Two athletes with hypertrophic cardiomyopathy continued to play against medical advice and died during exercise. Another 225 athletes had valvular or congenital disorders such as bicuspid aortic valve (68 of 225), atrial septal defect (62), aortic insufficiency (29) and mitral valve prolapse (24).

There were 23 deaths in total, eight (35 percent) of which were due to a cardiac cause. The second most common cause was road traffic accidents in seven (30 percent). Of the eight sudden cardiac deaths, four athletes were white, and six had passed the screening process as within normal ranges. The time between screening and death ranged from less than one year to 13.2 years. Autopsy data were available for all the deaths.

The calculated incidence of sudden cardiac death was one per 14,794 person-years or 6.8 per 100,000 athletes. Most of the deaths were due to cardiomyopathies that were not identified during the screening process. The overall prevalence of cardiac diagnoses associated with sudden cardiac death was 0.38 percent.

Limitations of the study include a focused cohort in terms of sport, gender, location; mortality data relied on recall on questionnaire by the football/soccer clubs, perhaps not capturing all cases; and an impressive screening program including ECG, echo, and renowned expert consultants that would not be easily replicated elsewhere.

Malhotra A, Dhutia H, Finocchiaro G, et al. N Engl J Med 2018;379:524-34.

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Marc S. Sabatine, MD, MPH, FACC, et al., found in the meta-analysis of statins that the mean LDL-C in the control arm was 65.7 mg/dL. A total of 1,922 major vascular events occurred. The risk ratio for major vascular events was 0.78 per 38.7-mg/dL reduction in LDL-C.

For the three trials of nonstatin therapies for lowering LDL-C added to statins, the median LDL-C in the control arms ranged from 63 mg/dL to 70 mg/dL in the 50,627 patients. A total of 9,570 major vascular events occurred. Nonstatin therapy lowered LDL-C by 11 mg/dL to 45 mg/dL. The risk ratio for major vascular events was 0.79 per 38.7-mg/dL reduction in LDL-C. Taken together, the risk ratio for statins and nonstatins was 0.79 (p<0.001).

LDL-C lowering was not associated with an increased risk of serious adverse events, myalgias and/or myositis, elevation in aminotransferases, new-onset diabetes, hemorrhagic stroke or cancer in any of the trials.

The authors write that these findings show a consistent clinical benefit from further LDL-C lowering in patient populations starting as low as a median of 63 mg/dL and achieving levels as low as a median of 21 mg/dL. These levels are considerably lower than the targets or thresholds for additional nonstatin LDL-C–lowering therapy in current cholesterol guidelines.

Sabatine MS, Wiviott SD, Im KH, et al. JAMA Cardiol 2018;Aug 1:[Epub ahead of print].

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The results showed that 22 percent of patients had carotid artery disease at the time of the TAVR procedure – 17.2 percent had moderate, 3.2 percent had severe and 1.6 percent had occlusive disease. Patients with carotid artery disease at baseline were more likely to have a history of hypertension, diabetes, stroke or myocardial infarction.

After one year, the primary endpoint of incidence of stroke in patients with and without carotid artery disease, respectively, was 4.5 vs. 4.1 percent. A secondary endpoint of all-cause mortality was 21.5 vs. 19.9 percent, respectively.

Although patients with carotid artery disease had higher cumulative incidence rates of stroke and mortality at 30 days and one year, these differences were not significant after adjusting for patient characteristics.

The researchers conclude that although stroke continues to be a complication in post-TAVR patients, the study suggests that “post-TAVR stroke seems to be because of mechanisms other than carotid artery disease.” Moving forward, their research could be “helpful in focusing attention toward other stroke reduction strategies.”

Kochar A, Li Z, Harrison JK, et al. Circ Cardiovasc Interv 2018;11:e006322.

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The mean age of the 727 TAVR and 431 SAVR patients was 81 years. Nine percent were classified as malnourished and 33 percent as at-risk for malnutrition. Worse nutritional scores were correlated with worse frailty scores (r=0.31). Unadjusted mortality at one year was higher in malnourished patients than in those with normal nutritional status (28 vs. 10 percent; p<0.01).

Variables independently associated with mortality at one year, after multivariable adjustment, were malnutrition (odds ratio [OR], 1.08 per point decrease in scale); frailty (OR, 1.14 per point decrease in scale); Society of Thoracic Surgeons-Predicted Risk of Mortality (STS-PROM) score (OR, 1.10 per percent); and TAVR (vs. SAVR) procedure (OR, 1.63).

According to the authors, this is the first study to systematically screen for malnutrition and demonstrate it predicts poor outcomes after TAVR and SAVR. The findings demonstrate: 1) screening for malnutrition is easy; 2) malnutrition is a risk factor for mid-term mortality and to a lesser extent short-term mortality and major morbidity post procedure; and 3) risk associated with malnutrition persists even after adjusting for physical function and other potential confounders.

The study raises the question of whether pre- and postoperative interventions should be recommended in malnourished cardiac patients to improve postoperative outcomes, they add. Clinical trials are needed to validate the beneficial clinical impact of targeted nutritional interventions in malnourished or at-risk older adults undergoing TAVR or SAVR.

Goldfarb M, Lauck S, Webb JG, et al. Circulation 2018;Jul 5:[Epub ahead of print].

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