The authors point out that prior trials with fibrates, niacin and most cholesterol ester transfer protein inhibitors that targeted raising HDL-C and/or lowering triglycerides have failed to demonstrate conclusive evidence of incremental event reduction after “optimally controlled” LDL-C levels with statins. While fibrates are effective in reducing elevated triglyceride levels, the authors note that evidence for reducing residual risk when combined with statins remains uncertain.

Furthermore, even though omega-3 fatty acids have been found to be efficacious in lowering triglyceride levels and may have pleiotropic effects such as reducing plaque instability and proinflammatory mediators of atherogenesis, the authors state that clinical outcomes data are currently lacking. Currently, several ongoing randomized trials of triglyceride-lowering strategies with optimal dosage of omega-3 fatty acids are nearing completion.

“If triglyceride reduction improves cardiovascular disease risk beyond LDL-C, the potential added benefit of omega-3 fatty acids may be considerable, especially in diabetic patients at high ASCVD residual-risk burden and frequently high triglyceride levels, in addition to elevated LDL-C,” the authors conclude.

Ganda OP, Bhatt DL, Mason RP, et al. J Am Coll Cardiol 2018;72:330-43.

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Advances in this technology allow patients and family members to better understand their cardiac conditions, helping them to make more informed decisions surrounding their medical care. Medical students and trainees can better visualize cardiac abnormalities with virtual reality, which allows trainees to simulate operating environments and multiple physicians to interact while viewing the same educational material in a natural environment. Additionally, 3D workstations may assist physicians in assessing the heart in surgical situations where it may be difficult to see.

Early research has shown that improved visualization due to virtual technology will allow physicians to learn more quickly, interpret images more accurately and accomplish interventions in less time. These improvements will most likely translate into lower cost procedures and better outcomes for patients.

“For years, virtual reality technology promised the ability for physicians to move beyond 2D screens in order to understand organ anatomy noninvasively,” writes Jennifer N.A. Silva, MD, lead author of the paper. “However, bulky equipment and low-quality virtual images hindered these developments. Led by the mobile device industry, recent hardware and software developments — such as head mounted displays and advances in display systems – have enabled new classes of 3D platforms that are transforming clinical cardiology.”

Silva JNA, Southworth M, Raptis C, Silva J. JACC Basic Trans Science 2018;3:420-30.

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Using data from Hong Kong’s Clinical Data Analysis and Reporting system, the researchers identified 15,292 participants, 48 percent of whom were women, who had a new AFib diagnosis between 2010 and 2015. Researchers conducted propensity scoring separately for men and women and matched DOAC users to warfarin users at a 1:1 ratio.

Among men, 152 (6.11 percent) of warfarin users and 140 (5.63 percent) of DOAC users experienced ischemic stroke and systemic embolism. In comparison, among women, ischemic stroke and systemic embolism occurred in 191 (7.9 percent) of warfarin users and 153 (6.33 percent) of DOAC users. Use of DOACs was associated with a reduced risk of intracranial hemorrhage and all-cause mortality when compared with warfarin among women only. DOAC use was associated with a lower risk of gastrointestinal bleeding for both men and women.

According to the authors, additional research is necessary to “evaluate the sex differences in the clinical outcomes of DOACs vs. warfarin based on the different mechanism of action of the drugs.”

Law SWY, Lau WCY, Wong ICK, et al. J Am Coll Cardiol 2018;72:271-82.

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A sample of 5,161 men from JUPITER was also included in this study for the validation models. A derivation sample of 16,400 women from WHS was used to examine the association of Lp(a) with incident cardiovascular disease. This was then tested in WHS validation data (n=8,158) and the other study samples. The primary outcome of interest was incident cardiovascular disease. Models included traditional cardiovascular risk factors with and without Lp(a) to examine risk reclassification.

Among the 24,558 women in the full WHS sample, the average age was 54 years, 11 percent were current smokers and 2 percent had diabetes at baseline. Mean values of total and HDL cholesterol were 211 and 54 mg/dL, respectively. The distribution of Lp(a) was highly skewed, with a median of 10.5 mg/dL (25th, 75th percentiles: 4.4, 32.3 mg/dL). Age, proportion who were black and systolic blood pressure increased with Lp(a) level, as did total cholesterol, LDL-C, apolipoprotein B, and high-sensitivity C-reactive protein.

Use of hormone therapy was highest in those at the lowest Lp(a) level. HDL-C and apolipoprotein A1 were not associated with Lp(a). A curvilinear association was observed in WHS, with increased cardiovascular disease risk among those with Lp(a) >50 mg/dL, but only among women with total cholesterol >220 mg/dL.

In the WHS test sample, there was a small but significant change in the C statistic (0.790-0.797; p=0.035), but no improvement in measures of reclassification. This pattern was replicated among women in the WHI and JUPITER trial. In contrast, there was a strong association of Lp(a) with cardiovascular disease among men with low total cholesterol levels in JUPITER.

The authors concluded that in three cohorts of women, Lp(a) was associated with cardiovascular disease only among those with high total cholesterol and improvement in prediction was minimal. These data have implications for Lp(a) in clinical practice among women and for trials of Lp(a)-lowering agents.

Cook NR, Mora S, Ridker PM. J Am Coll Cardiol 2018;72:287-96.

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Women with pre-eclampsia with severe features had the following significantly different (p<0.001) echocardiographic parameters compared with pregnant control patients: higher RVSP (31.0 vs. 22.5 mm Hg); decreased global RVLSS (–19.6 vs. –23.8); higher mitral septal e’ velocity (9.6 vs. 11.6 cm/s); higher septal E/e’ ratio (10.8 vs. 7.4); larger left atrial area size (20.1 vs. 17.3 cm2); and increased posterior and septal wall thickness (median 1.0 cm vs. 0.8 cm and 1.0 cm vs. 0.8 cm, respectively).

Of the women with pre-eclampsia with severe features, eight (12.7 percent) had grade II diastolic dysfunction and six (9.5 percent) had peripartum pulmonary edema.

“Our results provide further evidence that diastolic dysfunction and LV remodeling occur during pre-eclampsia,” the authors write. “In addition, we confirm a reduction in RVLSS, likely due to a combination of intrinsic subclinical RV dysfunction and increased RV afterload, and increased pulmonary artery pressures (i.e., elevated RVSP).”

The authors add that future studies should determine the timeline for development of the abnormal echocardiographic findings associated with pre-eclampsia and whether they are associated with short- and long-term cardiovascular sequelae.

Vaught AJ, Kovell LC, Szymanski LM, et al. J Am Coll Cardiol 2018;72:1-11

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