Ischemic cardiomyopathy results from the combination of scar with fibrosis replacement and areas of dysfunctional but viable myocardium that may improve contractile function with revascularization. ...Observational studies reported that only patients with substantial amounts of myocardial viability had better outcomes following surgical revascularization. Accordingly, dedicated noninvasive techniques have evolved to quantify viable myocardium with the objective of selecting patients for this form of therapeutic intervention. However, prospective trials have not confirmed the interaction between myocardial viability and the treatment effect of revascularization. Furthermore, recent observations indicate that recovery of left ventricular function is not the principal mechanism by which surgical revascularization improves prognosis. In this paper, the authors describe a more contemporary application of viability testing that is founded on the alternative concept that the main goal of surgical revascularization is to prevent further damage by protecting the residual viable myocardium from subsequent acute coronary events.
The role of myocardial viability assessment in identifying patients with ischemic cardiomyopathy who will benefit from surgical revascularization is controversial. This study assessed myocardial ...viability and its relationship to long-term outcomes in 601 patients with ischemic cardiomyopathy who were assigned to surgical revascularization plus medical therapy or medical therapy alone.
Older patients with atrial fibrillation (AF) are at higher risk of thromboembolic events and oral anticoagulant (OAC)-related bleeding complications. This meta-analysis evaluates the efficacy and ...safety of direct-acting OACs (DOACs) compared with warfarin in older patients with nonvalvular AF. PubMed, Embase, and Cochrane Central databases were searched for randomized controlled trials assessing the efficacy and safety of DOACs compared with warfarin in AF patients who were >75 years old. Treatment effects and relevant standard errors were calculated from the available data. These values were imputed in software R to perform meta-analysis through generic inverse variance method. Additionally, we performed a network meta-analysis to compare the relative efficacy and safety of each OAC. Five substudies of randomized controlled trials, comprising 28,135 older participants, were included in the analysis. DOACs as a group were found to have superior efficacy compared with warfarin in reducing stroke or systemic embolization (hazard ratio 0.76, 95% confidence intervals 0.67 to 0.86, p <0.01). The rate of major bleeding was similar, but intracranial hemorrhage was significantly lower in patients randomized to a DOAC (hazard ratio 0.48, 95% confidence intervals 0.34 to 0.67, p <0.01). Apixaban was the only DOAC that significantly reduced all 3 outcomes of systemic embolization, major bleeding, and intracranial hemorrhage compared with warfarin (by 29%, 36%, and 66%, respectively). In conclusion, DOACs were found to be safer and more effective than warfarin for the treatment of nonvalvular AF in older patients. Apixaban appears to provide the best combination of efficacy and safety in this population.
Hypertrophic cardiomyopathy is a genetic disease that frequently presents at a young age. Pregnancy represents a state of high physiological stress to the cardiovascular system. Thus, pregnant women ...with hypertrophic cardiomyopathy face the potential for higher morbidity and, therefore, their management may become a significant challenge when complications develop. Physiologic changes that occur during pregnancy, that is, decreased vascular resistance, increased blood volume, and increased heart rate can lead to worsening heart failure in women with hypertrophic cardiomyopathy. In addition, pregnant women with hypertrophic cardiomyopathy are at higher risk for arrhythmias. The hemodynamic effects of atrial fibrillation and ventricular tachycardia are significant and can be dangerous for the mother and the fetus. In addition, they can lead to heart failure exacerbation. Atrial fibrillation is of particular interest in this population subgroup. Pregnancy is a hypercoagulable state and atrial fibrillation is an arrhythmia associated with significant thromboembolic complications. Patients with hypertrophic cardiomyopathy that develop atrial fibrillation are especially at a higher risk of thrombosis. Anticoagulation is recommended regardless of CHA2DS2-VASc score. Anticoagulation during pregnancy is challenging not only because of the teratogenic effects of some drugs and the lack of evidence for some others, but also the differences in the plasma concentration of many anticoagulants. Overall, the potential for high morbidity in pregnant women with hypertrophic cardiomyopathy is not negligible. Major cardiac events such as arrhythmias and heart failure are common. However, early recognition and treatment of these complications can lead to full-term pregnancy and successful delivery.
Abstract Background Older women presenting with ST-segment elevation myocardial infarction (STEMI) are less likely to receive revascularization and have worse outcomes relative to their male ...counterparts. Objectives This study sought to determine temporal trends and sex differences in revascularization and in-hospital outcomes of younger patients with STEMI. Methods We used the 2004 to 2011 Nationwide Inpatient Sample databases to identify all patients age 18 to 59 years hospitalized with STEMI. Temporal trends and sex differences in revascularization strategies, in-hospital mortality, and length of stay were analyzed. Results From 2004 to 2011, of 1,363,492 younger adults (age <60 years) with acute myocardial infarction, 632,930 (46.4%) had STEMI. Younger women with acute myocardial infarction were less likely than men to present with STEMI (adjusted odds ratio OR: 0.74; 95% confidence interval CI: 0.73 to 0.75). Younger women with STEMI were less likely to receive reperfusion as compared with younger men (percutaneous coronary intervention adjusted OR: 0.74; 95% CI: 0.73 to 0.75) (coronary artery bypass grafting adjusted OR: 0.61; 95% CI: 0.60 to 0.62) (thrombolysis adjusted OR: 0.80; 95% CI: 0.78 to 0.82). From 2004 to 2011, use of percutaneous coronary intervention for STEMI increased in both younger men (63.9% to 84.8%; ptrend < 0.001) and women (53.6% to 77.7%; ptrend < 0.001). In-hospital mortality was significantly higher in younger women compared with men (4.5% vs. 3.0%; adjusted OR: 1.11; 95% CI: 1.07 to 1.15). There was an increasing trend in risk-adjusted in-hospital mortality in both younger men and women during the study period. Length of stay decreased in both younger men and women (ptrend < 0.001). Conclusions Younger women are less likely to receive revascularization for STEMI and have higher in-hospital mortality as compared with younger men. Use of percutaneous coronary intervention for STEMI and in-hospital mortality have increased, whereas length of stay has decreased in both sexes over the past several years.
Purpose of Review
We aim to reevaluate how the assessment of myocardial viability can guide optimal treatment strategies for patients with ischemic cardiomyopathy (ICM) based on a more contemporary ...understanding of the mechanism of benefit of revascularization.
Recent Findings
The assessment of viability in left ventricular (LV) segments with diminished contraction has been proposed as key to predict the benefit of revascularization and, therefore, as a requisite for the selection of patients to undergo this form of treatment. However, data from prospective trials have diverged from earlier retrospective studies.
Summary
Traditional binary viability assessment may oversimplify ICM’s complexity and the nuances of revascularization benefits. A conceptual shift from the traditional paradigm centered on the assessment of viability as a dichotomous variable to a more comprehensive approach encompassing a thorough understanding of ICM’s complex pathophysiology and the salutary effect of revascularization in the prevention of myocardial infarction and ventricular arrhythmias is required.
Among patients with ischemic cardiomyopathy, coronary-artery bypass grafting added to medical therapy led to significantly lower rates of death from any cause and of cardiovascular death over 10 ...years than did medical therapy alone.
Advances in the management of cardiovascular risk factors and acute coronary syndromes have increased survival among patients with coronary artery disease, transforming it into a chronic disease that affects 15.5 million U.S. patients; however, coronary artery disease still accounts for more than 538,000 deaths yearly in the United States alone.
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The major long-term manifestations of coronary artery disease, left ventricular dysfunction, and heart failure are projected to affect 8 million patients by 2030, which has enormous societal implications.
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Landmark clinical trials have established coronary-artery bypass grafting (CABG) as an effective treatment for patients with disabling angina symptoms.
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Patients with CAD and LV dysfunction were assigned to receive either medical therapy alone or medical therapy plus CABG. There was no evidence of significant interaction between myocardial viability ...and treatment assignment.
Coronary artery disease is an important contributor to the rise in the prevalence of heart failure and in associated mortality and morbidity.
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It has not been clearly established whether coronary-artery bypass grafting (CABG) has a role in improving the symptoms and the rate of survival of patients with coronary artery disease and heart failure. We conducted the multicenter Surgical Treatment for Ischemic Heart Failure (STICH) trial
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to examine two hypotheses, one of which (hypothesis 1) compared the efficacy of medical therapy alone with that of medical therapy plus CABG in patients with coronary artery disease and left ventricular . . .
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