Potential cardiovascular (CV) risks of testosterone replacement therapy (TRT) are currently a topic of intense interest. However, no studies have addressed CV risk as a function of the route of ...administration of TRT.
Two meta-analyses were conducted, one of CV adverse events (AEs) in 35 randomized controlled trials (RCTs) of TRT lasting 12 weeks or more, and one of 32 studies reporting the effect of TRT on serum testosterone and dihydrotestosterone (DHT).
CV risks of TRT: Of 2,313 studies identified, 35 were eligible and included 3,703 mostly older men who experienced 218 CV-related AEs. No significant risk for CV AEs was present when all TRT administration routes were grouped (relative risk (RR) = 1.28, 95% confidence interval (CI): 0.76 to 2.13, P = 0.34). When analyzed separately, oral TRT produced significant CV risk (RR = 2.20, 95% CI: 1.45 to 3.55, P = 0.015), while neither intramuscular (RR = 0.66, 95% CI: 0.28 to 1.56, P = 0.32) nor transdermal (gel or patch) TRT (RR = 1.27, 95% CI: 0.62 to 2.62, P = 0.48) significantly altered CV risk. Serum testosterone/DHT following TRT: Of 419 studies identified, 32 were eligible which included 1,152 men receiving TRT. No significant difference in the elevation of serum testosterone was present between intramuscular or transdermal TRT. However, transdermal TRT elevated serum DHT (5.46-fold, 95% CI: 4.51 to 6.60) to a greater magnitude than intramuscular TRT (2.20-fold, 95% CI: 1.74 to 2.77).
Oral TRT produces significant CV risk. While no significant effects on CV risk were observed with either injected or transdermal TRT, the point estimates suggest that further research is needed to establish whether administration by these routes is protective or detrimental, respectively. Differences in the degree to which serum DHT is elevated may underlie the varying CV risk by TRT administration route, as elevated serum dihydrotestosterone has been shown to be associated with CV risk in observational studies.
Substrate characterization is the mainstay of ablation for ventricular tachycardia (VT). Although the use of electroanatomic voltage mapping (EAVM) in the electrophysiology (EP) laboratory has ...enabled real-time approximation of myocardial scar, it has limitations. This is related to
the subjective and tedious nature of voltage mapping and the challenges of defining the transmurality of scar. Various noninvasive methods of scar assessment have emerged, with magnetic resonance imaging (MRI) being the most accurate. Integrated MRI and electroanatomic voltage mapping studies
demonstrate good correlation. Nonetheless, MRI has advantages. These include (1) preprocedure identification of epicardial and intramural scar, (2) assessment of ablative lesion formation after unsuccessful ablations, (3) identification of heterogeneous regions of scar, where critical conducting
channels are likely to occur, and (4) predictive value in the assessment of sudden cardiac death (SCD). Integration of scar imaging in ventricular tachycardia ablation and risk stratification has great potential to advance the practice of arrhythmia management.
Clinical excellence, education, and research are fundamental to this mission. ...the SCMR is committed to facilitating the publication of clinical documents that promote the standards of best ...practice and dissemination of clinically relevant advances in the field of CMR. In order to facilitate the publication of SCMR-endorsed documents, the publications committee performs the following specific activities: (1) soliciting and reviewing proposals for SCMR-endorsed publications from the SCMR leadership and its membership, (2) suggesting issues of importance for publication and recommending task groups to the SCMR Executive Committee, (3) making efforts to ensure that such task groups adequately represent the international membership of the SCMR in order limit bias and promote diversity, (4) broadly overseeing the writing process to ensure timely, state-of-the-art, and scientifically accurate communication that adequately meets the needs of CMR practitioners, (5) collaborating with other professional societies or joint task forces where appropriate, and (6) communicating with SCMR staff and the editorial staff of various peer-reviewed journals including SCMR’s own journal, the Journal of Cardiovascular Magnetic Resonance JCMR. C. Appropriate use criteria for CMR imaging, especially those specific to particular disease states or in the context of other imaging modalities and diagnostic tests A clinical practice guideline is an evidence-based document meant to improve clinical outcomes and promote efficiency of care by identifying best practices and reducing practice variations. A proposal for an SCMR-endorsed document should meet the following criteria: * Length the proposal should be 1–2 pages in length using Times New Roman 12 pt font size and double spaced text. * Title the title should include the phrases “SCMR” and “recommendations” or “expert consensus”. * Main purpose a statement of the aims, primary purpose, and audience of the proposal. * Justification the intended focus of the manuscript, the rationale for publication, and a confirmation that a brief literature review was performed to establish that paper does not overlap with previous or planned publications. * Relevance to SCMR provide the rationale as to why this proposal should be endorsed by the SCMR.
Cardiac resynchronization therapy (CRT) is a therapy of proven benefit in patients with advanced heart failure. Identifying potential responders remains challenging, and whether the etiology of the ...heart failure is related to the potential hemodynamic benefit and long-term outcome of CRT is unclear.
The purpose of this study was to evaluate whether heart failure etiology (ischemic cardiomyopathy ICM vs nonischemic dilated cardiomyopathy DCM) was associated with CRT outcome and implantable cardioverter-defibrillator (ICD) shocks.
The study included 503 CRT recipients (CRT-D 90%) in a longitudinal CRT database: ICM (n = 312) and DCM (n = 191). Clinical variables and echocardiographic measures preimplant and postimplant were collected. Actuarial survival and ICD therapy data were assessed with Kaplan-Meier curve and log rank tests.
Pre-CRT, ICM patients were older and had higher creatinine levels (P <.001). At median follow-up of 7.1 months, the DCM group experienced greater improvement in left ventricular ejection fraction (8.3% ± 10% vs 6.2% ± 10%, P = .05) and left ventricular end-diastolic volumes than did those with ICM (-28%.4 ± 53 mL vs -15.3 ± 46 mL, P = .024). Survival estimates at 4 years were 55% for ICM and 77% for DCM groups (P <.001), respectively, whereas no significant difference in the incidence of appropriate/inappropriate ICD shocks was observed. The ICM group remained at higher risk for death compared to the DCM group after controlling for preimplant variables (hazard ratio 1.6, 95% confidence interval 1.1-2.3, P = .008).
In response to CRT and in contrast to ICM, DCM patients experienced greater improvement in left ventricular systolic function and reverse remodeling while also sustaining a greater survival benefit.
Cardiac resynchronization therapy (CRT) improves outcomes in patients with left bundle branch block (LBBB), but the benefits of CRT in patients with other QRS morphologies or previous pacing are ...uncertain.
The purpose of this study was to describe outcomes in patients with prior right ventricular pacing and non-LBBB morphologies.
We studied 505 patients who underwent de novo CRT (n = 338) or CRT upgrade (n = 167). De novo patients were categorized by underlying QRS morphology: LBBB (67%), right bundle branch block (RBBB; 11%), intraventricular conduction delay (IVCD; 13%), and QRS <120 ms (9%). Upgrade patients were categorized by the percentage of previous ventricular pacing.
Patients were followed for death over a median of 2.6 years (interquartile range 1.6-4.0). New York Heart Association (NYHA) functional class and echocardiographic improvements were similar in de novo and upgrade patients. However, within the de novo group, NYHA improvements were less in patients with RBBB (0.3 +/- 0.8; P = .014) or IVCD (0.2 +/- 0.7; P = .001) than in those with LBBB (0.7 +/- 0.8). These patients had less left ventricular functional improvement as well. Survival was comparable after de novo versus upgrade CRT (61% vs 63% at 4 years; P = .906). No clinical or survival differences were noted in upgrade patients based on the percentage of previous pacing. However, survival in de novo CRT recipients with RBBB (32%) was lower than in those with LBBB (66%; P <.001), and RBBB independently predicted death (hazard ratio 3.5, confidence interval 1.9-6.5; P <.001).
RBBB and IVCD result in less clinical improvement or worsened survival after CRT. Additional selection criteria may be beneficial in identifying potential responders with RBBB, IVCD, or narrow QRS.
Readmission or death soon after heart failure (HF) admission is a significant problem. Traditional analyses for predicting such events often fail to consider the gamut of characteristics that may ...contribute– tending to focus on 30‐day outcomes even though the window of increased vulnerability may last up to 90 days. Risk assessments incorporating machine learning (ML) methods may be better suited than traditional statistical analyses alone to sort through multitude of data in the electronic health record (EHR) and identify patients at higher risk.
Hypothesis
ML‐based decision analysis may better identify patients at increased risk for 90‐day acute HF readmission or death after incident HF admission.
Methods and Results
Among 3189 patients who underwent index HF hospitalization, 15.2% experienced primary or acute HF readmission and 11.5% died within 90 days. For risk assessment models, 98 variables were considered across nine data categories. ML techniques were used to help select variables for a final logistic regression (LR) model. The final model's AUC was 0.760 (95% CI 0.752 to 0.767), with sensitivity of 83%. This proved superior to an LR model alone AUC 0.744 (95% CI 0.732 to 0.755). Eighteen variables were identified as risk factors including dilated inferior vena cava, elevated blood pressure, elevated BUN, reduced albumin, abnormal sodium or bicarbonate, and NT pro‐BNP elevation. A risk prediction ML‐based model developed from comprehensive characteristics within the EHR can efficiently identify patients at elevated risk of 90‐day acute HF readmission or death for whom closer follow‐up or further interventions may be considered.
Objectives We sought to determine the relationship between atrial fibrillation (AF) ablation efficacy, quality of life (QoL), and AF-specific symptoms at 2 years. Background Although the primary goal ...of AF ablation is QoL improvement, this effect has yet to be demonstrated in the long term. Methods A total of 502 symptomatic AF ablation recipients were prospectively followed for recurrence, QoL, and AF symptoms. Results In 323 patients with 2 years of follow-up, 72% achieved AF elimination off antiarrhythmic drugs (AADs), 15% achieved AF control with AADs, and 13% had recurrent AF. The physical component summary scores of the Medical Outcomes Study Short Form 36 increased from 58.8 ± 20.1 to 76.2 ± 19.2 (p < 0.001) and the mental component summary scores of the Short Form 36 increased from 65.3 ± 18.6 to 79.8 ± 15.8 (p < 0.001). Post-ablation QoL improvements were noted across ablation outcomes, including recurrent AF (change in physical component summary: 12.1 ± 19.7 and change in mental component summary: 9.7 ± 17.9), with no significant differences in QoL improvement across 3 ablative efficacy outcomes. However, in 103 patients who completed additional assessment with Mayo AF Symptom Inventories (on a scale of 0 to 48), those with AF elimination off AADs had a change in AF symptom frequency score of −9.5 ± 6.3, which was significantly higher than those with AF controlled with AADs (−5.6 ± 3.8, p = 0.03) or those with recurrent AF (−3.4 ± 8.4, p = 0.02). Independent predictors of limited QoL improvement included higher baseline QoL, obesity, and warfarin use at follow-up. Conclusions AF ablation produces sustained QoL improvement at 2 years in patients with and without recurrence. AF-specific symptom assessment more accurately reflects ablative efficacy.
The prevalence of ischemia on nuclear myocardial perfusion imaging (MPI) has been decreasing. Recent research has questioned the benefit of invasive revascularization for patients with moderate to ...severe ischemia. We hypothesized that patients with moderate to severe ischemia could routinely undergo successful revascularization.
We analyzed data from 544 patients who underwent an MPI at a single academic Veterans Affairs Medical Center. Patients with moderate to severe ischemia, defined as a summed difference score (SDS) 8 or greater, were compared to the rest of the cohort.
Of the total cohort (
= 544), 39 patients had MPI studies with resultant moderate to severe ischemia. Patients with ischemia were more likely to develop coronary artery disease (74.4% versus 38.8%,
< 0.0001) and have successful revascularization (38.5% versus 4.0%,
< 0.0001) during the following year. Revascularization was attempted in 31 patients with moderate to severe ischemia, though only 15 (47%) of these attempts were successful. Ischemia was predictive of myocardial infarction (5.1% versus 0.8%,
= 0.01) within 1 year.
Moderate to severe ischemia is an uncommon finding in a contemporary nuclear laboratory. Among patients with ischemia, revascularization is typically attempted but is frequently unsuccessful.
This trial does not appear on a registry as it is neither randomized nor prospective.
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