Tag: cardiac

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Cardiac rehab score predicts event risk at 1 year

Cardiac rehab score predicts event risk at 1 year

August 19, 2022

2 min read


Disclosures:
The authors report no relevant financial disclosures.


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Exercise performance during cardiac rehabilitation, scored with a novel index, can reliably predict CV event risk at 1 year, according to data from a single-center study.

“Participating in a cardiac rehabilitation program is essential to improving patients’ survival and quality of life following myocardial infarction or heart surgery and for patients with HF,” Ofir Koren, MD, FESC, an interventional cardiology fellow with the Cedars-Sinai Medical Center Smidt Heart Institute and a senior interventional cardiologist with Emek Medical Center in Afula, Israel, told Healio. “Our study supports previous evidence and emphasizes the importance of understanding the level of endurance required to promote improved outcomes by designing a simple-to-use formula that can guide physicians and physiotherapists toward a target-directed program.”



Graphical depiction of source quote presented in the article

Data were derived from Naami R, et al. Clin Cardiol. 2022;doi:10.1002/clc.23890.

Koren and colleagues analyzed data from 486 adults who participated in at least 80% of sessions in a cardiac rehabilitation program between January 2018 and August 2021 at Emek Medical Center in Israel. The rehab program is a twice weekly, 3-month government-funded program; each session includes exercises on a treadmill, elliptical, bicycle and handcycle. Researchers assessed patient performance using a novel index, the “CR score,” which integrated duration, speed of work and workload conducted on each training device. Researchers then determined the optimal thresholds for a cumulative CR score and assessed the mortality rate among patients who developed a major adverse CV event and those who did not (controls).

The findings were published in Clinical Cardiology.

Major adverse CV events occurred in 5.5% of patients at 1 year; events were more common among those with prior cerebrovascular accident or transient ischemic attack (14.8% vs. 3.5%; P < .001). Age, sex, comorbidities, HF and medical treatment did not affect the outcome.

The median cumulative CR score of the study group was lower compared with controls (median, 595 vs. 3,500; P < .0001). A cumulative CR score of greater than 1,132 correlated with the outcome with 98.5% sensitivity and 99.6% specificity (95% CI, 0.9850.997; P < .0001). Patients older than age 55 years with a cumulative CR score of greater than 1,132 were deemed at highest risk for a major adverse CV event at 1 year, with an OR of 7.4 (95% CI, 2.84-18.42); Kaplan-Meier survival curve indicated that major adverse CV events at 1 year occurred much earlier among patients with a low CR score (log-rank P = .03).

The researchers noted that the CR score is a novel score that has not been validated on a large scale.

“These data may assist physicians and physiotherapists in tailoring a specific CR program with clear physical targets,” Koren, also a clinic lecturer at Technion University in Israel, told Healio. “We need a prospective study involving two groups randomly assigned to two therapeutic options — current CR practice and a CR program directed using our model.”

For more information:

Ofir Koren, MD, FESC, can be reached at ofir.koren@cshs.org; Twitter: @dr_ofir.


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Disorders of hypertensive pregnancy associated with subsequent cardiac events

Washington [US], August 13 (ANI): According to new research, women who experienced complications related to developing high blood pressure, or hypertension, during pregnancy had a 63 per cent increased risk for developing cardiovascular disease later in life.

While hypertensive pregnancy complications previously have been linked to increased cardiovascular risks, the current study controlled for pre-pregnancy shared risk factors for these types of complications and cardiovascular disease. Researchers also found that high blood pressure, high cholesterol, type 2 diabetes, or being overweight or obese after pregnancy accounted for most of the increased risk between pregnancy complications and future cardiovascular events.

The findings, published in the Journal of the American College of Cardiology, could support healthcare providers in developing personalized heart disease prevention and monitoring strategies for women who had hypertension during pregnancy. The information could also help bridge the gap that often occurs after a woman ends obstetric care and resumes or starts care with another provider.

Using health data shared by more than 60,000 participants in the Nurses’ Health Study II, the research represents one of the most comprehensive reviews evaluating links between future cardiovascular events in women who have had preeclampsia or gestational hypertension. Gestational hypertension is characterized by an increase in blood pressure during pregnancy. Preeclampsia is a more severe complication marked by a sudden rise in blood pressure that can affect the organs and be dangerous for both mother and baby. Both conditions are often diagnosed after 20 weeks of pregnancy.

“Women with a history of gestational hypertension or preeclampsia should be informed that they have an increased risk for cardiovascular disease,” said Jennifer J. Stuart, Sc.D., a study author and associate epidemiologist in the Division of Women’s Health at Brigham and Women’s Hospital and Harvard Medical School, Boston. “While the American Heart Association and American College of Cardiology recognize these conditions as cardiovascular risk factors, women and their providers have lacked clear direction on what to do in the intervening years between delivery of a hypertensive pregnancy and the onset of cardiovascular disease.”

The researchers’ analysis showed that early screening and monitoring in four targeted areas — blood pressure, cholesterol and glucose levels, and body mass index — could provide even more personalized targets to help delay or possibly prevent future cardiovascular events among these women.

In this study, almost 10% of women developed hypertension during their first pregnancy. Among these women, 3,834 (6.4%) developed preeclampsia and 1,789 (3%) developed gestational hypertension. Women who were obese before pregnancy were three times more likely to experience a hypertensive pregnancy disorder, and those with a family history of heart disease or stroke also shared increased risks. In their analysis, the researchers controlled for these and other important pre-pregnancy factors that could increase the risk of developing hypertension during pregnancy and having a heart attack or stroke later in life.

After about 30 years, when the average age of women in the study was 61 years, approximately 1,074 (1.8%) of study participants had experienced a cardiovascular event, such as a heart attack or stroke. The type of event women had — and when they had it — often overlapped with specific pregnancy complications.

For example, compared to women with normal blood pressure in pregnancy, women with gestational hypertension, which was associated with a 41% increased risk for cardiovascular disease, were more likely to have a stroke about 30 years after their first pregnancy. Women with preeclampsia, which was associated with a 72% increased cardiovascular risk, were more likely to have a coronary artery event, such as a heart attack, as early as 10 years after their first pregnancy.

Post-pregnancy cardiometabolic risk factors, such as obesity, type 2 diabetes, and chronic hypertension, explained most of the increased cardiovascular risk observed among women with gestational hypertension or preeclampsia. Chronic hypertension was the largest contributor of all, accounting for 81% of increased cardiovascular disease risks among women who had gestational hypertension and for 48% of increased risks among women who had preeclampsia. Most women who experienced a hypertensive pregnancy disorder developed chronic hypertension in the years or decades after they gave birth.

“This study reinforces how important it is for women and their healthcare providers to address known cardiovascular disease risk factors, such as obesity or having high blood pressure, while thinking about starting a family and then during and after during pregnancy,” said Victoria Pemberton, R.N.C., a program officer at NHLBI.

For future research, Stuart said diversity is key. Most women in the Nurses’ Health Study II were white, which means the percentage of women affected by different risk factors may vary. The study also provides a foundation to expand on emerging associations, such as studying links between gestational hypertension and stroke and between preeclampsia and coronary artery disease.

Additionally, while over 80% of the increased risk for cardiovascular disease among women with a history of gestational hypertension appears to be jointly accounted for by established cardiovascular risk factors, nearly 40% of the risk for cardiovascular disease following preeclampsia remains unexplained.

Investigating these pathways may help clarify why some women who experienced preeclampsia are more likely to develop heart disease. By better understanding these connections, researchers may be able to contribute insight to help healthcare providers provide even more personalized recommendations and strategies for women at greatest risk.

The research was also supported by grants from the National Cancer Institute and the Eunice Kennedy Shriver National Institute of Child Health and Human Development. (ANI)

This report is auto-generated from ANI news service. ThePrint holds no responsibility for its content.

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Timely intervention critical for major cardiac events after immune checkpoint therapy

Key study takeaways

Source:

Naqash AR, et al. Abstract 2508. Presented at: ASCO Annual Meeting; June 3-7, 2022; Chicago.


Disclosures:
NIH funded this study. Naqash reports no relevant disclosures. Please see the abstract for all other researchers’ relevant financial disclosures.


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CHICAGO — Patients and prescribers should be more aware of the potential for major adverse cardiac events after immune checkpoint inhibitor-based therapy, according to retrospective study results presented at ASCO Annual Meeting.

The association between immune major adverse cardiac events (MACE) and noncardiac immune-related adverse events highlights the importance of a multidisciplinary management approach, researchers emphasized.


Key study takeaways

Data derived from Naqash AR, et al. Abstract 2508. Presented at: ASCO Annual Meeting; June 3-7, 2022; Chicago.

“To the best of our knowledge, this is the first-ever pooled analysis of immune checkpoint inhibitor clinical trials evaluating major adverse cardiac events,” Abdul Rafeh Naqash, MD, assistant professor in the early phase division of Stephenson Cancer Center at University of Oklahoma, said during a presentation. “These findings have important management implications, as more and more patients are being treated with anti-pD-1/PD-l1 combinations.”

Background and methods

Although rare, MACE can manifest in various ways among patients treated with immune checkpoint inhibitors. These events can result in considerable morbidity or death.

More work is needed to better define presentation of these events and their potential relationship with noncardiac immune-related adverse events among patients treated with immune checkpoint inhibitors, according to study background.

Abdul Rafeh Naqash, MD

Abdul Rafeh Naqash

Naqash and colleagues performed a retrospective pooled analysis of MACE captured in the NCI-Cancer Therapy Evaluation Program’s serious adverse events reporting database.

The analysis included patients treated with anti-PD-1/-PD-L1 therapy alone or in combination with other anticancer therapies as part of NCI-sponsored investigational clinical trials in the United States and Canada between June 2015 and December 2019.

The analysis included 6,925 patients. Slightly less than half (48%) received single-agent anti-PD-1/PD-L1 therapy. The remainder received those agents as part of combination therapy.

Results

Forty patients (0.6%; median age, 68.5 years; 60% men) developed immune checkpoint inhibitor-related MACE.

The most common malignancies in this group included melanoma (37.5%), genitourinary cancer (16%), gastrointestinal cancer (12.5%), gynecologic cancer (7.5%), lymphoma (5%) and lung cancer (5%).

Median time to MACE from initial immune checkpoint inhibitor administration was approximately 28 days.

Researchers characterized the majority (77.5%) of MACE as grade 3 or higher (grade 3, 50%; grade 4, 20%; grade 5, 7.5%).

Myocarditis accounted for nearly half (45%; n = 18) of MACE, occurring a median two doses after immune checkpoint inhibitor administration. The majority (78%) of cases were grade 3 or higher.

Seventy-two percent of patients with myocarditis had been treated with anti-PD-1/PD-L1-based combination regimens, the most common of which included an anti-CTLA-4 inhibitor (92%).

Researchers reported four myocarditis-related deaths. All four of these individuals had concurrent myositis and three had concurrent transaminitis.

Nonmyocarditis MACE included dysrhythmias, cardiomyopathy, pericardial disorders, acute coronary syndrome and cardiac arrest.

More than half (65%) of patients who developed MACE experienced multisystem organ involvement with other noncardiac immune-related adverse events, the two most common being myositis (27.5%) and transaminitis (25%).

Nearly all patients (92.5%) with MACE required hospitalization and 30% required ICU admission.

Most patients (83%) with myocarditis experienced at least one noncardiac immune-related adverse event, and 50% of those with non-myocarditis MACE developed noncardiac immune-related adverse events.

Forty percent of those who developed MACE received single-agent PD-1/PD-L1 agent therapy, and 60% had received anti-PD-1/PD-L1 in combination with other therapies.

MACE occurred more frequently among patients treated with anti-PD-1/PD-L1 plus targeted therapies (2.1%) than anti-PD-1/PD-L1 plus anti-CTLA-4 therapies (0.9%), anti-PD-1/PD-L1 plus chemotherapy (0.83%) or single-agent anti-PD-1/PD-L1 (0.47%).

Next steps

Immune checkpoint inhibitor-related MACE has heterogeneous presentation and often is associated with poor prognosis, Naqash said.

“This makes timely identification and intervention critical,” Naqash said. “We also saw complex noncardiac immune-related adverse events present concurrently, which makes incorporation of a multidisciplinary approach consisting of cardiologists, oncologists, internists and other subspecialists essential in the management of these patients. In addition, the type of combination therapy may influence MACE risk and incidence, which suggests better characterization of MACE with anti-PD-1/PD-L1-based combination therapies is required.”

Perspective

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Namrata (Neena) Vijayvergia, MD)

Namrata (Neena) Vijayvergia, MD

Anecdotes can sometimes scare us and give us the wrong perspective of a particular disease. However, anecdotes are not science. Until you study something in a research setting and a controlled environment, you don’t know for sure.

Immunotherapeutic drugs have changed the course of how we treat patients, but the risk for myocarditis or other serious side effects can be a detriment. Information like this from a large database allows us to educate our patients, and we can feel better about treating them thanks to this important work.

The 0.6% incidence of immune checkpoint inhibitor-related MACE is very comforting. I haven’t personally seen a patient with cardiac side effects from these drugs, but that doesn’t mean these events don’t happen. Seeing such a low number in a very big population of patients from NCI studies give us a real good picture of the landscape.

Myocarditis is inflammation in the heart. If you have an immune system that is revved up, it would be revved up everywhere, so it makes sense that patients with myocarditis would have other immune-related adverse events. Whether this is a cause or effect of what else is happening in the rest of the body is hard to tease out. However, we have learned that when patients have multiple immune-related adverse events, we should look for cardiac events, too.

The knowledge that these drugs are safe — and a deeper understanding of the potential side effects — makes us more empowered to look for these effects and treat them effectively. I will feel much better talking to my patients about their risk now that I have a concrete number to give them. These are retrospective data, so it will be important to replicate these findings in other large data sets. More work is needed, and that will only increase our confidence. However, someone using this drug for the first time should feel much more comfortable doing so based on data like this.

Namrata (Neena) Vijayvergia, MD

Fox Chase Cancer Center


Disclosures: Vijayvergia reports no relevant financial disclosures.


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ASCO Annual Meeting

ASCO Annual Meeting