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Cardiology

New 20-minute test diagnoses hidden heart condition

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University of Glasgow: New tests can diagnose ‘hidden’ heart diseases caused by problems with the small blood vessels supplying the heart, according to research funded by the British Heart Foundation (BHF) and presented at the Transcatheter Cardiovascular Therapeutics (TCT) conference today in San Diego.

The new tests are not yet standard in the NHS because, before now, there has not been enough evidence gathered about whether they would benefit patients. Now, researchers say that they should be routinely available to pinpoint the cause of chest pain.

Researchers from the University of Glasgow and the Golden Jubilee National Hospital performed the new ‘small vessel’ test which involves passing a thin, flexible wire into the heart and measuring how well a blood vessel relaxes.

The team performed the new test on 151 patients with chest pain who could not be diagnosed using currently available tests. The small vessel test results for half of the patients were made available to doctors to further guide the diagnosis and treatment, whereas, in the other half of the patients, the results were not disclosed. These patients followed standard care. The team found that the new tests were able to correctly diagnose four times as many patients as standard tests.

Even more importantly, 6 months later, symptoms of angina were less and quality of life was better in the patients whose care was guided by the new tests.

Chest pain originating from the heart is often a symptom of a condition called angina. Angina is triggered when the heart does not receive enough oxygen rich blood, often due to narrowed coronary arteries, the arteries which supply the heart itself. It often happens during exercise, cold weather and emotional stress and points to an underlying problem in the heart.

Doctors commonly recommend an angiogram, an invasive procedure which looks for narrowing of the heart’s main arteries. However, in around one half of patients with angina, this angiogram reveals no significant problems. Despite this, patients can experience severe chest pain and have a significantly higher risk of having a heart attack in the future.

In many people with angina, the pain may be caused by problems with the tiniest blood vessels in the heart—the micro vessels—which are too small to see with traditional tests. The conditions are called microvascular angina and vasospastic angina, which are commonly misdiagnosed. Because diagnosis is so difficult, patients are often left without firm answers about the cause of their chest pain.

Lead researcher Professor Colin Berry, Chair in Cardiology and Imaging at the University of Glasgow, said: “Microvascular angina and vasospastic angina are under-recognised problems. As the angiogram in these patients looks ‘clear’ they are commonly falsely reassured. Our study’s results indicate this to be the case.

“However, leaving microvascular angina and vasospastic angina undiagnosed and untreated presents a risk to patient wellbeing- these problems can be a precursor to a hospitalisation for chest pain and a heart attack – and symptoms persist in the longer term.

“We now hope to see this test rolled out across the country.”

Philippa Hobson, Senior Cardiac Nurse at the British Heart Foundation, which funded the research, said: “People living with microvascular angina suffer from crippling and frightening episodes of chest pain that dramatically affects their day to day life. They are unable to treat their symptoms effectively as their angiogram is essentially normal. Medication currently prescribed to people with diagnosed coronary heart disease does little to resolve their pain or reduce risk of heart attack, so they are left in limbo.

“This study is very reassuring news for sufferers who live in the fear of having a heart attack as for many, there is currently no conclusive proof they have heart disease.”

More information: Thomas J. Ford et al. Stratified Medical Therapy Using Invasive Coronary Function Testing In Angina: CorMicA Trial, Journal of the American College of Cardiology (2018). DOI: 10.1016/j.jacc.2018.09.006

Provided by: University of Glasgow

Cardiology

Aspirin could play valuable role as additional treatment for cancer

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Regular use of aspirin could help in the treatment of some cancers, finds a new review of 71 medical studies.

The systematic review, which looked at the survival of 120,000 patients with cancer who took aspirin, compared with 400,000 patients who did not, showed that at any time following the diagnosis of some cancers the proportion of patients who were still alive was 20-30% greater in those taking the drug. The spread of cancer to other parts of the body was also substantially reduced in patients using aspirin.

Peter Elwood, Honorary Professor at Cardiff University, who directed the study said: “The use of low-dose aspirin as a preventive in heart disease, stroke and cancer is well established but evidence is now emerging that the drug may have a valuable role as an additional treatment for cancer too.”

One of the colon cancer studies the researchers looked at suggested that a non-diabetic man of about 65 years who takes aspirin would have a prognosis similar to that of a man five years his junior who takes none. For a woman of similar age with colon cancer the addition of aspirin could lead to a similar prognosis of a woman four years younger.

Almost half the studies included in the review were of patients with bowel cancer, and most of the other studies were of patients with breast or prostate cancer. There were very few studies of patients with other less common cancers, but on the whole the pooled evidence for all the cancers is suggestive of benefit from aspirin.

All this evidence of benefit is however limited. First, it comes from observational studies of patients who took aspirin for reasons other than the treatment of cancer, and not from appropriate randomised trials designed to test aspirin and cancer.

Furthermore, the evidence is not entirely consistent and a few of the studies failed to detect benefit attributable to aspirin. More evidence is therefore urgently needed. A number of new randomised trials have been set up, but these are unlikely to report for quite a few years.

The issue of bleeding was examined carefully in the review. Information on bleeding was requested from an author of each of the 71 reports and replies were received from 31 authors.

Very few patients had serious bleeding. Amongst those who had, the proportion of patients taking aspirin who had a ‘serious’ bleed was no greater than the proportion of patients not taking aspirin who had experienced a ‘spontaneous’ stomach bleed due to causes other than aspirin. In two studies a very small number of fatal stomach bleeds had occurred, but again the proportion was no greater in the patients on aspirin than in those not taking aspirin.

Peter Elwood, Honorary Professor at Cardiff University, who directed the study says: “Patients with cancer should be given the evidence now available and be helped to make their own judgement of the balance between the risks and the benefits of daily low dose. Evidence from further studies is urgently required, and patients should be strongly encouraged to participate in appropriate research studies.

“All patients should consult their GP before starting new medication.”

The research “Systematic review update of observational studies further supports aspirin role in cancer treatment: time to share evidence and decision-making with patients?” is published in Plos One Medicine.

More information: Peter C. Elwood et al. Systematic review update of observational studies further supports aspirin role in cancer treatment: Time to share evidence and decision-making with patients?, PLOS ONE (2018). DOI: 10.1371/journal.pone.0203957

 

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Wearable defibrillator lowers sudden cardiac death, but only when you wear it

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An international clinical trial that studied wearable cardioverter defibrillators (WCDs) found that the devices did not significantly reduce sudden cardiac death—the primary goal of the device—among patients assigned to the device in the first 90 days after a heart attack, but did lower mortality among those who wore it as prescribed, according to a study led by researchers at UC San Francisco.

The devices, which consist of highly sensitive vests that can deliver an electric shock when the heart beats out of rhythm, are designed to provide medical intervention around the clock for patients who have had a heart attack and are at further risk of death due to arrhythmia. The study appears Sept. 27, 2018, in the New England Journal of Medicine (NEJM).

“It remains unclear how to reduce the risk of arrhythmic death definitively, beyond what is possible with appropriate medical therapy, in the early period after heart attack before implantable cardioverter defibrillators are suggested,” said UCSF Health cardiologist Jeffrey Olgin, MD, lead author of the paper and chief of the Division of Cardiology at UCSF. “However, given the totality of the data, the WCD may be reasonable in high-risk patients who are likely to wear the WCD based on shared decision-making.”

Patients who are prone to fast heart rhythms that can cause sudden death typically receive a surgically implanted type of cardiac pacemaker known as a cardioverter defibrillator (ICD). However, current medical guidelines recommend waiting at least 40 days after a heart attack before implanting the device, and 90 days if the patient has had a vascular stent implanted or has undergone bypass surgery.

The guidelines recommend considering a wearable device for a wide range of patients at risk of sudden cardiac death, including those who have low ejection fraction—a measure of the heart’s pumping ability—following a heart attack.

“Previous research has shown the risk of mortality in low ejection fraction patients is highest in the first 90 days after a cardiac event, such as a heart attack or a new diagnosis of heart failure,” said UCSF Health cardiologist Byron Lee, MD, MAS, professor of medicine and the Reeves Endowed Chair in Arrhythmia Research at UCSF and study co-principal investigator.

WCDs aim to bridge this sensitive period before a pacemaker can be implanted.

In collaboration with the National Institutes of Health (NIH) and device manufacturer Zoll Medical Corp., the Vest prevention of Early Sudden death Trial (VEST) enrolled 2,302 patients in the United States and Europe from July 2008 to April 2017 who had low ejection fractions within seven days of their hospital discharge for heart attack. Patients were randomly assigned in a 2-to-1 ratio to the LifeVest WCD with guideline-directed therapy (1,524) or directed therapy only (778).

Device participants were fitted, trained and instructed to wear it continuously except while bathing. The WCD group wore the device an average of 14.1 hours daily over the study period, starting at 18 hours and decreasing to 12 hours by day 90, at which point only half of the WCD patients still chose to wear the device.

The study found no statistical difference in sudden cardiac deaths or rehospitalization between the two groups, in part due to the lower-than-expected wear time, said Olgin, the Gallo-Chatterjee Distinguished Professor of Medicine at UCSF. However, death rates dropped significantly during times the WCD was worn compared to times it was not. The study found a 35.5 percent lower risk of overall mortality in the WCD group, at 3.1 percent versus 4.9 percent in the control group.

Twenty (1.3 percent) of the device participants experienced at least one appropriate shock during the study, while nine (0.6 percent) received an inappropriate shock. About 70 percent of participants who had an appropriate shock survived to 90 days. Of the 48 participants who died, only 12 were wearing the WCD at time of death.

“Although this study result is subject to confounding, it suggests a benefit to wearing the device and implies that low adherence to wearing it may be a limiting factor in the potential benefit of a wearable cardioverter-defibrillator,” said Mark J. Pletcher, MD, MPH, a UCSF professor of epidemiology and biostatistics who leads the VEST Data Coordinating Center.

The researchers are exploring new analyses for estimating the true causal effect of wearing the WCD, Pletcher said.

Source: University of California, San Francisco

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Prosthetic valve mismatches common in transcatheter valve replacement, ups risk of death

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In the largest multi-institutional study to date, led by researchers from Penn Medicine, the team found that among patients who underwent a transcatheter aortic valve replacement (TAVR), a high number experienced severe and moderate cases of prosthesis-patient mismatch (PPM)—meaning the implanted heart valve is too small for the patient which can lead to inadequate blood flow. The team also found that the risk of death and of heart failure readmissions were 19 percent and 12 percent higher, respectively, after one year as compared to patients without severe PPM.

Results of the study were presented today as a late-breaking abstract at the Transcatheter Cardiovascular Therapeutics (TCT) 2018 meeting in San Diego and simultaneously published online in the Journal of the American College of Cardiology.

“This is an important contemporary snapshot of what’s happening in the real world with commercial TAVR procedures,” said the study’s lead author Howard C. Herrmann, MD, FACC, MSCAI, the John W. Bryfogle Professor of Cardiovascular Medicine and Surgery at Penn’s Perelman School of Medicine and director of Penn Medicine’s Interventional Cardiology Program, who presented the results at TCT. “This is the first study that is large enough to demonstrate meaningful data associated with PPM for a relatively new procedure like TAVR. Based on these findings, PPM is an important problem in this population, one that deserves greater awareness among operators. And being aware of it is the first step in trying to prevent it.”

TAVR was approved by the Food and Drug Administration in 2011 for the treatment of aortic stenosis, a narrowing of the heart’s aortic valve, and has revolutionized valve replacement options for patients with this disease who are too sick or too high risk for surgical (open-heart) valve replacement (SAVR). This minimally invasive, catheter-based approach allows physicians to replace the aortic valve without need to remove the old, damaged one.

Of the 62,125 patients who received TAVRs in the United States between 2014 and 2017 and who were evaluated, researchers found 12 percent experienced severe PPM, while 25 percent had moderate PPM. Researchers collected and analyzed patient data from the U.S. STS/ACC Transcatheter Valve Therapy (TVT) Registry, which tracks all commercial procedures performed in the United States. To further study patient outcomes, the authors linked patients in the U.S. STS/ACC TVT registry to Centers for Medicare & Medicaid Services’ administrative claims data for 37,470 of their patients. After 30 days, patients with severe PPM had higher rates of heart failure hospitalization, stroke, and death.

Historically, PPM has been associated with worse outcomes after SAVR, however, less has been known about the incidence, outcomes, and predictors of PPM in TAVR patients. Past studies have been small, with limited follow up, and some from single centers—combined, they only represent 4,000 patients—and measurement techniques for the valve opening have been inconsistent.

PPM is a mismatch of the blood flow dynamics of the prosthetic valve and the amount of blood the heart needs to pump to the rest of the patient’s body. For example, having too small of a valve in a person with a large body surface area (height and weight) affects their ability to get enough blood flow when they exercise. In previous studies, severe PPM in both SAVR and TAVR patients have been associated with higher risk of death and hospital readmission, decreased exercise abilities, and a higher rate of valve deterioration over time.

The authors identified several predictors of PPM, including patients with a smaller valve prosthesis, those who had a larger body surface area, or patients who are female or younger.

“Severe PPM occurs frequently after TAVR procedures, and it results in worse outcomes, even after a short period of one year,” Herrmann said. “Now that we’re more aware of this, we need to look at strategies and compare devices and techniques in future studies to determine what will help us best limit this risk or avoid it in the future.”

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