The Author’s reply: We have read with interest the response letter to our paper ‘Outcomes in patients with moderate and asymptomatic severe aortic stenosis followed up in heart valve clinics’. The answers to the remarks of the author are perfectly summarised in the excellent editorial ‘Added value of heart valve clinics in the management of asymptomatic aortic stenosis’. The editorial underlines the gap between guidelinesrecommended intervention in valvular heart disease (VHD) and the realworld situation. This is certainly also the case for aortic valve stenosis (AS) and besides education, the organisation of ambulatory care of patients with AS in heart valve clinics (HVCs) offers a possibility for the optimisation of care. In our paper, we have shown for the first time how the approach in a dedicated HVC results in a better outcome compared with usual care. Improved followup with earlier recognition of symptoms and referral to surgery is the reason for these results. This was achieved by a higher number of consultations per year, longer average consultation time, more frequent use of exercise testing, biomarker use and CT. It is not surprising that the benefit was most important in the group with moderate AS. Besides the fact that we know that these patients are also at high risk of a bad outcome, the attention given to these patients (intended or not) in the usual care situation is less than when the treating cardiologist is alerted by aortic valve velocities >4 m/s, mean gradients >40 mm Hg and aortic valve areas <1 cm2. We agree that inequity in the management of patients with VHD/AS should be avoided and we should try to organise the care of these patients so that all patients are treated following the recommendations. The difficulty is the availability of material and human resources for a growing population of patients with AS. As for heart failure clinics, nurses specialised and trained for the followup of patients with AS could be part of the solution to this problem.
One of the challenges in prevention of stroke is identification of patients at risk of atrial fibrillation (AF) shortly before the onset of the arrhythmia so that prevention therapies can be promptly instituted. In this issue of Heart, Nadarajah and colleagues report the development and validation of an algorithm based on data from the UK Clinical Practice Research Datalink GOLD dataset that included 2 081 139 individuals of whom 7386 developed AF within 6 months. This new algorithm-Future Innovations in Novel Detection of Atrial Fibrillation (FINDAF) – identified a highrisk cohort with a 20fold higher 6 month incident of AF with a superior discrimination performance compared with other commonly used risk scores (figure 1). The 10 most important variables in the FINDAF score are age, ethnicity, heart failure, nonAF electrophysiology procedures, rhematic mitral stenosis, other mitral valve disease, chronic obstructive pulmonary disease, sex, gout and chronic ischaemic heart disease. In the accompanying editorial, Diederichsen and Swennbert comment that “The population studied was quite young and healthy at an average age of 50 years, and a low proportion developed AF (0.4%). Still, the model classified approximately 20% of individuals as high risk, with the risk of AF in those being 20fold higher compared with individuals classified as low risk.” The advantage of the FINDAF score is that is can be calculated automatically based on electronic health record data, not requiring biomarkers or imaging studies. Even so “screening and AF detection are not helpful themselves. Studies powered to investigate clinical outcomes downstream from screening are critically needed to reduce the risk of negative outcomes in undetected AF, but studies such as this help FIND a path forward.” Although opioids are though to reduce breathlessness in patients with heart failure (HF), a systemic review and metaanalysis of by Gaertner and colleagues of 7 randomised controlled trials with a total of 271 participants found no significant benefit of opioid therapy for symptom reduction (figure 2). Opioids also were associated with a higher risk of adverse effects including nausea, vomiting and constipation but not with more serious side effects such as respiratory depression or haemodynamic instability. Schlenker and Steiner put this study into a palliative care perspective. They comment that “we praise Gaertner and colleagues in their effort to clarify the role of opioids for dyspnoea management in heart failure. We agree that opioids may not be effective and may pose harm for some patients.” Even so, in endstage HF, “The experience of breathlessness can be terrifying for patients and is a major contributor to psychological distress in this population. Opioids are therefore a standard part of dyspnoea management at the end of life in an attempt to decrease the experience of air hunger.”
To the Editor No evaluation of cardiovascular disease and mortality sequelae of COVID19 would be complete without documentation of the increase in the prevalence of mechanical complications (MCs) of myocardial infarction (MI) attributable to delay in seeking or obtaining timely reperfusion treatment for ST elevation myocardial infarction (STEMI). This delay was associated with a resurgence of STEMIrelated MCs, namely, ventricularfree wall rupture, acute papillary muscle rupture with mitral regurgitation and ventricular septal rupture, which had hitherto undergone a significant decrease in prevalence. In Taiwan, Lin et al noted that among 1523 adult cardiac operations performed in two hospitals over a period of 5 years (January 2015 to December 2019), only 0.3% (95% CI 0.1% to 0.5%) of the patients were diagnosed with MCs of MI. However, within the first 5 months of 2020 (the COVID19 pandemic era), MIrelated MCs underwent an increase in prevalence amounting to 4.2% of 118 cardiac operations. In France, Bouisset et al studied the impact of delay in seeking medical attention (the socalled prehospital delay) on the prevalence of MCs of STEMI. Data on 6185 patients were evaluated in an analysis that covered two time periods, namely, 1 March 2019 to 31 May 2019 and 1 March 2020 to 31 May 2020. In that analysis, patients were allocated to four groups according to prehospital delay, as follows: 0–12 hours, 12–24 hours, 24–36 hours and 36–48 hours. In the four subgroups, global rates of MCs were 0.82%, 1.43%, 1.24% and 5.07%, respectively. The global rate of MC significantly (p<0.001) increased with prehospital delay. Lin et al attributed the prehospital delay to fear of contracting COVID19 infection. This was a fear also expressed by a number of patients in a narrative review of the association of COVID19 and STEMIrelated ventricular septal rupture.
Advances in breast cancer (BC) treatment have contributed to improved survival, but BC survivors experience significant short-term and long-term cardiovascular mortality and morbidity, including an elevated risk of heart failure with preserved ejection fraction (HFpEF). Most research has focused on HF with reduced ejection fraction (HFrEF) after BC; however, recent studies suggest HFpEF is the more prevalent subtype after BC and is associated with substantial health burden. The increased HFpEF risk observed in BC survivors may be explained by treatment-related toxicity and by shared risk factors that heighten risk for both BC and HFpEF. Beyond risk factors with physiological impacts that drive HFpEF risk, such as hypertension and obesity, social determinants of health (SDOH) likely contribute to HFpEF risk after BC, impacting diagnosis, management and prognosis.Increasing clinical awareness of HFpEF after BC and screening for cardiovascular (CV) risk factors, in particular hypertension, may be beneficial in this high-risk population. When BC survivors develop HFpEF, treatment focuses on initiating guideline-directed medical therapy and addressing underlying comorbidities with pharmacotherapy or behavioural intervention. HFpEF in BC survivors is understudied. Future directions should focus on improving HFpEF prevention and treatment by building a deeper understanding of HFpEF aetiology and elucidating contributing risk factors and their pathogenesis in HFpEF in BC survivors, in particular the association with different BC treatment modalities, including radiation therapy, chemotherapy, biological therapy and endocrine therapy, for example, aromatase inhibitors. In addition, characterising how SDOH intersect with these therapies is of paramount importance to develop future prevention and management strategies.
Use of CT coronary angiography (CTCA) to evaluate chest pain has rapidly increased over the recent years. While its utility in the diagnosis of coronary artery disease in stable chest pain syndromes is clear and is strongly endorsed by international guidelines, the role of CTCA in the acute setting is less certain. In the low-risk setting, CTCA has been shown to be accurate, safe and efficient but inherent low rates of adverse events in this population and the advent of high-sensitivity troponin testing have left little room for CTCA to show any short-term clinical benefit. In higher-risk populations, CTCA has potential to fulfil a gatekeeper role to invasive angiography. The high negative predictive value of CTCA is maintained while also identifying non-obstructive coronary disease and alternative diagnoses in the substantial group of patients presenting with chest pain who do not have type 1 myocardial infarction. For those with obstructive coronary disease, CTCA provides accurate assessment of stenosis severity, characterisation of high-risk plaque and findings associated with perivascular inflammation. This may allow more appropriate selection of patients to proceed to invasive management with no disadvantage in outcomes and can provide a more comprehensive risk stratification to guide both acute and long-term management than routine invasive angiography.
GREAT STRIDES have been made in the surgery of congenital heart disease during the past 20 years. The progress that dates from the first ligation of a patent ductus arteriosus in 1938, and culminates in the successful use of the pump-oxygenator technic in open-heart surgery, has made approximately 85 per cent of the defects in patients over 2 years of age potentially correctible today. The advent of these technics, and the understandable enthusiasm of cardiac surgeons for them, places a particular responsibility on the cardiologist. Indication for and optimal timing of corrective surgery may be very difficult to determine in the individual case. In the lesions grouped under the heading of "left-to-right shunts," which includes atrial and ventricular defects as well as patent ductus arteriosus, the question of operative indication is tied closely to the problem of pulmonary hypertension. When surgery on patent ductus arteriosus was first begun, it became obvious that patients with significant elevation of the pulmonary arterial pressure did not tolerate division of the ductus as well as those without pulmonary arterial hypertension. The same observations were made in regard to correction of atrial defects and more recently in regard to ventricular defects. These experiences led to closer examination
Inappropriate behaviour is an umbrella term including discrimination, harassment and bullying. This includes both actions and language and can affect any member of the cardiovascular workforce/team. Evidence has suggested that such behaviour is regularly experienced within UK cardiology departments, where inappropriate behaviour may represent longstanding cultural and practice issues within the unit. Inappropriate behaviour has negative effects on the workforce community as a whole, including impacts on recruitment and retention of staff and patient care. While only some members of the cardiology team may be directly impacted by inappropriate behaviour in individual departments, a wider group are significantly impacted as bystanders. As such, improving the culture and professional behaviours within UK cardiology departments is of paramount importance. As a negative workplace culture is felt to be a major driver of inappropriate behaviour, all members of the cardiovascular team have a role to play in ensuring a positive workplace culture is developed. Episodes of inappropriate behaviour should be challenged by cardiovascular team members. Informal feedback may be appropriate where 'one-off' episodes of inappropriate behaviour occur, but serious events or repeated behaviour should be escalated following formal human resources protocols.
alter-ations in the composition of the gut microbiota (dysbiosis). Dysbiosis determines the production of metabolite derived from the gut microbiota. 1
Recent studies have found an association between high volumes of physical activity and increased levels of coronary artery calcification (CAC) among older male endurance athletes, yet the underlying mechanisms have remained largely elusive. Potential mechanisms include greater exposure to inflammatory cytokines, reactive oxygen species and oxidised low-density lipoproteins, as acute strenuous physical activity has been found to enhance their systemic release. Other possibilities include post-exercise elevations in circulating parathyroid hormone, which can modify the amount and morphology of calcific plaque, and long-term exposure to non-laminar blood flow within the coronary arteries during vigorous physical activity, particularly in individuals with pre-existing atherosclerosis. Further, although the association has only been identified in men, the role of testosterone in this process remains unclear. This brief review discusses the association between high-volume endurance exercise and CAC in older men, elaborates on the potential mechanisms underlying the increased calcification, and provides clinical implications and recommendations for those at risk.
Although guidelines often recommend patients be managed at centres or in clinics that specialise in the patient’s specific medical condition, it has been challenging to convincingly demonstrate that specialised centres meaningfully impact patient outcomes. In this issue of Heart, Paolisso and colleagues report outcomes for 2129 patients seen for cardiovascular consultation with moderate aortic stenosis (mAS) or asymptomatic severe AS (asAS) in a single centre observational registry. The 251 patients seen in a heart valve clinic (HVC) were compared with the 1878 receiving standardofcare (SOC). Although those in the HVC group had more clinic visits and more diagnostic tests than the SOC group, even with propensity score matching, those in the HVC group also received aortic valve replacement more promptly once an indication was present. Importantly, allcause mortality (HR=0.63, 95% CI 0.40 to 0.98, p=0.038) and cardiovascular death (p=0.030) were lower in the HVC group compared with the SOC group. Management in a HVC remained an independent predictor of allcause mortality (HR=0.54, 95% CI 0.34 to 0.85, p=0.007) on multivariable analysis (figure 1). In the accompanying editorial, Iung emphasises the importance of frequent followup and patient education in patients with moderate to severe AS. As he comments on this study: “Relevant findings are the higher number of consultation (1.6±1.0 vs 0.8±0.9 per year) in the heart valve clinic and the average time duration of 40 min per visit, thereby allowing for improved patient education, particularly on the importance of reporting any new symptom. Close followup is crucial in asymptomatic AS to detect symptom onset without delay.” However, only a small proportion (12%) of the patients with mAS or asAS were seen in the HVC clinic so that “the generalisation of the followup of asymptomatic patients with AS in heart valve clinics raises concerns on the feasibility and economic consequences of this approach.” Sex has been identified as adverse risk factor in patients undergoing catheter ablation for atrial fibrillation (AF). To better define the association between sex and outcomes after AF ablation, Mszr and colleagues examined data from an observational cohort study of 58 960 adults undergoing AF ablation, of whom 34.6% were women. At baseline, compared with men, women were older (68 vs 64 years, p<0.001), had more comorbidities and a lower AFrelated quality of life. After AF ablation, women had a greater risk of a major adverse events (aOR 1.60 (95% CI 1.33 to 1.92) as well as other complications, including bradycardia requiring a permanent pacemaker, phrenic nerve injury, bleeding and vascular injury (figure 2). However, no mortality difference between men and women was found in this observational study. Arps and Piccini conclude in an editorial that data from this study “provide a convincing association between female sex and increased rates of complications related to AF ablation. Moving forward, we will need to identify the mechanisms behind these differences in order to narrow the safety gap between women and men undergoing catheter ablation.” Another important study in this issue addresses the clinical features of pulmonary hypertension (PH) after treatment of heart failure with preserved ejection Division of Cardiology, University of Washington, Seattle, Washington, USA
Echocardiographic screening is a powerful tool for early rheumatic heart disease (RHD) detection, so important consid-ering the known impact of secondary prophylaxis on disease regression. 1 Over the
The number of patients at the intersection of cancer and cardiovascular disease (CVD) is increasing, reflecting ageing global populations, rising burden of shared cardiometabolic risk factors, and improved cancer survival. Many cancer treatments carry a risk of cardiotoxicity. Baseline cardiovascular risk assessment is recommended in all patients with cancer and requires consideration of individual patient risk and the cardiotoxicity profile of proposed anticancer therapies. Patients with pre-existing CVD are potentially at high or very high risk of cancer-therapy related cardiovascular toxicity. The detection of pre-existing CVD should prompt cardiac optimisation and planning of surveillance during cancer treatment. In patients with severe CVD, the risk of certain cancer therapies may be prohibitively high. Such decisions require multidisciplinary discussion with consideration of alternative anti-cancer therapies, risk-benefit assessment, and patient preference. Current practice is primarily guided by expert opinion and data from select clinical cohorts. There is need for development of a stronger evidence base to guide clinical practice in cardio-oncology. The establishment of multicentre international registries and national-level healthcare data linkage projects are important steps towards facilitating enrichment of cardio-oncology research programmes. In this narrative review, we consider epidemiological trends of cancer and CVD comorbidities and the impact of their co-occurrence on clinical outcomes, current approach to supporting cancer patients with pre-existing CVD and gaps in existing knowledge.
ObjectiveThe purpose of this study is to describe recent mortality trends from aortic stenosis (AS) among eight high-income countries.MethodsWe analysed the WHO mortality database to determine trends in mortality from AS in the UK, Germany, France, Italy, Japan, Australia, the USA and Canada from 2000 to 2020. Crude and age-standardised mortality rates per 100 000 persons were calculated. We calculated age-specific mortality rates in three groups (<64, 65–79 and ≥80 years). Annual percentage change was analysed using joinpoint regression.ResultsDuring the observation period, the crude mortality rates per 100 000 persons increased in all the eight countries (from 3.47 to 5.87 in the UK, from 2.98 to 8.93 in Germany, from 3.84 to 5.52 in France, from 1.97 to 4.33 in Italy, from 1.12 to 5.49 in Japan, from 2.14 to 3.38 in Australia, from 3.58 to 4.22 in the USA and from 2.12 to 5.00 in Canada). In joinpoint regression of age-standardised mortality rates, trend changes towards a decrease were observed in Germany after 2012 (−1.2%, p=0.015), Australia after 2011 (−1.9%, p=0.005) and the USA after 2014 (−3.1%, p<0.001). Age-specific mortality rates in age group ≥80 years had shifts towards decreasing trends in all the eight countries in contrast to other younger age groups.ConclusionsWhile crude mortality rates increased in the eight countries, shifts towards decreasing trends were identified in age-standardised mortality rates in three countries and in the elderly aged ≥80 years in the eight countries. Further multidimensional observation is warranted to clarify the mortality trends.
