Abstract Spontaneous coronary artery dissection (SCAD) is gaining recognition as an important cause of myocardial infarction, especially in young women. There has been a surge in the diagnosis of ...SCAD in recent years, presumably due to an increased use of coronary angiography, and the clinical availability and application of high-resolution intracoronary imaging. The improved recognition and diagnosis, together with increased publications and attention through social media, have considerably raised awareness of this condition, which was once believed to be very rare. Recent publications of moderate to large contemporary case series have helped elucidate the early natural history, presenting characteristics (clinical and angiographic), underlying etiology, management, and cardiovascular outcomes with this condition, thus providing observations and important clinical insights of value to clinicians managing this challenging and perplexing patient cohort. The aim of our review is to provide a comprehensive contemporary update of SCAD to aid health care professionals in managing these patients in both the acute and chronic settings.
Objectives The purpose of this study was to investigate the 5-year outcome following transcatheter aortic valve implantation (TAVI). Background Little is known about long-term outcomes following ...TAVI. Methods The 5-year outcomes following successful TAVI with a balloon-expandable valve were evaluated in 88 patients. Patients who died within 30 days after TAVI were excluded. Results Mean aortic valve gradient decreased from 46 ± 18 mm Hg to 10 ± 4.5 mm Hg after TAVI and 11.8 ± 5.7 mm Hg at 5 years (p for post-TAVI trend = 0.06). Mean aortic valve area increased from 0.62 ± 0.17 cm2 to 1.67 ± 0.41 cm2 after TAVI and 1.40 ± 0.25 cm2 at 5 years (p for post-TAVI trend <0.01). At 5 years, 3 patients (3.4%) had moderate prosthetic valve dysfunction (moderate transvalvular regurgitation in 1, moderate stenosis in 1, and moderate mixed disease in 1). Survival rates at 1 to 5 years were 83%, 74%, 53%, 42%, and 35%, respectively. Median survival time after TAVI was 3.4 years (95% confidence interval CI: 2.6 to 4.3), and the risk of death was significantly increased in patients with chronic obstructive pulmonary disease (adjusted hazard ratio HR: 2.17; 95% CI: 1.28 to 3.70) and at least moderate paravalvular regurgitation (adjusted HR: 2.98; 95% CI: 1.44 to 6.17). Conclusions Our study demonstrated favorable long-term outcomes after TAVI. Signs of moderate prosthetic valve failure were observed in 3.4% of patients. No patients developed severe prosthetic regurgitation or stenosis. Comorbidities, notably chronic lung disease and at least moderate paravalvular regurgitation, were associated with reduced long-term survival.
Abstract
Aims
The long-term prognosis of angina in patients without obstructive coronary artery disease (CAD) is uncertain. To assess the incidence of long-term adverse outcomes in such patients.
...Methods and results
We searched PubMed, Cochrane Library, the Embase database, and the Clinical Trials Registry for studies published in English until January 2017, assessing the composite primary outcome of all-cause death and non-fatal myocardial infarction using random-effects models to estimate pooled incidences. We identified 54 studies, reporting outcomes in overall 35 039 patients (mean age 56, male/female ratio 0.51, 99 770 person-years) with angina and no obstructive CAD. After a median follow-up of 5 years (interquartile range 3–7 years), the pooled incidence of the primary outcome was 0.98/100 person-years 95% confidence interval (CI) 0.77–1.19%, with considerable heterogeneity among studies (I2 = 91%, P < 0.001). The primary outcome was associated with prevalent dyslipidaemia (P = 0.016), diabetes (P = 0.035), and hypertension (P = 0.016). Studies enrolling patients with less-than-obstructive CAD showed a higher incidence of the primary outcome (1.32/100 person-years, 95% CI 1.02–1.62) compared with studies including only patients with ‘entirely normal’ coronary arteries (0.52/100 person-years, 95% CI 0.34–0.79, respectively; P < 0.01). The incidence of the primary outcome did not differ significantly between studies enrolling only patients with documented myocardial ischaemia and those studies enrolling patients regardless of presence of ischaemia. However, ischaemia documented by non-invasive imaging techniques was associated with a higher incidence of events (P = 0.02). Overall, these patients, however, suffered from a high incidence of recurrent hospitalization.
Conclusion
Angina without obstructive CAD has a heterogeneous prognosis. A main determinant of major adverse events is the presence of ‘some’ coronary atherosclerosis, with unequivocal myocardial ischaemia being associated with worse clinical outcomes. Patients’ quality of life is also worsened by the high incidence of hospitalization, angina recurrence, and repeated coronary angiography.
Minerals play a major role in regulating cardiovascular function. Imbalances in electrolyte minerals are frequent and potentially hazardous occurrences that may lead to the development of ...cardiovascular diseases (CVDs). Transition metals, such as iron, zinc, copper and selenium, play a major role in cell metabolism. However, there is controversy over the effects of dietary and supplemental intake of these metals on cardiovascular risk factors and events. Since their pro-oxidant or antioxidant functions can have different effects on cardiovascular health. While deficiency of these trace elements can cause cardiovascular dysfunction, several studies have also shown a positive association between metal serum levels and cardiovascular risk factors and events. Thus, a J- or U-shaped relationship between the transition minerals and cardiovascular events has been proposed. Given the existing controversies, large, well-designed, long-term, randomized clinical trials are required to better examine the effects of trace mineral intake on cardiovascular events and all-cause mortality in the general population. In this review, we discuss the role of dietary and/or supplemental iron, copper, zinc, and selenium on cardiovascular health. We will also clarify their clinical applications, benefits, and harms in CVDs prevention.
Progression from paroxysmal to persistent atrial fibrillation (AF) has important clinical implications and is relevant to the management of patients with AF.
The purpose of this study was to define ...the long-term rate of progression from paroxysmal to persistent AF and the relevant clinical variables.
The Canadian Registry of Atrial Fibrillation enrolled patients after a first electrocardiographic diagnosis of paroxysmal AF. Associations between baseline characteristics and clinical outcomes were evaluated using a multivariable Cox proportional hazard model and a competing risk model accounting for death as a competing risk, where appropriate.
We enrolled 755 patients (61.7% men) aged between 14 and 91 years (mean age 61.2 ± 14.2 years). The median follow-up was 6.35 years (interquartile range 2.93-10.04 years), with a rate of progression to persistent AF at 1, 5, and 10 years was 8.6%, 24.3%, and 36.3%, respectively. All-cause mortality was 30.3% at 10 years. Factors associated with AF progression were increasing age (hazard ratio HR 1.40; 95% confidence interval CI 1.23-1.60, for each 10-year increment), mitral regurgitation (HR 1.87; 95% CI 1.28-2.73), left atrial dilatation (HR 3.01; 95% CI 2.03-4.47), aortic stenosis (HR 2.40; 95% CI 1.05-5.48), and left ventricular hypertrophy (HR .47; 95% CI 1.04-2.08). Factors associated with a lower rate of progression were a faster heart rate during AF (HR 0.94; 95% CI 0.92-0.96 per 5-beat/min increment) and angina (HR 0.54; 95% CI 0.38-0.77). After accounting for death as a competing risk, left ventricular hypertrophy and aortic stenosis were no longer significant.
Within 10 years of presenting with paroxysmal AF, >50% of patients will progress to persistent AF or be dead. Increasing age, mitral regurgitation, aortic stenosis, left ventricular hypertrophy, and left atrial dilatation were associated with progression to persistent AF.
Spontaneous coronary artery dissection (SCAD) was underdiagnosed and poorly understood for decades. It is increasingly recognized as an important cause of myocardial infarction (MI) in women. We ...aimed to assess the natural history of SCAD, which has not been adequately explored.
We performed a multicentre, prospective, observational study of patients with non-atherosclerotic SCAD presenting acutely from 22 centres in North America. Institutional ethics approval and patient consents were obtained. We recorded baseline demographics, in-hospital characteristics, precipitating/predisposing conditions, angiographic features (assessed by core laboratory), in-hospital major adverse events (MAE), and 30-day major adverse cardiovascular events (MACE). We prospectively enrolled 750 SCAD patients from June 2014 to June 2018. Mean age was 51.8 ± 10.2 years, 88.5% were women (55.0% postmenopausal), 87.7% were Caucasian, and 33.9% had no cardiac risk factors. Emotional stress was reported in 50.3%, and physical stress in 28.9% (9.8% lifting >50 pounds). Predisposing conditions included fibromuscular dysplasia 31.1% (45.2% had no/incomplete screening), systemic inflammatory diseases 4.7%, peripartum 4.5%, and connective tissue disorders 3.6%. Most were treated conservatively (84.3%), but 14.1% underwent percutaneous coronary intervention and 0.7% coronary artery bypass surgery. In-hospital composite MAE was 8.8%; peripartum SCAD patients had higher in-hospital MAE (20.6% vs. 8.2%, P = 0.023). Overall 30-day MACE was 8.8%. Peripartum SCAD and connective tissue disease were independent predictors of 30-day MACE.
Spontaneous coronary artery dissection predominantly affects women and presents with MI. Despite majority of patients being treated conservatively, survival was good. However, significant cardiovascular complications occurred within 30 days. Long-term follow-up and further investigations on management are warranted.
Stroke is a serious complication associated with atrial fibrillation (AF). Women with AF are at higher risk of stroke compared with men. Reasons for this higher stroke risk in women remain unclear, ...although some studies suggest that undertreatment with warfarin may be a cause.
To compare utilization patterns of warfarin and the risk of subsequent stroke between older men and women with AF at the population level.
Population-based cohort study of patients 65 years or older admitted to the hospital with recently diagnosed AF in the province of Quebec, Canada, 1998-2007, using administrative data with linkage between hospital discharge, physicians, and prescription drug claims databases.
Risk of stroke.
The cohort comprised 39,398 men (47.2%) and 44,115 women (52.8%). At admission, women were older and had a higher CHADS(2) (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack) score than men (1.99 SD, 1.10 vs 1.74 SD, 1.13, P < .001). At 30 days postdischarge, 58.2% of men and 60.6% of women had filled a warfarin prescription. In adjusted analysis, women appeared to fill more warfarin prescriptions compared with men (odds ratio, 1.07 95% CI, 1.04-1.11; P < .001). Adherence to warfarin treatment was good in both sexes. Crude stroke incidence was 2.02 per 100 person-years (95% CI, 1.95-2.10) in women vs 1.61 per 100 person-years (95% CI, 1.54-1.69) in men (P < .001). The sex difference was mainly driven by the population of patients 75 years or older. In multivariable Cox regression analysis, women had a higher risk of stroke than men (adjusted hazard ratio, 1.14 95% CI, 1.07-1.22; P < .001), even after adjusting for baseline comorbid conditions, individual components of the CHADS(2) score, and warfarin treatment.
Among older patients admitted with recently diagnosed AF, the risk of stroke was greater in women than in men, regardless of warfarin use.
"Gender" reflects social norms for women and men, whereas "sex" defines biological characteristics. Gender-related characteristics explain some differences in access to care for premature acute ...coronary syndrome (ACS); whether they are associated with cardiovascular outcomes is unknown.
This study estimated associations between gender and sex with recurrent ACS and major adverse cardiac events (MACE) (e.g., ACS, cardiac mortality, revascularization) over 12 months in patients with ACS.
We studied 273 women and 636 men age 18 to 55 years from GENESIS-PRAXY (GENdEr and Sex determInantS of cardiovascular disease: from bench to beyond-Premature Acute Coronary SYndrome), a prospective observational cohort study, who were hospitalized for ACS between January 2009 and April 2013. Gender-related characteristics (e.g., social roles) were assessed using a self-administered questionnaire, and a composite measure of gender was derived. Outcomes included recurrent ACS and MACE over 12 months.
Feminine roles and personality traits were associated with higher rates of recurrent ACS and MACE compared with masculine characteristics. This difference persisted for recurrent ACS, after multivariable adjustment (hazard ratio from score 0 to 100: 4.50; 95% confidence interval: 1.05 to 19.27), and was a nonstatistically significant trend for MACE (hazard ratio: 1.54; 95% confidence interval: 0.90 to 2.66). A possible explanation is increased anxiety, the only condition that was more prevalent in patients with feminine characteristics and that rendered the association between gender and recurrent ACS nonstatistically significant (hazard ratio: 3.56; 95% confidence interval: 0.81 to 15.61). Female sex was not associated with outcomes post-ACS.
Younger adults with ACS with feminine gender are at an increased risk of recurrent ACS over 12 months, independent of female sex.
Obstructive sleep apnea (OSA) patients are at increased risk of cardiovascular disease (CVD). Cell adhesion molecules (CAM) are increased in OSA and CAM are also implicated in the development of CVD. ...Do CAM (ICAM-1, VCAM-1 and E-selectin) have prognostic value in identifying risk of cardiovascular events in OSA? 418 patients were included in the analysis. Mostly male (68.2%), mean age of 50.7 yrs, median AHI 16.5 events/hour, and mean BMI of 31.7 kg/m.sup.2 . 36 cardiovascular events occurred in 8-yrs of follow up. Higher levels of ICAM-1 were associated with developing CVD (HR = 3.65 95% CI 1.40-9.53, 2.sup.nd and 3rd tertiles vs. 1.sup.st tertile), including in patients with OSA (HR = 3.1 95% CI 1.16-8.25). E-selectin was significantly associated with cardiovascular events in patients with moderate to severe OSA (HR = 3.31 95% CI 0.94-11.72, 2.sup.nd and 3.sup.rd tertiles vs. 1.sup.st tertile) but not in patients without moderate to severe OSA (HR = 0.67 95% CI 0.19-2.38), p-value for interaction = 0.07.
Background The incidence of atherosclerotic cardiovascular disease has declined in the past 2 decades. However, these benefits may not extend to young patients. The objective of this work was to ...assess temporal trends in the incidence, risk profiles, sex-related differences, and outcomes in a contemporary population of young patients presenting with coronary artery disease ( CAD ) in British Columbia, Canada. Methods and Results We used a provincial cardiac registry to identify young patients (men aged <50 years, women aged <55 years), with a first presentation of CAD between 2000 and 2016, who had either ≥50% stenosis of ≥1 coronary arteries on angiography or underwent coronary revascularization. A total of 12 519 patients (30% women) met our inclusion criteria. The incidence of CAD remained stable and was higher for men than women (46-53 versus 18-23 per 100 000). Of patients, 92% had at least one traditional cardiovascular risk factor and 67% had multiple risk factors. The prevalence of diabetes mellitus, obesity, and hypertension increased during the study period and was higher for women. Women had fewer emergent procedures and revascularizations. Mortality rates decreased by 31% between 2000 and 2007, then were stable for the remaining 9 years. Mortality was significantly higher for women aged <45 years compared with men. Conclusions The incidence of premature CAD has not declined, and the prevalence of 3 major cardiovascular risk factors increased between 2000 and 2016. The risk burden and mortality rates were worse for women. These data have important implications for the design of strategies to prevent CAD in young adults.
PDF
