JACC in a Flash
Featured topics and Editors' Picks from all of ACC’s JACC Journals.
Review Addresses Unmet Need For Dyslipidemia Therapy in Hypertriglyceridemia Management
Despite the important role of high-intensity statins in reducing atherosclerotic cardiovascular disease (ASCVD) events, substantial residual risk persists, according to a state-of-the-art review article published in the Journal of the American College of Cardiology.
Om P. Ganda, MD, et al., discuss how even after intensive statin therapy has been initiated and as defined by current guidelines, ASCVD risk continues and the prevalence of atherogenic dyslipidemia increases with the global epidemics of type 2 diabetes mellitus, metabolic syndrome and obesity. Read More >>>
The authors point out that prior trials with fibrates, niacin and most cholesterol ester transfer protein inhibitors that targeted raising HDL-C and/or lowering triglycerides have failed to demonstrate conclusive evidence of incremental event reduction after “optimally controlled” LDL-C levels with statins. While fibrates are effective in reducing elevated triglyceride levels, the authors note that evidence for reducing residual risk when combined with statins remains uncertain.
Furthermore, even though omega-3 fatty acids have been found to be efficacious in lowering triglyceride levels and may have pleiotropic effects such as reducing plaque instability and proinflammatory mediators of atherogenesis, the authors state that clinical outcomes data are currently lacking. Currently, several ongoing randomized trials of triglyceride-lowering strategies with optimal dosage of omega-3 fatty acids are nearing completion.
“If triglyceride reduction improves cardiovascular disease risk beyond LDL-C, the potential added benefit of omega-3 fatty acids may be considerable, especially in diabetic patients at high ASCVD residual-risk burden and frequently high triglyceride levels, in addition to elevated LDL-C,” the authors conclude.
Ganda OP, Bhatt DL, Mason RP, et al. J Am Coll Cardiol 2018;72:330-43.
Virtual Reality Transforming CV Treatment, Outcomes
Rapid advancements in the field of virtual reality are leading to new developments in cardiovascular treatment and improved outcomes for patients, according to a paper published in JACC: Basic to Translational Science. Extended reality applications in cardiac care include education and training, preprocedural planning, visualization during a procedure and rehabilitation in post-stroke patients.
Virtual reality provides complete control over the wearer’s visual and auditory experience as they interact within a completely synthetic environment, while augmented reality allows the wearer to see their native environment while placing 2D or 3D images within it. Merged reality and mixed reality allow for interaction with digital objects while preserving a sense of presence within the true physical environment. These technologies make up the full spectrum of extended reality, which is transforming the practice of cardiovascular medicine. Read More >>>
Advances in this technology allow patients and family members to better understand their cardiac conditions, helping them to make more informed decisions surrounding their medical care. Medical students and trainees can better visualize cardiac abnormalities with virtual reality, which allows trainees to simulate operating environments and multiple physicians to interact while viewing the same educational material in a natural environment. Additionally, 3D workstations may assist physicians in assessing the heart in surgical situations where it may be difficult to see.
Early research has shown that improved visualization due to virtual technology will allow physicians to learn more quickly, interpret images more accurately and accomplish interventions in less time. These improvements will most likely translate into lower cost procedures and better outcomes for patients.
“For years, virtual reality technology promised the ability for physicians to move beyond 2D screens in order to understand organ anatomy noninvasively,” writes Jennifer N.A. Silva, MD, lead author of the paper. “However, bulky equipment and low-quality virtual images hindered these developments. Led by the mobile device industry, recent hardware and software developments — such as head mounted displays and advances in display systems – have enabled new classes of 3D platforms that are transforming clinical cardiology.”
Silva JNA, Southworth M, Raptis C, Silva J. JACC Basic Trans Science 2018;3:420-30.
DOACs Associated With Reduced Risk of Intracranial Hemorrhage, All-Cause Mortality in Women
Direct oral anticoagulants (DOACs) are associated with a lower risk of intracranial hemorrhage and all-cause mortality among women with atrial fibrillation (AFib), according to a study in the Journal of the American College of Cardiology.
Researchers led by Sharon Law, MPharm, conducted a population-based cohort study to compare the effectiveness and safety of DOACs vs. warfarin in women and men with AFib, stratifying for anticoagulation control. The study’s primary outcome was the composite of ischemic stroke and systemic embolism. Secondary outcomes included intracranial hemorrhage, gastrointestinal bleeding and all-cause mortality. Read More >>>
Using data from Hong Kong’s Clinical Data Analysis and Reporting system, the researchers identified 15,292 participants, 48 percent of whom were women, who had a new AFib diagnosis between 2010 and 2015. Researchers conducted propensity scoring separately for men and women and matched DOAC users to warfarin users at a 1:1 ratio.
Among men, 152 (6.11 percent) of warfarin users and 140 (5.63 percent) of DOAC users experienced ischemic stroke and systemic embolism. In comparison, among women, ischemic stroke and systemic embolism occurred in 191 (7.9 percent) of warfarin users and 153 (6.33 percent) of DOAC users. Use of DOACs was associated with a reduced risk of intracranial hemorrhage and all-cause mortality when compared with warfarin among women only. DOAC use was associated with a lower risk of gastrointestinal bleeding for both men and women.
According to the authors, additional research is necessary to “evaluate the sex differences in the clinical outcomes of DOACs vs. warfarin based on the different mechanism of action of the drugs.”
Law SWY, Lau WCY, Wong ICK, et al. J Am Coll Cardiol 2018;72:271-82.
Lipoprotein(a) Associated with CV Disease in Some Women
Lipoprotein(a) [Lp(a)] is associated with cardiovascular disease in women with high levels of total cholesterol, according to a study published in the Journal of the American College of Cardiology.
Nancy R. Cook, ScD, et al., measured Lp(a) in three cohorts of women: the WHS (Women’s Health Study) included 24,558 women; the WHI (Women’s Health Initiative) observational study included a case-cohort sample of 1,815 cases and a subcohort of 1,989 controls; and the JUPITER trial included 2,569 women. Read More >>>
A sample of 5,161 men from JUPITER was also included in this study for the validation models. A derivation sample of 16,400 women from WHS was used to examine the association of Lp(a) with incident cardiovascular disease. This was then tested in WHS validation data (n=8,158) and the other study samples. The primary outcome of interest was incident cardiovascular disease. Models included traditional cardiovascular risk factors with and without Lp(a) to examine risk reclassification.
Among the 24,558 women in the full WHS sample, the average age was 54 years, 11 percent were current smokers and 2 percent had diabetes at baseline. Mean values of total and HDL cholesterol were 211 and 54 mg/dL, respectively. The distribution of Lp(a) was highly skewed, with a median of 10.5 mg/dL (25th, 75th percentiles: 4.4, 32.3 mg/dL). Age, proportion who were black and systolic blood pressure increased with Lp(a) level, as did total cholesterol, LDL-C, apolipoprotein B, and high-sensitivity C-reactive protein.
Use of hormone therapy was highest in those at the lowest Lp(a) level. HDL-C and apolipoprotein A1 were not associated with Lp(a). A curvilinear association was observed in WHS, with increased cardiovascular disease risk among those with Lp(a) >50 mg/dL, but only among women with total cholesterol >220 mg/dL.
In the WHS test sample, there was a small but significant change in the C statistic (0.790-0.797; p=0.035), but no improvement in measures of reclassification. This pattern was replicated among women in the WHI and JUPITER trial. In contrast, there was a strong association of Lp(a) with cardiovascular disease among men with low total cholesterol levels in JUPITER.
The authors concluded that in three cohorts of women, Lp(a) was associated with cardiovascular disease only among those with high total cholesterol and improvement in prediction was minimal. These data have implications for Lp(a) in clinical practice among women and for trials of Lp(a)-lowering agents.
Cook NR, Mora S, Ridker PM. J Am Coll Cardiol 2018;72:287-96.
Pre-Eclampsia Associated With Cardiac Dysfunction
Pre-eclampsia with severe features is associated with higher right ventricular systolic pressure (RVSP), higher rates of abnormal diastolic function, decreased global right ventricular longitudinal systolic strain (RVLSS), increased left atrial size and left ventricular (LV) wall thickness and pulmonary edema, according to research published in the Journal of the American College of Cardiology.
In this observational study, Arthur Jason Vaught, MD, et al., enrolled 63 women with pre-eclampsia with severe features and 36 pregnant control patients. Read More >>>
Women with pre-eclampsia with severe features had the following significantly different (p<0.001) echocardiographic parameters compared with pregnant control patients: higher RVSP (31.0 vs. 22.5 mm Hg); decreased global RVLSS (–19.6 vs. –23.8); higher mitral septal e’ velocity (9.6 vs. 11.6 cm/s); higher septal E/e’ ratio (10.8 vs. 7.4); larger left atrial area size (20.1 vs. 17.3 cm2); and increased posterior and septal wall thickness (median 1.0 cm vs. 0.8 cm and 1.0 cm vs. 0.8 cm, respectively).
Of the women with pre-eclampsia with severe features, eight (12.7 percent) had grade II diastolic dysfunction and six (9.5 percent) had peripartum pulmonary edema.
“Our results provide further evidence that diastolic dysfunction and LV remodeling occur during pre-eclampsia,” the authors write. “In addition, we confirm a reduction in RVLSS, likely due to a combination of intrinsic subclinical RV dysfunction and increased RV afterload, and increased pulmonary artery pressures (i.e., elevated RVSP).”
The authors add that future studies should determine the timeline for development of the abnormal echocardiographic findings associated with pre-eclampsia and whether they are associated with short- and long-term cardiovascular sequelae.
Vaught AJ, Kovell LC, Szymanski LM, et al. J Am Coll Cardiol 2018;72:1-11
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Advanced Lipid Testing, Hypertriglyceridemia, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Echocardiography/Ultrasound
Keywords: ACC Publications, Cardiology Magazine, Anticoagulants, Apolipoprotein A-I, Apolipoproteins, Atherosclerosis, Atrial Fibrillation, Blood Pressure, Brain Ischemia, Cardiovascular Diseases, Cholesterol, Cholesterol Ester Transfer Proteins, Cholesterol, HDL, C-Reactive Protein, Cohort Studies, Diabetes Mellitus, Diabetes Mellitus, Type 2, Diastole, Dyslipidemias, Echocardiography, Embolism, Fatty Acids, Omega-3, Fibric Acids, Heart Ventricles, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertriglyceridemia, Intracranial Hemorrhages, Lipoprotein(a), Metabolic Syndrome X, Niacin, Obesity, Peripartum Period, Pre-Eclampsia, Pregnancy, Prevalence, Pulmonary Artery, Pulmonary Edema, Risk Factors, Sex Characteristics, Stroke, Students, Medical, Systole, Treatment Outcome, Triglycerides, Warfarin
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