Background: Atrial fibrillation (AF) is the most common coronary artery bypass graft (CABG) post-operative arrhythmia. This complication can increase the patient’s chances for a more extended hospital stay, stroke, or death; resulting in additional healthcare costs. Prescribing statins (3-hydroxy-3-methylglutaryl COA reductase inhibitors) to reduce the risk of postoperative AF (POAF) is well studied, as they provide an anti-inflammatory and antioxidant benefit within hours of initiation. However, whether the statin type or dose is the origin for these benefits remains unknown; as research is conflicted. Methods: This ten-year retrospective observational study at a single institution, included all patients who underwent an isolated CABG; between January 1, 2005 - December 31, 2015 (n=3,226). For multiple CABG procedure cases, only the first incidence was included. Cases with a pacemaker, history of AF before CABG, or inflammatory disease that requires chronic steroid therapy, were excluded. The final population totaled 1,842 (non-AF n=867; AF n=975) cases, respectively. We analyzed the data using two-sample t-tests and chi-square tests to identify which patient characteristics were significantly associated with having POAF. To keep a representative sample of our study population, variables missing more than 80% of values were excluded. Multiple logistic regression was used to identify which combination of characteristics were most significant and then statin dose and type were each added to the model, individually and together. These two variables were highly correlated, thus for our final model, we used a professional statin dose comparison resource guide to create a dose-intensity variable that considered the type of statin and dose. Patients prescribed no statin was classified as a no dose group, while those prescribed statins were classified into a low, medium or high-intensity dose group. Results: The characteristics associated with a risk of POAF were age, history of vascular disease, and cardiomegaly. While, history of carotid disease, IV heparin within 24 hours of pre-op, and aspirin use were associated with a lower risk of POAF. Patients receiving a high-intensity dose had the lowest rate of POAF (46% vs. 67% for no statin, 57% for low and 53% for moderate, p<.001), and a one day shorter hospital stay. Statin-type became important after adjusting for a dose; simvastatin had the lowest and atorvastatin had the highest incidence of POAF. Conclusion: According to this CABG population analysis, a history of carotid disease, IV heparin within 4 hours of pre-op, and aspirin use were associated with a lower risk of POAF and both statin dose and type are essential factors in POAF prevention. High-intensity dose statins had the lowest rate of POAF, and a one day shorter hospital stay whereas simvastatin had the lowest and atorvastatin had the highest incidence of POAF.
Abstract Aims Prior evidence has implicated leucocyte expansion in several cardiovascular disorders, including heart failure (HF) with reduced ejection fraction (rEF). However, the prognostic importance of leucocyte count in HF with preserved EF (HFpEF) remains largely unexplored. Methods and results The Americas cohort of the treatment of preserved cardiac function heart failure with an aldosterone antagonist (TOPCAT‐Americas) was used to evaluate the association between total leucocyte count and clinical outcomes in HFpEF. The primary outcome was a composite of aborted cardiac arrest, cardiovascular mortality, or hospitalization for HF. Secondary outcomes were hospitalization for HF, aborted cardiac arrest, stroke, non‐fatal myocardial infarction (MI), cardiovascular mortality, non‐cardiovascular mortality, and all‐cause mortality. Survival models were used to identify the risk of the primary and secondary outcomes in those with leucocyte count above the median (7100 cells/μL), as compared to those with leucocyte count below the median, during the follow‐up period. A total of 1746 (out of 1767; 99%) patients from TOPCAT‐Americas were available for the analyses with a median follow up of 2.4 (25th to 75th percentile 1.4–3.9) years. Patients with leucocyte count >7100 cells/μL were 36% more likely to experience the primary endpoint compared to those with ≤7100 cells/μL (hazard ratio: 1.36, 95% confidence interval: 1.14–1.61). This association remained significant after extensive adjustment for potential confounders (hazard ratio: 1.27, 95% confidence interval: 1.06–1.52). We also observed a greater incidence of HF hospitalization and non‐fatal MI in patients with higher leucocyte count. These associations remained robust on sensitivity analyses, suggesting a low probability of confounding. Exploratory analyses suggested that both higher leucocyte count (integrating the combined influence of both myeloid and lymphoid immune cells) and augmented platelet count (as a surrogate for myeloid immune cell expansion) in the same model were associated with the primary outcome (both P < 0.05). Conclusions Leucocyte count >7100 cells/μL was independently associated with adverse clinical outcomes in HFpEF patients from TOPCAT‐Americas. These results were primarily driven by the HF hospitalization outcome but were also accompanied by an excess of non‐fatal MI. Further research is needed to define the mechanisms underlying our findings and their prognostic implications.
Background Aortic stiffness is an independent predictor of cardiovascular events in patients with arterial hypertension. Resistant hypertension is often linked to hyperaldosteronism and associated with adverse outcomes. Spironolactone, a mineralocorticoid receptor antagonist, has been shown to reduce both the arterial blood pressure (BP) and aortic stiffness in resistant hypertension. However, the mechanism of aortic stiffness reduction by spironolactone is not well understood. We hypothesized that spironolactone reduces aortic stiffness in resistant hypertension independently of BP change. Methods and Results Patients with uncontrolled BP (≥140/90 mm Hg) despite use of ≥3 antihypertensive medications (including diuretics) were prospectively recruited. Participants were started on spironolactone at 25 mg/d, and increased to 50 mg/d at 4 weeks while other antihypertensive medications were withdrawn to maintain constant mean BP. Phase-contrast cardiac magnetic resonance imaging of the ascending aorta was performed in 30 participants at baseline and after 6 months of spironolactone treatment to measure aortic pulsatility, distensibility, and pulse wave velocity. Pulse wave velocity decreased (6.3±2.3 m/s to 4.5±1.8 m/s, P<0.001) and pulsatility and distensibility increased (15.9%±5.3% to 22.1%±7.9%, P<0.001; and 0.28%±0.10%/mm Hg to 0.40%±0.14%/mm Hg, P<0.001, respectively) following 6 months of spironolactone. Conclusions Our results suggest that spironolactone improves aortic properties in resistant hypertension independently of BP, which may support the hypothesis of an effect of aldosterone on the arterial wall. A larger prospective study is needed to confirm our findings.
Pregnancy after cardiac transplantation poses immense challenges. Maternal risks include hypertensive disorders of pregnancy, rejection, and failure of the cardiac allograft that may lead to death. Fetal risks include potential teratogenic effects of immunosuppression and prematurity. Because of the high-risk nature of pregnancy in a heart transplant patient, management of reproductive health after cardiac transplantation should include preconception counseling to all women in the reproductive age group before and after cardiac transplantation. Reliable contraception is vital as nearly half of the pregnancies in this population are unintended. Despite the associated risks, successful pregnancies after cardiac transplantation have been reported. A multidisciplinary approach proposed in this review is essential for successful outcomes. A checklist for providers to guide management is provided.
Patients with systemic lupus erythematosus (SLE) can present with multiple cardiovascular pathologies, including pulmonary hypertension, valvular disease, pericarditis, myocarditis, and premature atherosclerosis. SLE medications can also cause cardiovascular side effects. We present a patient who developed a severe cardiomyopathy secondary to the hydroxychloroquine prescribed to treat her SLE. (Level of Difficulty: Beginner.)
Optimal left ventricular assist device (LVAD) cannula position is important for adequate ventricular unloading and LVAD function. Poor inflow cannula position predisposes to pump thrombosis, inotrope dependence, and mortality. We describe a novel technique of preoperative left ventricular apex marking using CT guidance and demonstrate in three cases the use of this method to achieve optimal inflow cannula positioning for lateral thoracotomy Heartware LVAD implantation.
