Patrick Campbell is the managing editor of HCPLive. Formerly the editorial lead of Endocrinology Network, Practical Cardiology, and Rheumatology Network, Patrick has spent years spearheading coverage surrounding cardiometabolic health and rheumatic disease for MJH Life Sciences. He now helps to lead coverage in each of these respective areas for HCPLive. Before joining MJH Life Sciences in 2019, he spent time as a beat reporter with the Pocono Record in Stroudsburg, PA, and Star News Group in Manasquan, NJ. He also touts experience in multimedia, having spent time as a multimedia specialist with NJ Advance Media and multimedia coordinator at the Pocono Record. Follow him on Twitter @RealPatCampbell or reach him via email at PCampbell@mjhlifesciences.com.

Patrick Campbell

The last full weekend of each month, our editorial team compiles a list of our most popular cardiology content from the past month for a month in review recap. The January 2023 cardiology month in review features a trio of articles related to management of atrial fibrillation, the FDA approval of Abbott’s Navitor system, and a study spotlighting the prevalence of mental health conditions among cardiologists.

Management of Arrhythmias Takes Center-Stage

The most common arrhythmia and among the most common forms of cardiovascular disease, atrial fibrillation represents one of the most underrecognized threats to public health in modern medicine. Linked to increase risk of stroke and mortality, the Centers for Disease Control and Prevention report atrial fibrillation was mentioned on more than 180,000 death certificates in 2019 and is projected to impact 12.1 million people in the US in 2030. As a result, atrial fibrillation is often at the forefront of discussion and research in cardiovascular medicine. January 2023 did not break this trend. Below, our editorial team highlights a trio of atrial fibrillation-related articles among the most popular cardiology content of the month.

ACTIVE-AF Suggests Physical Activity May Reduce Atrial Fibrillation Risk

Physical activity represents a cornerstone of cardiovascular risk reduction. Now, results of the ACTIVE-AF trial indicate increased levels of physical activity might reduce arrhythmia recurrence among patients with paroxysmal or persistent, symptomatic atrial fibrillation. 

A trial assessing the effects of a 6-month supervised exercise and home-based physical activity intervention, results of the trial suggest freedom from arrhythmia was achieved by 40% in the exercise group and 20% in the control group (HR, 0.50; 95% CI, 0.33-0.78) at 1 year. Results also indicated randomization to the exercise intervention was associated with a lower mean symptom severity score at both 6 and 12 months.

Atrial Fibrillation Associated with Poor Outcomes After Mechanical Thrombectomy for Stroke

On January 6, a systematic review and meta-analysis published in 

 provided an overview of the differences in outcomes following mechanical thrombectomy between patients with and without atrial fibrillation. Led by a team of 3 from the Mayo Clinic in Rochester, MN, the study leveraged data from 10 studies with a total population of 6543 and concluded those with atrial fibrillation had significantly higher rates of mortality and significantly lower rates of functional independence after mechanical thrombectomy compared to those without atrial fibrillation, even with comparable, successful reperfusion outcomes.

First-Time Catheter Ablation for Persistent AFib Not Benefited by Addition of PWI to PVI

A multicenter, randomized trial, the CAPLA study randomized 338 patients with persistent atrial fibrillation to compare the effects of pulmonary vein antral isolation (PVAI) against PVAI with posterior left atrial wall isolation (PWI) for achieving freedom from atrial arrhythmia of more than 30 seconds without the presence of antiarrhythmic medication at 12 months after a single ablation procedure. The trial also included 23 respecified secondary endpoints.

Results of the trial indicated freedom from recurrent atrial arrhythmia after 1 ablation procedure without the use of antiarrhythmic medication was present in 52.4% assigned to PVAI with PWI and 53.6% of those assigned to PVI alone (between-group difference, –1.2%; HR, 0.99 [95% CI, 0.73 - 1.36]; 

=.98). Findings of note from analysis of secondary endpoints indicated the mean procedural times (142 vs 121 minutes; mean difference, 21 minutes; 

 <.001) and radiofrequency abolition times (34 vs. 28 minutes; mean difference, 6 minutes; 

 <.001) were significantly shorter for PVI alone compared to PVAI with PWI.

FDA Approves Next-Generation TAVI System For Aortic Stenosis Treatment

On January 17, Abbott announced the US Food and Drug Administration had granted approval to the Navitor system for treatment of treat people with severe aortic stenosis who are at high or extreme risk for open-heart surgery. Billed as the latest addition to the company’s transcatheter structural heart portfolio, the transcatheter aortic valve implementation system features a unique fabric cuff to reduce or eliminate paravalvular leak. In their release, Abbott noted the Navitor system is implanted using Abbott's FlexNav delivery system, which is designed to accommodate different patient anatomies and small vessels for stable and accurate valve delivery and placement.

A pair of articles tackling different studies published in journals affiliated with the American College of Cardiology painting grim pictures for the field of cardiology round out our most popular content for January 2023. The first, details the prevalence of mental health conditions among cardiologists across the globe. The second, calls attention to a lack of uptake of guideline-directed medical therapy in heart failure.

More Than 1-In-4 Cardiologists Report Mental Health Conditions, Survey Finds

confirms what so many in cardiology already recognize as a reality: a considerable amount of the field is dealing with mental health struggles. An analysis of data from a 2019 survey conducted by the American College of Cardiology, results indicate 28% of the more than 5800 respondents reported some form of mental health condition, with more than 40% of cardiologists reporting a mental health condition also reporting being dissatisfied with 1 or more career-related metrics.

Check out the clip below from an interview with Andrew Sauer, MD, who authored an editorial comment that accompanied the study in 

, on the subject of mental health in cardiology.

Majority Of Patients Hospitalized With Acute Heart Failure Eligible For GDMT Initiation

With STRONG-HF outlining the benefit of in-hospital initiation and rapid uptitration of guideline-directed medical therapy in patients with heart failure, the community was compelled to adopt this strategy, which is what many in the community have been preaching for years. Less than 3 months after STRONG-HF stole the spotlight at AHA 2022, an analysis of the CAN-HF registry is shedding light on the proportion of patients hospitalized with acute heart failure considered eligible for each pillar of guideline-directed medical therapy.

Results of the study, which included data from 943 patients hospitalized at 7 medical centers in Canada from January 2017-April 2020, suggest 74% to 95% of the study cohort admitted with AHF were eligible for 1 of 4 foundational therapies and nearly three-quarters of patients were eligible for combined quadruple therapy.

Articles

The January 2023 cardiology month in review features a trio of articles related to management of atrial fibrillation, the FDA approval of Abbott’s Navitor system, and a study spotlighting the prevalence of mental health conditions among cardiologists.

Cardiology Month in Review: January 2023

The increased risk of acute myocardial infarction (AMI) and 

 associated with preeclampsia remains elevated for longer than 2 decades, according to new research from the University of Copenhagen.

A registry-based study of more than 1.15 million women with at least 1 pregnancy between 1978 and 20217, results of the study demonstrate women with preeclampsia had a 4-fold increase in risk of AMI and a more than 2-fold increase in risk of ischemic stroke compared to their counterparts without preeclampsia in the first 10 years following first pregnancy, with this increase in risk prevalent more than 20 years later.

“The high risk of cardiovascular disease after pre-eclampsia manifests at young ages and early after delivery,” said lead investigator Sara Hallum, MSc, an epidemiologist and PhD student at the University of Copenhagen, Denmark, 

. “This indicates that interventions to prevent heart attacks and strokes in affected women cannot wait until middle age when they become eligible for conventional cardiovascular screening programmes.”

In a field where mountains of research are published on a weekly basis, 

 of women remains overlooked and underresearched in the current landscape of cardiology. In a recent 

Martha Gulati, MD, offered insight into the recent progress made in reducing the burden of gender disparity in cardiovascular research. Among obstetric complications, the prevalence and associated risk of preeclampsia places it among the most significant risk factors for cardiovascular disease among women at a population level. With this in mind, Hallum and a team of collaborators from the institutions in Denmark designed the current research effort as a registry-based study with the intent of describing the long-term risk of AMI and ischemic stroke among women with preeclampsia and how this risk changes over time.

With this in mind, investigators designed the register-based study to leverage data from women with at least 1 pregnancy from 1978-2017 recorded within Denmark’s Civil Registration System and Medical Birth Register. Excluding those with any circulatory disorders registered prior to first delivery, investigators identified a cohort of 1,157,666 women for inclusion in their study. The median length of follow-up for this cohort was 20.5 (IQR, 10-30.5) years.

Among the overall study cohort 4.0% (n=45,820) had a first pregnancy complicated by preeclampsia. Among women with preeclampsia during first pregnancy, 7.1% (n=3270) had early pre-term preeclampsia, 11.8% (n=5405) had late pre-term preeclampsia, and 81.1% (n=37,145) had term preeclampsia. Investigators noted 58,120 women had 64,357 pregnancies complicated by preeclampsia during the entire duration of the study period.

During 23,503,887 person-years of follow-up, 2.5% (n=8702) of women had an AMI as their first ischemic event and 3.8% (n=13,999) of women experienced an ischemic stroke as their first ischemic events. During the first 20 year following their first pregnancy, 1.2% (n=3089) and 1.8% (n=5119) of women experienced AMI and ischemic stroke, respectively.

Results of the investigators’ analyses indicated up to 2% (95% CI, 1.46-2.82) of women with preeclampsia during their first pregnancy experienced an AMI or stroke within the first 2 decades following delivery compared with up to 1.2% (95% CI, 1.08-1.30) of women without a preeclampsia-complicated pregnancy. Investigators noted results of their analyses demonstrated differences in cumulative incidences in were evident between the study groups as early as 7 years after delivery.

Further analysis suggested preeclampsia was associated with a more than 4-fold risk of AMI (HR, 4.16 [95% CI, 3.16-5.49]) and a more than doubling in risk of ischemic stroke (HR, 2.59 [95% CI, 2.04-3.28]) than women without preeclampsia during the first 10 years after pregnancy, with this relative risk remaining at least doubled up to 20 years later. Investigators called attention to results of subgroup analyses stratified by age, which demonstrated women with preeclampsia aged 30-39 years had a nearly 5-fold increase in risk of AMI (HR, 4.88 [95% CI, 3.55-6.71]) and a more than 2-fold increase in risk of ischemic stroke (HR, 2.56 [95% CI, 1.95-3.36]) compared to their counterparts of the same age without preeclampsia.

“Our study suggests that the women most likely to benefit from screening are those who had preeclampsia after age 35 and those who had it more than once,” Hallum added. Prevention should start within a decade of delivery, for example by treating high blood pressure and informing women about risk factors for heart disease such as smoking and inactivity.”

Risk and trajectory of premature ischaemic cardiovascular disease in women with a history of pre-eclampsia: a nationwide register-based study

European Journal of Preventive Cardiology.

An analysis of registry data recorded in Denmark over a 4-decade period offers an overview of the risk of acute myocardial infarction and ischemic stroke incurred as a result of preeclampsia during pregnancy and how this risk changes over time.

Preeclampsia Increases Heart Attack, Stroke Risk for Up to 20 Years After Pregnancy

Few, outside of the person with diabetes and their care team, can understand the burden a diagnosis of diabetes places on the physical and mental health of 

. Now, a new study from investigators in Japan is shedding new light on the effects of self-stigma on glucose control among people with type 1 diabetes.

A single-center, cross-sectional study, which estimated associations between 9-item Self-Stigma Scale scores and HbA1c, results of the research endeavor provide insight into the mean self-stigma scores among people with type 1 diabetes and point to a positive association between self-stigma and HbA1c that remained significant after multivariable adjustment.

“We focused on this issue through clinical experiences with people with type 1 diabetes, whose glycemic management improved markedly by social supports of eliminating diabetes-related stigma. Although the finding of an association between self-stigma and HbA1c is significant, further longitudinal research is required to determine whether self-stigma leads to sub-optimal HbA1c,” said corresponding author Yukiko Onishi MD, PhD, of the Institute of Medical Science, Asahi Life Foundation, in Tokyo, 

. “This research does support and highlight the importance of eliminating self-stigma when treating people with type 1 diabetes.”

People with diabetes face a unique challenge not posed by many other chronic illnesses: stigma. Thankfully, not many people afflicted with disease are made to bear the disease burden and blame of diagnosis the way the general public has demonized the presence of diabetes. Although this more often pertains to stigma towards 

, particularly with weight stigma towards people with obesity, the mental hurdles of diabetes management are not unique to type 2 diabetes. In 

 Jill Weissberg-Benchell, PhD, a pediatric psychologist at the Ann & Robert H. Lurie Children’s Hospital of Chicago, sat down with hosts to discuss the importance of mental health and describe the challenges faced by people with diabetes in their daily lives.

Citing previous research linking perceived stigma with psychological and clinical outcomes in people with type 1 diabetes, Onishi and a team of collaborators sought to describe the impact of self-stigma on glucose control among adults with type 1 diabetes. With this in mind, investigators launched a single-center, cross-sectional study at the Institute of Medical Science, Asahi Life Foundation in Tokyo from August-November 2021. Limiting their study to those aged 18 years or older with a doctor-reported diagnosis of type 1 diabetes being treated with insulin injections and without serious mental health disorders, investigators identified a cohort of 166 for potential inclusion in their study.

The Self-Stigma Scale used in the study asked participants to provide scores using a 4-point Likert scale of agreement. The total scores possible with the scale ranged from 0 to 27, with higher scores indicating a greater level of self-stigma. For the purpose of analysis, mean HbA1c levels were calculated using HbA1c measurements from the last 3 clinical visits within 6 months, starting from the day the questionnaire was distributed.

After distributing questionnaires, which included the 9-item Self-Stigma Scale, to these patients, investigators collected responses from 140 participants. After excluding those not providing answers pertaining to self-stigma, those with missing data on insulin use, and those with a falsely low value of HbA1c due to anemia, investigators identified 109 people with type 1 diabetes for inclusion in the study. This cohort had a mean age of 58.3 years, 43.1% were women, a mean duration of diabetes was 25.5 years, a mean BMI of 22.9, and a mean BMI of 7.6%.

Upon analysis, the median of the total scores of the 9-item Self-Stigma scale was 11. For the cognitive, affective, and behavioral subscales, the median scores were 5, 3, and 1, respectively. In analyses adjusted for age, sex, employment status, BMI, duration of diabetes, and insulin secretion, there was a significant positive association between self-stigma and HbA1c (β=.05; 95% CI, 0.01-0.08).

“The present cross-sectional study showed an important finding that self-stigma is associated with HbA1c among adults with type 1 diabetes. Our study suggests that treatment of diabetes should be provided to persons with type 1 diabetes with considerations that HbA1c is associated with self-stigma,” wrote investigators.

Association of self-stigma with glycated hemoglobin: A single-center, cross-sectional study of adults with type 1 diabetes in Japan

A study of more than 100 adults with type 1 diabetes suggests those with increased levels of self-stigma had worse glucose control than their counterparts with lower levels of self-stigma.

Self-Stigma Could Contribute to Worsening Glucose Control in Type 1 Diabetes

Despite research efforts, disagreement still exists in regard to the utility of calprotectin levels for predicting or assessing inflammation and disease activity in people with 

, but a new study is shedding further light on these associations.

With a more significant emphasis on the identification of biomarkers for disease activity in recent years, results of the systematic review and meta-analysis, which leveraged data from more than 30 published articles, suggest calprotectin levels were associated with C-reactive protein and disease activity score, but failed to predict treatment outcomes in patients with rheumatoid arthritis.

“After integrated analyses, it was observed that blood calprotectin levels were higher in RA patients compared with healthy subjects; calprotectin was positively related to systemic inflammation and disease activity in RA patients. However, blood calprotectin levels failed to predict treatment outcomes in RA patients,” wrote investigators.

With an interest in leveraging advanced technologies to identify biomarkers for improving management of multiple conditions, numerous research endeavors have been launched in recent years, particularly in rheumatic disease. An inflammatory biomarker proven to reflect disease activity in multiple autoimmune inflammatory diseases, previous research has drawn mixed conclusions related to its specific utility as a biomarker in rheumatoid arthritis. With this in mind, a team of investigators from the Department of Immunology and Rheumatology at the Affiliated Hospital of Guizhou Medical University designed the current study to provide the field with an updated overview of data from studies investigating associations of calprotectin with inflammation, activity, and treatment response in rheumatoid arthritis patients.

For the purpose of analysis, investigators performed a search of relevant published works within the PubMed, Emboss, Web of Science, Cochrane databases, and their cited references from inception up to November 2021. A total of 38 articles were reviewed, 36 were assessed for further eligibility, and 31 were identified for inclusion in the investigators’ analyses. The primary outcomes of interest for the study were the standardized mean differences (MD) in calprotectin level among people with rheumatoid arthritis and healthy controls and associations between calprotectin levels with C-reactive protein, disease activity score, and treatment response, which was measured using pooled correlation coefficients (CC). Of the 31 articles included in the meta-analysis, 13 were included in the analysis of calprotectin levels between patients with rheumatoid arthritis and healthy controls, 19 were included in the analysis of the correlation between calprotectin levels and C-reactive protein, 4 were used in the analysis of the correlation between calprotectin levels and treatment response.

Upon analysis, results of the meta-analysis suggested levels of calprotectin were greater among those with rheumatoid arthritis compared to healthy controls (MD, 1.48 [95% CI, 1.16 to 1.79]). Further analysis of primary outcomes of interest revealed increased calprotectin levels were positively associated with C-reactive protein (CC, 0.58 [95% CI, 0.53 to 0.63]) and disease activity score (CC, 0.48 [95% CI, 0.38 to 0.58]) in patients with rheumatoid arthritis. Investigators noted results of their analyses demonstrated calprotectin showed an increased trend in rheumatoid arthritis responders compared to nonresponders, but this trend failed to reach statistical significance (MD, 0.38 [95% CI, -0.09 to 0.85]).

“This meta-analysis shows that calprotectin relates to disease risk, inflammation and activity in rheumatoid arthritis patients. It may also predict treatment response to some extent, but this issue needs further validation,” investigators concluded.

Linkage of calprotectin with inflammation, activity and treatment response of rheumatoid arthritis: a meta-analysis

A meta-analysis with data from more than 30 published articles provides an overview of associations between calprotectin levels and disease activity, treatment response, and inflammation among patients with rheumatoid arthritis.