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Role of cardiac T1 mapping and extracellular volume in the assessment of myocardial infarction.
Garg, P, Saunders, LC, Swift, AJ, Wild, JM, Plein, S
Anatolian journal of cardiology. 2018;(6):404-411
Abstract
Although late gadolinium enhancement on cardiac magnetic resonance imaging remains the reference standard for scar assessment, it does not provide quantitative information about the extent of pathophysiological changes within the scar tissue. T1 mapping and extracellular volume (ECV) mapping are steadily becoming diagnostic and prognostically useful tests for in vivo myocardial histology, influencing clinical decision-making. Quantitative native T1 maps (acquired without a contrast agent) represent the longitudinal relaxation time within the myocardium and changes with myocardial extracellular water (edema, focal, or diffuse fibrosis), fat, iron, and amyloid protein content. Post-contrast ECV maps estimate the size of the extracellular space and have sensitivity in the identification of interstitial disease. Both pre- and post-contrast T1 mapping are emerging as comprehensive tools for the assessment of numerous conditions including ischemic scarring that occurs post myocardial infarction (MI). This review outlines the current evidence and potential future role of T1 mapping in MI. We conclude by highlighting some of the remaining challenges such as quality control, standardization of image acquisition for clinical practice, and automated methods for quantifying infarct size, area at risk, and myocardial salvage post MI.
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Cardiovascular disease risk among women living with HIV in North America and Europe.
Stone, L, Looby, SE, Zanni, MV
Current opinion in HIV and AIDS. 2017;(6):585-593
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PURPOSE OF REVIEW To examine the epidemiology and mechanistic underpinnings of heightened cardiovascular disease (CVD) risk among women living with HIV (WLHIV) in North America and Europe. RECENT FINDINGS WLHIV in North America and Europe exhibit high CVD incidence rates, which are at par with those of compatriot men living with HIV. Compared with uninfected women, WLHIV in these regions face a 2-4-fold increased relative risk for myocardial infarction, stroke, and heart failure. HIV-associated CVD risk is fuelled by a negative synergy of traditional cardiometabolic risk factors and heightened systemic immune activation/inflammation. Among WLHIV, female sex and endogenous sex hormone production influence both traditional cardiometabolic risk factors and patterns of systemic immune activation/inflammation. WLHIV in North America and Europe may also experience heightened CVD risk in relation to a relatively increased prevalence of behavioral and psychosocial CVD risk factors, coupled with suboptimal therapeutic targeting of known traditional cardiometabolic risk factors. SUMMARY Additional research on sex-specific mechanisms of HIV-associated CVD - based not only out of North America and Europe but also and especially out of Africa, Asia, and South America - will inform the development of CVD prediction algorithms and prevention guidelines clinically relevant to the approximately 17 million women aging with HIV globally.
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Restarting Anticoagulant Therapy After Intracranial Hemorrhage: A Systematic Review and Meta-Analysis.
Murthy, SB, Gupta, A, Merkler, AE, Navi, BB, Mandava, P, Iadecola, C, Sheth, KN, Hanley, DF, Ziai, WC, Kamel, H
Stroke. 2017;(6):1594-1600
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BACKGROUND AND PURPOSE The safety and efficacy of restarting anticoagulation therapy after intracranial hemorrhage (ICH) remain unclear. We performed a systematic review and meta-analysis to summarize the associations of anticoagulation resumption with the subsequent risk of ICH recurrence and thromboembolism. METHODS We searched published medical literature to identify cohort studies involving adults with anticoagulation-associated ICH. Our predictor variable was resumption of anticoagulation. Outcome measures were thromboembolic events (stroke and myocardial infarction) and recurrence of ICH. After assessing study heterogeneity and publication bias, we performed a meta-analysis using random-effects models to assess the strength of association between anticoagulation resumption and our outcomes. RESULTS Eight studies were eligible for inclusion in the meta-analysis, with 5306 ICH patients. Almost all studies evaluated anticoagulation with vitamin K antagonists. Reinitiation of anticoagulation was associated with a significantly lower risk of thromboembolic complications (pooled relative risk, 0.34; 95% confidence interval, 0.25-0.45; Q=5.12, P for heterogeneity=0.28). There was no evidence of increased risk of recurrent ICH after reinstatement of anticoagulation therapy, although there was significant heterogeneity among included studies (pooled relative risk, 1.01; 95% confidence interval, 0.58-1.77; Q=24.68, P for heterogeneity <0.001). No significant publication bias was detected in our analyses. CONCLUSIONS In observational studies, reinstitution of anticoagulation after ICH was associated with a lower risk of thromboembolic complications and a similar risk of ICH recurrence. Randomized clinical trials are needed to determine the true risk-benefit profile of anticoagulation resumption after ICH.
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Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative.
Ades, PA, Keteyian, SJ, Wright, JS, Hamm, LF, Lui, K, Newlin, K, Shepard, DS, Thomas, RJ
Mayo Clinic proceedings. 2017;(2):234-242
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The primary aim of the Million Hearts initiative is to prevent 1 million cardiovascular events over 5 years. Concordant with the Million Hearts' focus on achieving more than 70% performance in the "ABCS" of aspirin for those at risk, blood pressure control, cholesterol management, and smoking cessation, we outline the cardiovascular events that would be prevented and a road map to achieve more than 70% participation in cardiac rehabilitation (CR)/secondary prevention programs by the year 2022. Cardiac rehabilitation is a class Ia recommendation of the American Heart Association and the American College of Cardiology after myocardial infarction or coronary revascularization, promotes the ABCS along with lifestyle counseling and exercise, and is associated with decreased total mortality, cardiac mortality, and rehospitalizations. However, current participation rates for CR in the United States generally range from only 20% to 30%. This road map focuses on interventions, such as electronic medical record-based prompts and staffing liaisons that increase referrals of appropriate patients to CR, increase enrollment of appropriate individuals into CR, and increase adherence to longer-term CR. We also calculate that increasing CR participation from 20% to 70% would save 25,000 lives and prevent 180,000 hospitalizations annually in the United States.
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Cardiac Rehabilitation: Improving Function and Reducing Risk.
Servey, JT, Stephens, M
American family physician. 2016;(1):37-43
Abstract
Cardiac rehabilitation is a comprehensive multidisciplinary program individually tailored to the needs of patients with cardiovascular disease. The overall goals focus on improving daily function and reducing cardiovascular risk factors. Cardiac rehabilitation includes interventions aimed at lowering blood pressure and improving lipid and diabetes mellitus control, with tobacco cessation, behavioral counseling, and graded physical activity. The physical activity component typically involves 36 sessions over 12 weeks, during which patients participate in supervised exercise under cardiac monitoring. There are also intensive programs that include up to 72 sessions lasting up to 18 weeks, although these programs are not widely available. Additional components of cardiac rehabilitation include counseling on nutrition, screening for and managing depression, and assuring up-to-date immunizations. Cardiac rehabilitation is covered by Medicare and recommended for patients following myocardial infarction, bypass surgery, and stent placement, and for patients with heart failure, stable angina, and several other conditions. Despite proven benefits in mortality rates, depression, functional capacity, and medication adherence, rates of referral for cardiac rehabilitation are suboptimal. Groups less likely to be referred are older adults, women, patients who do not speak English, and persons living in areas where cardiac rehabilitation is not locally available. Additionally, primary care physicians refer patients less often than cardiologists and cardiothoracic surgeons.
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Native Myocardial T1 Mapping, Are We There Yet?
Hamdy, A, Kitagawa, K, Ishida, M, Sakuma, H
International heart journal. 2016;(4):400-7
Abstract
T1 or longitudinal relaxation time is one of the very fundamental magnetic resonance imaging (MRI) time constants and a tissue characterizing parameter. Only during the last decade did it become possible to quantify T1 values of the myocardium through T1 mapping. Evolving from only region of interest analysis and long acquisition times to the pixel-based parametric mapping and short breath-hold sequences, T1 mapping is reaching maturity among cardiac magnetic resonance (CMR) techniques. Both inversion recovery methods such as MOdified Look-Locker Inversion (MOL-LI) and Shortened MOLLI (ShMOLLI) and saturation recovery methods such as Saturation recovery Single-Shot Acquisition (SASHA) are available for T1 quantification with variable degrees of accuracy, precision, and reproducibility. Native (non-contrast) T1 values increase with edema, amyloid deposition, and fibrosis, while they decrease in fat or iron deposition in the myocardium. These features enabled significant expansion of the clinical applications of native T1 mapping where it provides high sensitivity and specificity and even acts as a disease biomarker or a predictor of prognosis. It is of particular usefulness in diffuse myocardial diseases where conventional CMR techniques might be deceiving. A brighter future for the technique is expected if certain challenges are to be faced, examples of which are the need for standardization of normal values, acquisition techniques, and improving analysis tools.
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A proposal to incorporate trial data into a hybrid ACC/AHA algorithm for the allocation of statin therapy in primary prevention.
Ridker, PM, Rose, L, Cook, NR
Journal of the American College of Cardiology. 2015;(9):942-8
Abstract
Current algorithms for statin allocation in primary prevention use epidemiologic estimates of absolute risk. However, a global risk prediction score has not been used as an enrollment criterion in any randomized trial of statin therapy. Moreover, completed statin trials show greater relative risk reductions for those patients at lower levels of absolute risk. Thus, risk calculators that rely solely on epidemiologic modeling do not ensure that those who will benefit are selected for treatment. We propose a hybrid approach to statin prescription for apparently healthy men and women that strongly endorses pharmacologic treatment for those who have estimated 10-year risks ≥7.5% and for whom trial-based evidence supports statin efficacy in primary prevention. Although individuals could still be treated on the basis of absolute risk alone, the hybrid approach is evidence-based, is easily applied in clinical practice, and may increase the transparency of physician-patient interactions concerning prescription of statin therapy in primary prevention.
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New Insights from Major Prospective Cohort Studies with Cardiovascular Magnetic Resonance (CMR).
Arai, AE
Current cardiology reports. 2015;(6):46
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Since 1948, epidemiology studies played an important role in understanding cardiovascular disease and afforded an opportunity to learn about newer diagnostic tests. In 2000, the MESA Study incorporated several advanced cardiovascular imaging modalities including cardiac magnetic resonance imaging (MRI) and coronary artery calcium scans. The decade of follow-up enabled prognosis studies, an important step beyond association studies. In brief, left ventricular hypertrophy by cardiac MRI predicted incident heart failure and stroke. In the MESA Study, coronary artery calcium was a better predictor of coronary artery disease end points than the non-contrast-enhanced MRI scan. In the ICELAND MI substudy of the AGES-Reykjavik Study, a contrast-enhanced MRI scan detected many more unrecognized myocardial infarctions (MIs) (UMIs) than detected by electrocardiography and documented these UMI had adverse prognostic significance. Thus, cardiac MRI has been successfully incorporated into large population studies and shown added value over conventional measurements of cardiovascular disease.
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Tissue characterization of the myocardium: state of the art characterization by magnetic resonance and computed tomography imaging.
Pattanayak, P, Bleumke, DA
Radiologic clinics of North America. 2015;(2):413-23
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Late gadolinium enhancement (LGE) is a simple, robust, well-validated method for assessing scar in acute and chronic myocardial infarction. LGE is useful for distinguishing between ischemic and nonischemic cardiomyopathy. Specific LGE patterns are seen in nonischemic cardiomyopathy. Patient studies using T1 mapping have varied in study, design, and acquisition sequences. Despite the differences in technique, a clear pattern that has been seen is that in cardiac disease postcontrast T1 times are shorter. Extracellular volume fraction measured with cardiac computed tomography represents a new approach to the clinical assessment of diffuse myocardial fibrosis by evaluating the distribution of iodinated contrast.
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10.
Meta-analysis of cholesteryl ester transfer protein TaqIB polymorphism and risk of myocardial infarction.
Cao, M, Zhou, ZW, Fang, BJ, Zhao, CG, Zhou, D
Medicine. 2014;(26):e160
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Abstract
A number of studies have been conducted to explore the association between the cholesteryl ester transfer protein (CETP) TaqIB polymorphism and risk of myocardial infarction (MI); however, the results are inconsistent. Therefore, we conducted this meta-analysis to clarify the issue based on all the data available.Eligible studies were retrieved by searching PubMed, Embase, Web of Science, and Google Scholar. We calculated the crude odds ratios (ORs) and corresponding 95% confidence intervals (95% CIs) to assess the association between the TaqIB polymorphism and risk of MI.We included 13 studies involving 8733 MI cases and 8573 controls in the meta-analysis. The pooled results from all included studies showed decreased MI risk in the analysis of the B2B2 versus B1B1 (OR = 0.78, 95% CI = 0.68-0.91), dominant (OR = 0.88, 95% CI = 0.77-0.99), and recessive genetic models (OR = 0.84, 95% CI = 0.78-0.91). The frequency of the B2B2 genotype in MI patients was lower (OR = 0.87, 95% CI = 0.81-0.94). However, there was no significant association in the B1B2 versus B1B1 analysis (OR = 0.92, 95% CI = 0.81-1.05) and no significant difference for the B1B1 genotype (OR = 1.04, 95% CI = 0.98-1.11) and B1B2 genotype (OR = 1.03, 95% CI = 0.97-1.08). Cumulative analysis confirmed these results.Our results suggest that the B2B2 genotype of the CETP TaqIB polymorphism is a protective factor against the development of MI.