Left side: Heart with well-developed coronary collateral circulation and, therefore, much smaller area at risk compared with the heart on the right side with poorly developed collaterals. (Illustration by Anne Wadmore, Medical Illustrations Ltd, UK).
Hitherto, 12 studies have investigated the effect of collaterals on survival, the first in 1971,
Acute chest pain is a common cause of attendance at emergency departments and of emergency admission. Some patients have coronary artery disease or some other life-threatening condition, but many do not. Some have other conditions, but not all have an identifiable cause. There is an increasing drive to avoid unnecessary admission to hospital and to reduce length of stay when admission does occur, and new ways to do so are constantly being looked for. Simple clinical assessment in the patient with acute chest pain permits estimation of the likelihood of coronary disease but is not sufficiently sensitive to use in isolation for exclusion of an acute coronary syndrome
The National Institute of Clinical Excellence (NICE), in August 2010, published the Transient Loss of Consciousness guideline
To determine the cost-effectiveness of transcatheter aortic valve implantation (TAVI) compared with surgical aortic valve replacement (SAVR) in a high-risk aortic stenosis (AS) population.
A cost-utility analysis employing the National Institute of Clinical Excellence (NICE) reference case design for technology appraisals.
The perspective of the UK National Health Service.
Utility data from a UK high-risk AS population. TAVI and SAVR effectiveness was taken from the PARTNER A randomised controlled trial.
Costs modelled over a 10 year horizon using a Markov model. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curve were calculated with reference to the NICE willingness to pay per quality adjusted life year (QALY) gain threshold. Deterministic and probabilistic sensitivity analyses performed.
Despite greater procedural costs (£16 500 vs £9,256), TAVI was cost-effective compared with SAVR over the 10 year model horizon (costs £52 593 vs £53 943 and QALYs 2.81 vs 2.75), indicating that TAVI dominated SAVR. This appeared to be due to greater postsurgical costs, related to the length and cost of hospital stay. The results appeared robust to a number of deterministic sensitivity and probabilistic analyses. The cost-effectiveness acceptability curve indicated that at the NICE £20 000 willingness to pay threshold per QALY gained, TAVI had a 64.6% likelihood of being cost-effective, compared with 35.4% for SAVR.
TAVI is likely to be a cost-effective treatment for high-risk patients with AS compared with the reference standard of SAVR. However, uncertainty surrounding the long-term outcomes for TAVI patients remains; this could have a substantive impact on estimates of cost-effectiveness.
Discrepancy in the echocardiographic severity grading of aortic stenosis (AS) based on current guidelines has been reported. We sought to investigate the left ventricular outflow tract diameter (LVOTd) as a source of inconsistencies, and to explore hypothetical alternatives for discrepancy improvement.
Retrospective echocardiographic cross-sectional analysis.
From 2000 to 2010, we identified all AS patients with left ventricular EF ≥50%, mean gradient (MG) ≥20 mm Hg, aortic valve area (AVA) ≤2.5 cm2, <moderate (2+) aortic regurgitation; and divided them into three groups: patients with ‘small ’ LVOTd 1.7–1.9 cm, ‘average’ LVOTd 2.0–2.2 cm and ‘large’ LVOTd ≥2.3 cm. In each group, inconsistency of data for classification of severity of AS was assessed and alternative thresholds explored.
Of 9488 total patients, 58% were men, LVOTd 2.18±0.19 cm, peak velocity (Vmax) 3.9±0.8 m/s, MG 37±16 mm Hg, and AVA 1.09±0.34 cm2. Small LVOTd patients were older women (91%) with worse systemic haemodynamics and more prevalent paradoxical low-flow, compared with average and large LVOTd patients (all parameters p <0.001). Despite clinically similar MG and Vmax across all groups, mean AVA ranged from 0.88 to 1.25 cm2 (p <0.001), classifying small LVOTd patients as severe, average LVOTd as moderate-severe and large LVOTd as moderate. For patients with large, average and small LVOTd, an AVA of 1 cm2 corresponded to MG of 42, 35 and 29 mm Hg, Vmax of 4.1, 3.8 and 3.5 m/s and dimensionless index (DI) of 0.22, 0.29 and 0.36, respectively. An AVA cut-off of 0.8 cm2 reduced severe AS inconsistency from 48% to 26% for small LVOTd patients. An AVA cut-off of 0.9 cm2 reduced severe AS inconsistency from 37% to 26% for average LVOTd patients. The current AVA cut-off of 1 cm2 was consistent for large LVOTd patients.
The LVOTd is associated with significant inconsistencies in AS assessment by current guidelines. For patients with normal EF and normal flow, current guideline definition of severe AS is most consistent for patients with large LVOTd, but not so for patients with average or small LVOTd in whom lower AVA cut-offs should be further studied. The DI cut-off for severe AS is highly variable depending on the LVOTd and guideline revision of this threshold should be considered.
Aortic stenosis (AS) leads to diffuse fibrosis in the myocardium, which is linked to adverse outcome. Myocardial T1 values change with tissue composition.
To test the hypothesis that our recently developed non-contrast cardiac magnetic resonance (CMR) T1 mapping sequence could identify myocardial fibrosis without contrast agent.
A prospective CMR non-contrast T1 mapping study of 109 patients with moderate and severe AS and 33 age- and gender-matched controls.
CMR at 1.5 T, including non-contrast T1 mapping using a shortened modified Look–Locker inversion recovery sequence, was carried out. Biopsy samples for histological assessment of collagen volume fraction (CVF%) were obtained in 19 patients undergoing aortic valve replacement.
There was a significant correlation between T1 values and CVF% (r=0.65, p=0.002). Mean T1 values were significantly longer in all groups with severe AS (972±33 ms in severe asymptomatic, 1014±38 ms in severe symptomatic) than in normal controls (944±16 ms) (p<0.05). The strongest associations with T1 values were for aortic valve area (r=–0.40, p=0.001) and left ventricular mass index (LVMI) (r=0.36, p=0.008), and these were the only independent predictors on multivariate analysis.
Non-contrast T1 values are increased in patients with severe AS and further increase in symptomatic compared with asymptomatic patients. T1 values lengthened with greater LVMI and correlated with the degree of biopsy-quantified fibrosis. This may provide a useful clinical assessment of diffuse myocardial fibrosis in the future.
The aim of this nationwide case–control study was to identify and characterise symptoms before sudden death of young persons who had died due to coronary artery disease (CAD).
We have previously investigated the incidence of sudden cardiac death (SCD) in young Danish people aged 1–35 years in Denmark during 2000–2006. We included all deaths (n=6629) and identified 314 autopsied cases of SCD, 40 of whom (13%) died from CAD. To compare symptoms before death, the CAD case group was sex- and age-matched 1:2 with a control group randomly sampled from a population of 1497 individuals who had died in accidents. We used data from the National Patient Registry on previous contacts with the healthcare system for all persons and read all available patient records, including death certificates and autopsy reports.
A total of 31 (79%) persons with CAD-SCD had cardiac symptoms such as angina pectoris (n=24, 62%) and dyspnoea during the 12 months before death, and this was significantly higher than in the control group (p<0.001). In the case group, 18 persons (46%) had contacts with the healthcare system for cardiac symptoms before death, and this was also significantly higher than the control group (p<0.001).
In this nationwide study we found that 62% of young persons with SCD experienced angina before death, and nearly half of them who died of CAD had sought medical attention within the last year before death.
To explore whether increased adipocyte-derived serum fatty acid binding protein 4 (FABP4) predisposes to cardiac remodelling and left ventricular dysfunction in human obesity.
Cross-sectional investigation.
Academic clinical research centre.
108 overweight and obese non-diabetic women (body-mass index 33±5 kg/m²).
None.
Relationship between serum FABP4 and abdominal adipose tissue quantified by MRI. Relationship between serum FABP4 and left ventricular morphology and function assessed by cardiac MRI.
FABP4 was independently associated with visceral abdominal adipose tissue (β=0.34, p<0.01) and subcutaneous abdominal adipose tissue (β=0.22, p<0.05). After stratification into serum FABP4 tertiles, left ventricular masses were 92±16 g, 86±13 g and 81±12 g in women with high, intermediate and low FABP4 concentrations (p<0.01), respectively. Longitudinal systolic function was reduced by 8% in women with intermediate and high versus low FABP4 concentrations (p<0.01), whereas ejection fraction did not differ among tertiles (p=0.5). In multivariate linear analysis FABP4 remained an independent predictor of left ventricular mass (β=0.17, p<0.05) and reduced longitudinal fractional shortening (β=0.21, p<0.05).
In overweight and obese women, FABP4 showed an independent association with parameters of left ventricular remodelling.
The brain derived neurotrophic factor (BDNF) locus has been implicated in psychiatric and substance related disorders. Recent genome-wide association studies (GWAS) have shown strong associations between single nucleotide polymorphisms in BDNF, smoking behaviour and high body mass index (BMI). Our aim was to test whether genetic BDNF variation alters the risk of smoking related morbidity and mortality.
Cox proportional hazards models were used to relate the BDNF rs4923461(A/G) polymorphisms to all-cause, cancer and cardiovascular mortality and cardiovascular disease (CVD) incidence adjusted for age, sex, BMI, and smoking quantity.
The Malmö Diet and Cancer Study (MDCS), a population based prospective cohort study (n=30 447).
We obtained complete data on 25 071 subjects, of whom 6507 were current smokers and 18 564 were non-smokers who underwent a baseline examination from 1991–1996.
During a mean follow-up time of 12 years, 1049 deaths (346 cardiovascular deaths and 492 cancer deaths) and 802 incident CVD events occurred among current smokers.
The major allele (A) of rs4923461 was significantly associated with ever having smoked (p=0.03) and high BMI (p=0.001). The A-allele was associated with risk of all-cause (HR=1.12, 95% CI 1.00 to 1.25; p<0.05) and CVD (HR=1.23, 95% CI 1.01 to 1.49; p=0.04) mortality. There was no significant association between the rs4923461 and cancer mortality or CVD incidence.
Our data suggest that smoking- and obesity-associated variation of the BDNF gene affects the risk of death, especially due to cardiovascular causes, in smokers. Determination of the BDNF genotype in smokers may guide the need for smoking cessation interventions.
To examine the incidence, mortality and case fatality of acute coronary syndrome (ACS) in Finland during 1993–2007 and to create forecasts of the absolute numbers of ACS cases in the future, taking into account the aging of the population.
Community surveillance study and modelled forecasts of the future.
Two sets of population-based coronary event register data from Finland (FINAMI and the National Cardiovascular Disease Register (CVDR)). Bayesian age–period–cohort (APC) modelling.
24 905 observed ACS events in the FINAMI register and 364 137 in CVDR.
Observed trends of ACS events during 1993–2007, forecasted numbers of ACS cases, and the prevalence of ACS survivors until the year 2050.
In the FINAMI register, the average annual declines in age-standardised incidence of ACS were 1.6% (p<0.001) in men and 1.8% (p<0.001) in women. For 28-day case fatality of incident ACS, the average annual declines were 4.1% (p<0.001) in men and 6.7% (p<0.001) in women. Findings in the country-wide CVDR data were consistent with the FINAMI register. The APC model, based on the CVDR data, suggested that both the absolute numbers of ACS events and the prevalence of ACS survivors reached their peak in Finland around 1990, have declined since then, and very likely will continue to decline until 2050.
The ACS event rates and absolute numbers of cases have declined steeply in Finland. The declining trends are likely to continue in the future despite the aging of the population.
More recently, the remit of transcatheter heart valve (THV) technology has been expanded beyond that initially conceived: patients at lower surgical risk are being treated despite a lack of evidence in this patient populationw1; and novel implantation techniques, such as the transaortic approach, have been developed.w2 Perhaps the most notable adaptation of this technology is the treatment of patients with failing surgical bioprosthetic valves. In 2007, Wenaweser and colleagues reported the implantation of a Medtronic CoreValve (Medtronic CV, Luxembourg S.a.r.l.) into a degenerated surgical aortic bioprosthesis.
The authors also comment that ‘it may be that Melbourne CR programmes are really that good’.
In a well-designed study, Namtvedt et al
Our study had a rather extensive protocol starting with a screening questionnaire for sleep apnoea being mailed to 30 000 randomly selected individuals. The FMD...]]>
Coronary angiography revealed two-vessel spontaneous coronary artery dissection (SCAD) involving the right coronary artery extending into the postero-lateral artery (
Reveals a dissection within the right coronary artery extending into the postero-lateral artery.
Reveals a dissection within the proximal segment of the first diagonal branch of the left anterior descending artery.
SCAD is a rare cause of an acute coronary syndrome. It is more common in females between the ages of 30 and 50 years, and hypertensive...]]>
G Foldes, M Mioulane, M N Chahine et al. Human induced pluripotent stem cell-derived cardiomyocytes serve as in vitro model of cardiac hypertrophy. Heart;2011:97.e7. The authors have requested that their abstract is retracted.
]]>Sinus of Valsalva aneurysm (SVA) is rare (0.15%–1.5% of cardiopulmonary bypass cases) and usually presents acutely following rupture. Unruptured SVA is usually asymptomatic, but can lead to symptoms secondary to compression of adjacent cardiac structures. Ruptured SVA can lead to aortocardiac shunts and heart failure. About 65%–85% of SVAs originate from the right sinus, 10%–30% from non-coronary sinus and less than 5% from left sinus. SVA is often congenital. Causes of acquired SVA include atherosclerosis, infection and trauma. SVA is associated with increased morbidity and mortality and should be corrected by surgery or percutaneous device closure.
A 79-year-old man was referred to the cardiology clinic with 6 months history of progressive breathlessness. On examination, he had an early diastolic murmur in the aortic area and signs of right heart failure. Transthoracic echo showed severe aortic regurgitation and a very large unruptured SVA, arising from the right coronary sinus and...]]>