Faculty Bibliography

BACKGROUND:Central arteriovenous fistula (cAVF) has been investigated as a therapeutic measure for treatment resistant hypertension in patients without advanced chronic kidney disease (CKD). There is considerable experience with the use of arteriovenous fistula (AVF) for hemodialysis in patients with end stage renal disease (ESRD). However, there is sparse data on the blood pressure (BP) effects of an AVF among patients with ESRD. We hypothesized that AVF creation would significantly reduce BP compared to patients who did not have an AVF among patients with ESRD before starting hemodialysis. METHODS:Blood pressures were compared during the 12 months before hemodialysis initiation in 399 patients with an AVF or AV graft created and 4696 patients without either. RESULTS:After propensity score matching 1:2 ratio (AVF to no AVF), repeated measures analysis of variance revealed significant reductions of -1.7 mmHg systolic and -3.9 mmHg diastolic BP 12 months in patients after AVF creation; p=0.025 and p < 0.001, respectively, as compared to those with no AVF. CONCLUSIONS:These findings suggest that AVF creation results in modest BP reduction in patients with pre-dialysis ESRD who require AVF for eventual hemodialysis therapy. Preferential DBP reduction suggest greater work is needed to characterize the ideal patient subset in which to use cAVF for treatment resistant hypertension in those without advanced CKD.

Until recently, intraindividual visit-to-visit variability of cardiovascular risk factors has been dismissed as random fluctuation. This simplistic concept was challenged by demonstrating that visit-to-visit blood pressure variability, independent of average blood pressure, was a powerful risk factor for stroke. Subsequently, variability of other cardiovascular risk factors such as cholesterol, glycemia, and body weight was documented to increase risk independent of their absolute values. Variability of these risk factors has been demonstrated to be a powerful predictor for all-cause and cardiovascular mortality, stroke, coronary artery disease, heart failure, end-stage renal disease, and dementia. With the notable exception of heart rate, cardiovascular risk factors must now be defined by 2 components: the magnitude and duration of sustained risk factor elevation and, equally important, the variability of the same risk factor over time.

BACKGROUND:Patients with diabetes and those with chronic kidney disease (CKD) are at increased risk of cardiovascular events. Everolimus eluting stents (EES) have been shown to be superior to paclitaxel eluting stents (PES) in patients with diabetes. However, it is not known if EES is as beneficial in diabetic patients with CKD compared with those without CKD. METHODS AND RESULTS/RESULTS: = 0.04) such that EES was superior to PES in the non-CKD cohort but not in the CKD cohort. CONCLUSIONS:In subjects with diabetes, CKD is an independent predictor of adverse cardiovascular outcomes including increased risk of death driven largely by non-stent related events. While EES was superior to PES in patients without CKD, this was not the case in those with CKD (Clinical Trials Registry-India number, CTRI/2011/06/001830).

Kidney transplantation (KT) is the optimal therapy for end-stage kidney disease (ESKD), resulting in significant improvement in survival as well as quality of life when compared with maintenance dialysis. The burden of cardiovascular disease (CVD) in ESKD is reduced after KT; however, it still remains the leading cause of premature patient and allograft loss, as well as a source of significant morbidity and healthcare costs. All major phenotypes of CVD including coronary artery disease, heart failure, valvular heart disease, arrhythmias and pulmonary hypertension are represented in the KT recipient population. Pre-existing risk factors for CVD in the KT recipient are amplified by superimposed cardio-metabolic derangements after transplantation such as the metabolic effects of immunosuppressive regimens, obesity, posttransplant diabetes, hypertension, dyslipidemia and allograft dysfunction. This review summarizes the major risk factors for CVD in KT recipients and describes the individual phenotypes of overt CVD in this population. It highlights gaps in the existing literature to emphasize the need for future studies in those areas and optimize cardiovascular outcomes after KT. Finally, it outlines the need for a joint 'cardio-nephrology' clinical care model to ensure continuity, multidisciplinary collaboration and implementation of best clinical practices toward reducing CVD after KT.

Beta-blockers are commonly used medications, and they have been traditionally considered 'cardioprotective'. Their clinical use appears to be more widespread than the available evidence base supporting their role in cardioprotection. Beta blockers counteract neurohumoral activation in heart failure with reduced ejection fraction and offer both symptomatic improvement and reduction in adverse events. On the other hand, use of beta-blockers in uncomplicated hypertension results in suboptimal outcomes compared to the established first-line antihypertensive agents. Providers at all levels should be familiar with common misconceptions regarding beta-blocker use in routine clinical practice.

Importance/UNASSIGNED:It is unknown whether coronary revascularization, when added to optimal medical therapy, improves prognosis in patients with stable ischemic heart disease (SIHD) at increased risk of cardiovascular events owing to moderate or severe ischemia. Objective/UNASSIGNED:To describe baseline characteristics of participants enrolled and randomized in the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial and to evaluate whether qualification by stress imaging or nonimaging exercise tolerance test (ETT) influenced risk profiles. Design, Setting, and Participants/UNASSIGNED:The ISCHEMIA trial recruited patients with SIHD with moderate or severe ischemia on stress testing. Blinded coronary computed tomography angiography was performed in most participants and reviewed by a core laboratory to exclude left main stenosis of at least 50% or no obstructive coronary artery disease (CAD) (<50% for imaging stress test and <70% for ETT). The study included 341 enrolling sites (320 randomizing) in 38 countries and patients with SIHD and moderate or severe ischemia on stress testing. Data presented were extracted on December 17, 2018. Main Outcomes and Measures/UNASSIGNED:Enrolled, excluded, and randomized participants' baseline characteristics. No clinical outcomes are reported. Results/UNASSIGNED:A total of 8518 patients were enrolled, and 5179 were randomized. Common reasons for exclusion were core laboratory determination of insufficient ischemia, unprotected left main stenosis of at least 50%, or no stenosis that met study obstructive CAD criteria on study coronary computed tomography angiography. Randomized participants had a median age of 64 years, with 1168 women (22.6%), 1726 nonwhite participants (33.7%), 748 Hispanic participants (15.5%), 2122 with diabetes (41.0%), and 4643 with a history of angina (89.7%). Among the 3909 participants randomized after stress imaging, core laboratory assessment of ischemia severity (in 3901 participants) was severe in 1748 (44.8%), moderate in 1600 (41.0%), mild in 317 (8.1%) and none or uninterpretable in 236 (6.0%), Among the 1270 participants who were randomized after nonimaging ETT, core laboratory determination of ischemia severity (in 1266 participants) was severe (an eligibility criterion) in 1051 (83.0%), moderate in 101 (8.0%), mild in 34 (2.7%) and none or uninterpretable in 80 (6.3%). Among the 3912 of 5179 randomized participants who underwent coronary computed tomography angiography, 79.0% had multivessel CAD (n = 2679 of 3390) and 86.8% had left anterior descending (LAD) stenosis (n = 3190 of 3677) (proximal in 46.8% [n = 1749 of 3739]). Participants undergoing ETT had greater frequency of 3-vessel CAD, LAD, and proximal LAD stenosis than participants undergoing stress imaging. Conclusions and Relevance/UNASSIGNED:The ISCHEMIA trial randomized an SIHD population with moderate or severe ischemia on stress testing, of whom most had multivessel CAD. Trial Registration/UNASSIGNED:ClinicalTrials.gov Identifier: NCT01471522.

Pulmonary hypertension (PH), defined by a mean pulmonary artery pressure of >25mm Hg at rest, is strongly associated with morbidity and mortality in the perioperative period. The prevalence and outcomes of PH among patients referred for major noncardiac surgery in the United States are unknown. Patients ≥18 years of age hospitalized for noncardiac surgery were identified from Healthcare Cost and Utilization Project's National Inpatient Sample data from 2004 to 2014. Pulmonary hypertension was defined by International Classification of Diseases, Ninth Revision diagnosis codes. The primary outcome was perioperative major adverse cardiovascular events (MACCE), defined as in-hospital death, myocardial infarction, or ischemic stroke. Among 17,853,194 hospitalizations for major noncardiac surgery, 143,846 (0.81%) had PH. MACCE occurred in 8.3% of hospitalizations with any diagnosis of PH in comparison to 2.0% of those without PH (p <0.001), driven by an increased frequency of death (4.4% vs 1.1%, p <0.001) and nonfatal myocardial infarction (3.2% vs 0.6%, p <0.001). After adjusting for demographics, clinical covariates, and surgery type, PH remained independently associated with MACCE (aOR 1.43, 95% CI 1.40 to 1.46). In conclusion, PH is associated with perioperative major adverse cardiovascular events. Careful patient selection, recognition of perioperative risks, and appropriate intraoperative hemodynamic monitoring may improve perioperative cardiovascular outcomes.