Low QRS Voltages in Cardiac Amyloidosis: Clinical Correlates and Prognostic Value

LQRSVs are common but not ubiquitous in CA; they are more frequent in AL-CA than in ATTR-CA. LQRSVs reflect an advanced disease stage and independently predict CV death.

source: JACC CardioOnco

Summary

[Posted 7/Nov/2022]

AUDIENCE: Cardiology, Oncology

KEY FINDINGS: LQRSVs are common but not ubiquitous in CA; they are more frequent in AL-CA than in ATTR-CA. LQRSVs reflect an advanced disease stage and independently predict CV death. In ATTR-CA, LQRSVs can provide incremental prognostic accuracy over the NAC staging system in patients with intermediate risk.

BACKGROUND: Low QRS voltages (LQRSVs) are a common electrocardiographic feature in patients with light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR) cardiac amyloidosis (CA). The aim of this study was to identify clinical and echocardiographic correlates of LQRSV and to investigate their prognostic significance in patients with CA.

DETAILS: This was a multicenter, retrospective study performed in 6 CA referral centers including consecutive patients with AL- and ATTR-CA. LQRSVs were defined as a QRS amplitude <=5 mm (0.5 mV) in all peripheral leads. The study outcome was cardiovascular (CV) mortality. Overall, 411 (AL-CA: n = 120, ATTR-CA: n = 291) patients were included. LQRSVs were present in 66 (55%) patients with AL-CA and 103 (35%) with ATTR-CA (P < 0.001). In AL-CA, LQRSVs were independently associated with younger age (P = 0.015), higher New York Heart Association functional class (P = 0.016), and natriuretic peptides (P = 0.041); in ATTR-CA, LQRSVs were independently associated with pericardial effusion (P = 0.008) and lower tricuspid annulus peak systolic excursion (P = 0.038). During a median follow-up of 33 months (Q1-Q3: 21-46), LQRSVs independently predicted CV death in both AL-CA (HR: 1.76; 95% CI: 2.41-10.18; P = 0.031) and ATTR-CA (HR: 2.64; 95% CI: 1.82-20.17; P = 0.005). Together with the National Amyloidosis Centre (NAC) staging, LQRSVs provided incremental prognostic value in ATTR-CA (AUC for NAC model: 0.83 [95% CI: 0.77-0.89]; AUC for NAC + LQRSV model: 0.87 [95% CI: 0.81-0.93]; P = 0.040).

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Source: Cipriani, A., De Michieli, L., Porari, A., et al. (2022). Low QRS Voltages in Cardiac Amyloidosis: Clinical Correlates and Prognostic Value. J Am Coll Cardiol CardioOnc.. Published: October 7, 2022. DOI: 10.1016/j.jaccao.2022.08.007.



Clinical Implications of the "Broken Line" Angiographic Pattern in Patients With SCAD

Patients with SCAD presenting the BKL angiographic pattern are more frequently female and present more often as intramural hematoma with longer lesions and severe vessel tortuosity but have better coronary flow.

source: Am J Cardiol.

Summary

[Posted 6/Dec/2022]

AUDIENCE: Cardiology, Emergency Medicine

KEY FINDINGS: Patients with SCAD presenting the BKL angiographic pattern are more frequently female and present more often as intramural hematoma with longer lesions and severe vessel tortuosity but have better coronary flow. Patients with the BKL morphology have a favorable prognosis.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause of acute myocardial infarction. Coronary angiography remains the best diagnostic tool; however, clinical suspicion and experience is required to interpret angiographic findings.

DETAILS: This study sought to assess the clinical implications of the "broken line"”" (BKL) angiographic pattern in a large, nationwide, cohort of patients with SCAD. The Spanish SCAD registry prospectively enrolled consecutive patients with SCAD. All angiograms were centrally analyzed and the BKL pattern was systematically assessed. The BKL angiographic pattern was found in 64 of 389 patients (16%). Patients with the BKL appearance were more frequently female (97 vs 87%, p <0.05), presented more often as intramural hematoma (83 vs 58%, p <0.001), had longer lesions (47 ± 29 vs 36 ± 22 mm, p <0.01), and had severe tortuosity (25 vs 10%, p <0.01) but showed better initial coronary flow (thrombolysis in myocardial infarction flow 2.6 ± 0.8 vs 2.1 ± 1.2, p <0.01). Patients with BKL received more frequently conservative medical management (91 vs 76%, p <0.01). At late clinical follow-up (median 29 months, interquartile range 17 to 38) predefined adverse events (death, myocardial infarction, revascularization, recurrent SCAD, or stroke) occurred less frequently (3.5 vs 15%, p <0.05) in patients with the BKL appearance. The better clinical outcomes of patients in the BKL group persisted after adjusting for potential confounders (adjusted hazard ratio 0.2, 95% confidence interval 0.1 to 0.9, p <0.05).

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Source: Alfonso, F., Sanz-Ruiz, R., Sabate, M., et al. (2022). Clinical Implications of the "Broken Line" Angiographic Pattern in Patients With Spontaneous Coronary Artery Dissection. Am J Cardiol.. 2022; 185: 1-9. Published: December 15, 2022. DOI: 10.1016/j.amjcard.2022.09.017.



Apixaban Dosing Patterns Versus Warfarin in Patients With Nonvalvular Atrial Fibrillation Receiving Dialysis

Among patients with nonvalvular AF undergoing dialysis, warfarin is associated with an increased risk of bleeding compared with apixaban.

source: Am J Kidney Dis

Summary

A Retrospective Cohort Study

[Posted 24/Nov/2022]

AUDIENCE: Nephrology, Internal Medicine

KEY FINDINGS: Among patients with nonvalvular AF undergoing dialysis, warfarin is associated with an increased risk of bleeding compared with apixaban. The risk of bleeding with below-label apixaban was not detectably less than with label-concordant dosing. Label-concordant apixaban dosing is associated with a mortality benefit compared to warfarin. Label-concordant dosing, rather than reduced-label dosing, may offer the most favorable benefit-risk trade-off for dialysis patients with nonvalvular AF.

BACKGROUND: Comparison of clinical outcomes across anticoagulation regimens using different apixaban dosing or warfarin is not well-defined in patients with nonvalvular atrial fibrillation (AF) who are receiving dialysis. This study compared these outcomes in a US national cohort of patients with kidney failure receiving maintenance dialysis.

DETAILS: Patients receiving dialysis represented in the US Renal Data System database 2013-2018 who had AF and were treated with apixaban or warfarin. Cox proportional hazards models with inverse probability of treatment weighting. Analyses simulating an intention-to-treat (ITT) approach as well as those incorporating censoring at drug switch or discontinuation (CAS) were also implemented. Inverse probability of censoring weighting was used to account for possible informative censoring. Among 17,156 individuals, there was no difference in risk of stroke/systemic embolism among the label-concordant apixaban, below-label apixaban, and warfarin treatment groups. Both label-concordant (HR, 0.67 [95% CI, 0.55-0.81]) and below-label (HR, 0.68 [95% CI, 0.55-0.84]) apixaban dosing were associated with a lower risk of major bleeding compared with warfarin in ITT analyses. Compared with label-concordant apixaban, below-label apixaban was not associated with a lower bleeding risk (HR, 1.02 [95% CI, 0.78-1.34]). In the ITT analysis of mortality, label-concordant apixaban dosing was associated with a lower risk versus warfarin (HR, 0.85 [95% CI, 0.78-0.92]) while there was no significant difference in mortality between below-label dosing of apixaban and warfarin (HR, 0.97 [95% CI, 0.89-1.05]). Overall, results were similar for the CAS analyses.

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Source: Wetmore, J. B., Weinhandl, E. D., Yan, H., et al. (2022). Apixaban Dosing Patterns Versus Warfarin in Patients With Nonvalvular Atrial Fibrillation Receiving Dialysis: A Retrospective Cohort Study. XXXXXXXX. 2022; 80(5): 561-563. Published: November, 2022. DOI: 10.1053/j.ajkd.2022.03.007.



Electrocardiographic Abnormalities In Patients With Covid-19 Pneumonia And Raised Interleukin-6

Sinus tachycardia followed by atrial fibrillation and right bundle branch block are common ECG changes in patients with COVID-19 infection with raised IL-6.

source: J Family Med Prim Care

Summary

[Posted 8/Nov/2022]

AUDIENCE: Family Medicine, Infectious Disease

KEY FINDINGS: Sinus tachycardia followed by atrial fibrillation and right bundle branch block are common ECG changes in patients with COVID-19 infection with raised IL-6. The possible association of cardiac injury in patients with COVID-19 infection with coexisting raised IL-6 levels should be explored further.

BACKGROUND: Cardiac injury is associated with high mortality in patients with COVID-19 infection. Electrocardiographic changes can give clues to the underlying cardiovascular abnormalities. Raised inflammatory markers like raised interleukin-6 (IL-6) are associated with arrhythmia, heart failure, and coronary artery disease. However, past studies have not highlighted the electrocardiographic abnormalities in patients with COVID-19 infection with raised IL- 6 levels. This study compared the electrocardiogram (ECG) changes in COVID-19 patients with high and normal IL-6 levels.

DETAILS: A retrospective analysis of ECG of 306 patients with COVID-19 infection was done, out of which 250 patients had normal IL- 6 levels, whereas 56 patients had raised IL-6 levels. IL-6 levels were measured in all the patients. Detailed clinicodemographic profile of all the serial COVID-19 patients admitted with moderate to severe COVID-19 pneumonia was noted from the hospital record section. Electrocardiographic findings and biochemical parameters of all the patients were noted. Out of 56 patients with raised IL-6 levels, 41 (73.2%) patients had ECG abnormalities compared to 177 (70.8%) patients with normal IL-6 levels. This difference was not statistically significant. However, ECG abnormality such as sinus tachycardia was significantly more common in patients with raised IL-6 levels than those with normal levels. Among patients with raised IL-6 levels who were discharged, 5 (16.6%) had sinus tachycardia, 2 (6.6%) had ST/T wave changes as compared to 15 (57.6%), and 10 (38.4%) who had tachycardia and ST/T wave change respectably succumbed to death. This difference was statistically significant.

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Source: Kaeley, N., Mahala, P., Walia, R., et al. (2022). Electrocardiographic Abnormalities In Patients With Covid-19 Pneumonia And Raised Interleukin-6. J Family Med Prim Care. 2022; 11(10): 5902-5908. Published: October, 2022. DOI: 10.4103/jfmpc.jfmpc_135_22.



Monocyte Chemoattractant Protein-1 Is Not Predictive Of Cardiac Events In Patients With Non-Low-Risk Chest Pain

MCP-1 is not predictive of 90-day MACE in patients with non-low-risk chest pain.

source: Emerg Med J.

Summary

[Posted 3/Nov/2022]

AUDIENCE: Emergency Medicine, Cardiology

KEY FINDINGS: MCP-1 is not predictive of 90-day MACE in patients with non-low-risk chest pain.

BACKGROUND: Prior studies suggest monocyte chemoattractant protein-1 (MCP-1) may be useful for risk stratifying ED patients with chest pain. We hypothesise that MCP-1 will be predictive of 90-day major adverse cardiovascular events (MACEs) in non-low-risk patients.

DETAILS: A case–control study was nested within a prospective multicentre cohort (STOP-CP), which enrolled adult patients being evaluated for acute coronary syndrome at eight US EDs from 25 January 2017 to 06 September 2018. Patients with a History, ECG, Age, and Risk factor score (HEAR score) >=4 or coronary artery disease (CAD), a non-ischaemic ECG, and non-elevated contemporary troponins at 0 and 3 hours were included. Cases were patients with 90-day MACE (all-cause death, myocardial infarction or revascularisation). Controls were patients without MACE selected with frequency matching using age, sex, race, and HEAR score or the presence of CAD. Serum MCP-1 was measured. Sensitivity and specificity were determined for cut-off points of 194 pg/mL, 200 pg/mL, 238 pg/mL and 281 pg/mL. Logistic regression adjusting for age, sex, race, and HEAR score/presence of CAD was used to determine the association between MCP-1 and 90-day MACE. A separate logistic model also included high-sensitivity troponin (hs-cTnT). Among 40 cases and 179 controls, there was no difference in age (p=0.90), sex (p=1.00), race (p=0.85), or HEAR score/presence of CAD (p=0.89). MCP-1 was similar in cases (median 191.9 pg/mL, IQR: 161.8–260.1) and controls (median 196.6 pg/mL, IQR: 163.0–261.1) (p=0.48). At a cut-off point of 194 pg/mL, MCP-1 was 50.0% (95% CI 33.8% to 66.2%) sensitive and 46.9% (95% CI 39.4% to 54.5%) specific for 90-day MACE. After adjusting for covariates, MCP-1 was not associated with 90-day MACE at any cut-off point (at 194 pg/mL, OR 0.88 (95% CI 0.43 to 1.79)). When including hs-cTnT in the model, MCP-1 was not associated with 90-day MACE at any cut-off point (at 194 pg/mL, OR 0.85 (95% CI 0.42 to 1.73)).

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Source: Ashburn, N. P., Snavely, A. C., Allen B. R., et al. (2022). Monocyte Chemoattractant Protein-1 Is Not Predictive Of Cardiac Events In Patients With Non-Low-Risk Chest Pain. Emergency Medicine Journal. 2022; 39(11): 853-858. Published: November, 2022. DOI: 10.1136/emermed-2021-211266.



Heart-Type Fatty Acid Binding Protein, Cardiovascular Outcomes, and Death

Among patients with CKD, H-FABP was associated with non-CV death and MACE, even after adjustment for hs-TNT.

source: Am J Kidney Dis

Summary

Findings From the German CKD Cohort Study

[Posted 1/Nov/2022]

AUDIENCE: Nephrology, Internal Medicine

KEY FINDINGS: In this large cohort of patients with CKD, H-FABP was associated with non-CV death and MACE, even after adjustment for hs-TNT. Whether measurement of H-FABP improves cardiovascular disease risk prediction in these patients warrants further studies.

BACKGROUND: Heart-type fatty acid binding protein (H-FABP) is a biomarker that has been shown to provide long-term prognostic information in patients with coronary artery disease independently of high-sensitivity troponin T (hs-TNT). We examined the independent associations of H-FABP with cardiovascular outcomes in patients with chronic kidney disease (CKD).

DETAILS: 4,951 patients enrolled in the German Chronic Kidney Disease (GCKD) study with an estimated glomerular filtration rate of 30-60 mL/min/1.73 m2 or overt proteinuria (urinary albumin-creatinine ratio > 300 mg/g or equivalent). Hazard ratios (HRs) for associations of H-FABP and hs-TNT with outcomes were estimated using Cox regression analyses adjusted for established risk factors. During a maximum follow-up of 6.5 years, 579 non-CV deaths, 190 CV deaths, 522 MACE, and 381 CHF hospitalizations were observed. In Cox regression analyses adjusted for established risk factors, H-FABP was associated with all 4 outcomes, albeit with lower HRs than those found for hs-TNT. After further adjustment for hs-TNT levels, H-FABP was found to be associated with non-CV death (HR, 1.57 [95% CI, 1.14-2.18]) and MACE (HR, 1.40 [95% CI, 1.02-1.92]) but with neither CV death (HR, 1.64 [95% CI, 0.90-2.99]) nor CHF hospitalizations (HR, 1.02 [95% CI, 0.70-1.49]).

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Source: Schneider, M. P., Schmid, M., Nadal, J., et al. (2022). Heart-Type Fatty Acid Binding Protein, Cardiovascular Outcomes, and Death: Findings From the German CKD Cohort Study. Am J Kidney Dis. 2022; 80(4): 483-494. Published: October, 2022. DOI: 10.1053/j.ajkd.2022.01.424.

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