Two random clinical trials included in the review found no significant improvement in health outcomes for screening with exercise ECG in adults aged 50-75 years when compared with no screening, despite focusing on higher-risk populations with diabetes, according to Jonas, et al.

Evidence from nine cohort studies showed that adding resting ECG to traditional risk factors produced small improvements in discrimination and appropriate risk classification for prediction of multiple cardiovascular outcomes, but evidence for this finding was significantly limited by imprecision, quality, considerable heterogeneity and inconsistent use of risk thresholds used for clinical decision making.

In an accompanying JAMA editorial, Robert J. Myerburg, MD, FACC, suggests that moving forward, future research is needed on the topic of resting and exercise ECG markers of risk, for coronary atherosclerosis and other cardiovascular diseases, and for clarification of normal ECG variants in special populations, such as athletes.

In a separate editorial published in JAMA Cardiology, Joseph S. Alpert, MD, FACC, points out the USPSTF recommendations state that, “the resting or the exercise ECG test is not useful, nor should it be touted, as a screening test for predicting outcomes in asymptomatic individuals without cardiovascular disease.”

R. Sacha Bhatia, MD, MBA, and Paul Dorian, MD, MSc, note in a separate editorial comment in JAMA Internal Medicine, that “The USPSTF recommendations are consistent with guidelines from other societies, including the American College of Physicians, the American College of Preventive Medicine, and the American College of Cardiology, all of whom do not recommend ECG screening in patients at low risk for cardiovascular disease. The Choosing Wisely campaign also has recommendations against screening ECGs in asymptomatic patients at low risk for cardiovascular disease.”

US Preventive Services Task Force. JAMA 2018;319:2308-14.
Jonas DE, Reddy S, Middleton JC. JAMA 2018;319:2315-28.

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The most frequent symptom at presentation was chest pain (86.6 percent of patients), followed by dyspnea (19.2 percent). Prodromal symptoms were present in 80.5 percent of patients. Up to 7.2 percent of patients were observed to have an associated autoimmune disorder. Eosinophilic granulomatosis with polyangiitis and mixed connective tissue disease were the most frequently observed autoimmune or systemic inflammatory disorders. Acute myocarditis occurred more frequently in men (about 80 percent), although women more frequently had complicated acute myocarditis and were therefore at higher risk of complications.

At presentation, 26.6 percent (n=118) of patients had either a left ventricular ejection fraction (LVEF) <50 percent, sustained ventricular arrhythmias or a low cardiac output syndrome, whereas 73.4 percent (n=325) did not. EMB was performed in 12.6 percent (n=56) and a baseline cardiac MR was performed in 93.7 percent (n=415). Cardiac mortality plus heart transplant at one and five years was 3.0 percent and 4.1 percent, respectively. In patients with a complicated presentation, the rate of cardiac mortality plus heart transplant at one and five years was 11.3 percent and 14.7 percent, and it was 0 percent in those with an uncomplicated presentation (log-rank p<0.0001).

Major acute myocarditis-related cardiac events after the acute phase (postdischarge death and heart transplant, sustained ventricular arrhythmia treated with electrical shock or ablation, symptomatic heart failure needing device implantation) occurred in 2.8 percent at five years; this incidence was higher in patients with complicated acute myocarditis (10.8 vs. 0 percent in uncomplicated; log-rank p<0.0001).

The most frequently used medication was beta-adrenoceptor blockers, in both complicated (61.9 percent) and uncomplicated forms (53.8 percent; p=0.18) of acute myocarditis. After a median 196 days, 200 patients had follow-up cardiac MR. Further, eight patients (14.5 percent) who had a complicated presentation had an LVEF <50 percent at this time point, compared with one (0.7 percent) patient without a complicated presentation.

The authors conclude that overall serious adverse events after acute myocarditis were lower than previously reported. However, patients with LVEF <50 percent, ventricular arrhythmias or low cardiac output at presentation were at higher risk compared with uncomplicated cases that had a benign prognosis and low risk of subsequent LV systolic dysfunction.

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Results showed significant changes in the use of evidence-based strategies over the two-year study period, with the mean number of strategies used per hospital increasing from 2.4 at baseline to 3.9 at 24 months. Innovative approaches for integrating pharmacotherapy and pharmacy practice expertise included information technology solutions, targeted rounding for AMI patients, medication-bridging programs and AMI patient education.

Furthermore, the authors found that the inclusion of pharmacists strengthened relationships across disciplines and allowed them to become routinely embedded in broader quality efforts. The empowerment of pharmacists to solve problems also allowed for local innovation in the implementation of evidence-based strategies, tailoring solutions to fit the hospital context.

“Although previously published evidence about the impact of pharmacist involvement on a variety of clinical outcomes is mixed, several recent systematic reviews suggest that pharmacist expertise positively influences cardiac process-of-care measures and outcomes such as readmissions,” the authors write. “This study’s findings extend the published literature by describing an intervention that successfully engaged pharmacists as part of quality-improvement guiding coalitions.”

Curry LA, Brault MA, Cherlin E, Smith M. Am J Health Syst Pharm 2018;75:e342-52

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Results showed that cardiovascular events occurred in 288 participants: 96 events in the group assigned to a Mediterranean diet supplemented with extra-virgin olive oil (3.8 percent); 83 events in the group assigned to a Mediterranean diet supplemented with mixed nuts (3.4 percent); and 109 events in the control group (4.4 percent). Adjusting for baseline characteristics and propensity scores in all the participants, the hazard ratio was 0.69 for a Mediterranean diet with extra-virgin olive oil and 0.72 for a Mediterranean diet with nuts, both compared with the control diet.

The authors note that their analysis, which incorporated information about adherence to the diets, suggests that the difference in rate of cardiovascular events between those assigned to the Mediterranean diets and those assigned the control diet was greater among participants with better adherence. The authors add that they had previously reported results for the primary endpoint in 2013 in the New England Journal of Medicine, but they “have withdrawn our previously published report and now report revised effect estimates based on analyses that do not rely exclusively on the assumption that all the participants were randomly assigned.”

“In [previous] observational cohort studies and a secondary prevention trial, increasing adherence to the Mediterranean diet has been consistently associated with lower cardiovascular risk,” the authors conclude. “Our findings support a beneficial effect of the Mediterranean diet for the primary prevention of cardiovascular disease.”

Estruch R, Ros E, Salas-Salvadó J, et al. N Engl J Med 2018; June 13:[Epub ahead of print]

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