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Time to Clinical Benefit of Dapagliflozin and Significance of Prior Heart Failure Hospitalization in Patients With Heart Failure With Reduced Ejection Fraction
David D. Berg, MD, MPH; Pardeep S. Jhund, MBChB, MSc, PhD; Kieran F. Docherty, MBChB; et al.
doi : 10.1001/jamacardio.2020.7585
JAMA Cardiol. 2021;6(5):499-507
Importance Dapagliflozin has been shown to reduce the risk of cardiovascular death or worsening heart failure (HF) in patients with chronic HF and reduced ejection fraction (HFrEF). However, clinical inertia often underlies deferred initiation of effective therapies.
Association of Left Ventricular Systolic Function With Incident Heart Failure in Late Life
Anne Marie Reimer Jensen, BS; Rani Zierath, BS; Brian Claggett, PhD; et al.
doi : 10.1001/jamacardio.2021.0131
JAMA Cardiol. 2021;6(5):509-520
Importance Limited data exist regarding the association of subtle subclinical systolic dysfunction and incident heart failure (HF) in late life.
Comparison of New York Heart Association Class and Patient-Reported Outcomes for Heart Failure With Reduced Ejection Fraction
Stephen J. Greene, MD; Javed Butler, MD, MPH, MBA; John A. Spertus, MD, MPH; et al.
doi : 10.1001/jamacardio.2021.0372
JAMA Cardiol. 2021;6(5):522-531
Importance It is unclear how New York Heart Association (NYHA) functional class compares with patient-reported outcomes among patients with heart failure (HF) in contemporary US clinical practice.
Use of Artificial Intelligence and Deep Neural Networks in Evaluation of Patients With Electrocardiographically Concealed Long QT Syndrome From the Surface 12-Lead Electrocardiogram
J. Martijn Bos, MD, PhD; Zachi I. Attia, PhD; David E. Albert, MD; et al.
doi : 10.1001/jamacardio.2020.7422
JAMA Cardiol. 2021;6(5):532-538
Importance Long QT syndrome (LQTS) is characterized by prolongation of the QT interval and is associated with an increased risk of sudden cardiac death. However, although QT interval prolongation is the hallmark feature of LQTS, approximately 40% of patients with genetically confirmed LQTS have a normal corrected QT (QTc) at rest. Distinguishing patients with LQTS from those with a normal QTc is important to correctly diagnose disease, implement simple LQTS preventive measures, and initiate prophylactic therapy if necessary.
Long-term Clinical and Echocardiographic Outcomes in Young and Middle-aged Adults Undergoing the Ross Procedure
Jamie L. R. Romeo, MD, PhD; Grigorios Papageorgiou, MSC; Francisco F. D. da Costa, MD, PhD; et al.
doi : 10.1001/jamacardio.2020.7434
JAMA Cardiol. 2021;6(5):539-548
Importance There is no ideal valve substitute for young adults requiring aortic valve replacement. Multicenter data supporting use of the Ross procedure with respect to long-term postoperative valve–related mortality and reintervention, as well as function of the autograft and pulmonary homograft, are needed.
Magnetic Resonance Imaging in Patients With Cardiac Implantable Electronic Devices With Abandoned Leads
Robert D. Schaller, DO; Tamara Brunker, PA-C; Michael P. Riley, MD, PhD; et al.
doi : 10.1001/jamacardio.2020.7572
JAMA Cardiol. 2021;6(5):549-556
Importance Magnetic resonance imaging (MRI) is the modality of choice for many conditions. Conditional devices and novel protocols for imaging patients with legacy cardiac implantable electronic devices (CIEDs) have increased access to MRI in patients with devices. However, the presence of abandoned leads remains an absolute contraindication.
Screening for Atrial Fibrillation in the Older PopulationA Randomized Clinical Trial
David J. Gladstone, MD, PhD; Rolf Wachter, MD; Katharina Schmalstieg-Bahr, MD; et al.
doi : 10.1001/jamacardio.2021.0038
JAMA Cardiol. 2021;6(5):558-567
Importance Atrial fibrillation (AF) is a major cause of preventable strokes. Screening asymptomatic individuals for AF may increase anticoagulant use for stroke prevention.
Estimated Prevalence of Masked Asleep Hypertension in US Adults
Siling Li, MS; Joseph E. Schwartz, PhD; Daichi Shimbo, MD; et al.
doi : 10.1001/jamacardio.2020.5212
JAMA Cardiol. 2021;6(5):568-573
Importance High blood pressure (BP) during sleep (asleep blood pressure) is associated with an increased risk of cardiovascular disease, but a national prevalence estimate of masked asleep hypertension (high BP while sleeping but without high BP measured in the clinic [clinic BP]) for the United States is lacking.
Temporal Changes and Institutional Variation in Use of Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction With Multivessel Coronary Artery Disease in the United StatesAn NCDR Research to Practice Project
Eric A. Secemsky, MD; Neel Butala, MD; Aishwarya Raja, BSc; et al.
doi : 10.1001/jamacardio.2020.5354
JAMA Cardiol. 2021;6(5):574-580
Importance After disparate results from observational and small randomized studies, the COMPLETE trial demonstrated superiority of multivessel (MV) percutaneous coronary intervention (PCI) over culprit-only PCI for ST-elevation myocardial infarction (STEMI).
Association of Baseline Low-Density Lipoprotein Cholesterol and Percentage Low-Density Lipoprotein Cholesterol Reduction With Statins, Ezetimibe, and PCSK9 Inhibition
Daniel P. Marcusa, MD; Robert P. Giugliano, MD, SM; Jeong-Gun Park, PhD; et al.
doi : 10.1001/jamacardio.2020.6184
JAMA Cardiol. 2021;6(5):582-586
Importance Low-density lipoprotein cholesterol (LDL-C) is an important modifiable risk factor for atherosclerotic cardiovascular disease. It is unclear whether the percentage LDL-C lowering with pharmacotherapies differs on the basis of baseline LDL-C levels.
Association of Circulating Monocyte Chemoattractant Protein–1 Levels With Cardiovascular MortalityA Meta-analysis of Population-Based Studies
Marios K. Georgakis, MD, PhD; James A. de Lemos, MD; Colby Ayers, MS; et al.
doi : 10.1001/jamacardio.2020.5392
JAMA Cardiol. 2021;6(5):587-592
Importance Human genetics and studies in experimental models support a key role of monocyte-chemoattractant protein–1 (MCP-1) in atherosclerosis. Yet, the associations of circulating MCP-1 levels with risk of coronary heart disease and cardiovascular death in the general population remain largely unexplored.
Finding New Meaning in Everyday Electrocardiograms—Leveraging Deep Learning to Expand Our Diagnostic Toolkit
Geoffrey H. Tison, MD, MPH
doi : 10.1001/jamacardio.2020.7460
JAMA Cardiol. 2021;6(5):493-494
Few diagnostic tests are as synonymous with cardiac activity as the humble electrocardiogram (ECG). As the most commonly obtained cardiovascular diagnostic test, the ECG has a ubiquity that belies the underlying physiologic complexity that it captures. Similarly, although congenital long QT syndrome (LQTS) is usually recognized by its namesake prolongation of the QT interval on the 12-lead ECG, the underlying pathophysiologic mechanisms capable of causing this syndrome are heterogeneous, complex, and as yet incompletely understood. Despite the numerous advances made in elucidating the various genetic causes of LQTS, the everyday tool used by physicians to screen for LQTS remains the standard ECG.
Screening the Older Population for Atrial Fibrillation—Have We Moved the Needle Forward?
Roopinder K. Sandhu, MD, MPH; Christine Albert, MD, MPH
doi : 10.1001/jamacardio.2021.0052
JAMA Cardiol. 2021;6(5):495-496
In this issue of JAMA Cardiology, Gladstone and colleagues1 report the results of a multicenter, open-label, randomized clinical trial of screening high-risk older individuals for asymptomatic atrial fibrillation (AF). This study investigated a standard care approach of pulse palpation and auscultation in the clinic setting (baseline and 6 months) compared with a 2-week continuous electrocardiographic (cECG) patch monitor (baseline and 3 months) in addition to standard care. The primary outcome was AF or atrial flutter (?1 episode lasting >5 minutes with cECG monitoring or diagnosed clinically by 12-lead ECG) detected within 6 months. The investigators enrolled 856 participants aged 75 years or older with hypertension requiring antihypertensive medication (median CHA2DS2-VASc score, 4) and no history of AF who were recruited from 48 primary care clinics in Canada and Germany. The secondary outcome was oral anticoagulant (OAC) use at 6 months, and additional outcomes included clinical events, health care use, AF detection by a home blood pressure monitor used twice-daily during the period of patch monitoring, detection of other arrhythmias, and patch adherence. The key findings were (1) a screening approach with cECG patch monitoring yielded a 10-fold higher increase in AF detection rate compared with standard care, (2) most AF was paroxysmal (median, 6.3 hours) and detected during the first patch monitoring after 24 hours, and (3) 75.0% of patients with AF detected during patch monitoring had initiation of OAC therapy.
The Growing Case for Routine Collection of Patient-Reported Outcomes
Paul A. Heidenreich, MD, MS
doi : 10.1001/jamacardio.2021.0391
JAMA Cardiol. 2021;6(5):497-498
The clinical history elicited during the patient visit is traditionally viewed as the most important source of medical information,1,2 particularly for patients with heart failure.3 As medical students, we learned that although the patient is the source of the data, the expert clinician knows what is relevant and how best to integrate the patient’s information to determine diagnosis and prognosis.
Removing Obstacles to Magnetic Resonance Imaging for Patients With a Pacemaker or a Defibrillator
Robert J. Russo, MD, PhD
doi : 10.1001/jamacardio.2020.7593
JAMA Cardiol. 2021;6(5):556-557
In this issue of JAMA Cardiology, Schaller and colleagues1 present the results of a prospective registry examining the risks of magnetic resonance imaging (MRI) at 1.5 tesla in patients with a pacemaker or a defibrillator, and importantly, with at least 1 abandoned cardiac lead. A total of 139 patients with 243 abandoned leads underwent 200 MRI scans of several anatomic regions including the chest. The primary end points of the study were chest discomfort, sustained arrhythmia, or a change in device settings after MRI. One patient with an abandoned subcutaneous array experienced sternal heating; however, no arrhythmias were noted. Changes in device settings were infrequent and transient.
Multivessel Percutaneous Coronary Intervention During ST-Elevation Myocardial Infarction—A Dickensian Debate That Never Ends
John A. Bittl, MD
doi : 10.1001/jamacardio.2020.5361
JAMA Cardiol. 2021;6(5):580-581
When randomized clinical trials (RCTs) began to displace observational studies as the source of evidence for using multivessel percutaneous coronary intervention (PCI) during ST-elevation myocardial infarction (STEMI), guideline committees discovered that they had gotten it wrong. In a total reversal, they elevated the prior class III recommendation (“harm”)2 for multivessel PCI in patients in stable condition to a class IIa recommendation (“should be considered”)3 or a IIb recommendation (“may be considered”),4 and they downgraded the prior class IIa recommendation5 for multivessel PCI in patients with cardiogenic shock to a class III recommendation.3 Is there a better example in medical history of how RCTs and observational studies have generated such diametrically opposed recommendations?
Interpretation of the Seattle Angina Questionnaire as an Outcome Measure in Clinical Trials and Clinical CareA Review
Merrill Thomas, MD; Philip G. Jones, MS; Suzanne V. Arnold, MD, MHA; et al.
doi : 10.1001/jamacardio.2020.7478
JAMA Cardiol. 2021;6(5):593-599
Importance Patient-reported outcomes are increasingly used as end points in clinical trials, assessments in clinical care, and tools for population health, with an increasing role in quality assessment. For patients with coronary artery disease, the Seattle Angina Questionnaire (SAQ) has emerged as the most commonly used measure of disease-specific health status to quantify patients’ symptoms of angina and the extent to which their angina affects their functioning and quality of life. This review explains how to interpret the SAQ and describes the construction and face validity of the SAQ, focusing on aligning scores and changes in scores with clinical constructs.
A Middle-aged Woman With Recurrent Chest Pain With Troponin Elevation and Unobstructed Coronary Arteries
Jun Hua Chong, MBBS; Andreas Baumbach, MD; Mohammed Y. Khanji, MBBCh(Hons), PhD
doi : 10.1001/jamacardio.2021.0116
JAMA Cardiol. 2021;6(5):600-601
A middle-aged woman presented with chest pain, elevated troponin-T of 1037 ng/L (normal <14 ng/L; to convert to micrograms per liter, multiply by 1), and anterior T-wave inversion on electrocardiography. She was a smoker with hypertension and kidney dysfunction, with a history of left-sided paresthesia.
Persistent Opioid Use May Be a Failure of Pain Management Rather Than Prescribing
Roland Flores Jr, MD; Anna Weyand, MD
doi : 10.1001/jamacardio.2020.6824
JAMA Cardiol. 2021;6(5):602
To the Editor It was with great interest and some apprehension that we read “Development of Persistent Opioid Use After Cardiac Surgery” by Brown et al.1 We agree that new persistent opioid use after surgery is a substantial concern and that excessive opioid prescribing contributes to this phenomenon, but we worry that this article may lead to erroneous conclusions regarding treatment of pain by focusing on persistent opioid consumption strictly as an adverse outcome rather than elucidating a broader problem.
Persistent Opioid Use May Be a Failure of Pain Management Rather Than Prescribing—Reply
Chase R. Brown, MD, MSHP; Peter Groeneveld, MD, MS; Nimesh Desai, MD, PhD
doi : 10.1001/jamacardio.2020.6835
JAMA Cardiol. 2021;6(5):602-603
In Reply We appreciate the letter from Flores and Weyand concerning our article1 and agree that persistent pain after cardiac surgery is a concerning phenomenon and must be addressed with high-quality, evidence-based postoperative pain management in the hospital and after discharge. To be clear, when postoperative pain is properly controlled, patients’ recovery, quality of life, and functional status are enhanced. We strongly agree with Flores and Weyand that suboptimal postoperative pain management can lead to the development of chronic postsurgical pain.
To DOAC or Not to DOAC for Left Ventricular Thrombi—What Is the Dose?
Arun Manmadhan, MD; Jeffrey S. Berger, MD, MS; Tania Ahuja, PharmD
doi : 10.1001/jamacardio.2020.6894
JAMA Cardiol. 2021;6(5):603-604
To the Editor The observational study published by Robinson and colleagues (Retrospective Evaluation of DOACs and Vascular Endpoints of Left Ventricular Thrombi [RED VELVT] study)1 provides important new data to an area that lacks a robust base of evidence. Direct oral anticoagulants (DOACs) have become preferred pharmacotherapy options for adults with nonvalvular atrial fibrillation, given the noninferiority to warfarin for stroke prevention and superior safety profile with less major bleeding.2 Although vitamin K antagonists (eg, warfarin) remain preferred in those with mechanical valves, there has been interest in using DOACs off-label for other prothrombotic states, including those with moderate to severe mitral stenosis, suggested by observational data.3
To DOAC or Not to DOAC for Left Ventricular Thrombi—What Is the Dose?—Reply
Austin A. Robinson, MD; Cory R. Trankle, MD; Grayson Eubanks, MD
doi : 10.1001/jamacardio.2020.6897
JAMA Cardiol. 2021;6(5):604
In Reply We thank Manmadhan and colleagues for their interest regarding the Retrospective Evaluation of DOACs and Vascular Endpoints of Left Ventricular Thrombi (RED VELVT) study.1 We agree on the need for high-quality data to guide clinical decision-making. Further, the authors make an important point regarding anticoagulation dosing regimens.
Serum Monocyte-Chemoattractant Protein–1 Could Be an Indicator of Coronary Artery Calcium Score
?mdat Ero?lu, MD; Burcu ?elik Ero?lu, MD
doi : 10.1001/jamacardio.2021.0070
JAMA Cardiol. 2021;6(5):604-605
To the Editor Georgakis et al1 found an association between circulating monocyte-chemoattractant protein–1 (MCP-1) levels and long-term cardiovascular mortality in a recently published meta-analysis. In our opinion, the reason behind this result could be the association between MCP-1 and coronary artery calcium (CAC) score.
Serum Monocyte-Chemoattractant Protein–1 Could Be an Indicator of Coronary Artery Calcium Score—Reply
Marios K. Georgakis, MD, PhD; Martin Dichgans, MD
doi : 10.1001/jamacardio.2021.0073
JAMA Cardiol. 2021;6(5):605
In Reply We thank Ero?lu and Ero?lu for their interest in our article1 and for discussing endothelial calcium influx as a potential mechanism underlying the observed association between serum monocyte-chemoattractant protein–1 (MCP-1) levels and cardiovascular mortality. While this is an interesting hypothesis, we feel there are limited data to support this. Specifically, it remains unclear whether endothelial calcium influx itself is an event causally related to atheroprogression or simply an epiphenomenon of other causal mechanisms. In contrast, the chemoattractant effect of MCP-1 on circulating monocytes is well established, as is the key role of monocytes in lipoprotein phagocytosis and atheroprogression after migration to the subendothelial space as macrophages.2 Furthermore, MCP-1 has been shown to participate in monocyte egress from bone marrow,3 which might additionally contribute to the recruitment of monocytes toward atherosclerotic plaques.
Expediting the Benefits of Sodium-Glucose Cotransporter-2 Inhibitors for Heart Failure—There Is No Time for Delay
Gregg C. Fonarow, MD; Clyde W. Yancy, MD, MSc
doi : 10.1001/jamacardio.2020.7596
JAMA Cardiol. 2021;6(5):507-508
Findings from recent randomized clinical trials have established that sodium-glucose cotransporter-2 inhibitors (SGLT2i) improve clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF).1-3 The Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial demonstrated that dapagliflozin significantly reduces the composite end point of a first heart failure (HF) hospitalization, urgent HF visit, or cardiovascular mortality among patients with HFrEF.1 The clinical benefits were similar irrespective of the presence or absence of type 2 diabetes and incremental to background medical therapy. The Empagliflozin Outcome Trial in Patients With Chronic HFrEF (EMPEROR-Reduced) and the Effect of Sotagliflozin on Cardiovascular Events in Patients With Type 2 Diabetes Post Worsening HF (SOLOIST-WHF) trials also demonstrated comparable clinical benefits.2,3 These landmark trial data provide compelling evidence for the addition of SGLT2i as a new pillar of foundational therapy for HFrEF. Yet, while these randomized clinical trials have established remarkable benefits and reasonable safety of SGLT2-i in HFrEF, questions remain regarding the optimal timing of the initiation of this newer therapy compared with other established HFrEF medications.
Is the Left Ventricular Ejection Fraction Measurement Still Preeminent?—New Measures to Quantify Subclinical Systolic Dysfunction
Clyde W. Yancy, MD, MSc; Gregg C. Fonarow, MD
doi : 10.1001/jamacardio.2021.0143
JAMA Cardiol. 2021;6(5):521
In 1628, William Harvey1 assumed that the heart emptied completely in systole. In 1888, Roy and Adami2 confirmed that a residual volume remained in the heart. In 1906, Henderson3 estimated the normal ejection of blood from the heart with each beat to be approximately two-thirds. This principle is sacrosanct and describes normal left ventricular (LV) systolic function. It was Folse and Braunwald4 in 1962 who observed “estimations of the fraction of the left ventricular end-diastolic volume that is ejected into the aorta during each cycle…provide information that is fundamental to a hemodynamic analysis of left ventricular function.”4(p 684) This history of the assessment of ventricular function and origin of the ejection fraction is necessary because it establishes the primacy of this assessment of LV ejection fraction (LVEF). The question, however, is whether it remains preeminent.
Reconsidering the Ross Procedure
Robert O. Bonow, MD, MS; Patrick T. O’Gara, MD
doi : 10.1001/jamacardio.2021.0087
JAMA Cardiol. 2021;6(5):548
There is no perfect prosthetic valve substitute for young and middle-aged patients requiring aortic valve replacement (AVR). The long-term risks of anticoagulation with a mechanical prosthesis must be weighed against the risks of structural valve deterioration of a bioprosthetic valve. In patients aged 20 to 40 years, the decision almost always leads to the selection of a mechanical valve and lifelong anticoagulation. Unfortunately, aortic valve repair is an option for only a small number of patients who are highly selected.
JAMA Cardiology Peer Reviewers in 2020
doi : 10.1001/jamacardio.2021.0151
JAMA Cardiol. 2021;6(5):e210151
JAMA Cardiology
doi : 10.1001/jamacardio.2020.4552
JAMA Cardiol. 2021;6(5):492
Mission Statement:? JAMA Cardiology publishes exceptional original research, state-of-the-art reviews, and informative opinions that advance the science and practice of cardiology, enhance cardiovascular health, and inform health care policy. JAMA Cardiology is the definitive journal for clinical investigators, clinicians, and trainees in cardiovascular medicine worldwide. JAMA Cardiology focuses on all aspects of cardiovascular medicine, including epidemiology and prevention, diagnostic testing, interventional and pharmacologic therapeutics, translational research, health care policy and outcomes, and global health.
