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Aims: Clinical guidelines recommend that the exercise protocol of a stress echocardiogram is selected to induce volitional exhaustion after a target duration of at least 8 minutes. While the Bruce protocol is very commonly used for clinical stress tests, it is known to be "steep", and many patients therefore fail to reach 8 minutes. We studied predictors of failure and developed a method for identifying patients not suitable for Bruce protocol which was accurate and yet simple enough to be used as a point‐of‐care decision support tool. Methods and results: We studied data out‐patients undergoing Bruce protocol stress echocardiograms (n = 11 086) and analyzed predictors of inappropriate early termination (defined as test duration < 8 min as per current practice guidelines) using logistic regression. A prediction model was constructed as follows:.5 points were given for each of hypertension, diabetes, smoking, and E/e' > 7.9 in the resting echocardiogram;.1 point was added for each 1‐unit increment in body mass index; 1 point was added for patient age by decade; 2.0 points were subtracted for male sex (p for all < 0.001). In tests on held‐out validation data, the model was well calibrated (in plots of predicted vs actual risk) and discriminated failure versus non‐failure well (C‐statistic.86 for a score of 6.0 points; p < 0.001). Conclusion: These data may help to standardize protocol selection in stress echocardiography, by identifying patients pre‐hoc where Bruce protocol will be inappropriately steep. [ABSTRACT FROM AUTHOR]

Aims: Advances in diagnostic imaging have increased the recognition of coexisting transthyretin cardiac amyloidosis (ATTR‐CA) and severe aortic stenosis (AS), with a reported prevalence between 8–16%. In this prospective study, we aimed to evaluate the implications of ATTR‐CA on outcomes after transcatheter aortic valve replacement (TAVR). Methods and results: At two academic centres, we screened patients with severe AS undergoing TAVR for ATTR‐CA. Using Kaplan–Meier analysis, we compared survival free from death and a combined endpoint of death and first heart failure hospitalization between patients with and without ATTR‐CA. Cox proportional‐hazards models were used to determine the association of ATTR‐CA with these endpoints. The rate of heart failure hospitalization was compared amongst those with and without ATTR‐CA. Overall, 204 patients (83 years, 65% male, Society of Thoracic Surgeons score 6.6%, 72% New York Heart Association class III/IV) were included, 27 (13%) with ATTR‐CA. Over a median follow‐up of 2.04 years, there was no difference in mortality (log rank, P = 0.99) or the combined endpoint (log rank, P = 0.79) between patients with and without ATTR‐CA. In Cox proportional‐hazards models, the presence of ATTR‐CA was not associated with death. However, patients with ATTR‐CA had increased rates of heart failure hospitalization at 1 year (0.372 vs. 0.114 events/person‐year, P < 0.004) and 3 years (0.199 vs. 0.111 events/person‐year, P = 0.087) following TAVR. Conclusion: In moderate‐risk patients with severe AS undergoing TAVR, there was a 13% prevalence of ATTR‐CA, which did not affect mortality. The observed increase in heart failure hospitalization following TAVR in those with ATTR‐CA suggests the consequences of the underlying infiltrative myopathy. [ABSTRACT FROM AUTHOR]

Background: Myocardial infarction (MI) is a high‐risk condition especially when filling pressure is raised, and earlier reports have suggested that E/e' is associated with poor outcome. However, whether E/e' predicts risk better than LVEF, which is the current standard of practice, is not known. We investigated this question in the largest and most rigorous study of MI patients so far. Methods and Results: We studied 660 patients with ST‐elevation MI (STEMI) treated with primary percutaneous coronary intervention and related E/e' to short‐term mortality (in‐hospital death), as well as long‐term events at 2 years comprising (a) a composite of MI, stroke, heart failure, and death, and (b) death alone. Short‐term models were adjusted for age, sex, and LVEF. Long‐term models were adjusted for age, sex, diabetes, revascularization procedure, history of MI, hypertension, renal function, drugs on discharge, and LVEF. Elevated E/e'> 15 indicated higher risk of short‐term events (n = 19:7.0% (95% confidence interval 3.4‐10.8%) vs. 1.0% (0.3 ‐ 2.3%); adjusted odds ratio 3.7 (1.3‐10.5)). While elevated E/e' was also associated with long‐term outcomes (n = 103 composite events: 15.9% (11.9% – 21.4%) vs 6.8% (5.2% – 8.7%), P <.001; n = 38 death events: 6.0% (3.9% – 9.5%) vs 2.0% (1.3% – 3.2%), P =.001), E/e' was rendered nonsignificant for long‐term outcomes by multivariable adjustment (p = ns for both). LVEF, on the contrary, was a highly significant predictor in the adjusted long‐term model. Conclusion: E/e' is associated with poor outcome in STEMI, but LVEF is a stronger predictor of long‐term risk. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to determine the cardiovascular (CV) risk factor response in Irish patients with type 1 diabetes following simultaneous pancreas and kidney transplantation (SPK), analyzing response based on mode of immunosuppression and surgical drainage in a uniquely homogenous population. Methods: A retrospective review of SPKs carried out between 1993 and 2005 in the National Renal and Pancreatic Centre of Ireland was performed. Weight, glycated hemoglobin (HBA1c), lipid profile, and blood pressure (BP) were measured pre- and post-operatively. Results: Fifty-eight SPK patients with functioning grafts were analyzed. Thirty-two were male. Following transplantation, mean HbA1c fell from 8.1 (±1.5) to 5.2 (±0.5)% (p < 0.0001), total cholesterol from 5.2 (±1.2) to 4.5 (±1.0) mmol/L (p = 0.0004), serum triglycerides from 1.5 (±0.6) to 1.1 (±0.6) mmol/L (p < 0.0001), and serum creatinine from 699.3 (±273.4) to 162.5 (±135.8) mmol/L (p < 0.0001). Systolic and diastolic BP fell from 148.5 (±23.3) to 136.9 (±22.4) mmHg (p = 0.02), and 84.8 (±11.7) to 77.8 (±10.4) mmHg (p = 0.003), respectively. Cholesterol reduction was significantly greater in the group that received cyclosporine (n = 29) compared with a tacrolimus and mycophenolic acid mofetil (MMF) combination (1.3 ± 0.3 vs. 0.2 ± 0.2 mmol/L, p = 0.003). Choice of exocrine vs. endocrine graft drainage did not affect risk factor response. Conclusion: SPK resulted in significant improvements both in glucose control and other measured CV risk factors. [ABSTRACT FROM AUTHOR]

Background Aortic stenosis is prevalent in end-stage renal disease. Transcatheter aortic valve replacement (TAVR) is a plausible alternative for surgical aortic valve replacement. However, little is known regarding long-term outcomes in patients with end-stage renal disease who undergo TAVR. Methods and Results We identified all patients with end-stage renal disease who underwent TAVR from 2011 through 2016 using the United States Renal Data System. The primary end point was 5-year mortality after TAVR. Factors associated with 1- and 5-year mortality were analyzed. A total of 3883 TAVRs were performed for patients with end-stage renal disease. Mortality was 5.8%, 43.7%, and 88.8% at 30 days, 1 year, and 5 years, respectively. Case volumes increased rapidly from 17 in 2011 to 1495 in 2016. Thirty-day mortality demonstrated a dramatic reduction from 11.1% in 2012 to 2.5% in 2016 ( P =0.01). Age 75 or older (hazard ratio [HR], 1.14; 95% CI, 1.05-1.23 [ P =0.002]), body mass index <25 (HR, 1.18; 95% CI, 1.08-1.28 [ P <0.001]), chronic obstructive pulmonary disease (HR, 1.25; 95% CI, 1.1-1.35 [ P <0.001]), diabetes mellitus as the cause of dialysis (HR, 1.22; 95% CI, 1.11-1.35 [ P <0.001]), hypertension as the cause of dialysis (HR, 1.17; 95% CI, 1.06-1.29 [ P =0.004]), and White race (HR, 1.17; 95% CI, 1.06-1.3 [ P =0.002]) were independently associated with 5-year mortality. Conclusions Short-term outcomes of TAVR in patients with end-stage renal disease have improved significantly. However, long-term mortality of patients on dialysis remains high.