Search

Objectives: Type 2 myocardial infarction (MI) is a heterogenous condition and whether there are differences between women and men is unknown. We evaluated sex differences in clinical characteristics, investigations and outcomes in patients with type 2 MI.Methods: In the Swedish Web based system for Enhancement and Development of Evidence based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) registry, we compared patients admitted to coronary care units with a diagnosis of type 1 or type 2 MI. Sex-stratified Cox regression models evaluated the association with all-cause death in men and women separately.Results: We included 57 264 (median age 73 years, 65% men) and 6485 (median age 78 years, 50% men) patients with type 1 and type 2 MI, respectively. No differences were observed in the proportion of men and women with type 2 MI who underwent echocardiography and coronary angiography, but women were less likely than men to have left ventricular (LV) impairment and obstructive coronary artery disease (CAD). Compared with type 1 MI, patients with type 2 MI had higher risk of death regardless of sex (men: adjusted HR 1.55 (95% CI 1.44 to 1.67); women: adjusted HR 1.34 (95% CI 1.24 to 1.45)). In those with type 2 MI, the risk of death was lower for women than men (adjusted HR 0.85 (95% CI 0.76 to 0.92) (men, reference)).Conclusions: Type 2 MI occurred in men and women equally and we found no evidence of sex bias in the selection of patients for cardiac investigations. Patients with type 2 MI had worse outcomes, but women were less likely to have obstructive CAD or severe LV impairment and were more likely to survive than men. [ABSTRACT FROM AUTHOR]

Objective: To describe annual incidence and temporal trends (2002-2014) in incidence of long-term outcomes of adult out-of-hospital cardiac arrest (OHCA) of presumed cardiac aetiology attended by Queensland Ambulance Service (QAS) paramedics, by age, gender, geographical remoteness and socioeconomic status (SES).Methods: This is a retrospective cohort study. Cases were identified using the QAS OHCA Registry and were linked with entries in the Queensland Hospital Admitted Patient Data Collection and the Queensland Registrar General Death Registry. Population data were obtained from the Australian Bureau of Statistics to calculate incidence. Inclusion criteria were adult (18+ years) residents of Queensland who suffered OHCA of presumed cardiac aetiology and survived to hospital admission. Analyses were undertaken by three mutually exclusive outcomes: (1) survival to less than 30 days (Surv<30 days); (2) survival from 30 to 364 days (Surv30-364 days); and (3) survival to 365 days or more (Surv365+ days). Incidence rates were calculated for each year by gender, age, remoteness and SES. Temporal trends were analysed.Results: Over the 13 years there were 4393 cases for analyses. The incidence of total admitted events (9.72-10.13; p<0.01), Surv30-364 days (0.18-0.42; p<0.05) and Surv365+ days (1.94-4.02; p<0.001) increased significantly over time; no trends were observed for Surv<30 days. An increase in Surv365+ days over time was observed in all remoteness categories and most SES categories.Conclusion: Evidence suggests that implemented strategies to improve outcomes from OHCA have been successful and penetrated groups living in more remote locations and the lower socioeconomic groups. These populations still require focus. Ongoing reporting of long-term outcomes from OHCA should be undertaken using population-based incidence. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editor discusses various reports within the issue on topics including the relationship between congenital heart disease and atrial septal defects (ASDs), coronary diseases, and mitral regurgitation.

Objective: In the Fontan circulation, non-pulsatile pulmonary blood flow is suggested to negatively affect pulmonary artery growth. The pulmonary vasculature is regarded a key determinant of outcome after Fontan completion. We hypothesised that in Fontan patients pulmonary artery size correlates with follow-up and functional clinical status.Methods: This is a single-centre, cross-sectional cohort study. Thirty-nine paediatric and adult Fontan patients with a concomitant cardiac magnetic resonance (CMR) scan and a cardiopulmonary exercise test between 2012 and 2013 were included. CMR-derived left and right pulmonary artery cross-sectional areas were expressed as Nakata index. Functional status was defined as peak oxygen consumption (pVO2) indexed for weight, as percentage of predicted (pred) and as New York Heart Association Functional Class (NYHA-FC).Results: Age at CMR was 18±7.2 years. Time since Fontan completion was 11.9±7.4 years. Nakata index was lower versus the reference values (238.6±78.5 vs 330±30 mm2/m2, p<0.001). Nakata index correlated negatively with age at CMR (r=-0.393, p=0.013) and time since Fontan completion (r=-0.341, p=0.034). pVO2 was 27.9±8.9 mL/min/kg and pVO2pred was 58.1%±14.1%. Nakata index correlated positively with pVO2 (r=0.468, p=0.003) and pVO2pred (r=0.353, p=0.028). Nakata index correlated negatively with NYHA-FC (r=-0.450, p=0.004). Nakata index was an independent predictor (β=0.359, p=0.007) for pVO2 (adjusted R2=0.442, with maximum heart rate and oxygen pulse at peak exercise).Conclusions: Pulmonary artery size expressed as Nakata index is a novel independent predictor for functional clinical status. Nakata index negatively correlated with follow-up duration, suggesting that chronic abnormal non-pulsatile pulmonary blood flow plays a role in lagging pulmonary arterial growth in the Fontan circulation. [ABSTRACT FROM AUTHOR]

Objective: To examine the contemporary long-term outcome after coarctation repair.Methods: This is a retrospective cohort study of 834 patients aged ≥16 years who underwent coarctation repair under single-centre follow-up. Repair was performed at a median age of 3 years (lower-upper quartile: 1 month to 15 years) by surgery in 83% (690/834) and angioplasty/stenting in 17% (144/834). Survival was compared with an age- and gender matched normal population. Other outcomes included arch reintervention, aortic valve intervention, ascending aortic intervention, and residual/re-coarctation and resting hypertension at latest follow-up.Results: After a median follow-up of 27 years (lower-upper quartile: 18-36), there were 38 late deaths (5%, 38/834). Overall survival was 99%, 88% and 65% at 30, 50 and 70 years of age, respectively, significantly reduced compared with a matched normal population (standardised mortality ratio: 3.20, log-rank: p<0.001). Thirty per cent (246/834) required ≥1 arch reintervention, 13% (111/834) an aortic valve intervention and 5% (43/834) an ascending aortic intervention. Freedom from aortic valve and ascending aortic intervention was 83% and 92% at 50 years and 53% and 81% at 70 years of age, respectively. Residual/re-coarctation (gradient ≥25 mm Hg or repair site/diaphragm ratio ≤70%) at latest follow-up was present in 60% (282/474) and resting hypertension in 57% (379/661).Conclusions: Long-term survival in contemporary adult survivors of coarctation repair is significantly lower than a matched normal population with accelerated decline after the third decade. Nearly 60% of patients eventually develop hypertension, whereas approximately 50% require further invasive cardiovascular treatment by 50 years of age. Our risk-stratifying data may enable personalised follow-up strategies for this common congenital heart condition. [ABSTRACT FROM AUTHOR]

Objective: We aimed to compare the cardiopulmonary fitness of children with congenital heart diseases (CHD) with that of age-adjusted and gender-adjusted controls. We also intended to identify clinical characteristics associated with maximum oxygen uptake (VO2max) in this population.Methods and Results: We included in a cross-sectional multicentre study a total of 798 children (496 CHD and 302 controls) who underwent a complete cardiopulmonary exercise test (CPET). The association of clinical characteristics with VO2max was studied using a multivariate analysis. Mean VO2max in the CHD group and control represented 93%±20% and 107%±17% of predicted values, respectively. VO2max was significantly lower in the CHD group, overall (37.8±0.3vs 42.6±0.4 mL/kg/min, P<0.0001) and for each group (P<0.05). The mean VO2max decline per year was significantly higher in CHD than in the controls overall (-0.84±0.10 vs -0.19±0.14 mL/kg/min/year, P<0.01), for boys (-0.72±0.14vs 0.11±0.19 mL/kg/min/year, P<0.01) and for girls (-1.00±0.13 vs -0.55±0.21 mL/kg/min/year, P=0.05). VO2max was associated with body mass index, ventilatory anaerobic threshold, female gender, restrictive ventilatory disorder, right ventricle systolic hypertension, tricuspid regurgitation, the number of cardiac catheter or surgery procedures, and the presence of a genetic anomaly.Conclusions: Although the magnitude of the difference was not large, VO2max among children with CHD was significantly lower than in normal children. We suggest performing CPET in routine follow-up of these patients.Trial Registration Number: ClinicalTrials.gov NCT01202916;Post-results. [ABSTRACT FROM AUTHOR]

Objectives: To examine recent trends in first and recurrent ischaemic heart disease (IHD) deaths and hospitalisations.Methods: Using anonymous patient-linkage of routinely collected data, all New Zealanders aged 35-84 years who experienced an International Statistical Classification of Diseases and Related Health Problems I(CD)-coded IHD hospitalisation and/or IHD death between 1 January 2005 and 31 December 2015 were identified. A 10-year look-back period was used to differentiate those experiencing first from recurrent events. Age-standardised hospitalisation and mortality rates were calculated for each calendar year and trends compared by sex and age.Results: 160 109 people experienced at least one IHD event (259 678 hospitalisations and 35 548 deaths) over the 11-year study period, and there was a steady decline in numbers (from almost 24 000 in 2005 to just over 16 000 in 2015) and in age-standardised rates each year. With the exception of deaths in younger (35-64 years) women with prior IHD, there was a significant decline in IHD events in men and women of all ages, with and without a history of IHD. The decline in IHD mortality was greater for those experiencing a first rather than recurrent IHD event (3.8%-5.2% vs 0%-3.7% annually on average). In contrast, the decline in IHD hospitalisations was greater for those experiencing a recurrent compared with a first IHD event (5.6%-7.3% vs 3.2%-5.7% annually on average).Conclusions: The substantial decline in IHD hospitalisations and mortality observed in New Zealanders with and without prior IHD between 2005 and 2015 suggests that primary and secondary prevention efforts have been effective in reducing the occurrence of IHD events. [ABSTRACT FROM AUTHOR]

Objective: Patients with atherosclerotic cardiovascular disease (CVD) vary significantly in their risk of future CVD events; yet few clinical scores are available to aid assessment of risk. We sought to develop a score for use in primary care that estimates short-term CVD risk in these patients.Methods: Adults aged <80 years with prior CVD were identified from a New Zealand primary care cohort study (PREDICT), and linked to national mortality, hospitalisation and dispensing databases. A Cox model with an outcome of myocardial infarction, stroke or CVD death within 2 years was developed. External validation was performed in a cohort from the UK.Results: 24 927 patients, 63% men, 63% European, median age 65 years (IQR 58-72 years), experienced 1480 CVD events within 2 years after a CVD risk assessment. A risk score including ethnicity, comorbidities, body mass index, creatine creatinine and treatment, in addition to established risk factors used in primary prevention, predicted a median 2-year CVD risk of 5.0% (IQR 3.5%-8.3%). A plot of actual against predicted event rates showed very good calibration throughout the risk range. The score performed well in the UK cohort but overestimated risk for those at highest risk, who were predominantly patients defined as having heart failure.Conclusions: The PREDICT-CVD secondary prevention score uses routine measurements from clinical practice that enable it to be implemented in a primary care setting. The score will facilitate risk communication between primary care practitioners and patients with prior CVD, particularly as a resource to show the benefit of risk factor modification. [ABSTRACT FROM AUTHOR]

Objective: We studied evolving antithrombotic therapy patterns in patients with newly diagnosed non-valvular atrial fibrillation (AF) and ≥1 additional stroke risk factor between 2010 and 2015.Methods: 39 670 patients were prospectively enrolled in four sequential cohorts in the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF): cohort C1 (2010-2011), n=5500; C2 (2011-2013), n=11 662; C3 (2013-2014), n=11 462; C4 (2014-2015), n=11 046. Baseline characteristics and antithrombotic therapy initiated at diagnosis were analysed by cohort.Results: Baseline characteristics were similar across cohorts. Median CHA2DS2-VASc (cardiac failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65-74 and sex category (female)) score was 3 in all four cohorts. From C1 to C4, the proportion of patients on anticoagulant (AC) therapy increased by almost 15% (C1 57.4%; C4 71.1%). Use of vitamin K antagonist (VKA)±antiplatelet (AP) (C1 53.2%; C4 34.0%) and AP monotherapy (C1 30.2%; C4 16.6%) declined, while use of non-VKA oral ACs (NOACs)±AP increased (C1 4.2%; C4 37.0%). Most CHA2DS2-VASc ≥2 patients received AC, and this proportion increased over time, largely driven by NOAC prescribing. NOACs were more frequently prescribed than VKAs in men, the elderly, patients of Asian ethnicity, those with dementia, or those using non-steroidal anti-inflammatory drugs, and current smokers. VKA use was more common in patients with cardiac, vascular, or renal comorbidities.Conclusions: Since NOACs were introduced, there has been an increase in newly diagnosed patients with AF at risk of stroke receiving guideline-recommended therapy, predominantly driven by increased use of NOACs and reduced use of VKA±AP or AP alone.Trial Registration Number: NCT01090362; Pre-results. [ABSTRACT FROM AUTHOR]

Background: Data on stroke, mortality and associated comorbidities in elderly patients with atrial fibrillation (AF) in Japan may differ from Western countries. There have been few systematic comparisons between stroke risk profiles and outcomes among community-based elderly (aged ≥75 years) patients with AF in Japan and the UK.Objective and Methods: We compared clinical characteristics, stroke risk and outcomes among elderly patients with AF from the Fushimi AF Registry (Japan; N=1791) and the Darlington AF Registry (UK; N=1338).Results: The Fushimi cohort had a mean age 81.8 (standard deviation (SD) 5.3) years and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years (double), diabetes mellitus, previous thromboembolism (double), vascular disease, age 65-74 years and female gender) score 4.3 (1.4), whereas the Darlington cohort had a mean age 83.6 (5.7) years and CHA2DS2-VASc score 4.4 (1.4). Over a 12-month follow-up period, observed stroke and mortality rates in Fushimi were 3.4% (n=61) and 11.5% (n=206), while corresponding event rates in the Darlington cohort were 4.4% (n=59) and 14.1% (n=188), respectively. Appropriate use of oral anticoagulation (OAC, essentially a vitamin K antagonist) was <60% in both registries.On multivariable analysis, ethnicity (Japan vs UK) was neither associated with the risk of stroke (OR 0.92, 95% CI 0.63 to 1.36; p=0.69) nor death (OR 0.92, 95% CI 0.80 to 1.27; p=0.92). In a subgroup analysis of elderly patients not receiving OAC (n=1489), a history of stroke was associated with the risk of stroke (OR 2.42, 95% CI 1.39 to 4.12; p=0.002), but not ethnicity (OR 0.86, 95% CI 0.50 to 1.47; p=0.58).Conclusions: Elderly (age ≥75 years) patients with AF in both Japan and the UK are at similarly high risk of stroke and death, with OAC still underused in both populations. Ethnicity was not independently associated with the risk of stroke, regardless of OAC use or non-use. [ABSTRACT FROM AUTHOR]

Objective: To assess outcomes following primary percutaneous coronary intervention (PCI) for ST-segment elevation acute myocardial infarction (STEMI) in nonagenarian patients.Methods: We conducted a multicentre retrospective study between 2006 and 2013 in five international high-volume centres and included consecutive all-comer nonagenarians treated with primary PCI for STEMI. There were no exclusion criteria. We enrolled 145 patients and collected demographic, clinical and procedural data. Severe clinical events and mortality at 6 months and 1 year were assessed.Results: Cardiogenic shock was present at admission in 21%. Median (IQR) delay between symptom onset and balloon was 3.7 (2.4-5.6) hours and 60% of procedures were performed through the transradial approach. Successful revascularisation of the culprit vessel was obtained in 86% of the cases (thrombolysis in myocardial infarction flow of 2 or 3). Major or clinically relevant bleeding was observed in 4% of patients. Median left ventricular ejection fraction post PCI was 41.5% (32.0-50.0). The in-hospital mortality was 24%, with 6 months and 1-year survival rates of 61% and 53%, respectively.Conclusions: In our study, primary PCI in nonagenarians with STEMI was achieved and feasible through a transradial approach. It is associated with a high rate of reperfusion of the infarct-related artery and 53% survival at 1 year. These results suggest that primary PCI may be offered in selected nonagenarians with acute myocardial infarction. [ABSTRACT FROM AUTHOR]

Objective: High-sensitivity cardiac troponin I (hs-cTnI) is a novel biomarker of myocardial injury and ischaemia. Our objective was to ascertain correlates of hs-cTnI and its incremental prognostic utility for incident coronary heart disease (CHD) among older asymptomatic subjects.Methods: We performed a cohort study among 1135 asymptomatic control participants in the ADVANCE (Atherosclerotic Disease, VAscular FunctioN and GenetiC Epidemiology) study at Kaiser Permanente Northern California and Stanford University, with follow-up through 31 December 2014. Hs-cTnI was measured in stored baseline (2002-2004) serum samples.Results: After a median follow-up of 11.3 years, 164 CHD events were documented. The most significant correlates of hs-cTnI were black race, body mass index, hypertension, LDL cholesterol and estimated glomerular filtration rate (eGFR) (R(2)=0.16) After adjustment for race/ethnicity, education level, diabetes status, ATP-III Framingham risk score (FRS), C reactive protein and eGFR, each 1 SD increment of log-transformed Hs-cTnI was associated with 1.11 (95% CI 1.01 to 1.23, p=0.04) increased hazard of CHD. The c-statistic increased to 0.70 from 0.68 (p=0.16) and the category-based net reclassification index was 18% (95% CI 8% to 30%) after adding hs-cTnI to the model containing the ATP-III FRS.Conclusions: Hs-cTnI conveys incremental prognostic information for incident CHD among asymptomatic older adults. [ABSTRACT FROM AUTHOR]

Optimal management for asymptomatic severe aortic stenosis (AS) remains controversial. Considering the increase in elderly patients, improved surgical outcomes and the introduction of transcatheter aortic valve implantation, we must reconsider the optimal management of asymptomatic severe AS. In this article, previous studies regarding the natural history of asymptomatic severe AS were reviewed to obtain a clinical perspective of AS in the growing elderly patient population. The incidence of sudden death in asymptomatic severe AS varies among studies from 0.25% to 1.7% per year, with differences related to study design and patient background. Except for very severe AS, sudden death or AS-related cardiac death without preceding symptoms is uncommon if 'watchful' waiting strategy is possible. Therefore, early operation is reasonable in very severe AS, but it is not recommended for all patients with severe AS. Using exercise tests, plasma levels of natriuretic peptides and other parameters, risk stratification of asymptomatic severe AS is needed to select patients who may have greater benefit following early operation. On the other hand, 'watchful' waiting is not always possible in real world of our practice. Patient education and periodic echocardiography are essential in 'watchful' waiting, which is not simply waiting strategy without careful monitoring. Individualised discussion regarding the indication for early operation is necessary, considering age, clinical background, predicted natural history and operative risk in each patient. [ABSTRACT FROM AUTHOR]

With an ageing population, older patients with non-ST elevation acute coronary syndrome are at higher risk of adverse outcomes but are far less likely to receive invasive revascularisation, contemporary antiplatelet therapy or drug-eluting stents than their younger counterparts. Accurate risk stratification in the older age groups may aid individualised decision-making with respect to identifying which patients will benefit most from invasive revascularisation, but more research is needed in this field. Based on current knowledge in this field, it would be appropriate following risk stratification to offer optimal medical therapy plus invasive care to older patients at high risk of future cardiovascular events but at low risk of complications and to offer optimal medical therapy alone to those who are deemed low risk of future events with high risk of developing procedural complications and severely frail patients. [ABSTRACT FROM AUTHOR]

Objective: Cardiac growth may be modulated in part by the trophic effects of neurohormones. The aim of the present study was to investigate the relation between the basal activity of the renin-angiotensin-aldosterone system and left ventricular mass.Design: A population based sample of 615 middle-age subjects was studied by standardised echocardiography; anthropometric measurements; and biochemical quantification of renin, pro-renin, angiotensinogen, angiotensin converting enzyme (ACE), and aldosterone.Results: Echocardiographic left ventricular mass index correlated significantly with arterial blood pressure, age, and body mass index. In addition, in men ACE activity was significantly related to left ventricular mass index in univariate (P = 0.0007) and multivariate analyses (P = 0.008). Men with left ventricular hypertrophy presented with significantly higher serum ACE concentrations than those with normal left ventricular mass index (P = 0.002). In both men and women serum aldosterone was strongly related to septal and posterior wall thickness. Furthermore, in women serum aldosterone was positively and independently associated with left ventricular mass index (P = 0.0001). This effect was most prominent in hypertensive women. Finally, women with left ventricular hypertrophy presented with significantly higher serum aldosterone (P = 0.01). No significant associations with left ventricular mass index were observed for angiotensinogen, renin, or pro-renin.Conclusions: The data suggest that the variability of serum ACE or aldosterone, as occurred in this large population based sample, may contribute to the modulation of left ventricular mass. [ABSTRACT FROM AUTHOR]

Editorial. Discusses the surgical correction of tetralogy of Fallot (TOF), a complex congenital cardiac abnormality. Principles of surgical correction of TOF; Importance of achieving pulmonary competence at the time of TOF surgery; Optimal timing and surgical approach for correction of TOF.