Agentes antiplaquetarios múltiples o únicos para la prevención de la recurrencia temprana de un accidente cerebrovascular isquémico o un ataque isquémico transitorio / Multiple versus fewer antiplatelet agents for preventing early recurrence after ischaemic stroke or transient ischaemic attack

Título: Uso de agentes antiplaquetarios múltiples o único para la prevención de la recurrencia temprana de un ictus o un ataque isquémico transitorio Pregunta de revisión. ¿Son mejores los antiagregantes plaquetarios múltiples que los únicos para prevenir la recidiva temprana tras un ictus? Fundamento. El ictus es la segunda enfermedad no transmisible más frecuente en el mundo y conlleva un alto riesgo de recurrencia. La mayoría de las recurrencias se producen poco después del ictus, por lo que se necesitan tratamientos eficaces para evitarlas. Las directrices actuales recomiendan el uso de un fármaco antiplaquetario como la aspirina después de un ictus o un accidente isquémico transitorio (mini-ictus). Sin embargo, no se ha establecido con claridad la seguridad y el beneficio de utilizar más de un antiagregante plaquetario en los primeros momentos tras un ictus.Características del estudio. Se comparó el uso de múltiples fármacos antiplaquetarios frente a menos al principio del accidente cerebrovascular (ACV). Las pruebas son actuales hasta el 6 de julio de 2020. Se incluyeron 15 ensayos clínicos con un total de 17.091 participantes de diversas poblaciones asiáticas, europeas y norteamericanas. Las combinaciones antiplaquetarias más comunes probadas fueron aspirina y dipiridamol, y aspirina y clopidogrel.Resultados clave. Se observó que los fármacos antiplaquetarios múltiples reducían el riesgo de recurrencia del ictus, pero aumentaban el riesgo de hemorragia en comparación con un único fármaco antiplaquetario. Dos fármacos antiplaquetarios parecen ser más eficaces en la prevención de la recurrencia temprana del ACV que un solo fármaco antiplaquetario, pero hay un mayor riesgo de efectos secundarios, especialmente de hemorragia. Los beneficios de los antiagregantes plaquetarios dobles iniciados inmediatamente después de un ictus parecen superar los riesgos durante el primer mes. (AU)

Treatment with Granulocyte-colony Stimulating Factor (G-CSF) is not associated with Increased Risk of Brain Metastasis in Patients with De Novo Stage IV Breast Cancer.

Background: Survival outcome after developing brain metastasis is poor and there is an unmet need to identify factors that can promote brain metastasis. Granulocyte-colony stimulating factor (G-CSF) is given to support neutrophil recovery after myelosuppressive chemotherapy to some patients. However, there is emerging evidence that neutrophils can promote metastasis, including through the formation of neutrophil extracellular traps (NETs), scaffolds of chromatin with enzymes expelled from neutrophils to the extracellular space. In animal models, G-CSFs can induce NETs to promote liver and lung metastasis. The primary objective of this study was to test the association between G-CSF use and the later incidence of brain metastasis. Methods: Patients with de novo Stage IV breast cancer, without known brain metastasis at the time of initial diagnosis, were identified from electronic medical records covering the period from 1/1/2013 to 12/31/2020 at Northwell Health. Univariate and multivariate logistic regression models were used to test the association between variables of interest, including G-CSF use, and brain metastasis. Results: A total of 78 patients were included in the final analysis. Among those 78 patients, 24 patients (30.8%) had received G-CSF along with chemotherapy at least once. In logistic regression models, G-CSF use was not a significant factor to predict brain metastasis (OR 1.89 [95%CI 1.89-5.33]; P=0.23). Interestingly, in multivariate logistic models, pulmonary embolism (PE)/deep venous thrombosis (DVT) was a significant predictive factor of brain metastasis (OR 6.74 [95%CI 1.82-25.01]; P=0.004) (38.5% vs 21.5%). Conclusions: The use of G-CSF was not associated with increased risk of brain metastasis in patients with de novo Stage IV breast cancer. Interestingly, PE/DVT, which can be associated with elevated NETs, was associated with brain metastasis. Further studies are warranted to determine whether DVT/PE with or without elevated NETs levels in the blood, is predictive of developing brain metastasis in patients with de novo Stage IV breast cancer.

Can Sex and Seniority Predict the Quality of a Journal Reviewer's Manuscript Critique?

PURPOSE: To evaluate reviewers' timeliness and review quality for the International Journal of Radiation Oncology, Biology, Physics (IJROBP) by sex and seniority. METHODS AND MATERIALS: The IJROBP editorial office provided data on 3962 individuals invited to review manuscripts from 2011 through 2014. We identified 1657 reviewers who had been invited to provide a review on at least 3 occasions during the study period and compared review timeliness and scoring between male and female reviewers. We confirmed the reviewers' sex after having unblinded their names based on our personal acquaintance with them and via an Internet search on their department websites. We then did a subset analysis of 124 US-based reviewers who had returned a "major revision" decision. We used the Review Quality Instrument (RQI) to rate their reviews. We used odds ratios and t tests to look for differences in mean RQI scores and factors that might be associated with quality-in particular, Hirsch indices (h indices) and year of first certification. RESULTS: Of the 1657 reviewers of interest, 1245 (75.1%) were men and 412 (24.9%) were women. We found no statistically significant differences between men and women in the time to respond to invitations. There were no statistically significant differences in timeliness or review reminders based on sex. Our subset analysis showed no difference in quality (RQI scores) based on the reviewers' sex, h index, or year of first certification. CONCLUSIONS: Women and men render reviews of equal quality regardless of seniority and h index, yet women have been invited less frequently to review. This is likely because of the underrepresentation of women in radiation oncology. A more balanced academic population is needed to address this continuing disparity of women's representation in academic publishing.

Lower 24-Month Relative Survival among Black Patients with Non- Hodgkin's Lymphoma: An Analysis of the SEER Data 1997-2015.

Background: Recent progress in the therapies used in patients with Non- Hodgkin's lymphoma has improved survival. The incidence has been reported to be decreasing in the last few years, accounting for 4% of all cancers. This study analyzed time trends for incidence, mortality, and prevalence of NHL. Methods: We analyzed the SEER Cancer Database from 1997 to 2015. Join point regression analysis was used to determine age-adjusted incidence rates, 24-month relative survival rate, and to identify racial/ethnic groups with a lower survival. Results: The trend in incidence of NHL decreased between 2008 and 2011 at an annual percentage change rate of 3.74%. The male predominance among NHL patients between 1997-2015 was 57%. The number of male patients affected with NHL has been similar in the last 20 years. Female predominance with NHL was higher in 1998 at 46 %, and lower in 2010 at 42.85%. The 24-month relative survival rate was higher among white patients as compared to black patients with NHL. Conclusions: Our analysis demonstrated that the incidence of Non-Hodgkin's Lymphoma has decreased among minorities; however, the outcomes are inferior in terms of survival. This analysis showed an inferior 24-month relative survival rate among black patients compared with white patients. This analysis demonstrates the need for further research in NHL to determine the biological differences and social factors that influence the lower survival among black patients with NHL.

First Analysis of Same-day Pegfilgrastim Use with Concurrent Capecitabine-based Regimens in Patients with Gastrointestinal Malignancies.

BACKGROUND: Pegfilgrastim is administered 24 hours. after chemotherapy to reduce risks of myelosuppression. This requires an additional clinic visit, which can be difficult for some patients (pts) due to work and transportation issues. In GI malignancies, patients receiving capecitabine-based regimens also require pegfilgrastim to reduce myelotoxicity. We present here the first study to analyze safety and efficacy of administering pegfilgrastim on the same day as capecitabine-based regimens in patients with GI malignancies. METHODS: We evaluated 157 patients with GI malignancies who received a capecitabine-based chemotherapy regimen, including XELOX, EOX, ECX, XELIRI, MIXE, gemcitabine-capecitabine and same-day pegfilgrastim (6 mg) within 1 hr of completion of systemic agents. As per institutional guidelines, patients were counseled on risks of same-day pegfilgrastim prior to its administration. Patients were followed to determine the degree of neutropenia and toxicity. RESULTS: A total of 914 chemotherapy cycles in 157 patients were analyzed. Median ANC nadir for all cycles was 5634/uL (range: 450 - 23800). Grade 1 and 2 neutropenia developed in 11 of 914 cycles. Bone pain reported in 9 pts. There was 1 episode of grade >3 neutropenia resulting in infection and antibiotic use. No other patient required dose reductions, chemotherapy delays, or hospitalizations. No increased toxicity of capecitabine was noticed. CONCLUSIONS: We believe our study is the first in GI malignancies to report that same-day pegfilgrastim administration with capecitabine-based regimens may be as effective and safe as next-day administration. Additionally, given the absence of CD in human bone marrow, it appears capecitabine can be used concurrently with pegfilgrastim. Prospective studies should be done to further investigate, as this practice can benefit patients clinically, decrease office visits, increase patient's satisfaction and reduce healthcare costs.

Association Between FFRCT and Instantaneous Wave-Free Ratio (iFR) of Intermediate Lesions on Coronary Computed Tomography Angiography.

BACKGROUND: New data suggests long term outcomes of coronary revascularization based on instantaneous wave free ratio (iFR) are equivalent to invasive fractional flow reserve (FFR). We aimed to evaluate the correlation between non-invasive FFR derived from cardiac CT (FFRCT) and iFR. METHODS: Data from 21 patients with 26 vessels, who underwent both FFRCT computation and invasive iFR measurement, were analysed. We evaluated diagnostic performance of FFRCT according to two cut-off values of ≤0.80 and ≤0.70 with iFR ≤0.89 as the reference standard. RESULTS: In a per vessel analysis, the average diameter stenosis was 59%, mean FFRCT was 0.81 while mean iFR was 0.90. Using an FFRCT cut-off of 0.80, the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy for FFRCT were 86%, 84%, 67%, 94%, and 85% respectively. When the cut-off was lowered to 0.70, the sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy for FFRCT were 57%, 100%, 100%, 86% and 88% respectively. CONCLUSION: FFRCT correlates well with iFR in this small retrospective study. Larger studies are required to confirm this finding.

Attenuated regimen of biweekly gemcitabine/nab-paclitaxel in patients aged 65 years or older with advanced pancreatic cancer.

BACKGROUND: Treatment with gemcitabine/nab-paclitaxel confers a survival benefit over gemcitabine monotherapy in patients with advanced pancreatic cancer (APC). However, such treatment can be associated with significant toxicities especially in older patients and carries practical disadvantages related to a weekly schedule along with financial cost. We retrospectively analyzed patients >65 years of age with APC who received a modified biweekly regimen of gemcitabine/nab-paclitaxel to evaluate efficacy and toxicity. METHODS: Patients aged >65 years with chemo-naïve APC with Eastern Cooperative Oncology Group performance status ⩽2 were studied. Patients were treated with a modified regimen of gemcitabine 1000 mg/m2 and nab-paclitaxel 125 mg/m2 every 2 weeks on days 1 and 15 of a 28-day cycle. Patients were evaluated for progression-free survival (PFS) and overall survival (OS) with analyses performed using the Kaplan-Meier method. Adverse events were recorded on the day of chemotherapy. Cancer antigen 19.9 was measured in every cycle and restaging scans were performed every two cycles. RESULTS: A total of 73 patients (median age: 73 years; range: 66-93) were treated with biweekly gemcitabine/nab-paclitaxel as first-line treatment. The median OS and PFS were 9.1 months and 4.8 months, respectively. Around 66% of patients received growth-factor support based on American Society of Clinical Oncology guidelines and no patient developed neutropenic fever. The incidences of grade ⩾3 toxicity for neutropenia, anemia, thrombocytopenia, and neurotoxicity were 2%, 7%, 3%, and 5%, respectively. Dose reductions of gemcitabine/nab-paclitaxel were required in 10% and 4% patients, respectively. CONCLUSION: In patients older than >65 years of age with APC, a modified regimen of biweekly gemcitabine/nab-paclitaxel was found to be effective when compared with the historical control from the MPACT study. This regimen allowed for fewer dose reductions, reduced healthcare costs from additional appointments, travel-related cost, as well as a favorable side-effect profile while maintaining efficacy. Though retrospective in nature, this study underlines the need for further investigation, particularly in elderly patients with poor performance status, such as those with pancreatic cancer, and in order to combine with a third agent, such as a targeted treatment or immunotherapy.

Secondary prevention of cardiovascular diseases in India: Findings from registries and large cohorts.

Several registries and quality improvement initiatives have focused on assessing and improving secondary prevention of CVD in India. While the Treatment and Outcomes of Acute Coronary Syndromes in India (CREATE), Indian Heart Rhythm Society-Atrial Fibrillation (IHRS-AF), and Trivandrum Heart Failure (THF) registries are limited to collecting data, the Tamil Nadu-ST-Segment Elevation Myocardial Infarction (TN-STEMI) program was aimed at examining and improving access to revascularization after an ST-elevation myocardial infarction (STEMI). The Acute Coronary Syndromes: Quality Improvement in Kerala (ACS-QUIK) study recruited hospitals from the Kerala ACS registry to assess a quality improvement kit for patients with ACS while the Practice Innovation and Clinical Excellence India Quality Improvement Program (PIQIP) provides valuable data on outpatient CVD quality of care. Collaborative efforts between health professionals are needed to assess further gaps in knowledge and policy makers to utilize new and existing data to drive policy-making.

Multiple versus fewer antiplatelet agents for preventing early recurrence after ischaemic stroke or transient ischaemic attack.

BACKGROUND: Stroke is a leading cause of morbidity and mortality worldwide. Antiplatelet agents are considered to be the cornerstone for secondary prevention of stroke, but the role of using multiple antiplatelet agents early after stroke or transient ischaemic attack (TIA) to improve outcomes has not been established. OBJECTIVES: To determine the effectiveness and safety of initiating, within 72 hours after an ischaemic stroke or TIA, multiple antiplatelet agents versus fewer antiplatelet agents to prevent stroke recurrence. The analysis explores the evidence for different drug combinations. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (last searched 6 July 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 7 of 12, 2020) (last searched 6 July 2020), MEDLINE Ovid (from 1946 to 6 July 2020), Embase (1980 to 6 July 2020), ClinicalTrials.gov, and the WHO ICTRP. We also searched the reference lists of identified studies and reviews and used the Science Citation Index Cited Reference search for forward tracking of included studies. SELECTION CRITERIA: We selected all randomised controlled trials (RCTs) that compared the use of multiple versus fewer antiplatelet agents initiated within 72 hours after stroke or TIA. DATA COLLECTION AND ANALYSIS: We extracted data from eligible studies for the primary outcomes of stroke recurrence and vascular death, and secondary outcomes of myocardial infarction; composite outcome of stroke, myocardial infarction, and vascular death; intracranial haemorrhage; extracranial haemorrhage; ischaemic stroke; death from all causes; and haemorrhagic stroke. We computed an estimate of treatment effect and performed a test for heterogeneity between trials. We analysed data on an intention-to-treat basis and assessed bias for all studies. We rated the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included 15 RCTs with a total of 17,091 participants. Compared with fewer antiplatelet agents, multiple antiplatelet agents were associated with a significantly lower risk of stroke recurrence (5.78% versus 7.84%, risk ratio (RR) 0.73, 95% confidence interval (CI) 0.66 to 0.82; P < 0.001; moderate-certainty evidence) with no significant difference in vascular death (0.60% versus 0.66%, RR 0.98, 95% CI 0.66 to 1.45; P = 0.94; moderate-certainty evidence). There was a higher risk of intracranial haemorrhage (0.42% versus 0.21%, RR 1.92, 95% CI 1.05 to 3.50; P = 0.03; low-certainty evidence) and extracranial haemorrhage (6.38% versus 2.81%, RR 2.25, 95% CI 1.88 to 2.70; P < 0.001; high-certainty evidence) with multiple antiplatelet agents. On secondary analysis of dual versus single antiplatelet agent therapy, benefit for stroke recurrence (5.73% versus 8.06%, RR 0.71, 95% CI 0.62 to 0.80; P < 0.001; moderate-certainty evidence) was maintained as well as risk of extracranial haemorrhage (1.24% versus 0.40%, RR 3.08, 95% CI 1.74 to 5.46; P < 0.001; high-certainty evidence). The composite outcome of stroke, myocardial infarction, and vascular death (6.37% versus 8.77%, RR 0.72, 95% CI 0.64 to 0.82; P < 0.001; moderate-certainty evidence) and ischaemic stroke (6.30% versus 8.94%, RR 0.70, 95% CI 0.61 to 0.81; P < 0.001; high-certainty evidence) were significantly in favour of dual antiplatelet therapy, whilst the risk of intracranial haemorrhage became less significant (0.34% versus 0.21%, RR 1.53, 95% CI 0.76 to 3.06; P = 0.23; low-certainty evidence). AUTHORS' CONCLUSIONS: Multiple antiplatelet agents are more effective in reducing stroke recurrence but increase the risk of haemorrhage compared to one antiplatelet agent. The benefit in reduction of stroke recurrence seems to outweigh the harm for dual antiplatelet agents initiated in the acute setting and continued for one month. There is lack of evidence regarding multiple versus multiple antiplatelet agents. Further studies are required in different populations to establish comprehensive safety profiles and long-term outcomes to establish duration of therapy.

The Vulnerable Plaque: Recent Advances in Computed Tomography Imaging to Identify the Vulnerable Patient.

PURPOSE OF REVIEW: This review aims to summarize the role of coronary computed tomography plaque analysis in identifying high-risk patients and plaques. RECENT FINDINGS: In this review, we will describe the histopathological features of a vulnerable plaque as well as the coronary computed tomography characteristics including spotty calcification, low-attenuation fatty core, positive remodeling, and thin fibrous cap. We will also review several studies that assessed features of a vulnerable plaque on non-invasive imaging and evaluated them as risk predictors of future acute coronary events. Multiple recent studies suggested that coronary computed tomography angiography can accurately identify high-risk features of plaque that will predict future events.

Hyperpigmentation due to imatinib: A rare case of cutaneous involvement.

CASE REPORT: Imatinib mesylate is a well-known tyrosine kinase inhibitor used to treat chronic myeloid leukemia, gastrointestinal stromal tumor, as well as a variety of other malignancies.Management and outcome: As use of this medication continues to grow, providers must be aware of potential side effects and management thereof. The toxicity profile of imatinib has been well characterized with most patients experiencing a grade 1 or 2 adverse event. These side effects are usually mild, and most patients can continue treatment without interruption. Around 30% of patients on imatinib experience skin toxicity, with 5% being high grade. This rash is typically hypopigmented, which is explained by imatinib's effect on melanocytes. DISCUSSION: Although there have been several case reports describing hyperpigmentation of the oral mucosa or nails, very few have described skin hyperpigmentation. We previously reported the first two cases of imatinib-related squamous cell carcinoma in patients undergoing treatment for gastrointestinal stromal tumors. In this paper, we present a case of a patient on imatinib for management of gastrointestinal stromal tumor who experienced extensive skin hyperpigmentation and review the literature.

Association between frequency of primary care provider visits and evidence-based statin prescribing and statin adherence: Findings from the Veterans Affairs system.

BACKGROUND: Statin use remains suboptimal in patients with atherosclerotic cardiovascular disease (ASCVD). We assessed if the frequency of visits with primary care providers (PCPs) is associated with higher use of evidence-based statin prescriptions and adherence among patients with ASCVD. METHODS: We identified patients with ASCVD aged ≥18 years receiving care in 130 facilities and associated community-based outpatient clinics in the entire Veterans Affairs Health Care System between October 1, 2013 and September 30, 2014. Patients were divided into frequent PCP visitors (annual PCP visits ≥ median number of PCP visits for the entire cohort) and infrequent PCP visitors (annual PCP visits < median number of patient visits). We assessed any- and high-intensity statin prescription as well as statin adherence which was defined by proportion of days covered (PDC). RESULTS: We included 1,249,061 patients with ASCVD (mean age was 71.9 years; 98.0% male). Median number of annual PCP visits was 3. Approximately 80.1% patients were on statins with 23.8% on high-intensity statins. Mean PDC was 0.715 ±â€¯0.336 with 58.3% patients with PDC ≥0.8. Frequent PCP visitors had higher frequency of statin use (82.2% vs 77.4%), high-intensity statin use (26.4% vs 20.3%), and statin adherence (mean PDC 0.73 vs 0.68; P < .01) compared to infrequent PCP visitors. After adjusting for covariates, frequent PCP visits was associated with greater odds of being on any statin, high intensity statin, and higher statin adherence. CONCLUSION: Frequent visits with PCPs is associated with a higher likelihood of any statin use, high intensity statin use, and statin adherence. Further research endeavors are needed to understand the reasons behind these associations.

Coronary Embolism: A Systematic Review.

BACKGROUND: Coronary embolism is a rare and potentially fatal phenomenon that occurs primarily in patients with valvular heart disease and atrial fibrillation. There is a lack of consensus regarding the diagnosis, treatment, and management of coronary embolism, leaving management at the discretion of the treating physician. Through this review, we aim to establish a better understanding of coronary embolism, and to identify treatment options - invasive and non-invasive - that may be used to manage coronary embolism. METHODS AND RESULTS: Our systematic review included 147 documented cases of coronary embolism from case reports and case series. The average age of our population was 54.2 ±â€¯17.6 years. The most common causes of coronary embolism included infective endocarditis (22.4%), atrial fibrillation (17.0%), and prosthetic heart valve thrombosis (16.3%). Initial presentation was indistinguishable from an acute coronary syndrome (ACS) due to coronary atherosclerosis, and the diagnosis required a high level of suspicion and evaluation with angiography. Treatment strategies included, but were not limited to, thrombectomy, thrombolysis, balloon angioplasty and stent placement. Myocardial dysfunction on echocardiography was observed in over 80% of patients following coronary embolism. "Good outcomes" were reported in 68.7% of case reports and case series, with a mortality rate of 12.9%. CONCLUSION: Coronary embolism is an under-recognized etiology of myocardial infarction with the potential for significant morbidity and mortality. To improve outcomes, physicians should strive for early diagnosis and intervention based on the underlying etiology. Thrombectomy may be considered with the goal of rapid restoration of coronary flow.

Relation Between Cardiology Follow-Up Visits, Evidence-Based Statin Prescribing, and Statin Adherence (from the Veterans Affairs Health Care System).

Statin use remains suboptimal in patients with atherosclerotic cardiovascular disease (ASCVD). We assessed whether outpatient care with a cardiology provider is associated with evidence-based statin prescription and statin adherence. We identified patients with ASCVD aged ≥18 years receiving primary care in 130 facilities and associated community-based outpatient clinics in the entire Veterans Affairs Health Care System between October 1, 2013 and September 30, 2014. Patients were divided into: (1) patients with at least 1 outpatient cardiology visit and (2) patients with no outpatient cardiology visits in the year before the index primary care visit. We assessed any- and high-intensity statin prescription adjusting for several patient- and facility-level covariates, and statin adherence using proportion of days covered (PDC). We included 1,249,061 patients with ASCVD (mean age: 71.9 years; 98.0% male). After adjusting for covariates, patients who visited a cardiology provider had greater odds of being on a statin (87.4% vs 78.4%; Odds ratio [OR] 1.25, 95% Confidence interval [CI] 1.24 to 1.26), high-intensity statin (34.5% vs 21.2%; OR: 1.21, 95% CI 1.21 to 1.22), and higher statin adherence (mean PDC 0.76 ± 0.29 vs 0.70 ± 0.34, PDC ≥0.8: 62.0% vs 57.3%; OR 1.09, 95% CI 1.09 to 1.11). A dose response relation was seen with a higher number of cardiology visits associated with a higher statin use and statin adherence. In conclusion, compared with outpatient care delivered by primary care providers alone, care delivered by a cardiology provider for patients with ASCVD is associated with a higher likelihood of guideline-based statin use and statin adherence.

Optimal positioning of self-expanding valves before deployment decreases paravalvular regurgitation following transcatheter aortic valve replacement.

OBJECTIVES: To evaluate the association between measurements performed during Medtronic CoreValve (MCV) deployment and paravalvular leak (PVL). BACKGROUND: The MCV can be recaptured and repositioned, allowing the TAVR operator to implant at a more favorable position. The association between angiographic measurements of MCV position while the valve is recapturable and PVL post deployment has not been investigated. METHODS: 493 patients undergoing TAVR with MCV (January 2011-July 2017) were included. PVL was defined as intraprocedural aortic regurgitation that was judged clinically to require balloon postdilation. Depth of the valve at the left coronary cusp (LCC) and noncoronary cusp (NCC) were measured when the valve was 80% deployed. An optimal cutoff value for the ratio LCC/NCC for PVL was identified in 40 patients. Using this cutoff value, the association between LCC/NCC and PVL was then validated in 453 patients. RESULTS: The median LCC/NCC was 1.51 (interquartile range 1.06-1.89).The optimal cutoff value for LCC/NCC was 1.48 (93% sensitivity, 77% specificity, AUC0.85). In the validation group 112 (24.7%) patients had PVL. For LCC/NCC ≥ 1.48, the incidence of PVL was lower compared to LCC/NCC < 1.48 (9.58% vs. 41.78%, P < 0.0001). LCC/NCC of 1.48 had a sensitivity of 79.5% and specificity of 63.6% for PVL (AUC0.72). In a multivariate model, LCC/NCC < 1.48 independently predicted PVL (OR = 6.67, 95% CI 3.96-11.23, P < 0.0001). CONCLUSION: Positioning the MCV such that the LCC/NCC is ≥1.48 may result in less PVL.

Epidemiologic studies targeting primary cardiovascular disease prevention in South Asia.

South Asia has experienced a 73% increase in healthy life years lost due to ischemic heart disease between 1990 and 2010. There is a lack of quality data relating to cardiovascular risk factors and disease from this region. Several observational and prospective cohorts in South Asia have been established in recent times to evaluate the burden of cardiovascular disease and their risk factors. The Prospective Rural Urban Epidemiology (PURE) study is the largest of these studies that has provided data on social, environmental, behavioral and biologic risk factors that influence heart disease and diabetes. Some studies have also borrowed data from large datasets to provide meaningful insights. These studies have allowed a better understanding of cardiovascular disease risk factors indigenous to the South Asian population along with conventional risk factors. Culturally sensitive interventions geared towards treating risk factors identified in these studies are needed to fully realize the true potential of these epidemiologic studies.

Transcatheter valvular interventions in 2017: some things old, some things new!

PURPOSE OF REVIEW: Transcatheter valvular interventions have changed the landscape of valvular therapies. We examine some studies on transcatheter valvular interventions published in the year 2017 to better understand their implications on clinical practice and future research. RECENT FINDINGS: Findings from the SURTAVI study suggest TAVR to be a reasonable option in intermediate risk patients with aortic stenosis. Recent studies indicate that valve leaflet thrombosis is associated with poor outcomes. Data from the TVT registry on current transcatheter mitral valve repair are encouraging; alternative repair systems have been subjected to feasibility trials. TAVR for patients with bicuspid aortic valve stenosis appears to be improving. Cerebral embolic protection devices have shown promise but the population in whom they are most likely to provide benefit needs to be better defined. SUMMARY: The year 2017 has seen significant advances in the field of transcatheter valvular interventions. Strong foundations have been laid for future studies that are likely to significantly impact clinical practice.

Premature Coronary Heart Disease in South Asians: Burden and Determinants.

PURPOSE OF REVIEW: While the burden of cardiovascular disease (CVD) is on the decline globally, it is on the rise among South Asians. South Asians are also believed to present early with coronary artery disease (CAD) compared with other ethnicities. RECENT FINDINGS: South Asians have demonstrated a higher burden of premature CAD (PCAD) compared with other ethnicities. These findings are not limited to non-immigrant South Asians but have also been found in immigrant South Asians settled around the world. In this article, we first discuss studies evaluating PCAD among South Asians residing in South Asia and among South Asian immigrants in other countries. We then discuss several traditional risk factors that could explain PCAD in South Asians (diabetes, hypertension, dietary factors, obesity) and lipoprotein-associated risk (low HDL-C levels, higher triglycerides, and elevated apolipoprotein B levels). We then discuss several emerging areas of research among South Asians including the role of dysfunctional HDL, elevated lipoprotein(a), genetics, and epigenetics. Although various risk markers and risk factors of CAD have been identified in South Asians, how they impact therapy is not well-known. PCAD is prevalent in the South Asian population. Large-scale studies are needed to identify how this information can be rationally utilized for early identification of risk among South Asians, and how currently available therapies can mitigate this increased risk.

Facility-level variation in diabetes and blood pressure control in patients with diabetes: Findings from the Veterans Affairs national database.

BACKGROUND: Intensive glycemic and blood pressure (BP) control in diabetic patients is associated with improved cardiovascular outcomes. HYPOTHESIS: We hypothesized that there is suboptimal glycemic and BP control with significant facility-level variation in patients with diabetes. METHODS: We identified patients with diabetes receiving care in 130 facilities in the Veterans Affairs Health Care System. We assessed facility-level rates of glycemic (hemoglobin [Hb]A1c <7%), BP (BP <140/90 mmHg), and combined glycemic and BP control (HbA1c <7% and BP <140/90 mmHg), and their facility-level variation in using median rate ratios (MRR). RESULTS: Among 1 103 302 patients with diabetes, 50.2% participants had an HbA1c <7%, 77.5% had a BP <140/90 mmHg, and 39.8% had both, HbA1c <7% and BP <140/90 mmHg. Median facility-level rates were 50.3% (interquartile range [IQR], 47.9%-52.4%) for glycemic control, 78.4% (IQR, 75.2%-80.0%) for BP control, and 39.9% (IQR, 38.14%-42.34%) for combined glycemic and BP control. Unadjusted MRR for glycemic control was 1.61 (95% confidence interval [CI]: 1.51-1.70) which decreased to 1.16 (95% CI: 1.14-1.19) after adjusting for patient and facility-level variables, indicating a 16% variation in glycemic control between 2 identical patients receiving care at 2 random facilities. Unadjusted MRR for BP control was 1.49 (95% CI: 1.41-1.56), which decreased to 1.25 (95% CI: 1.21-1.28), whereas unadjusted MRR for combined glycemic and BP control was 1.59 (95% CI: 1.50-1.68), which decreased to 1.15 (95% CI: 1.13-1.17) after adjustment. CONCLUSIONS: Facility-level rates for BP control and glycemic control remain low with significant facility-level variation. Much of this is explained by patient and facility-level variables although 16%, 25%, and 15% variation in glycemic, BP, and combined glycemic and BP control remains unexplained.

Early Trifecta valve failure: Report of a cluster of cases from a tertiary care referral center.

BACKGROUND: The Trifecta valve (St Jude Medical, Inc, St Paul, Minn) was approved for commercial use by the US Food and Drug Administration in 2011. Several isolated cases have been reported since then, describing early structural valve deterioration. We report a case series of 8 Trifecta valve failures, describing patients' clinical substrate and management, and the pathologic characteristics of the explanted valves. METHODS: Trifecta valve failure occurred in 7 patients (8 valves) receiving 19-mm (n = 2), 21-mm (n = 3), 23-mm (n = 1), and 25-mm (n = 2) valves. The mean duration of valve durability was 32 ± 21 months, and the most common lesion was prosthetic regurgitation. The mean Society of Thoracic Surgeons risk score for perioperative mortality at the time of reintervention was 9.75% ± 8.1%. Heart failure exacerbation was the most common presenting symptom. RESULTS: Five patients underwent surgical aortic valve replacement, 2 patients received valve-in-valve transcatheter aortic valve replacement, and 1 patient died of cardiogenic shock before reintervention. The most common pathologic finding in the explanted valves was a tan-yellow fibrofatty circumferential pannus adherent to the inflow portion of the Trifecta valve. CONCLUSIONS: Our findings provide further insights into the pathologic mechanisms leading to early Trifecta valve failure. In addition to tear of the noncoronary cusp of the Trifecta prosthesis described as the most common mechanism in the literature for its failure, circumferential pannus formation composed of fibrofatty tissue in the inflow portion and leaflet calcification concentrated around the posts in the outflow portion are important mechanisms contributing toward early Trifecta valve failure.