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Journal Wrap
The hottest research from various peer-reviewed journals – handpicked weekly by the ACC.org Editorial Board led by Kim Eagle, MD, MACC.
New AFib Associated With High Risk of Early Events
Patients newly diagnosed with atrial fibrillation (AFib) are at a high risk of early events, particularly cardiovascular mortality, according to a study published in Circulation.
Jean-Pierre Bassand, MD, FACC, et al., assessed the risk of early events over a 12-month period after AFib diagnosis and their relation to the time after diagnosis of AFib in 52,014 patients enrolled in the GARFIELD-AF registry from March 2010 to August 2016.
Overall, 2,140 patients died during the 12-month period (mortality rate, 4.3 per 100 person-years); they tended to be older and have higher a prevalence of comorbidities compared with those who survived the first 12 months. During the first month, 288 patients (13.5 percent) died (mortality rate, 6.8 per 100 person-years).
The number of patients who died (percent of overall population) and the proportion per 100 person-years was 623 (29.1 percent) and 4.9 for months two to four; 621 (29.0 percent) for months five to eight; and 608 (29.4 percent) and 3.8 for months nine to 12.
Over 12 months, 657 patients suffered a stroke/systemic embolism (SE; 1.3 percent) and 411 had major bleeding (0.8 percent). During the first month, the rates (per 100 person-years) of stroke/SE and major bleed were 2.3 and 1.5, respectively.
The elevated all-cause mortality rate in the first month was mostly attributable to cardiovascular mortality (3.5 per 100-person years), particularly congestive heart failure (CHF), acute coronary syndrome and sudden death.
Higher rates of early death were seen across all ages, gender and comorbidities and especially those with a CHA2DS2-VASc score ≥3. The leading causes of early death were heart failure, sudden/unwitnessed death, acute coronary syndromes, infection/sepsis and respiratory failure.
Age, heart failure, prior stroke, history of cirrhosis, vascular disease, moderate-to-severe kidney disease, diabetes, and living in North or Latin America were independent predictors of a higher risk of early death, whereas anticoagulation and living in Europe or Asia were independent predictors of a lower risk of early death.
The authors write that the causality between new AFib and higher risk of death during the first month cannot be established.
"These data emphasize the importance of comprehensive care of patients with newly diagnosed AFib and should alert clinicians to detect warning signs of possible early mortality, particularly CHF," they conclude.
Bassand JP, Virdone S, Goldhaber SZ, et al. Circulation 2018;Nov 28:[Epub ahead of print].
Oral Anticoagulants, Especially Rivaroxaban, Associated With Upper GI Tract Bleeding
Among patients receiving oral anticoagulation, hospitalization for upper gastrointestinal (GI) tract bleeding was highest in patients prescribed rivaroxaban and lowest in patients prescribed apixaban, according to research published in the Journal of the American Medical Association. For all anticoagulants, the incidence of hospitalization for GI tract bleeding was lower among patients receiving proton pump inhibitor (PPI) co-therapy.
Wayne A. Ray, PhD, et al., studied 1,643,123 Medicare beneficiaries between Jan. 1, 2011 and Sept. 20, 2015. Among these patients, there were 1,713,183 new episodes of oral anticoagulant treatment included in the cohort and 1,161,989 person-years of follow-up. Cohort follow-up included 754,389 person-years of anticoagulant treatment without PPI co-therapy. For each individual oral anticoagulant, patients with PPI co-therapy had a higher prevalence of risk factors for GI bleeding.
In patients receiving anticoagulant treatment without PPI co-therapy, the adjusted incidence of hospitalization for upper GI tract bleeding (n=7,119) was 115 per 10,000 person-years. The incidence for rivaroxaban (144 per 10,000 person-years) was significantly greater than the incidence for apixaban (73 per 10,000 person-years; incidence rate ratio [IRR], 1.97; dabigatran (120 per 10,000 person-years; IRR, 1.19); and warfarin (113 per 10,000 person-years; IRR, 1.27).
For patients receiving anticoagulant treatment with PPI co-therapy, the adjusted incidence of hospitalization for upper GI tract bleeding (n=2,245; 76 per 10,000 person-years) was lower than the incidence in patients without PPI co-therapy (IRR, 0.66). With PPI co-therapy, the incidence of hospitalization for upper GI tract bleeding was significantly lower for each individual anticoagulant, with the lower incidence being most pronounced with dabigatran and least pronounced with rivaroxaban.
"Because rivaroxaban is given as a single daily dose intended to maintain 24-hour therapeutic levels, the relative peak plasma concentrations are higher than those for other oral anticoagulants," the authors write. "The steep rise of the risk of bleeding associated with increased non–vitamin K oral anticoagulant (NOAC) concentration may explain the elevated risk of hospitalization for upper GI tract bleeding."
The association of both anticoagulant choice and PPI co-therapy with the risk of hospitalization for upper GI tract bleeding varied according to patient's underlying GI risk. The authors conclude these findings may inform the assessment of risks and benefits of different anticoagulants.
Ray WA, Chung CP, Murray KT, et al. JAMA 2018;320:2221-30.
Mortality Rates High, Improvement in QOL in Surviving TMVR Patients
While mortality rates for transcatheter edge-to-edge mitral valve repair (TMVR) remain high, most surviving patients demonstrate improvements in symptoms, functional status and quality of life, according to a study published in JAMA: Cardiology.
Suzanne V. Arnold, MD, MHA, et al., analyzed patients in the Society of Thoracic Surgeons/ACC Transcatheter Valve Therapy (TVT) Registry between Nov. 2013 and March 2017. A total of 7,504 patients at 240 sites underwent edge-to-edge TMVR. Health status in these patients was markedly impaired prior to procedure. The 30-day cohort included 4,226 patients from 217 sites who survived 30 days and completed the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12) at baseline and follow-up. The KCCQ-12 assesses four domains of health status associated with valvular heart disease (physical limitation, symptom frequency, quality of life [QOL], social limitation), which are combined into an overall summary (KCCQ-OS) score. The one-year cohort included 1,124 patients from 142 sites who survived one year and completed the KCCQ instrument at both baseline and follow-up.
At baseline, the mean (SD) KCCQ-OS score was 41.9 (24.0) points, which indicates substantial impairment in health status prior to TMVR. After 30 days, scores had improved by a mean of 24.8 points to a mean (SD) score of 66.7 (24.5) points in the surviving patients. The largest improvement was observed in the quality of life domain, whereas the physical limitations domain improved the least. One year after TMVR, surviving patients continued to demonstrate substantial improvement in health status, with physical limitations remaining the lowest score.
Among the surviving patients, there were modest differences in mean one-year KCCQ-OS scores across subgroups of patients. Patients who had better health status at baseline were more likely to have better health status at 30 days after TMVR, with every 10-point increase in baseline KCCQ-OS score associated with 3.9-point higher 30-day KCCQ-OS score.
"Using these data to help inform the decision process prior to TMVR may help improve patient selection as well as patient expectations for recovery, particularly if a number of risk factors for worse health status are present in an individual patient," the authors write. "For a procedure that is currently reserved for patients who are poor candidates for valve surgery, is mainly performed to improve quality of life, and has low periprocedural risk, however, the health status outcomes of surviving patients are encouraging and support the continued use of edge-to-edge TMVR in selected patients who are poor candidates for cardiac surgery."
Arnold SV, Li Z, Vemulapalli S, et al. JAMA Cardiol 2018;Nov 21:[Epub ahead of print].
Significant Variations in Lipid Therapy: NCDR Study
Evidence-based use of lipid-lowering therapy (LLT) is low in patients with LDL-C ≥190 mg/dL, with significant practice-level variations, according to a study published in Circulation: Cardiovascular Quality and Outcomes.
Among 49,447 patients in ACC's PINNACLE Registry with LDL-C ≥190 mg/dL, about four in 10 were not receiving any statin therapy. Fewer than a third received a high-intensity statin. A 20 percent variation in use of statins and 131 percent variation in use of high-intensity statins was found for two similar patients treated at two random practices.
For each therapy, there were significant practice-level variations. Median practice-level rates after adjusting for median rate ratio were 56 percent for any statin; 30.2 percent for high-intensity statins; 31.8 percent for LLT with ≥50 percent reduction in LDL-C; 5.8 percent for ezetimibe; and 0.16 percent for PCSK9 inhibitors.
Virani SS, Kennedy KF, Akeroyd JM, et al. Circ Cardiovasc Qual Outcomes 2018;11: e004652.
NCDR Study Finds Machine Learning Could Improve AKI Risk Prediction After PCI
The use of machine learning and data-driven approaches could be more accurate at predicting acute kidney injury (AKI) in PCI patients than the current risk prediction model used in ACC's CathPCI Registry, according to a study published in PLoS Medicine.
Chenxi Huang, PhD, et al., used the original cohort – 947,091 patients – and variables that guided development of the CathPCI Registry's current AKI risk prediction model to create a series of new models with machine learning techniques and compared performance. In the original patient cohort, there were 69,826 (7.4 percent) AKI events.
In comparisons to the original model, the new model derived from machine learning reclassified 42,167 patients whose AKI risk was underestimated with the original model and 61,388 whose risk was overestimated. The researchers also validated the new models using a new cohort of 970,869 patients. Results showed that the machine learning model was more accurate than the traditional one in several variables.
According to the authors, the study demonstrates the potential of machine learning to improve risk prediction and identify patients who could benefit from strategies to minimize risk. Further research should evaluate feasibility of integrating the machine learning model into clinical care, the researchers noted.
Huang C, Murugiah K, Mahajan S, et al. PLoS One 2018;Nov 27:[Epub ahead of print].
Keywords: ACC Publications, Cardiology Magazine, Acute Coronary Syndrome, American Medical Association, Cardiac Surgical Procedures, Acute Kidney Injury, Cardiomyopathies, Diabetes Mellitus, Anticoagulants, Death, Sudden, Atrial Fibrillation, Embolism, Follow-Up Studies, Heart Failure, Heart Valve Diseases, Gastrointestinal Hemorrhage, Hospitalization, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Kidney Diseases, Liver Cirrhosis, Health Status, Lipids, Medicare, Mitral Valve, Percutaneous Coronary Intervention, Prevalence, Proton Pump Inhibitors, Comorbidity, Patient Selection, Pyrazoles, Research, Respiratory Insufficiency, Registries, Risk Assessment, Quality of Life, Risk Factors, Sepsis, Sepsis, Stroke, Pyridones, Incidence, Upper Gastrointestinal Tract, Surgeons, Warfarin
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