Research presented in the new Clinical and Investigative Horizons Session at ACC.23/WCC provides new insights on the risk for Black women carrying the amyloidogenic V122I transthyretin (TTR) gene mutation, managing patients with high-risk pulmonary embolism (PE), and using remote monitoring (RM) to reduce the carbon footprint from cardiovascular care. 

An analysis from the Women’s Health Initiative conducted by Bernhard Haring, MD, MPH, et al., examined the relationship between being a carrier of the V122I TTR gene mutation, one of the most common mutations of hereditary TTR cardiac amyloidosis, and cardiovascular disease and mortality. At enrollment, women were generally healthy and postmenopausal. Cases of cardiovascular disease were self-reported through an annual mailed health update and centrally adjudicated by trained physicians.

In the study population of 9,862 non-Hispanic Black/African American women (mean age 61 years), 3.4% (n=333) were carriers of the TTR mutation.

The primary composite endpoint of cardiovascular disease comprised coronary heart disease, stroke, acute heart failure, cardiovascular death and all-cause mortality. Over the mean 16.1 years of follow-up, new cardiovascular disease was reported in 2,229 noncarriers and 96 carriers, and 2,689 noncarriers and 108 carriers died.

After adjusting for demographic, lifestyle and medical history covariates using Cox proportional hazards models, researchers found that carriers of the mutation were at higher risk of the primary endpoint: hazard ratio, 1.52, 95% CI, 1.22-1.88.

Carriers were also at higher risk for the components of the composite endpoint. The hazard ratio was 2.21 for acute heart failure, 1.80 for coronary heart disease, 1.70 for cardiovascular death and 1.28 for all-cause mortality. Looking at the effects of age, blood pressure, heart rate, body mass index and physical activity, researchers found a significant interaction only with age.

Given their findings, the study authors concluded that the carrier status in African-American women may not be as benign as previously thought and recommend that, “African-American women with clinical suspicion of amyloidosis should be screened for TTR V1221 (pV1421) carrier status to ensure early treatment onset.” The study was simultaneously published in JACC: Heart Failure.

The FLAME study, presented by Mitchell J. Silver, DO, FACC, was a prospective, multicenter, parallel group, observational evaluation of outcomes in patients with high-risk PE treated with mechanical thrombectomy using the FlowTriever.

A total of 115 patients from 11 sites across the U.S. were included, with 53 in the FlowTriever arm and 61 in the context arm that consisted of other non-FlowTriever therapies as primary treatment. They were followed through discharge or 45 days. The trial was terminated early after meeting the prespecified interim analysis criterion of 50 patients treated with FlowTriever.

The primary endpoint of in-hospital composite events, defined as all-cause mortality, bailout to alternate thrombus removal strategy, clinical deterioration and major bleeding, occurred in 17.0% of the FlowTriever arm and 63.9% of the context arm. The rate of the primary endpoint in the FlowTriever arm was significantly lower than a performance goal of 32% that was established from a published meta-analysis by the study investigators.

Looking at the individual outcomes in the FlowTriever and context arms, respectively, in-hospital mortality was 1.9% and 29.5%; bailout was 3.8% and 26.2%; clinical deterioration was 15.1% and 21.3%; and major bleeding was 11.3% and 24.6%.

In what the investigators say is the largest interventional trial in patients with high-risk PE, they concluded that large-bore mechanical thrombectomy with the FlowTriever was associated with a significantly lower occurrence of meaningful in-hospital adverse clinical outcomes and a low rate of mortality. They noted that a care pathway similar with STEMI and stroke may benefit these patients.

Danish Bawa, MD, et al., conducted an observational study as part of the Global Cardiovascular Carbon Footprint Project to explore whether using RM rather than conventional monitoring for patients with cardiac implantable electronic devices (CIED) reduced costs and greenhouse gas (GHG) emissions and the relevance to the impact on the carbon footprint.

Based on data from 32,811 patient records from 67 device clinics across the U.S., and calculations on distance to a device monitoring clinic over two years, the researchers found that RM saved 31.7 million travel miles, equating to $3.45 million in savings and a reduction of 12,518 metric tons of GHG from gasoline.

Additional carbon footprint impacts included a reduction of 14.2 million pages of print outs, leading to $3 million in savings along with a 78 ton reduction of GHG, and an additional $3.7 million in savings resulting from improvement in workforce efficiency. The net savings was $10.15 million and 12,596 tons of GHG emissions.

“Numerous studies have demonstrated that RM of CIED is less resource intense, efficient and cost-effective, improved patient compliance and care, and reduces the number of planned as well as unplanned clinic visit as compared to conventional monitoring,” the study authors stated. They add that their findings show RM can also lead to significant reductions in the carbon footprint of cardiovascular care. The study was simultaneously published in JACC: Advances.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging

Keywords: ACC Annual Scientific Session, ACC23, Arrhythmias, Cardiac, Secondary Prevention, Angiography, Anticoagulants, Monitoring, Physiologic, Cardiovascular System, Carbon Footprint, Point-of-Care Systems, Thrombectomy, Pulmonary Embolism, Troponin I, Pre-Eclampsia, ACC.23/WCC Meeting Newspaper, ACC Scientific Session Newspaper

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