Tushar Acharya

Frequent Atrial Premature Complexes and Their Association With Risk of Atrial Fibrillation

Identification of precursors of atrial fibrillation (AF) may lead to early detection and prevent associated morbidity and mortality. This study aimed to examine the association between frequent atrial premature complexes (APCs) and incidence of AF. For this retrospective cohort study, we analyzed Holter recordings obtained from 2000 to 2010 of 1,357 veterans free of AF at baseline. All pertinent data in electronic medical records were reviewed to ascertain baseline characteristics. Holter groups with frequent (≥100/day) and infrequent (<100/day) APCs were compared for development of new AF over a median follow-up of 7.5 years. Multivariate Cox regression analyses were performed before and after propensity score matching. Mean age was 64 years with 93% men. Mean body mass index, hemoglobin A1C, low-density lipoprotein, left atrial size, and heart rate were 31.24 kg/m(2), 6.42%, 107.92 mg/dl, 4.26 cm, and 73 beats/min, respectively. AF was noted in 21.8% of patients with frequent APCs compared to 5.6% of those with infrequent APCs. After adjusting for demographics, medication use, co-morbidities, and laboratory and echocardiographic findings, multivariate Cox regression analyses confirmed frequent APCs to be independently associated with higher incidence of AF (hazard ratio [HR] 2.97, 95% confidence interval [CI] 1.85 to 4.80; p <0.001). In propensity-matched groups, this association remained significant (HR 2.87, 95% CI 1.65 to 4.98; p <0.001). Additionally, atrial couplets (≥50/day), atrial bigeminy (≥50/day), frequent runs of ≥3 APCs (≥20 runs/day), and longer runs (≥10 beats/run) were significantly associated with AF (HR 3.11, 3.67, 2.94, and 1.73, respectively, all p <0.05). In conclusion, frequent APCs (≥100/day) are associated with greater risk of AF.

Resistant Hypertension and Associated Comorbidities in a Veterans Affairs Population

Resistant hypertension (RH) is understudied and its reported prevalence varies with study populations. The authors sought to determine its prevalence and association with certain comorbid conditions in a Veterans Affairs population. This cross‐sectional study utilized demographic and clinical data from 17,466 patients. Chi‐square or t test was used for comparing groups with and without RH. Multivariate logistic regression analysis was used to determine independent associations. Overall, the prevalence of RH was 9%, and 13% of all hypertensive patients met criteria for RH. After adjusting for confounding variables, RH was significantly associated with older age (odds ratio [OR], 1.007), higher body mass index (OR, 1.04), Framingham score (OR, 1.14), and coexisting coronary artery disease, cerebrovascular accident/transient ischemic attack, peripheral vascular disease, congestive heart failure, chronic kidney disease, diabetes mellitus, erectile dysfunction, and metabolic syndrome (OR, 1.3, 1.32, 1.29, 2.88, 2.13, 1.2, 1.12, and 1.2, respectively; all P<.05). Our results indicate a complex interplay of certain comorbid conditions among patients with RH and suggest the need for multifaceted interventions in this high‐risk population to prevent cardiovascular events.

Finding the High-Risk Patient in Primary Prevention Is Not as Easy as a Conventional Risk Score!

Patients with coronary artery disease or its equivalent are an appropriate target for guideline-directed therapy. However, finding and treating the individuals at risk for myocardial infarction or sudden death in primary prevention has been problematic. Most initial cardiovascular events are acute syndromes, and only a minority of these occurs in those deemed high risk by contemporary algorithms. Even newer noninvasive modalities cannot detect a majority of those at risk. Furthermore, accurate and early detection of high risk/vulnerability does not guarantee event prevention. Until new tools can be identified, one should consider a few simplistic solutions. In addition to a greater emphasis on lifestyle, earlier use of statins than currently recommended and a direct assault on tobacco could go a long way in reducing acute syndromes and cardiovascular mortality. To achieve the tobacco goal, the medical community would have to be directly and communally engaged.

Reducing Acute Coronary Events: The Solution Is Not So Difficult!

It is well known to most physicians that cardiovascular disease, including acute myocardial infarction and sudden cardiac death, is the leading cause of mortality for adults in the United States, surpassing deaths related to cancer. Although the event rates have decreased through advances in medical care, the disease burden remains substantial. According to the American Heart Association, there are 720,000 new or recurrent acute myocardial infarctions and 424,000 sudden cardiac deaths every year. In the past, the primary method for reducing acute myocardial infarction and sudden cardiac death has been to identify those at risk or those with the acute presentation and to treat appropriately with guideline-directed medical, interventional, or surgical therapies. Identifying appropriate patients is easy in those with established disease or in those with coronary disease equivalents, such as diabetes, peripheral vascular disease, or significant renal insufficiency. Difficulty arises in trying to identify patients without a history. Those at highest risk according to Framingham have a 10-year event rate 20%, but most initial adverse cardiovascular events, including acute myocardial infarction and sudden cardiac death, occur in the intermediateand low-risk populations. The latter comprise a larger population overall, although at a lower event rate (percentage) than the high-risk population. In an effort to better characterize and treat these lower-risk populations, the new cholesterol guidelines have broadened their recommendations for statin therapy to include individuals aged 40 to 75 years with a 10-year risk of 7.5%. Other markers of atherosclerosis are being studied to enhance risk prediction. These include calcium scoring, carotid intimal-medial thickness measurements, high-sensitivity C-reactive protein, and several others. Ongoing studies, such as the High-Risk Plaque initiative, are assessing the additive benefit of some of these noninvasive imaging markers above standard risk factors in predicting first adverse cardiac events. Use of the polypill is another strategy that has been proposed to reduce patient noncompliance and ensure that those at risk receive appropriate therapies.

An evidence-based review of edoxaban and its role in stroke prevention in patients with nonvalvular atrial fibrillation.

Atrial fibrillation is the most common arrhythmia in the elderly. It is responsible for significant morbidity and mortality from cardioembolic complications like stroke. As a result, atrial fibrillation patients are risk-stratified using the CHADS2 or CHA2DS2-VASc scoring systems. Those at intermediate-to-high risk have traditionally been treated with therapeutic anticoagulation with warfarin for stroke prevention. Although effective, warfarin use is fraught with multiple concerns, such as a narrow therapeutic window, drug–drug and drug–food interactions, and excessive bleeding. Novel oral anticoagulant agents have recently become available as viable alternatives for warfarin therapy. Direct thrombin inhibitor dabigatran and factor Xa inhibitors like rivaroxaban and apixaban have already been approved by the US Food and Drug Administration (FDA) for stroke prevention in patients with nonvalvular atrial fibrillation. Edoxaban is the latest oral direct factor Xa inhibitor studied in the largest novel oral anticoagulant trial so far: ENGAGE AF-TIMI 48. Treatment with a 30 mg or 60 mg daily dose of edoxaban was found to be noninferior to dose-adjusted warfarin in reducing the rate of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, with a lower incidence of bleeding complications and cardiovascular deaths. Edoxaban was recently reviewed by an FDA advisory committee and recommended as a stroke-prophylaxis agent. Once approved, it promises to provide another useful alternative to warfarin therapy.

Compliance with guideline-directed therapy in diabetic patients admitted with acute coronary syndrome: Findings from the American Heart Association's Get With The Guidelines–Coronary Artery Disease (GWTG-CAD) program

Background To evaluate and compare baseline characteristics, outcomes and compliance with guideline based therapy at discharge among diabetic and non‐diabetic patients admitted with acute coronary syndromes (ACS). Methods and results Study population consisted of 151,270 patients admitted with ACS from 2002 through 2008 at 411 sites participating in the American Heart Associations Get with the Guidelines (GWTG) program. Demographic variables, physical exam findings, laboratory data, left ventricular ejection fraction, length of stay, in‐hospital mortality and discharge medications were compared between diabetic and non‐diabetic patients. Temporal trends in compliance with guidelines directed therapy were evaluated. Of 151,270 patients, 48,938 (32%) had diabetes. Overall, diabetic patients were significantly older and more likely non‐white. They had significantly more hypertension, atherosclerotic disease, CKD, and LV dysfunction and were more likely to present as NSTEMI. They had longer hospital stay and higher hospital mortality than non‐diabetic patients. Diabetic patients were less likely to get LDL checks (65% vs 70%) and less frequently prescribed statins (85% vs 89%), RAAS blockers for LV dysfunction (80% vs 84%) and dual‐antiplatelet therapy (69% vs 74%). Diabetic patients were less likely to achieve BP goals before discharge (75% vs 82%). Fewer diabetic patients met first medical contact to PCI time for STEMI (44% vs 52%). Temporal trends, however, showed continued progressive improvement in most performance measures from 2002 to 2008 (all P < .001). Conclusions These data from a large cohort of ACS patients demonstrate gaps in compliance with guidelines directed therapy in diabetic patients but also indicate significant and continued improvement in most performance measures over time. Concerted efforts are needed to continue this positive trend.

Hearty Breakfast for Healthier Arteries

B reakfast is the first meal of the day, and it is generally believed to be the most important meal because it provides balanced and nutritious food rich in fiber, vitamins, and other essential nutrients. Consumption of a hearty breakfast that provides at least 20% of the daily energy intake is generally associated with less frequent nibbling of unhealthy food later in the day. During the past decade, a number of studies have shown that skipping breakfast is associated with adverse cardiometabolic perturbations that can lead to the development of metabolic syndrome and diabetes, and eventually increase the risk of coronary heart disease (CHD) and stroke (1–8). The paper by Uzhova et al. (9) in this issue of the Journal provides a new insight into the chain of events by demonstrating a higher prevalence of subclinical atherosclerosis in breakfast skippers.

Mechanical Circulatory Support and Rationale for Future Research—Reply

Author Contributions: Ms Nath had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: All authors. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Nath, Costigan. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Nath. Administrative, technical, or material support: All authors. Study supervision: Nath, Hsia.

New Risk Factors of Cardiovascular Disease

Cardiovascular (CV) disease is the leading cause of death in the US and worldwide. Primary prevention of CV disease requires identification and treatment of risk factors. Since multiple risk factors coexist and interact leading to overt CVD, use of global risk assessment scores like Framingham risk score is recommended to identify and target high risk individuals. However, scores incorporating traditional risk factors like hypertension, diabetes, dyslipidemia and smoking are imperfect as the majority of cardiac events in the general population occur in low and intermediate risk individuals. This has led to the search for novel risk factors that may provide incremental value over and above the traditional risk models in predicting adverse CV events and reclassify patients to widen the scope of primary prevention. The following chapter aims to provide a comprehensive review of the major emerging risk factors by highlighting their background, evaluating supportive evidence and providing insight into their potential clinical utility. Unresolved or controversial issues will also be addressed.

MYOCARDIAL SEGMENTAL THICKNESS VARIABILITY ON ECHOCARDIOGRAPHY IS A HIGHLY SENSITIVE AND SPECIFIC MARKER TO DISTINGUISH ISCHEMIC AND NON-ISCHEMIC DILATED CARDIOMYOPATHY IN NEW ONSET CONGESTIVE HEART FAILURE

Distinction of ischemic dilated (ICM) from non-ischemic dilated cardiomyopathy (NICM) in new onset heart failure (HF) patients can be challenging. Our aim was to determine diagnostic markers that distinguish the two. We retrospectively identified 68 consecutive new HF patients with dilated