Gregory Roth, MD, on the global burden of cardiovascular disease. 

Welcome to the last Cardiac Wire of the year. Thank you to all of our readers and sponsors who make this newsletter possible, and keep an eye out for our next issue on January 5th, 2023.

Cardiovascular Disease

Global CVD Almanac

JACC released a special “almanac-style” issue highlighting the growing burden of cardiovascular disease worldwide. 

The Global Burden of Disease, Injuries, and Risk Factors study (GBD) is the world’s largest effort to track population cardiovascular health, recording global, regional, and national trends in mortality and disability since 1990. 

The analysis found that CVD remains the leading cause of death worldwide, responsible for 20M deaths and 400M disability-adjusted life-years lost in 2021. Here are the ACC’s main 2021 takeaways:

• Ischemic heart disease was the leading cause of CV death, accounting for 9.4M deaths.
  
• High systolic BP remained the leading modifiable risk factor for CV deaths, accounting for 10.8M. 

• Dietary risks (like too few healthy and too many unhealthy foods) accounted for 6.6M CV deaths. 

• CVD risk attributable to elevated systolic blood pressure was highest in Central Asia, Central Sub-Saharan Africa, and Eastern Europe.
  
• CVD burden attributable to dietary risks was highest in Central Asia, Oceania, and Eastern Europe.
  
• Central Asia had the highest age-standardized total CVD mortality at 517 deaths per 100k people, nearly 7 times higher than in Asia Pacific. 

On a brighter note, Australasia had the largest reduction (64.2%) in age-standardized CVD per 100k out of all other regions since 1990, driven by decreases in ischemic heart disease. 

The Takeaway

The ACC hopes to bring renewed attention to troubling trends related to the global CVD burden. The multi-year collaboration helps move the field forward by not only tracking CV risk and disease but also gauging whether interventions are actually effective. 

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The Wire

• Alternative Medicine in HF: The AHA released a scientific statement on the benefits and risks of using alternative medicines and therapies to manage heart failure symptoms. Aloe vera, caffeine, and L-arginine were labeled “potentially harmful,” while Co-Q10, D-Ribose, and Tai-Chi were deemed “potentially beneficial.” The document estimates that 30% of people with HF in the US use alternative therapies, which may explain why alternative medication within cardiology care has been an ongoing theme recently.

• COVID Infection & Vaccine Linked to POTS: A new study published in Nature Cardiovascular Research confirmed early reports that COVID infection – and, to a lesser extent, the COVID vaccine – may trigger postural orthostatic tachycardia syndrome (POTS), an autonomic disorder characterized by rapid heart rate, low BP, fainting, and lightheadedness. The study analyzed data from 280k COVID-vaccinated patients and 12k unvaccinated patients with a confirmed COVID infection. The authors found a minor link between vaccination status and POTS, although a COVID infection was associated with five times greater risk than the vaccine.

• Anumana & Pfizer Team Up: Mayo Clinic spinout Anumana announced a multi-year agreement with Pfizer to develop an AI-ECG algorithm that identifies people at risk for cardiac amyloidosis. Through the alliance, the companies will conduct a clinical validation trial and pursue De Novo classification for the algorithm. This is the latest example of pharma companies investing in heart disease detection startups devoted to identifying more patients while they are still treatable.

• Updated Diabetes Guidelines: The American Diabetes Association lowered target cholesterol and blood pressure ranges in its 2023 standards of care. The organization added nearly 100 new and updated recommendations, such as lowering the target for blood pressure to less than 130 over 80, along with calling for LDL-C levels of 70 (down from 100) for people without heart disease and 55 (down from 70) for people with heart disease. 

• CardioNXT & Field Medical PFA Partnership: Field Medical is partnering with CardioNXT to integrate its second generation focal pulse field ablation (PFA) therapy with CardioNXT’s iMap 3D mapping & navigation. The startups are combining forces to identify sources of cardiac arrhythmias and deliver therapy while optimizing safety and effectiveness. 

• Understanding AFib & Tricuspid Regurgitation: A study of nearly 700 patients with new-onset AFib found that about one-third developed clinically significant tricuspid regurgitation (TR) over a 13 year period, and the presence of TR nearly tripled their adjusted mortality risk (HR: 2.92). Early rhythm control reduced risk of both incident TR and mortality by approximately 30% each. The authors note a striking association of incident TR and being female, with an 83% risk increase. 

• Advancing Anticoagulation for Children: A new study in JACC found that edoxaban is a potential thromboprophylaxis therapy in children with cardiac disease showing low rates of bleeding and thrombotic events. The multicenter analysis compared edoxaban versus the standard DOAC treatment (heparin or VKAs) in 167 children. In the initial 3-month study period, one patient per group experienced nonmajor bleeding, with adverse events occurring in 47% of the edoxaban group and 41% in the standard care group. 

• Two Sides to Cytokinetics FDA Rejection: The FDA’s Cardiovascular and Renal Drugs Advisory Committee voted 8 to 3 against approving Cytokinetics heart failure medication omecamtiv mecarbil. The committee concluded that the benefits of the HFrEF medication don’t outweigh its risks. Cytokinetics said it was disappointed but will continue to “engage constructively with the FDA” ahead of its final decision. Counterintuitively, Cytokinetics stocks surged following this announcement, as investors see this as an opportunity for Cytokinetics to focus on developing its more promising aficamten cardiac myosin inhibitor.

• Experimental Sleep Restriction: A JACC study found that cardiologists should consider evaluating sleep loss and how it predisposes patients to abdominal visceral obesity when determining patients’ CVD risk. Nine men completed a 21-day study comparing restricted sleep (4 hrs) to the control (9 hrs). Restricted sleep led to greater calorie consumption but consistent energy expenditure, compared to the control, with significant increases in subcutaneous and visceral abdominal fat depots.

• Elucid’s Histological Plaque Evidence: A new Elucid-produced study provided solid evidence supporting its histological-based approach to CTA AI atherosclerosis risk assessments. The researchers used the Elucid AI system to analyze 408 vessel cross-sections from 23 patients, demonstrating “excellent agreement” with pathologist-defined histological plaque risk phenotypes (weighted kappa of 0.82), and accurately identifying plaques as unstable, stable, and minimal disease (AUCs: 0.97, 0.95¸ 0.99).

User Experience and Cardiovascular Imaging Transformation

Check out this Change Healthcare video discussing the importance of user experience in the adoption of structured reporting, and how it can lead to improvements in imaging speed, quality, and cardiologist workflow. 

The HeartFlow Story

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