|Year : 2017 | Volume
| Issue : 3 | Page : 139-142
Cardiology update 2017: The third quarter
Sridharan Umapathy, Sunil Kumar Verma
Department of Cardiology, AIIMS, New Delhi, India
|Date of Web Publication||1-Feb-2018|
Dr. Sunil Kumar Verma
Department of Cardiology, AIIMS, New Delhi
Source of Support: None, Conflict of Interest: None
In the third quarter of 2017, culprit only percutaneous coronary intervention (PCI) fares better in acute myocardial infarction with shock, guided de-escalation antiplatelet therapy seems noninferior, drug-eluting stent (DES) better in elderly patients undergoing PCI, DES with ultrathin struts proves superior, atrial fibrillation ablation improves left ventricular function in idiopathic cardiomyopathy, and edoxaban beneficial in preventing cancer-associated venous thromboembolism.
Keywords: 2017, review, update cardiology
|How to cite this article:|
Umapathy S, Verma SK. Cardiology update 2017: The third quarter. J Pract Cardiovasc Sci 2017;3:139-42
| Acute Coronary Syndrome|| |
In CULPRIT-SHOCK trial, 706 patients who had multivessel coronary artery disease (CAD) and acute myocardial infarction with cardiogenic shock were studied and it showed that 30-day risk of a composite of death or severe renal failure leading to renal replacement therapy was lower among those who initially underwent percutaneous coronary intervention (PCI) of the culprit lesion only than among those who underwent immediate multivessel PCI. STEMI and NSTEMI were equally distributed in both the groups.
EARLY-MYO trial showed that in patients with STEMI presenting ≤6 h after symptom onset and with an expected PCI-related delay (≥90 min), a pharmacoinvasive strategy with half-dose alteplase and timely PCI offers more complete epicardial and myocardial reperfusion when compared with primary PCI with no significant difference in major bleeding events.
TROPICAL-ACS trial showed that guided de-escalation of antiplatelet therapy (1-week prasugrel followed by 1-week clopidogrel and platelet function testing-guided maintenance therapy with clopidogrel or prasugrel from day 14 after hospital discharge) was noninferior to standard treatment with prasugrel at 1 year after PCI in terms of net clinical benefit.
| Coronary Artery Disease|| |
In SENIOR trial involving elderly patients aged ≥75 years who had PCI, it has been shown that usage of drug-eluting stent and a short duration of dual antiplatelet therapy (DAPT) (1 month for stable CAD and 6 months for unstable presentation) are better than bare metal stent and a similar duration of DAPT with respect to the occurrence of all-cause mortality, myocardial infarction, stroke, and ischemia-driven target lesion revascularization.
In ORBITA trial involving 200 patients with medically treated angina and severe coronary stenosis (≥70%), PCI did not increase exercise time by more than the effect of a placebo procedure. This small (though well-done) study enrolled very stable patients with angina lasting ~9 months, employed very intensive medical optimization, but had only 6 weeks of follow-up. These findings do not imply that patients should never undergo PCI for stable angina and do not apply to acute coronary syndromes, for which PCI has well-proven benefits.
In BIOFLOW V trial involving 4772 patients undergoing PCI of de novo native coronary lesions, ultrathin (strut thickness 60 μm), bioresorbable polymer sirolimus-eluting stent performed better over the durable polymer everolimus-eluting stent with respect to primary endpoint of target lesion failure.
In ABSORB III trial, 3-year adverse event rates were higher with bio vascular scaffolds than everolimus eluting stents, particularly target vessel MI (8.6% vs. 5.9%; P = 0.03) and device thrombosis (2.3% vs. 0.7%; P = 0.01).
In BIONICS trial, ridaforolimus eluting stent was found to be noninferior to zotarolimus-eluting stents for the primary end-point of target lesion failure at 12 months and had similar measures of late lumen loss.
A study evaluating the learning curve of transradial percutaneous coronary angioplasty with a team of operators trained with transfemoral coronary angioplasty demonstrated the ease of transradial technique with similar results. Although the study was done in acute STEMI setting (a more demanding scenario), the results can be applicable to elective cases also.
In DKCRUSH-V trial involving 482 patients, PCI of true distal left main bifurcation lesions using a planned double kissing (DK) crush 2-stent strategy resulted in a lower rate of target lesion failure at 1 year than provisional stenting strategy (5% vs. 10.7%). DK crush also resulted in lower rates of target vessel myocardial infarction I (2.9% vs. 0.4%; P = 0.03) and definite or probable stent thrombosis (3.3% vs. 0.4%; P = 0.02).
PRESERVE trial showed that in patients at high risk for renal complications who were undergoing angiography, there was no benefit of intravenous sodium bicarbonate over intravenous sodium chloride or of oral acetylcysteine over placebo for the prevention of death, need for dialysis, or persistent decline in kidney function at 90 days or for the prevention of contrast-associated acute kidney injury.
| Atherosclerosis|| |
A post hoc analysis from the WOSCOPS trial (West of Scotland Coronary Prevention Study) provides robust novel evidence for the short- and long-term benefits of lowering low-density lipoprotein cholesterol (LDL-C) for the primary prevention of cardiovascular disease among individuals with primary elevations of LDL-C ≥190 mg/dL. Among individuals with LDL-C ≥190 mg/dL, pravastatin reduced the risk of coronary heart disease by 27% (P = 0.033) and major adverse cardiovascular events by 25% (P = 0.037) during the initial trial phase and the risk of coronary heart disease death, cardiovascular death, and all-cause mortality by 28% (P = 0.020), 25% (P = 0.009), and 18% (P = 0.004), respectively, over a total of 20 years of follow-up.
| Heart Failure|| |
CAMERA-magnetic resonance imaging (MRI) trial showed that the restoration of sinus rhythm in patients with idiopathic cardiomyopathy and chronic atrial fibrillation (AF) by catheter ablation results in significant improvements in ventricular function, particularly in the absence of ventricular fibrosis on cardiac MRI.
| Hypertension|| |
Dietary approaches to stop hypertension (DASH) sodium trial showed that the combination of reduced sodium intake and the DASH diet-lowered systolic blood pressure (BP) throughout the range of pre and stage 1 hypertension, with progressively greater reductions at higher levels of baseline systolic BP. BP reductions in adults with the highest levels of systolic BP (≥150 mmHg) were striking and reinforce the importance of both sodium reduction and the DASH diet in this high-risk group.
| Electrophysiology|| |
In five patients suffering from refractory ventricular tachycardia, noninvasive electrophysiology-guided cardiac radioablation (stereotactic body radiation therapy) markedly reduced the burden of ventricular tachycardia over a period of 46 patient months with no reduction in mean left ventricular (LV) ejection fraction.
About 1500 patients with “legacy devices” (pacemakers or automated implantable cardioverter defibrillators that are considered to be non-MRI conditional) were subjected to about 2000 thoracic and nonthoracic MRIs of 1.5 tesla strength in a prospective, nonrandomized study  reported no clinically significant long-term adverse events. About 3%–4% of the patients developed changes in lead parameters (decrease in P-wave amplitude, increase in atrial capture threshold, increase in right ventricular capture threshold, and increase in LV capture threshold), but were not clinically significant and not required reprogramming or device revision.
| Atrial Fibrillation|| |
The long-term 5-year outcomes of the PREVAIL trial, combined with the 5-year outcomes of the PROTECT AF trial, demonstrate that left atrial appendage (LAA) closure with the Watchman device provides stroke prevention in nonvalvular AF patients to a similar degree as oral anticoagulation with warfarin. Furthermore, by virtue of its ability to minimize major bleeding, particularly hemorrhagic stroke, LAA device closure results in less disability, or death than warfarin.
Evaluation of records of about 1500 consecutive patients of HOCM for about 5 years duration to look for the effect of the development of AF on clinical course and outcome showed AF is not a major contributor to heart failure morbidity and/or a cause of sudden arrhythmic death. When treated, it is associated with low disease-related mortality, no different than patients without AF. AF is an uncommon primary cause of death in HCM virtually limited to embolic stroke, supporting a low threshold for initiating anticoagulation therapy.
| Structural Heart Disease|| |
In a study comparing mechanical and biologic prosthesis for mitral/aortic valve replacement over a period from 1996 to 2013, the long-term mortality benefit that was associated with a mechanical prosthesis, as compared with a biologic prosthesis, persisted until 70 years of age among patients undergoing mitral-valve replacement and until 55 years of age among those undergoing aortic-valve replacement. The incidence of reoperation was significantly higher with biologic prosthesis, and bleeding risk was higher with mechanical prosthesis.
In a single institutional analysis of ROSS procedure between January 1990 and December 2014, overall survival was excellent at 10 and 20 years being 94.1% and 83.6% respectively. However, long-term survival was lower in Ross patients compared with age- and sex-matched subjects.
In a retrospective study involving persons who had sudden cardiac arrest during participation in a sport, the incidence of sudden cardiac arrest was found to be 0.76 cases per 100,000 athlete years. Only three cases of sudden cardiac arrest that occurred during participation in competitive sports were determined to have been potentially identifiable if the athletes had undergone preparticipation screening.
In patients undergoing cardiac surgery who were at moderate-to-high risk for death (EUROSCORE I ≥ 6), a restrictive strategy regarding red-cell transfusion (transfuse only if Hb <7.5 g%) was noninferior to a liberal strategy (transfuse if Hb <9.5 g%) with respect to the composite outcome of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis, with less blood transfused.
| Venous Thromboembolism|| |
In cancer-associated venous thromboembolism (VTE), oral edoxaban was shown to be noninferior to subcutaneous dalteparin with respect to the composite outcome of recurrent VTE or major bleeding. The rate of recurrent VTE was lower; however, the rate of major bleeding was higher with edoxaban than with dalteparin.
ATTRACT trial showed that in patients with acute proximal deep-vein thrombosis, the addition of pharmacomechanical catheter-directed thrombolysis to anticoagulation did not result in a lower risk of the postthrombotic syndrome but did result in a higher risk of major bleeding over 24-month follow-up period.
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Conflicts of interest
There are no conflicts of interest.
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