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Journal Wrap
The hottest research from various peer-reviewed journals – handpicked weekly by the ACC.org Editorial Board led by Kim Eagle, MD, MACC.
Focused Ultrasound Accurate in AAS Diagnosis
Transthoracic focused cardiac ultrasound (FoCUS) may improve the ability to identify and exclude patients with suspected acute aortic syndromes (AAS), even in patients with low clinical probability, according to a study published in the European Heart Journal.
In this study by Peiman Nazerian, MD, et al., patients with suspected AAS underwent FoCUS for detection of direct/indirect signs of AAS. Clinical probability assessment was performed with the aortic dissection detection risk score. Diagnosis was based on advanced imaging, surgery, autopsy or 14-day follow-up.
A total of 864 patients with suspected AAS underwent FoCUS, with further analysis in 839. A diagnosis of AAS was reported in 146 of 839 study patients (17 percent). Direct signs, only indirect signs and negative findings on US were observed in 10 percent, 27 percent and 63 percent of patients, respectively.
With direct US findings, a diagnosis of AAS was reported in 78 percent; this was 29 percent with indirect findings and 3 percent with a negative US. The sensitivity and specificity was 45 percent and 97 percent for direct US findings, and 89 percent and 75 percent for any US findings.
The area under the receiver operator curve improved from 0.77 using the aortic dissection detection risk score alone to 0.85 with the addition of direct US findings and to 0.88 with the addition of any US findings. The use of US in patients with low clinical probability (aortic dissection detection risk score ≤1) and a D-dimer <500 mg/mL had a diagnostic sensitivity of 100 percent and specificity of 59 percent.
According to the authors, these findings validate recommendations for FoCUS for diagnosis of suspected AAS and support its adoption in clinical practice.
"The main utility of FoCUS is represented by identification of direct signs of AASs in a relatively small but significant subset of patients at low clinical probability," they write.
Nazerian P, Mueller C, Vanni S, et al. Eur Heart J 2019;Apr 25:[Epub ahead of print].
Increased Stroke Risk With New-onset Peri, Postoperative AFib
New-onset perioperative/postoperative atrial fibrillation (POAF) is associated with short- and long-term increased risk of stroke and mortality, found a study published in Stroke.
This meta-analysis from Meng-Hsin Lin, MD, et al., included 35 studies with 2,458,010 patients; 12 studies reported early outcomes and 28 reported late outcomes.
In the early outcomes studies, there were 60 stroke events in 8,588 patients with POAF (1.9 percent) and 240 stroke events in 24,731 patients without POAF (1.0 percent). In patients with POAF, there were 1,269 deaths among 30,361 patients (4.2 percent) vs. 7,942 deaths among 428,823 patients without POAF (1.9 percent).
Pooling in the random-effects model showed that POAF was associated with increased risks of early stroke (odds ratio [OR], 1.62; p<0.00001) and early mortality (OR, 1.44; p=0.007).
In the late outcomes studies, there were 643 stroke events in 26,925 patients with POAF (2.4 percent), and 7,008 stroke events in 1,710,493 patients without POAF (0.4 percent). In the patients with POAF, there were 5,912 deaths among 18,080 patients vs. 15,720 deaths in 70,217 patients without POAF (22.4 percent).
Pooling in the random-effects model showed that POAF was associated with increased risks of long-term stroke (hazard ratio [HR], 1.37; p=0.01) and long-term mortality (HR, 1.37; p<0.00001).
In patients with new-onset POAF, vs. without POAF, the risk of early stroke was 62 percent higher and the risk of death was 44 percent higher. Further, in these same groups, the risk of long-term stroke was 37 percent higher and the risk of death was 37 percent higher. The risk of long-term stroke was substantially higher among patients with new-onset POAF who received noncardiac surgery. Most POAF occurred two to four days after surgery.
The authors conclude "the best strategy to reduce stroke risk (empirical lifelong anticoagulation versus monitoring for AFib recurrence) needs to be determined in future studies."
Lin MH, Kamel H, Singer DE, et al. Stroke 2019;May 2:[Epub ahead of print].
Surgery Risky For Patients With History of VTE
In patients with a history of venous thromboembolism (VTE), surgery was associated with an increased risk of recurrent VTE, with the risk remaining high for up to six months after the procedure, The findings were published in JAMA Network Open.
Banne Nemeth, MD, et al., followed 3,741 patients with a history of VTE for a median of 5.7 years. Of these, 580 (15.5 percent) underwent surgery and 601 (16.1 percent) developed a recurrent VTE event.
The cumulative incidence of recurrent VTE after surgery was 2.1 percent at one month, and this increased to 3.3 percent at three months and 4.6 percent at six months.
Risk of VTE recurrence at six months ranged from 2.3 percent to 9.3 percent depending on the type of surgery. Independently associated with VTE recurrence post surgery, vs. patients without surgery, were Factor V Leiden mutation (hazard ratio [HR], 3.4) and male sex (HR, 2.7).
Cancer-related surgery, major orthopedic, gastrointestinal and heart-lung procedures were associated with the highest risks of recurrence, while outpatient and minor surgery came with lower risks.
"Given that VTE is the most preventable death in hospitals, and 60 percent of VTE cases occur during or following hospitalization, it is important to acknowledge the high recurrence risks associated with surgery when a patient has a history of VTE," the authors write.
They conclude these findings, "stress the need for a revision of the thromboprophylactic approach following surgery in patients with a history of VTE, the duration and dosage of which may need to be intensified and individualized."
Nemeth B, Lijfering WM, Nelissen RG, et al. JAMA Netw Open 2019;2:e193690.
Keywords: ACC Publications, Cardiology Magazine, Odds Ratio, Atrial Fibrillation, Venous Thromboembolism, Incidence, Outpatients, Minor Surgical Procedures, Follow-Up Studies, Autopsy, Neoplasms, Stroke, Risk, Probability, Hospitalization, Aneurysm, Dissecting, Mutation
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