Prognostic value of estimated functional capacity incremental to cardiac biomarkers in stable cardiac patients

Sex-Specific Functional Status Decline and Outcomes in Mild-to-Moderate Aortic Stenosis: Results From the PROGRESSA Study

Background

Little is known about the effect of sex on functional status decline in aortic valve stenosis (AS) patients.

Objectives

The purpose of this study was to examine the changes in functional status according to sex in patients with mild-to-moderate AS and its association with the composite of death or aortic valve replacement (AVR).

Methods

We included patients with mild-to-moderate AS prospectively recruited in the PROGRESSA (Metabolic Determinants of the Progression of Aortic Stenosis) study (NCT01679431). Functional status was assessed using the New York Heart Association classification and the Duke Activity Status Index (DASI).

Results

A total of 244 patients (mean age 64 ± 14 years, 29% women) were included. The mean follow-up was 4.3 ± 2.4 years. Women with intermediate-to-fast AS progression rate (median change in peak aortic jet velocity ≥0.11 m/s/year) had significantly faster decline in DASI score compared to men with similar progression rate (P < 0.05). In linear mixed analysis adjusted for several clinical and echocardiographic factors, female sex and change in peak aortic jet velocity remained strongly associated with the worsening of New York Heart Association class and the decline of DASI score (all, P < 0.001). The composite of death or AVR occurred in 115 patients (16 deaths and 99 AVRs). In multivariable Cox regression analyses, functional status decline during follow-up remained significantly associated with the composite of death or AVR (HR: 2.13; 95% CI: 1.22-3.73; P = 0.008).

Conclusions

In patients with mild-to-moderate AS at baseline, intermediate-to-fast progression rate of AS was associated with a more rapid decline of functional status during follow-up, particularly in women. Functional status decline during follow-up was strongly associated with the incidence of death or AVR, with comparable effect in both women and men.

Home-based EXercise and motivAtional programme before and after Liver Transplantation (EXALT): study protocol for phase II two-centre, randomised controlled trial

INTRODUCTION

Physical frailty is associated with increased mortality and poor quality of life (QoL) before and after liver transplantation (LT). Evidence is lacking on how to tailor exercise and behavioural techniques in this patient population.

METHODS AND ANALYSIS

Home-based EXercise and motivAtional programme before and after Liver Transplantation (EXALT) is a phase 2b, open-label, two-centre randomised controlled clinical trial designed to investigate whether a remotely monitored 'home-based exercise and theory-based motivation support programme (HBEP)' before and after LT improves QoL in LT recipients. Adult patients awaiting a primary LT will be assessed for eligibility at two LT centres (Birmingham, Royal Free London). Participants will be randomly assigned (1:1) to receive either an HBEP while on the LT waiting list through to 24 weeks after LT (Intervention) or a patient exercise advice leaflet (Control). Using a standard method of difference in means (two-sided significance level 0.05; power 0.90) and accounting for a 35% attrition/withdrawal rate, a minimum of 133 patients will be randomised to each treatment group. The primary outcome measure will be assessed using intention-to-treat analysis of the difference in the Physical Component Score of Short form-36 version 2.0 health-related QoL questionnaire between the groups at 24 weeks post-LT.

ETHICS AND DISSEMINATION

The protocol was approved by the South Central-Hampshire A National Research Ethics Committee. Recruitment into the EXALT trial started in May 2022 and is due to end in June 2024, with 217/266 patients randomised to date. The intervention follow-up is due to finish in May 2026. The findings of this trial will be disseminated through peer-reviewed publications, conferences and social media.

TRIAL REGISTRATION NUMBER

ISRCTN13476586.

Emergency Department Referral of Patients With Chest Pain for Noninvasive Cardiac Testing and 2-Year Clinical Outcomes

BACKGROUND

Noninvasive cardiac testing (NICT) has been associated with decreased long-term risks of major adverse cardiac events (MACEs) among emergency department patients at high coronary risk. It is unclear whether this association extends to patients without evidence of myocardial injury on initial ECG and cardiac troponin testing.

METHODS

A retrospective cohort study was conducted of patients presenting with chest pain between 2013 and 2019 to 21 emergency departments within an integrated health care system in Northern California, excluding patients with ST-segment-elevation myocardial infarction or myocardial injury by serum troponin testing. To account for confounding by indication, we grouped patient encounters by the NICT referral rate of the initially assigned emergency physician relative to local peers within discrete time periods. The primary outcome was MACE within 2 years. Secondary outcomes were coronary revascularization and MACE, inclusive of all-cause mortality. Associations between the NICT referral group (low, intermediate, or high) and outcomes were assessed using risk-adjusted proportional hazards methods with censoring for competing events.

RESULTS

Among 144 577 eligible patient encounters, the median age was 58 years (interquartile range, 48-68) and 57% were female. Thirty-day NICT referral was 13.0%, 19.9%, and 27.8% in low, intermediate, and high NICT referral groups, respectively, with a good balance of baseline covariates between groups. Compared with the low NICT referral group, there was no significant decrease in the adjusted hazard ratio of MACE within the intermediate (adjusted hazard ratio, 1.08 [95% CI, 1.02-1.14]) or high (adjusted hazard ratio, 1.05 [95% CI, 0.99-1.11]) NICT referral groups. Results were similar for MACE, inclusive of all-cause mortality, and coronary revascularization, as well as subgroup analyses stratified by estimated risk (history, electrocardiogram, age, risk factors, troponin [HEART] score: percent classified as low risk, 48.2%; moderate risk, 49.2%; and high risk, 2.7%).

CONCLUSIONS

Increases in NICT referrals were not associated with changes in the hazard of MACE within 2 years following emergency department visits for chest pain without evidence of acute myocardial injury. These findings further highlight the need for evidence-based guidance regarding the appropriate use of NICT in this population.

Duke Activity Status Index and Liver Frailty Index predict mortality in ambulatory patients with advanced chronic liver disease: A prospective, observational study

BACKGROUND

There remains a lack of consensus on how to assess functional exercise capacity and physical frailty in patients with advanced chronic liver disease (CLD) being assessed for liver transplantation (LT). Aim To investigate prospectively the utility of the Duke Activity Status Index (DASI) and Liver Frailty Index (LFI) in ambulatory patients with CLD.

AIM

To investigate prospectively the utility of the Duke Activity Status Index (DASI) and Liver Frailty Index (LFI) in ambulatory patients with CLD.

METHODS

We recruited patients from outpatient clinics at University Hospitals Birmingham, UK (2018-2019). We prospectively collated the DASI and LFI to identify the prevalence of, respectively, functional capacity and physical frailty, and to evaluate their accuracy in predicting overall and pre-LT mortality.

RESULTS

We studied 307 patients (57% male; median age 54 years; UKELD 52). Median DASI score was 28.7 (IQR 16.2-50.2), mean LFI was 3.82 (SD = 0.72), and 81% were defined either 'pre-frail' or 'frail'. Female sex and hyponatraemia were significant independent predictors of both DASI and LFI. Age and encephalopathy were significant independent predictors of LFI, while BMI significantly predicted DASI. DASI and LFI were significantly related to overall (HR 0.97, p = 0.001 [DASI], HR 2.04, p = 0.001 [LFI]) and pre-LT mortality (HR 0.96, p = 0.02 [DASI], HR 1.94, p = 0.04 [LFI]).

CONCLUSIONS

Poor functional exercise capacity and physical frailty are highly prevalent among ambulatory patients with CLD who are being assessed for LT. The DASI and LFI are simple, low-cost tools that predict overall and pre-LT mortality. Implementation of both should be considered in all outpatients with CLD to highlight those who may benefit from targeted nutritional and exercise interventions.

Predictors of gain in exercise capacity through cardiac rehabilitation: Sex and age matter

BACKGROUND

Cardiac rehabilitation (CR) is a cornerstone of secondary prevention that improves cardiovascular outcomes. However, the determinants of treatment success are poorly understood.

OBJECTIVES

We investigated the associations of health-related quality of life (HRQoL), sex, age, employment status and housing situation with improvement in exercise capacity throughout CR.

METHODS

We analyzed data from 392 CR outpatients (81% men and 19% women). Exercise capacity at baseline and upon completion of the program was measured with the 6-minute walk distance (6MWD). HRQoL at CR entry was assessed with the Short Form 36 Health Survey (SF-36).

RESULTS

A multivariable regression analysis revealed that both men and women showed significant improvement in exercise capacity (p < .001). Female sex (B = 18.118, 95% CI 0.341 - 36.035, p = .046) and younger age (B = -0.887, 95% CI -1.463 - -0.312, p = .003) emerged as predictors of greater improvement, while HRQoL, employment status, and housing situation were not associated with significant change in exercise capacity. The final model explained 25% of the variance in exercise capacity change (adjusted R2 = 0.25, p < .001).

CONCLUSIONS

Our results indicate that women and younger participants benefit from CR by improving their exercise capacity. Employment status, housing situation and HRQoL showed no effects on CR outcome.

Patient reported outcomes in obstructive hypertrophic cardiomyopathy undergoing myectomy: Results from SPIRIT-HCM study

BACKGROUND

Patient reported outcomes (PRO) can assess quality of life (QOL) in obstructive hypertrophic cardiomyopathy (oHCM). In symptomatic oHCM patients, we sought to study the correlation between various PROs, their association with physician reported New York Heart Association (NYHA) class and changes after surgical myectomy.

METHODS

We prospectively studied 173 symptomatic oHCM patients undergoing myectomy (age 51 years, 62% men) between 3/17-6/20. PROs, including a) Kansas City Cardiomyopathy Questionnaire (KCCQ) summary score b) Patient-Reported Outcomes Measurement Information System [PROMIS] c) Duke Activity Status Index [DASI] & d) European QOL score [EQ-5D], along with NYHA class, 6-min walk test (6MWT) distance and peak left ventricular outflow tract gradient (PLVOTG) were recorded at baseline and 12 month follow-up.

RESULTS

The median baseline PRO scores (KCCQ summary, PROMIS physical, PROMIS mental, DASI, EQ-5D) were 50, 67, 63, 25, 50, 37, 44, 25 and 0.61, respectively; 6MWT distance was 366 m. There were significant correlations between various PROs (r-values between 0.66 and 0.92, p < 0.001), but only modest correlations with 6MWT and provokable LVOTG (r-values between 0.2 and 0.5, p < 0.01). At baseline, 35-49% patients in NYHA class II had PROs worse than median, while 30-39% patients in NYHA Class III/IV had PROs better than median. At follow-up, a 20 point improvement in KCCQ summary score was observed in 80%, 4 point improvement in DASI score in 83%, 4 point improvement in PROMIS physical score 86% and a 0.04 point improvement in EQ-5D in 85%); along with improvements in NYHA class (67% in Class I) and peak LVOTG (median 13 mmHg) and 6MWT (median distance 438 m).

CONCLUSIONS

In a prospective study of symptomatic oHCM patients, surgical myectomy significantly improved PROs, LVOT obstruction, and functional capacity, with a high correlation between various PROs. However, there was high rate of discordance between PROs and NYHA class.

STUDY REGISTRATION

ClinicalTrials.gov: NCT03092843.

Prognostic Utility of a New Risk Stratification Protocol for Secondary Prevention in Patients Attending Cardiac Rehabilitation

Several risk scores have been used to predict risk after an acute coronary syndrome (ACS), but none of these risk scores include functional class. The aim was to assess the predictive value of risk stratification (RS), including functional class, and how cardiac rehabilitation (CR) changed RS. Two hundred and thirty-eight patients with ACS from an ambispective observational registry were stratified as low (L) and no-low (NL) risk and classified according to exercise compliance; low risk and exercise (L-E), low risk and control (no exercise) (L-C), no-low risk and exercise (NL-E), and no-low risk and control (NL-C). The primary endpoint was cardiac rehospitalization. Multivariable analysis was performed to identify variables independently associated with the primary endpoint. The L group included 56.7% of patients. The primary endpoint was higher in the NL group (18.4% vs. 4.4%, p < 0.001). After adjustment for age, sex, diabetes, and exercise in multivariable analysis, HR (95% CI) was 3.83 (1.51−9.68) for cardiac rehospitalization. For RS and exercise, the prognosis varied: the L-E group had a cardiac rehospitalization rate of 2.5% compared to 26.1% in the NL-C group (p < 0.001). Completing exercise training was associated with reclassification to low-risk, associated with a better outcome. This easy-to-calculate risk score offers robust prognostic information. No-exercise groups were independently associated with the worst outcomes. Exercise-based CR program changed RS, improving classification and prognosis.

Arterial stiffness and functional capacity in individuals with chronic stroke: a cross-sectional study

OBJECTIVE

To investigate the association between arterial stiffness and functional capacity in individuals with chronic stroke and compare the arterial stiffness between individuals with better and poor functional capacity.

DESIGN

Cross-sectional study.

PARTICIPANTS

Individuals after chronic stroke have their arterial stiffness index evaluated by augmentation index heart rate adjusted for 75 bpm (AIx@75), assessed by Mobil-O-Graph® device (IEM, Stolberg, Germany), in percent, on the paretic upper limb. Functional capacity was assessed with the Duke Activity Status Index (DASI) in metabolic equivalent (METS). The individuals were assigned into two groups: better (DASI ≥ 31.95) and poor (DASI < 31.95) functional capacity. Pearson's correlation and t test were used for analysis.

RESULTS

Twenty-eight individuals (arterial stiffness 23.8 ± 10% and functional capacity 29 ± 19 METS) were included. The association between arterial stiffness and functional capacity was negative and statistically significant, with moderate magnitude (r = -0.53, p < .001). Individuals who had better functional capacity have lower arterial stiffness indices (AIx@75 = 17.4% versus 27.4% in better and lower functional capacity, respectively) (p = .01).

CONCLUSION

Arterial stiffness of the paretic upper limb has a negative association with functional capacity.

Validation of open-source step-counting algorithms for wrist-worn tri-axial accelerometers in cardiovascular patients

BACKGROUND

Accurate quantification of daily steps in a cardiovascular patient population is of high importance for primary and secondary prevention. While sensor derived step counts have been sufficiently validated for hip-worn devices and commercial wrist-worn devices, there is a lack of knowledge on validity of freely available step counting algorithms for raw acceleration data collected at the wrist.

RESEARCH QUESTION

How accurate are step-counting algorithms for wrist worn tri-axial accelerometers in a cardiac rehabilitation training setting?

METHODS

Two step counting algorithms (Windowed Peak Detection, Autocorrelation) for tri-axial accelerometers (Axivity AX-3), were tested. Steps were recorded by chest-mounted GoPro video cameras as gold standard. Cardiovascular patients without neurological impairments enrolled in an ambulatory rehabilitation program were recruited. Recordings were performed during one 45-90 min outdoor physical therapy session of which 5-min segments of six movement categories, namely Walking, Running, Nordic, Stairs, Arm Movement [AM] With [+] and Without [-] Walking [W] were identified and analyzed. Mean absolute difference and mean absolute percentage error [MAPE] with regard to true steps measured from video are reported to report accuracy.

RESULTS

Training sessions of 22 patients were recorded and analyzed. Steps were overestimated during AM-W and underestimated during Walking, Running and Stairs. Windowed Peak Detection algorithm was more accurate during AM+W and AM-W and Autocorrelation performed better during Nordic. A MAPE of close or below 10% was achieved by both algorithms for the categories: Walking, Running, Stairs and Nordic.

SIGNIFICANCE

Both algorithms provided accurate results for estimation of step counts in a controlled setting of a cardiovascular patient population. The quantification of daily number of steps recorded by wrist-worn accelerometers delivering raw data analyzed by freely available algorithms is a cost-effective option for research studies.

Higher intensity of 72-h noninvasive cardiac test referral does not improve short-term outcomes among emergency department patients with chest pain

BACKGROUND

It is unclear whether referral for cardiac noninvasive testing (NIT) following emergency department (ED) chest pain encounters improves short-term outcomes.

METHODS

This was a retrospective cohort study of patients presenting with chest pain, without ST-elevation myocardial infarction or myocardial injury by serum troponin testing, between 2013 and 2019 to 21 EDs within an integrated health care system. We examined the association between NIT referral (within 72 h of the ED encounter) and a primary outcome of 60-day major adverse cardiac events (MACE). Secondary outcomes were 60-day MACE without coronary revascularization (MACE-CR) and 60-day all-cause mortality. To account for confounding by indication for NIT, we grouped patient encounters into ranked tertiles of NIT referral intensity based on the likelihood of 72-h NIT referral associated with the initially assigned emergency physician, relative to local peers and within discrete time periods. Associations between NIT referral-intensity tertile and outcomes were assessed using risk-adjusted multivariable logistic regression.

RESULTS

Among 210,948 eligible patient encounters, 72-h NIT referral frequency was 11.9%, 18.3%, and 25.9% in low, intermediate, and high NIT referral-intensity encounters, respectively. Compared with the low referral-intensity tertile, there was a higher risk of 60-day MACE within the high referral-intensity tertile (odds ratio [OR] = 1.11, 95% confidence interval [CI] = 1.04 to 1.17) due to more coronary revascularizations without corresponding differences in MACE-CR or all-cause mortality. In analyses stratified by patients' estimated risk (HEART score; 50.5% lower risk, 38.7% moderate risk, 10.8% higher risk), the difference in 60-day MACE was primarily attributable to moderate-risk encounters (OR = 1.15, 95% CI = 1.08 to 1.24), with no differences among either lower- (OR = 1.10, 95% CI = 0.92 to 1.31) or higher- (OR = 1.01, 95% CI = 0.90 to 1.14) risk encounters.

CONCLUSION

Higher referral intensity for 72-h NIT was associated with higher risk of coronary revascularization but no difference in adverse events within 60 days. These findings further call into question the urgency of NIT among ED patients without objective evidence of myocardial injury.

Recovery of a critically ill patient with COVID-19 myocarditis

Myocarditis is a concerning potential consequence of COVID-19 infection, attributed to ventricular dysfunction, cardiac fibrosis, ventricular arrhythmias, cardiogenic shock, and sudden cardiac death. Recently, the Israeli Health Ministry announced that a small number of cases of myocarditis may be linked to second dose of Pfizer’s BioNTech-partnered COVID-19 vaccine. The long-term impact of COVID-19 myocarditis and coronary microthrombosis which has also been described and the best therapies for these complications remain unknown. Indeed, monomorphic ventricular tachycardia and regular ventricular arrhythmias have previously been found to be more common in those recovered from myocarditis than in acute myocarditis itself. Follow-up assessment of cardiac function has been suggested for this cohort to detect and possibly prevent further cardiac events in the rehabilitation phase. Functional capacity has been shown to be a better determinant of long-term morbidity than diagnostic testing alone, but integrated approach is likely the way forward in clinical follow-up. Assessment of residual complications in the post-COVID-19 recovery phase may identify the population burden of long-term cardiac disease as a direct consequence of COVID-19.

Assessment of the Frail Patient With End-Stage Liver Disease: A Practical Overview of Sarcopenia, Physical Function, and Disability

Frailty has emerged as a powerful predictor of clinical outcomes (e.g., decompensation, hospitalization, mortality) in patients with end-stage liver disease (ESLD). It is therefore of paramount importance that all patients with ESLD undergo an assessment of frailty, to support life and death decision making (i.e., candidacy for critical care, transplantation) and aid with prioritization of evolving prehabilitation services (i.e., nutrition, physiotherapy, psychotherapy). This article aims to provide a practical overview of the recent advances in the clinical, radiological, and remote assessment tools of the frail patient with ESLD. Historically, clinicians have incorporated an assessment of frailty using the "end-of-the-bed test" or "eyeball test" into their clinical decision making. However, over the last decade, numerous nonspecific and specific tools have emerged. The current evidence supports the use of a combination of simple, user-friendly, objective measures to first identify frailty in ESLD (notably Clinical Frailty Scale, Liver Frailty Index), followed by a combination of serial tools to assess specifically sarcopenia (i.e., muscle ultrasound), physical function (i.e., chair stands, hand grip strength), functional capacity (i.e., 6-minute walk test), and physical disability (i.e., activities of daily living).

Reduced heart rate variability is associated with higher illness burden in bipolar disorder

BACKGROUND

Bipolar disorder (BD) is associated with premature death and ischemic heart disease is the main cause of excess mortality. Heart rate variability (HRV) predicts mortality in patients with or without cardiovascular disease. While several studies have analyzed the association between HRV and BD, none has analyzed the association of HRV with illness burden in BD.

METHODS

53 participants with BD I and II used a wearable device to assess the association between HRV and factors characterizing illness burden, including illness duration, number and type of previous episode(s), duration of the most severe episode, history of suicide attempts or psychotic symptoms during episodes, and co-morbid psychiatric disorders. We ran unadjusted models and models controlling statistically for age, sex, pharmacotherapy, baseline functional cardiovascular capacity, BMI, years of education, and marital status. We also explored the association between HRV and an overall illness burden index (IBI) integrating all these factors using a weighted geometric mean.

RESULTS

Adjusted and unadjusted models had similar results. Longer illness duration, higher number of depressive episodes, longer duration of most severe manic/hypomanic episode, co-morbid anxiety disorders, and family history of suicide were associated with reduced HRV, as was bipolar depression severity in the participants experiencing a depressive episode. Finally, a higher IBI score was associated with lower HRV.

CONCLUSIONS

High illness burden is associated with reduced HRV in BD. While the IBI needs to be validated in a larger sample, it may provide an overall measure that captures illness burden in BD.

Does Duke Activity Status Index help predicting functional exercise capacity and long-term prognosis in patients with pulmonary hypertension?

BACKGROUND

To investigate the association of Duke Activity Status Index (DASI) with 6-minute walk test (6MWT) and WHO-Functional Class (WHO-FC) in patients with pulmonary hypertension (PH), as well as exploring whether DASI can discriminate between the patients with better and worse long-term prognosis according to 400 m cut-off score in 6MWT.

METHODS

Eighty-five medically stable PH patients who met eligibility criteria were included. All patients were evaluated using 6MWT and DASI. The prognostic utility of the DASI was assessed using univariate linear regression and receiver operating characteristic (ROC) curve analysis.

RESULTS

The DASI was an independent predictor for both 6MWT and WHO-FC, explaining 50% of variance in 6MWT and 30% of variance in WHO-FC class (p < 0.001). In addition, DASI significantly correlated to 6MWT (r = 0.702) and WHO-FC class (r = 0.547). The ROC curve analysis revealed that the DASI had a discriminative value for identifying the patients with better long-term prognosis (p < 0.001), with an area under ROC curve of 0.867 [95% CI = 0.782-0.952]. The DASI ≥26 was the optimal cut-off value for better long-term prognosis, having sensitivity of 0.74 and a specificity of 0.88.

CONCLUSIONS

The DASI is a valid tool reflecting functional exercise capacity in patients with PH. Considering its ability to discriminate between the patients with better or worse long-term prognosis, it may help identifying the patients at higher risk.

A mixed methods study describing the self-care practices in an older working population with cardiovascular disease (CVD): Balancing work, life and health

BACKGROUND

Self-care is essential to cardiovascular disease (CVD) health outcomes, but may be challenging for older working adults.

OBJECTIVE

Describe self-care and the relationship of work-related characteristics to self-care among older workers with CVD.

METHODS

Convergent mixed methods design (n = 108) assessed self-care, organization of work, job-level and clinical factors; qualitative data (n = 40) explored self-care and working. Data integrated in the final analytic phase.

RESULTS

Sixty-eight percent reported adequate self-care maintenance (SC-CHDI maintenance ≥70); only 22% had adequate self-care management (SC-CHDI management ≥ 70). Controlling for physical capacity, work-related factors explained 22% variance in self-care maintenance; physical capacity was only significant determinant of self-care management. Individuals with poor self-care described low job control, job stress and work-life imbalance that interfered with routine self-care. Individuals with poor self-care management reported "feeling stressed out" and "extreme fatigue" attributed to their job.

CONCLUSIONS

Interventions targeting self-care, stress management and work-life balance among older workers with CVD are needed.

TMAO as a biomarker of cardiovascular events: a systematic review and meta-analysis

BACKGROUND

Unmasking the residual cardiovascular risk is a major research challenge in the attempt to reduce cardiovascular disease (CVD) morbidity and mortality. Mounting evidence suggests that a high circulating level of trimethylamine N-oxide is a new potential CVD risk factor. We performed a systematic review of the published studies to clarify the association between circulating high levels of TMAO and cardiovascular events.

METHODS

Studies evaluating the association between TMAO and CVD events were searched by electronic databases up to December 2018. Pooled results were expressed as risk ratio (RR) with 95% pertinent confidence interval (CI).

RESULTS

Three studies for a total of 923 patients at high/very high CVD risk were included in our analysis. Overall, a high TMAO level was associated with both major adverse cardiovascular events (RR = 2.05; 95% CI 1.61-2.61) and all-cause mortality (RR = 3.42; 95% CI 2.27-5.15).

CONCLUSIONS

Our findings support a role of high TMAO levels in predicting CVD events. High levels of TMAO may be a new CVD risk factor, potentially useful to better plan personalized CVD prevention strategies.

Cardiovascular Risk Assessment for Noncardiac Surgery: Are We Ready for Biomarkers?

Biomarkers aided perioperative cardiac assessment is a relatively new concept. Cardiac biomarkers with historical significance (aspartate transaminase, dehydrogenase, creatinine kinase and myoglobin) have paved the way for traditional biomarkers (cardiac troponin, C-reactive protein, lipoprotein). Contemporary biomarkers like natriuretic peptides (BNP and ProBNP) are validated risk markers in both acute and chronic cardiac diseases and are showing remarkable promise in predicting serious cardiovascular complications after non-cardiac surgery. This review is intended to provide a critical overview of traditional and contemporary biomarkers for perioperative cardiovascular assessment and management. This review also discusses the potential utility of newer biomarkers like galectin-3, sST-2, GDF-15, TNF-alpha, MiRNAs and many others that can predict inflammation, cardiac remodeling, injury and endogenous stress and need further investigations to establish their clinical utility. Though promising, biomarker led perioperative care is still in infancy and it has not been determined that it can improve clinical outcomes.

Cardiovascular Risk Factor Control and Lifestyle Factors in Young to Middle-Aged Adults with Newly Diagnosed Obstructive Coronary Artery Disease

BACKGROUND

While progress in the prevention of cardiovascular disease (CVD) has been noted over the past several decades, there are still those who develop CVD earlier in life than others.

OBJECTIVE

We investigated traditional and lifestyle CVD risk factors in young to middle-aged patients compared to older ones with obstructive coronary artery disease (CAD).

METHODS

A retrospective analysis of patients with a new diagnosis of obstructive CAD undergoing coronary intervention was performed. Young to middle-aged patients were defined as those in the youngest quartile (n = 281, mean age 50 ± 6 years, 81% male) compared to the other three older quartiles combined (n = 799, mean age 69 ± 7.5 years, 71% male). Obstructive CAD was determined by angiography.

RESULTS

Young to middle-aged patients compared to older ones were more likely to be male (p < 0.01), smokers (21 vs. 9%, p < 0.001), and have a higher body mass index (31 ± 6 vs. 29 ± 6 kg/m2, p < 0.001). Younger patients were less likely to eat fruits, vegetables, and fish and had fewer controlled CVD risk factors (2.7 ± 1.2 vs. 3.0 ± 1.0, p < 0.001). Compared to older patients, higher levels of psychological stress (aOR 1.6, 95% CI 1.1-2.4), financial stress (aOR 1.8, 95% CI 1.3-2.5), and low functional capacity (aOR 3.3, 95% CI 2.4-4.5) were noted in the young to middle-aged population as well.

CONCLUSION

Lifestyle in addition to traditional CVD risk factors should be taken into account when evaluating risk for development of CVD in a younger population.

Predictors of cardiorespiratory fitness improvement in phase II cardiac rehabilitation

BACKGROUND

Cardiac rehabilitation (CR) improves cardiorespiratory fitness (CRF) and has been shown to reduce cardiovascular events and death. However, data about predictors of fitness improvement during CR are limited and conflicting. The objective of this study was to determine predictors of improvement in metabolic equivalents of task (METs) based on formal exercise testing throughout phase II CR.

METHODS

We retrospectively reviewed 20 671 patients enrolled in phase II CR at our center from 2006 to 2016. Patients who completed 36 sessions and had entry and exit exercise stress tests were included for study. The short form-36 (SF-36) questionnaire was used to assess quality-of-life. Univariate and multivariate regression analyses were performed to determine independent predictors of METs improvement.

RESULTS

Of the full cohort, 827 patients completed 36 sessions and had entry/exit stress test data. The majority of patients (N = 647, 78.2%) had improvement in METs (mean Δ 2.0 ± 1.2 METs), including patients ≥65 and < 65 years old (77% vs 79%, P = 0.46 for difference). METs improvement was negatively associated with body mass index, diabetes, left ventricular dysfunction, and poor baseline fitness; and positively associated with SF-36 score (P < 0.05 for all). After multivariable adjustment, improvement was no longer affected by age, ejection fraction, or baseline fitness. Patients with poor fitness (≤5 METS) and adequate fitness (> 5 METS) both had improvement, with no statistical difference between the groups (P = 0.36).

CONCLUSIONS

In a large cohort of phase II CR patients, improvement in CRF was seen in the majority of patients across all ages, genders, and levels of baseline fitness.

Prognostic ability of cystatin C and homocysteine plasma levels for long-term outcomes in very old acute myocardial infarction patients

Background and aims

This study sought to evaluate the prognostic powers of combined use of cystatin C (Cys C) and homocysteine (Hcy) at predicting adverse events of patients >80 years old with acute myocardial infarction (AMI).

Patients and methods

The analysis involved 753 patients >80 years old undergoing coronary angiography for chest pain in China from January 2006 to December 2012. Kaplan–Meier method was used for survival and major adverse cardiac events (MACE) rates. Multivariate Cox regression was performed to identify mortality predictors. Receiver operating characteristic curve analysis was performed to predict the cutoff values of Cys C and Hcy for all-cause mortality.

Results

The duration of follow-up was 40–116 months (median, 63 months; interquartile range, 51–74 months). The long-term survival and event-free survival rates of AMI patients were significantly lower than those of unstable angina pectoris patients (P<0.05), and were significantly different according to the tertile concentration of Cys C of AMI patients (P<0.01). Cys C and Hcy were independent risk factors for long-term all-cause mortality (odds ratio [OR] =3.72 [2.27–6.09]; OR =1.59 [1.04–2.61]) and MACE (OR =2.83 [1.82–4.40]; OR =1.09 [1.04–1.21]) of AMI patients. The predictive cutoff value of Cys C was 1.815 mg/L (82.8%, 86.4%) and that of Hcy was 15.06 μmol/L (84.4%, 83.1%) in AMI patients. Combined use of both biomarker’s cutoff values further increased the sensitivity and specificity of all-cause mortality.

Conclusion

Cys C is a strong independent predictor of long-term all-cause death and MACE in very old AMI patients. The combined use of Cys C and Hcy further improves the predictive accuracy.

Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study

BACKGROUND

Functional capacity is an important component of risk assessment for major surgery. Doctors' clinical subjective assessment of patients' functional capacity has uncertain accuracy. We did a study to compare preoperative subjective assessment with alternative markers of fitness (cardiopulmonary exercise testing [CPET], scores on the Duke Activity Status Index [DASI] questionnaire, and serum N-terminal pro-B-type natriuretic peptide [NT pro-BNP] concentrations) for predicting death or complications after major elective non-cardiac surgery.

METHODS

We did a multicentre, international, prospective cohort study at 25 hospitals: five in Canada, seven in the UK, ten in Australia, and three in New Zealand. We recruited adults aged at least 40 years who were scheduled for major non-cardiac surgery and deemed to have one or more risk factors for cardiac complications (eg, a history of heart failure, stroke, or diabetes) or coronary artery disease. Functional capacity was subjectively assessed in units of metabolic equivalents of tasks by the responsible anaesthesiologists in the preoperative assessment clinic, graded as poor (<4), moderate (4-10), or good (>10). All participants also completed the DASI questionnaire, underwent CPET to measure peak oxygen consumption, and had blood tests for measurement of NT pro-BNP concentrations. After surgery, patients had daily electrocardiograms and blood tests to measure troponin and creatinine concentrations until the third postoperative day or hospital discharge. The primary outcome was death or myocardial infarction within 30 days after surgery, assessed in all participants who underwent both CPET and surgery. Prognostic accuracy was assessed using logistic regression, receiver-operating-characteristic curves, and net risk reclassification.

FINDINGS

Between March 1, 2013, and March 25, 2016, we included 1401 patients in the study. 28 (2%) of 1401 patients died or had a myocardial infarction within 30 days of surgery. Subjective assessment had 19·2% sensitivity (95% CI 14·2-25) and 94·7% specificity (93·2-95·9) for identifying the inability to attain four metabolic equivalents during CPET. Only DASI scores were associated with predicting the primary outcome (adjusted odds ratio 0·96, 95% CI 0·83-0·99; p=0·03).

INTERPRETATION

Subjectively assessed functional capacity should not be used for preoperative risk evaluation. Clinicians could instead consider a measure such as DASI for cardiac risk assessment.

FUNDING

Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.

Symptoms Suggestive of Acute Coronary Syndrome: When Is Sex Important?

BACKGROUND

Studies have identified sex differences in symptoms of acute coronary syndrome (ACS); however, retrospective designs, abstraction of symptoms from medical records, and variations in assessment forms make it difficult to determine the clinical significance of sex differences.

OBJECTIVE

The aim of this study is to determine the influence of sex on the occurrence and distress of 13 symptoms for patients presenting to the emergency department for symptoms suggestive of ACS.

METHODS

A total of 1064 patients admitted to 5 emergency departments with symptoms triggering a cardiac evaluation were enrolled. Demographic and clinical variables, symptoms, comorbid conditions, and functional status were measured.

RESULTS

The sample was predominantly male (n = 664, 62.4%), white (n = 739, 69.5%), and married (n = 497, 46.9%). Women were significantly older than men (61.3 ± 14.6 vs 59.5 ± 13.6 years). Most patients were discharged with a non-ACS diagnosis (n = 590, 55.5%). Women with ACS were less likely to report chest pain as their chief complaint and to report more nausea (odds ratio [OR], 1.56; confidence interval [CI], 1.00-2.42), shoulder pain (OR, 1.76; CI, 1.13-2.73), and upper back pain (OR, 2.92; CI, 1.81-4.70). Women with ACS experienced more symptoms (6.1 vs 5.5; P = .026) compared with men. Men without ACS had less symptom distress compared with women.

CONCLUSIONS

Women and men evaluated for ACS reported similar rates of chest pain but differed on other classic symptoms. These findings suggest that women and men should be counseled that ACS is not always accompanied by chest pain and multiple symptoms may occur simultaneously.

Predicting long-term prognosis in stable peripheral artery disease with baseline functional capacity estimated by the Duke Activity Status Index

BACKGROUND

The ability of a simple self-assessment tool for estimated functional capacity to predict long-term prognosis in patients with established peripheral artery disease (PAD) is unknown. We investigate whether subjective measurement of functional capacity estimated by using the Duke Activity Status Index (DASI) questionnaire predicts long-term prognosis in patients with established PAD.

METHODS

We administered the DASI questionnaire to 771 stable patients with established PAD who underwent elective diagnostic coronary angiography with 5-year follow-up all-cause mortality.

RESULTS

Two hundred ten patients (27%) died over a 5-year follow-up. The lowest DASI score was associated with a 3.2-fold increased risk of 5-year all-cause mortality (unadjusted hazard ratio 3.23, 95% CI 2.19-4.75, P<.001). After adjustments for traditional risk factors, estimated glomerular filtration rate, high-sensitivity C-reactive protein, and lowest DASI score remained predictive of 5-year all-cause mortality (adjusted hazard ratio 2.09, 95% CI 1.36-3.23, P<.001). Interestingly, the lowest DASI score remained to predict 5-year all-cause mortality regardless of each PAD diagnosis subtype (including lower extremity, non-lower extremity, or carotid artery PAD), although the mortality risk was attenuated when incorporating heart disease severity in the non-lower extremity group.

CONCLUSIONS

A simple self-assessment tool of functional capacity provides an independent and incremental prognosis value for long-term adverse clinical events in stable patients with established PAD beyond each PAD diagnostic subtype.

Ambient Air Pollution Is Associated With the Severity of Coronary Atherosclerosis and Incident Myocardial Infarction in Patients Undergoing Elective Cardiac Evaluation

Background

The effect of air pollution exposure on atherosclerosis severity or incident clinical events in patients with coronary artery disease is not known.

Methods and Results

We conducted a prospective longitudinal cohort study of 6575 Ohio residents undergoing elective diagnostic coronary angiography. Multinomial regression and Cox proportional hazards models were used to assess the relationship between exposure to fine particulate matter <2.5 μm in diameter (PM_2.5) and nitrogen dioxide on coronary artery disease severity at baseline and risk of myocardial infarction, stroke, or all‐cause mortality over 3 years of follow‐up. Among participants with coronary artery disease, exposure to PM_2.5 levels was associated with increased likelihood of having coronary atherosclerosis that was mild (odds ratio 1.43, 95% CI 1.11–1.83, P=0.005) and severe (odds ratio 1.63, 95% CI 1.26–2.11, P<0.0001), with the effect on severe coronary artery disease being significantly increased compared with mild disease (P_trend=0.03). Exposure to higher PM_2.5 levels was also significantly associated with increased risk of incident myocardial infarction (hazard ratio 1.33, 95% CI 1.02–1.73, P=0.03) but not stroke or all‐cause mortality. The association of PM_2.5 with incident myocardial infarction was not affected after adjustment for Framingham Adult Treatment Panel III (ATP III) risk score or statin therapy. In comparison, there were no significant associations between nitrogen dioxide levels and all‐cause mortality or risk of stroke after adjustment for Framingham ATP III risk score.

Conclusions

Exposure to PM_2.5 increased the likelihood of having severe coronary artery disease and the risk of incident myocardial infarction among patients undergoing elective cardiac evaluation. These results suggest that ambient air pollution exposure may be a modifiable risk factor for risk of myocardial infarction in a highly susceptible patient population.

Cardiac function in BRCA1/2 mutation carriers with history of breast cancer treated with anthracyclines

Animal data suggest that defects in BRCA1/2 genes significantly increase the risk of heart failure and mortality in mice exposed to doxorubicine. Women with BRCA1/2 mutations who develop breast cancer (BC) may receive anthracyclines but their risk of cardiac dysfunction has not been investigated. Our study tested the hypothesis that women with history of BRCA1/2 mutation-associated BC treated with anthracyclines have impaired parameters of cardiac function compared to similarly treated women with history of sporadic BC. Women with history of BC and anthracycline treatment underwent an echocardiographic exam for assessment of primary outcomes, left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). The sample size of 81 provided 79 % power with two-sided two-sample t test and alpha of 0.05 to detect a clinically meaningful difference in cardiac function of absolute 5 % points difference for LVEF and 2 % points difference for GLS. Of 81 normotensive participants, 39 were BRCA1/2 mutation carriers and 42 in the sporadic group. Mean age was 50 ± 9 years in both groups (P = 0.99) but BRCA1/2 mutation carriers had longer anthracycline treatment-to-enrollment time (7.5 ± 5.3 vs. 4.2 ± 3.3 years, P = 0.001). There were no significant differences in LVEF (P = 0.227) or GLS (P = 0.53) between the groups. LVEF was normal in 91 % of women and subclinical cardiac dysfunction defined as absolute GLS value <18.9 % was seen in 4 (10 %) BRCA1/2 mutation carriers and 7 (17 %) sporadic participants. In this first prospective examination of cardiac function in BRCA1/2 mutation carriers, we found no significant differences in sensitive echocardiographic parameters of cardiac function between BRCA1/2 mutation carriers and women with history of sporadic BC who received anthracycline treatment. In contrast to laboratory animal data, our findings indicate lack of elevated cardiac risk with the use of standard-doses of adjuvant anthracyclines in treatment of BRCA1/2 mutation carriers with early stage BC.