Andre Paixao

Atherosclerotic Cardiovascular Disease Prevention A Comparison Between the Third Adult Treatment Panel and the New 2013 Treatment of Blood Cholesterol Guidelines

The recently released American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines on the Treatment of Blood Cholesterol propose significant changes to current practice patterns.1 The adoption of these new guidelines in place of the National Cholesterol Education Program/Third Adult Treatment panel (ATPIII)2 recommendations has recently been estimated to result in an 11% increase in statin eligibility, representing 12.8 million Americans.3 Although the magnitude of change in statin eligibility has been a topic of focus, the impact of the new guidelines on atherosclerotic cardiovascular disease (ASCVD) event rates and efficiency of additional statin use cannot be determined from the studies published to date. Knowledge of ASCVD event rates among reclassified individuals is essential to fully understand the implications of adopting the ACC/AHA guidelines. We sought to assess the implications of applying this new paradigm in place of the ATPIII recommendations on ASCVD event reduction and efficiency of statin utilization. The Dallas Heart Study is a multiethnic cohort of Dallas County residents, age 30 to 65 years, examined between 2000 and 2002 and actively followed for cardiovascular outcomes.4 All participants provided informed consent, and the study was approved by the Institutional Review Board of the University of Texas Southwestern Medical Center. Sampling weights were applied to generate unbiased estimates of population frequencies in Dallas County.4 The primary outcome of ASCVD was defined as coronary heart disease (CHD) death, myocardial infarction, and fatal and nonfatal stroke.1 Secondary analysis was performed …

Coronary artery calcium improves risk classification in younger populations

OBJECTIVES This study sought to assess the effect of coronary artery calcium (CAC) on coronary heart disease (CHD) risk prediction in a younger population. BACKGROUND CAC measured by computed tomography improves CHD risk classification in older adults, but the effectiveness of CAC in younger populations has not been fully assessed. METHODS In the DHS (Dallas Heart Study), a multiethnic probability-based population sample, traditional CHD risk factors and CAC were measured in participants without baseline cardiovascular disease or diabetes. Incident CHD-defined as CHD death, myocardial infarction, or coronary revascularization-was assessed over a median follow-up of 9.2 years. Predicted CHD risk was assessed with a Weibull model inclusive of traditional risk factors before and after the addition of CAC as ln(CAC + 1). Participants were divided into 3 10-year risk categories, <6%, 6% to <20%, and ≥20%, and the net reclassification improvement (NRI) was calculated. We also performed a random-effects meta-analysis of NRI from previous studies inclusive of older individuals. RESULTS The analysis comprised 2,084 participants; mean age was 44.4 ± 9.0 years. CAC was independently associated with incident CHD (hazard ratio per SD: 1.90, 95% confidence interval [CI] 1.51 to 2.38; p < 0.001). The addition of CAC to the traditional risk factor model resulted in significant improvement in the C-statistic (delta = 0.03; p = 0.003). Among participants with CHD events, the addition of CAC resulted in net correct upward reclassification of 21%, and among those without CHD, a net correct downward reclassification of 0.5% (NRI: 0.216, p = 0.012). Results remained significant when the outcome was restricted to CHD death and myocardial infarction and when individuals with diabetes were included. The NRI observed in this study was similar to the pooled estimate from previous studies (0.200, 95% CI: 0.140 to 0.258) and the addition of our study to the meta-analysis did not result in significant heterogeneity (I(2) = 0%). CONCLUSIONS CAC scoring also improves CHD risk classification in younger adults.

Association of prediabetes by fasting glucose and/or haemoglobin A1c levels with subclinical atherosclerosis and impaired renal function: Observations from the Dallas Heart Study

Background: Prediabetes defined by fasting plasma glucose (FPG) and glycosylated haemoglobin (HbA1c) predicts incident diabetes, but their individual and joint associations with micro- and macro-vascular risk remain poorly defined. Methods: FPG, HbA1c, coronary artery calcium (CAC), carotid wall thickness, estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR) were measured in adults free from prior diabetes or cardiovascular disease (CVD) in the Dallas Heart Study 2 (DHS-2), a population-based cohort study. Prediabetes was defined by FPG 100–125 mg/dL and/or HbA1c 5.7%–6.4%. Multivariable logistic regression was used to analyse associations of HbA1c and/or FPG in the prediabetes range with subclinical atherosclerosis and renal measures. Results: The study comprised 2340 participants, median age = 49 years; 60% women and 50% black. Those with prediabetes were older (52 vs 48 years), more often men (63% vs 53%), black (53% vs 47%) and obese (58% vs 40%; p < 0.001 for each). Prediabetes was captured by FPG alone (43%), HbA1c alone (30%) or both (27%). Those with prediabetes by HbA1c or FPG versus normal HbA1c/FPG had more CAC [odds ratio (OR) = 1.8; 95% confidence interval (CI) = 1.5–2.2], higher carotid wall thickness (1.32 vs 1.29 mm, p < 0.001), eGFR < 60 mL/min [OR = 1.6 (95% CI = 1.1–2.4)], UACR > 30 mg/dL [OR = 1.8 (95% CI = 1.2–2.7)] and a higher odds for the composite eGFR + UACR [chronic kidney disease (CKD) ≥ 2] [OR = 1.9 (95% CI = 1.5–2.6)]. After multivariable adjustment, none of these associations remained significant. Conclusion: Prediabetes defined by HbA1c and/or FPG criteria is crudely associated with markers of diabetic macro- and micro-vascular disease, but not after statistical adjustment, suggesting the relationships are attributable to other characteristics of the prediabetes population.

Cardiovascular Lifetime Risk Predicts Incidence of Coronary Calcification in Individuals With Low Short‐Term Risk: The Dallas Heart Study

Background The absence of coronary artery calcium (CAC) in middle age is associated with very low short‐term risk for coronary events. However, the long‐term implications of a CAC score of 0 are uncertain, particularly among individuals with high cardiovascular lifetime risk. We sought to characterize the association between predicted lifetime risk and incident CAC among individuals with low short‐term risk. Methods and Results We included 754 Dallas Heart Study participants with serial CAC scans (6.9 years apart) and both low short‐term risk and baseline CAC=0. Lifetime risk for cardiovascular disease was estimated according to risk factor burden. Among this group, 365 individuals (48.4%) were at low lifetime risk and 389 (51.6%) at high lifetime risk. High lifetime risk was associated with higher annualized CAC incidence (4.2% versus 2.7%; P < 0.001). Similarly, mean follow‐up CAC scores were higher among participants with high lifetime risk (7.8 versus 2.4 Agatston units). After adjustment for age, sex, and race, high lifetime risk remained independently associated with incident CAC (OR 1.60; 95% CI 1.12 to 2.27; P=0.01). When assessing risk factor burden at the follow‐up visit, 66.7% of CAC incidence observed in the low lifetime risk group occurred among individuals reclassified to a higher short‐ or long‐term risk category. Conclusion Among individuals with low short‐term risk and CAC scores of 0, high lifetime risk is associated with a higher incidence of CAC. These findings highlight the importance of lifetime risk even among individuals with very low short‐term risk.

Disagreement Between Different Definitions of Coronary Artery Calcium Progression.

Progression of coronary artery calcium (CAC) as measured by computed tomography independently predicts coronary heart disease (CHD) events [(1)][1]. Several methods have been proposed to define and quantify CAC progression yet very few studies have compared different CAC progression definitions [(2,

Paravalvular Leaks: One Size (or Shape) Doesn't Always Fit All?

Paravalvular leak (PVL) remains as uncommon but serious complication after surgical prosthetic valve implantation. PVL when associated which congestive heart failure, hemolytic anemia, or infective endocarditis may require percutaneous treatment. High‐surgical risk is common in this population. Dedicated PVL devices are lacking often limiting optimal treatment.Key Points Paravalvular leak (PVL) remains as uncommon but serious complication after surgical prosthetic valve implantation. PVL when associated which congestive heart failure, hemolytic anemia, or infective endocarditis may require percutaneous treatment. High-surgical risk is common in this population. Dedicated PVL devices are lacking often limiting optimal treatment.

Risk factor burden and control at the time of admission in patients with acute myocardial infarction: Results from the NCDR.

BACKGROUND Understanding risk factor burden and control as well as perceived risk prior to acute myocardial infarction (MI) presentation may identify gaps in contemporary systems of care. METHODS Patients presenting with MI in the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry--Get With the Guidelines between January 2007 and November 2013 (N = 443,117) were stratified into 5 mutually exclusive risk categories: Framingham Risk Score (FRS) <10% 74,990 (16.9%), FRS 10% to 20% 90,429 (20.4%), FRS >20% 25,701 (5.8%), diabetes without cardiovascular disease (CVD) 67,779 (15.3%), and prior CVD 184,218 (41.6%). Low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol (non-HDL-C) goals and statin eligibility were determined based on the Third Adult Treatment Panel. RESULTS At presentation, 66.3% met the low-density lipoprotein cholesterol goal, 66.8% met the non-HDL-C goal, 63.7% were nonsmokers, and 65.1% of patients with prior CVD were on aspirin. Only 36.1% of patients met all assessed risk factor control metrics. Overall statin eligibility prior to MI was 60.8%, and 61.1% of statin-eligible patients reported statin use. CONCLUSION Risk factor control prior to MI was suboptimal, with the majority of individuals failing to meet at least 1 risk factor control metric. More effective system-based interventions are needed to promote adherence to prevention targets.

“Bringing on the light” in a complex clinical scenario: Optical coherence tomography–guided discontinuation of antiplatelet therapy in cancer patients with coronary artery disease (PROTECT-OCT registry)

Background Cancer patients with recently placed drug‐eluting stents (DESs) often require premature dual antiplatelet therapy (DAPT) discontinuation for cancer‐related procedures. Optical coherence tomography (OCT) can identify risk factors for stent thrombosis such as stent malapposition, incomplete strut coverage and in‐stent restenosis and may help guide discontinuation of DAPT. Methods We conducted a single‐center prospective study in cancer patients with recently placed (1–12 months) DES who required premature DAPT discontinuation. Patients were evaluated with diagnostic coronary angiogram and OCT. Individuals with appropriate stent strut coverage, expansion, apposition, and absence of in‐stent restenosis or intraluminal masses were considered low risk and transiently discontinued DAPT to allow optimal cancer therapy. Patients who did not meet all these criteria were considered high risk and underwent further endovascular treatment when appropriate and bridging with low‐molecular weight heparin. The incidence of adverse cardiovascular events was assessed after the procedure and at 12 months. Results A total of 40 patients were included. Twenty‐seven patients (68%) were considered low risk by OCT criteria and DAPT was transiently discontinued. Thirteen patients (32%) were considered high risk with one or more OCT findings: uncovered stent struts (4 patients, 10%); stent underexpansion (3 patients, 8%); malapposition (8 patients, 20%); in‐stent restenosis (2 patients, 5%). The high‐risk patients with uncovered stent struts and malapposition underwent additional stent dilatation. There were no cardiovascular events in the low‐risk group. One myocardial infarction occurred in the high‐risk group. Fourteen non‐cardiac deaths were registered before 12 months due to cancer progression or cancer therapy. Conclusion OCT imaging allows identification of low‐risk cancer patients with DES placed who may safely discontinue DAPT and proceed with cancer‐related surgery or procedures.

Immediate and intermediate-term results of optical coherence tomography guided atherectomy in the treatment of peripheral arterial disease: Initial results from the VISION trial

BACKGROUND Long-term patency rates for percutaneous peripheral arterial interventions are suboptimal. Optical coherence tomography (OCT) guided atherectomy may yield superior patency by optimizing plaque removal while preserving the tunica media and adventitia. METHODS The VISION study is a multicenter prospective study of patients with peripheral arterial disease undergoing OCT guided atherectomy with the Pantheris™ device. In 11 patients enrolled in a single center, we report procedural and clinical outcomes, at 30days and 6months. RESULTS The mean age was 63±11years and 73% (n=8) were men. The target lesion was in the superficial femoral artery in 82% (n=9) of the patients. Mean stenosis severity was 87%±10% and mean lesion length was 39±31mm. Procedural success was observed in all patients with no device related complications. Mean post-atherectomy stenosis was 18%±15%. Almost all excised tissue consisted of intimal plaque (94%). At 30days, significant improvements in Rutherford class, VascuQoL scores and ABI were observed, 0.9±0.8 vs. 3.1±0.7 (p=0.01), 4.9±1.9 vs. 3.6±1.5 (p=0.03) and 1.04±0.19 vs. 0.80±0.19 (p<0.01) respectively. At 6months, there were significant improvements in Rutherford class (1.0±1.0 vs. 3.1±0.7, p=0.01) and ABI (0.93±0.19 versus 0.80±0.19, p=0.02) but not in VascuQoL scores (3.7±1.4 versus 3.6±1.5, p=0.48). Target lesion revascularization occurred in 18% (n=2) of the patients. CONCLUSION OCT guided atherectomy resulted in high procedural success, no device related complications and encouraging results up to 6months. Histological analysis suggested little injury to the media and adventitia. Larger studies are needed to confirm the efficacy of this approach.

Acute Troponin Elevation and the Classification of Myocardial Infarction

A52-year-oldwomanwith a history of hypertension presented to the emergency department with chest pain that started while sitting at work 2 hours previously. She described the pain as “someone sitting on her chest” and reported associated diaphoresis and shortness of breath. She reported nonadherence to bloodpressuremedications. Onphysical examination, the heart rate was 99 beats per minute and blood pressure was 247/130mmHg. An electrocardiogram showed sinus rhythm with left ventricular hypertrophy (LVH) and inferior T-wave inversion. Laboratory values are shown in Table 1. AnechocardiogramshowedmoderateLVHwithpreserved left ventricular systolic function and no segmental wall motion abnormalities. The following day she underwent coronary angiography,which revealed onlymild nonobstructive coronary artery diseasewith a 20% stenosis of the proximal left circumflex coronary artery.