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Angina.com slideshare march 24 2013
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Angina.com slideshare march 24 2013

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Heart Disease Researchers discuss angina, heart disease, coronary artery surgery and heart disease risk factors.

Heart Disease Researchers discuss angina, heart disease, coronary artery surgery and heart disease risk factors.

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  • 1. Angina.com Angina.com March 24 2013Research Interviews on Heart DiseaseCoronary Artery Disease and Angina.
  • 2. Angina.comMarch 24 2013
  • 3. Medical Disclaimer | Terms and Conditions• The contents of the Hemodialysis.com Site, such as text, graphics, images, and other material contained on the Hemodialysis.com Site ("Content") are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on the Hemodialysis.com Site!• If you think you may have a medical emergency, call your doctor or 911 immediately. Hemodialysis.com does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the Site. Reliance on any information provided by Hemodialysis.com or other Eminent Domains Inc (EDI) websites, EDI employees, others appearing on the Site at the invitation of Hemodialysis.com or EDI, or other visitors to the Site is solely at your own risk.• The Site may contain health- or medical-related materials that are sexually explicit. If you find these materials offensive, you may not want to use our Site. The Site and the Content are provided on an "as is" basis. Read more interviews on Hemodialysis.com
  • 4. Cardiac troponin I levels measured with a high-sensitive assay increase over time and are strong predictors of mortality in an elderly population. Angina.com Interview with Kai M Eggers, MD, PhD Department of Medical Sciences, Cardiology, Uppsala University Uppsala, Sweden• Angina.com: What are the main findings of the study ?• Dr. Eggers: One main finding was that troponin I levels in our elderly study participants increased significantly over five years time. Troponin is reflective of myocardial abnormalities and in fact, the most pronounced increases were seen in subjects with evidence of heart disease or risk factors for its development. Accordingly, we found that subjects with higher troponin levels at baseline or greater increases had a significant risk for death, even when other risk factors or biomarkers were taken into account.• Another important result of our study was that we for the first time were able to measure troponin I levels in almost all of our study participants. This depends on the analytical performance of the applied assay from Abbott and is at difference to other studies in general populations in whom troponin remained undetectable in at least every third subject. Angina.com: Were any of the findings unexpected ?• Dr. Eggers: We suspected that troponin I would be a strong risk predictor but were surprised to see that it remained independently prognostic in analyses that were adjusted for CRP and NT-proBNP, biomarkers that have received much greater attention in studies performed in community populations.
  • 5. Cardiac troponin I levels measured with a high-sensitive assay increase over time and are strong predictors of mortality in an elderly population. Angina.com Interview with Kai M Eggers, MD, PhD Department of Medical Sciences, Cardiology, Uppsala University Uppsala, Sweden (cont)• Angina.com: Were any of the findings unexpected ?• Dr. Eggers: We suspected that troponin I would be a strong risk predictor but were surprised to see that it remained independently prognostic in analyses that were adjusted for CRP and NT-proBNP, biomarkers that have received much greater attention in studies performed in community populations.• Angina.com: What should clinicians and patients take home from this study ?• Dr. Eggers:Troponins are usually measured in patients with the suspicion of a heart attack. We have learned from our study that troponins can also be detected in presumably healthy subjects. This must be taken into account when interpreting troponin results in elderly patients who are admitted because of chest pain. Another important point is that troponin levels appear to increase with aging as result of age-related changes of the heart. This is discussed more in detail in another paper from our group published this month in Clinical Chemistry, and must probably be considered when defining reference levels for troponin.• Angina.com: What further research do you recommend as a result of your study?• Dr. Eggers: I would like to see a study investigating whether lifestyle changes or medical interventions could influence troponin levels, and whether this also might reflect better outcome. This issue has for example been investigated in an interesting paper from deFilippi and colleagues published last year in JACC demonstrating that physical exercise was related to a smaller increase in troponin levels over time. If we could show that troponin levels would mirror the beneficial cardiac effects of this kind of interventions, then this would be a big step towards personalized preventive strategies.• Cardiac troponin I levels measured with a high-sensitive assay increase over time and are strong predictors of mortality in an elderly population.• Citation:• Eggers KM, Venge P, Lindahl B, Lind L.• Department of Medical Sciences, Uppsala University, Sweden. J Am Coll Cardiol. 2013 Mar 6. pii: S0735-1097(13)00936-4. doi: 10.1016/j.jacc.2012.12.048. [Epub ahead of print]
  • 6. Estimating the effect of long-term physical activity on cardiovascular disease and mortality: evidence from the Framingham Heart Study Angina.com Interview with Susan M. Shortreed PhD Assistant Investigator 
Biostatistics Unit, Group Health Research Institute Group Health Research InstituteSeattle, WA 98101• Angina.com: What are the main findings of the study?• Dr. Shortreed: Physical activity throughout ones life is linked with longer life.• Angina.com: Were any of the findings unexpected?• Dr. Shortreed: The findings of this study confirmed that long-term physical activity has health benefits.• Our study followed individuals for a longer period of time than many previous studies in order to understand their physical activity habits and monitor their health outcomes.• Angina.com: What should clinicians and patients take away from this study?• Dr. Shortreed: Continued physical activity through out one’s life is important to a long life. Clinicians should talk with their patients about the benefits of physical activity and advise them on appropriate levels of physical activity considering their overall health. Patients should ask their clinician about the health benefits of physical activity and talk with their clinician before increasing their amount and intensity of physical activity.• The Centers for Disease Control and Prevention has some great online information and resources for both clinicians and patients on recommended physical activity levels for all ages.
  • 7. Estimating the effect of long-term physical activity on cardiovascular disease and mortality: evidence from the Framingham Heart Study Angina.com Interview with Susan M. Shortreed PhD Assistant Investigator 
Biostatistics Unit, Group Health Research Institute Group Health Research InstituteSeattle, WA 98101 (Cont)• Angina.com: What further research do you recommend as a result of your study?• Dr. Shortreed: We recommend studies investigate the long-term effects of physical activity in women and in diverse populations.• To investigate the effects of long-term physical activity, we recommend studies record information on activity levels over time and use appropriate analytic methods to quantify the link between long-term effects of physical activity and health benefits.• Citation:• Estimating the effect of long-term physical activity on cardiovascular disease and mortality: evidence from the Framingham Heart Study• Heart. 2013 Mar 8. [Epub ahead of print]• Shortreed SM, Peeters A, Forbes AB. Monash University, , Melbourne, Australia.
  • 8. Perioperative Dexmedetomidine Improves Outcomes of Cardiac Surgery Angina.com Interview with Hong Liu, MD Anesthesiology and Pain Medicine, University of California Davis Health System, 4150 V Street Suite 1200, Sacramento, CA, 95817• Angina.com: What are the main findings of the study?• Dr. Liu: Perioperative dexmedetomidine use in cardiac surgical patients were more likely to have better in-hospital, 30-day and 1- year survival. The perioperative use of dexmedetomidine is also associated with a significant decrease in the incidence of postoperative overall complications and delirium.• There was no evidence of adverse hemodynamic side effects of dexmedetomidine in patients undergoing cardiac surgery.• Angina.com: Were any of the findings unexpected?• Dr. Liu: Our study did not find perioperative dexmedetomidine improving postoperative kidney function.• On the contrary, it worsened postoperative renal function.
  • 9. Perioperative Dexmedetomidine Improves Outcomes of Cardiac Surgery Angina.com Interview with Hong Liu, MD Anesthesiology and Pain Medicine, University of California Davis Health System, 4150 V Street Suite 1200, Sacramento, CA, 95817 (cont)• Angina.com: What should clinicians and patients take away from this study?• Dr. Liu: Dexmedetomidine used in clinical practice have many desirable effects including analgesia, anxiolysis, inhibition of central sympathetic outflow and reduction of systemic norepinephrine release that improve hemodynamic stability, positively affect myocardial oxygen supply and demand and may provide myocardial protection. It also increased urine output. If indicated, physicians should consider use it.• Because of the above-mentioned properties of this medication, patients may have bradycardia and polyuria right after surgery.• Angina.com: What further research do you recommend as a result of your study?• Dr. Liu: Multicenter randomized, prospective trial. Dose-dependent on kidney protection• Citation:• Perioperative Dexmedetomidine Improves Outcomes of Cardiac Surgery• Fuhai Ji, Zhongmin Li, Hung Nguyen, Nilas Young, Pengcai Shi, Neal Fleming, and Hong Liu• Circulation. 2013;CIRCULATIONAHA.112.000936published online before print March 19 2013, doi:10.1161/CIRCULATIONAHA.112.000936
  • 10. Effect of Intensive versus Moderate Lipid-Lowering Therapy on Epicardial Adipose Tissue in Hyperlipidemic Postmenopausal Women: A Substudy of the BELLES (Beyond Endorsed Lipid Lowering with EBT Scanning) Trial) Angina.com Interview with Paolo Raggi, MD, FACC, FACP, FASNC, FCCT Director, Mazankowski Alberta Heart Institute Professor of Medicine, University of Alberta Capital Health Chair in Cardiac Sciences Edmonton, AB T6G 2B7, Ca• Angina.com: What are the main findings of the study?• Dr. Raggi: The present study was a sub-analysis of the BELLES study, originally designed to assess the effect of intensive versus moderate lipid-lowering therapy on coronary artery calcium in post- menopausal women.• In the present sub-analysis, the effect on epicardial adipose tissue (EAT) was examined; EAT has recently emerged as a local source of inflammation and a surrogate and a possible active component in the pathogenesis of coronary atherosclerosis and of the formation of vulnerable atherosclerotic plaques. The main findings of the present sub-analysis are that although both treatment strategies resulted in halting the progression of EAT increase with age, only intensive lipid-lowering therapy was associated with a decrease in EAT volume.
  • 11. Effect of Intensive versus Moderate Lipid-Lowering Therapy on Epicardial Adipose Tissue in Hyperlipidemic Postmenopausal Women: A Substudy of the BELLES (Beyond Endorsed Lipid Lowering with EBT Scanning) Trial) Angina.com Interview with Paolo Raggi, MD, FACC, FACP, FASNC, FCCT Director, Mazankowski Alberta Heart Institute Professor of Medicine, University of Alberta Capital Health Chair in Cardiac Sciences Edmonton, AB T6G 2B7, Ca (cont)• Angina.com: Were any of the findings unexpected?• Dr. Raggi: The decrease in EAT volume was not associated with the decrease in LDL (bad) cholesterol. This mostly unexpected finding denotes that the beneficial effect of statin therapy on EAT is mediated through other mechanisms than LDL lowering; the most plausible mechanism is through the well-known anti-inflammatory effects of statins.• Angina.com: What should clinicians and patients take away from this study?• Dr. Raggi: This study provides another possible link between the beneficial effects of statins on cardiovascular risk; i.e. EAT volume modulation. It also provides possible evidence for a greater beneficial effect of intensive versus moderate lipid-lowering therapy. Finally, EAT may be used as surrogate of the effectiveness of risk-reduction therapies.
  • 12. Effect of Intensive versus Moderate Lipid-Lowering Therapy on Epicardial Adipose Tissue in Hyperlipidemic Postmenopausal Women: A Substudy of the BELLES (Beyond Endorsed Lipid Lowering with EBT Scanning) Trial) Angina.com Interview with Paolo Raggi, MD, FACC, FACP, FASNC, FCCT Director, Mazankowski Alberta Heart Institute Professor of Medicine, University of Alberta Capital Health Chair in Cardiac Sciences Edmonton, AB T6G 2B7, Ca• Angina.com: What further research do you recommend as a result of your study?• Dr. Raggi: A study of statin therapy with both EAT measurement pre- and post- treatment with adequate number of patients and follow-up to assess both surrogate (i.e. EAT volume change) and clinical events (major adverse cardiovascular events); if positive, this would establish the role of EAT volume measurement as a surrogate of clinical outcome.• Citation:• Effect of Intensive versus Moderate Lipid-Lowering Therapy on Epicardial Adipose Tissue in Hyperlipidemic Postmenopausal Women: A Substudy of the BELLES (Beyond Endorsed Lipid Lowering with EBT Scanning) Trial)• Alexopoulos N, Melek BH, Arepalli CD, Hartlage GR, Chen Z, Kim S, Stillman AE, Raggi P.• Division of Cardiology, Department of Medicine, Emory University, Atlanta, GA, USA. J Am Coll Cardiol. 2013 Mar 13. pii: S0735-1097(13)01002-4. doi: 10.1016/j.jacc.2012.12.051. [Epub ahead of print]
  • 13. Severity of coronary atherosclerosis in patients with a first acute coronary event: a diabetes paradox Angina.com Interview with Giampaolo Niccoli, MD, PhD, FESC Interventional Cardiologist Assistant professor of Cardiology Institute of Cardiology Catholic University of the Sacred Heart Rome, Italy• Angina.com: What are the main findings of the study?• Dr. Niccoli :In this study, we aimed at comparing coronary artery disease features at the time of a first acute coronary syndrome in type II diabetic and non-diabetic patients by coronary angiography and by optical coherence tomography.• In the angiographic substudy, diabetes was independently associated with both stenosis score and extent index. Furthermore, well developed collateral circulation toward the culprit vessel was more frequent in diabetic than in non-diabetic patients. In the optical coherence tomography substudy, at minimal lumen diameter site lipid quadrants were less and the lipid arc was smaller in diabetic than in non-diabetic patients. Furthermore, the most calcified cross-section along the culprit segment had a greater number of calcified quadrants and a wider calcified arc in diabetic than in non-diabetic patients. Superficial calcified nodules were more frequently found in diabetic than in non-diabetic patients.• Thus, in spite of potent pro-inflammatory, pro-oxidant and pro-thrombotic stimuli operating in type II diabetes, diabetic patients exhibit substantially more severe coronary atherosclerosis than non- diabetic patients at the time of a first acute coronary event. Better collateral development toward the culprit vessel, a predominantly calcific plaque phenotype and, probably, yet unknown protective factors operating in diabetic patients may explain these intriguing paradoxical findings.
  • 14. Severity of coronary atherosclerosis in patients with a first acute coronary event: a diabetes paradox Angina.com Interview with Giampaolo Niccoli, MD, PhD, FESC Interventional Cardiologist Assistant professor of Cardiology Institute of Cardiology Catholic University of the Sacred Heart Rome, Italy (cont)• Angina.com: Were any of the findings unexpected?• Dr. Niccoli : When investigating the association of coronary artery disease burden and diabetes status in an acute setting, we found a more severe and extensive coronary atherosclerosis as compared to non- diabetic patients, although pro- thrombotic and pro-inflammatory stimuli are stronger in diabetic than non- diabetic patients.• Angina.com What should clinicians and patients take away from this study?• Dr. Niccoli : As demonstrated in our study, at the time of their first acute coronary syndrome, type II diabetic patients have more severe and extensive coronary atherosclerosis as compared to non-diabetic patients. Thus, diabetic patients may have protective factors that prevent a first acute coronary syndrome.• Indeed, we also showed that type II diabetic patients had better collateral circulation towards the culprit vessel than non-diabetic patients, Therefore, physicians should consider this apparent contradiction which is probably accounted for by the fact that diabetes offsets the detrimental effects of a high extent index on collateral development. Furthermore, a more calcific atherosclerosis may stabilize coronary plaque.
  • 15. Severity of coronary atherosclerosis in patients with a first acute coronary event: a diabetes paradox Angina.com Interview with Giampaolo Niccoli, MD, PhD, FESC Interventional Cardiologist Assistant professor of Cardiology Institute of Cardiology Catholic University of the Sacred Heart Rome, Italy (cont)• Angina.com: What further research do you recommend as a result of your study?• Dr. Niccoli : Further studies will probably identify other, and possibly more important, causes of the paradox that in diabetic patients the first acute event occurs in the presence of more severe coronary artery disease. Interestingly, protective effect mediated by inhibition of matrix metalloproteinase-9, which reduces elastin degradation might operate in the coronary circulation and should be investigated.• Citation:• Severity of coronary atherosclerosis in patients with a first acute coronary event: a diabetes paradox.• Eur Heart J. 2013 Mar;34(10):729-41. doi: 10.1093/eurheartj/ehs393. Epub 2012 Nov 27.• Niccoli G, Giubilato S, Di Vito L, Leo A, Cosentino N, Pitocco D, Marco V, Ghirlanda G, Prati F, Crea F.• Institute of Cardiology, Catholic University of the Sacred Heart, Largo F. Vito 1, 00168 Rome, Italy.
  • 16. Sexual Function After Left Ventricular Assist Device Angina.com Author Interview: Peter Eckman, M.D. Department of Medicine Cardiovascular Division, University of Minnesota Medical School, 420 Delaware Street S.E., MMC 508, Minneapolis, MN 55455• Angina.com: What are the main findings of the study?• Dr. Eckman: We found that 71% of men and 79% of women with a continuous flow left ventricular assist device (LVAD) met criteria for sexual dysfunction, as measured by the Changes in Sexual Function Questionnaire-14. Furthermore, more than half of the survey respondents noted worsening in arousal and orgasm. Age over 60 and history of ischemic heart disease were directly associated with sexual dysfunction. Psychological issues, including fear of damaging the LVAD, self- harm, device alarms, and hurting one’s partner were also cited, and most noted that the equipment was “somewhat” or a “major” obstacle to sexual satisfaction. Angina.com: Were any of the findings unexpected?• Dr. Eckman: LVADs have been shown to significant improve quality of life, so the relatively poorer sexual function was surprising. We were not surprised that older age and history of ischemic heart disease were associated with worse function. One participant said “Probably the least improved part of life before to after VAD.” On the other hand, we were encouraged to see that a notable minority of patients reported improvements in sexual function. We were also surprised that only a minority of patients reported improvement in desire.
  • 17. Sexual Function After Left Ventricular Assist Device Angina.com Author Interview: Peter Eckman, M.D. Department of Medicine Cardiovascular Division, University of Minnesota Medical School, 420 Delaware Street S.E., MMC 508, Minneapolis, MN 55455 (cont)• Angina.com: What should clinicians and patients take away from this study?• Dr. Eckman: This data should inform subsequent studies designed to evaluate and improve understanding of the specific factors involved in sexual health after LVAD implant. Equipment was often cited as an obstacle, and improvements to external components may have a favorable impact on sexual function. Willingness to address concerns about sexual function may help minimize barriers to sexual activity and satisfaction after LVAD• Angina.com: What further research do you recommend as a result of your study?• Dr. Eckman: It is unclear if our findings were driven by physiologic changes such as altered blood flow and endothelial function, or any of the myriad other factors that impact sexual function. Study of the physiology of genital blood flow after implant of continuous-flow LVAD may provide additional insight into the relative importance of pathophysiology on sexual health after LVAD.• Citation:• Sexual Function After Left Ventricular Assist Device• Eckman PM, Dhungel V, Mandras S, et al. J Am Coll Cardiol. 2013;():. doi:10.1016/j.jacc.2013.02.022.
  • 18. Yield and Diagnostic Value of Stress Myocardial Perfusion Imaging in Patients Without Known Coronary Artery Disease Presenting with Syncope Angina.com Interview with Wael A. AlJaroudi MD Division of Cardiovascular Disease American University of Beirut Medical Center Riad El-Solh, Beirut 1107 2020, Lebanon• Angina.com: What are the main findings of the study?• Answer: In this study, we investigated the diagnostic yield of stress myocardial perfusion imaging (MPI) for patients presenting for syncope without prior history of known coronary artery disease (CAD). Out of 700 patients, 659 (94%) had normal perfusion. Of the 41 patients with abnormal MPI, 18 had a coronary angiogram and half of them were falsely positive. The diagnostic yield of the stress MPI (95% CI) was 0.88% (0.3%, 2.6%), 1.3%(0.3%, 4.0%) and 2.4% (0.61%, 7.3%) for patients with low, intermediate and high risk categories based on Framingham scores, respectively. Also, an abnormal stress MPI did not have prognostic value, in part due to the low numbers of abnormal studies and high false- positive results.• As such, stress MPI for evaluation of syncope in patients without known CAD has a low diagnostic yield among all risk groups, and reaffirmation or revision of the appropriateness criteria should be considered.
  • 19. Yield and Diagnostic Value of Stress Myocardial Perfusion Imaging in Patients Without Known Coronary Artery Disease Presenting with Syncope Angina.com Interview with Wael A. AlJaroudi MD Division of Cardiovascular Disease American University of Beirut Medical Center Riad El-Solh, Beirut 1107 2020, Lebanon (cont)• Angina.com: Were any of the findings unexpected?• Answer: Based on our clinical experience, we were expecting a low diagnostic yield for stress MPI in such group of patients. However, there are limited data that justify using stress MPI to rule out ischemia as a cause of syncope in patients without known history of CAD. Given the high economic burden and radiation exposure from these tests, we sought to investigate whether indeed the diagnostic yield is high enough to justify using these test or whether the appropriateness criteria needs revisiting.• Angina.com: What should clinicians and patients take away from this study?• Answer: In patients without known CAD, syncope is not an anginal equivalent, and therefore the diagnostic yield of stress MPI is very low regardless of the Framingham score. Perhaps exercise stress echocardiogram might have better since it looks at structure, dynamic changes, and valves. This needs to be further studied and evaluated.
  • 20. Yield and Diagnostic Value of Stress Myocardial Perfusion Imaging in Patients Without Known Coronary Artery Disease Presenting with Syncope Angina.com Interview with Wael A. AlJaroudi MD Division of Cardiovascular Disease American University of Beirut Medical Center Riad El-Solh, Beirut 1107 2020, Lebanon (cont)• Angina.com: What further research do you recommend as a result of your study?• Answer: It would be interesting to evaluate the diagnostic yield of stress MPI for patients with known coronary artery disease and/or ischemic cardiomyopathy presenting with syncope.• Citation:• Yield and Diagnostic Value of Stress Myocardial Perfusion Imaging in Patients Without Known Coronary Artery Disease Presenting with Syncope• Wael A. AlJaroudi, M. Chadi Alraies, Oussama Wazni, Manuel D. Cerqueira, and Wael A. Jaber• Circ Cardiovasc Imaging. 2013;CIRCIMAGING.112.000051published online before print February 15 2013, doi:10.1161/CIRCIMAGING.112.000051
  • 21. Renoprotective effect of remote ischemic postconditioning by intermittent balloon inflations in patients undergoing percutaneous coronary intervention Angina.com Interview with Spyridon Deftereos, MD; Georgios Giannopoulos, MD University of Athens, Athens, Greece• Angina.com: What are the main findings of the study?• Answer: The principal finding of this study is that a procedure of repeated inflations and deflations of the stent balloon used to perform PCI (percutaneous coronary intervention) in patients with non-ST-elevation myocardial infarction leads to a reduction in the periprocedural acute kidney injury rate. This effect seems to have a clinical impact, as it was accompanied by a reduction (of borderline statistical significance) in the 30-day rate of death or rehospitalization for any cause.• The physiological process underlying this procedure is termed “remote ischemic conditioning” (“remote” because the conditioning stimulus is applied to a site far away from the organ that is protected against tissue damage; in our case, the conditioning stimulus is applied to the heart and the conditioned organ is the kidney) and, although a lot of unanswered questions remain as to its mechanisms, experimental and clinical evidence has repeatedly demonstrated its existence.
  • 22. Renoprotective effect of remote ischemic postconditioning by intermittent balloon inflations in patients undergoing percutaneous coronary intervention Angina.com Interview with Spyridon Deftereos, MD; Georgios Giannopoulos, MD University of Athens, Athens, Greece (cont)• Angina.com: Were any of the findings unexpected?• Answer: Actually no. The study results could have gone either way; that is a negative result would not have been a surprise either. However, we did have a smaller retrospective study published a couple of years ago suggesting that remote ischemic conditioning could be effective in this setting. Our present results show that that hypothesis-generating study pointed to the right direction.• Angina.com: What should clinicians and patients take away from this study?• Answer: An important point associated with this study is that cardiac interventionalists should always “remember the kidney” when performing cardiac catheterizations, especially in patients with acute coronary syndromes (since these patients are more vulnerable to acute renal damage compared to those undergoing elective procedures). Effective measures of renoprotection, including appropriate hydration, withholding of nephrotoxic drugs, parsimonious use of contrast and, probably (if our results are confirmed by further clinical trials), remote ischemic conditioning should be employed to reduce the likelihood of renal damage.
  • 23. Renoprotective effect of remote ischemic postconditioning by intermittent balloon inflations in patients undergoing percutaneous coronary intervention Angina.com Interview with Spyridon Deftereos, MD; Georgios Giannopoulos, MD University of Athens, Athens, Greece (cont)• Angina.com: What further research do you recommend as a result of your study?• Answer: Our positive results, along with other recent ones, should prompt a larger clinical study, powered enough to demonstrate clinical efficacy, if any, in terms of hard clinical endpoints.• Our study was underpowered to have a primary clinical endpoint, but the secondary finding of a reduction in the 30-day clinical event rate is certainly encouraging.• Citation:• Renoprotective effect of remote ischemic postconditioning by intermittent balloon inflations in patients undergoing percutaneous coronary intervention• Deftereos S, Giannopoulos G, Tzalamouras V, Raisakis K, Kossyvakis C, Kaoukis A, Panagopoulou V, Karageorgiou S, Avramides D, Toutouzas K, Hahalis G, Pyrgakis V, Manolis AS, Alexopoulos D, Stefanadis C, Cleman MW.• Department of Cardiology, Athens General Hospital “G. Gennimatas”, Athens, Greece.• J Am Coll Cardiol. 2013 Mar 13. pii: S0735-1097(13)01001-2. doi: 10.1016/j.jacc.2013.02.023. [Epub ahead of print]
  • 24. Duration of Ventilations during Cardiopulmonary Resuscitation by Lay-Rescuers and First Responders: Relationship between Delivering Chest Compressions and Outcomes Angina.com Interview with S.G. Beesems, MSc afdeling Cardiologie Kamer G4-248 Academisch Medisch Centrum 1105 AZ Amsterdam• Angina.com: What are the main findings of the study?• Answer: The results of our study show that lay-rescuers require a median ventilation time of 7 seconds to complete two ventilation attempts. Only 21% are able to fully meet the ventilation guidelines of 2010. However, 97% of all rescuers provided chest compressions above the recommended minimum of 60 chest compressions in one minute, 88% of all administered over 70 chest compressions in one minute and 63% of all administered over 80 chest compressions in one minute. Hospital survival of patients with all rhythms was 25%. Therefore, the objective of delivering sufficient chest compressions is met by all but a few rescuers.• Angina.com: Were any of the findings unexpected?• Answer: In our study, better survival was observed with longer ventilations. This is against the findings of other studies with long interruptions of chest compressions, mainly caused by pauses associated with defibrillation shocks. This paradox can be attributed to the fact that rescuers who had the longest pauses for ventilations also arrived and shocked earlier with the AED. After adjustment for the baseline factors, longer pauses for ventilation were not associated with worse survival. It is also possible that the suggested detrimental effect of perishock pauses does not apply to pauses for ventilation
  • 25. Duration of Ventilations during Cardiopulmonary Resuscitation by Lay-Rescuers and First Responders: Relationship between Delivering Chest Compressions and Outcomes Angina.com Interview with S.G. Beesems, MSc afdeling Cardiologie Kamer G4-248 Academisch Medisch Centrum 1105 AZ Amsterdam (cont)• Angina.com: What should clinicians and patients take away from this study?• Answer: Lay-rescuers with CPR training that includes chest compressions and ventilations are able to perform CPR better than previously believed. Longer pauses for ventilations are not associated with worse outcome. Guidelines may allow longer pauses for ventilations without detriment to survival.• Citation:• Duration of Ventilations during Cardiopulmonary Resuscitation by Lay-Rescuers and First Responders: Relationship between Delivering Chest Compressions and Outcomes.• Beesems SG, Wijmans L, Tijssen JG, Koster RW.• 1Academic Medical Center, Amsterdam, The Netherlands. Circulation. 2013 Mar 18. [Epub ahead of print]
  • 26. Troponin I, but not BNP, is Associated with Phosphorus, Calcium and Vitamin D in Stable Coronary Artery Disease Angina.com Interview with José Pedro L. Nunes M.D. Associate professor at University of Porto, Portugal.• Angina.com: What are the main findings of the study?• Dr. Nunes: Elevated plasma cardiac troponin, elevated plasma phosphorus and decreased plasma vitamin D are known to be associated with negative outcomes. In this study, data was obtained from a relatively small number of patients (sixty) with stable coronary artery disease and preserved left ventricular function, and patients with higher values for cardiac troponin I were shown to have higher plasma phosphorus, higher plasma calcium and lower plasma 25-OH vitamin D values when compared to patients with lower values for troponin. The same association was not found with BNP.• Angina.com: Were any of the findings unexpected?• Dr. Nunes: When you start an investigation, you do not know what you will find, but previous studies, carried out in renal patients, had shown an association between troponin levels and FGF-23, which itself is associated to phosphorus.
  • 27. Troponin I, but not BNP, is Associated with Phosphorus, Calcium and Vitamin D in Stable Coronary Artery Disease Angina.com Interview with José Pedro L. Nunes M.D. Associate professor at University of Porto, Portugal. (cont)• Angina.com: What should clinicians and patients take away from this study?• Dr. Nunes: Given the relatively small number of patients under study, the conclusions should be seen with some caution. In any event, troponin is no longer seen solely as a marker for myocardial infarction. Cardiac/renal connections could find here yet another important field of future research. As stated in the text, “the hypothesis is raised that deleterious effects of higher phosphorus and/or calcium and of lower vitamin D levels on the heart are reflected by an increase in plasma troponin I”.• Angina.com: What recommendations do you have for future research as a result of your study?• Dr. Nunes: It would be important to try to confirm these findings in larger and different sets of patients. If confirmed, these findings could be a starting point for significant advances in the understanding of mechanisms of cardiac injury, perhaps involving diet, lack of sunlight exposure and with a possible impact on vitamin D supplementation.• Citation:• Troponin I, but not BNP, is Associated with Phosphorus, Calcium and Vitamin D in Stable Coronary Artery Disease• Nunes J.P.L.• Faculdade de Medicina da Universidade do Porto: Center for Research in Health Technologies and Information Systems (Cintesis), Porto• Kidney Blood Press Res 2013;37:43-47 (DOI:10.1159/000343399)• Published online first (Issue-in-Progress)
  • 28. Primary Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction, Resuscitated Cardiac Arrest, and Cardiogenic Shock : The Role of Primary Multivessel Revascularization Angina.com Interview with Darren Mylotte MB BCh MD ICPS – Institut Cardiovasculaire Paris Sud · Interventional Cardiology• Angina.com: What are the main findings of the study?• Dr. Mylotte: The study demonstrates the very high mortality rate of patients with STEMI, cardiogenic shock and resuscitated cardiac arrest: 65.4% at 6-months. It also demonstrates that those with more extensive myocardial ischemia due to more widespread coronary disease have worse outcomes compared to those with less ischemia. Furthermore, it demonstrates that in those with multivessel coronary disease, multivessel PCI appears to improve survival compared to culprit-only PCI. Finally, successful PCI and multivessel PCI were independent predictors of 6-month survival in those with multivessel disease.
  • 29. Primary Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction, Resuscitated Cardiac Arrest, and Cardiogenic Shock : The Role of Primary Multivessel Revascularization Angina.com Interview with Darren Mylotte MB BCh MD ICPS – Institut Cardiovasculaire Paris Sud · Interventional Cardiology (cont)• Angina.com: Were any of the findings unexpected?• Dr. Mylotte: The fact that multivessel primary PCI was associated with improved survival was not a surprise. Indeed the study hypothesis stemmed from other data suggesting enhanced outcomes in this critically-ill patient population. However, the magnitude of the survival advantage (absolute survival advantage 23.5%) was unexpected. While this may also reflect some selection or treatment bias, there is a clear signal that in selected cases multivessel PCI is advantageous.• Angina.com: What should clinicians and patients take away from this study?• Dr. Mylotte: I think that the central message of this study is that in patients with multivessel disease and cardiogenic shock, refractory to culprit-artery PCI, that further revascularization should be considered.
  • 30. Primary Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction, Resuscitated Cardiac Arrest, and Cardiogenic Shock : The Role of Primary Multivessel Revascularization Angina.com Interview with Darren Mylotte MB BCh MD ICPS – Institut Cardiovasculaire Paris Sud · Interventional Cardiology (cont)• Angina.com: What further research do you recommend as a result of your study?• Dr. Mylotte: I think that this study highlights the need for further randomized trials comparing revascularization strategies in this very high-risk group of patients. Furthermore, it demonstrates the limitations of coronary revascularization and that other treatments need to be developed in order to significantly improve outcomes.• Citation:• Primary percutaneous coronary intervention in patients with acute myocardial infarction, resuscitated cardiac arrest, and cardiogenic shock: the role of primary multivessel revascularization.• Mylotte D, Morice MC, Eltchaninoff H, Garot J, Louvard Y, Lefèvre T, Garot P.• Institut Cardiovasculaire Paris Sud, Institut Hospitalier Jacques Cartier, Massy, and Hôpital Claude Galien, Quincy, France. JACC Cardiovasc Interv. 2013 Feb;6(2):115-25. doi: 10.1016/j.jcin.2012.10.006. Epub 2013 Jan 23.
  • 31. Genetic Determinants of Dabigatran Plasma Levels and Their Relation to Bleeding. Angina.com Interview with Guillaume Paré MD, MSc, FRCPC Assistant ProfessorPathology and Molecular Medicine (primary) Clinical Epidemiology & Biostatistics Canada Research Chair in Genetic and Molecular Epidemiology Director, Genetic and Molecular Epidemiology Laboratory Visiting Scientist, Harvard Medical School McMaster University• Angina.com: What are the main findings of the study?• Dr. Pare: We conducted a genome-wide association study of dabigatran peak and trough concentration in 2,944 RE-LY participants with both genetic and pharmacokinetic data. The CES1 SNP rs2244613 was associated with a 15% decrease in trough concentrations per allele, and the ABCB1 SNP rs4148738 and CES1 SNP rs8192935 were associated with peak concentrations at genome-wide significance (P<9 x 10-8), also with a gene-dose effect. CES1 encodes for the liver carboxylesterase 1 enzyme, an esterase responsible for the biotransformation of dabigatran etexilate into the active metabolite, dabigatran. The ABCB1 gene encodes for P-glycoprotein, an ATP-dependent drug efflux pump for xenobiotic compounds with broad substrate specificity. Dabigatran etexilate, but not dabigatran, is an ABCB1 substrate and ABCB1 inhibitors increase dabigatran bioavailability by 10-20%. When tested for association with bleed, the CES1 SNP rs2244613 was associated with a lower risk of any bleeding (OR=0.67, 95%CI 0.55-0.82; P=7 x 10-5) in dabigatran-treated participants, and with a consistent but non-significant lower risk of major bleeding (OR=0.66, 95%CI 0.43-1.01). Importantly, the interaction between treatment (warfarin versus all dabigatran) and carrier status was statistically significant (P=0.002) with carriers having less bleeding with dabigatran than warfarin (HR=0.59, 95%CI 0.46-0.76; P=5.2 x 10-5) in contrast to no difference in noncarriers (HR=0.96, 95%CI 0.81-1.14; P=0.65).
  • 32. Genetic Determinants of Dabigatran Plasma Levels and Their Relation to Bleeding. Angina.com Interview with Guillaume Paré MD, MSc, FRCPC Assistant ProfessorPathology and Molecular Medicine (primary) Clinical Epidemiology & Biostatistics Canada Research Chair in Genetic and Molecular Epidemiology Director, Genetic and Molecular Epidemiology Laboratory Visiting Scientist, Harvard Medical School McMaster University (cont)• Angina.com: Were any of the findings unexpected?• Dr. Pare: While the two gene loci identified were to be expected given dabigatran etexilate’s metabolism, we were surprised by the strength of the genetic effects, especially on bleeds. Also, dabigatran etexilate was thought to be converted into dabigatran completely and immediately by esterases. Identification of a genetic variant of CES1 associated with drug exposure suggests that biotransformation into dabigatran could be a rate-limiting factor in certain individuals.• Angina.com: What should clinicians and patients take away from this study?• Dr. Pare: These results are significant as the relative risk of bleeding was 0.73 (95%CI 0.63-0.86) for the 32.8% of RE-LY participants that are rs2244613 minor allele carriers versus noncarriers, whereas the reported relative risk of bleeding was 0.86 (95% CI 0.81-0.93) for the lower (110 mg bid) versus higher dose (150 mg bid) of dabigatran in the overall study. The observed genetic effect was thus larger than the effect of drug dosage in the parent study, suggesting a potential role of genetics to help determine the optimal dose of dabigatran etexilate in individual patients. For example, carriers of the protective allele could perhaps be safely prescribed the higher dose of dabigatran etexilate even if elderly.
  • 33. Genetic Determinants of Dabigatran Plasma Levels and Their Relation to Bleeding. Angina.com Interview with Guillaume Paré MD, MSc, FRCPC Assistant ProfessorPathology and Molecular Medicine (primary) Clinical Epidemiology & Biostatistics Canada Research Chair in Genetic and Molecular Epidemiology Director, Genetic and Molecular Epidemiology Laboratory Visiting Scientist, Harvard Medical School McMaster University (cont)• Angina.com: What further research do you recommend as a result of your study?• Dr. Pare: Many key questions remain to be addressed. Among them is whether the CES1 SNP rs2244613 is associated with ischemic events as well as bleeds. Indeed, despite the large sample size, only 66 dabigatran etexilate-treated individuals suffered from any ischemic event in the genetic analysis sub-group of the RE-LY trial and power to detect a genetic association was accordingly limited. Larger studies will therefore be necessary to properly answer this question. Finally, clinical utility of CES1 genotyping will need to be assessed through rigorous studies carefully evaluating the health benefit and cost of incorporating genotypes into dose selection decisions.• Citation:• Genetic Determinants of Dabigatran Plasma Levels and Their Relation to Bleeding.• Paré G, Eriksson N, Lehr T, Connolly S, Eikelboom J, Ezekowitz MD, Axelsson T, Haertter S, Oldgren J, Reilly P, Siegbahn A,• Syvänen AC, Wadelius C, Wadelius M, Zimdahl-Gelling H, Yusuf S, Wallentin L. 1Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada. Circulation. 2013 Mar 6. [Epub ahead of print]
  • 34. Rivaroxaban Reduces Spontaneous and Large Myocardial Infarctions: Findings from the ATLAS ACS 2 – TIMI 51 Trial Angina.com Interview with Matthew A. Cavender, M.D. Research Fellow, TIMI Study Group Brigham and Women’s Hospital Harvard Medical School Boston, Massachusetts 02115• Angina.com: What are the main findings of the study?• Dr. Cavender: The ATLAS ACS 2 – TIMI 51 trial showed that treatment with rivaroxaban reduces cardiovascular death, myocardial infarction and stroke. To better understand how this drug improves cardiovascular outcomes, it was important to understand the effect of the rivaroxaban on specific types of myocardial infarctions.• Angina.com: Were any of the findings unexpected?• Dr. Cavender: In the overall trial, rivaroxaban 2.5 mg twice daily reduced cardiovascular death, myocardial infarction, or stroke. In addition, rivaroxaban 2.5 mg was shown to reduce cardiovascular death. The present study offers insight into the possible mechanisms leading to this mortality benefit since rivaroxaban reduces both spontaneous and large myocardial infarctions.
  • 35. Rivaroxaban Reduces Spontaneous and Large Myocardial Infarctions: Findings from the ATLAS ACS 2 – TIMI 51 Trial Angina.com Interview with Matthew A. Cavender, M.D. Research Fellow, TIMI Study Group Brigham and Women’s Hospital Harvard Medical School Boston, Massachusetts 02115 (cont)• Angina.com: What should clinicians and patients take away from this study?• Dr. Cavender: Our analysis showed the majority of myocardial infarctions in the ATLAS ACS 2 – TIMI 51 trial occurred spontaneously due to plaque rupture and coronary artery thrombosis. Rivaroxaban was given to patients to prevent these types of thrombotic events. We found that treatment with rivaroxaban significantly reduced spontaneous myocardial infarctions by approximately 20%, and both the 2.5 and 5 mg doses had directionally similar effects.• Citation:• Presented at 2013 ACC American College of Cardiology March 2013 Rivaroxaban Reduces Spontaneous and Large Myocardial Infarctions: Findings from the ATLAS ACS 2 – TIMI 51 Trial
  • 36. Value of Myocardial Perfusion Imaging in Renal Transplant Evaluation Angina.com Interview with: Dr. Chong Ghee Chew Department of Nuclear Medicine, PET and Bone Mineral Densitometry, Royal Adelaide Hospital, Adelaide, SA• Angina.com: What are the main findings of the study?• Answer: This is a retrospective audit of the cardiac outcomes of renal failure patients who had been transplanted in South Australia between 1999 to 2009, who had myocardial perfusion SPECT scan for the transplant assessment. The results represent ”real world” outcomes as the scans were performed in the 3 major teaching hospitals in SA. 2 endpoints – “soft” = inpatient care with angina +/- PCI +/- CABG, and “hard” = inpatient care with myocardial infarction or cardiac death. With a negative scan this cohort had a statistically significant lower soft endpoint event rate than a positive scan …3.9% vs 20.8%, hazard ratio of 4.4 at 5 years post scan. The hard endpoint event rate was also lower for those with a negative scan but the difference did not reach statistical significance. The event rates of hard and soft endpoints were no different for the negative scans that were performed with a tachycardic stress (treadmill exercise, dobutamine or external wire right atrial pacing) versus dipyridamole induced coronary vasodilatation.
  • 37. Value of Myocardial Perfusion Imaging in Renal Transplant Evaluation Angina.com Interview with: Dr. Chong Ghee Chew Department of Nuclear Medicine, PET and Bone Mineral Densitometry, Royal Adelaide Hospital, Adelaide, SA (cont)• Angina.com: Were any of the findings unexpected?• Answer: No• Angina.com: What should clinicians and patients take away from this study?• Answer: Myocardial perfusion SPECT scan is a good predictor of cardiac events in renal failure patients who are being considered for transplantation.• This is a valid test for transplant assessment.• Angina.com: What further research do you recommend as a result of your study?• The study did not include patients who were assessed but were not transplanted. We are planning another similar audit to look at this cohort.• Citation:• ACC 2013 American College Cardiology Presentation Spring 2013
  • 38. Angiographic and clinical characteristics of type 1 versus type 2 perioperative myocardial infarction Angina.com Interview with: Ivan Hanson, M.D. Chief Interventional Cardiology Fellow Beaumont Hospital, Royal Oak, MI• Angina.com: What are the main findings of the study?• Dr. Hanson: Over half of patients with perioperative myocardial infarction (PMI) have invasive angiographic evidence of plaque rupture (type 1 PMI). Patients with type 1 PMI had more intraoperative hypotension, higher incidence of transmural ischemia, larger infarct size and trended toward worse outcome.• Angina.com: Were any of the findings unexpected?• Dr. Hanson: Our hypothesis was that the majority of PMI events were due to hemodynamic insults in the setting of stable, but severely stenotic, coronary artery stenoses (type 2 PMI).• Not only did we observe a higher incidence of type 1 PMI than type 2 PMI, but type 1 PMI patients actually had greater incidence of intraoperative hypotension. This challenges the notion that hemodynamic pertubations are more closely associated with type 2 PMI.• Furthermore, clinical assessment alone, including knowledge of intraoperative hemodynamics and postoperative ECG findings, are insufficient to diagnose type of PMI.
  • 39. Angiographic and clinical characteristics of type 1 versus type 2 perioperative myocardial infarction Angina.com Interview with: Ivan Hanson, M.D. Chief Interventional Cardiology Fellow Beaumont Hospital, Royal Oak, MI (cont)• Angina.com: What should clinicians and patients take away from this study?• Dr. Hanson: Our findings suggest that if a sophisticated understanding of type of PMI is desired, invasive angiography may be useful.• Patients that were formally assumed to have type 2 PMI may in fact have plaque rupture and coronary thrombosis, which would not be expected to resolve by optimization of coronary blood flow alone.• Angina.com: What further research do you recommend as a result of your study?• Dr. Hanson: To test the hypothesis that tailoring management of PMI based on angiographic findings results in optimal outcomes, a much larger study is required.• I am also very interested in the invasive imaging characteristics of plaques that lead to, or have caused, PMI.• Citation:• Angiographic and clinical characteristics of type 1 versus type 2 perioperative myocardial infarction.
  • 40. Centralized, Stepped, Patient Preference–Based Treatment for Patients With Post–Acute Coronary Syndrome Depression Angina.com Interview with Karina W. Davidson, PhD Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, New York• Angina.com: What are the main findings of the study?• Dr. Davidson: With a grant from the National Institutes of Health’s National Heart, Lung, and Blood Institute (NHLBI), Karina W. Davidson, PhD, director of the Center for Behavioral Cardiovascular Health at Columbia University Medical Center (CUMC), together with her colleagues at multiple sites in the U.S., completed a randomized controlled trial with 150 patients with elevated depressive symptoms two to six months after their hospitalization for heart disease. Patients were recruited from seven centers across the United States and were randomized to receive either six months of their preferred depression care (therapy, antidepressants or both) or to receive depression care determined by their physician upon notification that the patient had elevated depressive symptoms.• In the self-selected group, patients were given a choice of whether they wanted therapy or antidepressants, or both. “We tried to help them really think through what does it take to take a pill every day; what does it take to talk to a person about painful feelings and do homework, and really consider what will fit into their life,” said Dr. Davidson. “And every six to eight weeks, we revisited how their chosen treatment was working for them, and helped them make adjustments based upon their feedback.”
  • 41. Centralized, Stepped, Patient Preference–Based Treatment for Patients With Post–Acute Coronary Syndrome Depression Angina.com Interview with Karina W. Davidson, PhD Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, New York (cont)• Therapy in this study was given virtually (by phone or web-based) to ensure that patients had access to clinicians of a similar skill set – so two counselors (one at CUMC and another at Yale) provided the therapy in this study. The virtual therapy also helped connect patients with therapists at times that were most convenient for them. “Maybe 8 p.m. at your home is the right time for you, but not 8 p.m. if you have to go for a clinic or hospital and wait half an hour and travel back home afterwards, etc.,” said Dr. Davidson, who is also professor of behavioral medicine in medicine, cardiology, and psychiatry, CUMC. The therapy used in the trial was problem solving treatment (PST) – a practical, hands-on approach that asks patients to choose the problems in their life that they want to tackle, teaches them how to problem solve, and then they go out and do homework to try the solutions and come back and talk about what worked, what didn’t, and tackle the next problem.• Findings showed that depressive symptoms were reduced more in the patient-selected, centralized depression care group, than in the patients receiving usual care. At the start of the trial, patients had an average of 19 points on the BDI depression scale – at the end of the trial, BDI scores in the patient-selected group were significantly reduced by an average of 3-6 points more than the reduction that happened in the usual care group. Getting down below 10 on the BDI puts one in the normal range – and almost half of the patients who received patient- selected, centralized treatment get down to the normal range; whereas only one-third in the usual care group got down to the normal range.• Importantly, researchers found that running centralized depression care at seven sites nationwide was effective, suggesting that it is feasible to deliver depression care to those who don’t have specialists in their area. Overall, the total health care costs for the self-selected group was $325 less than the control group, even when factoring in the cost of providing them with the therapy. The centralized depression care group demonstrated a trend towards fewer hospitalizations, compared to the usual care group.
  • 42. Centralized, Stepped, Patient Preference–Based Treatment for Patients With Post–Acute Coronary Syndrome Depression Angina.com Interview with Karina W. Davidson, PhD Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, New York (cont)• Angina.com: Were any of the findings unexpected?• Dr. Davidson: Most depression trials in this area have gotten effect size of .3, which is one-third of the standard deviation. And we got .6, or 2/3 of the standard deviation. So we had almost double the size of treatment improvement compared to other people.• The research team believes that the difference in their findings can be explained in the difference between how previous published trials were conducted, versus how their trial was conducted. In previous trials, patients were often offered either one type of treatment or usual care, and they had to remain with that selection for the remainder of the trial. However, because it’s well known that there isn’t one magic bullet for depression; one thing doesn’t work for all patients, the CODIACS Vanguard trial was designed with a flexible algorithm that allowed the clinical team to regularly liaise with the patients to help them keep different treatment options and combinations, until one was found that suited them best.• Angina.com: What should clinicians and patients take away from this study?• Dr. Davidson: About 1.2 million Americans survive an ACS event every year and many of them have clinically significant and persistent depression. Post-ACS depression is also associated with an increased risk of ACS recurrence and with an increase in the relative risk of all-cause mortality, the authors write in the study background. These findings show that treating heart attack survivors for depressive symptoms is feasible, effective, and even has the tantalizing possibility of being cost- neutral. Importantly, treating depressive symptoms—as opposed to a diagnosis of depression— should be determined by an alliance between a healthcare professional and the patient – and regularly assessed for effectiveness and altered to continue to meet the patient’s needs.
  • 43. Centralized, Stepped, Patient Preference–Based Treatment for Patients With Post–Acute Coronary Syndrome Depression Angina.com Interview with Karina W. Davidson, PhD Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, New York (cont)• Angina.com: What further research do you recommend as a result of your study?Dr. Davidson: Dr. Karina Davidson and her team plan to explore whether these results can be replicated in a much larger nationwide randomized controlled trial, to examine whether treating them for depressive symptoms lowers their risk of death or having another heart attack.• Citation:• Centralized, Stepped, Patient Preference–Based Treatment for Patients With Post– Acute Coronary Syndrome Depression: CODIACS Vanguard Randomized Controlled Trial ONLINE FIRST• Karina W. Davidson, PhD; J. Thomas Bigger, MD; Matthew M. Burg, PhD; Robert M. Carney, PhD; William F. Chaplin, PhD; Susan Czajkowski, PhD; Ellen Dornelas, PhD; Joan Duer-Hefele, RN; Nancy Frasure-Smith, PhD; Kenneth E. Freedland, PhD; Donald C. Haas, MD, MPH; Allan S. Jaffe, MD; Joseph A. Ladapo, MD, PhD; Francois Lespérance, MD; Vivian Medina, MSW; Jonathan D. Newman, MD, MPH; Gabrielle A. Osorio, BS; Faith Parsons, BS; Joseph E. Schwartz, PhD; Jonathan A. Shaffer, PhD; Peter A. Shapiro, MD; David S. Sheps, MD; Viola Vaccarino, MD, PhD; William Whang, MD, MS; Siqin Ye, MD• JAMA Intern Med. 2013;():1-8. doi:10.1001/jamainternmed.2013.915. doi:10:1001/jama.2010.920
  • 44. Direct-to-consumer television advertising exposure, diagnosis with high cholesterol, and statin use Angina.com: Interview with Dr. Jeff Niederdeppe, Ph.D. Assistant Professor Department of Communication, Cornell University (cont)• Angina.com: What are the main findings of the study?• Dr. Niederdeppe: We examined the relationship between exposure to direct-to-consumer advertising (DTCA) for cholesterol-lowering drugs (most of which are statins) and two clinical variables: diagnosis with high cholesterol, and taking a statin drug in the past year. We found that greater exposure to statin DTCA was associated with an increased likelihood of being diagnosed with high cholesterol and taking a statin to treat it. We also found that these relationships were strongest for adults at comparatively low risk for cardiac events – those who tended to be younger, did not have high blood pressure, and did not smoke regularly. We did not find positive relationships between statin DTCA exposure and high cholesterol diagnosis or statin use for those at higher levels of risk, or those who reported having a history of heart disease or a previous heart attack.• Angina.com: Were any of the findings unexpected?• Dr. Niederdeppe: We were not surprised that statin DTCA exposure would be associated with high cholesterol diagnosis and statin use among lower-risk people, since that pattern has been found before for other types of pharmaceutical drugs. We were surprised, however, at the lack of a positive relationship for those at higher risk. In fact, we even found a negative relationship between DTCA exposure and statin use among high-risk women (those with a history of heart disease, a previous heart attack, and/or diabetes). In other words, greater exposure to statin DTCAs was linked to a lower likelihood of using the drug for this group. These results are puzzling and should be considered preliminary, but we think that future work should see whether or not this pattern exists in other studies with other populations.
  • 45. Direct-to-consumer television advertising exposure, diagnosis with high cholesterol, and statin use Angina.com: Interview with Dr. Jeff Niederdeppe, Ph.D. Assistant Professor Department of Communication, Cornell University• Angina.com: What should clinicians and patients take away from this study?• Dr. Niederdeppe: I’ll first acknowledge that I am not an M.D., and that I understand each patient has a unique set of risk factors, personal and family history, and medical profile. That said, one takeaway point is that we can expect patients to learn about pharmaceutical drugs from DTCA, and that is going to influence the clinical encounter. The average American is exposed to 16 hours of DTCA every year; in contrast they see the doctor an average of 15 minutes per year. Clinicians should be prepared to discuss both the risks and benefits of heavily- advertised pharmaceutical drugs.• I would encourage patients to ask their doctor about the ratio of risks to benefits related to drugs they see advertised. While all DTCAs have to disclose drug risks, the ads tend to do this in a way that focuses greater attention on benefits than risks.• Angina.com: What further research do you recommend as a result of your study?• Dr. Niederdeppe: Many statin DTCAs contain information about lifestyle changes (which are always recommended first to reduce cholesterol) and pharmaceutical drugs. One important question is how these ads might influence people’s lifestyle decisions – whether or not to engage in regular exercise, eat a heart-healthy diet, and maintain a healthy weight. We don’t yet know enough about some of the secondary impacts that these ads may be having on factors that influence the public’s health.• Citation:• Direct-To-Consumer Television Advertising Exposure, Diagnosis with High Cholesterol, and Statin Use.• Niederdeppe J, Byrne S, Avery RJ, Cantor J.• Department of Communication, Cornell University, 328 Kennedy Hall, Ithaca, NY, 14853, USA J Gen Intern Med. 2013 Mar 6. [Epub ahead of print
  • 46. Impact of Socioeconomic Deprivation and Area of Residence on Access to Coronary Revascularization and Mortality After a First Acute Myocardial Infarction in Québec Angina.com Interview with Cardiology Researcher: Stéphane Rinfret MD, SM, FRCPC Institut universitaire de cardiologie et de pneumologie de Québec, Québec City, Québec, Canada• Angina.com: What are the main findings of the study?• Dr. Rinfret : Study shows that patients unfortunately do not persist with dual antiplatelet therapy as we like to think they would do because of the consequences. A simple telephone intervention clearly helped to reach almost perfect adherence.• Angina.com: Were any of the findings unexpected?• Dr. Rinfret : Self-reported adherence is worth nothing. We relied on pharmacy data. When we compared with the answers patients gave to interviewers at 6 months and 1 year, there was very low correlation. Therefore pharmacy data are absolutely required to assess true adherence.
  • 47. Impact of Socioeconomic Deprivation and Area of Residence on Access to Coronary Revascularization and Mortality After a First Acute Myocardial Infarction in Québec Angina.com Interview with Cardiology Researcher: Stéphane Rinfret MD, SM, FRCPC Institut universitaire de cardiologie et de pneumologie de Québec, Québec City, Québec, Canada• Angina.com: What should clinicians and patients take away from this study?• Dr. Rinfret : We need to take responsibility and put systems in place to follow how patients take their medication following stenting. A simple advise not to stop the medication is clearly not enough.• Angina.com: What further research do you recommend as a result of your study?• Dr. Rinfret : As newer DES will likely mandate a shorter DAT duration, a shorter intervention with 1 or 2 calls may be enough. This will have to be tested.• Citation:• Impact of Socioeconomic Deprivation and Area of Residence on Access to Coronary Revascularization and Mortality After a First Acute Myocardial Infarction in Québec• Claudia Blais, PhD, Denis Hamel, MSc, Stéphane Rinfret, MD, SM, FRCPC• Impact of Socioeconomic Deprivation and Area of Residence on Access to Coronary Revascularization and Mortality After a First Acute Myocardial Infarction in Québec• Canadian Journal of Cardiology, Volume 28, Issue 2, March–April 2012, Pages 169–177
  • 48. Comparison of Coronary CT Angiography Image Quality With and Without Breast Shields. Angina.com Interview with Dr. Eddie Hulten, MD MPH Non-Invasive Cardiovascular Imaging Brigham and Women’s Hospital Harvard Medical School• Angina.com: What are the main findings of the study?• Dr. Hulten: We reviewed a convenience sample of patients who had previously been scanned with bismuth breast shields while undergoing coronary CT angiography. We found differences in noise and an association of different plaque types by shielded versus non-shielded groups. Image quality graded on a Likert scale was not significantly different with no difference in uninterpretable segments according to shielded versus not shielded.• Angina.com: Were any of the findings unexpected?• Dr. Hulten: We expected the difference in noise to be more dramatic and the image quality to be poorer for the shielded patients. However, it is important to note that most of the scans were performed using retrospective ECG gating, which delivers a higher overall radiation than most contemporary scans. Thus, the results should not be extrapolated to patients scanned using prospectively-triggered ECG gating or high pitch scans.
  • 49. Comparison of Coronary CT Angiography Image Quality With and Without Breast Shields. Angina.com Interview with Dr. Eddie Hulten, MD MPH Non-Invasive Cardiovascular Imaging Brigham and Women’s Hospital Harvard Medical School (cont)• Angina.com: What should clinicians and patients take away from this study?• Dr. Hulten: Patients scanned with breast shields in this study had interpretable coronary CT angiograms although the scans were noisier and had different plaque types detected, which could be associated with the shielding. However, breast shields are not currently recommended for clinical use by the SCCT or medical physicists due to concern for wasting radiation. Also other radiation sparing techniques may be more effective, reproducible, and impact image noise less.• Angina.com: What further research do you recommend as a result of your study?• Dr. Hulten: Study of additional radiation reducing methods during coronary CT angiography is indicated. While breast shields are not recommended for routine clinical use, further evaluation of shields’ impact upon coronary CT imaging may be warranted in specific research protocols.• Citation:• Comparison of Coronary CT Angiography Image Quality With and Without Breast Shields.• Hulten E, Devine P, Welch T, Feuerstein I, Taylor A, Petrillo S, Luncheon M, Nguyen B, Villines TC.• Cardiology Service, Walter Reed National Military Medical Center, Bethesda, MD. AJR Am J Roentgenol. 2013 Mar;200(3):529-36. doi: 10.2214/AJR.11.8302.
  • 50. Trajectories of cardiometabolic risk factors before diagnosis of three subtypes of type 2 diabetes Angina.com Interview with: Dr Kristine Færch PhD BSc, MSc (Human Nutrison), PhD. STAR Researcher Steno Diabetes Center Niels Steensens Vej 1 DK-2820 Gentofte Denmark• Angina.com: What are the main findings of the study?• Dr. Færch: Our study underscores the heterogeneity of type 2 diabetes. Individuals who develop type 2 diabetes have different underlying mechanisms dependent on whether they are diagnosed with diabetes by elevated fasting glucose, elevated 2-hour glucose (after an oral glucose tolerance test) or combined elevated fasting and 2-hour glucose. We found very different trajectories of beta cell function, obesity development and several cardiovascular risk factors prior to diagnosis of diabetes in the three groups.
  • 51. Trajectories of cardiometabolic risk factors before diagnosis of three subtypes of type 2 diabetes Angina.com Interview with: Dr Kristine Færch PhD BSc, MSc (Human Nutrison), PhD. STAR Researcher Steno Diabetes Center Niels Steensens Vej 1 DK-2820 Gentofte Denmark (cont)• Angina.com: Were any of the findings unexpected?• Dr. Færch: We expected to find different patterns of some cardiometabolic risk factors, but we were surprised that the differences were so pronounced in the different subtypes of type 2 diabetes – especially with regard to beta cell function. A classic pattern of early beta cell compensation followed by a progressive loss of beta cell function was only found in 25% of the individuals who developed diabetes, whereas 20% had a constant low beta cell function starting already 18 years before they were diagnosed with diabetes.• Angina.com: What should clinicians and patients take away from this study?• Dr. Færch: Most clinicians already acknowledge that type 2 diabetes is a heterogeneous disease, but this study adds to a deeper understanding of this heterogeneity. It is likely that the optimal treatment will differ among patients with the different subtypes identified in our study.
  • 52. Trajectories of cardiometabolic risk factors before diagnosis of three subtypes of type 2 diabetes Angina.com Interview with: Dr Kristine Færch PhD BSc, MSc (Human Nutrison), PhD. STAR Researcher Steno Diabetes Center Niels Steensens Vej 1 DK-2820 Gentofte Denmark (cont)• Angina.com: What further research do you recommend as a result of your study?• Dr. Færch: First of all, it is important to study the underlying mechanisms of the different type 2 diabetes subtypes in other populations because there may be ethnic differences. If our findings are confirmed in other populations, the next step will be to see how the different subtypes of type 2 diabetes respond to medication in regard to glucose control and prevention of diabetic complications. Also, it will be relevant to examine whether type 2 diabetes should be prevented differently in high-risk individuals with impaired fasting glycemia (elevated fasting glucose) and impaired glucose tolerance (elevated 2-hour glucose).• Citation:• Trajectories of cardiometabolic risk factors before diagnosis of three subtypes of type 2 diabetes: a post-hoc analysis of the longitudinal Whitehall II cohort study Dr Kristine Færch PhD,Daniel R Witte PhD,Adam G Tabák PhD,Leigh Perreault MD,Christian Herder PhD,Eric J Brunner PhD,Prof Mika Kivimäki PhD,Dorte Vistisen PhD The Lancet Diabetes & Endocrinology – 21 February 2013 DOI: 10.1016/S2213-8587(13)70008-1
  • 53. African American Race is a Correlate of Heart Failure in Breast Cancer Survivors: A study of 26,347 women identified with breast cancer from 1973-2007 Angina.com Interview with Anna Valina-Toth, MD, PhD Department of Internal Medicine Case Western Reserve University at MetroHealth• Angina.com: What are the main findings of the study?• Answer: – In female breast cancer survivors, the risk of developing heart failure is higher in African Americans compared to Caucasians.• Angina.com: Were any of the findings unexpected?• Answer: - We are not surprised that in breast cancer survivors, African Americans have higher heart failure occurrence compared to whites. African Americans, especially women, relative to whites, have excessive prevalence of hypertension, obesity and obesity related diseases (including diabetes), oxidative stress, inflammation, and endothelium nitric oxide-dependent vascular dysfunction and vitamin D deficiency.• All these aforementioned co-morbidities plausibly predispose African Americans to higher risk of HF events including those who are breast cancer survivors.
  • 54. African American Race is a Correlate of Heart Failure in Breast Cancer Survivors: A study of 26,347 women identified with breast cancer from 1973-2007 Angina.com Interview with Anna Valina-Toth, MD, PhD Department of Internal Medicine Case Western Reserve University at MetroHealth (cont)• Angina.com: What should clinicians and patients take away from this study?• Answer:- This study reveals a significant health disparity in heart failure prevalence that disproportionately affects African Americans compared to Caucasians in a cohort of breast cancer survivors.• Angina.com: What further research do you recommend as a result of your study?• Answer:- Future research to determine whether non-invasive cardiac imaging and pre-treatment with cardioprotective drugs such as ACE-inhibitors and beta blockers prior to initiation of antracyclines and trastuzumab based-chemotherapy would reduce the risk of heart failure in breast cancer patients especially in African Americans who are predisposed to developing heart failure merit investigation.• Citation:• African American Race is a Correlate of Heart Failure in Breast Cancer Survivors: A study of 26,347 women identified with breast cancer from 1973-2007 Presented at ACC 2013 March 2013
  • 55. Tooth Loss Is Highly Prevalent And Associated With Cardiovascular Risk Factors In Patients With Chronic Coronary Heart Disease In The Global Stability Trial Angina.com Interview with Dr. Ola Vedin, M.D. Department of Medical Sciences/Uppsala Clinical Research Centre (UCR) Uppsala University Uppsala SWEDEN• Angina.com: What are the main findings of the study?• Dr. Vedin: Self-reported tooth loss and gum bleeding, as markers of periodontal disease, are common in this global population of patients with established coronary heart disease (i.e. previous myocardial infarction or verified coronary artery stenosis). Poor dental health, especially tooth loss, is associated with several established cardiovascular risk factors, including diabetes, smoking, high blood pressure and obesity, but also with more novel ones including Lp-PLA2. Angina.com: Were any of the findings unexpected?
• Dr. Vedin: We were surprised by the large proportion of patients with no or very few teeth and had expected somewhat stronger associations between gum bleeding and cardiovascular risk factors.
  • 56. Tooth Loss Is Highly Prevalent And Associated With Cardiovascular Risk Factors In Patients With Chronic Coronary Heart Disease In The Global Stability Trial Angina.com Interview with Dr. Ola Vedin, M.D. Department of Medical Sciences/Uppsala Clinical Research Centre (UCR) Uppsala University Uppsala SWEDEN (cont)• Angina.com: What should clinicians and patients take away from this study?• Dr. Vedin: There is an association between self-reported tooth loss and cardiovascular risk factors but we do not yet know whether this relationship is causal.• Periodontal disease in relation to cardiovascular risk is a hot, but poorly understood topic that needs further exploring.
  • 57. Tooth Loss Is Highly Prevalent And Associated With Cardiovascular Risk Factors In Patients With Chronic Coronary Heart Disease In The Global Stability Trial Angina.com Interview with Dr. Ola Vedin, M.D. Department of Medical Sciences/Uppsala Clinical Research Centre (UCR) Uppsala University Uppsala SWEDEN (cont)• Angina.com: What further research do you recommend as a result of your study?• Dr. Vedin: We are anticipating outcome data later this year when the study closes. Then we can relate the data on dental health to cardiovascular outcome and, after adjusting for common risk factors, clarify whether self-reported tooth loss and gum bleeding may actually be associated with myocardial infarction and death.• More widely speaking, there is a need for independent studies designed to determine whether poor dental health, or periodontal disease, actually causes coronary heart disease and if so, if periodontal treatment lowers cardiovascular risk.• Citation:• Tooth Loss Is Highly Prevalent And Associated With Cardiovascular Risk Factors In Patients With Chronic Coronary Heart Disease In The Global Stability Trial• Dr. Vedin presented the study “Tooth Loss Is Highly Prevalent And Associated With Cardiovascular Risk Factors In Patients With Chronic Coronary Heart Disease In The Global Stability Trial” on Saturday, March 9 at 3:45 p.m., in Moscone Center, Expo North during the ACC13 meeting
  • 58. Sleep Apnea and Risk of Peptic Ulcer Bleeding Angina.com Interview with: Chou, Kun-Ta, M.D Taipei Veterans General Hospital, Taipei, Taiwan• Angina.com: What are the main findings of the study?• Response: In this retrospective matched-control cohort study including 35,480 patients (7,096 sleep apnea patients vs. 28,384 controls) with a mean follow-up period of 3.57 years, we found patients with sleep apnea experienced a 2.400- fold (95% CI, 1.544-3.731, p<0.001) higher risk for incident peptic ulcer bleeding after adjusting other significant variables.
  • 59. Sleep Apnea and Risk of Peptic Ulcer Bleeding Angina.com Interview with: Chou, Kun-Ta, M.D Taipei Veterans General Hospital, Taipei, Taiwan (cont)• Angina.com: Were any of the findings unexpected?• Response: Sleep apnea is a common disease and linked with a variety of cardiovascular diseases, such as hypertension, atherosclerosis, and arrhythmia. However, its impact on the affected individuals seems more widespread than we would expect, not exclusively limited to the cardiovascular system. The gastrointestinal system is probable to be affected as well. We found it surprising that sleep apnea confers a higher risk for incident peptic ulcer bleeding, even within a relatively short follow-up period in such a young population (aged 46.61 years on average).
  • 60. Sleep Apnea and Risk of Peptic Ulcer Bleeding Angina.com Interview with: Chou, Kun-Ta, M.D Taipei Veterans General Hospital, Taipei, Taiwan (cont)• Angina.com: What should clinicians and patients take away from this study?• Response: Our results suggest that sleep apnea is an independent risk factor for peptic ulcer bleeding. Despite clear conclusion provided, this study is limited by its retrospective design and inability to include information about the lifestyle of the enrollees, such as smoking, alcohol consumption, obesity etc., which may possibly confound our results.• For treatment of peptic ulcer bleeding in clinical practice, the clinicians should go through the traditional risk factors in such patients. For those without apparent risk factors identified, we may survey for sleep apnea as a potential predisposing factor.
  • 61. Sleep Apnea and Risk of Peptic Ulcer Bleeding Angina.com Interview with: Chou, Kun-Ta, M.D Taipei Veterans General Hospital, Taipei, Taiwan (cont)• Response: What further research do you recommend as a result of your study?• Response: Our study may prompt further elaborate prospective research to confirm our conclusion and probe into the mechanism underlying the linkage of sleep apnea and its gastrointestinal complications.• Citation:• Sleep Apnea and Risk of Peptic Ulcer Bleeding: A Nationwide Population-based Study• Am J Med. 2013 Mar;126(3):249-255.e1. doi: 10.1016/j.amjmed.2012.08.017.• Shiao TH, Liu CJ, Luo JC, Su KC, Chen YM, Chen TJ, Chou KT, Shiao GM, Lee YC. Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
  • 62. The Effect of Weight Loss on the Incidence of Heart Failure or Death in MADIT-CRT Patients Angina.com Interview with Dr. Valentina Kutyifa, MD, MSc University of Rochester Medical Center NY• Angina.com: What are the main findings of the study?• Dr. Kutyifa: In 170 of 994 (17%) patients implanted with CRT-D in the MADIT-CRT clinical trial, an unplanned, greater than – 2 kg weight loss was observed at 12 months after device implantation. The risk of heart failure or death was significantly higher in patients with unanticipated, significant weight loss as compared to those without weight loss. Each kilogram weight loss was associated with 4% increase in the risk of heart failure or death during an average of 29 months follow-up in the study. Patients with left bundle branch block and significant weight loss (> – 2kg) doubled their risk of heart failure or death.
  • 63. The Effect of Weight Loss on the Incidence of Heart Failure or Death in MADIT-CRT Patients Angina.com Interview with Dr. Valentina Kutyifa, MD, MSc University of Rochester Medical Center NY (cont)• Angina.com: Were any of the findings unexpected?• Dr. Kutyifa: This study is consistent with the findings from other studies that have looked at the obesity paradox, suggesting that patients with weight loss have worse clinical outcome as compared to those without a weight loss. We need to stress that in this particular study, patients were not following any dietary rules, and they were not encouraged to lose weight, the weight loss was unanticipated.• Angina.com: What should clinicians and patients take away from this study?• Dr. Kutyifa: In patients with heart failure who receive a cardiac resynchronization device with defibrillator (CRT-D), unintended weight loss increases the risk of heart failure or death.• It may be advisable for heart failure patients with unplanned significant weight loss to consult their doctor, and physicians may perform diagnostic tests, refining medical treatment if necessary, and monitor these patients more closely to prevent the development of serious events.• However, we still suggest implementing weight control under a physician’s supervision in obese heart failure patients, because obesity is known to be associated with diabetes, high blood pressure, and the development of coronary artery disease.
  • 64. The Effect of Weight Loss on the Incidence of Heart Failure or Death in MADIT-CRT Patients Angina.com Interview with Dr. Valentina Kutyifa, MD, MSc University of Rochester Medical Center NY (cont)• Angina.com: What further research do you recommend as a result of your study?• Dr. Kutyifa: The effects of weight loss needs to be further evaluated in patients with an implanted CRT-D, and baseline obesity needs to be taken into consideration. It would be interesting to see, if this effect is maintained regardless of the baseline weight, and baseline body mass index (BMI), or less obese patients would more affected than those with obesity to start with.• Citation:• The Effect of Weight Loss on the Incidence of Heart Failure or Death in MADIT-CRT Patients• American College of Cardiology annual meeting in San Francisco Abstract: 308 Valentina Kutyifa ,Mehmet Aktas, David Huang, Scott McNitt, Arthur Moss, Wojciech Zareba, University of Rochester Medical Center, Heart Research FollowUp Program, Rochester, NY, USA
  • 65. Association of Body Mass Index with Risks of Myocardial Infarction and Ischemic Stroke in Young Women Angina.com Interview with Michelle Schmiegelow PhD student at the University of Copenhagen• Angina.com: What are the main findings of the study?• Answer: In this nationwide register-based study of 273,000 healthy women with a median age of approximately 30 years, we found obesity (body mass index >30 kg/m2) to be associated with a significantly increased risk of myocardial infarction and ischemic stroke within 4.5 years following childbirth. The absolute risks were low, but the key message is clear.• Angina.com: Were any of the findings unexpected?• Answer: We found it surprising that the obesity-associated health risk becomes apparent within a relatively short follow-up in such a young population of women even following adjustment for important cardiovascular risk factors.
  • 66. Association of Body Mass Index with Risks of Myocardial Infarction and Ischemic Stroke in Young Women Angina.com Interview with Michelle Schmiegelow PhD student at the University of Copenhagen (cont)• Angina.com: What should clinicians and patients take away from this study?• Answer: From register-based studies it is not possible to conclude about causal relationships, only associations.• Patients should be aware that the consequences of their lifestyle become apparent in the short- term.• The clinician on the other hand should go through the risk profile of the obese woman in front of him/her to improve the overall risk profile with a particular focus on the traditional risk factors and physical activity.• Angina.com: What further research do you recommend as a result of your study?• Answer: It would be very interesting to find out whether obesity is an independent risk factor itself in such a young population or whether the associations found are mediated by the lifestyle that leads to obesity: poor diet, inactive lifestyle etc.• A prospective study of this kind will however be difficult to conduct due to the rarity of the events in such a young population and therefore the need of a large study population.• Association of Body Mass Index with Risks of Myocardial Infarction and Ischemic Stroke in Young Women - 
a Nationwide Study• Dr. Schmiegelow will present the study “Association of Body Mass Index with Risks of Myocardial Infarction and Ischemic Stroke in Young Women – a Nationwide Study” Saturday, March 9 at 10:00 a.m., in Moscone Center, Expo North.
  • 67. Prevalence of Regional Myocardial Thinning and Relationship With Myocardial Scarring in Patients With Coronary Artery Disease Angina.com Interview with Dipan J. Shah, M.D., F.A.C.C. Assistant Professor of Medicine Weill Cornell Medical College Director, Cardiovascular MRI Laboratory The Methodist DeBakey Heart & Vascular Center Houston, TX 77030• Angina.com: What are the main findings of the study?• Dr. Shah: Traditional thinking is that heart muscle that is thinned in the setting of coronary artery disease is completely scar tissue with no potential for improvement of muscle pumping function. Our study demonstrated that this traditional thinking may be incorrect.• Using a cardiovascular magnetic resonance (CMR) technique we studied 1,055 patients and found that large areas of wall thinning occurred in 19% (201 patients). Furthermore we found in the patients with wall thinning that 18% (37 of 201 patients) had little to no scarring despite the presence of wall thinning. Strikingly we found that these patients with thinning but limited scar were able to improve muscle pumping function after revascularization. Even more striking, we found that these patients could have disappearance of wall thinning as the heart muscle “plumped” back to normal thickness.
  • 68. Prevalence of Regional Myocardial Thinning and Relationship With Myocardial Scarring in Patients With Coronary Artery Disease Angina.com Interview with Dipan J. Shah, M.D., F.A.C.C. Assistant Professor of Medicine Weill Cornell Medical College Director, Cardiovascular MRI Laboratory The Methodist DeBakey Heart & Vascular Center Houston, TX 77030 (cont)• Angina.com: Were any of the findings unexpected?• Dr. Shah: Yes, the fact that limited scarring can occur even in thinned myocardium is unexpected as most clinicians believe thinned myocardium should be equated with extensive scar tissue, without potential for functional recovery. More strikingly however was the complete disappearance of wall thinning following revascularization in the patients identified as having limited scar by CMR. The phenomenon of disappearance of wall thinning, has never been described in the literature; this is the first systematic report to identify its existence. We reiterate our belief that the presented data has paradigm-shifting ramifications for how scientists consider myocardial remodeling and the adaptability of the myocardium in the setting of ischemic injury.
  • 69. Prevalence of Regional Myocardial Thinning and Relationship With Myocardial Scarring in Patients With Coronary Artery Disease Angina.com Interview with Dipan J. Shah, M.D., F.A.C.C. Assistant Professor of Medicine Weill Cornell Medical College Director, Cardiovascular MRI Laboratory The Methodist DeBakey Heart & Vascular Center Houston, TX 77030 (cont)• Angina.com: What should clinicians and patients take away from this study?• Dr. Shah:• 1) That the presence of wall thinning should not be equated with extensive scar, as some patients may have limited scar.• 2) CMR is the only technique to identify patients with this entity – wall thinning with limited scar.• 3) Patients with wall thinning but limited scar on CMR can not only improve contractile function, but can also demonstrate disappearance of wall thinning. We believe this could have significant ramifications for the clinical management of patients with ischemic heart disease since it behooves the clinician to consider coronary revascularization in a population who are typically advised to not undergo this intervention.
  • 70. Prevalence of Regional Myocardial Thinning and Relationship With Myocardial Scarring in Patients With Coronary Artery Disease Angina.com Interview with Dipan J. Shah, M.D., F.A.C.C. Assistant Professor of Medicine Weill Cornell Medical College Director, Cardiovascular MRI Laboratory The Methodist DeBakey Heart & Vascular Center Houston, TX 77030• Angina.com: What further research do you recommend as a result of your study?• Dr. Shah: We have demonstrated for the first time and some patients with wall thinning can improve contractile function and undergo reversal of wall thinning. The logical next is to demonstrate an improvement in survival in patients with wall thinning who are identified by CMR to have limited scar.• Citation:• Prevalence of regional myocardial thinning and relationship with myocardial scarring in patients with coronary artery disease.• Shah DJ, Kim HW, James O, Parker M, Wu E, Bonow RO, Judd RM, Kim RJ.• Duke Cardiovascular MRI Center, DUMC 3934, Durham, NC 27710, USA. JAMA. 2013 Mar 6;309(9):909-18. doi: 10.1001/jama.2013.1381.
  • 71. The relationship between metabolic risk factors and incident cardiovascular disease in Europeans, South Asians and African Caribbeans. Angina.com Author Interview: Therese Tillin, MSc, MBBS International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA (cont)• Angina.com: What are the main findings of the study?• Response: We followed a large group of British Europeans, South Asians (from the Indian subcontinent) and African Caribbeans for 20 years from mid-life. Compared with the European population, British South Asians are at markedly higher risk of coronary heart disease, while African Caribbeans are at substantially lower risk. Risk factors measured in mid- life, such as insulin resistance, blood fats, blood pressure and body build did not explain these ethnic differences.• Stroke rates (both fatal and non-fatal) were raised in both ethnic minority groups and this was particularly marked for those with diabetes. Compared with Europeans with diabetes, South Asians with diabetes experienced 1.8 times higher stroke risk and African Caribbeans experienced more than twice the risk. These excess stroke risks were not explained by differences in risk factors measured in mid-life.
  • 72. The relationship between metabolic risk factors and incident cardiovascular disease in Europeans, South Asians and African Caribbeans. Angina.com Author Interview: Therese Tillin, MSc, MBBS International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA (cont)• Angina.com: Were any of the findings unexpected?• Response: Previous findings from this cohort had suggested that diabetes carried added ‘toxicity’ in terms of stroke mortality for these ethnic minorities. We have now confirmed these findings for both fatal and non-fatal strokes.• Angina.com: What should clinicians and patients take away from this study?• Response: Diabetes may be more strongly associated with stroke risk in people of South Asian and African Caribbean origins compared with Europeans with diabetes and although further confirmation is needed in larger studies, we suggest that early interventions to reduce cardiovascular risk may be of particular importance in these high risk populations.
  • 73. The relationship between metabolic risk factors and incident cardiovascular disease in Europeans, South Asians and African Caribbeans. Angina.com Author Interview: Therese Tillin, MSc, MBBS International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, 59-61 North Wharf Road, London W2 1LA (cont)• Angina.com: What further research do you recommend as a result of your study?• Response: Understanding the mechanisms which underlie the toxic effects of diabetes on the cardiovascular system is key to understanding how best to implement preventive strategies in people of all ethnicities.• It will be important to identify metabolic and hemodynamic factors which act at critical stages of life. Ongoing follow-up of existing multi-ethnic cohorts to confirm our findings will be important. The study of new techniques such as metabolomics, which can provide metabolic profiling, are more likely to capture complex disturbances than single risk factors and will be useful in identifying ethnicity-specific profiles which are most strongly predictive of cardiovascular events.• Thus we could begin to tease out the mechanisms underlying ethnic differences in the development of diabetes and its many complications.• Citation:• The relationship between metabolic risk factors and incident cardiovascular disease in Europeans, South Asians and African Caribbeans. SABRE (Southall and Brent revisited) – a prospective population based study Therese Tillin, Alun D. Hughes, Jamil Mayet, Peter Whincup, Naveed Sattar, Nita G. Forouhi, Paul M. McKeigue, Nish Chaturvedi Journal of the American College of Cardiology• In Press, Accepted Manuscript, Available online 28 February 2013
  • 74. Staged Versus One-time Complete Revascularization With Percutaneous Coronary Intervention for Multivessel Coronary Artery Disease Patients Without ST-Elevation Myocardial Infarction Angina.com Author Interview: Edward L. Hannan, PhD, FACC School of Public Health, State University of New York, University at Albany, One University Place, Rensselaer, New York, 12144-3456• Angina.com: What are the main findings of your study?• Dr. Hannan: Patients without STEMI (either patients with ACS, or patients with stable CAD) fare as well.• Angina.com: Where any of the findings unexpected?• Dr. Hannan: We didn’t know what to expect because this topic had not been studied before.
  • 75. Staged Versus One-time Complete Revascularization With Percutaneous Coronary Intervention for Multivessel Coronary Artery Disease Patients Without ST-Elevation Myocardial Infarction Angina.com Author Interview: Edward L. Hannan, PhD, FACC School of Public Health, State University of New York, University at Albany, One University Place, Rensselaer, New York, 12144-3456 (cont)• Angina.com: What would you recommend to clinicians and patients as a result of your study?• Dr. Hannan: That it may be best to use complete revascularization in the index admission for patients with multi-vessel disease and are not STEMI patients.• This is particularly important when cost is taken into consideration in addition to outcomes.• Furthermore, some patients who are staged may be lost to follow-up with the staged approach.• Angina.com: What further research would you recommend as a result of this study?• Dr. Hannan: This study should be replicated in other settings, and RCTs should be conducted to determine if they arrive at the same conclusions.• Citation:• Staged Versus One-time Complete Revascularization With Percutaneous Coronary Intervention for Multivessel Coronary Artery Disease Patients Without ST-Elevation Myocardial Infarction• Hannan EL, Samadashvili Z, Walford G, Jacobs AK, Stamato NJ, Venditti FJ, Holmes DR Jr, Sharma S, King SB 3rd.• University at Albany, State University of New York, Albany, NY.• Circ Cardiovasc Interv. 2013 Feb 1;6(1):12-20. doi: 10.1161/CIRCINTERVENTIONS.112.974485. Epub 2013 Jan 15.
  • 76. Coronary plaque component in patients with vasospastic angina: A virtual histology intravascular ultrasound study Angina.com Author Interview: Kenichi Tsujita, MD, PhD Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan• Angina.com What are the main findings of the study?• Dr. Tsujita: Volumetric intravascular ultrasound (IVUS) analysis and virtual histology (VH)-IVUS was done in 26 patients with vasospastic angina (VSA) and 16 control subjects to elucidate the tissue component of spastic coronary arteries and its gender differences in patients with VSA.• VSA group had diffusely thickened intima compared with non-VSA group. However, plaque components of patients with VSA were fibrous-dominant, similar with that of non-VSA patients without gender difference.• Angina.com Were any of the findings unexpected?• Dr. Tsujita: Absence of gender difference on plaque components in patients with VSA
  • 77. Coronary plaque component in patients with vasospastic angina: A virtual histology intravascular ultrasound study Angina.com Author Interview: Kenichi Tsujita, MD, PhD Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan (cont)• Angina.com What should clinicians and patients take away from this study?• Dr. Tsujita: Our findings might suggest the role of vasospasm in the development of atherosclerosis.• We, cardiologists, should pay attention to atherosclerosis development in patients with VSA.• Angina.com What further research do you recommend as a result of your study?• Dr. Tsujita: It would be interesting to look at the occurrence of TCFA in patients with VSA.• Citation:• Coronary plaque component in patients with vasospastic angina: A virtual histology intravascular ultrasound study.• Kenichi Tsujita, Kenji Sakamoto, Sunao Kojima, Shinobu Kojima, Naoko Takaoka, Yasuhiro Nagayoshi, Tomohiro Sakamoto, Shinji Tayama, Koichi Kaikita, Seiji Hokimoto, Hitoshi Sumida, Seigo Sugiyama, Sunao Nakamura, Hisao Ogawa International Journal of Cardiology – 01 March 2013 (10.1016/j.ijcard.2013.02.002)
  • 78. Medication, reperfusion therapy and survival in a community-based setting of hospitalized myocardial infarction Angina.com Author Interview: Dr. Emily O’Brien MD Duke Clinical Research Institute, 2400 Pratt Street Durham, NC 27705,• Angina.com: What are the main findings of the study?• Dr. O’Brien: The primary finding of this study is that the use of 6 medications and procedures were associated with mortality benefits following discharge in a racially and geographically diverse population of validated myocardial infarction (MI) events. The effect persisted after including other medications received during hospitalization in the model.• Furthermore, we found evidence of temporal increases in the total number of medications per hospitalization over the study period (1987-2008), suggesting that the average MI patient today receives more medications than the average MI patient in 1987.
  • 79. Medication, reperfusion therapy and survival in a community-based setting of hospitalized myocardial infarction Angina.com Author Interview: Dr. Emily O’Brien MD Duke Clinical Research Institute, 2400 Pratt Street Durham, NC 27705,• Angina.com: Were any of the findings unexpected?• Dr. O’Brien: The consistency of our effect estimates between different propensity score models was unexpected.• We found similar benefits associated with each medication and procedure regardless of method chosen to account for other therapies.• This finding was encouraging, since results can often vary significantly depending on the statistical approach.• Angina.com: What should clinicians and patients take away from this study?• Dr. O’Brien: Much of the evidence that supports clinical decision-making is derived from clinical trials, which often have stringent exclusion criteria and focus on the therapeutic benefits associated with a single medication.• This study provides support for the mortality benefits of in-hospital therapies in a community-based random sample of MI, which is more likely to be representative of the broader MI population than are clinical trial populations.• Clinicians should be encouraged that similar mortality benefits are observed in this real-world population, where patients often receive more than one therapy.
  • 80. Medication, reperfusion therapy and survival in a community-based setting of hospitalized myocardial infarction Angina.com Author Interview: Dr. Emily O’Brien MD Duke Clinical Research Institute, 2400 Pratt Street Durham, NC 27705,• Angina.com: What further research do you recommend as a result of your study? Dr. O’Brien: One of the main limitations of our study was that information on medication use following after discharge was not available.• Changes to medication regimens and non-compliance are critical in the period following MI discharge.• Patients taking large numbers of medications may not only be sicker but also more vulnerable to side effects and problems with adherence. More information on patterns of medication use and which factors are related to compliance in patients who are prescribed complex medication regimens is needed.• Citation:• Medication, reperfusion therapy and survival in a community-based setting of hospitalized myocardial infarction• Emily C O’Brien, Kathryn M Rose, Chirayath M Suchindran, Til Stürmer, Patricia P Chang, Lloyd Chambless, Cameron S Guild, Wayne D Rosamond• Heart heartjnl-2012-303244 Published Online First: 2 March 2013 doi:10.1136/heartjnl-2012-303244
  • 81. nsomnia and the risk of incident heart failure Angina.com Author Interview: Dr Lars E Laugsand Norwegian University of Science and Technology, Trondheim• Angina.com: What are the main findings of the study?• Answer: The main finding in the study is that insomnia symptoms are associated with an increased risk of having future heart failure.• There was a dose-dependent association between the number of insomnia symptoms and risk of heart failure.
  • 82. nsomnia and the risk of incident heart failure Angina.com Author Interview: Dr Lars E Laugsand Norwegian University of Science and Technology, Trondheim (cont)• Angina.com: Where any of the findings unexpected?• Answer: Among men, we found an inverse association between having the feeling of non-restorative sleep and risk of incident heart failure. This was an unexpected and unexplained finding that should be confirmed in other studies.• Angina.com: What should patients and clinicians take away from your study?• Answer: Our results suggest that the evaluation of insomnia may add useful information to clinical cardiovascular risk assessment. If subsequent studies confirm our findings and if causality is better established, the observed association between insomnia and heart failure risk could have implications for cardiovascular prevention since insomnia is an easily recognized and potentially treatable condition.
  • 83. nsomnia and the risk of incident heart failure Angina.com Author Interview: Dr Lars E Laugsand Norwegian University of Science and Technology, Trondheim (cont)• Angina: What suggestions for future research do you have as a result of your study:• Answer: More studies should be done to reveal the possible mechanisms for the observed association.• Clinical trials are also needed to determine whether improving sleep, improves cardiovascular risk factor and cardiovascular outcomes.• Citation:• Insomnia and the risk of incident heart failure: A population study.• Laugsand LE, Strand LB, Platou, et al. Eur Heart J 2013; DOI: 10.1093/eurheartj/eht019.
  • 84. Association of Epicardial Fat With Cardiovascular Risk Factors and Incident Myocardial Infarction in the General Population Angina.com Author Interview: Dr. Amir Abbas Mahabadi Department of Cardiology, West-German Heart Center, University of Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany• Angina.com: What are the main findings of the study?• Dr. Amir Abbas Mahabadi: In the present study, we investigated the association of epicardial adipose tissue (EAT) with incident coronary events in the population- based Heinz Nixdorf Recall Study. We found that EAT was associated with future events not only independent of traditional cardiovascular risk factors but also of coronary artery calcification, an itself strong predictor of cardiac events. Interestingly, in those subjects developing an event, adipose tissue volume around the coronary vessel with the culprit lesion was even more increased. Therefore, our results support the hypothesis of a local influence of visceral adipose tissues on atherosclerosis development in underlying vessels.
  • 85. Association of Epicardial Fat With Cardiovascular Risk Factors and Incident Myocardial Infarction in the General Population Angina.com Author Interview: Dr. Amir Abbas Mahabadi Department of Cardiology, West-German Heart Center, University of Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany (cont)• Angina.com: Were any of the findings unexpected?• Dr. Amir Abbas Mahabadi: When investigating the association of EAT with coronary artery calcification, we found no link after adjustment of traditional risk factors. Together with the finding that the link of EAT with events was even more distinct in subjects with no or low coronary calcification, these results suggest that EAT may be linked with future coronary events through a mechanistic pathway different to that of coronary calcification such as early and non-calcified plaque burden.
  • 86. Association of Epicardial Fat With Cardiovascular Risk Factors and Incident Myocardial Infarction in the General Population Angina.com Author Interview: Dr. Amir Abbas Mahabadi Department of Cardiology, West-German Heart Center, University of Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany (cont)• Angina.com: What should clinicians and patients take away from this study?• Dr. Amir Abbas Mahabadi: As demonstrated in our study, quantification of EAT complements prognostic information from coronary artery calcification. Therefore, once cardiac CT imaging is performed, physicians may consider EAT assessment as this information is readily available without the need of additional radiation exposure or contrast administration.
  • 87. Association of Epicardial Fat With Cardiovascular Risk Factors and Incident Myocardial Infarction in the General Population Angina.com Author Interview: Dr. Amir Abbas Mahabadi Department of Cardiology, West-German Heart Center, University of Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany (cont)• Angina.com: What further research do you recommend as a result of your study?• Dr. Amir Abbas Mahabadi: To date, little is known about how EAT volume can be influenced. While a positive effect of physical activity was suggested in the literature, further research is needed to establish predictors of EAT changes.• Citation:• Association of Epicardial Fat With Cardiovascular Risk Factors and Incident Myocardial Infarction in the General Population: The Heinz Nixdorf Recall Study.• Mahabadi AA, Berg MH, Lehmann N, Kälsch H, Bauer M, Kara K, Dragano N, Moebus S, Jöckel KH, Erbel R, Möhlenkamp S.• Department of Cardiology, West-German Heart Center, University of Duisburg-Essen, Essen, Germany. J Am Coll Cardiol. 2013 Feb 14. pii: S0735-1097(13)00174-5. doi: 10.1016/j.jacc.2012.11.062. [Epub ahead of print]
  • 88. Randomized Comparison of Sirolimus-Eluting and Everolimus-Eluting Coronary Stents in the Treatment of Total Coronary Occlusions: Results From the Chronic Coronary Occlusion Treated by Everolimus-eluting Stent Randomized Trial Angina.com Author Interview: Raul Moreno, MD, PhD University Hospital La Paz, Paseo La Castellana 261, 28046 Madrid, Spain• Angina.com: What are the main findings of the study?• Dr. Moreno: Chronic coronary occlusions (CTO) constitute one of the most challenging scenario for interventional cardiologists, not only because of a lower initial angiographic success rate of these lesions, but also because patients with an initial successful result have a high risk of restenosis and subsequent cardiac events. Because of that, the presence of CTO is a predictor of either sending a patient for surgical revascularization or to leave him/her on medical treatment alone.• It is difficult to undergo a randomized trial focused on CTO, and because of that randomized trials in this type of lesions/setting are very uncommon. The sirolimus-eluting coronary stent (SES) was the only drug-eluting stent that was randomly compared with bare-metal stens in this unfavourable subgroup of patients.• The main findings of the CIBELES study is that a second-generation drug.eluting stent releasing everolimus with a cobalt-chromium platform (EES) provides a similar efficacy than the SES in patients with CTO.
  • 89. Randomized Comparison of Sirolimus-Eluting and Everolimus-Eluting Coronary Stents in the Treatment of Total Coronary Occlusions: Results From the Chronic Coronary Occlusion Treated by Everolimus-eluting Stent Randomized Trial Angina.com Author Interview: Raul Moreno, MD, PhD University Hospital La Paz, Paseo La Castellana 261, 28046 Madrid, Spain (cont)• Angina.com: Were any of the findings unexpected?• Dr. Moreno: In the CIBELES trial, the rate of stent thrombosis (definitive or probable) was less frequent in patients allocated to EES, with a p value of 0.07. This suggests that EES could be safer than SES in CTO.
  • 90. Randomized Comparison of Sirolimus-Eluting and Everolimus-Eluting Coronary Stents in the Treatment of Total Coronary Occlusions: Results From the Chronic Coronary Occlusion Treated by Everolimus-eluting Stent Randomized Trial Angina.com Author Interview: Raul Moreno, MD, PhD University Hospital La Paz, Paseo La Castellana (cont)• Angina.com: What should clinicians and patients take away from this study?• Dr. Moreno: First, that when drug-eluting stents are routinely used in patients with CTO, the rate of cardiac events during follow-up is low. This should encourage interventional cardiologists to treat this type of lesions.• Second, that the second-generation drug-eluting stents seem to be safer than the first-generation drug-eluting stents. The concerns about late and very late stent thrombosis came from the studies that evaluated first-generation drug-eluting stents, but this problem has not been found in second- generation devices.• Citation:• Randomized Comparison of Sirolimus-Eluting and Everolimus-Eluting Coronary Stents in the Treatment of Total Coronary Occlusions: Results From the Chronic Coronary Occlusion Treated by Everolimus-eluting Stent Randomized Trial.• Moreno R, García E, Teles R, Rumoroso JR, Carvalho HC, Goicolea FJ, Moreu J, Mauri J, Sabaté M, Mainar V, Patricio L, Valdés M, Fernández Vázquez F, Sánchez-Recalde A, Galeote G, Jimenez-Valero S, Almeida M, de Sa EL, Calvo L, Plaza I, Lopez-Sendón JL, Martín JL; CIBELES Investigators.• Hospital Universitario La Paz, Madrid, Spain.• Circ Cardiovasc Interv. 2013 Feb 1;6(1):21-8. doi: 10.1161/CIRCINTERVENTIONS.112.000076. Epub 2013 Feb 12.
  • 91. Elevated coronary whole blood viscosity in acute coronary syndrome patients Author Interview Robert S. Rosenson, MD, FACC Professor of Medicine at the Icahn School of Medicine Mount Sinai where he serves as Director of Cardiometabolic Disorders (cont)• Angina.com: What are the main findings of the study?• Dr. Rosenson: Low-shear and high shear blood viscosity measures obtained from the coronary artery ostia and femoral artery were significantly higher in the 22 patients undergoing diagnostic coronary arteriography who presented with an acute coronary syndrome (unstable angina [n=13], acute myocardial infarction [n=9]) than in the 16 patients who had coronary stenoses <50%. ACS was defined by acute onset chest pain at rest that lasted >20 min within the last 48 hours together with electrocardiographic changes and/or elevation in cardiac enzymes (creatinine kinase, creatinine kinase MB or troponin).
  • 92. Elevated coronary whole blood viscosity in acute coronary syndrome patients Author Interview Robert S. Rosenson, MD, FACC Professor of Medicine at the Icahn School of Medicine Mount Sinai where he serves as Director of Cardiometabolic Disorders• Angina.com: Were any of the findings unexpected?• Dr. Rosenson: Overall, these results confirmed previous studies in acute myocardial infarction patients who had blood samples obtained from antecubital veins. Unexpected findings included the lack of difference in blood viscosity values measured from the right and left coronary artery ostia. Thus, the coronary artery with the culprit lesion had no difference in blood viscosity measured proximal to the stenosis. However, we were unable to sample blood distal to the coronary stenosis due to potential harm to the patient.
  • 93. Elevated coronary whole blood viscosity in acute coronary syndrome patients Author Interview Robert S. Rosenson, MD, FACC Professor of Medicine at the Icahn School of Medicine Mount Sinai where he serves as Director of Cardiometabolic Disorders (cont)• Angina.com: What should clinicians and patients take away from this study?• Dr. Rosenson: This study provides data that blood rheology is altered in ACS patients. The higher low-shear blood viscosity in ACS patients increases oscillatory low wall shear stress, which contriubtes to increased expression of inflammatory genes, transmigration of monocytes into the subendothelial space, enhanced incorporation of lipoproteins into tissue macrophages, and increased expression of endothelial matrix metalloproteinase-9 (MMP-9). Elevated high-shear blood viscosity has been shown to increase endothelial cell erosion and dispose the plaque to rupture.
  • 94. Elevated coronary whole blood viscosity in acute coronary syndrome patients Author Interview Robert S. Rosenson, MD, FACC Professor of Medicine at the Icahn School of Medicine Mount Sinai where he serves as Director of Cardiometabolic Disorders (cont)• Angina.com: What further research do you recommend as a result of your study?• Dr. Rosenson: Further research will require larger numbers of patients who are followed prospectively in order to ascertain whether low-shear and/or high-shear blood viscosity are predictive of coronary heart disease events• Citation:• Elevated coronary whole blood viscosity in acute coronary syndrome patients.• Lee SR, Jung JM, Jung LY, Lee JH, Lee SH, Rhee KS, Chae JK, Kim WH, Ko JK, Lee DH, Rosenson RS.• Division of Cardiology, Drexel University, Philadelphia, PA, USA. Clin Hemorheol Microcirc. 2013 Feb 27. [Epub ahead of print]
  • 95. Angiographic Success and Procedural Complications in Patients Undergoing Percutaneous Coronary Chronic Total Occlusion Interventions Angina.com Authors’ Interview: Emmanouil S. Brilakis, MD, PhD, FACC, FAHA, FESC, FSCAI Director, Cardiac Catheterization Laboratories VA North Texas Health Care System Associate Professor of Medicine The University of Texas Southwestern Medical Center at Dallas Division of Cardiology (111A) Dr. Vishal Patel Cardiology Fellow The University of Texas Southwestern Medical Center at Dallas• Angina.com: What are the main findings of the study?• Response: The main findings of the study are that chronic total occlusion (CTO) percutaneous coronary interventions (PCI) can be performed with high angiographic success and a low rate of major complications. Moreover, success rates appear to be improving, while the complications rates are declining. As expected, successful CTO PCI was associated with a lower risk of major complications compared to unsuccessful procedures. Finally, use of the retrograde approach to CTO PCI was associated with a low procedural complication risk.
  • 96. Angiographic Success and Procedural Complications in Patients Undergoing Percutaneous Coronary Chronic Total Occlusion Interventions Angina.com Authors’ Interview: Emmanouil S. Brilakis, MD, PhD, FACC, FAHA, FESC, FSCAI Director, Cardiac Catheterization Laboratories VA North Texas Health Care System Associate Professor of Medicine The University of Texas Southwestern Medical Center at Dallas Division of Cardiology (111A) Dr. Vishal Patel Cardiology Fellow The University of Texas Southwestern Medical Center at Dallas (cont)• Angina.com: Were any of the findings unexpected?• Response: A common perception prior to this study was that CTO PCI is associated with a high risk of major periprocedural complications without high success rates.• Our study challenges those perceptions demonstrating that angiographic success can currently be achieved in approximately 80% of cases with only a 0.5% rate of major complications.• Another unexpected finding is that use of the retrograde approach which is technically more complex was also associated with a low risk of major complications with similarly high rates of angiographic success.• Angina.com: What should clinicians and patients take away from this study?• Response: Clinicians and patients should understand that PCI is an effective and safe therapeutic option for revascularizing coronary CTOs, a lesion subset that historically has been treated with coronary artery bypass grafting. While success rates are not as high as that of routine PCI, they have clearly been improving and will hopefully continue to do so over time, while maintaining a low rate of major complications.
  • 97. Angiographic Success and Procedural Complications in Patients Undergoing Percutaneous Coronary Chronic Total Occlusion Interventions Angina.com Authors’ Interview: Emmanouil S. Brilakis, MD, PhD, FACC, FAHA, FESC, FSCAI Director, Cardiac Catheterization Laboratories VA North Texas Health Care System Associate Professor of Medicine The University of Texas Southwestern Medical Center at Dallas Division of Cardiology (111A) Dr. Vishal Patel Cardiology Fellow The University of Texas Southwestern Medical Center at Dallas (cont)• Angina.com: What further research do you recommend as a result of your study?• Response: While our study shows that CTOs can be tackled safely and effectively through a percutaneous approach, the next challenge is to clearly define the clinical indications and benefits of treating these lesions through well designed randomized-controlled trials.• Another important area of research is to develop better models for predicting the risk of complication and likelihood of success from CTO PCI based on a patient’s specific clinical and anatomic characteristics. This would allow both patients and clinicians to make more informed decisions. Finally, more research is needed on the outcomes after using novel CTO crossing strategies, such as dissection/re-reentry and the retrograde approach, which have revolutionized our ability to successfully treat those challenging lesions.• Citation:• Angiographic Success and Procedural Complications in Patients Undergoing Percutaneous Coronary Chronic Total Occlusion Interventions: A Weighted Meta-Analysis of 18,061 Patients From 65 Studies• Patel VG, Brayton KM, Tamayo A, Mogabgab O, Michael TT, Lo N, Alomar M, Shorrock D, Cipher D, Abdullah S, Banerjee S, Brilakis ES. Veterans Administration North Texas Healthcare System and University of Texas Southwestern Medical School, Dallas, Texas. JACC Cardiovasc Interv. 2013 Feb;6(2):128-36. doi: 10.1016/j.jcin.2012.10.011. Epub 2013 Jan 23.
  • 98. Interactive effects of fitness and statin treatment on mortality risk in veterans with dyslipidaemia Angina.com Author Interview: Prof. Peter Kokkinos PhD, FAHA, FACSM Veterans Affairs Medical Center, Director, LIVe Program Georgetown University School of Medicine George Washington University School of Medicine and Health Sciences• Angina.com: What are the main findings of the study?• Prof. Kokkinos: The main findings of the study are:• Both statin therapy and increased fitness were associated with lower mortality risk. This was evident when all co-morbidities were considered.• The mortality risk for those treated with statins was 35% lower when compared to those not treated with statins.• The fitness-mortality risk association was inverse and graded. When compared to the least fit (exercise capacity ≤5 MET) mortality risk for the entire cohort was 30% lower in those with exercise capacity or 5.1-7.0 METs and declined progressively to 50% and 62% for those with an exercise capacity of 7.1-9 METs and >9.0 METs, respectively.
  • 99. Interactive effects of fitness and statin treatment on mortality risk in veterans with dyslipidaemia Angina.com Author Interview: Prof. Peter Kokkinos PhD, FAHA, FACSM Veterans Affairs Medical Center, Director, LIVe Program Georgetown University School of Medicine George Washington University School of Medicine and Health Sciences (cont)• When we assessed the fitness impact on those treated and not treated with statins separately, we noted that the decline in mortality risk was similar to that observed in the entire cohort for both groups.• To assess the independent impact of fitness on mortality, we compared the least fit individuals treated with statins to those with increased fitness, treated and not treated with statins.• For the least fit individuals not treated with statins the risk was 35% higher. This increased risk was eliminated for those in the next fitness category (5.1-7 METs). The risk then declined by approximately 20% for those with an exercise capacity of 7.1-9 METs and 47% for those in the highest fitness category (>9.0 METs).• For those treated with statins, mortality risk declined by 35% for those with an exercise capacity of 5.1-7.0 METs and 70% for those with an exercise capacity >9 METs. Thus, mortality risk was the lowest when the increased fitness and statin therapy were combined.
  • 100. Interactive effects of fitness and statin treatment on mortality risk in veterans with dyslipidaemia Angina.com Author Interview: Prof. Peter Kokkinos PhD, FAHA, FACSM Veterans Affairs Medical Center, Director, LIVe Program Georgetown University School of Medicine George Washington University School of Medicine and Health Sciences (cont)• Angina.com: Were any of the findings unexpected?• Prof. Kokkinos: The surprising finding was that fitness had a substantially greater impact on mortality risk than statins.• For example, the mortality risk of moderate -fit individuals (7.1-9.0 METs) treated with statins was 35% lower than the least fit on statins.• The mortality risk for High-fit individuals not treated with statins was 47% lower.• Angina.com: What should clinicians and patients take away from this study?• Prof. Kokkinos: The level of fitness necessary for the aforementioned health benefits is achievable by brisk walking or similar activities for approximately 30 minutes on most days of the week.• This level of physical activity is attainable by most middle-aged and older individuals. Thus, we hope that physicians and other health care professionals encourage people to take up exercise and improve their fitness status regardless of dylipideamia, or whether a person is on statin therapy.
  • 101. Interactive effects of fitness and statin treatment on mortality risk in veterans with dyslipidaemia Angina.com Author Interview: Prof. Peter Kokkinos PhD, FAHA, FACSM Veterans Affairs Medical Center, Director, LIVe Program Georgetown University School of Medicine George Washington University School of Medicine and Health Sciences (cont)• Angina.com: What further research do you recommend as a result of your study?• Prof. Kokkinos: We believe that the efficacy of pharmacotherapy can be improved substantially when combined with increased fitness. Studies to substantiate this notion should be designed for individuals with chronic health conditions such as type 2 diabetes mellitus, hypertension and obesity.• Citation:• Interactive effects of fitness and statin treatment on mortality risk in veterans with dyslipidaemia: a cohort study.• Kokkinos PF, Faselis C, Myers J, Panagiotakos D, Doumas M.• Cardiology Department, Veterans Affairs Medical Center, Washington DC 20422, USA Lancet. 2013 Feb 2;381(9864):394-9. doi: 10.1016/S0140-6736(12)61426- 3. Epub 2012 Nov 28.

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