 to MAUDE-derived event rates for the Sapien XT and CoreValve devices, both Food and Drug Administration–approved in 2014. Results Regression analysis demonstrated close correlation between TVT and MAUDE rates for both TAVR and Mitraclip, with R 2 values of 0.86 and 0.77, respectively. The rates for all events except bleeding were not statistically significantly different. We demonstrated similar increased rates of permanent pacemaker implantation in the 2014 TVT and MAUDE data sets consistent with approval of the CoreValve. Conclusions We demonstrated that natural language processing technology sorted through raw MAUDE data, allowing identification of the most common events associated with TAVR and Mitraclip procedures, and that MAUDE-derived event rates were not statistically significantly different from TVT event rates. This technology has important public health implications because it improves postmarket surveillance of implantable devices and permits rapid and early dissemination of vital information.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.10.013
      Issue No: Vol. 198 (2018)
  • Ultrahigh-resolution ultrasound characterization of access site trauma and
           intimal hyperplasia following use of a 7F sheathless guide versus 6F
           sheath/guide combination for transradial artery PCI: Results of the
           PRAGMATIC trial
    • Authors: Wayne Batchelor; Vishal Dahya; Dan McGee; John Katopodis; William Dixon; James Campbell; Ashley Meredith; Patty Knap; Mathew Parkin; Thomas Noel
      Pages: 75 - 83
      Abstract: Publication date: April 2018
      Source:American Heart Journal, Volume 198
      Author(s): Wayne Batchelor, Vishal Dahya, Dan McGee, John Katopodis, William Dixon, James Campbell, Ashley Meredith, Patty Knap, Mathew Parkin, Thomas Noel
      There exist limited data on the relative degree of acute injury and late healing of the radial artery after transradial artery (TRA) percutaneous coronary intervention (PCI) with a 7F sheathless guide catheter compared with a 6F sheath/guide combination. We used ultrahigh-resolution (55 MHz) vascular ultrasound to compare intimal-medial thickening (IMT) and early and late radial artery (RA) injury resulting from a sheathless 7F guide catheter versus a 6F sheath/guide combination for TRA-PCI. Methods Forty-one consecutive consenting patients undergoing elective nonemergent TRA-PCI at a single institution from June 2016 to December 2016 were included. Patients were randomized (stratified by sex) to undergo TRA-PCI using a 7F sheathless guide catheter versus a 6F sheath/6F guide combination. Ultrahigh-resolution vascular ultrasound (55MHz) of the RA access site was performed at 24hours and 90days post–TRA-PCI. The primary outcome of the study was a noninferiority comparison of radial artery IMT thickness at 90days. PCI success rates, fluoroscopy times, number of guides used, and crossover rates to a femoral approach were also compared. Results Baseline characteristics were similar between groups. Radial arterial IMT (mm) was similar between the 7F sheathless and 6F sheath/guide groups at 24hours (0.27 vs 0.29, respectively; P =.43) and at 90days (0.35 vs 0.34, respectively; P =.96). The P value for the noninferiority testing of a 0.07-mm limit was .002. Limited access site intimal tears were relatively common in both groups at 24hours (4 vs 5, P =.53) but often healed by 90days. Radial artery occlusion was infrequent at 90days (2 vs 1, P =.10), and no frank dissections were noted. PCI success rates (100% vs 95%, P =.59), fluoroscopy times (16 vs 12minutes, P =.17), number of guides used (1.1 vs 1.2, P =.48), and femoral crossover rates (0% vs 0%) were similar between the 2 respective groups. Conclusions A 7F sheathless approach to TRA-PCI results in no more IMT and early or late RA trauma than a standard 6F sheath/guide combination, rendering the 7F sheathless technique an attractive option for complex TRA-PCI.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.11.017
      Issue No: Vol. 198 (2018)
  • Symptomatic event reduction with extended-duration betrixaban in acute
           medically ill hospitalized patients
    • Authors: C. Michael Gibson; Tarek Nafee; Megan K. Yee; Gerald Chi; Serge Korjian; Yazan Daaboul; Fahad AlKhalfan; Mathieu Kerneis; Samuel Z. Goldhaber; Russel Hull; Adrian F. Hernandez; Alexander T. Cohen; Robert A. Harrington
      Pages: 84 - 90
      Abstract: Publication date: April 2018
      Source:American Heart Journal, Volume 198
      Author(s): C. Michael Gibson, Tarek Nafee, Megan K. Yee, Gerald Chi, Serge Korjian, Yazan Daaboul, Fahad AlKhalfan, Mathieu Kerneis, Samuel Z. Goldhaber, Russel Hull, Adrian F. Hernandez, Alexander T. Cohen, Robert A. Harrington
      Background Approximately 15%-30% of patients in trials of medical thromboprophylaxis will have missing compression ultrasound (CUS) data. The goal of the present analysis was to perform analyses to minimize missing data. Methods The APEX trial randomized 7,513 acutely medically ill hospitalized patients to thromboprophylaxis with either betrixaban for 35-42 days or enoxaparin for 6-14 days. A modified intent-to-treat (mITT) analysis was performed and included all subjects administered study drug, irrespective of CUS performance, and an analysis of symptomatic events which do not require performance of a CUS (symptomatic deep vein thrombosis, nonfatal pulmonary embolism, and venous thromboembolism (VTE)–related mortality). Results In the mITT population, betrixaban significantly reduced the primary end point (which included both symptomatic and CUS events) (165 [4.4%] vs 223 [6.0%]; relative risk = 0.75; 95% CI 0.61-0.91; P = .003; absolute risk reduction [ARR] = 1.6%; number needed to treat [NNT] = 63). Betrixaban also reduced symptomatic VTE through day 42 (35 [1.28%] vs 54 [1.88%], hazard ratio [HR] = 0.65; 95% CI 0.42-0.99; P = .044; ARR = 0.6%; NNT=167) as well as through day 77 (37 [1.02%] vs 67 [1.89%]; HR= 0.55; 95% CI 0.37-0.83; P = .003; ARR = 0.87%; NNT=115) as well as the individual end point of nonfatal pulmonary embolism (9 [0.25%] vs 20 [0.55%]; HR= 0.45; 95% CI 0.21-0.99; P = .041; ARR = 0.30%; NNT=334). On an “as-treated” basis, 80 mg of betrixaban reduced VTE-related mortality through day 77 (10 [0.34%] vs. 22 [0.79%]; HR=0.46; 95% CI 0.22-0.96; P = .035; ARR = 0.45%; NNT=223). Conclusion In an mITT analysis of all patients administered study drug, extended-duration betrixaban reduced the primary end point as well as symptomatic events. In an as-treated analysis, 80 mg of betrixaban reduced VTE-related death.

      PubDate: 2018-02-05T09:43:19Z
      DOI: 10.1016/j.ahj.2017.12.015
      Issue No: Vol. 198 (2018)
  • Left ventricular ejection fraction reassessment post–myocardial
           infarction: Current clinical practice and determinants of adverse
    • Authors: Derek S. Chew; Stephen B. Wilton; Katherine Kavanagh; Danielle A. Southern; Liong Eng Tan-Mesiatowsky; Derek V. Exner
      Pages: 91 - 96
      Abstract: Publication date: April 2018
      Source:American Heart Journal, Volume 198
      Author(s): Derek S. Chew, Stephen B. Wilton, Katherine Kavanagh, Danielle A. Southern, Liong Eng Tan-Mesiatowsky, Derek V. Exner
      Background Left ventricular (LV) dysfunction may be sustained or aggravated during the convalescent months following an acute myocardial infarction (MI) and is difficult to predict. We sought to determine current practice patterns of LV ejection fraction (LVEF) reassessment during the months following MI and evaluate the predictors and clinical significance of LVEF change in a prospective post-MI patient cohort. Methods Patients with an acute MI between June 2010 and August 2014 were identified using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry. Patients with initial LV dysfunction (LVEF <40% with first MI or <45% with multiple MI events) underwent a protocol-driven repeat LVEF assessment in follow-up if routine LVEF reassessment was not performed. Results Of 5,964 MI patients, follow-up LVEF assessments were attained for 442 of the 695 patients who had significant LV dysfunction. A sizable proportion (25%) had either no increase or a decline in LVEF. Adverse remodeling was associated with an anterior MI location, a greater peak serum troponin T, and a higher baseline LVEF at time of MI. Adverse LV remodeling conferred a 3-fold risk of death (hazard ratio 3.0, 95% CI 1.6-5.7, P =.001) adjusted for baseline LVEF, anterior MI location, and medication use. Conclusions Current practice of LVEF reassessment during the convalescent months post-MI is suboptimal despite a sizeable proportion of patients that undergo adverse LV remodeling. Targeting processes affecting low rates of LVEF reassessment may reduce missed care opportunities and ensure that patients consistently receive appropriate evidence-based and guideline-recommended care.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.11.014
      Issue No: Vol. 198 (2018)
  • Hospital evaluation of health literacy and associated outcomes in patients
           after acute myocardial infarction
    • Authors: Jennifer A. Rymer; Lisa A. Kaltenbach; Kevin J. Anstrom; Gregg C. Fonarow; Nathaniel Erskine; Eric D. Peterson; Tracy Y. Wang
      Pages: 97 - 107
      Abstract: Publication date: April 2018
      Source:American Heart Journal, Volume 198
      Author(s): Jennifer A. Rymer, Lisa A. Kaltenbach, Kevin J. Anstrom, Gregg C. Fonarow, Nathaniel Erskine, Eric D. Peterson, Tracy Y. Wang
      Background Low health literacy is common in the United States and may affect outcomes after myocardial infarction (MI). How often hospitals screen for low health literacy is unknown. Methods We surveyed 122 hospitals in the TRANSLATE-ACS study and divided them into those that reported routinely (>75% of patients), selectively (1%-75%), or never (0%) screening MI patients for low health literacy prior to discharge. We performed logistic regression with random intercepts to compare 6-week and 6-month patient-reported medication adherence and multivariable Cox regression to compare 1-year major adverse cardiovascular events and all-cause readmission risks between hospital groups. Results Overall, 25 (20.5%), 47 (38.5%), and 50 (41.0%) hospitals reported routinely, selectively, or never screening patients for low health literacy, respectively. Patients discharged from hospitals that routinely screened were more likely to report 6-week medication adherence [routinely: adjusted odds ratio (OR) 1.26, 95% CI 1.01-1.57; selectively: adjusted OR 1.19, 95% CI 1.00-1.43, both referenced to those discharged from hospitals that never screened]. Compared with hospitals that never screened health literacy, 1-year major adverse cardiovascular events were similar for hospitals that reported routinely screening (adjusted HR 0.92, 95% CI 0.75-1.14) or selectively screening (adjusted HR 1.01, 95% CI 0.84-1.21). Hospitals that reported selectively screening health literacy were associated with a lower adjusted risk of 1-year all-cause readmission (adjusted HR 0.89, 95% CI 0.79-1.00, P =.041). Conclusion Only a minority of US hospitals routinely screen MI patients for low health literacy. Hospital screening was associated with higher medication adherence and lower readmission risk. Further investigation is needed to understand how inpatient screening can be implemented to improve longitudinal post-MI care.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.08.024
      Issue No: Vol. 198 (2018)
  • Impact of hormone therapy on Medicare spending in the Women’s Health
           Initiative randomized clinical trials
    • Authors: Jacqueline B. Shreibati; JoAnn E. Manson; Karen L. Margolis; Rowan T. Chlebowski; Marcia L. Stefanick; Mark A. Hlatky
      Pages: 108 - 114
      Abstract: Publication date: April 2018
      Source:American Heart Journal, Volume 198
      Author(s): Jacqueline B. Shreibati, JoAnn E. Manson, Karen L. Margolis, Rowan T. Chlebowski, Marcia L. Stefanick, Mark A. Hlatky
      Background Randomized trials can compare economic as well as clinical outcomes, but economic data are difficult to collect. Linking clinical trial data with Medicare claims could provide novel information on health care utilization and cost. Methods We linked data from Medicare claims of women ≥65 years old who had Medicare fee-for-service coverage with their clinical data from the Women’s Health Initiative trials of conjugated equine estrogens plus medroxyprogesterone acetate (CEE+MPA) versus placebo and of CEE‐alone versus placebo. The primary outcome was total Medicare spending during the intervention phase of the trial, and the secondary outcomes were spending on diseases hypothesized a priori to be sensitive to the effects of hormone therapy. Results In the CEE+MPA trial, 4,557 participants ≥65 years old were included. Women randomly assigned to CEE+MPA had 4% higher mean Medicare spending overall ($45,690 vs $43,920, P = .08) but 0.5% lower spending for hormone-sensitive diseases ($3,526 vs $3,547, P = .07), with 73% higher spending for coronary heart disease (P = .045) and 122% higher spending for pulmonary embolism (P = .026). In the CEE-alone trial, 3,107 participants were included. Total spending among women randomly assigned to CEE was 3.3% higher ($75,411 vs $72,997, P = .16), and 1.7% higher spending for hormone-sensitive diseases ($5,213 vs $5,127, P = .57), but with 39% lower spending for hip fracture (p<0.03). Conclusions Menopausal hormone therapy increased spending for some diseases, but decreased spending for others. These offsetting effects led to modest (3%-4%), nonsignificant increases in overall spending among women aged 65 years and older.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.12.016
      Issue No: Vol. 198 (2018)
  • Rationale and design of the Statins Evaluation in Coronary procedUres and
           REvascularization: The SECURE-PCI Trial
    • Authors: Otavio Berwanger; Pedro G.M. de Barros e Silva; Frederico Toledo Campo Dall Orto; Pedro Beraldo de Andrade; Igor Ribeiro de Castro Bienert; Carlos Eduardo Bosso; José Mangione; Carisi Anne Polanczyk; Amanda Sousa; Renato Kalil; Luciano de Moura Santos; Andrei C. Sposito; Rafael L. Rech; Antonio Carlos Sobral Sousa; Felipe Baldissera; Bruno Ramos Nascimento; Isabella de Andrade Jesuíno; Eliana Vieira Santucci; Lucas Petri Damiani; Ligia N. Laranjeira; Juliana A. Borges de Oliveira; Roberto R. Giraldez; Alexandre Biasi Cavalcanti; Sabrina Bernardez Pereira; Luiz Alberto Mattos; Luciana Vidal Armaganijan; Hélio Penna Guimarães; José Eduardo Sousa; John H. Alexander; Christopher B. Granger; Renato D. Lopes
      Pages: 129 - 134
      Abstract: Publication date: April 2018
      Source:American Heart Journal, Volume 198
      Author(s): Otavio Berwanger, Pedro G.M. de Barros e Silva, Frederico Toledo Campo Dall Orto, Pedro Beraldo de Andrade, Igor Ribeiro de Castro Bienert, Carlos Eduardo Bosso, José Mangione, Carisi Anne Polanczyk, Amanda Sousa, Renato Kalil, Luciano de Moura Santos, Andrei C. Sposito, Rafael L. Rech, Antonio Carlos Sobral Sousa, Felipe Baldissera, Bruno Ramos Nascimento, Isabella de Andrade Jesuíno, Eliana Vieira Santucci, Lucas Petri Damiani, Ligia N. Laranjeira, Juliana A. Borges de Oliveira, Roberto R. Giraldez, Alexandre Biasi Cavalcanti, Sabrina Bernardez Pereira, Luiz Alberto Mattos, Luciana Vidal Armaganijan, Hélio Penna Guimarães, José Eduardo Sousa, John H. Alexander, Christopher B. Granger, Renato D. Lopes
      Background Previous evidence suggests that acute treatment with statins reduce atherosclerotic complications, including periprocedural myocardial infarction, but currently, there are no large, adequately powered studies to define the effects of early, high-dose statins in patients with acute coronary syndrome (ACS) and planned invasive management. Objectives The main goal of Statins Evaluation in Coronary procedUres and REvascularization (SECURE-PCI) Trial is to determine whether the early use of a loading dose of 80 mg of atorvastatin before an intended percutaneous coronary intervention followed by an additional dose of 80 mg 24 hours after the procedure will be able to reduce the rates of major cardiovascular events at 30 days in patients with an ACS. Design The SECURE-PCI study is a pragmatic, multicenter, double-blind, placebo-controlled randomized trial planned to enroll around 4,200 patients in 58 different sites in Brazil. The primary outcome is the rate of major cardiovascular events at 30 days defined as a composite of all-cause mortality, nonfatal acute myocardial infarction, nonfatal stroke, and coronary revascularization. Summary The SECURE PCI is a large randomized trial testing a strategy of early, high-dose statin in patients with ACS and will provide important information about the acute treatment of this patient population.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.12.018
      Issue No: Vol. 198 (2018)
  • ASCEND: A Study of Cardiovascular Events iN Diabetes: Characteristics of a
           randomized trial of aspirin and of omega-3 fatty acid supplementation in
           15,480 people with diabetes
    • Authors: Louise Bowman; Marion Mafham; William Stevens; Richard Haynes; Theingi Aung; Fang Chen; Georgina Buck; Rory Collins; Jane Armitage
      Pages: 135 - 144
      Abstract: Publication date: April 2018
      Source:American Heart Journal, Volume 198
      Author(s): Louise Bowman, Marion Mafham, William Stevens, Richard Haynes, Theingi Aung, Fang Chen, Georgina Buck, Rory Collins, Jane Armitage
      Objectives The use of aspirin for the secondary prevention of cardiovascular disease (CVD) is firmly established, and the proportional reductions in heart attacks and strokes appear to be similar in people with and without diabetes. Uncertainty remains about the role of antiplatelet treatments for primary prevention of CVD, and guidelines vary in their recommendations. It has also been hypothesized that long-term aspirin can prevent gastro-intestinal and other cancers. Observational studies suggest associations between higher intakes of omega-3 fatty acids (FA) and lower rates of CVD, but there is no large-scale randomized evidence to support using prophylactic omega-3 FA supplementation in primary prevention. ASCEND is a randomized trial assessing whether 100 mg daily aspirin safely prevents CVD and cancer in patients with diabetes without known arterial disease. It is also assessing whether supplementation with 1 g omega-3 FA daily prevents CVD. This paper describes the methods and baseline characteristics of the randomized participants. Methods and results Between 2005 and 2011, using mail-based methods, 15,480 people with diabetes were randomized to aspirin versus placebo and, in a factorial design, to omega-3 FA supplementation versus placebo. Blood and urine samples were collected to allow baseline stratification by biochemical prognostic variables (e.g. HbA1c, blood lipids). Follow-up is for a median of at least 7 years. Conclusions Demonstrating that prophylactic aspirin safely reduces the risk of CVD or cancer in the primary prevention setting, or that omega-3 FA supplementation prevents CVD, would be relevant to hundreds of millions of people worldwide who are currently not receiving such therapies. The results of ASCEND will be reported in 2018.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.12.006
      Issue No: Vol. 198 (2018)
  • Apixaban following acute coronary syndromes in patients with prior stroke:
           Insights from the APPRAISE-2 trial
    • Authors: Matthew W. Sherwood; Renato D. Lopes; Jie Lena Sun; Danny Liaw; Robert A. Harrington; Lars Wallentin; Daniel T. Laskowitz; Stefan K. James; Shaun G. Goodman; Harald Darius; Basil S. Lewis; C. Michael Gibson; Karen S. Pieper; John H. Alexander
      Pages: 1 - 8
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Matthew W. Sherwood, Renato D. Lopes, Jie Lena Sun, Danny Liaw, Robert A. Harrington, Lars Wallentin, Daniel T. Laskowitz, Stefan K. James, Shaun G. Goodman, Harald Darius, Basil S. Lewis, C. Michael Gibson, Karen S. Pieper, John H. Alexander
      Background and Purpose Patients with prior stroke are at greater risk for recurrent cardiovascular events post-acute coronary syndromes (ACS) and may have a different risk/benefit profile with antithrombotic therapy than patients without prior stroke. Methods We studied 7391 patients with ACS from APPRAISE-2, stratified by the presence or absence of prior stroke. Baseline characteristics and outcomes of cardiovascular death, myocardial infarction (MI), or stroke were compared between groups. Interactions between prior stroke, treatment assignment (apixaban vs placebo), and outcomes were tested before and after multivariable adjustment with Cox proportional hazards models. Results A total of 902 patients (12%) had prior stroke. Those with prior stroke were older (69 vs 67 years), had more hypertension (91% vs 77%), peripheral vascular disease (22% vs18%), and impaired renal function (38% vs 30%) but less diabetes (44% vs 48%) than those without prior stroke. Patients with prior stroke vs no prior stroke had higher unadjusted rates of cardiovascular death (4.8% vs 4.0%), MI (11.2% vs 7.1%), and ischemic stroke (3.2% vs 0.9%). Patients with prior stroke assigned to apixaban had similar rates of the composite of cardiovascular death, MI, or stroke compared with those assigned to placebo (HR 1.39; 95% CI 0.92–2.08). Patients without prior stroke assigned to apixaban had similar rates of cardiovascular death, MI, or ischemic stroke compared with those assigned to placebo (HR 0.87; 95% CI 0.73–1.04; P-interaction=.041). Median follow-up was 240 days. Conclusions Patients with prior stroke are at higher risk for recurrent cardiovascular events post-ACS and had a differential risk/benefit profile with oral anticoagulation.

      PubDate: 2018-01-10T03:52:35Z
      DOI: 10.1016/j.ahj.2017.09.020
      Issue No: Vol. 197 (2018)
  • Comprehensive electrocardiogram-to-device time for primary percutaneous
           coronary intervention in ST-segment elevation myocardial infarction: A
           report from the American Heart Association mission: Lifeline program
    • Authors: Jay S. Shavadia; William French; Anne S. Hellkamp; Laine Thomas; Eric R. Bates; Steven V. Manoukian; Michael C. Kontos; Robert Suter; Timothy D. Henry; Harold L. Dauerman; Matthew T. Roe
      Pages: 9 - 17
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Jay S. Shavadia, William French, Anne S. Hellkamp, Laine Thomas, Eric R. Bates, Steven V. Manoukian, Michael C. Kontos, Robert Suter, Timothy D. Henry, Harold L. Dauerman, Matthew T. Roe
      Background Assessing hospital-related network-level primary percutaneous coronary intervention (PCI) performance for ST-segment elevation myocardial infarction (STEMI) is challenging due to differential time-to-treatment metrics based on location of diagnostic electrocardiogram (ECG) for STEMI. Methods STEMI patients undergoing primary PCI at 588 PCI-capable hospitals in AHA Mission: Lifeline (2008–2013) were categorized by initial STEMI identification location: PCI-capable hospitals (Group 1); pre-hospital setting (Group 2); and non–PCI-capable hospitals (Group 3). Patient-specific time-to-treatment categories were converted to minutes ahead of or behind their group-specific mean; average time-to-treatment difference for all patients at a given hospital was termed comprehensive ECG-to-device time. Hospitals were then stratified into tertiles based on their comprehensive ECG-to-device times with negative values below the mean representing shorter (faster) time intervals. Results Of 117,857 patients, the proportion in Groups 1, 2, and 3 were 42%, 33%, and 25%, respectively. Lower rates of heart failure and cardiac arrest at presentation are noted within patients presenting to high-performing hospitals. Median comprehensive ECG-to-device time was shortest at −9 minutes (25th, 75th percentiles: −13, −6) for the high-performing hospital tertile, 1 minute (−1, 3) for middle-performing, and 11 minutes (7, 16) for low-performing. Unadjusted rates of in-hospital mortality were 2.3%, 2.6%, and 2.7%, respectively, but the adjusted risk of in-hospital mortality was similar across tertiles. Conclusions Comprehensive ECG-to-device time provides an integrated hospital-related network-level assessment of reperfusion timing metrics for primary PCI, regardless of the location for STEMI identification; further validation will delineate how this metric can be used to facilitate STEMI care improvements.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.10.017
      Issue No: Vol. 197 (2018)
  • Nonprimary PCI at hospitals without cardiac surgery on-site: Consistent
           outcomes for all'
    • Authors: Matthew J. Czarny; Julie M. Miller; Daniel Q. Naiman; Chao-Wei Hwang; Rani K. Hasan; Cynthia C. Lemmon; Thomas Aversano
      Pages: 18 - 26
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Matthew J. Czarny, Julie M. Miller, Daniel Q. Naiman, Chao-Wei Hwang, Rani K. Hasan, Cynthia C. Lemmon, Thomas Aversano
      Background The CPORT-E trial showed the noninferiority of nonprimary percutaneous coronary intervention (PCI) at hospitals without cardiac surgery on-site (SoS) compared with hospitals with SoS for 6-week mortality and 9-month major adverse cardiac events (MACE). However, target vessel revascularization (TVR) was increased at non-SoS hospitals. Therefore, we aimed to determine the consistency of the CPORT-E trial findings across the spectrum of enrolled patients. Methods Post hoc subgroup analyses of 6-week mortality and 9-month MACE, defined as the composite of death, Q-wave myocardial infarction, or TVR, were performed. Patients with and without 9-month TVR and rates of related outcomes were compared. Results There was no interaction between SoS status and clinically relevant subgroups for 6-week mortality or 9-month MACE (P for any interaction=.421 and .062, respectively). In addition to increased 9-month rates of TVR and diagnostic catheterization at hospitals without SoS, non-TVR was also increased (2.7% vs 1.9%, P =.002); there was no difference in myocardial infarction–driven TVR, non-TVR, or diagnostic catheterization. Predictors of 9-month TVR included intra-aortic balloon pump use, any index PCI complication, and 3-vessel PCI, whereas predictors of freedom from TVR included SoS, discharge on a P2Y12 inhibitor, and stent implantation. Conclusions The noninferiority of nonprimary PCI at non-SoS hospitals was consistent across clinically relevant subgroups. Elective PCI at an SoS hospital conferred a TVR benefit which may be related to a lower rate of referral for diagnostic catheterization for reasons other than myocardial infarction.

      PubDate: 2018-01-10T03:52:35Z
      DOI: 10.1016/j.ahj.2017.10.023
      Issue No: Vol. 197 (2018)
  • Prediction of long-term net clinical outcomes using the TIMI-AF score:
           Comparison with CHA2DS2-VASc and HAS-BLED
    • Authors: José Miguel Rivera-Caravaca; Vanessa Roldán; María Asunción Esteve-Pastor; Mariano Valdés; Vicente Vicente; Francisco Marín; Gregory Y.H. Lip
      Pages: 27 - 34
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): José Miguel Rivera-Caravaca, Vanessa Roldán, María Asunción Esteve-Pastor, Mariano Valdés, Vicente Vicente, Francisco Marín, Gregory Y.H. Lip
      The TIMI-AF score was described to predict net clinical outcomes (NCOs) in atrial fibrillation (AF) patients receiving warfarin. However, this score derived from the ENGAGE AF-TIMI 48 trial, and no external validation exists in real world clinical practice. We tested the long-term predictive performance of the TIMI-AF score in comparison with CHA2DS2-VASc and HAS-BLED in a ‘real-world’ cohort of anticoagulated AF patients. Methods We included 1156 consecutive AF patients stable on vitamin K antagonist (INR 2.0-3.0) during 6 months. The baseline risk of NCOs (composite of stroke, life-threatening bleeding, or all-cause mortality) was calculated using the novel TIMI-AF score. During follow-up, all NCOs were recorded and the predictive performance and clinical usefulness of TIMI-AF was compared with CHA2DS2-VASc and HAS-BLED. Results During 6.5 years (IQR 4.3-7.9), there were 563 NCOs (7.49%/year). ‘Low-risk’ (6.07%/year) and ‘medium-risk’ (9.49%/year) patients defined by the TIMI-AF suffered more endpoints that low- and medium-risk patients of CHA2DS2-VASc and HAS-BLED (2.37%/year and 4.40%/year for low risk; 3.48%/year and 6.39%/year for medium risk, respectively). The predictive performance of TIMI-AF was not different from CHA2DS2-VASc (0.678 vs 0.677, P = .963) or HAS-BLED (0.644 vs 0.671, P = .054). Discrimination and reclassification did not show improvement of prediction using the TIMI-AF score, and decision curves analysis did not demonstrate higher net benefit. Conclusions In VKA-experienced AF patients, the TIMI-AF score has limited usefulness predicting NCOs over a long-term period of follow-up. This novel score was not superior to CHA2DS2-VASc and HAS-BLED identifying low-risk AF patients.

      PubDate: 2018-01-10T03:52:35Z
      DOI: 10.1016/j.ahj.2017.11.004
      Issue No: Vol. 197 (2018)
  • Comparison of drug-eluting stents and drug-coated balloon for the
           treatment of drug-eluting coronary stent restenosis: A randomized RESTORE
    • Authors: Yiu Tung Anthony Wong; Do-Yoon Kang; Jin Bae Lee; Seung-Woon Rha; Young Joon Hong; Eun-Seok Shin; Sung-Ho Her; Chang Wook Nam; Woo-Young Chung; Moo Hyun Kim; Cheol Hyun Lee; Pil Hyung Lee; Jung-Min Ahn; Soo-Jin Kang; Seung-Whan Lee; Young-Hak Kim; Cheol Whan Lee; Seong-Wook Park; Duk-Woo Park; Seung-Jung Park
      Pages: 35 - 42
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Yiu Tung Anthony Wong, Do-Yoon Kang, Jin Bae Lee, Seung-Woon Rha, Young Joon Hong, Eun-Seok Shin, Sung-Ho Her, Chang Wook Nam, Woo-Young Chung, Moo Hyun Kim, Cheol Hyun Lee, Pil Hyung Lee, Jung-Min Ahn, Soo-Jin Kang, Seung-Whan Lee, Young-Hak Kim, Cheol Whan Lee, Seong-Wook Park, Duk-Woo Park, Seung-Jung Park
      Background This study sought to evaluate the optimal treatment for in-stent restenosis (ISR) of drug-eluting stents (DESs). Methods This is a prospective, multicenter, open-label, randomized study comparing the use of drug-eluting balloon (DEB) versus second-generation everolimus-eluting stent for the treatment of DES ISR. The primary end point was in-segment late loss at 9-month routine angiographic follow-up. Results A total of 172 patients were enrolled, and 74 (43.0%) patients underwent the angiographic follow-up. The primary end point was not different between the 2 treatment groups (DEB group 0.15±0.49 mm vs DES group 0.19±0.41 mm, P =.54). The secondary end points of in-segment minimal luminal diameter (MLD) (1.80±0.69 mm vs 2.09±0.46 mm, P =.03), in-stent MLD (1.90±0.71 mm vs 2.29±0.48 mm, P =.005), in-segment percent diameter stenosis (34%±21% vs 26%±15%, P =.05), and in-stent percent diameter stenosis (33%±21% vs 21%±15%, P =.002) were more favorable in the DES group. The composite of death, myocardial infarction, or target lesion revascularization at 1 year was comparable between the 2 groups (DEB group 7.0% vs DES group 4.7%, P =.51). Conclusions Treatment of DES ISR using DEB or second-generation DES did not differ in terms of late loss at 9-month angiographic follow-up, whereas DES showed better angiographic results regarding minimal MLD and percent diameter stenosis. Both treatment strategies were safe and effective up to 1year after the procedure.

      PubDate: 2018-01-10T03:52:35Z
      DOI: 10.1016/j.ahj.2017.11.008
      Issue No: Vol. 197 (2018)
  • Representation of black patients in randomized clinical trials of heart
           failure with reduced ejection fraction
    • Authors: Lonnie T. Sullivan; Tiffany Randolph; Peter Merrill; Larry R. Jackson; Chidiebube Egwim; Monique A. Starks; Kevin L. Thomas
      Pages: 43 - 52
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Lonnie T. Sullivan, Tiffany Randolph, Peter Merrill, Larry R. Jackson, Chidiebube Egwim, Monique A. Starks, Kevin L. Thomas
      Background Black individuals have a disproportionately higher burden of heart failure with reduced ejection fraction (HFrEF) relative to other racial and ethnic populations. We conducted a systematic review to determine the representation, enrollment trends, and outcomes of black patients in historic and contemporary randomized clinical trials (RCTs) for HFrEF. Methods We searched PubMed and Embase for RCTs of patients with chronic HFrEF that evaluated therapies that significantly improved clinical outcomes. We extracted trial characteristics and compared them by trial type. Linear regression was used to assess trends in enrollment among HFrEF RCTs over time. Results A total of 25 RCTs, 19 for pharmacotherapies and 6 (n=9,501) for implantable cardioverter defibrillators, were included in this analysis. Among these studies, there were 78,816 patients, 4,640 black (5.9%), and the median black participation per trial was 162 patients. Black race was reported in the manuscript of 14 (56.0%) trials, and outcomes by race were available for 12 (48.0%) trials. Implantable cardiac defibrillator trials enrolled a greater percentage of black patients than pharmacotherapy trials (7.1% vs 5.7%). Overall, patient enrollment among the 25 RCTs increased over time (P = .075); however, the percentage of black patients has decreased (P = .001). Outcomes varied significantly between black and white patients in 6 studies. Conclusions Black patients are modestly represented among pivotal RCTs of individuals with HFrEF for both pharmacotherapies and implantable cardioverter defibrillators. The current trend for decreasing black representation in trials of HF therapeutics is concerning and must improve to ensure the generalizability for this vulnerable population.

      PubDate: 2018-01-10T03:52:35Z
      DOI: 10.1016/j.ahj.2017.10.025
      Issue No: Vol. 197 (2018)
  • Design of DISCO—Direct or Subacute Coronary Angiography in
           Out-of-Hospital Cardiac Arrest study
    • Authors: Rickard Lagedal; Ludvig Elfwén; Stefan James; Jonas Oldgren; David Erlinge; Ollie Östlund; Ewa Wallin; Ing-Marie Larsson; Gisela Lilja; Tobias Cronberg; Sten Rubertsson; Per Nordberg
      Pages: 53 - 61
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Rickard Lagedal, Ludvig Elfwén, Stefan James, Jonas Oldgren, David Erlinge, Ollie Östlund, Ewa Wallin, Ing-Marie Larsson, Gisela Lilja, Tobias Cronberg, Sten Rubertsson, Per Nordberg
      Background Acute coronary syndrome is a common cause of out-of-hospital cardiac arrest (OHCA). In patients with OHCA presenting with ST elevation, immediate coronary angiography and potential percutaneous coronary intervention (PCI) after return of spontaneous circulation are recommended. However, the evidence for this invasive strategy in patients without ST elevation is limited. Observational studies have shown a culprit coronary artery occlusion in about 30% of these patients, indicating the electrocardiogram's (ECG's) limited sensitivity. The aim of this study is to determine whether immediate coronary angiography and subsequent PCI will provide outcome benefits in OHCA patients without ST elevation. Methods/design We describe the design of the DIrect or Subacute Coronary angiography in Out-of-hospital cardiac arrest study (DISCO)—a pragmatic national, multicenter, randomized, clinical study. OHCA patients presenting with no ST elevation on their first recorded ECG will be randomized to a strategy of immediate coronary angiography or to standard of care with admission to intensive care and angiography after 3days at the earliest unless the patient shows signs of acute ischemia or hemodynamic instability. Primary end point is 30-day survival. An estimated 1,006 patients give 80% power (α = .05) to detect a 20% improved 30-day survival rate from 45% to 54%. Secondary outcomes include good neurologic recovery at 30days and 6months, and cognitive function and cardiac function at 6months. Conclusion This randomized clinical study will evaluate the effect of immediate coronary angiography after OHCA on 30-day survival in patients without ST elevation on their first recorded ECG.

      PubDate: 2018-01-10T03:52:35Z
      DOI: 10.1016/j.ahj.2017.11.009
      Issue No: Vol. 197 (2018)
  • Association of lipoprotein-associated phospholipase A2 and risk of
           incident atrial fibrillation: Findings from 3 cohorts
    • Authors: Parveen K. Garg; Traci M. Bartz; Faye L. Norby; Neal W. Jorgensen; Robyn L. McClelland; Christie M. Ballantyne; Lin Y. Chen; John S. Gottdiener; Philip Greenland; Ron Hoogeveen; Nancy S. Jenny; Jorge R. Kizer; Robert S. Rosenson; Elsayed Z. Soliman; Mary Cushman; Alvaro Alonso; Susan R. Heckbert
      Pages: 62 - 69
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Parveen K. Garg, Traci M. Bartz, Faye L. Norby, Neal W. Jorgensen, Robyn L. McClelland, Christie M. Ballantyne, Lin Y. Chen, John S. Gottdiener, Philip Greenland, Ron Hoogeveen, Nancy S. Jenny, Jorge R. Kizer, Robert S. Rosenson, Elsayed Z. Soliman, Mary Cushman, Alvaro Alonso, Susan R. Heckbert
      Background Multiple prospective studies have established an association between inflammation and higher risk of atrial fibrillation (AF), but the association between lipoprotein-associated phospholipase A2 (Lp-PLA2) mass and activity and incident AF has not been extensively evaluated. Methods Using data from 10,794 Atherosclerosis Risk In Communities (ARIC) study participants aged 53-75 years, 5,181 Cardiovascular Health Study (CHS) participants aged 65 to 100 years, and 5,425 Multi-Ethnic Study of Atherosclerosis (MESA) participants aged 45-84 years, we investigated the association between baseline Lp-PLA2 levels and the risk of developing AF. Incident AF was identified in each cohort by follow-up visit electrocardiograms, hospital discharge coding of AF, or Medicare claims data. Results Over a mean of 13.1, 11.5, and 10.0 years of follow-up, 1,439 (13%), 2,084 (40%), and 615 (11%) incident AF events occurred in ARIC, CHS, and MESA, respectively. In adjusted analyses, each SD increment in Lp-PLA2 activity was associated with incident AF in both ARIC (hazard ratio [HR] 1.13, 95% CI 1.06-1.20) and MESA (HR 1.24, 95% CI 1.05-1.46). Each SD increment in Lp-PLA2 mass was also associated with incident AF in MESA (HR 1.25, 95% CI 1.11-1.41). No significant associations were observed among CHS participants. Conclusions Although higher Lp-PLA2 mass and activity were associated with development of AF in ARIC and MESA, this relationship was not observed in CHS, a cohort of older individuals.

      PubDate: 2018-01-10T03:52:35Z
      DOI: 10.1016/j.ahj.2017.11.010
      Issue No: Vol. 197 (2018)
  • High-sensitivity cardiac troponin T, left ventricular function, and
           outcome in non–ST elevation acute coronary syndrome
    • Authors: K.M. Eggers; T. Jernberg; B. Lindahl
      Pages: 70 - 76
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): K.M. Eggers, T. Jernberg, B. Lindahl
      Background Cardiac troponin (cTn) levels reflect infarct size and depressed left ventricular ejection fraction (LVEF) in patients with non–ST elevation acute coronary syndrome (NSTE-ACS). However, there is very limited information on whether cTn measured with a high-sensitivity (hs) assay would provide incremental prognostic information to the LVEF in NSTE-ACS patients. Methods This was a registry-based study (SWEDEHEART registry) investigating 20,652 NSTE-ACS patients with available information on hs-cTnT (highest level recorded during the hospitalization) and the LVEF estimated using echocardiography. All patients had been followed for 1 year. Results Hs-cTnT levels independently predicted major cardiovascular events (MACE) in cohorts with normal, slightly depressed, moderately depressed, and severely depressed LVEF. The adjusted hazard ratios in these cohorts were 1.18 (95% CI 1.13-1.23), 1.12 (95% CI 1.06-1.18), 1.12 (95% CI 1.06-1.19), and 1.21 (95% CI 1.13-1.30), respectively. Hs-cTnT levels were particularly predictive for cardiovascular mortality and readmission for heart failure. Excluding patients with previous cardiac disease did not affect the overall interrelations of hs-cTnT and LVEF with MACE. Conclusions Hs-cTnT levels provide incremental prognostic value independent of the LVEF in patients with NSTE-ACS. Hs-cTnT is particularly predictive for MACE in patients with severely depressed LVEF but also in those with a normal LVEF. Accordingly, a normal LVEF should not be used as an argument not to target patients to thorough workup.

      PubDate: 2018-01-10T03:52:35Z
      DOI: 10.1016/j.ahj.2017.11.012
      Issue No: Vol. 197 (2018)
  • Rationale and design of the comparison between a P2Y12 inhibitor
           monotherapy versus dual antiplatelet therapy in patients undergoing
           implantation of coronary drug-eluting stents (SMART-CHOICE): A prospective
           multicenter randomized trial
    • Authors: Young Bin Song; Seok Kyu Oh; Ju-Hyeon Oh; Eul-Soon Im; Deok-Kyu Cho; Byung Ryul Cho; Jong-Young Lee; Joo Myung Lee; Taek Kyu Park; Jeong Hoon Yang; Jin-Ho Choi; Seung-Hyuck Choi; Sang Hoon Lee; Hyeon-Cheol Gwon; Joo-Yong Hahn
      Pages: 77 - 84
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Young Bin Song, Seok Kyu Oh, Ju-Hyeon Oh, Eul-Soon Im, Deok-Kyu Cho, Byung Ryul Cho, Jong-Young Lee, Joo Myung Lee, Taek Kyu Park, Jeong Hoon Yang, Jin-Ho Choi, Seung-Hyuck Choi, Sang Hoon Lee, Hyeon-Cheol Gwon, Joo-Yong Hahn
      Background and rationale Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor reduces thrombotic events in patients undergoing percutaneous coronary intervention (PCI), but these benefits come at the expense of increased risk of bleeding when compared with aspirin monotherapy. It is unclear whether P2Y12 inhibitor monotherapy might maintain anti-ischemic efficacy while reducing the bleeding risk compared with DAPT after implantation of the current generation of drug-eluting stents (DES). Study design The SMART-CHOICE trial is a prospective, open-label, multi-center, and randomized study designed to test the non-inferiority of P2Y12 inhibitor monotherapy compared with aspirin plus a P2Y12 inhibitor after mandatory 3-month DAPT in patients undergoing PCI with current-generation DES. A total of 3000 patients will be randomized to 1 of the 2 antiplatelet treatment strategy groups. Randomization will be stratified by stent type (cobalt-chromium everolimus-eluting stents, platinum-chromium everolimus-eluting stents, and sirolimus-eluting stents with bioresorbable polymer), P2Y12 inhibitors (clopidogrel, prasugrel, and ticagrelor), clinical presentation (acute coronary syndrome and stable ischemic heart disease), and investigational centers. The primary end point is a composite of all-cause death, myocardial infarction, and cerebrovascular events at 12 months after the index procedure. The key secondary end points are definite/probable stent thrombosis defined by the Academic Research Consortium, and bleeding defined by Bleeding Academic Research Consortium type 2–5. Conclusions The SMART-CHOICE trial aims to examine the non-inferiority of monotherapy with one of any available oral P2Y12 inhibitors versus conventional DAPT of an identical P2Y12 inhibitor plus aspirin in a broad spectrum of patients receiving representative current-generation DES.

      PubDate: 2018-01-10T03:52:35Z
      DOI: 10.1016/j.ahj.2017.12.002
      Issue No: Vol. 197 (2018)
  • The influence of febuxostat on coronary artery endothelial dysfunction in
           patients with coronary artery disease: A phase 4 randomized,
           placebo-controlled, double-blind, crossover trial
    • Authors: Allison G. Hays; Micaela Iantorno; Michael Schär; Shenghan Lai; Matthew Czarny; Elayne Breton; Robert N. Palmer; Andrew Whelton; Robert G. Weiss; Gary Gerstenblith
      Pages: 85 - 93
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Allison G. Hays, Micaela Iantorno, Michael Schär, Shenghan Lai, Matthew Czarny, Elayne Breton, Robert N. Palmer, Andrew Whelton, Robert G. Weiss, Gary Gerstenblith
      Background The xanthine oxidase (XO) system is a significant source of vascular oxidative stress, which is believed to impair endothelial function, an important contributor to atherosclerotic disease. We tested whether febuxostat, a potent XO inhibitor, improves coronary endothelial function (CEF) in patients with stable coronary artery disease (CAD) in a single-center, randomized, placebo-controlled, double-blind crossover trial. Methods CEF was measured using noninvasive magnetic resonance imaging (MRI) assessment of changes in 30 patients with stable CAD and baseline impaired CEF. Patients received either febuxostat or placebo for 6 weeks and then were crossed over to the alternative for an additional 6 weeks. MRI-detected changes in coronary flow and in coronary cross-sectional area from rest to isometric handgrip exercise, a known endothelial-dependent stressor, were measured at the end of each 6 week period. Results Mean serum urate levels were lower at the end of the 6-week febuxostat period (2.9±0.8mg/dL) than at the end of the 6-week placebo period (5.9±0.04, P <.001). However, there were no significant differences in any of the CEF parameters measured at the end of the febuxostat and placebo periods. Conclusions In summary, although XO inhibition with febuxostat was well tolerated and lowered serum urate, it did not improve the primary end point of the study, CEF measured using MRI after 6 weeks of treatment. In conclusion, these findings suggest that short-term inhibition of XO does not significantly improve impaired CEF in patients with stable CAD.

      PubDate: 2018-01-10T03:52:35Z
      DOI: 10.1016/j.ahj.2017.11.006
      Issue No: Vol. 197 (2018)
  • Fine particulate matter and incident coronary heart disease in the REGARDS
    • Authors: Matthew Shane Loop; Leslie A. McClure; Emily B. Levitan; Mohammad Z. Al-Hamdan; William L. Crosson; Monika M. Safford
      Pages: 94 - 102
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Matthew Shane Loop, Leslie A. McClure, Emily B. Levitan, Mohammad Z. Al-Hamdan, William L. Crosson, Monika M. Safford
      Chronic exposure to fine particulate matter (PM2.5) is accepted as a causal risk factor for coronary heart disease (CHD). However, most of the evidence for this hypothesis is based upon cohort studies in whites, comprised of either only males or females who live in urban areas. It is possible that many estimates of the effect of chronic exposure to PM2.5 on risk for CHD do not generalize to more diverse samples. Methods Therefore, we estimated the relationship between chronic exposure to PM2.5 and risk for CHD in among participants in the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort who were free from CHD at baseline (n=17,126). REGARDS is a sample of whites and blacks of both genders living across the continental United States. We fit Cox proportional hazards models for time to CHD to estimate the hazard ratio for baseline 1-year mean PM2.5 exposure, adjusting for environmental variables, demographics, and other risk factors for CHD including the Framingham Risk Score. Results The hazard ratio (95% CI) for a 2.7-μg/m3 increase (interquartile range) 1-year mean concentration of PM2.5 was 0.94 (0.83-1.06) for combined CHD death and nonfatal MI, 1.13 (0.92-1.40) for CHD death, and 0.85 (0.73-0.99) for nonfatal MI. We also did not find evidence that these associations depended upon overall CHD risk factor burden. Conclusions Our results do not provide strong evidence for an association between PM2.5 and incident CHD in a heterogeneous cohort, and we conclude that the effects of chronic exposure to fine particulate matter on CHD require further evaluation.

      PubDate: 2018-01-10T03:52:35Z
      DOI: 10.1016/j.ahj.2017.11.007
      Issue No: Vol. 197 (2018)
  • Efficacy and safety of dual antiplatelet therapy after coronary stenting
           in patients with chronic kidney disease
    • Authors: Doyeon Hwang; Kyung Woo Park; Joo Myung Lee; Tae-Min Rhee; Myeong-Ki Hong; Yangsoo Jang; Marco Valgimigli; Antonio Colombo; Martine Gilard; Tullio Palmerini; Gregg W. Stone; Hyo-Soo Kim
      Pages: 103 - 112
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Doyeon Hwang, Kyung Woo Park, Joo Myung Lee, Tae-Min Rhee, Myeong-Ki Hong, Yangsoo Jang, Marco Valgimigli, Antonio Colombo, Martine Gilard, Tullio Palmerini, Gregg W. Stone, Hyo-Soo Kim
      Background We compared efficacy and safety of short- (3 or 6 months) versus long-term (≥12 months) dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation, according to the presence of chronic kidney disease (CKD). Methods Patient-level pooled analysis was performed with 7242 patients (87.2% with 2nd generation DES) from 5 randomized controlled trials. Results In both CKD (1273 patients) and non-CKD (5969 patients) population, the rates of patient-oriented composite outcomes at 1-year (POCO, all-cause death, any myocardial infarction [MI], stroke and TIMI major bleeding) were not different between the short- and long-term DAPT (hazard ratio [HR] 1.19, 95% confidence interval [CI] 0.76–1.86, P =.449 in CKD population; HR 1.14, 95% CI 0.83–1.56, P =.434 in non-CKD population). The rates of coronary thrombotic events (any MI and definite/probable stent thrombosis) also did not differ between short- and long-term DAPT in either CKD or non-CKD population. As for bleeding events, long-term DAPT increased the TIMI major bleeding (HR 2.91, 95% CI 1.31–6.48, P =.009) in non-CKD population. The similar trend was observed with long-term DAPT in CKD population. But it did not reach statistical significance (HR 3.15, 95% CI 0.64–15.63, P =.160). Conclusions The rates of POCO and coronary thrombotic events were significantly higher in patients with CKD compared with those without CKD, which were not affected by short- or long-term DAPT. Higher bleeding incidence by long-term DAPT was only observed in non-CKD patients but not in CKD patients. Further large scale studies are warranted to confirm our findings.

      PubDate: 2018-01-10T03:52:35Z
      DOI: 10.1016/j.ahj.2017.11.013
      Issue No: Vol. 197 (2018)
  • The Optimal Anti-Coagulation for Enhanced-Risk Patients Post–Catheter
           Ablation for Atrial Fibrillation (OCEAN) trial
    • Authors: Atul Verma; Andrew C.T. Ha; Paulus Kirchhof; Gerhard Hindricks; Jeff S. Healey; Michael D. Hill; Mukul Sharma; D. George Wyse; Jean Champagne; Vidal Essebag; George Wells; Dhiraj Gupta; Hein Heidbuchel; Prashanthan Sanders; David H. Birnie
      Pages: 124 - 132
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Atul Verma, Andrew C.T. Ha, Paulus Kirchhof, Gerhard Hindricks, Jeff S. Healey, Michael D. Hill, Mukul Sharma, D. George Wyse, Jean Champagne, Vidal Essebag, George Wells, Dhiraj Gupta, Hein Heidbuchel, Prashanthan Sanders, David H. Birnie
      Background The optimal long-term antithrombotic regimen for patients after successful catheter-based atrial fibrillation (AF) ablation is not well defined. Presently, practice variation exists, and the benefits of oral anticoagulation over antiplatelet therapy across the entire spectrum of stroke risk profile remain undefined in the postablation population. To date, there are no randomized trials to inform clinicians on this therapeutic question. Objective The objective was to assess whether rivaroxaban is superior to acetylsalicylic acid (ASA) in reducing the risk of clinically overt stroke, systemic embolism, or covert stroke among patients without apparent recurrent atrial arrhythmias for at least 1 year after their most recent AF ablation procedure. Methods/design A prospective, multicenter, open-label, randomized trial with blinded assessment of outcomes is under way (NCT02168829). Atrial fibrillation patients with at least 1 stroke risk factor (as defined by the CHA2DS2-VASc score) and without known atrial arrhythmia recurrences for at least 12 months after ablation are randomized to rivaroxaban 15 mg or ASA 75-160 mg daily. The primary outcome is a composite of clinically overt stroke, systemic embolism, and covert stroke based on brain magnetic resonance imaging. Key secondary outcomes include major bleeding outcomes, intracranial hemorrhage, transient ischemic attack, neuropsychological testing, quality of life, and an economic analysis. Subjects will be followed for 3 years. The estimated overall sample size is 1,572 subjects (786 per arm). Discussion The OCEAN trial is a multicenter randomized controlled trial evaluating 2 antithrombotic treatment strategies for patients with risk factors for stroke after apparently successful AF ablation. We hypothesize that rivaroxaban will reduce the occurrence of clinically overt stroke, systemic embolism, and covert stroke when compared with ASA alone.

      PubDate: 2018-01-23T04:54:00Z
      DOI: 10.1016/j.ahj.2017.12.007
      Issue No: Vol. 197 (2018)
  • Percutaneous coronary intervention and antiplatelet therapy in patients
           with atrial fibrillation receiving apixaban or warfarin: Insights from the
           ARISTOTLE trial
    • Authors: David Kopin; W. Schuyler Jones; Matthew W. Sherwood; Daniel M. Wojdyla; Lars Wallentin; Basil S. Lewis; Freek W.A. Verheugt; Dragos Vinereanu; M. Cecilia Bahit; Sigrun Halvorsen; Kurt Huber; Alexander Parkhomenko; Christopher B. Granger; Renato D. Lopes; John H. Alexander
      Pages: 133 - 141
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): David Kopin, W. Schuyler Jones, Matthew W. Sherwood, Daniel M. Wojdyla, Lars Wallentin, Basil S. Lewis, Freek W.A. Verheugt, Dragos Vinereanu, M. Cecilia Bahit, Sigrun Halvorsen, Kurt Huber, Alexander Parkhomenko, Christopher B. Granger, Renato D. Lopes, John H. Alexander
      Background We assessed antiplatelet therapy use and outcomes in patients undergoing percutaneous coronary intervention (PCI) during the ARISTOTLE trial. Methods Patients were categorized based on the occurrence of PCI during follow-up (median 1.8 years); PCI details and outcomes post-PCI are reported. Of the 18,201 trial participants, 316 (1.7%) underwent PCI (152 in apixaban group, 164 in warfarin group). Results At the time of PCI, 84% (267) were on study drug (either apixaban or warfarin). Of these, 19% did not stop study drug during PCI, 49% stopped and restarted <5 days post-PCI, and 30% stopped and restarted >5 days post-PCI. At 30 days post-PCI, 35% of patients received dual -antiplatelet therapy (DAPT), 23% received aspirin only, and 13% received a P2Y12 inhibitor only; 29% received no antiplatelet therapy. Triple therapy (DAPT + oral anticoagulant [OAC]) was used in 21% of patients, 23% received OAC only, 15% received OAC plus aspirin, and 9% received OAC plus a P2Y12 inhibitor; 32% received antiplatelet agents without OAC. Post-PCI, patients assigned to apixaban versus warfarin had numerically similar rates of major bleeding (5.93 vs 6.73 events/100 patient-years; P = .95) and stroke (2.74 vs 1.84 events/100 patient-years; P = .62). Conclusions PCI occurred infrequently during follow-up. Most patients on study drug at the time of PCI remained on study drug in the peri-PCI period; 19% continued the study drug without interruption. Antiplatelet therapy use post-PCI was variable, although most patients received DAPT. Additional data are needed to guide the use of antithrombotics in patients undergoing PCI.

      PubDate: 2018-02-05T09:43:19Z
      DOI: 10.1016/j.ahj.2017.11.005
      Issue No: Vol. 197 (2018)
  • Percutaneous coronary intervention of lesions with in-stent restenosis: A
           report from the ADAPT-DES study
    • Authors: Björn Redfors; Philippe Généreux; Bernhard Witzenbichler; Akiko Maehara; Giora Weisz; Thomas McAndrew; Roxana Mehran; Ajay J. Kirtane; Gregg W. Stone
      Pages: 142 - 149
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Björn Redfors, Philippe Généreux, Bernhard Witzenbichler, Akiko Maehara, Giora Weisz, Thomas McAndrew, Roxana Mehran, Ajay J. Kirtane, Gregg W. Stone
      Background There is a paucity of data from large contemporary cohorts of patients with in-stent restenosis (ISR) treated with drug-eluting stents (DESs), and no studies have examined the impact of high platelet reactivity (HPR) on the occurrence of ischemic events after ISR percutaneous coronary intervention (PCI) with DESs. We sought to report outcomes after PCI of ISR lesions and its association with HPR. Methods Patients in the prospective, multicenter ADAPT-DES study were stratified according to whether they had ISR versus non-ISR PCI. Two-year outcomes were compared between the groups using Cox proportional hazards models. HPR was defined as on-clopidogrel P2Y12 platelet reaction units >208 as measured by the VerifyNow assay; target vessel failure (TVF) was defined as the composite of all-cause death, myocardial infarction, or ischemia-driven target vessel revascularization. Results Among the 8,582 patients included in the ADAPT-DES study, 840 (9.8%) patients underwent successful ISR PCI. ISR PCI was independently associated with a higher 2-year risk of TVF (adjusted hazard ratio [HR] 1.95; 95% CI 1.68-2.27; P <.001) and stent thrombosis (adjusted HR 1.95; 95% CI 1.08-3.51; P =.027) but not bleeding (adjusted HR 0.94; 95% CI 0.73-1.21; P =.64). There was no statistical interaction between HPR and ISR versus non-ISR PCI in regard to TVF (adjusted P interaction =.81). Conclusions ISR PCI is associated with a considerably higher risk of 2-year adverse ischemic events, with HPR conferring similar risk in ISR and non-ISR PCI. More effective therapeutic strategies for managing ISR lesions are necessary.

      PubDate: 2018-02-05T09:43:19Z
      DOI: 10.1016/j.ahj.2017.11.011
      Issue No: Vol. 197 (2018)
  • A population health perspective on a claims and electronic health
           record–based tool to screen for suboptimal medication adherence
    • Authors: Leah L. Zullig; Lesley H. Curtis
      Pages: 150 - 152
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Leah L. Zullig, Lesley H. Curtis

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.10.012
      Issue No: Vol. 197 (2018)
  • The relative benefits of claims and electronic health record data for
           predicting medication adherence trajectory
    • Authors: Jessica M. Franklin; Chandrasekar Gopalakrishnan; Alexis A. Krumme; Karandeep Singh; James R. Rogers; Joe Kimura; Caroline McKay; Newell E. McElwee; Niteesh K. Choudhry
      Pages: 153 - 162
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Jessica M. Franklin, Chandrasekar Gopalakrishnan, Alexis A. Krumme, Karandeep Singh, James R. Rogers, Joe Kimura, Caroline McKay, Newell E. McElwee, Niteesh K. Choudhry
      Background Healthcare providers are increasingly encouraged to improve their patients' adherence to chronic disease medications. Prediction of adherence can identify patients in need of intervention, but most prediction efforts have focused on claims data, which may be unavailable to providers. Electronic health records (EHR) are readily available and may provide richer information with which to predict adherence than is currently available through claims. Methods In a linked database of complete Medicare Advantage claims and comprehensive EHR from a multi-specialty outpatient practice, we identified patients who filled a prescription for a statin, antihypertensive, or oral antidiabetic during 2011 to 2012. We followed patients to identify subsequent medication filling patterns and used group-based trajectory models to assign patients to adherence trajectories. We then identified potential predictors from both claims and EHR data and fit a series of models to evaluate the accuracy of each data source in predicting medication adherence. Results Claims were highly predictive of patients in the worst adherence trajectory (C=0.78), but EHR data also provided good predictions (C=0.72). Among claims predictors, presence of a prior gap in filling of at least 6 days was by far the most influential predictor. In contrast, good predictions from EHR data required complex models with many variables. Conclusion EHR data can provide good predictions of adherence trajectory and therefore may be useful for providers seeking to deploy resource-intensive interventions. However, prior adherence information derived from claims is most predictive, and can supplement EHR data when it is available.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.09.019
      Issue No: Vol. 197 (2018)
  • Cognition and brain changes associated with high-dose atorvastatin: A BOLD
    • Authors: Jeffrey N. Browndyke; Mitchell T. Heflin
      Pages: 163 - 165
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Jeffrey N. Browndyke, Mitchell T. Heflin

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.12.003
      Issue No: Vol. 197 (2018)
  • The effect of high-dose atorvastatin on neural activity and cognitive
    • Authors: Beth A. Taylor; Alecia D. Dager; Gregory A. Panza; Amanda L. Zaleski; Shashwath Meda; Gregory Book; Michael C. Stevens; Sarah Tartar; C. Michael White; Donna M. Polk; Godfrey D. Pearlson; Paul D. Thompson
      Pages: 166 - 174
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Beth A. Taylor, Alecia D. Dager, Gregory A. Panza, Amanda L. Zaleski, Shashwath Meda, Gregory Book, Michael C. Stevens, Sarah Tartar, C. Michael White, Donna M. Polk, Godfrey D. Pearlson, Paul D. Thompson
      Background Functional magnetic resonance imaging (fMRI) has not been used to assess the effects of statins on the brain. We assessed the effect of statins on cognition using standard neuropsychological assessments and brain neural activation with fMRI on two tasks. Methods Healthy statin-naïve men and women (48±15 years) were randomized to 80 mg/day atorvastatin (n=66; 27 men) or placebo (n=84; 48 men) for 6 months. Participants completed cognitive testing while on study drug and 2 months after treatment cessation using alternative test and task versions. Results There were few changes in standard neuropsychological tests with drug treatment (all P >.56). Total and delayed recall from the Hopkins Verbal Learning Test-Revised increased in both groups (P <.05). The Stroop Color-Word score increased (P <.01) and the 18-Point Clock Test decreased in the placebo group (P =.02) after drug cessation. There were, however, small but significant group-time interactions for each fMRI task: participants on placebo had greater activation in the right putamen/dorsal striatum during the maintenance phase of the Sternberg task while on placebo but the effect was reversed after drug washout (P <.001). Participants on atorvastatin had greater activation in the bilateral precuneus during the encoding phase of the Figural Memory task while on-drug but the effect was reversed after drug washout (P <.001). Conclusion Six months of high dose atorvastatin therapy is not associated with measurable changes in neuropsychological test scores, but did evoke transient differences in brain activation patterns. Larger, longer-term clinical trials are necessary to confirm these findings and evaluate their clinical implications.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.10.027
      Issue No: Vol. 197 (2018)
  • Changes in lipoprotein(a) following bariatric surgery
    • Authors: Bing-Xue Lin; Matthew C. Weiss; Manish Parikh; Jeffrey S. Berger; Edward A. Fisher; Sean P. Heffron
      Pages: 175 - 176
      Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197
      Author(s): Bing-Xue Lin, Matthew C. Weiss, Manish Parikh, Jeffrey S. Berger, Edward A. Fisher, Sean P. Heffron

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.10.020
      Issue No: Vol. 197 (2018)
  • Information for Readers
    • Abstract: Publication date: March 2018
      Source:American Heart Journal, Volume 197

      PubDate: 2018-02-14T12:18:47Z
  • Trends in the incidence and outcomes of patients with aortic stenosis
    • Authors: Andrew Czarnecki; Feng Qiu; Maria Koh; David Alter; Peter C. Austin; Stephen E. Fremes; Jack V. Tu; Harindra C. Wijeysundera; Andrew T. Yan; Dennis T. Ko
      Abstract: Publication date: Available online 13 February 2018
      Source:American Heart Journal
      Author(s): Andrew Czarnecki, Feng Qiu, Maria Koh, David Alter, Peter C. Austin, Stephen E. Fremes, Jack V. Tu, Harindra C. Wijeysundera, Andrew T. Yan, Dennis T. Ko
      Background Although the burden of aortic stenosis (AS) on our health care system is expected to rise, little is known regarding its epidemiology at the population level. Our primary objective was to evaluate trends in AS hospitalization, treatment and outcomes. Methods We performed a population-based observational study including 37,970 patients newly hospitalized with AS from 2004 and 2013 in Ontario, Canada. We calculated age- and sex-standardized rate of AS hospitalization through direct standardization. The independent association between year of the hospitalization, and 30-day and 1-year mortality rate was evaluated using logistic regression models to account for temporal changes in patient characteristics. Results The overall age- and sex-standardized AS hospitalization rate increased slightly from 36 per 100,000 in 2004 to 39 per 100,000 in 2013. A substantial increase was seen in patients ≥85years, where hospitalization rates increased 29% from 400 to 516 per 100,000 from 2004 to 2013 (P <.001). In this study period, 36.2% of patients received aortic valve interventions within 30days of hospitalization. Among treated patients, an improving mortality trend was observed in which the adjusted odds ratio (OR) was significantly lower in 2013 as compared to 2004 (OR 0.55 for 30-day mortality, 0.74 for 1-year morality). In contrast, no significant temporal change in mortality was seen among patients without aortic valve intervention. Conclusion AS hospitalizations in the elderly increased significantly beyond that was expected from population growth. Many AS patients did not receive aortic valve intervention after hospitalization. Mortality among the treated patients improved significantly over time.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2018.02.010
  • The prognostic value of heart rate recovery in patients with coronary
           artery disease A systematic review and meta-analysis
    • Authors: Sangeeta Lachman; Michel S. Terbraak; Jacqueline Limpens; Harald Jorstad; Cees Lucas; Wilma Scholte op Reimer; S. Matthijs Boekholdt; Gerben ter Riet; Ron J.G. Peters
      Abstract: Publication date: Available online 13 February 2018
      Source:American Heart Journal
      Author(s): Sangeeta Lachman, Michel S. Terbraak, Jacqueline Limpens, Harald Jorstad, Cees Lucas, Wilma Scholte op Reimer, S. Matthijs Boekholdt, Gerben ter Riet, Ron J.G. Peters
      Background Routine outpatient care of patients with coronary artery disease (CAD) lacks a simple measure of physical fitness and risk of mortality. Heart rate recovery (HRR) is noninvasive and easily obtainable in outpatient settings. Prior studies have suggested that delayed post-exercise HRR in the first minutes is associated with mortality in several types of populations. However, a comprehensive overview of the prognostic value of delayed HRR for time to mortality specifically in CAD patients is not available. The purpose of the current meta-analysis is to evaluate the prognostic value of delayed HRR in CAD patients. Methods We conducted a systematic search in OVID MEDLINE and OVID EMBASE to identify studies reporting on HRR and risk of incident cardiovascular events or mortality in CAD patients. Hazard ratios for delayed vs non-delayed HRR were pooled using random effects meta-analysis. Results Four studies were included, comprising 2428 CAD patients. The study quality of the included studies was rated moderate (n=2) to high (n=2). Delayed HRR was defined by ≤12 to ≤21 bpm in the recovery period. During follow-up (range 2.0-9.8 years), 151 patients died (6.2% (range 2.5%-19.5%)). Only data on mortality could be pooled. Heterogeneity was limited (I2=32%; p=0.23), pooled unadjusted hazard ratio for mortality, based on 3 studies, was 5.8 (95%CI 3.2-10.4). Conclusion In CAD patients, delayed HRR is significantly associated with all-cause mortality. As exercise testing is performed routinely in CAD patients, HRR can be considered in monitoring exercise, still further research must investigate the addition of HRR in current risk scores.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2018.02.008
  • Rationale and Methods of the Prospective Study of Biomarkers, Symptom
           Improvement, and Ventricular Remodeling During Sacubitril/Valsartan
           Therapy for Heart Failure (PROVE-HF)
    • Authors: James L. Januzzi; Javed Butler; Emmanuel Fombu; Alan Maisel; Kevin McCague; Ileana L. Piña; Margaret F. Prescott; Jerome B. Riebman; Scott Solomon
      Abstract: Publication date: Available online 13 February 2018
      Source:American Heart Journal
      Author(s): James L. Januzzi, Javed Butler, Emmanuel Fombu, Alan Maisel, Kevin McCague, Ileana L. Piña, Margaret F. Prescott, Jerome B. Riebman, Scott Solomon
      Background Sacubitril/valsartan is an angiotensin receptor-neprilysin inhibitor (ARNI) indicated for the treatment of patients with chronic heart failure (HF) with reduced ejection fraction (HFrEF); however, its mechanism of benefit remains unclear. Biomarkers that are linked to ventricular remodeling, myocardial injury, and fibrosis may provide mechanistic insight and important clinical guidance regarding sacubitril/valsartan use. Methods This 52-week, multicenter, open-label, single-arm study is designed to: (1) correlate biomarker changes with cardiac remodeling parameters, cardiovascular outcomes, and patient-reported outcome data; and (2) determine short- and long-term changes in concentrations of biomarkers related to potential mechanisms of action and effects of sacubitril/valsartan therapy. Approximately 830 patients with HF with reduced ejection fraction will be initiated and titrated on sacubitril/valsartan according to United States prescribing information. Primary efficacy endpoints include the changes in N-terminal pro–B-type natriuretic peptide (NT-proBNP) concentrations and cardiac remodeling from baseline to 1 year. Secondary endpoints include changes in concentrations of NT-proBNP and remodeling to 6 months, and changes in patient-reported outcomes using the Kansas City Cardiomyopathy Questionnaire-23 from baseline to 1 year. In addition, several other relevant biomarkers will be measured. Biomarker changes relative to the number of cardiovascular events in 12 months will also be assessed as exploratory endpoints. Conclusions Results from the Prospective Study of Biomarkers, Symptom Improvement, and Ventricular Remodeling During Sacubitril/Valsartan Therapy for Heart Failure (PROVE-HF) will help establish a mechanistic understanding of ARNI therapeutic benefits and provide clinicians with clarity on how to interpret information on biomarkers during treatment (PROVE-HF identifier: NCT02887183).
      Graphical abstract image

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2017.12.021
  • Prevalent Digoxin Use and Subsequent Risk of Death or Hospitalization in
           Ambulatory Heart Failure Patients with a Reduced Ejection Fraction –
           Findings from the HF-ACTION Randomized Controlled Trial
    • Authors: Andrew P. Ambrosy; Ankeet S. Bhatt; Amanda L. Stebbins; Lisa M. Wruck; Marat Fudim; Stephen J. Greene; William E. Kraus; Christopher M. O'Connor; Ileana L. Piña; David J. Whellan; Robert J. Mentz
      Abstract: Publication date: Available online 11 February 2018
      Source:American Heart Journal
      Author(s): Andrew P. Ambrosy, Ankeet S. Bhatt, Amanda L. Stebbins, Lisa M. Wruck, Marat Fudim, Stephen J. Greene, William E. Kraus, Christopher M. O'Connor, Ileana L. Piña, David J. Whellan, Robert J. Mentz
      Background Despite more than 200 years of clinical experience and a pivotal trial, recently published research has called into question the safety and efficacy of digoxin therapy in heart failure (HF). Methods HF-ACTION ( Number: NCT00047437 ) enrolled 2331 outpatients with HF and an EF ≤35% between April 2003 and February 2007 and randomized them to aerobic exercise training versus usual care. Patients were grouped according to prevalent digoxin status at baseline. The association between digoxin therapy and outcomes was assessed using Cox proportional hazard and inverse-probability weighted (IPW) regression models adjusted for demographics, medical history, medications, laboratory values, quality of life, and exercise parameters. Results The prevalence of digoxin therapy decreased from 52% during the first 6 months of enrollment to 35% at the end of the HF-ACTION trial (p-value = <0.0001). Study participants were 59± 13 years of age, 72% were male, and approximately half had an ischemic etiology of HF. Patients receiving digoxin at baseline tended to be younger and were more likely to report New York Heart Association functional class III/IV symptoms (rather than class II) compared to those not receiving digoxin. Patients taking digoxin had worse baseline exercise capacity as measured by peak VO2 and 6-min walk test and greater impairments in health status as reflected by the Kansas City Cardiomyopathy Questionnaire. The association between digoxin and the risk of death or hospitalization differed depending on whether Cox proportional hazard (Hazard Ratio 1.03, 95% Confidence Interval 0.92–1.16; p-value = 0.62) or IPW regression models (HR 1.08, 95% CI 1.00–1.17; p-value = 0.057) were used to adjust for potential confounders. Conclusion Although digoxin use was associated with high-risk clinical features, the association between digoxin therapy and outcomes was dependent on the statistical methods used for multivariable adjustment. Clinical equipoise exists and additional prospective research is required to clarify the role of digoxin in contemporary clinical practice including its effects on functional capacity, quality of life, and long-term outcomes.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2018.02.004
  • Dual Antiplatelet Therapy for Perioperative Myocardial Infarction
           Following CABG Surgery
    • Authors: Alice Wang; Angie Wu; Daniel Wojdyla; Renato D. Lopes; L. Kristin Newby; Mark F. Newman; Peter K. Smith; John H. Alexander
      Abstract: Publication date: Available online 11 February 2018
      Source:American Heart Journal
      Author(s): Alice Wang, Angie Wu, Daniel Wojdyla, Renato D. Lopes, L. Kristin Newby, Mark F. Newman, Peter K. Smith, John H. Alexander
      Objectives Perioperative myocardial infarction (MI) after coronary artery bypass graft surgery (CABG) has been associated with adverse outcome. Whether perioperative MI should be treated with dual antiplatelet therapy (DAPT) is unknown. We compared the effect of DAPT versus aspirin alone on short-term outcomes among patients with perioperative MI following CABG. Methods We used data from 3 clinical trials that enrolled patients undergoing isolated CABG: PREVENT IV (2002–2003), MEND-CABG II (2004–2005), and RED-CABG (2009–2010) (n = 9117). Perioperative MI was defined as CK-MB >5 times the upper limit of normal within 24 h of surgery (n = 2052). DAPT was defined as DAPT given after surgery and prior to discharge. A Cox regression model was used to assess the association between DAPT and 30-day nonfatal MI, stroke, or mortality after adjustment for baseline covariates. Results DAPT (n = 527) and aspirin alone (n = 1525) cohorts were similar in baseline comorbidities. Off pump bypass was used in 5.2% (n = 106) of patients. There was no difference in the 30-day composite of death, MI or stroke between patients receiving DAPT versus aspirin alone, nor in any of the individual components. There were fewer all-cause re-hospitalizations at 30 days following surgery among patients in the DAPT group (adjusted HR 0.71, CI 0.52–0.97, P = .033). Conclusion One-quarter of CABG patients who had perioperative MI were treated with DAPT. DAPT was not associated with a difference in MI, stroke, or mortality at 30 days, but was associated with fewer re-hospitalizations. Further studies are needed to determine the optimal antiplatelet regimen following perioperative MI. What is already known about this subject' Perioperative myocardial infarction portends poor outcome but optimal management is currently unclear. While dual antiplatelet therapy is standard of care for acute coronary syndrome, its role in perioperative myocardial infarction is unknown. What does this study add' Dual antiplatelet therapy use during perioperative myocardial infarction was not associated with a difference in myocardial infarction, stroke or mortality at 30 days. It was, however, associated with fewer re-hospitalizations at 30 days. How might this impact on clinical practice' Dual antiplatelet therapy may be a potential treatment option for perioperative myocardial infarction after CABG surgery. Further studies are needed to better understand treatment for this disease process.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2018.02.006
  • Telemedicine Cardiovascular Risk Reduction in Veterans: The CITIES trial
    • Authors: Hayden B. Bosworth; Maren K. Olsen; Felicia McCant; Karen M. Stechuchak; Susanne Danus; Matthew J. Crowley; Karen M. Goldstein; Leah L. Zullig; Eugene Z. Oddone
      Abstract: Publication date: Available online 10 February 2018
      Source:American Heart Journal
      Author(s): Hayden B. Bosworth, Maren K. Olsen, Felicia McCant, Karen M. Stechuchak, Susanne Danus, Matthew J. Crowley, Karen M. Goldstein, Leah L. Zullig, Eugene Z. Oddone
      Background Comprehensive programs addressing tailored patient self-management and pharmacotherapy may reduce barriers to cardiovascular disease (CVD) risk reduction. Methods Two-arm (clinical pharmacist specialist (CPS)-delivered, telehealth intervention and education control) randomized controlled trial including Veterans with poorly-controlled hypertension and/or hypercholesterolemia. Primary outcome was Framingham CVD risk score at 6 and 12 months, with systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), body mass index, and for those with diabetes, HbA1c as secondary outcomes. Results Among 428 Veterans, 50% were African American, 85% were men, and 33% had limited health literacy. Relative to the education control group, the CPS-delivered intervention did not show a reduction in CVD risk score at 6 months (-1.8, 95% CI: -3.9, 0.3; p=0.10) or 12 months (-0.3, 95% CI: -2.4, 1.7; p=0.74). No differences were seen in SBP, DBP, LDL at 6 or 12 months. We did observe a significant decline in total cholesterol at 6 months (-7.0, 95% CI: -13.4, -0.6; p=0.03) in the intervention relative to education control group. Among patients in the intervention group, 34% received at least 5 of the 12 planned intervention calls and were considered “compliers”. A sensitivity analysis of the “complier average causal effect” of intervention compared to control showed a mean difference in CVD risk score reduction of 5.7 (95% CI -12.0, 0.7) at 6 months and -1.7 (95% CI: -7.6, 4.8) at 12 months. Conclusion Despite increased access to pharmacist resources, we did not observe significant improvements in CVD risk for patients randomized to the intervention compared to education control over 12 months. However, the intervention may have positive impact among those who actively participate, particularly in the short-term.

      PubDate: 2018-02-14T12:18:47Z
      DOI: 10.1016/j.ahj.2018.02.002
  • Topographical Distribution of Perioperative Cerebral Infarction Associated
           with Transcatheter Aortic Valve Implantation
    • Authors: Jonathon P. Fanning; Allan J. Wesley; Darren L. Walters; Andrew A. Wong; Adrian G. Barnett; Wendy E. Strugnell; David G. Platts; John F. Fraser
      Abstract: Publication date: Available online 8 December 2017
      Source:American Heart Journal
      Author(s): Jonathon P. Fanning, Allan J. Wesley, Darren L. Walters, Andrew A. Wong, Adrian G. Barnett, Wendy E. Strugnell, David G. Platts, John F. Fraser
      Background Transcatheter aortic valve implantation (TAVI) is associated with a high incidence of cerebrovascular injury. As these injuries are thought to be primarily embolic, neuroprotection strategies have focussed on embolic protection devices. However, the topographical distribution of cerebral emboli and how this impacts on the effectiveness of these devices has not been thoroughly assessed. Here, we evaluated the anatomical characteristics of magnetic resonance imaging (MRI)-defined cerebral ischaemic lesions occurring secondary to TAVI to enhance our understanding of the distribution of cardioembolic phenomena. Methods Forty patients undergoing transfemoral TAVI with an Edwards SAPIEN-XT™ valve under general anaesthesia were enrolled prospectively in this observational study. Participants underwent brain MRI pre-procedure, and 3±1days and 6±1months post-procedure. Results Mean±standard deviation participant age was 82±7years. Patients had an intermediate-to-high surgical risk, with a mean Society of Thoracic Surgeons score of 6.3±3.5 and EuroSCORE of 18.1±10.6. Post-TAVI there were no clinically apparent cerebrovascular events but MRI assessments identified 83 new lesions across 19/31 (61%) participants, with a median±inter-quartile range number and volume of 1±2.8 lesions and 20±190 μL per patient. By volume, 80% of the infarcts were cortical, 90% in the posterior circulation and 81% in the right hemisphere. Conclusions The distribution of lesions that we detected suggests that cortical grey matter, the posterior circulation, and the right hemisphere are all particularly vulnerable to perioperative cerebrovascular injury. This finding has implications for the use of intraoperative cerebral embolic protection devices, particularly those that leave the left subclavian and, therefore, left vertebral artery unprotected.
      Graphical abstract image

      PubDate: 2017-12-13T02:15:29Z
      DOI: 10.1016/j.ahj.2017.12.008
  • A “Shocking” New Code Status
    • Authors: Anant Mandawat; Aditya Mandawat; Gregory Curfman; L. Kristin Newby
      Abstract: Publication date: Available online 7 December 2017
      Source:American Heart Journal
      Author(s): Anant Mandawat, Aditya Mandawat, Gregory Curfman, L. Kristin Newby

      PubDate: 2017-12-13T02:15:29Z
      DOI: 10.1016/j.ahj.2017.12.004
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