Psychological Characteristics of Patients with Takotsubo Syndrome and Patients with Acute Coronary Syndrome: An Explorative Study toward a Better Personalized Care

During an acute cardiac event, Takotsubo Syndrome (TTS) and Acute Coronary Syndrome (ACS) apparently share very similar clinical characteristics. Since only a few inconsistent studies have evaluated the psychological features that characterize these different patients, the aim of the present explorative research was to investigate if post-recovery TTS and ACS patients present different psychological profiles. We also investigated whether the occurrence of acute psychological stressful episodes that had occurred prior to the cardiac event could be found in either syndrome. Twenty TTS and twenty ACS female patients were recruited. All patients completed self-report questionnaires about anxiety and depressive symptoms, perceived stress, type-D personality and post-traumatic symptoms. Results showed that only three subscales of health anxiety (i.e., Fear of Death/Diseases, Interference and Reassurance) significantly differed between the two groups, while no differences were found in the other psychological measurements. Moreover, personality traits seem to not be associated with the impact of the cardiac traumatic event. Finally, only TTS patients reported the presence of a significant emotional trigger preceding the acute cardiac event. In conclusion, post-recovery TTS patients differ from ACS patients in their level of concern about their health and in their need of reassurance and information only, probably as a result of the different clinical characteristics of the two illnesses.

Driving Restrictions and Early Arrhythmias in Patients Receiving a Secondary Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD-II study)

Background: Regulatory authorities of most industrialized countries recommend 6-months of private driving restriction after implantation of a secondary prevention ICD. These driving restrictions result in significant inconvenience and social implications. The purpose of this study was to assess the incidence rate of appropriate device therapies in contemporary recipients of a secondary prevention ICD. Methods: A retrospective study at three Canadian tertiary care centers enrolling consecutive patients with new secondary prevention ICD implants between 2016-2020. Results: 721 patients were followed for a median of 760 days (324, 1190). The risk of recurrent ventricular arrhythmia was highest during the first three months after device insertion (34.4%), and decreased over time (10.6% between 3−6 months, 11.7% between 6-12 months). The corresponding incidence rate per 100 patient-days was 0.48 (95% CI 0.35-0.64) at 90 days, 0.28 (95% CI 0.18−0.48) at 180 days and 0.20 (95% CI 0.13−0.31) between 181-365 days after ICD insertion (p<0.001). The cumulative incidence of arrhythmic syncope resulting in sudden cardiac incapacitation was 1.8% within the first 90 days and subsequently dropped to 0.4% between 91-180 days (p<0.001) after ICD insertion. Conclusions: The incidence rate of appropriate therapies resulting in sudden cardiac incapacitation in contemporary recipients of a secondary prevention ICD is much lower than previously reported, and significantly declines after the first three months. Lowering driving restrictions to three months after the index cardiac event seems safe and revision of existing guidelines recommending should be considered in countries still adhering to a 6-months period. Existing restrictions for private driving after implantation of a secondary prevention ICD should be reconsidered.

Supporting patients to make meaning, create connections and live life post cardiac event

Rosemary Higgins shares her insight into supporting patients mentally and emotionally after a cardiac event

Cardiac Events in Patients with Acute Myeloid Leukemia Treated with Venetoclax in Combination with Hypomethylating Agents

Background: Venetoclax, a small-molecule inhibitor of B cell leukemia/lymphoma-2, in combination with hypomethylating agents (HMA) has shown improved efficacy and survival benefit compared to HMA alone (DiNardo et al, 2020) in elderly/unfit patients with acute myeloid leukemia (AML). Since FDA-approval of this regimen for elderly/unfit AML patients, it is frequently utilized both in the upfront and relapsed/refractory setting. Cardiac events with venetoclax are not well described. In the VIALE-E trial, which included patients ineligible for standard induction chemotherapy due to congestive heart failure or stable angina, 15% of patients receiving azacitidine plus venetoclax experienced atrial fibrillation as a serious adverse event, vs. 1% in the azacitidine plus placebo group (DiNardo et al, 2020). Our objective was to provide an estimate of the prevalence of and a description of all cardiac events that occurred in AML patients undergoing treatment with venetoclax + HMA. Methods: 170 consecutive patients with AML who received venetoclax +HMA (azacitidine or decitabine) outside the context of a clinical trial between 1/2017-11/2020 at the Mayo Clinic were included. Patients received venetoclax + HMA either as upfront treatment or for relapsed/refractory disease. Patients with relapse following allogeneic stem cell transplant were excluded. We evaluated all cardiac events that occurred while treatment with venetoclax + HMA was ongoing. Baseline patient and treatment characteristics were compared using the Mann-Whitney U-test and the Fisher's exact test. All statistics were computed using EZR (Version 1.53). Results: 1. Patient characteristics A total of 170 patients who received venetoclax + HMA (median age 69 years [range 17-91], 63% males) were included. ELN risk category was either adverse risk (48%, 82/170) or intermediate risk (48%, 82/170) in the majority of patients. 64% (109/170) of patients received venetoclax + HMA as upfront treatment. Characteristics including age, ELN cytogenetic risk, cardiovascular risk factors, and upfront vs relapsed therapy were similar among patients with or without cardiac events. The only exception was a higher incidence of CEBPA mutation amongst those with cardiac events (12% vs 2%, p=0.03). The majority (83%, 141/170) of patients underwent an echocardiogram prior to initiation of therapy. 2. Cardiac events Of 170 patients treated with venetoclax + HMA during the study period, 34 (20%) patients experienced a total of 48 cardiac events. Of patients experiencing cardiac events, 32% (11/34) had no pre-existing cardiac disease and 12% (4/34) had no cardiovascular risk factors (Table 1). The majority of events occurred early in treatment course: 41% during cycle 1, 26% during cycle 2 and 15% during cycle 3 (Table 1). The most frequently occurring cardiac event (21%, 10/48 events) was a decrease in left ventricular ejection fraction on echocardiography, which was associated with symptoms in all ten patients. Second most frequent was atrial fibrillation with rapid ventricular response at 17% (8/48 events), followed by troponin elevation without electrocardiogram changes at 15% (7/46 events). Of patients with troponin elevation, 57% (4/7 events) occurred in the setting of another inciting factor such as severe anemia, while 43% represented a troponin elevation without explanation (Table 1). Other cardiac events included heart failure with preserved ejection fraction (n=4), other symptomatic arrhythmia (n=4), and symptomatic pericardial effusion or pericarditis (n=3). In addition, 2 of 34 (6%) patients experienced fatal cardiopulmonary arrest. The majority (88%) of cardiac events required either inpatient admission (62%, 21/34 patients) or intensive care unit (ICU) care (26%, 9/34 patients). 77% of patients required new cardiac medications or procedural intervention (n=4). In 27% of cases (9/34 patients), the cardiac event directly contributed to death (Table 1). Conclusions: Cardiac complications were observed in one-fifth (20%) of AML patients treated with venetoclax + HMA, despite the absence of preexisting cardiac disease in a third of cases; moreover 27% of events were fatal. Further comparative studies are required to identify salient clinical features predictive of cardiac complications in these patients. Figure 1 Figure 1. Disclosures Al-Kali: Novartis: Research Funding; Astex: Other: Research support to institution. Litzow: Astellas: Research Funding; Amgen: Research Funding; Omeros: Other: Advisory Board; AbbVie: Research Funding; Actinium: Research Funding; Pluristem: Research Funding; Jazz: Other: Advisory Board; Biosight: Other: Data monitoring committee. Patnaik: Kura Oncology: Research Funding; StemLine: Research Funding.

The Role of STEMI Communication Network with Major Adverse Cardiac Event Incidence in STEMI Patients Hospitalized in Saiful Anwar General Hospital Malang

Background : Patient with ST-Elevation Myocardial Infarction (STEMI) requires urgent reperfusion either with fibrinolytic or primary Percutaneous Coronary Intervention (PCI). In Malang, a communication network of STEMI has been developed. It connects Saiful Anwar General Hospital with all of the Public Health Centers (PHC) in Malang Raya to shorten system delay since 2015. Objective : To elucidate Malang’s communication network’s role in decreasing Major Adverse Cardiac Event (MACE) in STEMI patients. Methods : This is a retrospective cohort study. Study sample was taken from medical record. Non-network: 96 patients and 88 network patients. Statistical tests using SPSS version 20.0 software. Results : Bivariate analysis showed network-group has a significantly lower MACE (p=0.001). Door-to-balloon time was also lower in network-group (p=0.026). Multivariate analysis without confounder showed that network-group had significantly shorter door-to-reperfusion time (p=0.032) and lower MACE (p=0.035) compared to non-network group. But multivariate analysis with confounder door-to-balloon and door-to-needle failed to explain lower MACE incidence. Network-group (p=0.005) and reperfusion with primary PCI (p=0.05) significantly decreased MACE incidence. Conclusion : Malang’s STEMI communication network and reperfusion with primary PCI reduced MACE in STEMI patients in Saiful Anwar General Hospital Malang.

Getting ‘Back on Track’ after a cardiac event: Protocol for a Randomised Controlled Trial of an online self-management program (Preprint)

BACKGROUND After a cardiac event, a large majority of cardiac patients do not achieve recommended behaviour change targets for secondary prevention. Mental health issues can also impact on the ability to engage in health behaviour change. There is a need for innovative, flexible and theory driven e-health programs which include evidence-based strategies to assist cardiac patients with their recovery, especially in behavioural and emotional self-management. OBJECTIVE The aim of this study is to determine the short and longer-term behavioural and emotional wellbeing outcomes of the Back on Track online self-management program. In addition, this study will test whether there is enhanced benefit of providing one-on-one telephone support from a trained lifestyle counsellor, over and above benefit obtained through completing the online program alone. METHODS People who have experienced a cardiac event in the previous 12 months and have access to the internet will be eligible for this study (N=120). Participants will be randomly assigned to one of the two study conditions: either ‘self-directed’ completion of the Back on Track program (without assistance), or ‘supported’ completion of the Back on Track program (additional two telephone sessions with a lifestyle counsellor). All participants will have access to the Back on Track online program for 2 months. Telephone sessions with the supported arm participants will occur at approximately 2- and 6-weeks post enrolment. Measures will be assessed at baseline, and then 2 and 6 months later. Outcome measures assessed at all three timepoints include dietary intake, physical activity and sitting time, smoking status, anxiety and depression, stage of change and self-efficacy in relation to behavioural and emotional self-management, quality of life and self-rated health and wellbeing. A demographic questionnaire will be included at baseline only and program acceptability at 2 months only. RESULTS Recruitment began in May 2020 and concluded in August 2021. Data collection for the 6-month follow-up will be completed by February 2022 and data analysis and publication of results will be complete by June 2022. A total of 122 participants were enrolled in this study. CONCLUSIONS The Back on Track trial will enable us to quantify the behavioural and emotional improvements obtained and maintained for cardiac patients and, in particular, to compare two modes of delivery – one fully self-directed and the other supported by a lifestyle counsellor. We anticipate that the Back on Track online program will assist patients in their recovery and self-management after an acute event, and represents an effective, flexible and easily accessible adjunct to centre-based rehabilitation programs. CLINICALTRIAL Australian New Zealand Clinical Trials Registry (Trial Registration Number: ACTRN12620000102976); http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378920&isReview=true

Functional Capacity Change after Phase II Cardiac Rehabilitation as a Predictor of Major Adverse Cardiac Event in Left Ventricular Dysfunction Patients Underwent Coronary Artery Bypass Grafting

Background: Phase II cardiac rehabilitation is essential for management post coronary artery bypass graft (CABG), especially in patients with left ventricular systolic dysfunction. Change in functional capacity after phase II cardiac rehabilitation (∆METs) is an indicator of cardiopulmonary and hemodynamic improvement after CABG. This study assessed the correlation of ∆METs as a predictor of major adverse cardiac event (MACE) 3 months after CABG in patients with left ventricular systolic dysfunction. Methods: A cohort study was conducted on patients with left ventricular systolic dysfunction who underwent CABG between January 2019 to January 2021. Then patients were recruited to phase II cardiac rehabilitation, ∆METs was measured and tabulated by differences of functional capacity before and after the program. The abnormalities of ∆METs were discovered as a predictor of MACE determined by cut-off point, which is combination of death and rehospitalization. Patients were monitored for 3 months after CABG. Result: Among 91 patients, 24.2% had MACE (6.6% death and 17.6% rehospitalization). We found significant correlation between ∆METs and MACE with cut-off point 3.25 METs (p <0.001). Multivariate analysis using logistic regression showed lower ∆METs group had significant correlation with MACE (OR 0.135; p 0.03). Kaplan Meier survival analysis showed lower ∆METs group was predictor of MACE on 3 months after CABG, risk of MACE occurrence 3.9 times than higher ∆METs group (p <0.001). Conclusion: Change in functional capacity could predict MACE on 3 months follow-up of left ventricular systolic dysfunction patients who underwent CABG. Keywords: Change in functional capacity; left ventricular systolic dysfunction; MACE; CABG.

Inflammation-Related Biomarkers Are Associated with Heart Failure Severity and Poor Clinical Outcomes in Patients with Non-Ischemic Dilated Cardiomyopathy

Inflammation-related biomarkers are associated with clinical outcomes in mixed-etiology chronic heart failure populations. Inflammation-related markers tend to be higher in ischemic than in non-ischemic dilated cardiomyopathy (NI-DCM) patients, which might impact their prognostic performance in NI-DCM patients. Therefore, we aimed to assess the association of inflammation-related biomarkers with heart failure severity parameters and adverse cardiac events in a pure NI-DCM patient cohort. Fifty-seven patients with NI-DCM underwent endomyocardial biopsy. Biopsies were evaluated by immunohistochemistry for CD3+, CD45ro+, CD68+, CD4+, CD54+, and HLA-DR+ cells. Blood samples were tested for high-sensitivity C-reactive protein (hs-CRP), interleukin-6, tumor necrosis factor-α (TNF-α), soluble urokinase-type plasminogen activator receptor and adiponectin. During a five-year follow-up, twenty-seven patients experienced at least one composite adverse cardiac event: left ventricle assist device implantation, heart transplantation or death. Interleukin-6, TNF-α and adiponectin correlated with heart failure severity parameters. Patients with higher levels of interleukin-6, TNF-α, adiponectin or hs-CRP, or a higher number of CD3+ or CD45ro+ cells, had lower survival rates. Interleukin-6, adiponectin, and CD45ro+ cells were independently associated with poor clinical outcomes. All patients who had interleukin-6, TNF-α and adiponectin concentrations above the threshold experienced an adverse cardiac event. Therefore, a combination of these cytokines can identify high-risk NI-DCM patients.