JACC in a Flash

Featured topics and Editors' Picks from all of ACC's JACC Journals.

Women With HFrEF Live Longer, But Not Better, Lives

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Women with heart failure with reduced ejection fraction (HFrEF) live longer than men, but their additional years of life are of poorer quality, with greater psychological and physical disability, according to research published in the Journal of the American College of Cardiology.

Pooja Dewan, MBChB, et al., analyzed 3,357 women and 12,058 men enrolled in two large HFrEF trials: PARADIGM-HF and ATMOSPHERE. The inclusion and exclusion criteria of the two trials were nearly identical. Patients were included if they were >18 years old, had NYHA functional class II-IV HF, left ventricular ejection fraction (LVEF) ≤35 percent, elevated natriuretic peptide levels and were taking an angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB), beta-blocker (unless contraindicated or not tolerated) and mineralocorticoid receptor antagonists (MRAs), if indicated.

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Primary outcomes (composite of first HF hospitalization or cardiovascular death in both trials), its components, sudden death, pump failure death, non-cardiovascular death, and all-cause death were compared in women and men.

Women comprised 21.8 percent of the cohort and tended to be older than men; 36.7 percent of women were >70 years compared with 28.1 percent of men. Aside from hypertension (70.6 percent of women vs. 65.5 percent of men) and clinically significant valvular disease (5.3 vs. 4.6 percent), women were less likely to have a history of major cardiovascular comorbid conditions such as atrial fibrillation (32.6 vs. 36.4 percent), previous myocardial infarction (30.0 vs. 45.4 percent) and stroke (7.4 vs. 8.0 percent).

Women had a lower prevalence of coronary artery disease (43 vs. 56 percent), were less likely to have an ischemic etiology (50.0 vs. 60.5 percent), had been hospitalized for HF less often than men (58.1 vs. 62.3 percent) and reported moderate to extreme depression or anxiety more often than men (44 vs. 29 percent).

Women reported more symptoms of HF than men and had significantly worse quality of life – based on Kansas City Cardiomyopathy Questionnaire scores – and greater functional impairment than men. Baseline use of beta-blockers, diuretics and MRAs was similar between men and women, while women had greater use of digitalis and ARBs and less use of ACE inhibitors.

Anticoagulation was used less often in women and they were less likely to have received a device than men: ICD (8.6 vs. 16.6 percent) and cardiac resynchronization therapy (4.1 vs. 6.9 percent). Women were also less likely to be referred to a disease management program or to be prescribed exercise.

Regarding harder endpoints, women had significantly lower mortality (hazard ratio [HR], 0.68; 95 percent confidence interval [CI], 0.62-0.74; p<0.001) and lower risk of HF hospitalization (HR, 0.80; 95 percent CI, 0.72-0.89; p<0.001), but higher rates of stroke.

According to the authors, the different sex-related experience of HFrEF is unexplained and it is uncertain whether physicians recognize it. Women continue to receive suboptimal treatment compared with men.


Dewan P, Rørth R, Jhund PS, et al. J Am Coll Cardiol 2019;73:29-40.

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Does Sleep Impact Atherosclerosis?

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People who sleep less than six hours a night may be at increased risk of atherosclerosis compared with those who sleep between seven and eight hours, according to a study published in the Journal of the American College of Cardiology.

Fernando Domínguez, MD, PhD, et al., performed seven-day actigraphic recording in 3,974 bank employees in Spain from the PESA CNIC- Santander study. They were divided into four groups by numbers of hour of sleep: less than six, six to seven, seven to eight and more than eight. The participants underwent 3D heart ultrasound and cardiac CT scans to look for cardiovascular disease.

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The study found that when traditional risk factors for cardiovascular disease were considered, participants who slept less than six hours were 27 percent more likely to have atherosclerosis throughout the body compared with those who slept seven to eight hours.

Women who slept more than eight hours per night were also at an increased risk for atherosclerosis. Those who had a poor quality of sleep, defined by how often they woke during the night and the frequency of movements during sleep, were 34 percent more likely to have atherosclerosis compared with those who had a good quality of sleep.

The researchers found that alcohol and caffeine consumption were higher in participants with short and disrupted sleep.

In an accompanying editorial comment, Daniel J. Gottlieb, MD, MPH, and Deepak L. Bhatt, MD, MPH, FACC, said further studies are needed to determine whether changing sleep behaviors will improve cardiovascular health.

"The potentially enormous impact of sleep deprivation and disruption on population health, reinforced by the present study, is ample justification for such trials, which are needed to place sleep with confidence alongside diet and exercise as a key pillar of a healthy lifestyle," they wrote.


Domínguez F, Fuster V, Fernández-Alvira JM, et al. J Am Coll Cardiol 2019;73:134-44.

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JACC Journals at ACC.19: Mark Your Calendar!

On Saturday, March 16, you're invited to the JACC reception to meet the editors-in-chief of all the JACC Journals. Joining the reception are the two newest editors-in-chief for the online, open-access JACC Journals launching this year: JACC: Case Reports and JACC: CardioOncology. It all starts at 7:30 p.m. CT, in the St. James Ballroom at the Hilton New Orleans Riverside, next to the New Orleans Convention Center.

On Monday, March 18, don't miss the Best of JACC Journals and the Eugene Braunwald Keynote (Session 411), from 12:30-1:45 p.m. Each editor-in-chief will present the best manuscripts from their journal, followed by the Keynote by Paul M. Ridker, MD, MPH, FACC, titled 100 Years from CRP to Anti-Cytokine Therapy for Atherosclerosis.

Don't forget to visit JACC.org throughout the meeting for all the ACC.19 simultaneous publications in the JACC Family of journals.

FRANCE TAVI: Predictors of Mortality After TAVR

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After successful transcatheter aortic valve replacement (TAVR), sex, chronic renal failure and atrial fibrillation (AFib) were the strongest predictors of mortality, according to research published in the Journal of the American College of Cardiology.

Although anticoagulation use was strongly linked to AFib and other comorbidities, it remained a correlate of mortality. The risk of bioprosthetic valve dysfunction (BVD) was decreased with post-TAVR anticoagulation compared with antiplatelet treatment.

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Pavel Overtchouk, MD, et al., aimed to identify independent correlates of long-term all-cause mortality and early BVD, defined as increased prosthetic gradient ≥10 mm Hg or new gradient ≥20 mm Hg. Using the FRANCE TAVI registry, they identified patients who had undergone TAVR between Jan. 1, 2013 and Dec. 31, 2015. To account for missing values, multiple imputations were performed.

The final study cohort included 11,469 patients. Survival rate was 90.4 percent at one year, 80.1 percent at two years, and 69.9 percent at three years. A total of 33.4 percent of patients were discharged on an oral anticoagulant, of whom 71 percent had AFib. Male sex, history of AFib and moderate to severe chronic renal failure were the most potent independent correlates of mortality. Neither aspirin nor clopidogrel was independently associated with mortality.

Anticoagulation at discharge and a nonfemoral approach were independently associated with lower rates of BVD, whereas chronic renal failure prosthesis size ≤23 mm was associated with a higher risk of BVD.

"The role of anticoagulation after TAVR is difficult to study in registries, considering all the potential confounding variables, and it should be used according to the current guidelines," the authors write. "Only the ongoing randomized trials will provide the best evidence for optimal antithrombotic management after TAVR."


Overtchouk P, Guedeney P, Rouanet S, et al. J Am Coll Cardiol 2019;73:13-21.

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Elevated Cardiac Troponin Associated With MAEs in Undiagnosed ACS

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Cardiac troponin (cTn) elevation is associated with adverse outcomes in patients admitted with suspected acute coronary syndrome (ACS) in whom no definite diagnosis could have been established, even in the absence of significant coronary artery disease or left ventricular (LV) dysfunction, according to a study published in the Journal of the American College of Cardiology.

In 48,872 patients from the SWEDEHEART registry in whom cTn was measured but who were discharged without a diagnosis, Kai M. Eggers, MD, PhD, et al., examined the association between cTn levels, clinical characteristics and long-term outcomes in three nested subcohorts.

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Subcohort 1 consisted of patients without previous ACS, revascularization, stroke or known heart failure. Subcohort 2 further excluded patients with significant renal dysfunction (estimated glomerular filtration rate <60 ml/min/1.73 m2. Subcohort 3 further excluded patients with an ejection fraction ≤50 percent or significant coronary artery disease ≥50 percent stenosis on angiography. Patients were stratified by cTn levels less than or equal to the assay-specific 99th percentile and separated by assay-specific cTn tertiles in case of higher levels.

In total, 9,800 (20.1 percent) patients had a cTn level above the 99th percentile. The numbers of patients with a cTn level >99th percentile in subcohorts 1, 2 and 3 were 6,952 (18.2 percent), 5,468 (17.2 percent) and 601 (30.8 percent), respectively.

The majority (94.8 percent) of patients had been admitted because of acute chest pain. The prevalence of cardiovascular risk factors and LV dysfunction increased across cTn strata, except for current smoking which decreased.

In total, 7,529 patients (15.4 percent) experienced a major adverse event (MAE) during the median follow-up period of 4.9 years. Overall, the incidence of MAE increased in stepwise fashion across strata of higher cTn levels, with survival curves diverging early (less than six months of follow-up). Results were mostly consistent between all three subcohorts and with multivariable analyses. Notably, high cTn levels in patients in subcohort 3 were associated with a 3.5-fold increase in the risk of MAE.

The authors write these findings demonstrate that cTn elevation is an important risk predictor in patients admitted with suspected but undiagnosed ACS. They note that with the implementation of high-sensitivity assays in routine diagnosis, clinicians will be more frequently confronted with patients having cTn elevation that is difficult to explain and careful work-up is required for these patients.


Eggers KM, Jernberg T, Lindahl B. J Am Coll Cardiol 2019;73:1-9

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Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), ACS and Cardiac Biomarkers, Anticoagulation Management and ACS, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging, Diet, Hypertension, Smoking, Sleep Apnea

Keywords: ACC Publications, Cardiology Magazine, Acute Coronary Syndrome, Access to Information, Angiography, Adrenergic beta-Antagonists, Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Anticoagulants, Aspirin, Atrial Fibrillation, Anxiety, Caffeine, Atherosclerosis, Cardiac Resynchronization Therapy, Cardiovascular Diseases, Cohort Studies, Chest Pain, Comorbidity, Confidence Intervals, Cardiomyopathies, Confounding Factors (Epidemiology), Constriction, Pathologic, Coronary Artery Disease, Cytokines, Death, Sudden, Depression, Diet, Coronary Stenosis, Digitalis, Follow-Up Studies, Disease Management, Diuretics, Glomerular Filtration Rate, Heart Failure, Hospitalization, Hypertension, Incidence, Kidney Failure, Chronic, Mineralocorticoid Receptor Antagonists, Myocardial Infarction, Natriuretic Peptides, Peptidyl-Dipeptidase A, Prostheses and Implants, Quality of Life, Risk Factors, Sleep Deprivation, Smoking, Stroke, Stroke Volume, Survival Rate, Registries, Tomography, X-Ray Computed, Ticlopidine, Transcatheter Aortic Valve Replacement, Troponin


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