Episodes Archives - Cardionerds

CardioNerds Tommy Das (Program Director of the CardioNerds Academy and cardiology fellow at Cleveland Clinic), Rick Ferraro (cardiology fellow at the Johns Hopkins Hospital), and Dr. Aliza Hussain (cardiology fellow at Baylor College Medicine) take a deep dive on the REDUCE-IT trial with Dr. Peter Toth, director of preventive cardiology at the CGH medical center in Sterling, Illinois, clinical professor in family and community medicine at the University of Illinois School of Medicine, and past president of the National Lipid Association and the American Board of Clinical Lipidology.  Special introduction to CardioNerds Clinical Trialist Dr. Jeff Wang (Emory University). Audio editing by CardioNerds academy intern, Shivani Reddy.

This episode is part of the CardioNerds Lipids Series which is a comprehensive series lead by co-chairs Dr. Rick Ferraro and Dr. Tommy Das and is developed in collaboration with the American Society For Preventive Cardiology (ASPC).

Relevant disclosures: None

Pearls • Notes • References • Guest Profiles • Production Team

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The Reduction of Cardiovascular Events with EPA-Intervention Trial (REDUCE-IT) trial was a large randomized controlled trial that showed a significant reduction in atherosclerotic cardiovascular disease (ASCVD) events with use of icosapent ethyl ester in secondary prevention patients and high risk primary prevention patients with diabetes and residual elevated triglycerides between 135 to 499 mg/dL on top of maximally tolerated statin therapy1.

1. Despite the use of high intensity statin therapy, considerable residual risk for future atherosclerotic cardiovascular disease exists in patients with ASCVD.
2. Elevated triglycerides (TGs) are an important marker of increased residual ASCVD risk2.
3. There are two primary types of Omega-3 fish oils: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Omege-3 fish oils have been shown to lower triglyceride levels.
4. Low-dose combination EPA and DHA has not exhibited incremental cardiovascular benefit in either primary prevention and secondary prevention patients on top of statin therapy3-5.
5. REDUCE-IT showed the use of high dose EPA in patients with either ASCVD or DM and one additional risk factor, and relatively well-controlled LDL-C levels on maximally tolerated statin therapy and residual hypertriglyceridemia (TG 135-499 mg/dL) results in significant reductions in cardiovascular events over a median follow-up period of 4.9 years1.

• Multiple epidemiologic and Mendelian randomization studies have established elevated triglyceride (TG) levels as an important risk factor for atherosclerotic cardiovascular events6-8. However previous clinical trials using TG-lowering medication such as niacin, fibrates and low dose omega-3 fish oil have not shown to reduce cardiovascular events when added to statin therapy in patients with or without ASCVD,9,10.
• The JELIS trial first demonstrated a significant reduction in cardiovascular events when 1.8g daily of eicosapentaenoic acid (EPA) was added to low-intensity statin therapy in patients with ASCVD and hypercholesterolemia, However, the trial was limited due to open label design without placebo, use of low doses of background statin therapy, and geographic/demographic limitations to participants in Japan11.
• In a large international multicenter randomized controlled trial, the Reduction of Cardiovascular Events with Icosapent Ethyl–Intervention Trial (REDUCE-IT) randomized 8,179 patients with established atherosclerotic heart disease or diabetes and an additional risk factor, on maximally tolerated statin therapy, to 4 gm/day of icosapent ethyl (a highly purified and stable EPA ethyl ester) or mineral oil1. 
• Over a median follow up of 4.9 years, the use of icosapent ethyl ester was associated with significant reductions in major cardiovascular events (cardiovascular death, nonfatal MI, nonfatal stroke, coronary revascularization, or unstable angina) compared to placebo, with an absolute risk reduction of 4.8% and NNT of 21.
• There were similar reductions in the key components of the primary endpoint, including a 20% relative risk reduction in cardiovascular death with icosapent ethyl.
• Median TG levels were reduced by 18% in the icosapent ethyl group and rose by 2.2% in the placebo group. LDL levels increased in both groups, although to a lesser degree in the icosapent ethyl group.
• There was a trend towards increased bleeding (2.7% with icosapent ethyl versus 2.1% with placebo, p=0.06) and a modest but significant increase in hospitalizations for atrial fibrillation or flutter with icosapent ethyl (3.1% versus 2.1%).
• Since the publication of REDUCE-IT, several clinical practice guidelines, including those of the American Diabetes Association (ADA), National Lipid Association (NLA) and the European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS), have endorsed the use of icosapent ethyl in their recommendations to further reduce ASCVD risk in select patients.

1. Bhatt DL, Steg PG, Miller M, et al. Cardiovascular risk reduction with icosapent ethyl for hypertriglyceridemia. N Engl J Med. 2019;380(1):11-22. doi: 10.1056/NEJMoa1812792. https://www.nejm.org/doi/full/10.1056/nejmoa1812792
2. Libby P. Triglycerides on the rise: Should we swap seats on the seesaw? Eur Heart J. 2015;36(13):774-776. doi: 10.1093/eurheartj/ehu500.  https://academic.oup.com/eurheartj/article/36/13/774/475534
3. Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: Results of the GISSI-prevenzione trial. gruppo italiano per lo studio della sopravvivenza nell’infarto miocardico. Lancet. 1999;354(9177):447-455. doi: S0140673699070725. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(99)07072-5/fulltext
4. Risk and Prevention Study Collaborative Group, Roncaglioni MC, Tombesi M, et al. N-3 fatty acids in patients with multiple cardiovascular risk factors. N Engl J Med. 2013;368(19):1800-1808. doi: 10.1056/NEJMoa1205409. https://www.nejm.org/doi/10.1056/NEJMoa1205409?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov
5. ASCEND Study Collaborative Group, Bowman L, Mafham M, et al. Effects of n-3 fatty acid supplements in diabetes mellitus. N Engl J Med. 2018;379(16):1540-1550. doi: 10.1056/NEJMoa1804989. https://www.nejm.org/doi/10.1056/NEJMoa1804989?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov
6. Triglyceride Coronary Disease Genetics Consortium and Emerging Risk Factors Collaboration, Sarwar N, Sandhu MS, et al. Triglyceride-mediated pathways and coronary disease: Collaborative analysis of 101 studies. Lancet. 2010;375(9726):1634-1639. doi: 10.1016/S0140-6736(10)60545-4. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60545-4/fulltext
7. Do R, Willer CJ, Schmidt EM, et al. Common variants associated with plasma triglycerides and risk for coronary artery disease. Nat Genet. 2013;45(11):1345-1352. doi: 10.1038/ng.2795. https://www.nature.com/articles/ng.2795
8. Sarwar N, Danesh J, Eiriksdottir G, et al. Triglycerides and the risk of coronary heart disease: 10,158 incident cases among 262,525 participants in 29 western prospective studies. Circulation. 2007;115(4):450-458. doi: CIRCULATIONAHA.106.637793. https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.106.637793?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
9. Keech A, Simes RJ, Barter P, et al. Effects of long-term fenofibrate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus (the FIELD study): Randomised controlled trial. Lancet. 2005;366(9500):1849-1861. doi: S0140-6736(05)67667-2. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)67667-2/fulltext
10. ACCORD Study Group, Ginsberg HN, Elam MB, et al. Effects of combination lipid therapy in type 2 diabetes mellitus. N Engl J Med. 2010;362(17):1563-1574. doi: 10.1056/NEJMoa1001282. https://www.nejm.org/doi/full/10.1056/nejmoa1001282
11. Yokoyama M, Origasa H, Matsuzaki M, et al. Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): A randomised open-label, blinded endpoint analysis. Lancet. 2007;369(9567):1090-1098. doi: S0140-6736(07)60527-3. https://www.thelancet.com/article/S0140-6736(07)60527-3/fulltext
12. Nicholls SJ, Lincoff AM, Garcia M, et al. Effect of high-dose omega-3 fatty acids vs corn oil on major adverse cardiovascular events in patients at high cardiovascular risk: The STRENGTH randomized clinical trial. JAMA. 2020;324(22):2268-2280. doi: 10.1001/jama.2020.22258. https://doi.org/10.1001/jama.2020.22258. .

Dr. Peter Toth is the Director of Preventive Cardiology at CGH Medical Center in Sterling, IL, and Professor of Clinical Family and Community Medicine at the University of Illinois College of Medicine in Peoria, and adjunct associate professor of medicine, Johns Hopkins University School of Medicine. He received his medical degree from Wayne State University School of Medicine in Detroit, MI, and PhD in Biochemistry from Michigan State University in East Lansing. He has written extensively on the topic of lipids and is Co-Editor of twenty textbooks in preventive cardiology, diabetes, hypertension, and lipidology. Additionally, Dr. Toth is the President of the American Society of Preventive Cardiology, past President of the National Lipid Association, as well as incoming chair of the American Heart Association’s Council on Lipoproteins, Lipid Metabolism, and Thrombosis.

Dr. Aliza Hussain is a cardiology fellow at Baylor College of Medicine. She completed a fellowship in prevention at Baylor College of Medicine Cardiovascular Research Institute, and internal medicine residency at UPCM.

The following question refers to Section 4.11 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Christian Faaborg-Andersen, answered first by UCSF resident Dr. Jessie Holtzman, and then by expert faculty Dr. Laurence Sperling.

Dr. Laurence Sperling is the Katz Professor in Preventive Cardiology at the Emory University School of Medicine and Founder of Preventive Cardiology at the Emory Clinic. Dr. Sperling was a member of the writing group for the 2018 Cholesterol Guidelines, serves as Co-Chair for the ACC’s Cardiometabolic and Diabetes working group, and is Co-Chair of the WHF Roadmap for Cardiovascular Prevention in Diabetes.

The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.

Medically supervised cardiac rehabilitation programs after ASCVD events and for patient with heart failure carries a Class I recommendation. However, placement of referrals, uptake and enrollment after referral, and rigor of rehabilitation all remain inconsistent. What minimum cumulative duration of cardiac rehabilitation has been chosen as a threshold of effectiveness for cardiac rehabilitation by the European Society of Cardiology?

A. 100-300 minutes, 10 sessions
B. 300-500 minutes, 16 sessions
C. 500-700 minutes, 22 sessions
D. 700-1000 minutes, 28 sessions
E. >1000 minutes, 36 sessions

The correct answer is E: >1000 minutes across 36 sessions.

Cardiac rehabilitation is a comprehensive, multidisciplinary intervention not just including exercise training and physical activity counselling, but also education, risk factor modification, diet/nutritional counselling, and vocational and psychosocial support.

A broad evidence base demonstrates that multidisciplinary cardiac rehabilitation and prevention programs after ASCVD events or revascularization reduce recurrent cardiovascular hospitalizations, myocardial infarction, and cardiovascular mortality. In patients with chronic HF (mainly HFrEF), exercise based cardiac rehabilitation (EBCR) may improve all-cause mortality, reduce hospital admissions, and improve exercise capacity and quality of life. Such programs include a wide array of activities including physical activity, risk factor modification, psychosocial support, nutrition counseling, and more. Despite the heterogenous design of clinical trials, cardiac rehabilitation has been shown to be a cost-effective intervention.

Based upon the available review data, the European Association of Preventive Cardiology and the European Society of Cardiology proposed minimum standards for secondary prevention cardiac rehabilitation programs. Based upon a comprehensive review of the literature, ESC recommends that cardiac rehabilitation be multidisciplinary, supervised by health professionals, and start as soon as possible after a cardiovascular event. Cardiac rehabilitation should include both aerobic and muscular resistance tailored to the fitness level of the participant, should carry a duration of >1000 minutes in total, and should exceed 36 sessions total.

While uptake remains limited, electronic prompts within the medical record and automatic referrals should be considered to enhance referral and participation. Future research should continue to explore the benefit of home-based cardiac rehabilitation with or without telemonitoring. Lastly, studies have shown that uptake remains lower among women, and targeted programs should be undertaken to address such disparities.

Main Takeaway

Current European Society of Cardiology guidelines provide a Class I (LOE A) recommendation for the participation in multidisciplinary cardiac rehabilitation programs for the secondary prevention of ASCVD events including revascularization and in individuals with heart failure (mainly HFrEF) to improve patient outcomes.

Guideline Location

Section 4.11, Page 3292.

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The following question refers to Section 6.1 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Christian Faaborg-Andersen, answered first by UCSD cardiology fellow Dr. Harpreet Bhatia, and then by expert faculty Dr. Eugenia Gianos.

Dr. Gianos specializes in preventive cardiology, lipidology, cardiovascular imaging, and women’s heart disease; she is the director of the Women’s Heart Program at Lenox Hill Hospital and director of Cardiovascular Prevention for Northwell Health.

The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.

A 70-year-old man with a history of hypertension, diabetes, hyperlipidemia, peptic ulcer disease with a prior upper GI bleed, as well as coronary artery disease presents to clinic. About one year ago he suffered an NSTEMI treated with percutaneous coronary intervention to the mid LAD. He is feeling well and able to walk 1 mile daily with no anginal symptoms. He is currently taking aspirin 81 mg daily, ticagrelor 90 mg BID, atorvastatin 40 mg daily, metoprolol 25 mg BID, lisinopril 5 mg daily, and lansoprazole 15mg daily. He has a preserved ejection fraction. His BP in clinic is 110/70 and HR is 65 bpm. His LDL is 50 mg/dL. What do you recommend for his further management?

A. Switch ticagrelor to clopidogrel, continue indefinitely
B. Stop ticagrelor, continue aspirin indefinitely
C. Continue aspirin + ticagrelor indefinitely
D. Stop ticagrelor, start rivaroxaban 2.5 mg BID

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The correct answer is B – stop ticagrelor, continue aspirin indefinitely.

Twelve months of DAPT is recommended for acute coronary syndromes (Class I, LOE A). Long-term secondary prevention with dual anti-thrombotic therapy (DAPT > 12 months with a P2Y12 inhibitor and low-dose aspirin or low-dose rivaroxaban 2.5mg BID with low-dose aspirin) may be considered for patients who are at high ischemic risk without high risk of bleeding (Class IIa, LOE A). However, this patient is at increased bleeding risk (peptic ulcer disease with prior GI bleeding) and has no ischemic symptoms, and so neither would be recommended.

Main Takeaway

In summary, 12 months of DAPT is recommended after ACS. Prolonged DAPT or low-dose rivaroxaban may be considered with high ischemic risk and low bleeding risk.

Guideline Location

Section 6.1, Pages 3294-3295.

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The following question refers to Section 4.6 of the  2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Shivani Reddy, answered first by NP Carol Patrick, and then by expert faculty Dr. Eileen Handberg.

Dr. Handberg is an Adult Nurse Practitioner, Professor of Medicine, and Director of the Cardiovascular Clinical Trials Program in the Division of Cardiovascular Medicine at the University of Florida. She has served as Chair of the Cardiovascular Team Section and the Board of Trustees with the ACC and is the President Elect for the PCNA.

The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.

Ms. DW is a 67-year-old woman with a history of coronary artery disease and prior percutaneous coronary intervention in 2019 with a drug-eluting stent to the proximal left anterior descending artery. They have transitioned to your clinic from a previous provider, and their LDL is 134 mg/dL. What would be the ESC recommended goal LDL-C level for this patient? 

A. <30 mg/dL
B. <55 mg/dL
C. <70 mg/dL
D. <100 mg/dL

The correct answer is B.

The ESC guidelines outline a robust LDL-C reduction goal of <55mg/dL (<1.4mmol/L) and ≥50% reduction from baseline in those with known atherosclerotic cardiovascular disease, with the highest possible Class I (LOE A) recommendation for this goal. A goal LDL-C <55mg/dL with ≥50% reduction from baseline should also be considered in apparently healthy persons <70 years of age who are at very high risk (Class IIa, LOE C). 

To achieve these goals, the guidelines recommend a stepwise approach to treatment including dietary, lifestyle, and medical management. Recognizing that lower LDL-C is better, the guidelines recommend liberal intensification of treatment especially if using submaximal doses of generic or low-cost statins and side effects are not apparent. High-intensity statin is recommended to be prescribed to the highest tolerated dose to reach LDL-C goals set for each specific risk group (Class I, LOE A). If these goals are not achieved with the maximum tolerated dose of a statin, combination therapy with ezetimibe is recommended (Class I, LOE B).

Choice A is incorrect. An LDL-C <30mg/dL is a more significant reduction than that recommended by the guidelines, even for patients with known ASCVD. Notably, for patients with ASCVD who experience a second vascular event within 2 years while taking maximum tolerated statin-based therapy, an LDL-C goal of <1.0 mmol/L (40 mg/dL) may be considered.

Choice C is incorrect. The ESC prevention guidelines recommend considering a goal of <70mg/dL for patients in the primary prevention setting at high risk who are <70 years of age (Class IIa, LOE C). (Recall again that for those at very high risk the primary prevention recommendation is target LDL-C <55 mg/dL).

Choice D is incorrect. LDL-C <100mg/dL was a frequently cited goal in older iterations of various prevention and lipid guidelines. As the data has shifted to support lower LDL-C goals, this is not a noted goal within the 2021 ESC prevention guidelines for patients <70 years of age.

Main Takeaway

Lower is better when it comes to LDL-C

For those with known atherosclerotic cardiovascular disease, liberal intensification of lipid lowering treatment is recommended. 

Guideline Location

Section 4.6.2.1, page 3276-3279, Figure 6 on page 3252, Figure 7 on page 3253

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The following question refers to Section 4.3 of the 2021 ESC CV Prevention Guidelines. The question is asked by Dr. Maryam Barkhordarian, answered first by pharmacy resident Dr. Anushka Tandon, and then by expert faculty Dr. Noreen Nazir.

Dr. Noreen Nazir is Assistant Professor of Clinical Medicine at the University of Illinois at Chicago, where she is the director of cardiac MRI and the preventive cardiology program.

The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.

Mr. A is a 28-year-old man who works as an accountant in what he describes as a “desk job” setting. He shares that life got “a little off-track” for him in 2020 between the COVID-19 pandemic and a knee injury. His 2022 New Years’ resolution is to improve his overall cardiovascular and physical health. He has hypertension and a family history of premature ASCVD in his father, who died of a heart attack at age 50. Prior to his knee injury, he went to the gym 3 days a week for 1 hour at a time, split between running on the treadmill and weightlifting. He has not returned to the gym since his injury and has been largely sedentary, although he is trying to incorporate a 20-minute daily walk into his routine. Which of the following exercise-related recommendations is most appropriate?

A. A target of 75-150 minutes of vigorous-intensity or 150-300 minutes of moderate-intensity aerobic physical exercise weekly is recommended to reduce all-cause mortality, CV mortality, and morbidity.
B. Bouts of exercise less than 30 minutes are not associated with favorable health outcomes.
C. Exercise efforts should be focused on aerobic activity, since only this type of activity is associated with mortality and morbidity benefits.
D. Light-intensity aerobic activity like walking is expected to have limited health benefits for persons with predominantly sedentary behavior at baseline.

The correct answer is A.

There is an inverse relationship between moderate-to-vigorous physical activity and CV morbidity/mortality, all-cause mortality, and incidence of type 2 diabetes, with additional benefits accrued for exercise beyond the minimum suggested levels. The recommendation to “strive for at least 150-300 min/week of moderate-intensity, or 75-150 min/week of vigorous-intensity aerobic physical activity, or an equivalent combination thereof” is a Class 1 recommendation per the 2021 ESC guidelines, and a very similar recommendation (at least 75 minutes of vigorous-intensity or 150 minutes of moderate-intensity activity) is also Class 1 recommendation per 2019 ACC/AHA primary prevention guidelines. Both the ESC and ACC/AHA provide examples of activities grouped by absolute intensity (the amount of energy expended per minute of activity), but the ESC guidelines also offer suggestions for measuring the relative intensity of an activity (maximum/peak associated effort) in Table 7, which allows for a more individualized, customizable approach to setting activity goals. Importantly, individuals who are unable to meet minimum weekly activity recommendations should still be encouraged to stay as active as their abilities and health conditions allow to optimize cardiovascular and overall health.

Choice B is incorrect, as data suggests physical activity episodes of any duration, including <10 min, are associated with favorable outcomes like all-cause mortality benefit. The duration of a single exercise bout is less correlated with health benefits than the total physical activity time accumulated per week.

Choice C is incorrect. Per the ESC guidelines, it is a class 1 recommendation to perform resistance exercise, in addition to aerobic activity, on 2 or more days per week to reduce all-cause mortality. Data indicate that the addition of resistance exercise to aerobic activity is associated with lower risks of total CV events and all-cause mortality, so it’s expected that a combination of weightlifting and aerobic activity may be more beneficial for than either type of activity alone. The 2019 ACC/AHA prevention guidelines do not make a formal recommendation regarding resistance exercise; they do note that it has multiple health benefits (e.g., BP-lowering, improved glycemic control) though state its association with ASCVD risk reduction is unclear. 

Choice D is incorrect: sedentary time is independently associated with greater risk for several major chronic diseases and mortality. Reducing sedentary time for inactive adults and adding in light-intensity physical activity (as little as 15 minutes daily) is a class 1 recommendation to reduce all-cause and CV mortality and morbidity. The 2019 ACC/AHA guidelines suggest that reduced sedentary behavior may be “reasonable for ASCVD risk reduction” (Class 2b). Assuming our patient has had predominantly sedentary behavior, starting with a 20-minute daily walk can provide initial health benefits while working up to more and higher-intensity activity.

Main Takeaway

Physical activity should be individually assessed and prescribed in terms of frequency, intensity, time (duration), type, and progression.

Guideline Location

Section 4.3.1, Pages 3268-3269, Table 7

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This question refers to Sections 3.1 of the 2021 ESC CV Prevention Guidelines. The question is asked by CardioNerds Academy Intern, student Dr. Hirsh Elhence, answered first by internal medicine resident at Beaumont Hospital and soon to be Mayo Clinic cardiology fellow and Dr. Teodora Donisan and then by expert faculty Dr. Eugene Yang.

Dr. Yang is professor of medicine of the University of Washington where he is medical director of the Eastside Specialty Center and the co-Director of the Cardiovascular Wellness and Prevention Program. Dr. Yang is former Governor of the ACC Washington Chapter and current chair of the ACC Prevention of CVD Section.

The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.

Please read the following patient vignettes and choose the FALSE statement.

A. A 39-year-old man who comes for a regular physical, has normal vitals and weight, denies any significant past medical or family history – does not need systematic cardiovascular disease (CVD) assessment.
B. A 39-year-old woman who comes for a regular physical, has normal vitals and weight, and has a history of radical hysterectomy (no other significant past medical or family history) – could benefit from systematic or opportunistic CVD assessment.
C. A 39-year-old woman who comes for a regular physical, has normal vitals except for a BMI of 27 kg/m2 and a family history of hypertension – requires a systematic global CVD assessment.
D. A 39-year-old man who comes for a regular physical, has normal vitals and weight, and has a personal history of type I diabetes – requires a systematic global CVD assessment.

The correct answer is C.

Option A is an accurate statement, as systematic CVD risk assessment is not recommended in men < 40 years-old and women < 50 years-old, if they have no known cardiovascular (CV) risk factors. (Class III, level C)

Option B is an accurate statement, as this patient had a radical hysterectomy, which means the ovaries have been removed as well and she is considered postmenopausal. Systematic or opportunistic CV risk assessment can be considered in men > 40 years-old and women > 50 years-old or postmenopausal, even in the absence of known ASCVD risk factors. (Class IIb, level C)

Option C is a false statement and thus the correct answer, as the recommendations for global screening in this patient are not as strong and would require shared decision making. Opportunistic screening of blood pressure can be considered in her, as she is at risk for developing hypertension. Blood pressure screening should be considered in adults at risk for the development of hypertension, such as those who are overweight or with a known family history of hypertension. (Class IIa, level B)

Option D is an accurate statement, as systematic global CVD risk assessment is recommended in individuals with any major vascular risk factor (i.e., family history of premature CVD, familial hyperlipidemia, CVD risk factors such as smoking, arterial hypertension, DM, raised lipid level, obesity, or comorbidities increasing CVD risk). (Class I, level C)

Additional learning points:

Do you know the difference between opportunistic and systematic CVD screening?

• Opportunistic screening refers to screening without a predefined strategy when the patient presents for different reasons. This is an effective and recommended way to screen for ASCVD risk factors, although it is unclear if it leads to benefits in clinical outcomes.
• Systematic screening can be done following a clear strategy formally evaluating either the general population or targeted subpopulations (i.e., type 2 diabetics or patients with significant family history of CVD). Systematic screening results in improvements in risk factors but has no proven effect on CVD outcomes.

Main Takeaway

Systematic CVD risk assessment in the general population without CV risk factors does not seem to be cost effective and has unclear benefits on outcomes, although it does lead to increased detection of potentially actionable CV risk factors. Risk assessment is not a one-time event and should be repeated (e.g., every 5 years), but there is no clear data to guide intervals.

Guideline Location

Section 3.1, page 3236; Table on page 3242.

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The following question refers to Section 3.4 of the 2021 ESC CV Prevention Guidelines. The question is asked by student Dr. Adriana Mares, answered first by early career preventive cardiologist Dr. Dipika Gopal, and then by expert faculty Dr. Michael Wesley Milks.

Dr. Milks is a staff cardiologist and assistant professor of clinical medicine at the Ohio State University Wexner Medical Center where he serves as the Director of Cardiac Rehabilitation and an associate program director of the cardiovascular fellowship. He specializes in preventive cardiology and is a member of the American College of Cardiology’s Cardiovascular Disease Prevention Leadership Council.

The CardioNerds Decipher The Guidelines Series for the 2021 ESC CV Prevention Guidelines represents a collaboration with the ACC Prevention of CVD Section, the National Lipid Association, and Preventive Cardiovascular Nurses Association.

While you are on holiday break visiting your family, your aunt pulls you aside during the family gathering to ask a few questions about your 70-year-old uncle. He has hypertension, hyperlipidemia, type 2 diabetes mellitus, and moderate chronic obstructive pulmonary disease. His medications include Fluticasone/Salmeterol, Tiotropium, Albuterol, Lisinopril, Simvastatin, and Metformin. She is very concerned about his risk for heart disease as he has never had his “heart checked out.” She asks if the presence of COPD increases his chance of having heart disease. Which of the following statements would best answer her question?

A. Systemic inflammation and oxidative stress caused by COPD promote vascular remodeling and a paradoxical ‘anticoagulant’ state affecting all vasculature types.
B. Although chronic COPD is associated with increased cardiovascular events, individual exacerbations have no impact on risk of cardiovascular events.
C. Patients with mild-moderate COPD are 8-10x more likely to die from atherosclerotic cardiovascular disease than respiratory failure.
D. Cardiovascular mortality increases proportionally with an increase in forced expiratory volume in 1 second (FEV1)

The correct answer is C.

Patients with mild-moderate COPD are 8-10x more likely to die from atherosclerotic cardiovascular disease than respiratory failure. Patients with COPD have a 2-3-fold increased risk of CV events compared to age-matched controls even when adjusted for tobacco smoking, a shared risk factor. This can be partly explained by other common risk factors including aging, hypertension, hyperlipidemia, and low physical activity.

Interestingly, CVD mortality increases proportionally with a decrease (rather than increase) in FEV1, making answer choice D wrong (28% increase CVD mortality for every 10% decrease in FEV1). Additionally, COPD exacerbations and related infections are associated with a 4x increase in CVD events, making answer choice B incorrect.

COPD has several effects on the vasculature which creates a ‘procoagulant’ not ‘anticoagulant’ effect on all vascular beds. This is associated with increased risk of cognitive impairment due to cerebral microvascular damage as well as increased risk of ischemic and hemorrhagic stroke.

Main Takeaway

The presence of COPD (even mild to moderate) has a significant impact on the incidence of non-fatal coronary events, stroke, and cardiovascular mortality mediated by inherent disease process and progression, risk factors (smoking, aging, hypertension, and hyperlipidemia), and systemic inflammation altering vasculature creating a ‘procoagulant’ effect. The ESC gives a Class I indication (LOE C) to investigate for ASCVD and ASCVD risk factors in patients with COPD.

Guideline Location

3.4.5, Page 3264.

CardioNerds Decipher the Guidelines – 2021 ESC Prevention Series
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CardioNerds (Amit Goyal, Daniel Ambinder) and special co-host Dr. Mark Belkin, join the Journal of Cardiac Failure Family to discuss the 2022 AHA/ACC/HFSA Guideline for The Management of Heart Failure. The JCF Editor-In-Chief Dr. Robert Mentz, Deputy Editor Dr. Anu Lala, and FIT editors — Dr. Vanessa Bluemer, Dr. Ashish Corrhea, and Dr. Quinton Youmans — share their hot takes and practical takeaways from the guidelines.

At JCF, we’re privileged to share this important document that will support improved care for those living with heart failure,” stated Editor-in Chief Dr. Robert J. Mentz and Deputy Editor Anu Lala. “The 2022 guidelines convey patient-centered updates regarding the language we use to communicate disease considerations (e.g., stages of HF) and practice-changing guidance around the diagnosis and management of HF including newer therapeutics (e.g., SGLT2i). There is an emphasis not only on managing HF but also on how to treat important comorbidities as part of the holistic care for patients living with HF.”

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

Executive Summary

A Clinician’s Guide to the 2022 ACC/AHA/HFSA Guideline for the Management of Heart Failure by Dr. Michelle Kittleson

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1. Guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (HFrEF) now includes 4 medication classes that include sodium-glucose cotransporter-2 inhibitors (SGLT2i).

2. SGLT2i have a Class of Recommendation 2a in HF with mildly reduced ejection fraction (HFmrEF). Weaker recommendations (Class of Recommendation 2b) are made for ARNi, ACEi, ARB, MRA, and beta blockers in this population.

3. New recommendations for HFpEF are made for SGLT2i (Class of Recommendation 2a), MRAs (Class of Recommendation 2b), and ARNi (Class of Recommendation 2b). Several prior recommendations have been renewed including treatment of hypertension (Class of Recommendation 1), treatment of atrial fibrillation (Class of Recommendation 2a), use of ARBs (Class of Recommendation 2b), and avoidance of routine use of nitrates or phosphodiesterase-5 inhibitors (Class of Recommendation 3: No Benefit).

4. Improved LVEF is used to refer to those patients with previous HFrEF who now have an LVEF >40%. These patients should continue their HFrEF treatment.

5.Value statements were created for select recommendations where high-quality, cost-effectiveness studies of the intervention have been published.

6. Amyloid heart disease has new recommendations for treatment including screening for serum and urine monoclonal light chains, bone scintigraphy, genetic sequencing, tetramer stabilizer therapy, and anticoagulation.

7. Evidence supporting increased filling pressures is important for the diagnosis of HF if the LVEF is >40%. Evidence for increased filling pressures can be obtained from noninvasive (e.g., natriuretic peptide, diastolic function on imaging) or invasive testing (e.g., hemodynamic measurement).

8. Patients with advanced HF who wish to prolong survival should be referred to a team specializing in HF. A HF specialty team reviews HF management, assesses suitability for advanced HF therapies, and uses palliative care including palliative inotropes where consistent with the patient’s goals of care.

9. Primary prevention is important for those at risk for HF (stage A) or pre-HF (stage B). Stages of HF were revised to emphasize the new terminologies of “at risk” for HF for stage A and pre-HF for stage B.

10.Recommendations are provided for select patients with HF and iron deficiency, anemia, hypertension, sleep disorders, type 2 diabetes, atrial fibrillation, coronary artery disease, and malignancy.

CardioNerds (Amit Goyal and Daniel Ambinder) join Dr. Phoo Pwint Nandar (former FIT Ambassador), Dr. Deep Shah (current FIT Ambassador), and Dr. Sugat Wagle from the Summa Health Cardiology Department for an afternoon at Cuyahoga National Valley Park. We discuss a case of a post-partum woman who presented with ventricular fibrillation arrest due to SCAD. She had ongoing advanced cardiac life support (ACLS) for nearly 60 minutes before obtaining return of spontaneous circulation. We discuss the broad differential of VF arrest, including acute coronary syndrome and spontaneous coronary artery dissection (SCAD) – among many others. We also go over the etiology and management of SCAD as well the complications. Pregnancy is a crucial stressor to the cardiovascular system and understanding its hemodynamic changes is crucial to all physicians. The E-CPR segment is provided by Dr. Grace Ayafor, Interventional cardiology faculty, Summa Health.

This episode is made possible with support from Medmastery. At Medmastery you can learn some of the most important clinical skills like echo, advanced EKG, coronary angiography, PCI basics, pacemaker- and ICD troubleshooting and so much more. CardioNerds listeners can get an exclusive 15% discount on a lifetime subscription. Click HERE for details.

Jump to: Case media – Case teaching – References

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1. SCAD remains underdiagnosed. It has a wide range of clinical presentations, including chest pain, ACS, VT/VF arrest, and cardiogenic shock.
2. Underlying etiologies of SCAD include autoimmune diseases, connective tissue disorders, fibromuscular dysplasia, external stressors, and pregnancy.
3. There are 3 types of SCAD, and coronary angiogram is the gold standard for diagnosis.
4. Common areas of involvement of SCAD include left anterior descending and left circumflex arteries; however, SCAD can manifest in any coronary artery as well as simultaneously in multiple coronary arteries. Left main trunk involvement is rare, more likely to be associated with the peri-partum state, and requires complex management decisions guided by a heart team approach.
5. Most SCAD cases are benign and treated conservatively, however, some require intervention (PCI or CABG) depending on clinical severity and course.
6. Recurrent SCAD has been reported in 10-30% of the patients and aggressive management of hypertension is recommended.
7. Guidelines regarding SCAD management are largely based on expert consensus due to a dearth of high-quality data. Efforts to raise awareness and study this syndrome are of paramount importance.

1. What is SCAD and how does it present?

• Spontaneous coronary artery dissection (SCAD) is defined as an epicardial coronary dissection that is not associated with atherosclerosis or instrumentation.
• This occurs with hematoma formation within the tunica media,  thereby potentially compressing the arterial true lumen leading to ischemia.
• There are two proposed mechanisms of hematoma formation: “inside-out” and “outside-in”. The inside-out hypothesis posits that the hematoma arises from the true lumen via a dissection flap – an endothelial-intimal disruption. Conversely the outside-in hypothesis posits that the hematoma arises de novo within the media through disruption of traversing microvessels.
• There is a wide range of clinical presentation for SCAD varying in severity including asymptomatic / benign presentation, anginal syndromes, acute myocardial infarction, VT/VF arrest, and cardiogenic shock. Our patient presented with VF arrest and ACS.
• SCAD epidemiology is confounded by a lack of awareness. A high index of suspicion is warranted. Diagnosis can be missed in young or mid-life without CV risk factors who would present with atypical/mild chest pain.

2. What are the etiologies of SCAD?

• SCAD is associated with the peripartum state (presumed due to combination of hormonal mediated vessel wall integrity changes and hemodynamic stressors), illicit substance use, autoimmune disorders, connective tissue disorders, fibromuscular dysplasia, and vigorous external stressors.
• Many patients recall extreme physical or emotional stress preceding the event. Men are more likely to present in the setting of a physical stressor whereas women are more likely to report an emotional stressor.
• Pregnancy-associated SCAD is most common in the first week after delivery like our patient.
• Genetic evaluation for connective tissue disorders and aortopathy syndromes (i.e., Marfan, Loeys-Dietz, and Ehlers-Danlos) should be considered.
• Arterial imaging to identify significant extracoronary vascular abnormalities is recommended since there is the association of SCAD with fibromuscular dysplasia.

3. What is the gold standard to diagnose SCAD?

• Coronary angiography performed by an experienced interventional cardiologist is the gold standard to diagnose SCAD. The left anterior descending artery is most commonly affected, and most cases of SCAD occur in the mid-distal arteries.
• There are 3 angiographic variants SCAD.
  • Type 1 is with evident with the contrast dye staining the arterial wall with multiple radiolucent lumen.
  • Type 2 (majority of the cases including the present case) is diffuse stenosis of varying severity with subtle abrupt changes in arterial caliber (long smooth narrowing).
  • Type 3 mimics atherosclerosis and is often difficult to differentiate from it.

4. What is the management of SCAD in acute setting?

• Management of SCAD depends on clinical severity. Thrombolytics should be avoided. Most cases are benign and treated conservatively with work up for secondary causes. 95% of conservatively treated patients with mild SCAD such as minimal ongoing ischemia with preserve coronary flow will heal within 30 days. More severe cases of SCAD require intervention such as PCI or CABG. Surgical approaches are preferred in left main involvement, long segments, and with diffuse coronary artery involvement like in our case. Utilizing vein grafts is preferred as most SCAD cases heal with eventual graft closure. Off note, PCI in SCAD is associated with higher complication rates and suboptimal outcomes, including risk of iatrogenic dissection or propagation of hematoma.

5. What is the management of SCAD in pregnant patient?

• The management strategy of SCAD during pregnancy is similar to that in the nonpregnant state, with additional considerations to optimize maternal and fetal outcomes. After 20 weeks gestation, recommend left lateral recumbent positioning whenever possible to reduce aortocaval compression and optimize venous return. If necessary, consider maternal stabilization and optimization of cardiac status followed by planned delivery under controlled conditions. For more, enjoy Episode #167 – Cardiac Interventions During Pregnancy with Dr. Michael Luna.

5. What is the prognosis of SCAD and long-term management?  

• Recurrent SCAD has been reported in 10-30% of patients. Post-SCAD chest pain is common and may persist for many months. Due to iatrogenic risk from invasive angiography, serial electrocardiography and biomarker assessment, and noninvasive cardiac computed tomography angiography should be considered. Standard heart failure medications are indicated for left ventricular dysfunction, and hypertension should be treated.

6. How to prevent recurrent SCAD?

• The factors associated with recurrence remain poorly understood. After SCAD, further pregnancy should perhaps be discouraged and contraception should be discussed. Women who strongly desire pregnancy should receive thorough preconception counseling.

1. Macaya, F., Salinas, P., Gonzalo, N., Fernández-Ortiz, A., Macaya, C., & Escaned, J. (2018). Spontaneous coronary artery dissection: contemporary aspects of diagnosis and patient management. Open Heart, 5(2), e000884.
2. Hayes, S. N., Kim, E. S. H., Saw, J., Adlam, D., Arslanian-Engoren, C., Economy, K. E., Ganesh, S. K., Gulati, R., Lindsay, M. E., Mieres, J. H., Naderi, S., Shah, S., Thaler, D. E., Tweet, M. S., & Wood, M. J. (2018). Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association. Circulation, 137(19).
3. McGrath-Cadell, L., McKenzie, P., Emmanuel, S., Muller, D. W. M., Graham, R. M., & Holloway, C. J. (2016). Outcomes of patients with spontaneous coronary artery dissection. Open Heart, 3(2), e000491.
4. Alonso-Fernández-Gatta, M., Uribarri, A., Diego-Nieto, A., & Sánchez, P. L. (2017). Progressive spontaneous coronary artery dissection secondary to fibromuscular dysplasia requiring mechanical circulatory support. Journal of Cardiology Cases, 16(6), 216–218.
5. Cepas-Guillén, P. L., Flores-Umanzor, E. J., Sabate, M., & Masotti, M. (2019). Multivessel spontaneous coronary artery dissection involving the left main coronary artery: a case report. European Heart Journal – Case Reports, 3(1).
6. Tweet, M. S., Eleid, M. F., Best, P. J. M., Lennon, R. J., Lerman, A., Rihal, C. S., Holmes, D. R., Jr, Hayes, S. N., & Gulati, R. (2014). Spontaneous Coronary Artery Dissection. Circulation: Cardiovascular Interventions, 7(6), 777–786.
7. Hayes SN, Tweet MS, Adlam D, et al. Spontaneous Coronary Artery Dissection: JACC State-of-the-Art Review. J Am Coll Cardiol 2020;76:961-984.

CardioNerds (Daniel Ambinder), ACHD series co-chairs,  Dr. Josh Saef (ACHD fellow, University of Pennsylvania) Dr. Daniel Clark (ACHD fellow, Vanderbilt University), and ACHD FIT lead Dr. Jon Kochav (Columbia University) join Dr. Eric Krieger (Director of the Seattle Adult Congenital Heart Service and the ACHD Fellowship, University of Washington) to discuss multimodality imaging in congenital heart disease. Audio editing by CardioNerds Academy Intern, Dr. Maryam Barkhordarian. Special introduction to CardioNerds Clinical Trialist Dr. Shiva Patlolla (Baylor University Medical Center).

In this episode we discuss the strengths and weaknesses of the imaging modalities most commonly utilized in the diagnosis and surveillance of patients with ACHD.  Specifically, we discuss transthoracic and transesophageal echocardiography, cardiac MRI and cardiac CT. The principles learned are then applied to the evaluation of two patient cases – a patient status post tetralogy of Fallot repair with a transannular patch, and a patient presenting with right ventricular enlargement of undetermined etiology.

The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark.

The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more

Disclosures: None

Pearls • Notes • References • Guest Profiles • Production Team

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1. Transthoracic echocardiography (TTE) is the first line diagnostic test for the diagnosis and surveillance of congenital heart disease due to widespread availability, near absent contraindications, and ability to perform near comprehensive structural, functional, and hemodynamic assessments in patients for whom imaging windows allow visualization of anatomic areas of interest.
2. Transesophageal echocardiography (TEE) use in ACHD patients is primarily focused on similar indications as in acquired cardiovascular disease patients: the assessment of endocarditis, valvular regurgitation/stenosis severity and mechanism, assessment of interatrial communications in the context of stroke, evaluation for left atrial appendage thrombus, and for intraprocedural guidance. When CT or MRI are unavailable or contraindicated, TEE can also be used when transthoracic imaging windows are poor, or when posterior structures (e.g. sinus venosus, atrial baffle) need to be better evaluated.
3. Cardiac MRI (CMR) with MR angiography imaging is unencumbered by imaging planes or body habitus and can provide comprehensive high resolution structural and functional imaging of most cardiac and extracardiac structures. Additional key advantages over echocardiography are ability to reproducibly quantify chamber volumes, flow through a region of interest (helpful for quantifying regurgitation or shunt fraction), assess for focal fibrosis via late gadolinium enhancement imaging, and assess the right heart.
4. Cardiac CT has superior spatial resolution in a 3D field of view which makes it useful for clarifying anatomic relationships between structures, visualizing small vessels such as coronary arteries or collateral vessels, and assessing patency of larger vessels (e.g branch pulmonary arteries) through metallic stents which may obscure MR imaging. Downsides relative to CMR include requirement of nephrotoxic contrast for imaging of intracardiac/intravascular structures, and while gated images can be obtained throughout the cardiac cycle similarly to CMR, this is particularly costly from an ionizing radiation standpoint.
5. When working up an unknown congenital lesion, it is critical to communicate the differential diagnosis when ordering a test so that the imager can protocol the study accordingly. Not all echocardiograms, CT or MRI scans are the same.

What are the key strengths and weaknesses of transthoracic echocardiography?

STRENGTHS:

(1) “Most important ability is availability”: Transthoracic echocardiography is the first line imaging modality in the assessment of patients with congenital heart disease because it is widely available at significantly lower cost with no contraindications or risks to the patient.

(2) Versatility: A wide array of echo approaches can be employed to provide comprehensive structural and physiological data. 2D echo techniques are most useful for visual assessment of cardiac structural abnormalities. Color doppler provides qualitative data regarding flow, and spectral doppler (inclusive of tissue doppler imaging) provides quantitative data defining intracardiac hemodynamics. 3D echo can be applied to optimize imaging planes for valve area planimetry and quantify chamber volumes as well as global contractile function. Strain imaging using 2D speckle tracking techniques can be employed to evaluate regional contractility.

(3) High temporal resolution: High temporal resolution makes echocardiography a superior modality for imaging fast-moving structures (e.g., valvular vegetations or intracardiac masses).

WEAKNESSES:

(1) “You can’t study what you can’t see”: Suboptimal ultrasound penetration can limit transthoracic imaging quality in patients with large body habitus, or patients in the post-operative state. Furthermore, imaging planes are limited by sonographic windows – many anatomic cardiac (e.g., sinus venosus and coronary sinus defects, anomalous coronary arteries) and extracardiac (e.g., aortic dilation/coarctation, anomalous venous return) abnormalities are often incompletely evaluated by echocardiography in adult patients. This is a major limitation as many ACHD conditions are associated with aortopathy and anomalous pulmonary or systemic venous return which may necessitate dedicated cross-sectional imaging. Finally, right ventricular imaging is limited by near field artifact and complex chamber geometry; and similarly anterior structures such as right ventricular to pulmonary arterial conduits are poorly evaluated with transthoracic echocardiography.

What differentiates a congenital echocardiogram from a standard adult protocol?

Congenital echocardiograms obtain more comprehensive anatomic evaluation to visualize structural anomalies that might not be evident in standard imaging planes. Most congenital echo protocols begin with a subcostal short axis and long axis sweep to determine segmental anatomy, visceral and atrial situs, cardiac position, cardiac looping, and arterial situs. Additional views are attempted from the suprasternal position to better characterize major venous and arterial connections and anatomy (bidirectional Glenn, etc.). Sweeps are often obtained between views within the same window to clarify the relationships between anatomic structures and identify abnormalities (e.g. inter-chamber connections) not apparent in the standard imaging planes.

What is the role of transesophageal echocardiography in adult congenital cardiology imaging?

In adult patients with acquired cardiovascular disease, transesophageal echocardiography (TEE) is most commonly employed for the assessment of endocarditis, valvular regurgitation/stenosis severity and mechanism, assessment of interatrial communications in the context of stroke, evaluation for left atrial appendage thrombus, and for intraprocedural guidance. Each of these indications are also commonly encountered in an ACHD population. In congenital cardiology, improved spatial resolution of posterior heart structures can similarly be leveraged to image pathology not well visualized by a transthoracic approach such as for identifying sinus venosus defects, characterizing secundum atrial septal defects to determine feasibility of percutaneous closure, or for assessment of baffle leak on Fontan or atrial switch D-TGA patients. Additionally, TEE increasingly plays a critical role in the perioperative setting (e.g., examining physiology pre- and post-bypass) and for monitoring and guidance of percutaneous interventions in the cardiac catheterization lab.

What are the key strengths and weaknesses of Cardiac MRI?

STRENGTHS:

(1) Unencumbered imaging planes: Unlike echocardiography, for which views are limited by echocardiographic windows, cardiac MRI technicians can prescribe unlimited imaging planes for a more complete coverage of both intracardiac and extracardiac anatomy – particularly with addition of MR angiography. This allows for improved assessment of anterior structures (e.g., the RV, RV-PA conduits), posterior structures (e.g., atrial baffles, sinus venosus or coronary sinus defects), and extracardiac anomalies (e.g., anomalous venous return, aortopathies, pulmonary arterial stenoses), which are usually poorly imaged by echocardiography in adults. Additionally, imaging is generally unaffected by body habitus, and may be used as the primary imaging modality for patients with poor transthoracic windows.

(2) Reproducible volumetric quantification: Cardiac MRI is the gold standard for chamber volume assessment. Chamber volumes are obtained from endocardial contouring of Cine-CMR short axis stacks, allowing for measurements that are independent of geometric assumptions – particularly useful for right ventricular or single ventricle assessments. High inter- and intra-reader reproducibility makes CMR an ideal tool for surveillance of chamber size and function over time, and for assessing response to interventions.

(3) Reproducible flow quantification: Phase contrast pulse sequences are utilized to quantify flow in any imaging plane though a region of interest (e.g., aortic/pulmonary arteries, systemic/pulmonary venous return, branch arteries). This tool can be used in ACHD patients for non-invasive measurement of Qp (pulmonary circuit flow) and Qs (systemic circuit flow) to determine shunt fraction (Qp/Qs), or for quantification of regurgitant volumes in valvular insufficiency (e.g., quantification of pulmonary regurgitation). Measurement of flow velocity across a stenosis can be used to estimate trans-stenotic pressure gradients analogous to echocardiographic spectral doppler – however gradients may be underestimated due to decreased temporal resolution of CMR imaging (peak velocity through region of interest can be missed) or imaging plane not being at the vena contracta (a higher velocity may be obtained at a higher or lower imaging plane).

(4) Tissue characterization: Late gadolinium enhancement CMR can be utilized to assess for myocardial fibrosis – which can be used to identify myocardial infarction in patients with coronary abnormalities, and risk-stratify arrhythmic risk in various conditions (e.g., Tetralogy of Fallot, systemic right ventricle).

(5) 3D evaluation: 3D images can be obtained, allowing for assessment of cardiac structures and their anatomic relations in all planes post image acquisition. Images can be used to produce 3D-printed heart models for surgical planning.

WEAKNESSES:

(1) Not everyone can get an MRI: CMR is contraindicated in patients with ferrous metallic implants. Guidelines now support the use of CMR with both MRI-conditional and legacy cardiac implantable electrical devices – but the need for careful device reprograming and patient monitoring may present logistical hurdles. The risk of nephrogenic systemic fibrosis with the use of gadolinium-based contrast agents in patients with advanced renal disease seems to have been largely mitigated with increased use of cyclic gadolinium-based contrast agents. Moreover, contrast is not required for most of the imaging indications in congenital heart disease. Claustrophobia may be a barrier to a complete CMR study in some patients, as may be intolerance of prescribed breath holds and/or prolonged reclined positioning for patients with heart failure and pulmonary edema.

(2) Reduced image quality in irregular heartbeats: Irregular heart rhythms can impact gating and degrade image quality – a limitation that can be partially mitigated with prospective gating techniques.

(3) The study is only as good as the protocol: MRI technicians prescribe various pulse sequences in specific imaging planes in accordance with the ordered protocol. If there is miscommunication with respect to the clinical question being asked, or the technician is not experienced in imaging patients with congenital heart disease, targeted imaging may not be performed rendering the test nondiagnostic (e.g., a cardiac MRI without MR angiography may miss an anomalous pulmonary vein in a patient with dilated right ventricle).

Is Cardiac CT just Cardiac MRI with iodinated contrast and ionizing radiation?

Cardiac CT has a number of distinct advantages over cardiac MRI – including rapid image acquisition time, greater spatial resolution in a 3-dimensional field of view useful for evaluation of small structures (coronaries, AV malformations, collaterals) and for clarifying anatomic relationships between structures (ideal modality for 3D printing), and ability to be used in patients with cardiac implanted electrical devices without logistic headaches. Gated acquisitions throughout the cardiac cycle can be used to assess ventricular function, although temporal resolution is lesser compared to cardiac MRI and radiation dose for such acquisitions can be substantial. CT angiography also has advantages over MRI in patients for whom prior implanted devices (e.g., stents, coils) obscure the imaging field of interest due to magnetic susceptibility artifact. Ultimately, in young patients who will need multiple imaging studies over the course of their lives, the cumulative ionizing radiation dose associated with cardiac CT is a significant disadvantage. Unlike Echo or CMR, CT imaging does not provide any information on blood flow or cardiac hemodynamics.

Lesion-specific examples:

In these notes, and in the episode, we present two common clinical scenarios in adult congenital heart disease to highlight the importance of a multimodality imaging approach for the diagnosis and surveillance of patients with adult congenital heart disease – (1) assessment of patients with tetralogy of Fallot, and (2) evaluation of patients with right-sided dilatation for shunt. The optimal care of these complex patients often requires appropriate utilization of multiple modalities to leverage the strengths of each.

1.  Di Salvo G, Miller O, Babu Narayan S, et al. Imaging the adult with congenital heart disease: a multimodality imaging approach-position paper from the EACVI. Eur Heart J Cardiovasc Imaging. 2018;19(10):1077-1098.

2. Stout KK, Daniels CJ, Aboulhosn JA, et al. 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;139(14):e637-e697.

3. Sachdeva R, Valente AM, Armstrong AK, et al. ACC/AHA/ASE/HRS/ISACHD/SCAI/SCCT/SCMR/SOPE 2020 Appropriate Use Criteria for Multimodality Imaging During the Follow-Up Care of Patients With Congenital Heart Disease: A Report of the American College of Cardiology Solution Set Oversight Committee and Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography. J Am Coll Cardiol. 2020;75(6):657-703.

Adult Congenital Heart Association
Founded in 1998, the Adult Congenital Heart Association is an organization begun by and dedicated to supporting individuals and families living with congenital heart disease and advancing the care and treatment available to our community. Our mission is to empower the congenital heart disease community by advancing access to resources and specialized care that improve patient-centered outcomes. Visit their website (https://www.achaheart.org/) for information on their patient advocacy efforts, educational material, and membership for patients and providers

CHiP Network

The CHiP network is a non-profit organization aiming to connect congenital heart professionals around the world. Visit their website (thechipnetwork.org) and become a member to access free high-quality educational material, upcoming news and events, and the fantastic monthly Journal Watch, keeping you up to date with congenital scientific releases. Visit their website (https://thechipnetwork.org/) for more information.

Heart University
Heart University aims to be “the go-to online resource” for e-learning in CHD and paediatric-acquired heart disease. It is a carefully curated open access library of educational material for all providers of care to children and adults with CHD or children with acquired heart disease, whether a trainee or a practicing provider. The site provides free content to a global audience in two broad domains: 1. A comprehensive curriculum of training modules and associated testing for trainees. 2. A curated library of conference and grand rounds recordings for continuing medical education. Learn more at www.heartuniversity.org/

Dr. Eric Krieger is the Associate Director of the University of Washington’s Adult Congenital Heart Disease Program – where he directs the ACHD training program. Dr. Krieger is a multimodality imager – with expertise in applications of cardiac MRI in congenital heart disease.

Dr. Jon Kochav is an ACHD fellow at Columbia University Medical center. During his general fellowship he spent two research years at the Cardiac MRI lab at Weill Cornell Medical Center.