Boris Arbit

Prognostic Contribution of Exercise Capacity, Heart Rate Recovery, Chronotropic Incompetence, and Myocardial Perfusion Single-Photon Emission Computerized Tomography in the Prediction of Cardiac Death and All-Cause Mortality.

Chronotropic incompetence, measured by the percentage (%) of heart rate (HR) reserve achieved (%HR reserve), abnormal HR recovery, reduced exercise capacity (EC), and myocardial perfusion single-photon emission computerized tomography (SPECT MPS) abnormalities are known predictors of all-cause mortality (ACM) and cardiac death (CD). The aim of this study was to determine if EC, %HR reserve, and HR recovery add incremental value to MPS in the prediction of ACM and CD. A total of 11,218 patients without valvular disease and not on β blockers underwent symptom-limited exercise MPS. %HR reserve was (peak HR - rest HR)/(220 - age - rest HR) × 100, with %HR reserve <80 defined as low. HR recovery was peak HR - recovery HR. An HR recovery <22 beats/min at 2 minutes after peak exercise was considered abnormal. Poor EC was defined as exercise duration ≤6 minutes (7 metabolic equivalents). Summed stress scores (SSSs) were calculated using a 20-segment, 5-point MPS model. Statistical analysis was performed using Cox regression models. There were 445 deaths (148 CD) during a mean follow-up of 3.2 ± 2.5 years. In multivariate analysis, the independent predictors of ACM were age, χ(2) = 154.81; EC, χ(2) = 74.00; SSS, χ(2) = 32.99; %HR reserve, χ(2) = 24.74; abnormal electrocardiogram at rest, χ(2) = 23.13; HR recovery, χ(2) = 18.45; diabetes, χ(2) = 17.75; and previous coronary artery disease, χ(2) = 11.85 (p ≤0.0006). The independent predictors of CD were SSS, χ(2) = 54.25; EC, χ(2) = 49.34; age, χ(2) = 46.45; abnormal electrocardiogram at rest, χ(2) = 30.60; previous coronary artery disease, χ(2) = 20.69; Duke treadmill score, χ(2) = 19.50; %HR reserve, χ(2) = 11.43; diabetes, χ(2) = 10.23 (all p ≤0.0014); and HR recovery, χ(2) = 5.30 (p = 0.0214). The exercise variables showed increases in Harrells C static and net improvement reclassification, with EC showing the strongest incremental improvement in predicting ACM and CD (respective C-index 76.5% and 83.3% and net reclassification index 0.3201 and 0.4996). In conclusion, EC, %HR reserve, and HR recovery are independent predictors of ACM and CD and add incremental prognostic value to extent and severity of MPS.

Prognostic Usefulness of Proenkephalin in Stable Ambulatory Patients With Heart Failure

Patients with heart failure have a poor prognosis, yet outcomes might be improved by early identification of risk. Proenkephalin (proENK), a novel biomarker, is a stable surrogate marker for endogenous enkephalins and is an independent predictor of heart failure and death in patients who had an acute myocardial infarction. This is the first study to evaluate the prognostic utility of this biomarker in stable ambulatory patients. We conducted a 4-year single-center prospective cohort study of 200 patients who were referred for an outpatient echocardiogram. Blood samples were obtained to analyze levels of proENK at the time of the initial echocardiogram. Patients were evaluated for the combined end point cardiovascular-related hospital admission or death. Participants with higher proENK levels were older and had higher serum creatinine and lower estimated glomerular filtration rate, lower ejection fraction, and higher rates of hypertension and diabetes (p ≤0.009). Highest proENK tertile had a hazard ratio of 3.0 (95% confidence interval 1.4 to 6.7) compared with the first tertile (p <0.007) for the primary end point. In conclusion, proENK demonstrated significant prognostic utility for cardiovascular-related hospital admission or death.

Current and novel biomarkers in heart failure: bench to bedside.

Purpose of review Natriuretic peptides, high-sensitivity cardiac troponins, and suppression of tumorigenicity 2 are novel biomarkers that reflect the intricate pathophysiology of heart failure and can thus be used for the diagnosis, management, and prognosis of heart failure. Recent findings This review article describes the significance of B-type natriuretic peptide (BNP), N-terminal prohormone of BNP, ST2, and cardiac troponins. We outline their new roles in guiding the management of heart failure as well as strong prognostic indicators for adverse cardiovascular outcomes. Summary By recognizing the diagnostic and prognostic significance of these biomarkers, clinicians can utilize these biomarkers to more accurately evaluate and risk stratify patients. These markers can also be used to help guide the medical management of heart failure. The best approach for an accurate diagnosis, management, and prognosis of heart failure will likely involve a multimarker panel of biomarkers, which may include high-sensitivity troponins, BNP, N-terminal prohormone of BNP, and ST2.

Reversal agents for direct oral anticoagulants: A focused review

For several decades the vitamin K antagonist oral anticoagulants were the only outpatient therapy that existed to reduce the risk of stroke and thromboembolism. When the new direct oral anticoagulants were approved for use and addressed many of the issues associated with oral vitamin K antagonists, a new concern arose-the lack of rapid ability to reverse these agents. Physicians and patients were concerned that in cases of life-threatening bleeding or need for emergent surgery, an antidote to reverse the anticoagulation effect of these agents did not exist. Contemporary research has aimed to produce reversal agents that can be administered to safely neutralize the anticoagulant effect. In this focused review we describe the clinical development as well as mechanisms of action of three agents (idarucizumab, andexanet alpha, and ciraparantag). We review the pharmacokinetics, animal and human study data of these reversal agents and outline the evidence supporting their use. Although questions of safety and appropriate use remain, these reversal agents offer a significant step forward in the widespread use of direct oral anticoagulants and overall management of the anticoagulant effect.

Antithrombotic regimens in patients with atrial fibrillation and coronary artery disease after percutaneous coronary intervention: A focused review

Atrial fibrillation and coronary artery disease are common comorbidities with increasing incidences worldwide. About 5-15% of atrial fibrillation patients will require coronary stenting at some point in their lives, which necessitates dual antiplatelet therapy with aspirin and a P2Y12 antagonist. Triple therapy refers to the clinical scenario in which a patient is prescribed aspirin, P2Y12 antagonist, and oral anticoagulant, usually in the setting of atrial fibrillation. Current guidelines on atrial fibrillation do not offer strong recommendations on triple therapy management. Furthermore, the optimal duration of dual antiplatelet therapy after percutaneous coronary intervention is evolving based on contemporary research and development of newer generation drug eluting stents, changing the necessary duration of triple therapy in patients with atrial fibrillation. This review will offer an in-depth survey of current guidelines, current evidence, and future studies regarding triple therapy in atrial fibrillation patients undergoing percutaneous coronary intervention.

Non–Vitamin K Antagonist Oral Anticoagulant Use in Patients With Atrial Fibrillation and Associated Intracranial Hemorrhage: A Focused Review

Atrial fibrillation (AF) is the most common cardiac arrhythmia and predisposes patients to an increased risk of embolic stroke. After nearly 60 years, warfarin is no longer the only effective therapeutic option for patients with AF. Large randomized trials have consistently shown that non–vitamin K oral anticoagulants (NOACs) including dabigatran, rivaroxaban, apixaban, and edoxaban significantly reduce from the risk of intracranial hemorrhage (ICH) compared with warfarin. We provide a focused review regarding the NOACs and ICH in AF patients by summarizing findings of these large clinical trials, mechanisms of lower ICH, reversal strategies with specific agents, and monitoring strategies.

Heart Failure With Recovered Ejection Fraction in African Americans: Results From the African-American Heart Failure Trial

BACKGROUND Recent studies have described the entity of heart failure with recovered ejection fraction (HFrecEF), but population-specific studies remain lacking. The aim of this study was to characterize patients enrolled in the African-American Heart Failure Trial (A-HeFT) who had significant improvement in their ejection fraction (EF) during the 1st 6 months of follow-up. METHODS AND RESULTS Subjects with HFrecEF (improvement in EF from <35% to >40% in 6 months; n = 59) were compared with 259 subjects with heart failure and persistently reduced EF (HFrEF), defined as EF ≤40% at 6-month follow-up. The effects of improvement in EF on all-cause mortality and 1st and all hospitalizations were analyzed. Compared with HFrEF, subjects with HFrecEF had a nonsignificant trend toward lower mortality (hazard ratio [HR] 0.16, 95% confidence interval [CI] 0.02-1.15; P = .068), fewer 1st HF hospitalizations (HR 0.22, 95% CI 0.07-0.71; P = .011), fewer recurrent HF hospitalizations (HR 0.13, 95% CI 0.05-0.37; P <.001), similar 1st all-cause hospitalizations (HR 0.67, 95% CI 0.39-1.15; P = .150), and fewer recurrent all-cause hospitalizations (HR 0.41, 95% CI 0.24-0.68; P <.001). CONCLUSIONS These data confirm that, as in other populations, a small subgroup of black patients receiving standard care improve their EF with favorable outcomes. Further studies are required to determine whether myocardial recovery is permanent and the best management strategies in such patients.

TCT-624 Clinical Outcomes with Everolimus-Eluting Stent for the Treatment of Cardiac Allograft Vasculopathy

Background: “One-stop” hybrid coronary revascularization (HYBRID) with LIMALAD bypass grafting and DES implantations in non-LAD lesions is a newer therapy for the treatment of multivessel coronary artery disease. The present study aimed to compare the angiographic patency rates between HYBRID and PCI at mid-term repeat coronary angiogram. Methods: From June 2007 to December 2009, 104 patients underwent HYBRID and 7165 patients underwent PCI with DES implantations at our center. The major inclusion criteria of the study are: 1) triple vessel disease including revascularizable LAD lesion; 2) heart team consensus reached that either HYBRID or PCI could be performed in each individual; 3) no chest pain and MACCE occurred during clinical follow-up. According to these, 102 patients in Hybrid group and 157 patients in PCI group who agrees to take repeat angiogram were enrolled. From October, 2010 to December, 2011, 50 HYBRID patients signed the agreement and underwent angiogram. Among the 157 PCI cases, 50 patients (1:1) are selected for repeat angiography with the use of propensity score matching method. Results: The angiographic follow-up durations were similar the two groups (18 8.03 months vs. 19.3 9.12 months). There are no significant differences in baseline characteristics. There were 50 LIMA grafts and 64 non-LAD target vessels in Hybrid group; the angiographic target vessel patency rate was 89.5%, and the TLR rate was 7.9%. In PCI group, the angiographic target vessel patency rate was 82.7%, and the TLR rate was 20.4%. There was no significant difference in overall patency between the Hybrid group and PCI group (89.5% vs. 82.7%, p 0.07), but a significantly higher patency rate of LIMA-LAD graft in Hybrid group vs. that of stented LAD in PCI group (98% vs. 80%, p 0.004); and no significant difference in non-LAD target vessel patency between the two groups (82.8% vs. 85.2%, p 0.727). Conclusions: Compared to PCI with DES implantations, the treatment of multivessel coronary artery disease with “one-stop” hybrid revascularization demonstrated that the patency rate of LIMA-LAD graft was superior to that of PCI in LAD, and the non-LAD vessel patency rate was similar in two groups.