People are more likely to die of alcohol-associated liver disease (ALD) when there are fewer gastroenterologists in their state, researchers say.

The finding raises questions about steps that policymakers could take to increase the number of gastroenterologists and spread them more evenly around the United States.

“We found that there’s a fivefold difference in density of gastroenterologists through different states,” said Brian P. Lee, MD, MAS, an assistant professor of clinical medicine at the University of Southern California, Los Angeles.

Dr. Lee and colleagues published their findings in Clinical Gastroenterology and Hepatology.

ALD is becoming more common, and it is killing more people. Research among veterans has linked visits to gastroenterologists to a lower risk for death from liver disease.

To see whether that correlation applies more broadly, Dr. Lee and colleagues compared multiple datasets. One from the U.S. Health Resources & Service Administration provided the number of gastroenterologists per 100,000 population. The other from the U.S. Centers for Disease Control and Prevention provided ALD-related deaths per 1,000,000 adults for each state and the District of Columbia.

The researchers adjusted for many variables that could affect the relationship between the availability of gastroenterologists and deaths related to ALD, including the age distribution of the population in each state, the gender balance, race and ethnicity, binge drinking, household income, obesity, and the proportion of rural residents.

They found that for every additional gastroenterologist, there is almost one fewer ALD-related death each year per 100,000 population (9.0 [95% confidence interval, 1.3-16.7] fewer ALD-related deaths per 1,000,000 population for each additional gastroenterologist per 100,000 population).

The strength of the association appeared to plateau when there were at least 7.5 gastroenterologists per 100,000 people.

From these findings, the researchers calculated that as many as 40% of deaths from ALD nationwide could be prevented by providing more gastroenterologists in the places where they are lacking.

The mean number of gastroenterologists per 100,000 people in the United States was 4.6, and the annual ALD-related death rate was 85.6 per 1,000,000 people.

The Atlantic states had the greatest concentration of gastroenterologists and the lowest ALD-related mortality, whereas the Mountain states had the lowest concentration of gastroenterologists and the highest ALD-related mortality.

The lowest mortality related to ALD was in New Jersey, Maryland, and Hawaii, with 52 per 1,000,000 people, and the highest was in Wyoming, with 289.
 

Study shines spotlight on general GI care

Access to liver transplants did not make a statistically significant difference in mortality from ALD.

“It makes you realize that transplant will only be accessible for really just a small fraction of the population who needs it,” Dr. Lee told this news organization.

General gastroenterologic care appears to make a bigger difference in saving patients’ lives. “Are they getting endoscopy for bleeding from varices?” Dr. Lee asked. “Are they getting appropriate antibiotics prescribed to prevent bacterial infection of ascites?”

The concentration of primary care physicians did not reduce mortality from ALD, and neither did the concentration of substance use, behavioral disorder, and mental health counselors.

Previous research has shown that substance abuse therapy is effective. But many people do not want to undertake it, or they face barriers of transportation, language, or insurance, said Dr. Lee.

“I have many patients whose insurance will provide them access to medical visits to me but will not to substance-use rehab, for example,” he said.

To see whether the effect was more generally due to the concentration of medical specialists, the researchers examined the state-level density of ophthalmologists and dermatologists. They found no significant difference in ALD-related mortality.

The finding builds on reports by the American Gastroenterological Association and the American Association for the Study of Liver Diseases that the number of gastroenterologists has not kept up with the U.S. population nor the burden of digestive diseases, and that predicts a critical shortage in the future.
 

Overcoming barriers to care for liver disease

The overall supply of gastroenterologists could be increased by reducing the educational requirements and increasing the funding for fellowships, said Dr. Lee.

“We have to have a better understanding as to the barriers to gastroenterology practice in certain areas, then interventions to address those barriers and also incentives to attract gastroenterologists to those areas,” Dr. Lee said.

The study underscores the importance of access to gastroenterological care, said George Cholankeril, MD, assistant professor of medicine at Baylor College of Medicine, Houston, who was not involved in the study. That urgency has only grown as ALD has spiraled up with the COVID-19 pandemic, he said.

“Anyone in clinical practice right now will be able to say that there’s been a clear rising tide of patients with alcohol-related liver disease,” he told this news organization. “There’s an urgent need to address this and provide the necessary resources.”

Prevention remains essential, Dr. Cholankeril said.

Gastroenterologists and primary care physicians can help stem the tide of ALD by screening their patients for the disease through a tool like AUDIT (Alcohol Use Disorders Identification Test), he said. They can then refer patients to substance abuse treatment centers or to psychologists and psychiatrists.

Dr. Lee and Dr. Cholankeril report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

People are more likely to die of alcohol-associated liver disease (ALD) when there are fewer gastroenterologists in their state, researchers say.

The finding raises questions about steps that policymakers could take to increase the number of gastroenterologists and spread them more evenly around the United States.

“We found that there’s a fivefold difference in density of gastroenterologists through different states,” said Brian P. Lee, MD, MAS, an assistant professor of clinical medicine at the University of Southern California, Los Angeles.

Dr. Lee and colleagues published their findings in Clinical Gastroenterology and Hepatology.

ALD is becoming more common, and it is killing more people. Research among veterans has linked visits to gastroenterologists to a lower risk for death from liver disease.

To see whether that correlation applies more broadly, Dr. Lee and colleagues compared multiple datasets. One from the U.S. Health Resources & Service Administration provided the number of gastroenterologists per 100,000 population. The other from the U.S. Centers for Disease Control and Prevention provided ALD-related deaths per 1,000,000 adults for each state and the District of Columbia.

The researchers adjusted for many variables that could affect the relationship between the availability of gastroenterologists and deaths related to ALD, including the age distribution of the population in each state, the gender balance, race and ethnicity, binge drinking, household income, obesity, and the proportion of rural residents.

They found that for every additional gastroenterologist, there is almost one fewer ALD-related death each year per 100,000 population (9.0 [95% confidence interval, 1.3-16.7] fewer ALD-related deaths per 1,000,000 population for each additional gastroenterologist per 100,000 population).

The strength of the association appeared to plateau when there were at least 7.5 gastroenterologists per 100,000 people.

From these findings, the researchers calculated that as many as 40% of deaths from ALD nationwide could be prevented by providing more gastroenterologists in the places where they are lacking.

The mean number of gastroenterologists per 100,000 people in the United States was 4.6, and the annual ALD-related death rate was 85.6 per 1,000,000 people.

The Atlantic states had the greatest concentration of gastroenterologists and the lowest ALD-related mortality, whereas the Mountain states had the lowest concentration of gastroenterologists and the highest ALD-related mortality.

The lowest mortality related to ALD was in New Jersey, Maryland, and Hawaii, with 52 per 1,000,000 people, and the highest was in Wyoming, with 289.
 

Study shines spotlight on general GI care

Access to liver transplants did not make a statistically significant difference in mortality from ALD.

“It makes you realize that transplant will only be accessible for really just a small fraction of the population who needs it,” Dr. Lee told this news organization.

General gastroenterologic care appears to make a bigger difference in saving patients’ lives. “Are they getting endoscopy for bleeding from varices?” Dr. Lee asked. “Are they getting appropriate antibiotics prescribed to prevent bacterial infection of ascites?”

The concentration of primary care physicians did not reduce mortality from ALD, and neither did the concentration of substance use, behavioral disorder, and mental health counselors.

Previous research has shown that substance abuse therapy is effective. But many people do not want to undertake it, or they face barriers of transportation, language, or insurance, said Dr. Lee.

“I have many patients whose insurance will provide them access to medical visits to me but will not to substance-use rehab, for example,” he said.

To see whether the effect was more generally due to the concentration of medical specialists, the researchers examined the state-level density of ophthalmologists and dermatologists. They found no significant difference in ALD-related mortality.

The finding builds on reports by the American Gastroenterological Association and the American Association for the Study of Liver Diseases that the number of gastroenterologists has not kept up with the U.S. population nor the burden of digestive diseases, and that predicts a critical shortage in the future.
 

Overcoming barriers to care for liver disease

The overall supply of gastroenterologists could be increased by reducing the educational requirements and increasing the funding for fellowships, said Dr. Lee.

“We have to have a better understanding as to the barriers to gastroenterology practice in certain areas, then interventions to address those barriers and also incentives to attract gastroenterologists to those areas,” Dr. Lee said.

The study underscores the importance of access to gastroenterological care, said George Cholankeril, MD, assistant professor of medicine at Baylor College of Medicine, Houston, who was not involved in the study. That urgency has only grown as ALD has spiraled up with the COVID-19 pandemic, he said.

“Anyone in clinical practice right now will be able to say that there’s been a clear rising tide of patients with alcohol-related liver disease,” he told this news organization. “There’s an urgent need to address this and provide the necessary resources.”

Prevention remains essential, Dr. Cholankeril said.

Gastroenterologists and primary care physicians can help stem the tide of ALD by screening their patients for the disease through a tool like AUDIT (Alcohol Use Disorders Identification Test), he said. They can then refer patients to substance abuse treatment centers or to psychologists and psychiatrists.

Dr. Lee and Dr. Cholankeril report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

People are more likely to die of alcohol-associated liver disease (ALD) when there are fewer gastroenterologists in their state, researchers say.

The finding raises questions about steps that policymakers could take to increase the number of gastroenterologists and spread them more evenly around the United States.

“We found that there’s a fivefold difference in density of gastroenterologists through different states,” said Brian P. Lee, MD, MAS, an assistant professor of clinical medicine at the University of Southern California, Los Angeles.

Dr. Lee and colleagues published their findings in Clinical Gastroenterology and Hepatology.

ALD is becoming more common, and it is killing more people. Research among veterans has linked visits to gastroenterologists to a lower risk for death from liver disease.

To see whether that correlation applies more broadly, Dr. Lee and colleagues compared multiple datasets. One from the U.S. Health Resources & Service Administration provided the number of gastroenterologists per 100,000 population. The other from the U.S. Centers for Disease Control and Prevention provided ALD-related deaths per 1,000,000 adults for each state and the District of Columbia.

The researchers adjusted for many variables that could affect the relationship between the availability of gastroenterologists and deaths related to ALD, including the age distribution of the population in each state, the gender balance, race and ethnicity, binge drinking, household income, obesity, and the proportion of rural residents.

They found that for every additional gastroenterologist, there is almost one fewer ALD-related death each year per 100,000 population (9.0 [95% confidence interval, 1.3-16.7] fewer ALD-related deaths per 1,000,000 population for each additional gastroenterologist per 100,000 population).

The strength of the association appeared to plateau when there were at least 7.5 gastroenterologists per 100,000 people.

From these findings, the researchers calculated that as many as 40% of deaths from ALD nationwide could be prevented by providing more gastroenterologists in the places where they are lacking.

The mean number of gastroenterologists per 100,000 people in the United States was 4.6, and the annual ALD-related death rate was 85.6 per 1,000,000 people.

The Atlantic states had the greatest concentration of gastroenterologists and the lowest ALD-related mortality, whereas the Mountain states had the lowest concentration of gastroenterologists and the highest ALD-related mortality.

The lowest mortality related to ALD was in New Jersey, Maryland, and Hawaii, with 52 per 1,000,000 people, and the highest was in Wyoming, with 289.
 

Study shines spotlight on general GI care

Access to liver transplants did not make a statistically significant difference in mortality from ALD.

“It makes you realize that transplant will only be accessible for really just a small fraction of the population who needs it,” Dr. Lee told this news organization.

General gastroenterologic care appears to make a bigger difference in saving patients’ lives. “Are they getting endoscopy for bleeding from varices?” Dr. Lee asked. “Are they getting appropriate antibiotics prescribed to prevent bacterial infection of ascites?”

The concentration of primary care physicians did not reduce mortality from ALD, and neither did the concentration of substance use, behavioral disorder, and mental health counselors.

Previous research has shown that substance abuse therapy is effective. But many people do not want to undertake it, or they face barriers of transportation, language, or insurance, said Dr. Lee.

“I have many patients whose insurance will provide them access to medical visits to me but will not to substance-use rehab, for example,” he said.

To see whether the effect was more generally due to the concentration of medical specialists, the researchers examined the state-level density of ophthalmologists and dermatologists. They found no significant difference in ALD-related mortality.

The finding builds on reports by the American Gastroenterological Association and the American Association for the Study of Liver Diseases that the number of gastroenterologists has not kept up with the U.S. population nor the burden of digestive diseases, and that predicts a critical shortage in the future.
 

Overcoming barriers to care for liver disease

The overall supply of gastroenterologists could be increased by reducing the educational requirements and increasing the funding for fellowships, said Dr. Lee.

“We have to have a better understanding as to the barriers to gastroenterology practice in certain areas, then interventions to address those barriers and also incentives to attract gastroenterologists to those areas,” Dr. Lee said.

The study underscores the importance of access to gastroenterological care, said George Cholankeril, MD, assistant professor of medicine at Baylor College of Medicine, Houston, who was not involved in the study. That urgency has only grown as ALD has spiraled up with the COVID-19 pandemic, he said.

“Anyone in clinical practice right now will be able to say that there’s been a clear rising tide of patients with alcohol-related liver disease,” he told this news organization. “There’s an urgent need to address this and provide the necessary resources.”

Prevention remains essential, Dr. Cholankeril said.

Gastroenterologists and primary care physicians can help stem the tide of ALD by screening their patients for the disease through a tool like AUDIT (Alcohol Use Disorders Identification Test), he said. They can then refer patients to substance abuse treatment centers or to psychologists and psychiatrists.

Dr. Lee and Dr. Cholankeril report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Key clinical point: Baseline hepatitis B virus (HBV) DNA levels are not associated with the clinical outcomes of patients with HBV-related hepatocellular carcinoma (HCC) treated with anti-programmed cell death protein 1 (anti-PD-1)-based immunotherapy.

Major finding: Baseline HBV DNA levels were not significantly associated with the overall survival (adjusted hazard ratio [aHR] 0.77; P  =  .59) or progression-free survival (aHR 0.68; P  =  .098).

Study details: This single-center retrospective observational study included 217 patients with advanced HBV-related HCC who received ≥1 dose of anti-PD-1 therapy.

Disclosures: This study was supported by the National Natural Science Foundation of China and Medical Science and Technology Research Project of Health Commission of Henan Province. The authors declared no conflicts of interest.

Source: An M et al. Association of hepatitis B virus DNA levels with overall survival for advanced hepatitis B virus-related hepatocellular carcinoma under immune checkpoint inhibitor therapy. Cancer Immunol Immunother. 2022 (Jul 30). Doi: 10.1007/s00262-022-03254-w

Key clinical point: Baseline hepatitis B virus (HBV) DNA levels are not associated with the clinical outcomes of patients with HBV-related hepatocellular carcinoma (HCC) treated with anti-programmed cell death protein 1 (anti-PD-1)-based immunotherapy.

Major finding: Baseline HBV DNA levels were not significantly associated with the overall survival (adjusted hazard ratio [aHR] 0.77; P  =  .59) or progression-free survival (aHR 0.68; P  =  .098).

Study details: This single-center retrospective observational study included 217 patients with advanced HBV-related HCC who received ≥1 dose of anti-PD-1 therapy.

Disclosures: This study was supported by the National Natural Science Foundation of China and Medical Science and Technology Research Project of Health Commission of Henan Province. The authors declared no conflicts of interest.

Source: An M et al. Association of hepatitis B virus DNA levels with overall survival for advanced hepatitis B virus-related hepatocellular carcinoma under immune checkpoint inhibitor therapy. Cancer Immunol Immunother. 2022 (Jul 30). Doi: 10.1007/s00262-022-03254-w

Key clinical point: Baseline hepatitis B virus (HBV) DNA levels are not associated with the clinical outcomes of patients with HBV-related hepatocellular carcinoma (HCC) treated with anti-programmed cell death protein 1 (anti-PD-1)-based immunotherapy.

Major finding: Baseline HBV DNA levels were not significantly associated with the overall survival (adjusted hazard ratio [aHR] 0.77; P  =  .59) or progression-free survival (aHR 0.68; P  =  .098).

Study details: This single-center retrospective observational study included 217 patients with advanced HBV-related HCC who received ≥1 dose of anti-PD-1 therapy.

Disclosures: This study was supported by the National Natural Science Foundation of China and Medical Science and Technology Research Project of Health Commission of Henan Province. The authors declared no conflicts of interest.

Source: An M et al. Association of hepatitis B virus DNA levels with overall survival for advanced hepatitis B virus-related hepatocellular carcinoma under immune checkpoint inhibitor therapy. Cancer Immunol Immunother. 2022 (Jul 30). Doi: 10.1007/s00262-022-03254-w

Key clinical point: Compared with transcatheter arterial chemoembolization (TACE), hepatic arterial infusion chemotherapy (HAIC) offers better efficacy in patients with advanced hepatocellular carcinoma (HCC) and portal vein tumor thrombosis (PVTT) without significantly compromising safety.

Major finding: Patients receiving HAIC vs TACE had a significantly longer median overall survival (11.2 vs 9.0 months; P  =  .010) and progression-free survival (5.6 vs 2.0 months; P  =  .006) and a higher objective response rate (56.8% vs 18.2%; P < .001). No treatment‐related grade 4/5 adverse events were reported.

Study details: This was a propensity score‐matched cohort study including 44 pairs of adult patients with advanced HCC and PVTT who underwent HAIC with oxaliplatin plus raltitrexed or TACE.

Disclosures: This study was supported by the Guiding Project of Science and Technology Program of Fujian Province, China.

Source: Chen S, Yuan B, et al. Hepatic arterial infusion oxaliplatin plus raltitrexed and chemoembolization in hepatocellular carcinoma with portal vein invasion: A propensity score-matching cohort study. J Surg Oncol. 2022 (Jul 20). Doi: 10.1002/jso.27023

Key clinical point: Compared with transcatheter arterial chemoembolization (TACE), hepatic arterial infusion chemotherapy (HAIC) offers better efficacy in patients with advanced hepatocellular carcinoma (HCC) and portal vein tumor thrombosis (PVTT) without significantly compromising safety.

Major finding: Patients receiving HAIC vs TACE had a significantly longer median overall survival (11.2 vs 9.0 months; P  =  .010) and progression-free survival (5.6 vs 2.0 months; P  =  .006) and a higher objective response rate (56.8% vs 18.2%; P < .001). No treatment‐related grade 4/5 adverse events were reported.

Study details: This was a propensity score‐matched cohort study including 44 pairs of adult patients with advanced HCC and PVTT who underwent HAIC with oxaliplatin plus raltitrexed or TACE.

Disclosures: This study was supported by the Guiding Project of Science and Technology Program of Fujian Province, China.

Source: Chen S, Yuan B, et al. Hepatic arterial infusion oxaliplatin plus raltitrexed and chemoembolization in hepatocellular carcinoma with portal vein invasion: A propensity score-matching cohort study. J Surg Oncol. 2022 (Jul 20). Doi: 10.1002/jso.27023

Key clinical point: Compared with transcatheter arterial chemoembolization (TACE), hepatic arterial infusion chemotherapy (HAIC) offers better efficacy in patients with advanced hepatocellular carcinoma (HCC) and portal vein tumor thrombosis (PVTT) without significantly compromising safety.

Major finding: Patients receiving HAIC vs TACE had a significantly longer median overall survival (11.2 vs 9.0 months; P  =  .010) and progression-free survival (5.6 vs 2.0 months; P  =  .006) and a higher objective response rate (56.8% vs 18.2%; P < .001). No treatment‐related grade 4/5 adverse events were reported.

Study details: This was a propensity score‐matched cohort study including 44 pairs of adult patients with advanced HCC and PVTT who underwent HAIC with oxaliplatin plus raltitrexed or TACE.

Disclosures: This study was supported by the Guiding Project of Science and Technology Program of Fujian Province, China.

Source: Chen S, Yuan B, et al. Hepatic arterial infusion oxaliplatin plus raltitrexed and chemoembolization in hepatocellular carcinoma with portal vein invasion: A propensity score-matching cohort study. J Surg Oncol. 2022 (Jul 20). Doi: 10.1002/jso.27023

Key clinical point: Heavy alcohol intake and ALDH2 rs671 polymorphism are associated with a significantly increased risk for hepatocellular carcinoma (HCC) development in patients with hepatitis B virus (HBV)-related cirrhosis.

Major finding: Alcohol intake amount (>160 vs 80-160 g/day: adjusted hazard ratio [aHR] 1.78; P  =  .04) and ALDH2 rs671 polymorphism (GA/AA vs GG genotype: aHR 5.61; P < .001) were significantly associated with an increased incidence of HCC.

Study details: This retrospective cohort study enrolled 1515 patients with cirrhosis due to heavy alcoholism or HBV infection.

Disclosures: This study was sponsored by the Ministry of Science and Technology, Taiwan, E-Da Hospital-National Taiwan University Hospital Joint Research Program, and others.

Source: Tsai MC et al. Association of heavy alcohol intake and ALDH2 rs671 polymorphism with hepatocellular carcinoma and mortality in patients with hepatitis B virus–related cirrhosis. JAMA Netw Open. 2022;5(7):e2223511 (Jul 25). Doi: 10.1001/jamanetworkopen.2022.23511

Key clinical point: Heavy alcohol intake and ALDH2 rs671 polymorphism are associated with a significantly increased risk for hepatocellular carcinoma (HCC) development in patients with hepatitis B virus (HBV)-related cirrhosis.

Major finding: Alcohol intake amount (>160 vs 80-160 g/day: adjusted hazard ratio [aHR] 1.78; P  =  .04) and ALDH2 rs671 polymorphism (GA/AA vs GG genotype: aHR 5.61; P < .001) were significantly associated with an increased incidence of HCC.

Study details: This retrospective cohort study enrolled 1515 patients with cirrhosis due to heavy alcoholism or HBV infection.

Disclosures: This study was sponsored by the Ministry of Science and Technology, Taiwan, E-Da Hospital-National Taiwan University Hospital Joint Research Program, and others.

Source: Tsai MC et al. Association of heavy alcohol intake and ALDH2 rs671 polymorphism with hepatocellular carcinoma and mortality in patients with hepatitis B virus–related cirrhosis. JAMA Netw Open. 2022;5(7):e2223511 (Jul 25). Doi: 10.1001/jamanetworkopen.2022.23511

Key clinical point: Heavy alcohol intake and ALDH2 rs671 polymorphism are associated with a significantly increased risk for hepatocellular carcinoma (HCC) development in patients with hepatitis B virus (HBV)-related cirrhosis.

Major finding: Alcohol intake amount (>160 vs 80-160 g/day: adjusted hazard ratio [aHR] 1.78; P  =  .04) and ALDH2 rs671 polymorphism (GA/AA vs GG genotype: aHR 5.61; P < .001) were significantly associated with an increased incidence of HCC.

Study details: This retrospective cohort study enrolled 1515 patients with cirrhosis due to heavy alcoholism or HBV infection.

Disclosures: This study was sponsored by the Ministry of Science and Technology, Taiwan, E-Da Hospital-National Taiwan University Hospital Joint Research Program, and others.

Source: Tsai MC et al. Association of heavy alcohol intake and ALDH2 rs671 polymorphism with hepatocellular carcinoma and mortality in patients with hepatitis B virus–related cirrhosis. JAMA Netw Open. 2022;5(7):e2223511 (Jul 25). Doi: 10.1001/jamanetworkopen.2022.23511

Key clinical point: The excellent 10-year post-liver transplant (LT) outcomes in patients with hepatocellular carcinoma (HCC) successfully downstaged to within Milan criteria (MC) substantiate the validity of the national downstaging policy.

Major finding: At 10 years after LT, patients with HCC always within MC, those with HCC downstaged before LT, and those with HCC unsuccessfully downstaged/progressed beyond MC during LT had survival rates of 61.5%, 52.1%, and 43.3%, respectively, and recurrence rates of 13.3%, 20.6%, and 41.4%, respectively.

Study details: This retrospective cohort study analyzed the prospective data of 2645 adult patients with HCC who underwent LT at 5 US academic centers.

Disclosures: This study was sponsored by the US Department of Defense, Samuel Waxman Cancer Research Foundation, Spanish National Health Institute, and Cancer Research UK, among others. Two authors reported receiving grants or a board of directors’ honoraria from various sources.

Source: Tabrizian P et al. Ten-year outcomes of liver transplant and downstaging for hepatocellular carcinoma. JAMA Surg. 2022 (Jul 20). Doi: 10.1001/jamasurg.2022.2800

Key clinical point: The excellent 10-year post-liver transplant (LT) outcomes in patients with hepatocellular carcinoma (HCC) successfully downstaged to within Milan criteria (MC) substantiate the validity of the national downstaging policy.

Major finding: At 10 years after LT, patients with HCC always within MC, those with HCC downstaged before LT, and those with HCC unsuccessfully downstaged/progressed beyond MC during LT had survival rates of 61.5%, 52.1%, and 43.3%, respectively, and recurrence rates of 13.3%, 20.6%, and 41.4%, respectively.

Study details: This retrospective cohort study analyzed the prospective data of 2645 adult patients with HCC who underwent LT at 5 US academic centers.

Disclosures: This study was sponsored by the US Department of Defense, Samuel Waxman Cancer Research Foundation, Spanish National Health Institute, and Cancer Research UK, among others. Two authors reported receiving grants or a board of directors’ honoraria from various sources.

Source: Tabrizian P et al. Ten-year outcomes of liver transplant and downstaging for hepatocellular carcinoma. JAMA Surg. 2022 (Jul 20). Doi: 10.1001/jamasurg.2022.2800

Key clinical point: The excellent 10-year post-liver transplant (LT) outcomes in patients with hepatocellular carcinoma (HCC) successfully downstaged to within Milan criteria (MC) substantiate the validity of the national downstaging policy.

Major finding: At 10 years after LT, patients with HCC always within MC, those with HCC downstaged before LT, and those with HCC unsuccessfully downstaged/progressed beyond MC during LT had survival rates of 61.5%, 52.1%, and 43.3%, respectively, and recurrence rates of 13.3%, 20.6%, and 41.4%, respectively.

Study details: This retrospective cohort study analyzed the prospective data of 2645 adult patients with HCC who underwent LT at 5 US academic centers.

Disclosures: This study was sponsored by the US Department of Defense, Samuel Waxman Cancer Research Foundation, Spanish National Health Institute, and Cancer Research UK, among others. Two authors reported receiving grants or a board of directors’ honoraria from various sources.

Source: Tabrizian P et al. Ten-year outcomes of liver transplant and downstaging for hepatocellular carcinoma. JAMA Surg. 2022 (Jul 20). Doi: 10.1001/jamasurg.2022.2800

Key clinical point: Lenvatinib combined with transarterial chemoembolization (LEN-TACE) is more effective than LEN alone as the first-line therapy for advanced hepatocellular carcinoma (HCC).

Major finding: After a 17.0-month median follow-up, the LEN-TACE vs LEN group had a significantly longer median overall survival (17.8 vs 11.5 months; hazard ratio [HR] 0.45; P < .001) and progression-free survival (10.6 vs 6.4 months; HR 0.43; P < .001) and higher objective response rate (54.1% vs 25.0%; P < .001).

Study details: Findings are from a multicenter, phase 3 trial, LAUNCH, that included 338 adult patients with treatment-naive primary or initial recurrent advanced HCC after surgery who were randomly assigned to receive LEN-TACE (n = 170) or LEN monotherapy (n = 168).

Disclosures: This study was supported by Science and Technology Innovation 2030 Major Projects, China, among others. One author declared serving as a consultant/advisor for and receiving honoraria and research funding from GenomiCare.

Source: Peng Z et al. Lenvatinib combined with transarterial chemoembolization as first-line treatment for advanced hepatocellular carcinoma: A phase III, randomized clinical trial (LAUNCH). J Clin Oncol. 2022 (Aug 3). Doi: 10.1200/JCO.22.00392

Key clinical point: Lenvatinib combined with transarterial chemoembolization (LEN-TACE) is more effective than LEN alone as the first-line therapy for advanced hepatocellular carcinoma (HCC).

Major finding: After a 17.0-month median follow-up, the LEN-TACE vs LEN group had a significantly longer median overall survival (17.8 vs 11.5 months; hazard ratio [HR] 0.45; P < .001) and progression-free survival (10.6 vs 6.4 months; HR 0.43; P < .001) and higher objective response rate (54.1% vs 25.0%; P < .001).

Study details: Findings are from a multicenter, phase 3 trial, LAUNCH, that included 338 adult patients with treatment-naive primary or initial recurrent advanced HCC after surgery who were randomly assigned to receive LEN-TACE (n = 170) or LEN monotherapy (n = 168).

Disclosures: This study was supported by Science and Technology Innovation 2030 Major Projects, China, among others. One author declared serving as a consultant/advisor for and receiving honoraria and research funding from GenomiCare.

Source: Peng Z et al. Lenvatinib combined with transarterial chemoembolization as first-line treatment for advanced hepatocellular carcinoma: A phase III, randomized clinical trial (LAUNCH). J Clin Oncol. 2022 (Aug 3). Doi: 10.1200/JCO.22.00392

Key clinical point: Lenvatinib combined with transarterial chemoembolization (LEN-TACE) is more effective than LEN alone as the first-line therapy for advanced hepatocellular carcinoma (HCC).

Major finding: After a 17.0-month median follow-up, the LEN-TACE vs LEN group had a significantly longer median overall survival (17.8 vs 11.5 months; hazard ratio [HR] 0.45; P < .001) and progression-free survival (10.6 vs 6.4 months; HR 0.43; P < .001) and higher objective response rate (54.1% vs 25.0%; P < .001).

Study details: Findings are from a multicenter, phase 3 trial, LAUNCH, that included 338 adult patients with treatment-naive primary or initial recurrent advanced HCC after surgery who were randomly assigned to receive LEN-TACE (n = 170) or LEN monotherapy (n = 168).

Disclosures: This study was supported by Science and Technology Innovation 2030 Major Projects, China, among others. One author declared serving as a consultant/advisor for and receiving honoraria and research funding from GenomiCare.

Source: Peng Z et al. Lenvatinib combined with transarterial chemoembolization as first-line treatment for advanced hepatocellular carcinoma: A phase III, randomized clinical trial (LAUNCH). J Clin Oncol. 2022 (Aug 3). Doi: 10.1200/JCO.22.00392

Symptoms of six common cardiovascular diseases (CVD) – acute coronary syndromes, heart failure, valvular disorders, stroke, rhythm disorders, and peripheral vascular disease – often overlap and may vary over time and by sex, the American Heart Association noted in a new scientific statement.

“Symptoms of these cardiovascular diseases can profoundly affect quality of life, and a clear understanding of them is critical for effective diagnosis and treatment decisions,” Corrine Y. Jurgens, PhD, chair of the writing committee, said in a news release.

Copyright pixelheadphoto/Thinkstock

This scientific statement is a “compendium detailing the symptoms associated with CVD, similarities or differences in symptoms among the conditions, and sex differences in symptom presentation and reporting,” said Dr. Jurgens, associate professor at Connell School of Nursing, Boston College.

The new statement was published online in Circulation.

The writing group noted that measuring CVD symptoms can be challenging because of their subjective nature. Symptoms may go unrecognized or unreported if people don’t think they are important or are related to an existing health condition.

“Some people may not consider symptoms like fatigue, sleep disturbance, weight gain, and depression as important or related to cardiovascular disease. However, research indicates that subtle symptoms such as these may predict acute events and the need for hospitalization,” Dr. Jurgens said.
 

ACS – chest pain and associated symptoms

The writing group noted that chest pain is the most frequently reported symptom of ACS and has often been described as substernal pressure or discomfort and may radiate to the jaw, shoulder, arm, or upper back.

The most common co-occurring symptoms are dyspnea, diaphoresis, unusual fatigue, nausea, and lightheadedness. Women are more likely than men to report additional symptoms outside of chest pain.

As a result, they have often been labeled “atypical.” However, a recent AHA advisory notes that this label may have been caused by the lack of women included in the clinical trials from which the symptom lists were derived.

The writing group said there is a need to “harmonize” ACS symptom measurement in research. The current lack of harmonization of ACS symptom measurement in research hampers growth in cumulative evidence.

“Therefore, little can be done to synthesize salient findings about symptoms across ischemic heart disease/ACS studies and to incorporate evidence-based information about symptoms into treatment guidelines and patient education materials,” they cautioned. 
 

Heart failure

Turning to heart failure (HF), the writing group noted that dyspnea is the classic symptom and a common reason adults seek medical care.

However, early, more subtle symptoms should be recognized. These include gastrointestinal symptoms such as upset stomach, nausea, vomiting, and loss of appetite; fatigue; exercise intolerance; insomnia; pain (chest and otherwise); mood disturbances (primarily depression and anxiety); and cognitive dysfunction (brain fog, memory problems).

Women with HF report a wider variety of symptoms, are more likely to have depression and anxiety, and report a lower quality of life, compared with men with HF.

“It is important to account for dyspnea heterogeneity in both clinical practice and research by using nuanced measures and probing questions to capture this common and multifaceted symptom,” the writing group said.

“Monitoring symptoms on a spectrum, versus present or not present, with reliable and valid measures may enhance clinical care by identifying more quickly those who may be at risk for poor outcomes, such as lower quality of life, hospitalization, or death,” Dr. Jurgens added.

“Ultimately, we have work to do in terms of determining who needs more frequent monitoring or intervention to avert poor HF outcomes,” she said.
 

Valvular heart disease

Valvular heart disease is a frequent cause of HF, with symptoms generally indistinguishable from other HF causes. Rheumatic heart disease is still prevalent in low- and middle-income countries but has largely disappeared in high-income countries, with population aging and cardiomyopathies now key drivers of valve disease.

In the absence of acute severe valve dysfunction, patients generally have a prolonged asymptomatic period, followed by a period of progressive symptoms, resulting from the valve lesion itself or secondary myocardial remodeling and dysfunction, the writing group said. 

Symptoms of aortic valve disease often differ between men and women. Aortic stenosis is typically silent for years. As stenosis progresses, women report dyspnea and exercise intolerance more often than men. Women are also more likely to be physically frail and to have a higher New York Heart Association class (III/IV) than men. Men are more likely to have chest pain.

“Given the importance of symptom assessment, more work is needed to determine the incremental value of quantitative symptom measurement as an aid to clinical management,” the writing group said.
 

Stroke

For clinicians, classic stroke symptoms (face drooping, arm weakness, speech difficulty), in addition to nonclassic symptoms, such as partial sensory deficit, dysarthria, vertigo, and diplopia, should be considered for activating a stroke response team, the group says.

A systematic review and meta-analysis revealed that women with stroke were more likely to present with nonfocal symptoms (for example, headache, altered mentality, and coma/stupor) than men, they noted.

To enhance public education about stroke symptoms and to facilitate the diagnosis and treatment of stroke, they say research is needed to better understand the presentation of stroke symptoms by other select demographic characteristics including race and ethnicity, age, and stroke subtype.

Poststroke screening should include assessment for anxiety, depression, fatigue, and pain, the writing group said.
 

Rhythm disorders

Turning to rhythm disorders, the writing group wrote that cardiac arrhythmias, including atrial fibrillation (AFib), atrial flutter, supraventricular tachycardia, bradyarrhythmia, and ventricular tachycardia, present with common symptoms.

Palpitations are a characteristic symptom of many cardiac arrhythmias. The most common cardiac arrhythmia, AFib, may present with palpitations or less specific symptoms (fatigue, dyspnea, dizziness) that occur with a broad range of rhythm disorders. Chest pain, dizziness, presyncope/syncope, and anxiety occur less frequently in AFib, the group said.

Palpitations are considered the typical symptom presentation for AFib, yet patients with new-onset AFib often present with nonspecific symptoms or no symptoms, they pointed out.

Women and younger individuals with AFib typically present with palpitations, whereas men are more commonly asymptomatic. Older age also increases the likelihood of a nonclassic or asymptomatic presentation of AFib.

Despite non-Hispanic Black individuals being at lower risk for development of AFib, research suggests that Black patients are burdened more with palpitations, dyspnea on exertion, exercise intolerance, dizziness, dyspnea at rest, and chest discomfort, compared with White or Hispanic patients.

Peripheral vascular disease

Classic claudication occurs in roughly one-third of patients with peripheral arterial disease (PAD) and is defined as calf pain that occurs in one or both legs with exertion (walking), does not begin at rest, and resolves within 10 minutes of standing still or rest.

However, non–calf exercise pain is reported more frequently than classic claudication symptoms. Women with PAD are more likely to have nonclassic symptoms or an absence of symptoms.

Assessing symptoms at rest, during exercise, and during recovery can assist with classifying symptoms as ischemic or not, the writing group said.

PAD with symptoms is associated with an increased risk for myocardial infarction and stroke, with men at higher risk than women.

Similar to PAD, peripheral venous disease (PVD) can be symptomatic or asymptomatic. Clinical classification of PVD includes symptoms such as leg pain, aching, fatigue, heaviness, cramping, tightness, restless legs syndrome, and skin irritation.

“Measuring vascular symptoms includes assessing quality of life and activity limitations, as well as the psychological impact of the disease. However, existing measures are often based on the clinician’s appraisal rather than the individual’s self-reported symptoms and severity of symptoms,” Dr. Jurgens commented.
 

Watch for depression

Finally, the writing group highlighted the importance of depression in cardiac patients, which occurs at about twice the rate, compared with people without any medical condition (10% vs. 5%).

In a prior statement, the AHA said depression should be considered a risk factor for worse outcomes in patients with ACS or CVD diagnosis.

The new statement highlights that people with persistent chest pain, people with HF, as well as stroke survivors and people with PAD commonly have depression and/or anxiety. In addition, cognitive changes after a stroke may affect how and whether symptoms are experienced or noticed.

While symptom relief is an important part of managing CVD, it’s also important to recognize that “factors such as depression and cognitive function may affect symptom detection and reporting,” Dr. Jurgens said.

“Monitoring and measuring symptoms with tools that appropriately account for depression and cognitive function may help to improve patient care by identifying more quickly people who may be at higher risk,” she added.

The scientific statement was prepared by the volunteer writing group on behalf of the AHA Council on Cardiovascular and Stroke Nursing; the Council on Hypertension; and the Stroke Council. The research had no commercial funding. The authors reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Symptoms of six common cardiovascular diseases (CVD) – acute coronary syndromes, heart failure, valvular disorders, stroke, rhythm disorders, and peripheral vascular disease – often overlap and may vary over time and by sex, the American Heart Association noted in a new scientific statement.

“Symptoms of these cardiovascular diseases can profoundly affect quality of life, and a clear understanding of them is critical for effective diagnosis and treatment decisions,” Corrine Y. Jurgens, PhD, chair of the writing committee, said in a news release.

Copyright pixelheadphoto/Thinkstock

This scientific statement is a “compendium detailing the symptoms associated with CVD, similarities or differences in symptoms among the conditions, and sex differences in symptom presentation and reporting,” said Dr. Jurgens, associate professor at Connell School of Nursing, Boston College.

The new statement was published online in Circulation.

The writing group noted that measuring CVD symptoms can be challenging because of their subjective nature. Symptoms may go unrecognized or unreported if people don’t think they are important or are related to an existing health condition.

“Some people may not consider symptoms like fatigue, sleep disturbance, weight gain, and depression as important or related to cardiovascular disease. However, research indicates that subtle symptoms such as these may predict acute events and the need for hospitalization,” Dr. Jurgens said.
 

ACS – chest pain and associated symptoms

The writing group noted that chest pain is the most frequently reported symptom of ACS and has often been described as substernal pressure or discomfort and may radiate to the jaw, shoulder, arm, or upper back.

The most common co-occurring symptoms are dyspnea, diaphoresis, unusual fatigue, nausea, and lightheadedness. Women are more likely than men to report additional symptoms outside of chest pain.

As a result, they have often been labeled “atypical.” However, a recent AHA advisory notes that this label may have been caused by the lack of women included in the clinical trials from which the symptom lists were derived.

The writing group said there is a need to “harmonize” ACS symptom measurement in research. The current lack of harmonization of ACS symptom measurement in research hampers growth in cumulative evidence.

“Therefore, little can be done to synthesize salient findings about symptoms across ischemic heart disease/ACS studies and to incorporate evidence-based information about symptoms into treatment guidelines and patient education materials,” they cautioned. 
 

Heart failure

Turning to heart failure (HF), the writing group noted that dyspnea is the classic symptom and a common reason adults seek medical care.

However, early, more subtle symptoms should be recognized. These include gastrointestinal symptoms such as upset stomach, nausea, vomiting, and loss of appetite; fatigue; exercise intolerance; insomnia; pain (chest and otherwise); mood disturbances (primarily depression and anxiety); and cognitive dysfunction (brain fog, memory problems).

Women with HF report a wider variety of symptoms, are more likely to have depression and anxiety, and report a lower quality of life, compared with men with HF.

“It is important to account for dyspnea heterogeneity in both clinical practice and research by using nuanced measures and probing questions to capture this common and multifaceted symptom,” the writing group said.

“Monitoring symptoms on a spectrum, versus present or not present, with reliable and valid measures may enhance clinical care by identifying more quickly those who may be at risk for poor outcomes, such as lower quality of life, hospitalization, or death,” Dr. Jurgens added.

“Ultimately, we have work to do in terms of determining who needs more frequent monitoring or intervention to avert poor HF outcomes,” she said.
 

Valvular heart disease

Valvular heart disease is a frequent cause of HF, with symptoms generally indistinguishable from other HF causes. Rheumatic heart disease is still prevalent in low- and middle-income countries but has largely disappeared in high-income countries, with population aging and cardiomyopathies now key drivers of valve disease.

In the absence of acute severe valve dysfunction, patients generally have a prolonged asymptomatic period, followed by a period of progressive symptoms, resulting from the valve lesion itself or secondary myocardial remodeling and dysfunction, the writing group said. 

Symptoms of aortic valve disease often differ between men and women. Aortic stenosis is typically silent for years. As stenosis progresses, women report dyspnea and exercise intolerance more often than men. Women are also more likely to be physically frail and to have a higher New York Heart Association class (III/IV) than men. Men are more likely to have chest pain.

“Given the importance of symptom assessment, more work is needed to determine the incremental value of quantitative symptom measurement as an aid to clinical management,” the writing group said.
 

Stroke

For clinicians, classic stroke symptoms (face drooping, arm weakness, speech difficulty), in addition to nonclassic symptoms, such as partial sensory deficit, dysarthria, vertigo, and diplopia, should be considered for activating a stroke response team, the group says.

A systematic review and meta-analysis revealed that women with stroke were more likely to present with nonfocal symptoms (for example, headache, altered mentality, and coma/stupor) than men, they noted.

To enhance public education about stroke symptoms and to facilitate the diagnosis and treatment of stroke, they say research is needed to better understand the presentation of stroke symptoms by other select demographic characteristics including race and ethnicity, age, and stroke subtype.

Poststroke screening should include assessment for anxiety, depression, fatigue, and pain, the writing group said.
 

Rhythm disorders

Turning to rhythm disorders, the writing group wrote that cardiac arrhythmias, including atrial fibrillation (AFib), atrial flutter, supraventricular tachycardia, bradyarrhythmia, and ventricular tachycardia, present with common symptoms.

Palpitations are a characteristic symptom of many cardiac arrhythmias. The most common cardiac arrhythmia, AFib, may present with palpitations or less specific symptoms (fatigue, dyspnea, dizziness) that occur with a broad range of rhythm disorders. Chest pain, dizziness, presyncope/syncope, and anxiety occur less frequently in AFib, the group said.

Palpitations are considered the typical symptom presentation for AFib, yet patients with new-onset AFib often present with nonspecific symptoms or no symptoms, they pointed out.

Women and younger individuals with AFib typically present with palpitations, whereas men are more commonly asymptomatic. Older age also increases the likelihood of a nonclassic or asymptomatic presentation of AFib.

Despite non-Hispanic Black individuals being at lower risk for development of AFib, research suggests that Black patients are burdened more with palpitations, dyspnea on exertion, exercise intolerance, dizziness, dyspnea at rest, and chest discomfort, compared with White or Hispanic patients.

Peripheral vascular disease

Classic claudication occurs in roughly one-third of patients with peripheral arterial disease (PAD) and is defined as calf pain that occurs in one or both legs with exertion (walking), does not begin at rest, and resolves within 10 minutes of standing still or rest.

However, non–calf exercise pain is reported more frequently than classic claudication symptoms. Women with PAD are more likely to have nonclassic symptoms or an absence of symptoms.

Assessing symptoms at rest, during exercise, and during recovery can assist with classifying symptoms as ischemic or not, the writing group said.

PAD with symptoms is associated with an increased risk for myocardial infarction and stroke, with men at higher risk than women.

Similar to PAD, peripheral venous disease (PVD) can be symptomatic or asymptomatic. Clinical classification of PVD includes symptoms such as leg pain, aching, fatigue, heaviness, cramping, tightness, restless legs syndrome, and skin irritation.

“Measuring vascular symptoms includes assessing quality of life and activity limitations, as well as the psychological impact of the disease. However, existing measures are often based on the clinician’s appraisal rather than the individual’s self-reported symptoms and severity of symptoms,” Dr. Jurgens commented.
 

Watch for depression

Finally, the writing group highlighted the importance of depression in cardiac patients, which occurs at about twice the rate, compared with people without any medical condition (10% vs. 5%).

In a prior statement, the AHA said depression should be considered a risk factor for worse outcomes in patients with ACS or CVD diagnosis.

The new statement highlights that people with persistent chest pain, people with HF, as well as stroke survivors and people with PAD commonly have depression and/or anxiety. In addition, cognitive changes after a stroke may affect how and whether symptoms are experienced or noticed.

While symptom relief is an important part of managing CVD, it’s also important to recognize that “factors such as depression and cognitive function may affect symptom detection and reporting,” Dr. Jurgens said.

“Monitoring and measuring symptoms with tools that appropriately account for depression and cognitive function may help to improve patient care by identifying more quickly people who may be at higher risk,” she added.

The scientific statement was prepared by the volunteer writing group on behalf of the AHA Council on Cardiovascular and Stroke Nursing; the Council on Hypertension; and the Stroke Council. The research had no commercial funding. The authors reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Symptoms of six common cardiovascular diseases (CVD) – acute coronary syndromes, heart failure, valvular disorders, stroke, rhythm disorders, and peripheral vascular disease – often overlap and may vary over time and by sex, the American Heart Association noted in a new scientific statement.

“Symptoms of these cardiovascular diseases can profoundly affect quality of life, and a clear understanding of them is critical for effective diagnosis and treatment decisions,” Corrine Y. Jurgens, PhD, chair of the writing committee, said in a news release.

Copyright pixelheadphoto/Thinkstock

This scientific statement is a “compendium detailing the symptoms associated with CVD, similarities or differences in symptoms among the conditions, and sex differences in symptom presentation and reporting,” said Dr. Jurgens, associate professor at Connell School of Nursing, Boston College.

The new statement was published online in Circulation.

The writing group noted that measuring CVD symptoms can be challenging because of their subjective nature. Symptoms may go unrecognized or unreported if people don’t think they are important or are related to an existing health condition.

“Some people may not consider symptoms like fatigue, sleep disturbance, weight gain, and depression as important or related to cardiovascular disease. However, research indicates that subtle symptoms such as these may predict acute events and the need for hospitalization,” Dr. Jurgens said.
 

ACS – chest pain and associated symptoms

The writing group noted that chest pain is the most frequently reported symptom of ACS and has often been described as substernal pressure or discomfort and may radiate to the jaw, shoulder, arm, or upper back.

The most common co-occurring symptoms are dyspnea, diaphoresis, unusual fatigue, nausea, and lightheadedness. Women are more likely than men to report additional symptoms outside of chest pain.

As a result, they have often been labeled “atypical.” However, a recent AHA advisory notes that this label may have been caused by the lack of women included in the clinical trials from which the symptom lists were derived.

The writing group said there is a need to “harmonize” ACS symptom measurement in research. The current lack of harmonization of ACS symptom measurement in research hampers growth in cumulative evidence.

“Therefore, little can be done to synthesize salient findings about symptoms across ischemic heart disease/ACS studies and to incorporate evidence-based information about symptoms into treatment guidelines and patient education materials,” they cautioned. 
 

Heart failure

Turning to heart failure (HF), the writing group noted that dyspnea is the classic symptom and a common reason adults seek medical care.

However, early, more subtle symptoms should be recognized. These include gastrointestinal symptoms such as upset stomach, nausea, vomiting, and loss of appetite; fatigue; exercise intolerance; insomnia; pain (chest and otherwise); mood disturbances (primarily depression and anxiety); and cognitive dysfunction (brain fog, memory problems).

Women with HF report a wider variety of symptoms, are more likely to have depression and anxiety, and report a lower quality of life, compared with men with HF.

“It is important to account for dyspnea heterogeneity in both clinical practice and research by using nuanced measures and probing questions to capture this common and multifaceted symptom,” the writing group said.

“Monitoring symptoms on a spectrum, versus present or not present, with reliable and valid measures may enhance clinical care by identifying more quickly those who may be at risk for poor outcomes, such as lower quality of life, hospitalization, or death,” Dr. Jurgens added.

“Ultimately, we have work to do in terms of determining who needs more frequent monitoring or intervention to avert poor HF outcomes,” she said.
 

Valvular heart disease

Valvular heart disease is a frequent cause of HF, with symptoms generally indistinguishable from other HF causes. Rheumatic heart disease is still prevalent in low- and middle-income countries but has largely disappeared in high-income countries, with population aging and cardiomyopathies now key drivers of valve disease.

In the absence of acute severe valve dysfunction, patients generally have a prolonged asymptomatic period, followed by a period of progressive symptoms, resulting from the valve lesion itself or secondary myocardial remodeling and dysfunction, the writing group said. 

Symptoms of aortic valve disease often differ between men and women. Aortic stenosis is typically silent for years. As stenosis progresses, women report dyspnea and exercise intolerance more often than men. Women are also more likely to be physically frail and to have a higher New York Heart Association class (III/IV) than men. Men are more likely to have chest pain.

“Given the importance of symptom assessment, more work is needed to determine the incremental value of quantitative symptom measurement as an aid to clinical management,” the writing group said.
 

Stroke

For clinicians, classic stroke symptoms (face drooping, arm weakness, speech difficulty), in addition to nonclassic symptoms, such as partial sensory deficit, dysarthria, vertigo, and diplopia, should be considered for activating a stroke response team, the group says.

A systematic review and meta-analysis revealed that women with stroke were more likely to present with nonfocal symptoms (for example, headache, altered mentality, and coma/stupor) than men, they noted.

To enhance public education about stroke symptoms and to facilitate the diagnosis and treatment of stroke, they say research is needed to better understand the presentation of stroke symptoms by other select demographic characteristics including race and ethnicity, age, and stroke subtype.

Poststroke screening should include assessment for anxiety, depression, fatigue, and pain, the writing group said.
 

Rhythm disorders

Turning to rhythm disorders, the writing group wrote that cardiac arrhythmias, including atrial fibrillation (AFib), atrial flutter, supraventricular tachycardia, bradyarrhythmia, and ventricular tachycardia, present with common symptoms.

Palpitations are a characteristic symptom of many cardiac arrhythmias. The most common cardiac arrhythmia, AFib, may present with palpitations or less specific symptoms (fatigue, dyspnea, dizziness) that occur with a broad range of rhythm disorders. Chest pain, dizziness, presyncope/syncope, and anxiety occur less frequently in AFib, the group said.

Palpitations are considered the typical symptom presentation for AFib, yet patients with new-onset AFib often present with nonspecific symptoms or no symptoms, they pointed out.

Women and younger individuals with AFib typically present with palpitations, whereas men are more commonly asymptomatic. Older age also increases the likelihood of a nonclassic or asymptomatic presentation of AFib.

Despite non-Hispanic Black individuals being at lower risk for development of AFib, research suggests that Black patients are burdened more with palpitations, dyspnea on exertion, exercise intolerance, dizziness, dyspnea at rest, and chest discomfort, compared with White or Hispanic patients.

Peripheral vascular disease

Classic claudication occurs in roughly one-third of patients with peripheral arterial disease (PAD) and is defined as calf pain that occurs in one or both legs with exertion (walking), does not begin at rest, and resolves within 10 minutes of standing still or rest.

However, non–calf exercise pain is reported more frequently than classic claudication symptoms. Women with PAD are more likely to have nonclassic symptoms or an absence of symptoms.

Assessing symptoms at rest, during exercise, and during recovery can assist with classifying symptoms as ischemic or not, the writing group said.

PAD with symptoms is associated with an increased risk for myocardial infarction and stroke, with men at higher risk than women.

Similar to PAD, peripheral venous disease (PVD) can be symptomatic or asymptomatic. Clinical classification of PVD includes symptoms such as leg pain, aching, fatigue, heaviness, cramping, tightness, restless legs syndrome, and skin irritation.

“Measuring vascular symptoms includes assessing quality of life and activity limitations, as well as the psychological impact of the disease. However, existing measures are often based on the clinician’s appraisal rather than the individual’s self-reported symptoms and severity of symptoms,” Dr. Jurgens commented.
 

Watch for depression

Finally, the writing group highlighted the importance of depression in cardiac patients, which occurs at about twice the rate, compared with people without any medical condition (10% vs. 5%).

In a prior statement, the AHA said depression should be considered a risk factor for worse outcomes in patients with ACS or CVD diagnosis.

The new statement highlights that people with persistent chest pain, people with HF, as well as stroke survivors and people with PAD commonly have depression and/or anxiety. In addition, cognitive changes after a stroke may affect how and whether symptoms are experienced or noticed.

While symptom relief is an important part of managing CVD, it’s also important to recognize that “factors such as depression and cognitive function may affect symptom detection and reporting,” Dr. Jurgens said.

“Monitoring and measuring symptoms with tools that appropriately account for depression and cognitive function may help to improve patient care by identifying more quickly people who may be at higher risk,” she added.

The scientific statement was prepared by the volunteer writing group on behalf of the AHA Council on Cardiovascular and Stroke Nursing; the Council on Hypertension; and the Stroke Council. The research had no commercial funding. The authors reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Key clinical point: Gastrointestinal (GI)‐specific anxiety was the strongest contributor to reduced quality of life (QoL) in patients with irritable bowel syndrome (IBS).

Major finding: The factors independently associated with reduced IBS-QoL were a higher stool frequency (β −0.109; P  =  .022), GI (β −0.160; P  =  .009) and overall somatic symptom severity (β −0.171; P  =  .005), and psychological distress (β −0.194; P  =  .011), with GI‐specific anxiety (β −0.330; P < .001) being the strongest contributor.

Study details: This study included 314 patients with IBS from 2 prospective cohorts who completed the IBS-QoL and self‐report symptom questionnaires and tests for the measurement of oroanal transit time and rectal sensitivity.

Disclosures: This study was funded by Swedish state under the agreement between the Swedish government and the county councils (the ALF‐agreement) and others. Some authors declared serving as consultants/advisory board members or on speakers’ bureau for various sources.

Source: Melchior C et al. Irritable bowel syndrome: Factors of importance for disease-specific quality of life. United European Gastroenterol J. 2022 (Jul 13). Doi: 10.1002/ueg2.12277

Key clinical point: Gastrointestinal (GI)‐specific anxiety was the strongest contributor to reduced quality of life (QoL) in patients with irritable bowel syndrome (IBS).

Major finding: The factors independently associated with reduced IBS-QoL were a higher stool frequency (β −0.109; P  =  .022), GI (β −0.160; P  =  .009) and overall somatic symptom severity (β −0.171; P  =  .005), and psychological distress (β −0.194; P  =  .011), with GI‐specific anxiety (β −0.330; P < .001) being the strongest contributor.

Study details: This study included 314 patients with IBS from 2 prospective cohorts who completed the IBS-QoL and self‐report symptom questionnaires and tests for the measurement of oroanal transit time and rectal sensitivity.

Disclosures: This study was funded by Swedish state under the agreement between the Swedish government and the county councils (the ALF‐agreement) and others. Some authors declared serving as consultants/advisory board members or on speakers’ bureau for various sources.

Source: Melchior C et al. Irritable bowel syndrome: Factors of importance for disease-specific quality of life. United European Gastroenterol J. 2022 (Jul 13). Doi: 10.1002/ueg2.12277

Key clinical point: Gastrointestinal (GI)‐specific anxiety was the strongest contributor to reduced quality of life (QoL) in patients with irritable bowel syndrome (IBS).

Major finding: The factors independently associated with reduced IBS-QoL were a higher stool frequency (β −0.109; P  =  .022), GI (β −0.160; P  =  .009) and overall somatic symptom severity (β −0.171; P  =  .005), and psychological distress (β −0.194; P  =  .011), with GI‐specific anxiety (β −0.330; P < .001) being the strongest contributor.

Study details: This study included 314 patients with IBS from 2 prospective cohorts who completed the IBS-QoL and self‐report symptom questionnaires and tests for the measurement of oroanal transit time and rectal sensitivity.

Disclosures: This study was funded by Swedish state under the agreement between the Swedish government and the county councils (the ALF‐agreement) and others. Some authors declared serving as consultants/advisory board members or on speakers’ bureau for various sources.

Source: Melchior C et al. Irritable bowel syndrome: Factors of importance for disease-specific quality of life. United European Gastroenterol J. 2022 (Jul 13). Doi: 10.1002/ueg2.12277

Key clinical point: The colonic microbial environment changes with exacerbation of symptoms in patients with irritable bowel syndrome with diarrhea (IBS-D).

Major finding: The fecal alpha-diversity was significantly different between IBS without vs with symptom exacerbation (P < .01). The transcription levels of genes involved in enzymatic glutamine to tryptophan synthesis, putrescine to GABA synthesis, inositol degradation, menaquinone synthesis, crotonyl-CoA to butyrate synthesis, and propionate synthesis were significantly lower in IBS with vs without symptom exacerbation (P < .05).

Study details: Findings are from an analysis of 43 male patients with IBS-D and 40 healthy male controls.

Disclosures: This study was supported by grants from JSPS KAKENHI, Japan, the Japanese Food Science Institute Foundation, and others. The authors declared no conflicts of interest.

Source: Tanaka Y et al. Omics profiles of fecal and oral microbiota change in irritable bowel syndrome patients with diarrhea and symptom exacerbation. J Gastroenterol. 2022 (Jul 30).  Doi: 10.1007/s00535-022-01888-2

Key clinical point: The colonic microbial environment changes with exacerbation of symptoms in patients with irritable bowel syndrome with diarrhea (IBS-D).

Major finding: The fecal alpha-diversity was significantly different between IBS without vs with symptom exacerbation (P < .01). The transcription levels of genes involved in enzymatic glutamine to tryptophan synthesis, putrescine to GABA synthesis, inositol degradation, menaquinone synthesis, crotonyl-CoA to butyrate synthesis, and propionate synthesis were significantly lower in IBS with vs without symptom exacerbation (P < .05).

Study details: Findings are from an analysis of 43 male patients with IBS-D and 40 healthy male controls.

Disclosures: This study was supported by grants from JSPS KAKENHI, Japan, the Japanese Food Science Institute Foundation, and others. The authors declared no conflicts of interest.

Source: Tanaka Y et al. Omics profiles of fecal and oral microbiota change in irritable bowel syndrome patients with diarrhea and symptom exacerbation. J Gastroenterol. 2022 (Jul 30).  Doi: 10.1007/s00535-022-01888-2

Key clinical point: The colonic microbial environment changes with exacerbation of symptoms in patients with irritable bowel syndrome with diarrhea (IBS-D).

Major finding: The fecal alpha-diversity was significantly different between IBS without vs with symptom exacerbation (P < .01). The transcription levels of genes involved in enzymatic glutamine to tryptophan synthesis, putrescine to GABA synthesis, inositol degradation, menaquinone synthesis, crotonyl-CoA to butyrate synthesis, and propionate synthesis were significantly lower in IBS with vs without symptom exacerbation (P < .05).

Study details: Findings are from an analysis of 43 male patients with IBS-D and 40 healthy male controls.

Disclosures: This study was supported by grants from JSPS KAKENHI, Japan, the Japanese Food Science Institute Foundation, and others. The authors declared no conflicts of interest.

Source: Tanaka Y et al. Omics profiles of fecal and oral microbiota change in irritable bowel syndrome patients with diarrhea and symptom exacerbation. J Gastroenterol. 2022 (Jul 30).  Doi: 10.1007/s00535-022-01888-2

Key clinical point: A starch‐ and sucrose‐reduced diet (SSRD) led to a significant shift in the gut microbiota, which correlated with reduced gastrointestinal (GI) symptoms, in patients with irritable bowel syndrome (IBS).

Major finding: A significant shift in beta-diversity was observed in the intervention group (P < .001), along with a significant increase in the abundance of Proteobacteria (P  =  .0036), Lentisphaerae (P  =  .0038), and Cyanobacteria (P  =  .038) and a decrease in Bacteroidetes (P < .001). The abundance of Proteobacteria correlated positively (P  =  .0016) and Bacteroidetes negatively (P  =  .0017) with reduced total GI symptoms.

Study details: This study included 105 patients with IBS who were randomly assigned to receive a 4‐week SSRD intervention (n = 80) or habitual (n = 25) diet.

Disclosures: This study was partially funded by the Skåne University Hospital Foundation, Dir Albert Påhlsson Foundation, and others. The authors declared no conflicts of interest.

Source: Nilholm C et al. A starch- and sucrose-reduced dietary intervention in irritable bowel syndrome patients produced a shift in gut microbiota composition along with changes in phylum, genus, and amplicon sequence variant abundances, without affecting the micro-RNA levels. United European Gastroenterol J. 2022;10(4):363-375 (Apr 28). Doi: 10.1002/ueg2.12227

Key clinical point: A starch‐ and sucrose‐reduced diet (SSRD) led to a significant shift in the gut microbiota, which correlated with reduced gastrointestinal (GI) symptoms, in patients with irritable bowel syndrome (IBS).

Major finding: A significant shift in beta-diversity was observed in the intervention group (P < .001), along with a significant increase in the abundance of Proteobacteria (P  =  .0036), Lentisphaerae (P  =  .0038), and Cyanobacteria (P  =  .038) and a decrease in Bacteroidetes (P < .001). The abundance of Proteobacteria correlated positively (P  =  .0016) and Bacteroidetes negatively (P  =  .0017) with reduced total GI symptoms.

Study details: This study included 105 patients with IBS who were randomly assigned to receive a 4‐week SSRD intervention (n = 80) or habitual (n = 25) diet.

Disclosures: This study was partially funded by the Skåne University Hospital Foundation, Dir Albert Påhlsson Foundation, and others. The authors declared no conflicts of interest.

Source: Nilholm C et al. A starch- and sucrose-reduced dietary intervention in irritable bowel syndrome patients produced a shift in gut microbiota composition along with changes in phylum, genus, and amplicon sequence variant abundances, without affecting the micro-RNA levels. United European Gastroenterol J. 2022;10(4):363-375 (Apr 28). Doi: 10.1002/ueg2.12227

Key clinical point: A starch‐ and sucrose‐reduced diet (SSRD) led to a significant shift in the gut microbiota, which correlated with reduced gastrointestinal (GI) symptoms, in patients with irritable bowel syndrome (IBS).

Major finding: A significant shift in beta-diversity was observed in the intervention group (P < .001), along with a significant increase in the abundance of Proteobacteria (P  =  .0036), Lentisphaerae (P  =  .0038), and Cyanobacteria (P  =  .038) and a decrease in Bacteroidetes (P < .001). The abundance of Proteobacteria correlated positively (P  =  .0016) and Bacteroidetes negatively (P  =  .0017) with reduced total GI symptoms.

Study details: This study included 105 patients with IBS who were randomly assigned to receive a 4‐week SSRD intervention (n = 80) or habitual (n = 25) diet.

Disclosures: This study was partially funded by the Skåne University Hospital Foundation, Dir Albert Påhlsson Foundation, and others. The authors declared no conflicts of interest.

Source: Nilholm C et al. A starch- and sucrose-reduced dietary intervention in irritable bowel syndrome patients produced a shift in gut microbiota composition along with changes in phylum, genus, and amplicon sequence variant abundances, without affecting the micro-RNA levels. United European Gastroenterol J. 2022;10(4):363-375 (Apr 28). Doi: 10.1002/ueg2.12227