Journal Wrap

The hottest research from various peer-reviewed journals — handpicked weekly by the Editorial Board led by Kim Eagle, MD, MACC.

GATEWAY: Is Bariatric Surgery Effective For BP Control in Obese Patients?

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Bariatric surgery may be an effective strategy for blood pressure control in patients with obesity and hypertension, according to results from GATEWAY presented at AHA 2017 and published in Circulation.

Carlos Aurelio Schiavon, MD, PhD, et al., evaluated 100 patients with hypertension and a body mass index between 30.0 and 39.0 kg/m2. Patients were randomized to Roux-en-Y gastric bypass plus medical therapy or medical therapy alone.

The primary endpoint – a reduction of ≥30 percent of the total number of antihypertensive medications while maintaining systolic and diastolic blood pressure <140 mm Hg and <90 mm Hg, respectively, at 12 months – occurred in 41 of 49 patients (83.7 percent) in the gastric bypass group vs. six of 47 patients (12.8 percent) in the medical therapy alone group. Read More >>>

In a post-hoc analysis, 11 patients from the gastric bypass group and none in the medical therapy alone group were able to achieve SPRINT levels without antihypertensive drugs.

The authors caution that given the morbidity of surgery, not all patients with obesity and hypertension with similar characteristics to those included in their trial should receive bariatric surgery.

However, they conclude that “gastric bypass represents one extra option to help achieve blood pressure control with the added benefit of improving metabolic and inflammatory profile.” They add that “taken together, such effects have the potential to reduce major cardiovascular events,” but moving forward, additional trials are needed to confirm these benefits.

Schiavon CA, Bersch-Ferreira AC, Santucci EV, et al. Circulation 2017;Nov 13:[Epub ahead of print].

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STEMI ACCELERATOR-2: Intensive Regional Coordination Results in Better STEMI Care

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Emergency medical services and hospitals that coordinate emergency cardiovascular care on a regional basis may result in optimized treatment and better outcomes for STEMI patients, according to results of STEMI ACCELERATOR-2 presented at AHA 2017 and published in Circulation.

James G. Jollis, MD, FACC, et al., worked with 12 metropolitan regions to further reduce time to reperfusion and mortality in STEMI patients. Participating hospitals were enrolled in ACC’s ACTION Registry. Key program elements included pre-hospital activation of cath labs and bypassing emergency department when appropriate; pre-specified treatment protocols; measurement and feedback in regional reports; broad regional leadership; and ongoing implementation of quality improvement efforts by a dedicated regional coordinator. Read More >>>

Of 10,730 patients transported to PCI-capable hospitals, 974 received PCI in the baseline quarter and 972 in the final quarter. Symptom onset to first medical contact was 50 minutes in both quarters.

Significant increases were found in proportion of patients with first medical contact to device time of ≤90 minutes (from 67 to 74 percent) and first medical contact to cath lab activation <20 minutes (from 38 to 56 percent). In patients transported to PCI-capable hospitals, in-hospital mortality decreased from 4.4 to 2.3 percent and heart failure complications decreased from 7.4 to 5.0 percent.

“This small infrastructure added to the significant resources dedicated to cardiovascular care at the individual hospital level has the potential to expedite care and improve outcomes for acute coronary syndrome patients across entire regions,” the authors conclude.

Jollis JG, Al-Khalidi HR, Roettig ML, et al. Circulation 2017;Nov 14:[Epub ahead of print].

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Hospital Readmission Reduction Program Could Have Unintended Consequences For HF Patients

While the Hospital Readmissions Reduction Program (HRRP) may be responsible for reducing 30-day and one-year readmissions for heart failure patients, new research presented at AHA 2017 and published in JAMA Cardiology suggests the program may be unintentionally associated with increased mortality.

Study authors analyzed data from 115,245 fee-for-service Medicare beneficiaries who were hospitalized for heart failure between Jan. 1, 2006 and Dec. 31, 2014 at 416 U.S. hospitals. Risk-adjusted 30-day and one-year all-cause readmission and mortality rates were examined over three separate time intervals: 1) prior to HRRP implementation (January 2006 to March 2010); during HRRP implementation (April 2010 to September 2012); and once HRRP penalties went into effect (October 2012 to December 2014). Read More >>>

Results showed 30-day risk-adjusted readmission rates declined from 20.0 percent before the HRRP implementation to 18.4 percent in the HRRP penalties phase. However, the 30-day risk-adjusted mortality rate increased from 7.2 percent prior to HRRP implementation to 8.6 percent in the HRRP penalties phase. Study authors noted a similar pattern in one-year risk adjusted readmission and mortality rates in the same period, with a decline in the readmission rate from 57.2 percent to 56.3 percent and an increase in the mortality rate from 31.3 percent to 36.3 percent.

“The results persisted despite extensive risk adjustment with prospectively captured clinical data and consideration of hospice use,” the authors said. “These findings raise concerns that the HRRP, while achieving desired reductions in readmissions, may have incentivized hospitals in a way that has compromised the survival of patients with [heart failure].” They suggest, that if confirmed, the study’s finding “may require reconsideration of the HRRP in heart failure.”

Gupta A, Allen LA, Bhatt DL, et al. JAMA Cardiology 2017;Nov 12:[Epub ahead of print].

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REDUCE LAP-HF: Interatrial Shunt Device Effective For HF Treatment

In patients with heart failure (HF), treatment with an interatrial shunt may reduce pulmonary capillary wedge pressure during exercise, according to results from REDUCE LAP-HF presented at AHA 2017 and published in Circulation.

Sanjiv J. Shah, MD, FACC, et al., examined 44 HF patients with preserved ejection fraction ≥40 percent and exercise pulmonary capillary wedge pressure ≥25 mm Hg. Patients were randomized to receive an interatrial shunt to lower left arterial pressure or a sham procedure.

At one month, the interatrial shunt device resulted in “a greater reduction in pulmonary capillary wedge pressure” vs. the sham procedure (p = 0.028 accounting for all exercise stages). Peak pulmonary capillary wedge pressure decreased by 3.5 mm Hg in the interatrial shunt group vs. 0.5 mm Hg in the sham procedure group (p = 0.14).

The authors conclude that moving forward, “further investigation in a large-scale pivotal randomized, sham-controlled clinical trial” of the interatrial shunt in HF patients with preserved ejection fraction is warranted.

Feldman T, Mauri L, Kahwash R, et al. Circulation 2017;Nov 15:[Epub ahead of print].

PROPEL: No Benefit to GM-CSF to Improve PAD Walking Performance

In patients with peripheral artery disease (PAD), supervised treadmill exercise may improve walking performance, whereas granulocyte-macrophage colony-stimulating factor (GM-CSF) either alone or in combination with exercise showed no improvement, according to results from the PROPEL trial presented at AHA 2017 and published in the Journal of the American Medical Association.

Mary M. McDermott, MD, et al., evaluated 210 patients with PAD randomized to supervised exercise plus GM-CSF (n = 53); supervised exercise alone (n = 53); GM-CSF alone (n = 53); or attention control plus placebo (n = 51). Supervised exercise included treadmill exercise three times weekly for six months. Attention control included weekly educational lectures by clinicians for six months.

At 12-weeks, exercise plus GM-CSF “did not significantly improve 6-minute walk distance” more than exercise alone (mean difference, −6.3 m; p = 0.61) or more than GM-CSF alone (mean difference, +28.7 m; Hochberg-adjusted p = 0.052).

The authors conclude their results “confirm the benefits of exercise but do not support using GM-CSF to treat walking impairment in patients with PAD.”

McDermott MM, Ferrucci L, Tian L, et al. JAMA 2017;Nov 15:[Epub ahead of print].

ICare-ACS: Clinical Pathway Implementation Reduces Length of Stay

Implementation of a clinical pathway for assessment of patients with suspected acute coronary syndrome (ACS) may reduce the length of stay in hospital emergency departments, according to results from the ICare-ACS trial presented at AHA 2017 and published in Circulation.

Martin P. Than, MBBS, et al., assesed 31,332 patients with suspected ACS in seven hospitals in New Zealand. Clinical pathway implementation included a clinical pathway document, structured risk stratification, specified time points for electrocardiographic and serial troponin testing within three hours after arrival, and directions for combining risk stratification and electrocardiographic and troponin testing in an accelerated diagnostic protocol.

Overall, the mean six-hour discharge rate increased from 8.3 percent to 18.4 percent in patients who underwent clinical pathway implementation. Further, in patients discharged within six hours, there was no change in 30-day major adverse cardiac event rates, and no adverse events occurred when clinical pathways were correctly followed.

The authors conclude that “the implementation of hospital clinical pathways to assess patients with suspected ACS safely reduced length of stay while increasing the rate of safe discharge within six hours.” Moving forward, “this has the potential to reduce the use of hospital resources and provides rapid reassurance to many patients who presented to [emergency departments] with symptoms consistent with ACS.”

Than MP, Pickering JW, Dryden JM, et al. Circulation 2017;Nov 14:[Epub ahead of print].

Clinical Topics: Acute Coronary Syndromes, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure, Exercise, Hypertension

Keywords: ACC Publications, Cardiology Magazine, Acute Coronary Syndrome, American Medical Association, Antihypertensive Agents, Arterial Pressure, Bariatric Surgery, Blood Pressure, Body Mass Index, Clinical Protocols, Critical Pathways, Electrocardiography, Emergency Medical Services, Emergency Service, Hospital, Fee-for-Service Plans, Gastric Bypass, Granulocyte-Macrophage Colony-Stimulating Factor, Heart Failure, Hospices, Hospital Mortality, Hypertension, Leadership, Length of Stay, Macrophage Colony-Stimulating Factor, Medicare, Obesity, Patient Discharge, Patient Readmission, Peripheral Arterial Disease, Pulmonary Wedge Pressure, Quality Improvement, Registries, Risk Adjustment, Myocardial Infarction, Stroke Volume, Troponin, Walking

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