Featured topics and Editors’ Picks from all of ACC’s JACC Journals. JACC Journals continue to rank among the most trusted sources for the latest in cardiovascular research and perspectives. This year, JACC retained the top spot for impact factor rankings among cardiovascular journals, with JACC: Cardiovascular Interventions, JACC: Cardiovascular Imaging and JACC: Heart Failure also ranking in the top 10. In this issue of Cardiology, we look back at some of the most popular papers published in the JACC journals during 2016. JACC Consensus Statement Offers Guidance on Preventing Sudden Cardiac Death in Athletes A consensus statement developed by a task force convened by the National Collegiate Athletic Association (NCAA) established guidance for conducting pre-participation screenings of college athletes. It also encouraged the development of emergency action plans for quickly responding to sudden cardiac arrest. The task force included multidisciplinary physician specialists and athletic trainers representing national sports and medical associations, including the ACC. Hainline B, JA, Baggish A, et al. J Am Coll Cardiol. 2016;67:2981-2995. Fuster Says the Stethoscope is Alive and Well In a March 2016 editor’s page, JACC Editor-in-Chief Valentin Fuster, MD, PhD, MACC, weighed in on the idea that the stethoscope is dead, determining it to still by very much alive and necessary. “[E]chocardiography systems are not — and will never be — poised to totally eradicate the stethoscope, as it is not possible for every clinician to possess a handheld echocardiography within and outside the United States,” Fuster writes. “Thus, we cannot discontinue the important training that takes place during physical exam, which can be aided through the amplified sounds of a stethoscope. … We cannot teach our medical students to become reliant upon advanced technologies without which they become useless.” Fuster V. J Am Coll Cardiol. 2016;67:1118-1119. State of the Art Review Examines Contrast-Induced Acute Kidney Injury Despite advancements in imaging and interventional techniques, iodinated contrast continues to pose a risk of contrast-induced acute kidney injury (CI-AKI) for a subgroup of patients at risk for this complication. There has been a consistent and graded signal of risk for associated outcomes including need for renal replacement therapy, rehospitalization and death, related to the incidence and severity of CI-AKI. According to the review, minimizing contrast by using the “as low as reasonably achievable” (ALARA) principles and strategies to maximize the benefit of contrast exposure, such as revascularization are reasonable. Although no adjunctive therapy is prophylactic or therapeutic for CI-AKI, statin use appears to reduce the incidence and severity of AKI, whereas continuation of renin-angiotensin system inhibitors appears to increase the risk for CI-AKI. McCullough PA, Choi JP, Feghali GA, et al. J Am Coll Cardiol. 2016;68:1465-1473. JACC: Cardiovascular Interventions Immediate vs. Delayed Invasive Intervention in NSTEMI An immediate invasive strategy (median time 1.4 hours) may be superior to a delayed invasive strategy (median time 61 hours) in improving cardiovascular outcomes in non–ST-segment myocardial infarction (NSTEMI) patients, mainly driven by a reduction in the rate of reinfarction. Researchers examined 323 NSTEMI patients and found that at 30-day follow-up, faster treatment was associated with lower rates of death or new MI compared with delayed treatment. These findings persisted at one year. This difference was attributable to lower rates of new MI in patients who underwent an immediate invasive procedure, particularly during the period prior to catheterization. Milosevic A, Vasiljevic-Pokrajcic Z, Milasinovic D, et al. JACC Cardiovasc Interv. 2016;9:541-549. JACC: Cardiovascular Imaging ACC Imaging Council Weighs Screening Options For Diabetic Patients Coronary artery calcium (CAC) screening is the best non-invasive tool for measuring the risk of cardiovascular disease in asymptomatic patients with diabetes, according to a state-of-the-art paper from ACC’s Imaging Council. The Council examined all screening tools currently used for risk assessment in patients with diabetes, including stress testing, carotid intima-media thickness, CAC screening, echocardiography, radionuclide imaging, coronary computed tomography angiogram and cardiac magnetic resonance imaging. According to the authors, patients with type 2 diabetes have higher amounts of CAC than non-diabetic patients, but a high proportion of adults with diabetes have a CAC score of 0 or very low. They explain that CAC provides strong risk stratification of these patients. Mortality risks are higher for each CAC category in patients with diabetes compared to those without. Patients with rapid progression of CAC are at a higher risk of coronary heart disease events. Budof MJ, Raggi P, Beller GA, et al. J Am Coll Cardiol Img. 2016;9:176-192. JACC: Heart Failure PARADIGM-HF: LCZ696 Superior to Enalapril in HF Patients Combined angiotensin-receptor blocker (valsartan)/neprilysin inhibitor (sacubitril) LCZ696 was superior to enalapril in patients with heart failure due to reduced ejection fraction in the PARADIGM-HF trial. Overall, 8,442 participants were randomized. Systolic blood pressure at eight months was 3.2 mm Hg lower with LCZ696 compared with enalapril. The trial was stopped early due to prespecified stopping rules for benefit. At a median of 27 months, the primary outcome of cardiovascular death or hospitalization for heart failure occurred in 21.8 percent of the LCZ696 group vs. 26.5 percent of the enalapril group (p < 0.001). This benefit was consistent among all subgroups. The association for the primary outcome did not vary according to time from heart failure hospitalization to screening. Solomon SD, Claggett B, Packer M, et al. JACC Heart Fail. 2016;4:816-822. JACC: Clinical Electrophysiology Can CPVT Patients Compete in Sports? Patients with catecholaminergic polymorphic ventricular tachycardia (CPVT), who are usually disqualified from participating in most sports due to a risk of sudden cardiac death, may be able to safely participate in athletics if they are well treated and well informed. Researchers examined 63 patients ages six and older with CPVT to determine the impact of continued sports participation and found no difference in events or event rates between patients identified as athletes vs. those considered non-athletes. According to the researchers, the decision for these patients to compete in sports is complex and must involve all relevant family members and coaches, especially if the patient is a minor. There must be a discussion of the risks and benefits associated with sports, the diagnosis, and the impact of any side effects associated with treatment before a decision is made. Ostby SA, Bos JM, Owen HJ, et al. JACC Clin Electrophysiol. 2016;2:253-262. ? JACC: Basic to Translational Science Fewer CV Drugs Being Studied in Clinical Trials The number of cardiovascular drugs in the research pipeline has declined across all phases of development in the last 20 years even as cardiovascular disease has become the number one cause of death worldwide. Researchers analyzed data from a large commercial database of drug development activity, which tracks the pipeline of pharmaceutical research and development projects. The study included all products that had entered Phase 1 clinical trials between Jan. 1, 1990, and Dec. 31, 2012, and focused on drugs intended to treat cardiovascular disorders. During the study period, the number of cardiovascular drugs entering clinical trials in all stages of development declined over time. Between 1990 and 1995, 108 of 679 (16 percent) of Phase 1 trials were initiated for cardiovascular drugs, compared with 125 of 2,366 (5 percent) of Phase 1 trials between 2005 and 2012. Cardiovascular drugs accounted for 21 percent of Phase 3 trials in 1990 but only 7 percent in 2012. In comparison, the number of cancer drugs increased over the same time period. Hwang TJ, Lauffenburger JC, Franklin JM, et al. JACC Basic Trans Science. 2016;1:301-308. BP Game Plan Needed for Football Linemen? Football players at the collegiate level may be at higher risk for increased blood pressure and changes in size, shape, structure and function of the heart, with lineman at an even greater risk, according to a study published Dec. 5 in JACC: Cardiovascular Imaging. Researchers, led by Jeffrey Lin, MD, FACC, examined 87 football participants, including 30 linemen and 57 non-linemen. Prior to the season, 57 percent of linemen and 51 percent of non-linemen met the criteria for pre-hypertension. However, after the season, 90 percent of linemen met the criteria for prehypertension or Stage 1 hypertension, while only 49 percent of nonlinemen, similar to the preseason, had elevated blood pressure. These changes in blood pressure, particularly among athletes who played at the lineman field positions, were accompanied by thickening of the heart walls and a mild but significant decline in contractile function. The authors conclude that the pattern of heart remodeling seen among football lineman differs markedly from the “athletic heart” patterns common among endurance athletes and more closely approximate patterns seen in older populations with overt hypertension and hypertensive cardiovascular disease. In an accompanying editorial, William A. Zoghbi, MD, MACC, explains that “the findings are important and point to a different cardiac adaptive response in linemen compared to non-linemen. While questions abound, the current investigation has highlighted this unusual adverse cardiac remodeling in sports with the hope of alerting players and their health care professionals, furthering research, and ultimately addressing ways to protect and improve the health of all athletes in team sports.” Lin, J; et al. JACC: Cardiovascular Imaging. 2016;9:367- 1376. An Inside Look at TAVR Trends and Improvements The Society of Thoracic Surgeons (STS)/ACC TVT Registry has revealed a number of important trends and improvements in the patient outcomes and clinical care of transcatheter aortic valve replacement (TAVR) patients, according to the 2016 Annual Report of the STS/ACC TVT Registry published in JACC. The annual report focuses on patient characteristics, trends and outcomes of transcatheter aortic and mitral valve catheter-based valve procedures in the U.S. from late 2011 through December 2015. The TVT Registry has three modules: TAVR, transcatheter mitral leaflet clip (TMC), and transcatheter mitral valve-in-valve therapy/ transcatheter mitral valve-in-ring therapy (TMViV/TMViR). The registry’s TAVR module shows that actual TAVR in-hospital, 30-day, and one-year mortality significantly decreased over time. Of note, one-year mortality decreased from 25.8 percent in 2012 to 21.6 percent in 2014 (p < 0.0001), and the report found modest but significant decreases in acute kidney injury and major bleeding over time. Moderate/severe aortic regurgitation has decreased over time with acceptable gradients at discharge. “The improved results are likely related to greater experience, a lower-risk patient population, as well as improving technology and anesthetic techniques,” says Frederick L. Grover, MD, FACC, vice chair of the STS/ACC TVT Registry Steering Committee, et al. Positive results also were shown in the TMViV/TMViR module. Among the predominantly high-risk patient population, in-hospital and 30-day mortality were considerably lower than their STS Predicted Risk of Mortality. Few patients who underwent TMViV/TMViR procedures experienced post-operative left ventricular outflow tract obstruction, in-hospital stroke or required dialysis. The authors state that “the early results in this rather high-risk group of patients, who were able to avoid an open reoperation, are encouraging and this procedure appears to be an attractive treatment option for this group of patients.” The report’s authors explain that a number of quality assurance programs are in place to continually improve the registry, including electronic data checks, proactive training and orientation for participating hospitals, data completeness assessment and reporting to sites, as well as an annual NCDR Data Managers Meeting. In addition, several data quality improvements are currently taking place. Looking ahead to developing technology and other opportunities, data elements are being developed to capture transcatheter replacement and for metrics to report appropriate use criteria for TAVR procedures. “TAVR is a transformation technology success story having been approved in the U.S. only in 2011 to now having been used in > 80,000 commercial patients,” said David R. Holmes Jr., MD, MACC, a past president of the ACC and chair of the STS/ACC TVT Registry Steering Committee. “As part of the approval process, the TVT Registry was born under the auspices of ACC and STS to provide ongoing information about this evolving technology as well as to evaluate catheter-based options used to treat disease related to the other cardiac valve. The registry acts as a lens showing us where we have been and where we are now, and it helps shape the future of where we are going. This annual report is a cornerstone of the mission of the TVT Registry to monitor our performance in optimizing health care of the growing number of patients with structural heart disease.” Grover, F. L., et al. J Am Coll Cardiol. 2016;Dec 2:[Epub ahead of print].
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