|Year : 2018 | Volume
| Issue : 2 | Page : 77-80
Cardiology update: 2nd half 2018
Department of Cardiology, AIIMS, New Delhi, India
|Date of Web Publication||10-Sep-2018|
Dr. Shanmugam Krishnan
Department of Cardiology, AIIMS, New Delhi
Source of Support: None, Conflict of Interest: None
In the past few months, guidelines have come up on the diagnosis and management of syncope, registry data on heart failure management in the US find many patients not getting guideline-based therapy, a nasal spray-based calcium channel blocker for arrhythmias, positron emission tomography scans for prosthetic valve endocarditis, radial artery graft patency, pharmacist-led blood pressure reduction, choice of beta-blockers for ventricular tachycardia storm, and no role for high-dose multivitamins.
Keywords: 2018, cardiology, update
|How to cite this article:|
Krishnan S. Cardiology update: 2nd half 2018. J Pract Cardiovasc Sci 2018;4:77-80
| Introduction|| |
We start this news round up with a nasal spray-based calcium channel blocker. The nasal-spray preparation etripamil was tested in paroxysmal supraventricular tachycardia (VT) proven to work and well tolerated in a Phase 2 study in electrophysiological lab testing. Efficacy varied from 65% to 95% versus 35% in the placebo group and the median time to conversion was <3 min.
Data on medication practice in the US for heart failure are interesting: in patients eligible to receive medication, 27% were not prescribed an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker/angiotensin receptor–neprilysin inhibitor, 33% did not get a β-blocker, and 67% were not prescribed a mineralocorticoid receptor antagonist, in Change the Management of Patients with Heart Failure registry. Only one in four patients were receiving all the three guideline-recommended drug types. Another study on heart failure reports the use of subcutaneous frusemide.,
In a meta-analysis of aspirin in the primary prevention of cardiovascular events, testing the effect of low-dose versus high-dose aspirin therapy, the authors determined that increased weight (>70 kg) limited the efficacy of low-dose aspirin in reducing cardiovascular events. High-dose aspirin therapy only reduced cardiovascular event risk in people weighing >70 kg. Low-weight individuals receiving aspirin therapy were also at higher risk for sudden death.
A study comparing 57 patients receiving epinephrine or norepinephrine for cardiogenic shock following an acute myocardial infarction (MI) found that there is a higher risk of refractory shock in patients treated with epinephrine compared to norepinephrine.
Patients with a prosthetic heart valve (PV) with suspected endocarditis underwent 18F-Fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for diagnosing PV endocarditis, and this study found that it was accurate in diagnosing prosthetic valve endocarditis using both visual and quantitative assessment, and FDG PET/CT should be used in the initial diagnostic workup.
Patients with degenerated mitral bioprostheses who underwent repeat surgical mitral valve replacement or transcatheter mitral valve-in-valve replacement (TMVR) were assessed, and the TMVR group had significantly shorter total procedure time, Intensive Care Unit hours, and postprocedure length of stay. Mortality at 1 year was similar in the two groups.
In a study to evaluate the use of myocardial perfusion single-photon emission CT imaging, machine learning was better at predicting major adverse cardiac events (MACE) than the other means of assessment tested.
In a meta-analysis, there was evidence that folic acid and Vitamin B supplementation improves cardiovascular disease (CVD) or stroke outcomes, but there is no effect with multivitamin, Vitamins C and D, β-carotene, calcium, and selenium supplementation. Furthermore, antioxidant combinations and niacin preparations were associated with increased risk of CVD or stroke.
Syncope guidelines have also been updated with a downgrade of use of tilt table testing for diagnostic purposes and upgrade of catheter ablation in selected patients with atrial fibrillation (AF) and syncope and the use of implantable cardioverter-defibrillator in selected patients with various cardiac conditions and syncope.
Patients with end-stage renal disease (ESRD) with AF can receive direct oral anticoagulants. Apixaban and rivaroxaban for AF in patients with ESRD and the data are reviewed in this article.
In an analysis of newer anticoagulants, there was less bleeding but greater mortality risk than warfarin in patients with and without AF, but there is a potentially increased mortality risk. Even though bleeding is less across all group of patients, increased mortality raises a big concern in this registry study.
In a landmark 2013 study from Spain (the PREDIMED study), the 5-composite cardiovascular outcome was significantly lower in patients who consumed a Mediterranean diet that was supplemented with olive oil or nuts compared with a low-fat “control” diet; however, several irregularities in the randomization process led to a recent withdrawal of the study by the New England Journal of Medicine. The researchers have reanalyzed the data and the results are unchanged: the 5-year incidence of the composite outcome is significantly lower and these have been now published.
In a study of myocarditis, at presentation, 26.6% (n = 118 patients) had either left ventricular (LV) ejection fraction <50%, sustained ventricular arrhythmias, or a low cardiac output syndrome, while 325 (73.4%) had no such complications. Cardiac mortality and transplant were 11.3% and 14.7% in patients with complicated presentation, respectively, and 0% in uncomplicated cases.
In VT storm, a single-center study compared nonselective beta-blocker propranolol to selective beta-blocker metoprolol. Propranolol was found to shorten the recurrence of VT acutely and shorten hospital duration, but in the long term, both drugs fared equally. Termination of VT was 77.5% less likely with metoprolol than propranolol. At the end of 24 h, 90% of patients were free of arrhythmic events in propranolol group compared to 53% in metoprolol group. Though there was no mortality in either group, this study opens an interesting debate.
In a meta-analysis on patency of radial artery grafts versus saphenous vein grafts, individual patient data analysis of six randomized controlled trials (RCTs) found longer patency rates with radial artery grafts than saphenous vein grafts (rates of 19 events vs. 46 events per 1000 patient-years). Rates of MI and repeat revascularization were significantly less likely with radial artery grafts. However, whether this holds good for patients who underwent radial artery angiography in the same arm needs to be studied well in RCT.
Even though mechanical valve thrombosis is a major problem in developing countries, studies on lower intensity anticoagulation for newer valves are available (ProACT trial). On-X valve is a newer generation bileaflet mechanical valve designed to have lower thrombogenicity primarily because of absence of silicone. This trial tested two arms of low risk and high risk with any one of the risk factors (chronic AF, severe LV dysfunction, left atrial dimension >50 mm or SEC (spontaneous echo contrast), history of CVA <1 year hypercoagulability). In the low-risk arm, dual antiplatelet therapy with clopidogrel and aspirin was found to be inferior to standard intensity anticoagulation (29 vs. 13 events, P = 0.003). In the high-risk arm, low-intensity anticoagulation was found to be better than standard intensity anticoagulation (international normalized value of 1.5–2 vs. 2–3) in terms of bleeding events (15 vs. 43 events) with no significant difference in thromboembolic events (10 vs. 13 events).
Five-year outcomes of FAME 2 trial were published. Out of a total of 888 patients who underwent randomization, primary endpoint of death, MI, or urgent revascularization was significantly less in patients who underwent percutaneous coronary intervention (PCI) than in the medical therapy group predominantly driven by decreased urgent revascularization (6.3% vs. 21.3%). There was a trend toward decreased incidence of MI (8.1% vs. 12.0%, hazard ratio [HR]: 0.66, confidence interval [CI]: 0.43–1.00). Relief of angina which was more pronounced after PCI compared to medical therapy waned at 5 years.
Epinephrine was tested in an RCT (PARAMEDIC 2) with a placebo for out-of-hospital cardiac arrest in a double-blind trial. Out of a total recruitment of 8014 patients, significantly more patients were alive in the adrenaline group. In this trial after initial attempts with CPR and defibrillation, failed patients were given epinephrine 1 mg every 3–5 min. The heart restarted 36.3% versus 11.7% in the placebo arm; 130 patients (3.2%) in the epinephrine group and 94 (2.4%) patients in the saline placebo group were alive at 30 days, however, at the cost of more neurologic impairment in survivors in the epinephrine group (31% vs. 17.8%). Overall survival was poor in this overall trial (2.4–3.2%), and epinephrine dose was administered after a median time of 21 min. Benefit in shockable rhythm is still debatable as seen in subgroup analysis.,
Ambulatory blood pressure (BP) monitoring may be ideal, but clinical evidence is lacking. A registry analysis from Spain revealed that ambulatory systolic blood pressure (SBP) is strongly associated with mortality (HR: 1.58 per 1 standard deviation increase in SBP vs. 1.02 for clinic SBP). Masked hypertension was more strongly associated than sustained hypertension. Interestingly, white coat hypertension was also strongly associated with mortality (HR: 1.79, CI: 1.38–2.32).
Pharmacist-led BP reduction may be better than doctor-led intervention. This strategy was tested in a cluster randomized trial in Black barber shops. There was a significant reduction in mean SBP at 6 months in the pharmacist group (27 mmHg vs. 9.3 mmHg, P < 0.001). Goal BP was achieved more frequently in the pharmacist group (63.6% vs. 11.7%, P < 0.001). This trial could pave way for a novel approach for the management of uncontrolled hypertension and achieving goal BP in hypertension.
Two-year outcomes of HEART MATE 3 device (a magnetically levitated centrifugal continuous-flow pump vs. the HeartMate II [mechanical-bearing axial continuous-flow pump]) were published. It found the rate of survival free of disabling stoke or reoperation to be significantly more in HeartMate 3 device (79.5% vs. 60.2%, P < 0.001). Rates of stroke and reoperation were less frequent in HeartMate 3 device. There were only two patients (1.1%) of suspected pump thrombosis in continuous flow arm versus 27 patients (15.7%) in the axial group arm.
In infective endocarditis (IE), two registry studies gave us insights into predisposing factors, risk in bicuspid aortic valve (BAV), and mitral valve prolapse (MVP). Isabel et al. found that BAV and MVP both were associated with equal complications compared to high-risk group, predominantly prosthetic valves, and the need for cardiac surgery was higher in BAV (68% vs. 39%). Focus of entry was different between the groups with a higher incidence of odontological focus in BAV and MVP groups (15%–18% vs. 6%) compared to prosthetic valve groups. This study argues for a prophylaxis in these groups which may well concur for RHD group in India also. A second study from Sweden, a case crossover study, found several common low-risk procedures to be associated with IE risk including blood transfusion, dialysis, bone marrow biopsy, and common cardiovascular procedures arguing for better aseptic measures and possible prophylactic antibiotics precardiac catheterization.,,,
Contrast-induced acute kidney injury (AKI) following cardiac catheterization is traditionally given with normal saline at 1 ml/kg/h pre- and post-procedure. Whether patients with low body fluid level may do better with more fluids was tested in HYDRA trial. This trial used bioimpedance vector analysis for determining low body fluid status. Approximately 150 patients were randomized into double-volume (2 ml/kg/h) versus normal-volume group. Incidence of AKI was significantly lower with double-volume group than normal-volume group (11.5% vs. 22.3%, P = 0.015). Other simpler methods for volume repletion need to be tested in trials.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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