Secondary prevention and outcomes in outpatients with coronary artery disease, atrial fibrillation or heart failure: a focus on disease overlap

Leukocyte Telomere Length as a Molecular Biomarker of Coronary Heart Disease

Background. This work is a review of preclinical and clinical studies of the role of telomeres and telomerase in the development and progression of coronary heart disease (CHD). Materials and methods. A search for full-text publications (articles, reviews, meta-analyses, Cochrane reviews, and clinical cases) in English and Russian was carried out in the databases PubMed, Oxford University Press, Scopus, Web of Science, Springer, and E-library electronic library using keywords and their combinations. The search depth is 11 years (2010–2021). Results. The review suggests that the relative leukocyte telomere length (LTL) is associated with the development of socially significant and widespread cardiovascular diseases such as CHD and essential hypertension. At the same time, the interests of researchers are mainly focused on the study of the relative LTL in CHD. Conclusions. Despite the scientific and clinical significance of the analyzed studies of the relative length of human LTL as a biological marker of cardiovascular diseases, their implementation in real clinical practice is difficult due to differences in the design and methodology of the analyzed studies, as well as differences in the samples by gender, age, race, and ethnicity. The authors believe that clinical studies of the role of the relative length of leukocyte telomeres in adult patients with coronary heart disease are the most promising and require large multicenter studies with a unified design and methodology.

Long-Term Outpatient Care and Rehospitalizations in Patients after Cardiac Electrotherapy Device Implantation

Background and Objectives: Cardiovascular implantable electronic device (CIED) treatment is widely used in modern cardiology. Indications for this type of treatment are increasing. However, a significant proportion of CIED implantation patients require subsequent hospitalization for cardiovascular reasons. Older age and the associated complex clinical picture necessitate multidisciplinary outpatient specialist care for these patients. The aim of this study was to analyze the reasons for subsequent hospitalizations in the cardiology department and the impact of outpatient specialty care on these hospitalizations. To the best of our knowledge, there are no such studies in the available literature. Materials and Methods: This study was conducted on a population of patients treated with CIED. Reasons for subsequent hospitalizations were divided into clinically and statistically valid groups according to the main diagnosis. Using an electronic database, causes of hospitalization were determined based on this diagnosis. Using data on consultations at outpatient specialty clinics, a logistic regression model was created for the probability of subsequent hospitalization for cardiovascular causes according to the specialty of the clinic. Results: The 9-year follow-up included a population of 2071 patients treated with CIED. During the follow-up period, 508 patients (approximately 24.5%) required subsequent hospitalization for cardiovascular reasons. The most common leading causes were heart failure, atrial fibrillation, and coronary artery disease. The need for consultation at outpatient specialty clinics increased the likelihood of hospitalization. Moreover, the need to consult patients in nephrology outpatient, pulmonary disease outpatient, and orthopedic outpatient clinics was the most significant. Conclusions: The use of electronic implantable cardiovascular devices is a very important part of therapy in modern cardiology. The methods for their use are constantly being improved. However, they represent only one stage of cardiac treatment. After CIED procedures, patients require further care in both inpatient and outpatient specialty care settings. In this paper, we outline the reasons for subsequent hospitalizations and the importance of outpatient specialty care in this context. Effective organization of care after CIED procedures may be important in reducing the most expensive component of this care, that is, inpatient treatment.

Very long-term outcomes of older adults with stable coronary artery disease (from the CORONOR study)

BACKGROUND

There are limited data on stable coronary artery disease (CAD) in the very elderly. The present study aimed to investigate incident cardiovascular events and mortality in older adults (≥85 years) included in a multicenter registry on stable CAD.

METHODS

A long-term follow-up was performed in 198 patients ≥85 years with stable CAD, free from myocardial infarction (MI) or coronary revascularization within the year. The median age was 87 years. Clinical events during the follow-up period [death, MI, ischemic stroke, coronary revascularization and hospitalization for heart failure (HF)] were centrally adjudicated.

RESULTS

There were 164 deaths during follow-up. The cumulative risk of all-cause death was 9.1% at 1 year, 53.9% at 5 years and 85.5% at 10 years. The cause of death was adjudicated as cardiovascular in 64 patients with death from HF in 36 patients. Male gender, previous hospitalization for HF and an estimated glomerular filtration rate <60 ml/min/1.73 m2 were independently associated with all-cause death. Ten-year cumulative incidences of MI, ischemic stroke and coronary revascularization were low (6.6, 7.7 and 6.6%, respectively). By contrast, the 10-year cumulative incidence of hospitalization for HF was high (27.8%).

CONCLUSION

The 10-year mortality of elderly patients with stable CAD is very high. While ischemic events are relatively unfrequent, HF events are frequent and represent the most common cause of cardiovascular death in this population. Prevention and management of HF are important goals for physicians in charge of older adults with stable CAD.

Relative Importance of Heart Failure Events Compared to Stroke and Bleeding in AF Patients

Introduction: Incident heart failure (HF), ischemic stroke and systemic embolism (IS/SE), and major bleeding related to anticoagulation therapy are still the most frequent events occurring in patients with atrial fibrillation (AF). The aim of this study was to assess the 3-year incidence, predictors, and related mortality of IS/SE, major bleeding, and HF in a large cohort of AF outpatients. Methods and results: We studied 4973 outpatients with prevalent AF included in the CARDIONOR registry. The mean age was 72.9 ± 11.2 years, 24.1% had diabetes mellitus and 78.9% had anticoagulant therapy at baseline. The mean CHA₂DS₂Vasc score was 3.4 ± 1.7. After a median follow-up of 3.2 years (IQR: 2.8 to 3.5), incident HF, IS/SE and major bleeding occurred in 10.5%, 3.3% and 2.1% of patients, respectively. When analyzed as time-dependent variables, IS/SE, major bleeding and hospitalization for decompensated HF were all strongly associated with mortality. The independent predictors of incident HF were age, women, hypertension, diabetes mellitus, coronary artery disease and a previous history of HF. A sensitivity analysis in patients without history of HF at inclusion revealed that incident HF remained the most frequent adverse event, occurring in 5.3% of patients, compared to IS/SE (1.7%) and major bleeding (2.5%). Conclusion: HF is a common residual cardiovascular adverse event occurring in AF outpatients and is associated with a very high mortality. Since modifiable risk factors are associated with incident HF, upstream intensive management of these risk factors would be of interest.

Relative impact of bleedings over ischaemic events in patients with heart failure: insights from the CARDIONOR registry

AIMS

Major bleeding events in heart failure (HF) patients are poorly described. We sought to investigate the importance of major bleeding and its impact on outcomes in HF patients.

METHODS AND RESULTS

We analysed incident bleeding and ischaemic events during a 3 year follow-up in 2910 HF outpatients included in a prospective multicentre registry. Major bleeding was defined as a Type ≥3 bleed using the Bleeding Academic Research Consortium definition. Ischaemic event was a composite of ischaemic stroke and myocardial infarction. Events were adjudicated by a blinded committee. At inclusion, most patients (89%) received at least one antithrombotic: anticoagulation (53.9%) and/or antiplatelet therapy (46.2%). Bleeding occurred in 111 patients {3 year cumulative incidence: 3.6% [95% confidence interval (CI) 3.0-4.3]} and ischaemic events in 102 patients [3 year cumulative incidence: 3.3% (95% CI 2.7-4.0)]. Most bleedings were Bleeding Academic Research Consortium 3a (32.5%) or 3b (31.5%). Most frequent sites of bleeding were gastrointestinal (40.6%) and intracranial (27.9%). Variables associated with bleeding were atrial fibrillation [hazard ratio (HR) = 2.63 (95% CI 1.66-4.19), P < 0.0001], diabetes [HR = 1.62 (95% CI 1.11-2.38), P = 0.012], and older age [HR = 1.19 per 10 year increase (95% CI 1.00-1.41), P = 0.049]. Anticoagulation use was associated with a two-fold increase in the bleeding risk. Bleeding events as well as ischaemic events were strongly associated with subsequent mortality [adjusted HRs: 5.67 (4.41-7.29), P < 0.0001 and 4.29 (3.18-5.78), P < 0.0001, respectively].

CONCLUSIONS

In HF outpatients, antithrombotics are widely used. Bleeding occurs at a stable rate of 1.2% annually (as frequent as ischaemic events) and is associated with a dramatic increase in mortality (at least as severe as ischaemic events). Most events occurred in patients receiving anticoagulation. Knowledge of these findings may help physicians to manage antithrombotics in HF patients.

Apolipoprotein Proteomic Profiling for the Prediction of Cardiovascular Death in Patients with Heart Failure

PURPOSE

Risk stratification in chronic systolic heart failure (HF) is critical to identify the patients who may benefit from advanced therapies. It is aimed at identifying new biomarkers to improve prognosis evaluation and help to better understand HF physiopathology.

EXPERIMENTAL DESIGN

Prognostic evaluation is performed in 198 patients with chronic systolic HF: 99 patients who died from cardiovascular cause within three years are individually matched for age, sex, and HF etiology (ischemic vs not) with 99 patients who are alive after three years of HF evaluation. A proteomic profiling of 15 apolipoproteins (Apo) is performed: Apo-A1, -A2, -A4, -B100, -C1, -C2, -C3, -C4, -D, -E, -F, -H, -J, -L1, and -M using LC-MRM-MS.

RESULTS

In univariate analysis, the levels of Apo-B100 and -L1 are significantly lower and the levels of Apo-C1, -J, and -M are significantly higher in patients who died from cardiovascular cause as compared with patients alive. In the final statistical model, Apo-C1, Apo-J, and Apo-M improve individually the prediction of cardiovascular death. Ingenuity pathway analysis indicates these three Apo in a network associated with lipid metabolism, atherosclerosis signaling, and retinoid X receptor activation.

CONCLUSIONS

Proteomic profiling of apolipoproteins using LC-MRM-MS might be useful in clinical practice for risk stratification of HF patients.

Real-Life Incident Atrial Fibrillation in Outpatients with Coronary Artery Disease

Background: The risk, correlates, and consequences of incident atrial fibrillation (AF) in patients with chronic coronary artery disease (CAD) are largely unknown. Methods and results: We analyzed incident AF during a 3-year follow-up in 5031 CAD outpatients included in the prospective multicenter CARDIONOR registry and with no history of AF at baseline. Incident AF occurred in 266 patients (3-year cumulative incidence: 4.7% (95% confidence interval (CI): 4.1 to 5.3)). Incident AF was diagnosed during cardiology outpatient visits in 177 (66.5%) patients, 87 of whom were asymptomatic. Of note, 46 (17.3%) patients were diagnosed at time of hospitalization for heart failure, and a few patients (n = 5) at the time of ischemic stroke. Five variables were independently associated with incident AF: older age (p < 0.0001), heart failure (p = 0.003), lower left ventricle ejection fraction (p = 0.008), history of hypertension (p = 0.010), and diabetes mellitus (p = 0.033). Anticoagulant therapy was used in 245 (92%) patients and was associated with an antiplatelet drug in half (n = 122). Incident AF was a powerful predictor of all-cause (adjusted hazard ratio: 2.04; 95% CI: 1.47 to 2.83; p < 0.0001) and cardiovascular mortality (adjusted hazard ratio: 2.88; 95% CI: 1.88 to 4.43; p < 0.0001). Conclusions: In CAD outpatients, real-life incident AF occurs at a stable rate of 1.6% annually and is frequently diagnosed in asymptomatic patients during cardiology outpatient visits. Anticoagulation is used in most cases, often combined with antiplatelet therapy. Incident AF is associated with increased mortality.