Featured topics and Editors’ Picks from all of ACC’s JACC Journals. First Data Standard Published for Pediatric and Congenital Cardiology The ACC, along with the American Heart Association (AHA), has developed the first extensive data dictionary, with data elements and definitions, specifically for the use in the outpatient domain of pediatric and congenital cardiology. The 2017 AHA/ACC Key Data Elements and Definitions for Ambulatory Electronic Health Records in Pediatric and Congenital Cardiology published on July 14 in the Journal of the American College of Cardiology. The need for a master set of data elements and definitions is of topical interest for the pediatric and congenital heart disease clinician where data sharing is critical to identify best practices, develop evidence-based guidelines and determine statistical significance in patient populations. In contrast to adult cardiac disease where there is a large population of patients who experience a more homogenous set of disease processes, there is a wide range of disease processes across a relatively small set of patients in pediatric and congenital heart disease. The writing committee explains the challenges in getting to outcome measures in pediatric cardiology and cardiac surgery. There are many obstacles within standardizing and sharing data in pediatric cardiac surgery — including variation in surgical techniques and skills, variations in perioperative care, variation in underlying anatomy, adequate risk stratification, lack of natural history of unoperated patients in the present era and insufficient patient numbers from which to draw statistically significant conclusions The writing committee identified pediatric and congenital terms for electronic health records (EHR) — history of present illness, risk factors, past medical history, physical examination and common cardiac diagnoses. They suggest the need to compile through the EHR the collective-comparative needs of the many clinical, medical and surgical domains in the care of pediatric and congenital heart disease patients. This approach covers the cardiology clinic, cardiac diagnostic imaging, interventional, cardiac critical care and cardiac care programs. “We see this plan as a first step toward achieving EHR data exchange for the continuity of clinical care of the pediatric and congenital heart disease patient,” the committee writes. “As for future steps, we see the need for aligning the ACC and AHA pediatric data set to the adult data set and for aligning the ACC and AHA pediatric data set to U.S. Meaningful Use data standards. To do so, immediate next steps for the Task Force will involve further mapping of existing clinical data registries and clinical domain needs to better understand issues around common data standards, overlaps, and gaps in data content.” Boris JR, Béland MJ, Bergensen LJ, et al. J Am Coll Cardiol 2017;July 14:[Epub ahead of print]. Some Plant-Based Diets May Increase Heart Disease Risk Plant-based diets are recommended to reduce the risk of heart disease, but some may be associated with a higher risk, according to a study published July 17 in the Journal of the American College of Cardiology. Ambika Satija, ScD, et al., created three versions of a plant-based diet: an overall plant-based diet which emphasized the consumption of all plant food and reduced (but did not eliminate) animal food intake; a healthful plant-based diet that emphasized the intake of healthy plant foods such as whole grains, fruits and vegetables; and an unhealthful plant-based diet which emphasized consumption of less healthy plant foods such as refined grains. The researchers used a baseline sample of 73,710 women from the Nurses’ Health Study, 92,320 women from the Nurses’ Health Study 2 and 43,259 men from the Health Professionals Follow-Up Study. The participants responded to a followup questionnaire every two years for over two decades on lifestyle, health behaviors and medical history. During follow-up, 8,631 participants developed coronary heart disease. Overall, adherence to a plant-based diet was associated with a lower risk of heart disease. A higher intake of a more healthful plant-based diet – one rich in whole grains, fruits, vegetables, etc. – was associated with a substantially lower risk of heart disease. However, a plant-based diet that emphasized less healthy plant foods like sweetened beverages, refined grains, potatoes and sweets had the opposite effect. In an accompanying editorial, Kim Allan Williams, Sr., MD, MACC, past president of the ACC, said the study adds to the substantial evidence that a predominately plant-based diet reduces heart disease risk. Not all plant-based foods are equally healthy, but plant-based diets with whole grains, unsaturated fats and an abundance of fruits and vegetables “deserve more emphasis in dietary recommendations.” He adds that the long-term follow up allowed authors to examine dietary patterns and analyze the effect of gradual adherence to a plant-based diet through reduced animal food intake and increased plant food intake on heart disease risk. Satija A, Bhupathiraju SN, Spiegelman D, et al. J Am Coll Cardiol 2017;704:11-22. New Insights into SCAD and Its Association With Pregnancy Women with pregnancyassociated spontaneous coronary artery dissection (P-SCAD) have more acute presentations and high-risk features than women with SCAD not associated with pregnancy (NPSCAD), according to results from a novel study published July 17 in the Journal of the American College of Cardiology. Marysia S. Tweet, MD, FACC, et al., analyzed records of 54 women who had SCAD while pregnant or ≤12 weeks postpartum between July 2011 and February 2016, and compared them with 269 NP-SCAD patients. Approximately half of the enrolled patients participated virtually in the Mayo Clinic SCAD registry. The mean age of P-SCAD patients was 35 ± 4 years. Most women with P-SCAD were Caucasian, older at the time of their first childbirth and had multiple pregnancies compared with NP-SCAD patients; however, no difference was found in the number of live childbirths. The study resulted in multiple novel findings, identifying the timeline, associated risks and potential factors for patients with P-SCAD. For example, 70 percent of P-SCAD-related events occurred during the first month following delivery or miscarriage, while 54 percent occurred within the first week (median five days). “This timing might correlate in part with the cardiac stress due to the rapid post-delivery uterine contraction and return of massive blood volume to the systemic circulation. However, hemodynamic changes alone might not account for the entire pathogenesis of SCAD,” write the study authors. Compared with women with NP-SCAD, P-SCAD patients were also more likely to present with STEMI (57 vs. 37 percent; p = 0.009), left main SCAD (24 vs. 5 percent; p < 0.0001), multivessel SCAD (33 vs. 14 percent; p = 0.00237) and left ventricular function ≤35 percent (26 vs. 10 percent; p = 0.0071). Medical therapy was more likely to fail in P-SCAD patients, resulting in subsequent revascularization. The study authors also found P-SCAD patients had a lower prevalence of fibromuscular dysplasia (42 vs. 64 percent; p = 0.047) and extracoronary vascular abnormalities (46 vs. 77 percent; p = 0.0032) than NP-SCAD patients who underwent extracoronary vascular imaging. “This unexpected observation is hypothesis generating, highlighting the potential importance of other contributing factors in P-SCAD,” they continue. Upon comparing the study results to U.S. birth data, researchers found P-SCAD patients were more often multiparous (p = 0.0167), treated for infertility (p = 0.0004) and had pre-eclampsia (p = 0.001). They note that the “overlap of P-SCAD with pre-eclampsia and similar pattern of presentation with PPCM [post-partum cardiomyopathy] observed in our study is hypothesis generating, particularly because pre-eclampsia and PPCM are speculated as possibly sharing mechanisms of pathogenesis.” “In addition to these findings, what is remarkable about this study is how it reflects the great progress that has been made in understanding SCAD (pregnancy-associated or not) during the past decade and the rapid evolution of this field,” states Heather L. Gornik, MD, FACC. In a related editorial comment, Gornik highlights how SCAD survivors are “highly motivated to participate in clinical research,” but that only nine observational or interventional studies have enrolled SCAD patients thus far. Tweet MS, Hayes SN, Codsi E, et al. J Am Coll Cardiol 2017;70:426-35. Gender-Specific Strategies Necessary For Optimal Heart Health Radical changes to our health care system that account for the unique needs of women, including minority populations, are needed to ensure women are receiving the same high-quality care as men, according to a state-of-the-art review paper published July 10 in the Journal of the American College of Cardiology and written by members of the ACC’s Cardiovascular Disease in Women Committee. Leslee Shaw, PhD, FACC, et al., write that struggles to achieve highquality and equitable heart health care today persist for many women and evidence shows the quality of care that women of diverse races and ethnicities receive is suboptimal. As many as 60 million adult women in the U.S. are affected. With this review the committee aims to promote enhanced awareness, develop critical thinking in sex and gender science and identify strategic pathways to improve the cardiovascular health of women. The authors looked at the socioeconomic disadvantages influencing the care of women, including social and cultural determinants of health and disease, how financial disparities influence health-seeking behaviors, the influence of race and ethnicity in equity of care, and the ethical accountability of health care providers and the health care system. Researchers also sought to define equitable care for women, stating that equity is not always characterized as women and men receiving the same care but that any adequate concept of equity must incorporate biological differences. The committee offers suggestions for creating an equitable health care system that would include prioritizing and funding sex and gender science, personalizing care to meet the needs of specific localities, and requiring public reporting of data to include information on age, sex, race and ethnicity. “Realistically, full transformation [of the health care system] is unachievable,” Shaw said. “But delineation of the components of necessary, but high-quality health care, including a women-specific research agenda, remains a vital part of strategic planning to improve the lives of women at risk for and living with cardiovascular disease.” Shaw LJ, Pepine CJ, Xie J, et al. J Am Coll Cardiol 2017;70:373-88. Does Shingles Increase the Risk of Heart Attack, Stroke? A history of herpes zoster, or shingles, was found to have an apparent association with an increased risk of stroke and heart attack, according to a research letter published July 3 in the Journal of the American College of Cardiology. Researchers in South Korea, led by Sung-Han Kim, MD, PhD, used the National Health Insurance Service’s “medical check-up” database to identify patients with newly diagnosed shingles, stroke and heart attack using the relevant International Classification of Disease-10 diagnostics codes. A total of 519,880 patients were followed from 2003- 2013. There were 23,233 cases of shingles during this period. The final cohort of 23,213 was matched with the same number of shingles-free control subjects. Shingles was found to raise the risk of a composite of cardiovascular events including heart attack and stroke by 41 percent, the risk of stroke by 35 percent and the risk of heart attack by 59 percent. The risk for stroke was highest in those under 40 years old, a relatively younger population with fewer risks for atherosclerosis. The risks of both stroke and heart attack were highest the first year after the onset of shingles and decreased with time. However, these risks were evenly distributed in the shingles-free group. “While these findings require further study into the mechanism that causes shingles patients to have an increased risk of heart attack and stroke, it is important that physicians treating these patients make them aware of their increased risk,” Kim said. ACC.org Editor-in-Chief Kim A. Eagle, MD, MACC, comments that patients who get shingles may be more susceptible to having a heart attack, although the mechanism for this is unknown and further study is needed. Kim MC, Yun SC, Lee HB, et al. J Am Coll Cardiol 2017;70:295-96. Palliative Care Improves Quality of Life in Advanced HF Patients An interdisciplinary palliative care intervention in patients with advanced heart failure (HF) improved quality of life (QOL), anxiety, depression and spiritual well-being compared with usual care alone in the Palliative Care in Heart Failure (PAL-HF) study, published July 10 in the Journal of the American College of Cardiology. Patients with advanced HF and a high six-month mortality risk were randomized to usual care (UC) alone or UC plus palliative care intervention (UC+PAL). The patients were followed until death or end of the study. The primary endpoints were HF-specific QOL (Kansas City Cardiomyopathy Questionnaire [KCCQ] overall summary score) and general and palliative care-specific, health related QOL (Functional Assessment of Chronic Illness Therapy–Palliative Care scale [FACIT-Pal]). A nurse practitioner collaborated with a palliative medicine physician and hospice to manage the intervention, in coordination with the clinical cardiology team. The nurse practitioner contacted patients in the intervention group every three months to provide ongoing support and clinical care. A cardiologist-directed team managed symptom-relief and evidence-based therapies in the UC-alone group. The study enrolled 150 patients, equally divided between the two arms. During the six-month follow-up, 30 percent of patients were hospitalized and 29 percent died. Improvements in the KCCQ overall summary score were significantly greater in the UC+PAL group compared with the UC-alone group, with a 9.49 point difference (p = 0.030). Patients in the UC+PAL group also had greater improvement in the FACIT-Pal score (11.77 point difference; p = 0.035). Significant improvements were observed with UC+PAL vs. UC-alone for the secondary endpoints of depression (p = 0.02), anxiety (p= 0.048) and spiritual well-being (p = 0.027). PAL-HF is the first randomized, controlled trial to show a significant clinical benefit by adding palliative care to usual care for patients with advanced HF – a finding that suggests that practitioners should consider adding palliative care to guideline directed medical therapy for these patients, say the authors. Rogers JG, Patel CB, Mentz RJ, et al. J Am Coll Cardiol 2017;70:331-41. Read the complete issues, listen to audio summaries, download central illustrations, earn CME/MOC credit, and more at OnlineJACC.org
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