Additionally, invasive management was associated with lower incidence of hospital admissions for heart failure (adjusted rate ratio compared with non-invasive management 0·67, 95% CI 0·48–0·93).4 ...Inclusion of patients aged 80 years or older in randomised trials is challenging. Several randomised trials have been done in severe symptomatic aortic stenosis (eg, comparing catheter-based aortic valve replacement versus open surgery), but only two randomised trials have been completed in NSTE-ACS.5,6 Serious symptomatic aortic stenosis are known to negatively affect patients' quality of life, symptoms, and prognosis; however, these effects might be different for medically stabilised patients aged 80 years or older with NSTE-ACS. ...motivation for participation in clinical trials (preferably randomised trials) might be reduced for both patients and physicians. Decision making in older patients must be individually tailored, considering life expectancy, comorbidity, ischaemic versus bleeding risk, cognitive and functional status (ie, frailty), and patient preference.7 Thus, we have a large number of possible treatment combinations in patients aged 80 years or older.
There are unresolved questions related to the proper use of editing the region of interest (ROI) for measurements of global longitudinal strain (GLS). The purpose of the present study was to compare ...the semi-automatic default GLS value by the vendor’s software with manually adjusted GLS and test the impact on GLS measures with different ROI widths. We selected 25 patients post myocardial infarction treated with PCI who had excellent echocardiographic recordings after 2–5 days and 3 months. The different GLS values were assessed from these 50 analyses in three steps. The semi-automatically GLS by default ROIs was compared with manually adjusted ROIs widths selected by an expert and then with manual adjustments, but with fixed ROIs being narrow, medium and wide. Their mean age was 64 (± 12) years, 52% had ST elevation MI and mean LVEF was 52 (± 4)%. Mean default GLS was − 15.3 (± 2.5)% with the widest ROI level selected semi-automatically in 78% of all widths. The mean expert GLS with manually adjusted ROI was − 14.7 (± 2.4)%, and the medium ROI level was selected by the expert in 85% of all examinations. The mean adjusted GLS, but with fixed ROIs widths was − 15.0 (± 2.5%)% with narrow ROI, − 14.7 (± 2.6)% with medium and − 13.5 (± 2.3)% with wide ROI width (p < 0.001 vs. default GLS). The Intra Class Coefficient Correlation between default and manually adjusted expert GLS was 0.93 (p < 0.001). The difference between the default and the manually adjusted expert GLS was neglectable. These findings may represent a simplification of the assessment of GLS that might increase its use in clinical practice. The GLS measurements with a fixed wide ROIs were significantly different from the expert measurements and indicate that a wide ROI should be avoided.
Background. The Nod-Like-Receptor-Protein-3 (NLRP3) inflammasome and the Interleukin-6 (IL-6) pathways are central mechanisms of the inflammatory response in myocardial reperfusion injury. Expanding ...our knowledge about the inflammasome signaling axis is important to improve treatment options. In a cross-sectional study, we aimed to study presence, localization, and genetic expression of inflammasome- and IL-6- signaling-related proteins in coronary thrombi and circulating leukocytes from ST-elevation myocardial infarction (STEMI) patients, with relation to myocardial injury and time from symptoms to PCI. Methods. Intracoronary thrombi were aspirated from 33 STEMI patients. Blood samples were drawn. mRNA of Toll-Like-Receptor-4 (TLR4), NLRP3, caspase 1, Interleukin-1β (IL1-β), Interleukin-18 (IL-18), IL-6, IL-6-receptor (IL-6R), and glycoprotein 130 (gp130) were isolated from thrombi and circulating leukocytes and relatively quantified by RT-PCR. A part of each thrombus was embedded in paraffin for histology and immunohistochemistry analyses. Results. Genes encoding the 8 markers were present in 76-100% of thrombi. Expression of TLR4 in thrombi significantly correlated to troponin T (r=0.455, p=0.013), as did NLRP3 (r=0.468, p=0.024). Troponin T correlated with expression in circulating leukocytes of TLR4 (r=0.438, p=0.011), NLRP3 (r=0.420, p=0.0149), and IL-1β (r=0.394, p=0.023). IL-6R expression in thrombi correlated significantly to troponin T (r=0.434, p=0.019), whereas gp130 was inversely correlated (r=−0.398, p=0.050). IL-6 in circulating leukocytes correlated inversely to troponin T (r=−0.421, p=0.015). There were no significant correlations between genes expressed in thrombi and time from symptom to PCI. Conclusions. The inflammasome signaling pathway was actively regulated in coronary thrombi and in circulating leukocytes from patients with STEMI, in association with myocardial damage measured by troponin T. This supports the strategy of medically targeting this pathway in treating myocardial infarction and contributes to sort out optimal timing and targets for anti-inflammatory treatment. The study is registered at clinicaltrials.gov with identification number NCT02746822.
Cardiac allograft vasculopathy (CAV) remains a leading cause of long‐term mortality after heart transplantation. Both preventive measures and treatment options are limited. This study aimed to ...evaluate the short‐term effects of high‐intensity interval training (HIT) on CAV in de novo heart transplant (HTx) recipients as assessed by optical coherence tomography (OCT). The study population was a subgroup of the 81‐patient HITTS study in which HTx recipients were randomized to HIT or moderate intensity continuous training (MICT) for nine consecutive months. OCT images from baseline and 12 months were compared to assess CAV progression. The primary endpoint was defined as the change in the mean intima area. Paired OCT data were available for 56 patients (n = 23 in the HIT group and n = 33 in the MICT group). The intima area in the entire study population increased by 25% from 1.8±1.4 mm2 to 2.3±2.0 mm2, P < .05. The change was twofold higher in the MICT group (.6±1.2 mm2) than in the HIT group (.3±.6 mm2). However, the treatment effect of HIT was not significant (treatment effect = –.3 mm2, 95% CI –.825 to .2 mm2 P = .29). These results suggest that early initiation of HIT compared with MICT does not attenuate CAV progression in de novo HTx recipients.
Background
Global longitudinal strain has shown variable results in detecting ischemia in patients admitted to the emergency department with chest pain, but without other clear evidence of coronary ...artery disease (CAD). Our aim was to investigate whether assessment of regional longitudinal myocardial function could assist in detecting significant CAD in these patients.
Methods
Clinical evaluation, electrocardiogram, echocardiogram and troponin T were evaluated in 126 patients admitted with chest pain. A subsequent invasive coronary angiography divided patients into two groups: significant CAD (CAD+) or non-significant CAD (CAD−). Global and regional myocardial function were evaluated by speckle tracking echocardiography. Regional longitudinal strain was defined as the highest longitudinal strain values in four adjacent left ventricular segments and termed 4AS.
Results
CAD+ was found in 37 patients (29%) of which 51% had elevated troponin. Mean 4AS was − 13.1% (± 3.5) in the CAD+ and − 15.2% (± 2.7) (
p
= 0.002) in the CAD− group. Predictors for CAD+ were age OR 1.06 (1.01–1.11,
p
= 0.026), smoking OR 3.39 (1.21–9.51,
p
= 0.020), troponin OR 3.32 (1.28–8.60,
p
= 0.014)) and 4AS (OR 1.24 (1.05–1.46,
p
= 0.010). A cutoff for 4AS of > − 15% showed the best diagnostic performance with event-reclassification of 0.41 (
p
< 0.001), non-event-reclassification of − 0.34 (
p
< 0.001) and net reclassification improvement 0.07 (
p
= 0.60).
Conclusion
Decreased myocardial function in four adjacent LV segments assessed by strain has the potential to detect significant CAD in patients admitted with chest pain and negative/slightly elevated initial troponin.
Trial registration:
Current Research information system in Norway (CRISTIN). Id: 555249.
Little is known about self-reported health in octogenarians (≥80 years) and nonagenarians (≥90 years) following percutaneous coronary intervention (PCI), including characteristics of different health ...outcomes. This study aimed to phenotype latent health profiles of self-reported health in older adults 2 months post-PCI.
A prospective, multicentre, real-world study (CONCARDPCI) of 270 octogenarians and nonagenarians was performed with five validated and standardised measures of self-reported health at 2 months post-PCI. Latent profile analysis was used to identify health profiles, and multinomial logistic regression analyses were used to investigate the associations between patient characteristics and health profiles.
Three latent health profiles were identified: The Poor health profile included 29%, the Moderate health profile included 39%, and the Good health profile included 32% of the participants. Older adults who were frail (OR 2.50, 95% CI 1.17–5.33), had a low exercise level (OR 0.49, 95% CI 0.39–0.95), and low alcohol intake (OR 0.61, 95% CI 0.39–0.95) were more likely to belong to the Poor health profile relative to the Good health profile. Furthermore, older age (OR 1.19, 95% CI 1.03–1.37) and lower exercise level (OR 0.64, 95% CI 0.43–0.97) were associated with belonging to the Moderate health profile relative to the Good health profile.
Two months after PCI, most participants displayed having Moderate to Good health profiles. Those with a Poor health profile were more likely to be frail and less active. These findings highlight that follow-up care has to be patient-centred and tailored to improve the health status of older adults.
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Summary Background Non-ST-elevation myocardial infarction (NSTEMI) and unstable angina pectoris are frequent causes of hospital admission in the elderly. However, clinical trials targeting this ...population are scarce, and these patients are less likely to receive treatment according to guidelines. We aimed to investigate whether this population would benefit from an early invasive strategy versus a conservative strategy. Methods In this open-label randomised controlled multicentre trial, patients aged 80 years or older with NSTEMI or unstable angina admitted to 16 hospitals in the South-East Health Region of Norway were randomly assigned to an invasive strategy (including early coronary angiography with immediate assessment for percutaneous coronary intervention, coronary artery bypass graft, and optimum medical treatment) or to a conservative strategy (optimum medical treatment alone). A permuted block randomisation was generated by the Centre for Biostatistics and Epidemiology with stratification on the inclusion hospitals in opaque concealed envelopes, and sealed envelopes with consecutive inclusion numbers were made. The primary outcome was a composite of myocardial infarction, need for urgent revascularisation, stroke, and death and was assessed between Dec 10, 2010, and Nov 18, 2014. An intention-to-treat analysis was used. This study is registered with ClinicalTrials.gov , number NCT01255540. Findings During a median follow-up of 1·53 years of participants recruited between Dec 10, 2010, and Feb 21, 2014, the primary outcome occurred in 93 (40·6%) of 229 patients assigned to the invasive group and 140 (61·4%) of 228 patients assigned to the conservative group (hazard ratio HR 0·53 95% CI 0·41–0·69, p=0·0001). Five patients dropped out of the invasive group and one from the conservative group. HRs for the four components of the primary composite endpoint were 0·52 (0·35–0·76; p=0·0010) for myocardial infarction, 0·19 (0·07–0·52; p=0·0010) for the need for urgent revascularisation, 0·60 (0·25–1·46; p=0·2650) for stroke, and 0·89 (0·62–1·28; p=0·5340) for death from any cause. The invasive group had four (1·7%) major and 23 (10·0%) minor bleeding complications whereas the conservative group had four (1·8%) major and 16 (7·0%) minor bleeding complications. Interpretation In patients aged 80 years or more with NSTEMI or unstable angina, an invasive strategy is superior to a conservative strategy in the reduction of composite events. Efficacy of the invasive strategy was diluted with increasing age (after adjustment for creatinine and effect modification). The two strategies did not differ in terms of bleeding complications. Funding Norwegian Health Association (ExtraStiftelsen) and Inger and John Fredriksen Heart Foundation.
High-intensity interval training (HIT) improves peak oxygen consumption (VO2peak) in de novo heart transplant (HTx) recipients. It remains unclear whether this improvement early after HTx is solely ...dependent on peripheral adaptations, or due to a linked chain of central and peripheral adaptations. The objective of this study was to determine whether HIT results in structural and functional adaptations in the cardiovascular system.
Eighty-one de novo HTx recipients were randomly assigned to participate in either 9 months of supervised HIT or standard care exercise-based rehabilitation. Cardiac function was assessed by echocardiogram and the coronary microcirculation with the index of microcirculatory resistance (IMR) at baseline and 12 months after HTx.
Cardiac function as assessed by global longitudinal strain was significantly better in the HIT group than in the standard care group (16.3±1.2% vs 15.6±2.2%, respectively, treatment effect = -1.1% (95% CI -2.0% to -0.2%), p=0.02), as was the end-diastolic volume (128.5±20.8 mL vs 123.4±15.5 mL, respectively, treatment effect=4.9 mL (95% CI 0.5 to 9.2 mL), p=0.03). There was a non-significant tendency for IMR to indicate improved microcirculatory function (13.8±8.0 vs 16.8±12.0, respectively, treatment effect = -4.3 (95% CI -9.1 to 0.6), p=0.08).
When initiated early after HTx, HIT leads to both structural and functional cardiovascular adaptations.
NCT01796379.
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