Publications by authors named "Daniel P Morin"

84 Publications

The ENHANCE-AF clinical trial to evaluate an atrial fibrillation shared decision-making pathway: Rationale and study design.

Am Heart J 2022 May 28;247:68-75. Epub 2022 Jan 28.

Stanford University Medical School, Stanford, CA, USA.

Introduction: Shared decision making (SDM) may result in treatment plans that best reflect the goals and wishes of patients, increasing patient satisfaction with the decision-making process. There is a knowledge gap to support the use of decision aids in SDM for anticoagulation therapy in patients with atrial fibrillation (AF). We describe the development and testing of a new decision aid, including a multicenter, randomized, controlled, 2-arm, open-label ENHANCE-AF clinical trial (Engaging Patients to Help Achieve Increased Patient Choice and Engagement for AF Stroke Prevention) to evaluate its effectiveness in 1,200 participants.

Methods: Participants will be randomized to either usual care or to a SDM pathway incorporating a digital tool designed to simplify the complex concepts surrounding AF in conjunction with a clinician tool and a non-clinician navigator to guide the participants through each step of the tool. The participant-determined primary outcome for this study is the Decisional Conflict Scale, measured at 1 month after the index visit during which a decision was made regarding anticoagulation use. Secondary outcomes at both 1 and 6 months will include other decision making related scales as well as participant and clinician satisfaction, oral anticoagulation adherence, and a composite rate of major bleeding, death, stroke, or transient ischemic attack. The study will be conducted at four sites selected for their ability to enroll participants of varying racial and ethnic backgrounds, health literacy, and language skills. Participants will be followed in the study for 6 months.

Conclusions: The results of the ENHANCE-AF trial will determine whether a decision aid facilitates high quality shared decision making in anticoagulation discussions for stroke reduction in AF. An improved shared decision-making experience may allow patients to make decisions better aligned with their personal values and preferences, while improving overall AF care.
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http://dx.doi.org/10.1016/j.ahj.2022.01.013DOI Listing
May 2022

Development and Validation of a Multivariable Risk Prediction Model for COVID-19 Mortality in the Southern United States.

Mayo Clin Proc 2021 12 17;96(12):3030-3041. Epub 2021 Sep 17.

John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA; University of Queensland School of Medicine, Brisbane, Australia.

Objective: To evaluate clinical characteristics of patients admitted to the hospital with coronavirus disease 2019 (COVID-19) in Southern United States and development as well as validation of a mortality risk prediction model.

Patients And Methods: Southern Louisiana was an early hotspot during the pandemic, which provided a large collection of clinical data on inpatients with COVID-19. We designed a risk stratification model to assess the mortality risk for patients admitted to the hospital with COVID-19. Data from 1673 consecutive patients diagnosed with COVID-19 infection and hospitalized between March 1, 2020, and April 30, 2020, was used to create an 11-factor mortality risk model based on baseline comorbidity, organ injury, and laboratory results. The risk model was validated using a subsequent cohort of 2067 consecutive hospitalized patients admitted between June 1, 2020, and December 31, 2020.

Results: The resultant model has an area under the curve of 0.783 (95% CI, 0.76 to 0.81), with an optimal sensitivity of 0.74 and specificity of 0.69 for predicting mortality. Validation of this model in a subsequent cohort of 2067 consecutively hospitalized patients yielded comparable prognostic performance.

Conclusion: We have developed an easy-to-use, robust model for systematically evaluating patients presenting to acute care settings with COVID-19 infection.
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http://dx.doi.org/10.1016/j.mayocp.2021.09.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8445799PMC
December 2021

Cardiac magnetic resonance in the diagnosis of the unusually detected acute myocarditis in the young people: a case report.

AME Case Rep 2021 25;5:35. Epub 2021 Oct 25.

Department of Physiology, Faculty of Medicine, University of Valencia and INCLIVA Biomedical Research Institute, Valencia, Spain.

Myocarditis is among the causes of arrhythmic sudden cardiac death (SCD) in young athletes, with viral infection being the most common cause worldwide. Myocarditis recently has been reported as one of the cardiac complications of coronavirus disease 2019 (COVID-19) in athletes. Here we present a case of a 20-year-old male recreational soccer player with an episode of loss of consciousness in the context of respiratory infection. The patient reports having woken up with symptoms of an upper respiratory tract infection, and after playing a soccer match, he developed dizziness and a headache. He then suffered vasovagal syncope without loss of sphincter control. Physical examination, heart auscultation, peripheral and carotid pulses, and blood, microbiological/serological tests result on admission were normal. Moreover, no jugular engorgement at 45º, malleolar edema, or other heart failure signs were found. The 12-lead electrocardiogram (ECG), echocardiogram, 24-hour Holter-ECG did not reveal any significant finding. A cardiac magnetic resonance (CMR) was finally performed, revealing an abnormal signal increase was observed at the apical level in the short-tau inversion-recovery (STIR) and 4-chamber sequences. In addition, a pattern of apical fibrosis was observed in 4- and 2-chamber and short-axis late enhancement sequences for assessment of myocardial viability confirming the diagnosis of myocarditis. In athletes with suspected myocarditis, CMR seems to be a useful diagnostic tool, with excellent sensitivity for detecting inflammation, myocardial edema, and/or focal scarring.
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http://dx.doi.org/10.21037/acr-21-24DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8572676PMC
October 2021

Diagnosis of pulmonary embolism: Know your strengths well, and know your weaknesses better.

Trends Cardiovasc Med 2021 Aug 11. Epub 2021 Aug 11.

Ochsner Medical Center, John Ochsner Heart and Vascular Institute, New Orleans, LA, United States; Ochsner Clinical School, Queensland University School of Medicine, New Orleans, LA, United States. Electronic address:

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http://dx.doi.org/10.1016/j.tcm.2021.08.002DOI Listing
August 2021

The role of atrial fibrillation catheter ablation in patients with heart failure.

Prog Cardiovasc Dis 2021 May-Jun;66:80-85

Ochsner Medical Center, New Orleans, LA, USA.

Atrial Fibrillation (AF) and heart failure (HF) with reduced ejection fraction (HFrEF) frequently coexist, resulting in significant morbidity and mortality. Therapeutic options for patients with AF and HFrEF are limited due to few antiarrhythmic drug (AAD) choices and historically equivocal effects of procedural interventions on mortality. However, recent randomized trials examining catheter ablation (CA) in AF patients with HFrEF have shown a beneficial effect on arrhythmic burden and HF symptoms, as well as an improvement in mortality. This review focuses on the role of CA for AF patients with HFrEF.
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http://dx.doi.org/10.1016/j.pcad.2021.06.002DOI Listing
August 2021

Epidemiology, evaluation, and management of conduction disturbances after transcatheter aortic valve replacement.

Prog Cardiovasc Dis 2021 May-Jun;66:37-45

Ochsner Medical Center, New Orleans, LA, United States of America. Electronic address:

Aortic stenosis is the most common valvulopathy requiring replacement by means of the surgical or transcatheter approach. Transcatheter aortic valve replacement (TAVR) has quickly become a viable and often preferred treatment strategy compared to surgical aortic valve replacement. However, transcatheter heart valve system deployment not infrequently injures the specialized electrical system of the heart, leading to new conduction disorders including high-grade atrioventricular block and complete heart block (CHB) necessitating permanent pacemaker implantation (PPI), which may lead to deleterious effects on cardiac function and patient outcomes. Additional conduction disturbances (e.g., new-onset persistent left bundle branch block, PR/QRS prolongation, and transient CHB) currently lack clearly defined management algorithms leading to variable strategies among institutions. This article outlines the current understanding of the pathophysiology, patient and procedural risk factors, means for further risk stratification and monitoring of patients without a clear indication for PPI, our institutional approach, and future directions in the management and evaluation of post-TAVR conduction disturbances.
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http://dx.doi.org/10.1016/j.pcad.2021.06.004DOI Listing
August 2021

Emerging topics in electrophysiology.

Prog Cardiovasc Dis 2021 May-Jun;66

Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA.

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http://dx.doi.org/10.1016/j.pcad.2021.06.001DOI Listing
August 2021

Blood Thinners for Atrial Fibrillation Stroke Prevention.

Circ Arrhythm Electrophysiol 2021 06 11;14(6):e009389. Epub 2021 Jun 11.

Department of Medicine (B.L., R.S.S.), Stanford University, CA.

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http://dx.doi.org/10.1161/CIRCEP.120.009389DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8208521PMC
June 2021

Impact of Preinfection Left Ventricular Ejection Fraction on Outcomes in COVID-19 Infection.

Curr Probl Cardiol 2021 Oct 19;46(10):100845. Epub 2021 Mar 19.

Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, LA; Ochsner Center for Outcomes and Health Sciences Research, New Orleans, LA.

Coronavirus disease 2019 (COVID-19) has high infectivity and causes extensive morbidity and mortality. Cardiovascular disease is a risk factor for adverse outcomes in COVID-19, but baseline left ventricular ejection fraction (LVEF) in particular has not been evaluated thoroughly in this context. We analyzed patients in our state's largest health system who were diagnosed with COVID-19 between March 20 and May 15, 2020. Inclusion required an available echocardiogram within 1 year prior to diagnosis. The primary outcome was all-cause mortality. LVEF was analyzed both as a continuous variable and using a cutoff of 40%. Among 396 patients (67 ± 16 years, 191 [48%] male, 235 [59%] Black, 59 [15%] LVEF ≤40%), 289 (73%) required hospital admission, and 116 (29%) died during 85 ± 63 days of follow-up. Echocardiograms, performed a median of 57 (IQR 11-122) days prior to COVID-19 diagnosis, showed a similar distribution of LVEF between survivors and decedents (P = 0.84). Receiver operator characteristic analysis revealed no predictive ability of LVEF for mortality, and there was no difference in survival among those with LVEF ≤40% versus >40% (P = 0.49). Multivariable analysis did not change these relationships. Similarly, there was no difference in LVEF based on whether the patient required hospital admission (56 ± 13 vs 55 ± 13, P = 0.38), and patients with a depressed LVEF did not require admission more frequently than their preserved-LVEF peers (P = 0.87). A premorbid history of dyspnea consistent with symptomatic heart failure was not associated with mortality (P = 0.74). Among patients diagnosed with COVID-19, pre-COVID-19 LVEF was not a risk factor for death or hospitalization.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.100845DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972833PMC
October 2021

Right ventricular lead location and outcomes among patients with cardiac resynchronization therapy: A meta-analysis.

Prog Cardiovasc Dis 2021 May-Jun;66:53-60. Epub 2021 Apr 20.

Division of Cardiology, Duke University Medical Center, Durham, NC 27710, United States of America; Duke Clinical Research Institute, Durham, NC 27710, United States of America.

Background: Cardiac resynchronization therapy (CRT) has been demonstrated to improve heart failure (HF) symptoms, reverse LV remodeling, and reduce mortality and HF hospitalization (HFH) in patients with a reduced left ventricular (LV) ejection fraction (LVEF). Prior studies examining outcomes based on right ventricular (RV) lead position among CRT patients have provided mixed results. We performed a systematic review and meta-analysis of randomized controlled trials and prospective observational studies comparing RV apical (RVA) and non-apical (RVNA) lead position in CRT.

Methods: Our meta-analysis was constructed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews and meta-analyses. We searched EMBASE and MEDLINE. Eligible studies reported on at least one of the following outcomes of interest: all-cause mortality, the composite endpoint of death and first HFH hospitalization, change in LVEF, New York Heart Association (NYHA) class improvement, and change in LV end systolic volume (LVESV). We performed meta-analysis summaries using a DerSimonian-Laird random-effects model and conservatively used the Knapp-Hartung approach to adjust the standard errors of the estimated model coefficients.

Results: We included nine studies representing a total of 1832 patients. Of those, 1318 (72%) patients had RVA lead placement and 514 (28%) had RVNA lead placement. The mean age of patients was 65.5 ± 4.4 years, and they were predominantly men (69%-97%). There was no statistically significant difference in all-cause mortality by RVA vs. RVNA (OR = 0.77, 95% CI 0.32-1.89; I = 16.7%, p = 0.31), or in the combined endpoint of all-cause mortality and first HFH (OR 0.88, 95% CI 0.62-1.25; I = 0%, p = 0.84). Also, there was no difference between RVA and RVNA for NYHA class improvement (OR = 1.03, 95% CI 0.9-1.17; I = 0%, p = 0.99), change in LVEF (mean difference (MD) = 1.33, 95% CI -1.45 to 4.10; I = 47%; p = 0.093), and change in LVESV (MD = -1.11, 95% CI -3.34 to 1.12; I = 0%; p = 0.92).

Conclusion: This meta-analysis shows that in CRT pacing, RV lead position does not appear to be associated with clinical outcomes or LV reverse remodeling. Further studies should focus on the relationship of RV lead vis-à-vis LV lead location, and its clinical importance.
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http://dx.doi.org/10.1016/j.pcad.2021.04.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8667053PMC
August 2021

PET Stress Testing with Coronary Flow Capacity in the Evaluation of Patients with Coronary Artery Disease and Left Ventricular Dysfunction: Rethinking the Current Paradigm.

Curr Cardiol Rep 2021 03 24;23(4):50. Epub 2021 Mar 24.

Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, 1514 Jefferson Highway, New Orleans, LA, 70121-2483, USA.

Purpose Of Review: Cardiomyopathy with underlying left ventricular (LV) dysfunction is a heterogenous group of disorders that may be present with, and/or secondary to, coronary artery disease (CAD). The purpose of this review is to demonstrate, via case illustrations, the benefits offered by cardiac positron-emission tomography (PET) stress testing with coronary flow capacity (CFC) in the evaluation and treatment of patients with left ventricular (LV) dysfunction and CAD.

Recent Findings: CFC, a metric that is increasing in prominence, represents the integration of several absolute perfusion metrics into clinical strata of CAD severity. Our prior work has demonstrated improvement in regional perfusion metrics as a result of revascularization to territories with severe reduction in CFC. Conversely, when CFC is adequate, there is no change in regional perfusion metrics following revascularization, despite angiographically severe stenosis. Furthermore, Gould et al. demonstrated decreased rates of myocardial infarction and death following revascularization of myocardium with severely reduced CFC, with no clinical benefit observed following revascularization of patients with preserved CFC. In a series of cases, we present pre-revascularization and post-revascularization PET scans with perfusion metrics in patients with LV dysfunction and CAD. In these examples, we demonstrate improvement in LV function and perfusion metrics following revascularization only in cases where baseline CFC is severely reduced. PET with CFC offers unique guidance regarding revascularization in patients with reduced LV function and CAD.
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http://dx.doi.org/10.1007/s11886-021-01478-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7990801PMC
March 2021

Cancer Radiation Therapy May Be Associated With Atrial Fibrillation.

Front Cardiovasc Med 2021 22;8:610915. Epub 2021 Jan 22.

Department of Medicine and Center of Excellence for Cardiovascular Diseases & Sciences, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA, United States.

The association of atrial fibrillation (AF) with cancer and cancer types is inconclusive. Similarly, data regarding the association of AF with different cancer therapies are controversial. To study the association of AF with cancer subtypes and cancer therapies. We studied all patients aged 18-89 years who presented to the Feist Weiller Cancer Center, with or without a diagnosis of cancer, between January 2011 and February 2016. Electronic health records were systematically queried for baseline demographics and ICD-9 and ICD-10 codes for specific co-morbidities. Patients with a diagnosis of AF were tabulated based on cross-validation with the ECG database and/or by recorded history. We assessed the prevalence and risk of AF based on cancer diagnosis, specific cancer type, and cancer therapy. A total of 14,600 patients were analyzed. Compared to non-cancer patients ( = 6,801), cancer patients ( = 7,799) had a significantly higher prevalence of AF (4.3 vs. 3.1%; < 0.001). However, following correction for covariates in a multivariable logistic regression model, malignancy was not found to be an independent risk factor for AF ( = 0.32). While patients with solid tumors had a numerically higher prevalence of AF than those with hematological malignancies (4.3 vs. 4.1%), tumor type was not independently associated with AF ( = 0.13). AF prevalence was higher in patients receiving chemotherapy (4.1%), radiation therapy (5.1%), or both (6.9%) when compared to patients not receiving any therapy (3.6%, = 0.01). On multivariable logistic regression, radiation therapy remained an independent risk factor for AF for the entire study population ( = 0.03) as well as for the cancer population ( < 0.01). Radiation therapy for cancer is an independent risk factor for AF. The known association between cancer and AF may be mediated, at least in part, by the effects of radiation therapy.
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http://dx.doi.org/10.3389/fcvm.2021.610915DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7862558PMC
January 2021

Leadless and Wireless Cardiac Devices: The Next Frontier in Remote Patient Monitoring.

Curr Probl Cardiol 2021 May 24;46(5):100800. Epub 2021 Jan 24.

John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, LA; Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA. Electronic address:

In the last decade, advances in wireless and sensor technologies, and the implementation of telemedicine, have led to innovative digital health care for cardiac patients. Continuous monitoring of patients' biomedical signals, and acute changes in these signals, may result in timely, accurate diagnoses and implementation of early interventions. In this review, we discuss commonly used wireless and leadless cardiac devices including pulmonary artery pressure sensors, implantable loop recorders, leadless pacemakers and subcutaneous implantable cardioverter-defibrillators. We discuss the concept and function of each device, indications, methods of delivery, potential complications, consideration for implantation, and cost-effectiveness.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.100800DOI Listing
May 2021

Google Search Activity and Heart Failure: Analysis of the US Population's Interest in Heart Failure and Its Correlation with Heart Failure-Associated Mortality.

J Card Fail 2021 Jan 12;27(1):123-125. Epub 2020 Nov 12.

The Department of Medicine and Center of Excellence for Cardiovascular Diseases & Sciences, Louisiana State University Health Sciences Center-Shreveport, Louisiana. Electronic address:

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http://dx.doi.org/10.1016/j.cardfail.2020.11.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8772295PMC
January 2021

Risk stratification using late gadolinium enhancement on cardiac magnetic resonance imaging in patients with hypertrophic cardiomyopathy: A systematic review and meta-analysis.

Prog Cardiovasc Dis 2021 May-Jun;66:10-16. Epub 2020 Nov 7.

Duke Clinical Research Institute, Durham, NC, USA.

Background The role of late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (c-MRI) for predicting outcomes of patients with hypertrophic cardiomyopathy (HCM) has been debated. Methods We searched PubMed and Embase and various published bibliographies for prospective studies published in English between January 1990 and February 2019. Two investigators screened 2646 abstracts and full-text articles for inclusion and relevant outcomes. We then performed a systematic review and meta-analysis to calculate pooled odds ratios for LGE on c-MRI and a pooled sensitivity and specificity analysis. Results Our systematic review included 8 prospective studies and 3808 patients. LGE positivity was associated with higher odds of the endpoint of sudden cardiac death (SCD;OR 1.69, 95%CI 1.03-2.78), aborted SCD or appropriate implantable cardioverter- defibrillator (ICD) discharge (OR 3.27 [1.75-6.10]), SCD or aborted SCD or appropriate ICD discharge (OR 2.32 [1.56-3.43]), and all-cause mortality (OR 2.10 [CI 1.00-4.41]). The pooled sensitivity and specificity of positive LGE on c-MRI for SCD were 65% and 42%, respectively; for aborted SCD or appropriate ICD discharge, 79% and 39%; for SCD or aborted SCD or appropriate ICD discharge, 74% and 39%; and for all-cause mortality, 78% and 39%. Conclusion In patients with HCM, LGE on c-MRI is a strong predictor of arrhythmic outcomes including SCD, aborted SCD, and appropriate ICD therapy. These data support the routine use of LGE on c-MRI as a marker of SCD risk in this population.
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http://dx.doi.org/10.1016/j.pcad.2020.11.001DOI Listing
August 2021

Dimensionless index of the mitral valve for evaluation of degenerative mitral stenosis.

Echocardiography 2020 10 7;37(10):1533-1542. Epub 2020 Sep 7.

Division of Cardiovascular Disease, John Ochsner Heart and Vascular Institute, New Orleans, Louisiana, USA.

Purpose: Degenerative mitral stenosis (DMS) is an increasingly recognized cause of mitral stenosis. The goal of this study was to compare echocardiographic differences between DMS and rheumatic mitral stenosis (RMS), identify echocardiographic variables reflective of DMS severity, and propose a dimensionless mitral stenosis index (DMSI) for assessment of DMS severity.

Methods: This is a single-center, retrospective cohort study. We included patients with at least mild MS and a mean transmitral pressure gradient (TMPG) ≥4 mm Hg. Mitral valve area by the continuity equation (MVA ) was used as an independent reference. The DMSI was calculated as follows: DMSI = VTI / VTI All-cause mortality data were collected retrospectively.

Results: A total of 64 patients with DMS and 24 patients with RMS were identified. MVA was larger in patients with DMS (1.43 ± 0.4 cm ) than RMS (0.9 ± 0.3 cm ) by ~0.5 cm (P = <.001), and mean TMPG was lower in the DMS group (6.0 ± 2 vs 7.9 ± 3 mm Hg, P = .003). A DMSI of ≤0.50 and ≤0.351 was associated with MVA ≤1.5 and MVA ≤1.0 cm (P < .001), respectively. With the progression of DMS from severe to very severe, there was a significant drop in DMSI. There was a nonsignificant trend toward worse survival in patients with MVA ≤1.0 cm and DMSI ≤0.35, suggesting severe stenosis severity.

Conclusion: Our results show that TMPG correlates poorly with MVA in patients with DMS. Proposed DMSI may serve as a simple echocardiographic indicator of hemodynamically significant DMS.
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http://dx.doi.org/10.1111/echo.14847DOI Listing
October 2020

Amiodarone in the COVID-19 Era: Treatment for Symptomatic Patients Only, or Drug to Prevent Infection?

Am J Cardiovasc Drugs 2020 Oct;20(5):413-418

Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.

Amiodarone, one of the most widely prescribed antiarrhythmic drugs to treat both ventricular and supraventricular arrhythmias, has been identified as a candidate drug for use against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We present the rationale of using amiodarone in the COVID-19 scenario, as well as whether or not amiodarone administration represents a potential strategy to prevent SARS-CoV-2 infection, rather than simply used to treat patients already symptomatic and/or with severe coronavirus disease 2019 (COVID-19), based on current evidence.
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http://dx.doi.org/10.1007/s40256-020-00429-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7394926PMC
October 2020

Utility of serial measurement of biomarkers of cardiovascular stress and inflammation in systolic dysfunction.

Europace 2020 07;22(7):1044-1053

Division of Electrophysiology, Department of Cardiology, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70118, USA.

Aims: Evidence links markers of systemic inflammation and heart failure (HF) with ventricular arrhythmias (VA) and/or death. Biomarker levels, and the risk they indicate, may vary over time. We evaluated the utility of serial laboratory measurements of inflammatory biomarkers and HF, using time-dependent analysis.

Methods And Results: We prospectively enrolled ambulatory patients with left ventricular ejection fraction (LVEF) ≤35% and a primary-prevention implanted cardioverter-defibrillator (ICD). Levels of established inflammatory biomarkers [C-reactive protein, erythrocyte sedimentation rate (ESR), suppression of tumourigenicity 2 (ST2), tumour necrosis factor alpha (TNF-α)] and brain natriuretic peptide (BNP) were assessed at 3-month intervals for 1 year. We assessed relationships between biomarkers modelled as time-dependent variables, VA, and death. Among 196 patients (66±14 years, LVEF 23±8%), 33 experienced VA, and 18 died. Using only baseline values, BNP predicted VA, and both BNP and ST2 predicted death. Using serial measurements at 3-month intervals, time-varying BNP independently predicted VA, and time-varying ST2 independently predicted death. C-statistic analysis revealed no significant benefit to repeated testing compared with baseline-only measurement. C-reactive protein, ESR, and TNF-α, either at baseline or over time, did not predict either endpoint.

Conclusion: In stable ambulatory patients with systolic cardiomyopathy and an ICD, BNP predicts ventricular tachyarrhythmia, and ST2 predicts death. Repeated laboratory measurements over a year's time do not improve risk stratification beyond baseline measurement alone.

Clinical Trial Registration: Clinicaltrials.gov NCT01892462 (https://clinicaltrials.gov/ct2/show/NCT01892462).
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http://dx.doi.org/10.1093/europace/euaa075DOI Listing
July 2020

In reply: Impaired myocardial blood flow in atrial fibrillation.

J Cardiovasc Electrophysiol 2020 07 15;31(7):1883. Epub 2020 Apr 15.

Department of Cardiology, Ochsner Clinical School, University of Queensland, New Orleans, Louisiana.

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http://dx.doi.org/10.1111/jce.14491DOI Listing
July 2020

Impact of wearable cardioverter-defibrillator compliance on outcomes in the VEST trial: As-treated and per-protocol analyses.

J Cardiovasc Electrophysiol 2020 05 3;31(5):1009-1018. Epub 2020 Mar 3.

Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California.

Background: Vest Prevention of Early Sudden Death Trial did not demonstrate a significant reduction in arrhythmic death with the wearable cardioverter-defibrillator (WCD), but compliance with the device may have substantially affected the results. ThePletcher influence of WCD compliance on outcomes has not yet been fully evaluated.

Methods: Using linear and pooled logistic models, we performed as-treated analyses omitting person-time in the hospital and adjusted for correlates of WCD compliance. To assess the impact of early stopping of WCD, we performed a per-protocol Kaplan-Meier analysis, censoring after the last day the WCD was worn. Interactions of potential effect modifiers with treatment assignment and WCD compliance on outcomes were investigated. Finally, we used linear models to identify predictors of WCD compliance.

Results: A per-protocol analysis demonstrated a significant reduction in total (P < .001) and arrhythmic (P = .001) mortality. Better WCD compliance was independently predicted by cardiac arrest during index myocardial infarction (MI), higher Cr, diabetes, prior heart failure, EF ≤ 25%, Polish enrolling center and number of WCD alarms, while worse compliance was predicted by being divorced, Asian race, higher body mass index, prior percutaneous coronary intervention, or any WCD shock. Neither excluding time in hospital from the as-treated analysis nor adjustment for factors affecting WCD compliance materially changed the results. No variable demonstrated a significant interaction in either the intention-to-treat or as-treated analysis.

Conclusion: Robust sensitivity analyses of as-treated and per-protocol analyses suggest that the WCD is protective in compliant patients with ejection fraction less than or equal to 35% during the first 3 months post-MI.
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http://dx.doi.org/10.1111/jce.14404DOI Listing
May 2020

Positron emission tomography absolute stress myocardial blood flow for risk stratification in nonischemic cardiomyopathy.

J Cardiovasc Electrophysiol 2020 05 1;31(5):1137-1146. Epub 2020 Mar 1.

Department of Cardiology, Division of Electrophysiology, Ochsner Medical Center, New Orleans, Louisiana.

Introduction: Sudden cardiac death is a substantial cause of mortality in patients with cardiomyopathy, but evidence supporting implantable cardioverter-defibrillator (ICD) implantation is less robust in nonischemic cardiomyopathy (NICM) than in ischemic cardiomyopathy. Improved risk stratification is needed. We assessed whether absolute quantification of stress myocardial blood flow (sMBF) measured by positron emission tomography (PET) predicts ventricular arrhythmias (VA) and/or death in patients with NICM.

Methods: In this pilot study, we prospectively followed patients with NICM (left ventricular ejection fraction ≤ 35%) and an ICD who underwent cardiac PET stress imaging with sMBF quantification. NICM was defined as the absence of angiographic obstructive coronary stenosis, significant relative perfusion defects on imaging, coronary revascularization, or acute coronary syndrome. Endpoints were appropriate device therapy for VA and all-cause mortality. Subgroup analysis was performed in patients who had no prior history of VA (ie, the primary prevention population).

Results: We followed 37 patients (60 ± 14 years, 46% male) for 41 ± 23 months. The median sMBF was 1.56 mL/g/min (interquartile range: 1.00-1.82). Lower sMBF predicted VA, both in the whole population (hazard ratio [HR] for each 0.1 mL/g/min increase: 0.84, P = .015) and in the primary prevention subset (n = 27; HR for each 0.1 mL/g/min increase: 0.81, P = .049). Patients with sMBF below the median had significantly more VA than those above the median, both in the whole population (P = .004) and in the primary prevention subset (P = .046). Estimated 3-year VA rates in the whole population were 67% among low-flow patients vs 13% among high-flow patients, and 39% vs 8%, respectively, among primary-prevention patients. sMBF did not predict all-cause mortality.

Conclusions: In patients with NICM, lower sMBF predicts VA. This relationship may be useful for risk stratification for ventricular arrhythmia and decision making regarding ICD implantation.
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http://dx.doi.org/10.1111/jce.14395DOI Listing
May 2020

Class 1C antiarrhythmic drugs in atrial fibrillation and coronary artery disease.

J Cardiovasc Electrophysiol 2020 03 24;31(3):607-611. Epub 2020 Jan 24.

Department of Cardiology, Ochsner Clinical School, University of Queensland, New Orleans, Louisiana.

Background: Class 1C antiarrhythmic drugs (AADs) are effective first-line agents for atrial fibrillation (AF) treatment. However, these agents commonly are avoided in patients with known coronary artery disease (CAD), due to known increased risk in the postmyocardial infarction population. Whether 1C AADs are safe in patients with CAD but without clinical ischemia or infarct is unknown. Reduced coronary flow capacity (CFC) on positron emission tomography (PET) reliably identifies myocardial regions supplied by vessels with CAD causing flow limitation.

Objective: To assess whether treatment with 1C AADs increases mortality in patients without known CAD but with CFC indicating significantly reduced coronary blood flow.

Methods: In this pilot study, we compared patients with AF and left ventricular ejection fraction ≥50% who were treated with 1C AADs to age-matched AF patients without 1C AAD treatment. No patient had clinically evident CAD (ie, reversible perfusion defect, known ≥70% epicardial lesion, percutaneous coronary intervention, coronary artery bypass grafting, or myocardial infarction). All patients had PET-based quantification of stress myocardial blood flow and CFC. Death was assessed by clinical follow-up and social security death index search.

Results: A total of 78 patients with 1C AAD exposure were matched to 78 controls. Over a mean follow-up of 2.0 years, the groups had similar survival (P = .54). Among patients with CFC indicating the presence of occult CAD (ie, reduced CFC involving ≥50% of myocardium), 1C-treated patients had survival similar to (P = .44) those not treated with 1C agents.

Conclusions: In a limited population of AF patients with preserved left ventricle function and PET-CFC indicating occult CAD, treatment with 1C AADs appears not to increase mortality. A larger study would be required to confidently assess the safety of these drugs in this context.
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http://dx.doi.org/10.1111/jce.14335DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7079139PMC
March 2020

First in human: the effects of biventricular pacing on cardiac output in severe pulmonary arterial hypertension.

Heart Vessels 2020 Jun 2;35(6):852-858. Epub 2019 Dec 2.

Department of Cardiovascular Diseases, Ochsner Clinical School, John Ochsner Heart and Vascular Institute, The University of Queensland School of Medicine, New Orleans, LA, USA.

Pulmonary arterial hypertension (PAH) carries high morbidity and mortality despite available treatment options. In severe PAH, right ventricular (RV) diastolic pressure overload leads to interventricular septal bowing, hindering of left ventricular diastolic filling and reduced cardiac output (CO). Some animal studies suggest that pacing may mitigate this effect. We hypothesized that eliminating late diastole via ventricular pacing could improve CO in human subjects with severe PAH. Using minimal to no sedation, we performed transvenous acute biventricular (BiV) pacing and right heart catheterization in six patients with symptomatic PAH. Hemodynamic measurements were taken at baseline and during BiV pacing at various 20-ms intervals of V-V timing. We compared baseline CO to (1) CO while pacing the RV first by 80 ms (mimicking RV-only pacing), and then to (2) CO during pacing at the V-V timing that resulted in the highest CO. All participants were female, PASP 74 ± 14 mmHg, QRS duration 104 ± 20 ms. Compared with baseline, the CO decreased when the RV was paced first by 80 ms (7.2 ± 1.0 vs. 6.2 ± 1.1 L/min, p = 0.028). Pacing with optimal V-V timing produced CO similar to baseline (7.2 ± 1.0 vs. 7.4 ± 1.4, p = 0.92). Two patients (33%) met the predefined endpoint of a 15% increase in CO during pacing at the optimal V-V timing. In symptomatic PAH, V-V optimized acute BiV pacing does not consistently improve CO. However, acute BiV pacing did improve CO in a subset of this cohort. Further research is needed to identify predictors of response to cardiac resynchronization therapy in this population.
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http://dx.doi.org/10.1007/s00380-019-01540-9DOI Listing
June 2020

Who Should Receive a Wearable Defibrillator Vest at Hospital Discharge?

Curr Cardiol Rep 2019 09 7;21(10):125. Epub 2019 Sep 7.

Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, LA, USA.

Purpose Of Review: To discuss the role of wearable cardioverter defibrillator (WCD) vests in preventing sudden cardiac death (SCD) in at-risk populations.

Recent Findings: The impact of randomized-controlled trials with implantable cardioverter-defibrillators (ICD) therapy is well established in randomized clinical trials in ischemic cardiomyopathy. Although the benefits are not as clear in non-ischemic cardiomyopathy, meta-analyses show significant mortality benefits from immediate electrical cardioversion strategies. The role of WCDs in at-risk populations in whom ICD therapy is temporarily not indicated is not as well-established. Smaller cohort trials have shown efficacy in patients with newly-diagnosed cardiomyopathy, requiring temporary ICD explantation, and others with less common indications for WCD therapy. The Vest Prevention of Early Sudden Death Trial was a landmark randomized control study seeking to examine the benefits of WCD therapy in at-risk population, and although the primary endpoint of reducing arrhythmic death was not reached, the structure of the trial and significant differences in total mortality make a compelling case for continued use of WCD therapies in our healthcare systems.
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http://dx.doi.org/10.1007/s11886-019-1215-8DOI Listing
September 2019

Advances in the Risk Stratification, Prevention, and Treatment of Sudden Cardiac Death.

Prog Cardiovasc Dis 2019 May - Jun;62(3):203-204

University of Texas Southwestern Medical Center, Dallas, TX, United States of America.

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http://dx.doi.org/10.1016/j.pcad.2019.05.008DOI Listing
October 2019

Sudden cardiac death in Long QT syndrome (LQTS), Brugada syndrome, and catecholaminergic polymorphic ventricular tachycardia (CPVT).

Prog Cardiovasc Dis 2019 May - Jun;62(3):227-234. Epub 2019 May 9.

Department of Internal Medicine, Division of Cardiology, UT Southwestern Medical Center, Dallas, TX, United States of America.

Sudden cardiac death (SCD) accounts for 230,000 to 350,000 deaths per year in the United States. While many who suffer SCD possess underlying structural heart disease, inherited arrhythmia syndromes are also important contributors to SCD. In patients without structural heart disease, inherited arrhythmia syndromes are identified in >50% of the remaining patients. In this review, we will focus on the presentation and management of three major inherited syndromes that lead to SCD in patients without structural heart disease: long QT syndrome (LQTS), Brugada syndrome, and catecholaminergic polymorphic ventricular tachycardia (CPVT). All these syndromes can present in patients who are asymptomatic or, at the other extreme, with syncope and even SCD. LQTS syndrome and Brugada are the most common inherited arrhythmogenic syndromes, while CPVT is much rarer. Determining which patients need pharmacologic treatment and those who would benefit from more aggressive treatment such as sympathectomies and implantable defibrillators is not always clear.
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http://dx.doi.org/10.1016/j.pcad.2019.05.006DOI Listing
October 2019

The wearable cardioverter-defibrillator vest: Indications and ongoing questions.

Prog Cardiovasc Dis 2019 May - Jun;62(3):256-264. Epub 2019 May 9.

Division of Cardiology, Electrophysiology and Arrhythmia Service, University of California, San Francisco. Electronic address:

Multiple clinical trials have demonstrated the efficacy of implantable cardioverter-defibrillators (ICDs) for the prevention of sudden cardiac death (SCD) among specific high-risk populations. However, it remains unclear how to optimally treat those patients who are at elevated risk of cardiac arrest but are not among the presently identified groups proven to benefit from an ICD, are unable to tolerate surgical device implantation, or refuse invasive therapies. The wearable cardioverter-defibrillator (WCD) is an alternative antiarrhythmic device that provides continuous cardiac monitoring and defibrillation capabilities through a noninvasive, electrode-based system. The WCD has been shown to be highly effective at restoration of sinus rhythm in patients with a ventricular tachyarrhythmia, and one randomized trial using the WCD in patients with recent myocardial infarction at elevated risk for arrhythmic death reported a decrease in overall mortality despite no SCD mortality benefit. The current clinical indications for WCD use are varied and continue to evolve as experience with this technology increases.
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http://dx.doi.org/10.1016/j.pcad.2019.05.005DOI Listing
October 2019
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