Atrial fibrillation in embolic stroke of undetermined source: role of advanced imaging of left atrial function

AIMS

Atrial fibrillation (AF) is detected in over 30% of patients following an embolic stroke of undetermined source (ESUS) when monitored with an implantable loop recorder (ILR). Identifying AF in ESUS survivors has significant therapeutic implications, and AF risk is essential to guide screening with long-term monitoring. The present study aimed to establish the role of left atrial (LA) function in subsequent AF identification and develop a risk model for AF in ESUS.

METHODS AND RESULTS

We conducted a single-centre retrospective case-control study including all patients with ESUS referred to our institution for ILR implantation from December 2009 to September 2019. We recorded clinical variables at baseline and analysed transthoracic echocardiograms in sinus rhythm. Univariate and multivariable analyses were performed to inform variables associated with AF. Lasso regression analysis was used to develop a risk prediction model for AF. The risk model was internally validated using bootstrapping. Three hundred and twenty-three patients with ESUS underwent ILR implantation. In the ESUS population, 293 had a stroke, whereas 30 had suffered a transient ischaemic attack as adjudicated by a senior stroke physician. Atrial fibrillation of any duration was detected in 47.1%. The mean follow-up was 710 days. Following lasso regression with backwards elimination, we combined increasing lateral PA (the time interval from the beginning of the P wave on the surface electrocardiogram to the beginning of the A' wave on pulsed wave tissue Doppler of the lateral mitral annulus) [odds ratio (OR) 1.011], increasing Age (OR 1.035), higher Diastolic blood pressure (OR 1.027), and abnormal LA reservoir Strain (OR 0.973) into a new PADS score. The probability of identifying AF can be estimated using the formula. Model discrimination was good [area under the curve (AUC) 0.72]. The PADS score was internally validated using bootstrapping with 1000 samples of 150 patients showing consistent results with an AUC of 0.73.

CONCLUSION

The novel PADS score can identify the risk of AF on prolonged monitoring with ILR following ESUS and should be considered a dedicated risk stratification tool for decision-making regarding the screening strategy for AF in stroke.

Circulating intermediate monocytes CD14++CD16+ are increased after elective percutaneous coronary intervention

AIM

Inflammation plays a central role in the pathogenesis of atherosclerosis and in the sequelae of percutaneous coronary intervention (PCI). Previous work demonstrated that intermediate monocytes (CD14++CD16+) are associated with adverse cardiovascular events, yet monocyte subset response following elective PCI has not been described. This article explores the changes in monocyte subset and humoral response after elective PCI.

METHODS

This prospective study included 30 patients without inflammatory diseases being referred for elective PCI. We included patients treated with drug coated balloons or 2nd generation drug eluting stents. Patients underwent blood tests at baseline (prior to PCI), four hours, two weeks and two months later. Analyses were performed in terms of monocyte subsets (classical CD14++CD16-, intermediate CD14++CD16+ and non-classical CD14+CD16++), gene expression of CD14+ leucocytes and humoral biomarkers.

RESULTS

Intermediate monocytes decreased significantly four hours after PCI, were recovered at two weeks, and increased significantly at two months post elective, uncomplicated PCI. They remain significantly elevated in the DES group but not in the DCB group. Gene expression analysis of CD14+ leucocytes showed IL18 had decreased expression at two weeks, CXCR4 and IL1β decreased at two months, while pentraxin 3 increased at two weeks and two months. In terms of humoral biomarkers, hsTnI remains elevated up to two weeks post PCI while IL6 and TNFα remain elevated till two months post PCI.

CONCLUSION

Intermediate monocytes increase significantly two months following elective, uncomplicated PCI. They remain significantly elevated in the DES group but not in the DCB group suggesting that the PCI strategy could be one of the ways to modulate the inflammatory response post PCI.

Paclitaxel drug-coated balloon-only angioplasty for de novo coronary artery disease in elective clinical practice

OBJECTIVE

We aimed to investigate the safety of drug-coated balloon (DCB)-only angioplasty compared to drug-eluting stent (DES), as part of routine clinical practice.

BACKGROUND

The recent BASKETSMALL2 trial demonstrated the safety and efficacy of DCB angioplasty for de novo small vessel disease. Registry data have also demonstrated that DCB angioplasty is safe; however, most of these studies are limited due to long recruitment time and a small number of patients with DCB compared to DES. Therefore, it is unclear if DCB-only strategy is safe to incorporate in routine elective clinical practice.

METHODS

We compared all-cause mortality and major cardiovascular endpoints (MACE), including unplanned target lesion revascularisation (TLR) of all patients treated with DCB or DES for first presentation of stable angina due to de novo coronary artery disease between 1st January 2015 and 15th November 2019. Data were analysed with Cox regression models and cumulative hazard plots.

RESULTS

We present 1237 patients; 544 treated with DCB and 693 treated with DES for de novo, mainly large-vessel coronary artery disease. On multivariable Cox regression analysis, only age and frailty remained significant adverse predictors of all-cause mortality. Univariable, cumulative hazard plots showed no difference between DCB and DES for either all-cause mortality or any of the major cardiovascular endpoints, including unplanned TLR. The results remained unchanged following propensity score-matched analysis.

CONCLUSION

DCB-only angioplasty, for stable angina and predominantly large vessels, is safe compared to DES as part of routine clinical practice, in terms of all-cause mortality and MACE, including unplanned TLR.

Assessment of Paclitaxel Drug-Coated Balloon Only Angioplasty in STEMI

BACKGROUND

Primary percutaneous coronary intervention (pPCI) with drug-eluting stents (DES) has emerged as the standard of care, but stent-related events have persisted. Drug-coated balloon (DCB)-only angioplasty is an emerging technology, although it is not fully evaluated compared with DES in the context of pPCI.

OBJECTIVES

The aim of this study was to investigate the safety of DCB-only angioplasty compared with second-generation DES in pPCI.

METHODS

All-cause mortality and net adverse cardiac events (cardiovascular mortality, acute coronary syndrome, ischemic stroke or transient ischemic attack, major bleeding, and unplanned target lesion revascularization [TLR]) were compared among all patients treated with DCBs only or with second-generation DES only for first presentation of ST-segment elevation myocardial infarction (STEMI) due to de novo disease between January 1, 2016, and November 15, 2019. Patients treated with both DCBs and DES were excluded. Data were analyzed using Cox regression models, Kaplan-Meier estimator plots and propensity score matching.

RESULTS

Among 1,139 patients with STEMI due to de novo disease, 452 were treated with DCBs and 687 with DES. After a median follow-up period of >3 years, all-cause mortality was 49 of 452 and 62 of 687 in the DCB and DES groups, respectively (P = 0.18). On multivariable Cox regression analysis, there was no difference in mortality between DCBs and DES in the full and propensity score-matched cohorts. Age, frailty risk, history of heart failure, and family history of ischemic heart disease remained significant independent predictors of mortality. There was no difference in any of the secondary endpoints, including unplanned TLR.

CONCLUSIONS

DCB-only angioplasty appears safe compared with DES for STEMI in terms of all-cause mortality and all net adverse cardiac events, including unplanned TLR. DCB may be an efficacious and safe alternative to DES in selected patient groups. (Drug Coated Balloon Only vs Drug Eluting Stent Angioplasty; NCT04482972).

CT angiography compared to invasive angiography for stable coronary disease as predictors of major adverse cardiovascular events- A systematic review and meta-analysis

BACKGROUND

Computational tomography coronary angiography (CTCA) is increasingly the diagnostic test of choice for investigating patients with stable anginal symptoms.

OBJECTIVES

We sought to conduct a systematic review and meta-analysis comparing CTCA with invasive coronary angiography (ICA) with regards to major adverse cardiovascular events (MACE), procedural complications and rates of revascularisation.

METHODS

We conducted a systematic review and meta-analysis in line with the PRISMA statement. A literature search was conducted using PubMed, MEDLINE Ovid and Embase, with three studies included in meta-analysis. Statistical analysis was undertaken using Review Manager 5.3 for MacOS software and outcomes expressed as odds ratio, with 95% confidence intervals and sensitivity analysis was conducted.

RESULTS

A total of 5662 patients were included in this study level meta-analysis. There was no difference in MACE between CT and angiography [2.97% v 3.45%, fixed-effect model, OR: 0.84 (0.62-1.14), p = 0.26, I² 0%] and no difference found in rates of myocardial infarction, death or stroke. CTCA was associated with a reduced rate of revascularisation [12.6% v 18.3%, fixed-effects model, OR: 0.64 (0.55-0.75), p<0.00001, I² =0%]. However, CTCA was not associated with a significantly lower complication rate [0.5% v 1.72%, random effects model, OR: 0.52 (0.06-4.38), p = 0.55, I² 52%].

CONCLUSION

CTCA is a safe strategy for investigating patients with stable angina with no associated increase in MACE but a reduction in revascularisation rates.

High prevalence of asymptomatic left ventricular diastolic dysfunction and its detection among South Asian patients with Type 2 Diabetes Mellitus compared with White Europeans

Background

Heart failure (HF) is an important manifestation of Type 2 Diabetes (T2D). The development of HF in T2D may be preceded by Stage B HF. Asymptomatic left ventricular impairment, especially left ventricular diastolic dysfunction (LVDD), is a defining early feature of Stage B HF. Detection of Stage B HF is crucial as it provides an opportune target for intervention with cardio-protective therapy to prevent the development of symptomatic HF in T2D. The risk of T2DM is higher in South Asian populations resulting in increased risk of macrovascular and microvascular complications. The prevalence of Stage B HF in South Asian patients with T2DM is not known.

Purpose

(i) To compare the prevalence of Stage B HF in South Asians in India compared with White Europeans in Scotland; (ii) To test the role of NT-proBNP in identifying Stage B HF

Methods

This study involved the comparison between two independently conducted, cross-sectional studies. The patients were asymptomatic patients with T2DM with no prior history of cardiovascular disease from Chennai, India (n=246) and Tayside, Scotland (n=246). All patients underwent transthoracic echocardiogram (echo) examination to detect the presence of structural and functional echo features of Stage B HF: left atrial enlargement (LAE), left ventricular hypertrophy (LVH), LVDD and LV systolic dysfunction (LVSD). Receiver operating curves (ROC) were used to determine the predictive ability of NT-proBNP to predict LAE/LVDD/LVD/LVSD.

Results

The prevalence of Stage B HF was high in South-Asian patients with T2DM (median age of 55 [49, 62] with a high prevalence of LVDD (5% had LVH, 7.3% had LAE, 70% had LVDD and 0% had LVSD (Figure 1B). 10% of the South Asian patients had at least 2 factors contributing to Stage B HF and these patients had higher NT-proBNP titres (703.4 [500.0, 949.2] vs 423.7 [35.0, 754.2], p&lt;0.001). ROC curves show that NT-proBNP can predict these participants with 2 or more echo features [Figure 2B, AUC: 0.7043 (0.6159, 0.7928) p&lt;0.05]. The prevalence of Stage B HF among White Europeans (median age of 67 [61, 72].) was lower compared with South Asian patients: 15% had LVH, 13% had LAE, 19% had LVDD and 2% had LVSD (Figure 1A). 8% of White Europeans had at least 2 factors contributing to Stage B HF and these had higher NT-proBNP titres (368.9 [154.6, 1087.8] vs 186.8 [79.7, 411.5], p=0.02). ROC curves show that NT-proBNP can predict participants with 2 or more factors [Figure 2A, AUC: 0.6399 (0.5122, 0.7676) p&lt;0.05].

Conclusion

Our study has shown that South Asian patients with T2DM have a high prevalence of Stage B HF compared with White Europeans and that the predominant Stage B HF feature is LVDD.

We also found that NTproBNP could potentially be used to detect Stage B HF and help identify at-risk patients for cardio-protective therapy such as SGLT2 inhibitor therapy that has been shown to prevent the development of future HF events.

Funding Acknowledgement

Type of funding sources: None.

Mitogen and Stress-Activated Kinases 1 and 2 Mediate Endothelial Dysfunction

Inflammation promotes endothelial dysfunction, but the underlying mechanisms remain poorly defined in vivo. Using translational vascular function testing in myocardial infarction patients, a situation where inflammation is prevalent, and knock-out (KO) mouse models we demonstrate a role for mitogen-activated-protein-kinases (MAPKs) in endothelial dysfunction. Myocardial infarction significantly lowers mitogen and stress kinase 1/2 (MSK1/2) expression in peripheral blood mononuclear cells and diminished endothelial function. To further understand the role of MSK1/2 in vascular function we developed in vivo animal models to assess vascular responses to vasoactive drugs using laser Doppler imaging. Genetic deficiency of MSK1/2 in mice increased plasma levels of pro-inflammatory cytokines and promoted endothelial dysfunction, through attenuated production of nitric oxide (NO), which were further exacerbated by cholesterol feeding. MSK1/2 are activated by toll-like receptors through MyD88. MyD88 KO mice showed preserved endothelial function and reduced plasma cytokine expression, despite significant hypercholesterolemia. MSK1/2 kinases interact with MAPK-activated proteins 2/3 (MAPKAP2/3), which limit cytokine synthesis. Cholesterol-fed MAPKAP2/3 KO mice showed reduced plasma cytokine expression and preservation of endothelial function. MSK1/2 plays a significant role in the development of endothelial dysfunction and may provide a novel target for intervention to reduce vascular inflammation. Activation of MSK1/2 could reduce pro-inflammatory responses and preserve endothelial vasodilator function before development of significant vascular disease.

Neutrophil-to-lymphocyte ratio and outcomes in patients with new-onset or worsening heart failure with reduced and preserved ejection fraction

AIMS

Inflammation is thought to play a role in heart failure (HF) pathophysiology. Neutrophil-to-lymphocyte ratio (NLR) is a simple, routinely available measure of inflammation. Its relationship with other inflammatory biomarkers and its association with clinical outcomes in addition to other risk markers have not been comprehensively evaluated in HF patients.

METHODS

We evaluated patients with worsening or new-onset HF from the BIOlogy Study to Tailored Treatment in Chronic Heart Failure (BIOSTAT-CHF) study who had available NLR at baseline. The primary outcome was time to all-cause mortality or HF hospitalization. Outcomes were validated in a separate HF population.

RESULTS

1622 patients were evaluated (including 523 ventricular ejection fraction [LVEF] < 40% and 662 LVEF ≥ 40%). NLR was significantly correlated with biomarkers related to inflammation as well as NT-proBNP. NLR was significantly associated with the primary outcome in patients irrespective of LVEF (hazard ratio [HR] 1.18 per standard deviation increase; 95% confidence interval [CI] 1.11-1.26, P < 0.001). Patients with NLR in the highest tertile had significantly worse outcome than those in the lowest independent of LVEF (<40%: HR 2.75; 95% CI 1.84-4.09, P < 0.001; LVEF ≥ 40%: HR 1.51; 95% CI 1.05-2.16, P = 0.026). When NLR was added to the BIOSTAT-CHF risk score, there were improvements in integrated discrimination index (IDI) and net reclassification index (NRI) for occurrence of the primary outcome (IDI + 0.009; 95% CI 0.00-0.019, P = 0.030; continuous NRI + 0.112, 95% CI 0.012-0.176, P = 0.040). Elevated NLR was similarly associated with adverse outcome in the validation cohort. Decrease in NLR at 6 months was associated with reduced incidence of the primary outcome (HR 0.75; 95% CI 0.57-0.98, P = 0.036).

CONCLUSIONS

Elevated NLR is significantly associated with elevated markers of inflammation in HF patients and is associated with worse outcome. Elevated NLR might potentially be useful in identifying high-risk HF patients and may represent a treatment target.

A randomized controlled trial of metformin on left ventricular hypertrophy in patients with coronary artery disease without diabetes: the MET-REMODEL trial

Aim

We tested the hypothesis that metformin may regress left ventricular hypertrophy (LVH) in patients who have coronary artery disease (CAD), with insulin resistance (IR) and/or pre-diabetes.

Methods and results

We randomly assigned 68 patients (mean age 65 ± 8 years) without diabetes who have CAD with IR and/or pre-diabetes to receive either metformin XL (2000 mg daily dose) or placebo for 12 months. Primary endpoint was change in left ventricular mass indexed to height^1.7 (LVMI), assessed by magnetic resonance imaging. In the modified intention-to-treat analysis (n = 63), metformin treatment significantly reduced LVMI compared with placebo group (absolute mean difference −1.37 (95% confidence interval: −2.63 to −0.12, P = 0.033). Metformin also significantly reduced other secondary study endpoints such as: LVM (P = 0.032), body weight (P = 0.001), subcutaneous adipose tissue (P = 0.024), office systolic blood pressure (BP, P = 0.022) and concentration of thiobarbituric acid reactive substances, a biomarker for oxidative stress (P = 0.04). The glycated haemoglobin A1C concentration and fasting IR index did not differ between study groups at the end of the study.

Conclusion

Metformin treatment significantly reduced LVMI, LVM, office systolic BP, body weight, and oxidative stress. Although LVH is a good surrogate marker of cardiovascular (CV) outcome, conclusive evidence for the cardio-protective role of metformin is required from large CV outcomes trials.