In 2016, the American College of Cardiology published the first expert consensus decision pathway (ECDP) on the role of non-statin therapies for low-density lipoprotein (LDL)-cholesterol lowering in ...the management of atherosclerotic cardiovascular disease (ASCVD) risk. Since the publication of that document, additional evidence and perspectives have emerged from randomized clinical trials and other sources, particularly considering the longer-term efficacy and safety of proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors in secondary prevention of ASCVD. Most notably, the FOURIER (Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk) trial and SPIRE-1 and -2 (Studies of PCSK9 Inhibition and the Reduction of Vascular Events), assessing evolocumab and bococizumab, respectively, have published final results of cardiovascular outcomes trials in patients with clinical ASCVD and in a smaller number of high-risk primary prevention patients. In addition, further evidence on the types of patients most likely to benefit from the use of ezetimibe in addition to statin therapy after acute coronary syndrome has been published. Based on results from these important analyses, the ECDP writing committee judged that it would be desirable to provide a focused update to help guide clinicians more clearly on decision making regarding the use of ezetimibe and PCSK9 inhibitors in patients with clinical ASCVD with or without comorbidities. In the following summary table, changes from the 2016 ECDP to the 2017 ECDP Focused Update are highlighted, and a brief rationale is provided. The content of the full document has been changed accordingly, with more extensive and detailed guidance regarding decision making provided both in the text and in the updated algorithms. Revised recommendations are provided for patients with clinical ASCVD with or without comorbidities on statin therapy for secondary prevention. The ECDP writing committee judged that these new data did not warrant changes to the decision pathways and algorithms regarding the use of ezetimibe or PCSK9 inhibitors in primary prevention patients with LDL-C <190 mg/dL with or without diabetes mellitus or patients without ASCVD and LDL-C ≥190 mg/dL not due to secondary causes. Based on feedback and further deliberation, the ECDP writing committee down-graded recommendations regarding bile acid sequestrant use, recommending bile acid sequestrants only as optional secondary agents for consideration in patients intolerant to ezetimibe. For clarification, the writing committee has also included new information on diagnostic categories of heterozygous and homozygous familial hypercholesterolemia, based on clinical criteria with and without genetic testing. Other changes to the original document were kept to a minimum to provide consistent guidance to clinicians, unless there was a compelling reason or new evidence, in which case justification is provided.
Subsequent independent guideline groups, including the 2014 Joint British Societies Consensus Recommendations for the Prevention of Cardiovascular Disease (JBS3) (3), the 2014 Veterans' ...Administration/Department of Defense Guidelines on Management of Dyslipidemia (4), and the recent U.S. Preventive Services Task Force draft recommendations (5), have used similar, rigorous approaches to reviewing and synthesizing evidence, resulting in similar treatment recommendations.\n Joseph Butterfield Chair in Pediatrics Sanofi-Aventis None None None None None Scott M. Grundy Content Reviewer--Chair, Update to ACC/AHA Cholesterol Guideline University of Texas Southwestern Medical Center at Dallas--Professor of Internal Medicine None None None None None None James L. Januzzi Content Reviewer--Chair, ACC Task Force on Clinical Expert Consensus Documents Massachusetts General Hospital--Director, Dennis and Marilyn Barry Fellowship in Cardiology Research Cardiology Division; Harvard Medical School--Hutter Family Professor of Medicine Novartislow * Rochelow * None None Amgen (DSMB) None None Joseph J. Saseen Content Reviewer--Cardiovascular Team Council University of Colorado Anschutz Medical Campus --Professor and Vice Chair, Department of Clinical Pharmacy, Professor, Department of Family Medicine None None None None None None Michael D. Shapiro Content Reviewer--Prevention Council Oregon Health & Science University--Associate Professor of Medicine and RadiologyDirector, Cardiac MR CT ProgramCenter for Preventive CardiologyKnight Cardiovascular Institute None None None Amarindagger Amgendagger Isisdagger Sanofidagger Synagevadagger None None Barbara S. Wiggins Content Reviewer--ACC Task Force on Clinical Expert Consensus Documents Medical University of South Carolina--Clinical Pharmacy Specialist Cardiology, Department of Pharmacy Services None None None None None None black square This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant to this document.
Chronic kidney disease (CKD) is associated with worse survival in patients with heart disease including those with implantable devices. Cardiac resynchronization therapy (CRT) can potentially improve ...renal function. To assess the relation between the change in renal function and survival with CRT, 238 patients undergoing initial CRT with defibrillator implantation between 2002 and 2011 were followed. The primary end point was all-cause mortality. The estimated glomerular filtration rate (eGFR), before implantation and 6 ± 3 months after CRT was calculated. Patients were grouped at baseline into mild (stage I/II) or advanced (stage III/IV) CKD. Patients with end-stage renal disease were excluded. The mean follow-up time was 4.3 years. Multivariate analysis of baseline clinical characteristics showed that only renal function predicted the change in eGFR over the first 6 months of CRT. In the subgroup with mild CKD, eGFR decreased (78.5 ± 17.3 to 67.8 ± 26.8 p <0.001), whereas eGFR did not change in the subgroup with advanced CKD (45.6 ± 11.1 to 46.8 ± 17.0, p = 0.46). Patients with advanced CKD had higher mortality than those with mild CKD (p <0.002). In both subgroups, an increase in eGFR was associated with improved survival (hazard ratio = 0.79, p <0.001). In conclusion, baseline renal function and the subsequent change in eGFR are associated with long-term survival with CRT.
Background
Cardiac resynchronization therapy (CRT) improves functional status, reduces heart failure hospitalizations, and decreases mortality. Several comorbidities including renal function affect ...outcomes with CRT. However, moderate to severe chronic kidney disease (CKD) was an exclusion criterion in the large randomized control trials.
Objective
To evaluate the association of renal function on survival following CRT implantation.
Methods
This was a retrospective analysis of 432 consecutive patients implanted with an implantable cardioverter defibrillator with CRT (CRT‐D). The primary end point was defined as death by any cause, and it was determined using hospital records and the U.S. Social Security Death Index. A Kaplan‐Meier analysis was performed separating renal dysfunction into renal stage based on glomerular filtration rate. Multivariate analysis was performed to assess the clinical predictors of mortality.
Results
Patients were followed for up to 12 years with a mean follow‐up time of 4.3 ± 3.2 years. A total of 164 patients (39.3%) died over the course of the study. Patients with normal and mild renal diseases (Stages 1 and 2) had improved survival compared with those with moderate‐, severe‐, or end‐stage (Stages 3–5) renal disease. This effect remained statistically significant after multivariate analysis. The estimated 5‐year mortality was 36.3% for stage 1, 33.4% for stage 2, 40.6% for stage 3, and 62.1% for stage 4/5 kidney disease (P = 0.004 by log‐rank test).
Conclusion
CKD is a strong and an independent predictor of long‐term mortality among patients undergoing CRT‐D implantation.
Objective: The first goal of our study was to investigate major determinants of aortic stiffness in postmenopausal women using an echocardiographic method to calculate global pulse wave velocity ...(PWVg) rather than the less accurate carotid–femoral pulse wave velocity (PWVc). The second goal was to relate PWVg to the absolute risk of major cardiovascular (CV) events estimated by CV risk factors. Patients and methods: Two hundred forty‐four consecutive women who presented to our heart station were screened. One hundred twenty‐two were postmenopausal, either natural or surgical, whereas 122 were premenopausal. The mean age of the patients was 54 ± 13 years. Individuals were categorized as current smokers, former smokers, or nonsmokers and hypertensive or not. Hypercholesterolemia and diabetes mellitus were defined. Aortic stiffness was assessed by PWVg measured with pulsed Doppler, the interval between the beginning of QRS complex and the foot of the systolic upstroke in the Doppler spectral envelope was calculated at the aortic valve site and at the right common femoral artery. PWVg was calculated between the aortic valve and right common femoral artery by dividing the straight line distance between the two by the transit time. Results: There was a highly significant statistical difference (P < 0.0012) in PWVg between menstruating women and postmenopausal women. Similarly, this difference in PWVg was also noted among the menstruating population (P < 0.0014) when comparing normotensive women and hypertensive women. In postmenopausal women, PWVg was 6.8 m/sec in normotensive women and 7.56 m/sec in hypertensive women (P < 0.007). Conclusion: PWVg was increased in postmenopausal women compared with menstruating women. Systemic hypertension has an independent, but additive effect on aortic stiffness assessed by PWVg. Our study supports the usefulness of the assessment of aortic stiffness as a marker of CV disease and to identify subjects at risk at an early age.
Percutaneous closure of secundum atrial defects has become an accepted treatment in part because it is minimally invasive and relatively low risk. Despite recent advances in implantation technique ...and device improvements, complications occur. Here, we report a case of device embolization during percutaneous repair of an atrial septal defect (ASD) with multiple fenestrations. We highlight the value of using live/real time three‐dimensional transesophageal echocardiography to help plan the percutaneous procedure and detect complications.
Pericardial cysts are rare anomalies of the pericardium that are usually asymptomatic and followed by two‐dimensional (2D) echocardiography. Here we report a large pericardial cyst that could not be ...measured accurately by 2D echocardiography but three‐dimensional (3D) echocardiography enabled measurements of the cyst that correlated well with computed tomography measurements. In addition, 3D echocardiography demonstrated the mono‐trabeculated nature of the cyst further suggesting the incremental value of 3D echocardiography in the evaluation of pericardial cysts. The cyst was subsequently resected surgically.
In this study, a case of a right ventricular myxoma and a case of a right ventricular hemangioma are used to demonstrate the ability of live three‐dimensional transesophageal echocardiography (3DTEE) ...to assess the site of tumor attachment. Because 3DTEE has the ability to visualize desired structures in multiple planes, we defined the attached portion of the tumors and measured the en face view dimensions. In addition, the improved ability of 3DTEE to evaluate tissue characteristics allowed differentiation of the heterogeneous myxoma and highly vascular hemangioma. On the contrary, because two‐dimensional (2D) TEE only allows structures to be viewed in a 2D plane, the attachment site can be located but complete delineation and measurement of area is not possible. As surgical options become less invasive, accurate attachment site location and size will become more important to ensure complete excision. (Echocardiography 2011;28:1041‐1045)
Cholelithiasis is a very common disease in the United States. Most cases remain asymptomatic but a fraction of these patients can develop serious complications such as cholecystitis which may lead to ...gallbladder perforation and gallbladder cancer which is much less common. Here, we present three cases of cholelithiasis where transthoracic echocardiography was performed routinely. In each case, echocardiography detected cholelithiasis which prompted three‐dimensional (3D) echocardiographic evaluation. Three‐dimensional echocardiography allowed for more comprehensive examination of the gallbladder shape, size, and wall thickening and the measurement and composition of the stones in three dimensions, measurement of stone volumes, and minimized shadowing produced by stone calcifications. These cases suggest that routine echocardiography has value in detecting gallstones and that 3D echocardiography has incremental value over two‐dimensional echocardiography due to pyramidal data sets which allow sequential slicing through the gallbladder and full gallbladder examination without a technologist who is trained in gallbladder imaging. These pyramidal data sets can be further viewed and cropped by a radiologist specialized in abdominal ultrasound.
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