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| REVIEW ARTICLE |
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| Year : 2017 | Volume
: 3
| Issue : 2 | Page : 79-81 |
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Cardiology update 2017: The second quarter
Sunil Kumar Verma1, S Umapathy2
1 Department of Cardiology, AIIMS, New Delhi, India
2 Department of Cardiology, CTC, AIIMS, New Delhi, India
| Date of Web Publication | 20-Nov-2017 |
Correspondence Address:
Sunil Kumar Verma
Suite No. 24, 7th Floor, Department of Cardiology, CTC, AIIMS, Ansari Nagar, New Delhi - 110 029
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jpcs.jpcs_38_17
How to cite this article:
Verma SK, Umapathy S. Cardiology update 2017: The second quarter. J Pract Cardiovasc Sci 2017;3:79-81 |
| Heart Failure | |  |
In LEVO-CTS trial, prophylactic levosimendan use did not reduce short-term composite end point of death, renal replacement therapy, perioperative myocardial infarction (MI), or use of a mechanical cardiac assist device compared to placebo among patients with a reduced left ventricular function who were undergoing cardiac surgery with cardiopulmonary bypass.
[1] Similarly, in a study by CHEETAH study group in patients who required perioperative hemodynamic support after cardiac surgery, low-dose levosimendan in addition to standard care did not result in lower 30-day mortality.[2]
Rates of sudden death in patients with heart failure with reduced ejection fraction who were enrolled in clinical trials have declined substantially emphasizing the cumulative benefit of evidence-based therapy in a data analysis of 40,195 patients from 1995 to 2014. This study has excluded the patients on implantable cardioverter-defibrillator at the time of trial enrollment. The rate of sudden death was not higher among patients with a recent diagnosis of heart failure than among those with a long-standing diagnosis.[3]
| Hypertension | | |
Renal nerve denervation (RND) therapy was again tested with some changes in techniques, patients profile, operators experiences, and antihypertensive medications monitoring in SPYRAL HTN-OFF MED [4] trial in a multicentre, international, single-blind, randomized, sham-controlled, proof-of-concept manner in eighty patients (n = 38 in RND group and n = 42 in sham control group). At 3 months, the mean difference of the systolic and diastolic blood pressures between the two groups favoured the RND.
Treatment with low-dose aspirin during pregnancy (150 mg OD, starting from 11 to 14 weeks of gestation and continuing up to 36 weeks of gestation) in women with high risk of preeclampsia reduced the preterm preeclampsia as compared to placebo without any significant neonatal adverse events or outcomes.[5]
| Atherosclerosis | | |
In ACCELERATE trial involving 12,092 patients, cholesteryl ester transport protein (CETP) inhibitor, Evacetrapib did not show reduction in cardiovascular (CV) events compared to placebo despite having favourable effects on lipid biomarkers (increased levels of high density lipoprotein-cholesterol (HDL-C) and reduction of low density lipoprotein-cholesterol (LDL)-C) among patients with high-risk vascular disease.[6]
Whereas in REVEAL trial, the use of another CETP inhibitor, anacetrapib in addition to intensive statin therapy resulted in a lower incidence of major coronary events than placebo during 4 years of treatment. This study differed from ACCELERATE as it had more patients (30,449 vs. 12,092), extended duration of follow-up (50 months vs. 26 months), and more primary CV outcomes (3443 vs. 1555).[7]
In discovEHR study, heterozygous loss of function variants in the angiopoietin-like 3 gene (ANGPTL3) have been associated with decreased plasma levels of triglycerides, LDL-C, and HDL-C.[8]
Genetic and therapeutic antagonism of ANGPTL3 in humans and of ANGPTL3 in mice was associated with decreased levels of all three major lipid fractions and decreased odds of atherosclerotic CV disease.[9]
In two trials involving patients with type 2 diabetes and an elevated risk of CV disease (CANVAS and CANVAS-R), patients treated with canagliflozin (a sodium glucose cotransporter 2 inhibitor) had a lower risk of CV events compared to placebo (26.9 vs. 31.5 participants/1000 patient years) but a greater risk of amputation, primarily at the level of the toe or metatarsal.[10]
Among patients with type 2 diabetes with or without previous CV disease, the incidence of major adverse CV events did not differ significantly between patients who received exenatide versus placebo.[11] Exenatide is an exendin-4 based glucagon-like peptide-4 receptor antagonist approved for the treatment of type 2 diabetes mellitus. It has shown favourable metabolic and hemodynamic profile other than increase in heart rate.
In the CANTOS study, anti-inflammatory therapy targeting the interleukin-1 β innate immunity pathway with canakinumab at a dose of 150 mg every 3 months led to a significantly lower rate of recurrent CV events than placebo, independent of lipid level lowering in patients with previous MI and high-sensitivity C-reactive protein 2 or >2 mg/L. However, canakinumab was associated with a higher incidence of fatal infection than was placebo.[12]
The FOURIER OUTCOME trial study [13] showed that (1) LDL-C can now be reduced to unprecedented low levels with statin + PCSK91 mM); (2) a strong progressive relationship of achieved LDL-C and CV events seen, down to LDL <0.26 mM (<10 mg/dL); (3) no excess in events with very low achieved LDL-C < 0.5 mM (<20 mg/dL) at 2.2 years.
Prospective Urban Rural Epidemiology study [14] stated that the high carbohydrate intake is associated with higher risk of total mortality, whereas total fat and individual types of fat are related to the lower total mortality. Total fat and types of fat are not associated with CV disease, MI, or CV disease mortality whereas saturated fat has an inverse relationship with stroke.
| Acute Coronary Syndromes | | |
In an investigator-initiated, registry-based, randomized clinical trial (VALIDATE-SWEDEHEART), patients with STEMI or NSTEMI who were undergoing PCI predominantly with the use of a radial approach and receiving treatment with aspirin and potent P2Y12 inhibitors, without the planned use of glycoprotein IIb/IIIa inhibitors were studied. In these patients, anticoagulation with bivalirudin was not superior to unfractionated heparin with respect to the composite end point of death from any cause, MI, or major bleeding at 180 days.[15]
In DETO2X-AMI trial, routine use of supplemental oxygen in patients with suspected MI who did not have hypoxemia was not found to reduce 1-year all-cause mortality.[16]
| Atrial Fibrillation | | |
The results of IMPACT-AF [17] trial showed that education and monitoring are effective ways to improve the adherence to oral anticoagulant medications in patients with atrial fibrillation (AF).
The RACE-3 study [18] demonstrated that risk factor-driven upstream therapy, including treatment of risk factor and change in lifestyle, is effective and feasible to improve the maintenance of sinus rhythm in patients with early persistence AF and heart failure.
| Coronary Artery Disease | | |
In ROOBY-FS trial, off-pump coronary artery bypass graft (CABG) had lower rates of 5-year survival (15.9% vs 11.9%) and event-free survival than on-pump CABG (31% vs. 27.1%). For the 5-year secondary outcomes, no significant differences were observed: for nonfatal MI, (12.1 vs. 9.6%, P = 0.05); for death from cardiac causes (6.3% vs. 5.3%, P = 0.29); for repeat revascularization (13.1% vs. 11.9%, P = 0.39), and for repeat CABG (1.4% vs. 0.5%, P = 0.02).[19]
In patients with AF who had undergone PCI (RE-DUAL), the risk of bleeding was lower among those who received dual therapy with dabigatran and a P2Y12 inhibitor than among those who received triple therapy with warfarin, a P2Y12 inhibitor, and aspirin. Dual therapy was found to be noninferior to triple therapy with respect to the risk of thromboembolic events.[20]
In patients with stable atherosclerotic vascular disease (COMPASS), those assigned to rivaroxaban (2.5 mg twice daily) plus aspirin had better CV outcomes (4.1% vs. 5.4%) and more major bleeding events (3.1% vs. 1.9%) than those assigned to aspirin alone. Rivaroxaban (5 mg twice daily) alone did not result in better CV outcomes than aspirin alone and resulted in more major bleeding events.[21]
Rheumatic heart disease
Watkins et al.[22] estimated the global prevalence of rheumatic heart disease over 25 years (from 1990 to 2015) and concluded that the health-related burden of the disease has declined worldwide and but high rates of disease persist in some of the poorest nations of the world.
| Electrophysiology | | |
The results of CASTLE-AF [23] trial showed that the catheter ablation of AF in patients with left ventricular systolic dysfunction results in lower mortality and less hospitalization as compared to conventional treatment.
| Structural Heart Disease | | |
In recent three trials, REDUCE,[24] CLOSE,[25] follow-up of RESPECT [26] trials have shown that PFO closure in patients with cryptogenic stroke reduces the risk of recurrent stroke compared to medical therapy alone. However, PFO closure was associated with higher rates of device-related complications and AF.
| The Lancet Collection | | |
Compassionate use of the PASCAL transcatheter mitral valve repair system for patients with severe mitral regurgitation: A multicentre, prospective, observational, first-in-man study.[27]
Twenty-three patients elderly patients with moderate-to-severe mitral regurgitation had treatment using the Edwards PASCAL TMVr system. The implantation was successful in all patients, with 6 needing two implants. Technical success was achieved in 22 of 23 patients. This study establishes the feasibility of the Edwards PASCAL TMVr system.
Global mortality variations in patients with heart failure: Results from the International Congestive Heart Failure (INTER-CHF) prospective cohort study.[28]
This study enrolled 5823 patients and the mortality was 16.5% with the mortality varying from being highest in Africa (34%) and India (23%), to Southeast Asia (15%), and in China (7%). Independent predictors of mortality included functional Class III or IV, admission for heart failure, valve disease and chronic kidney disease, and obstructive pulmonary disease.
| References | | |
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| 2. | Landoni G, Lomivorotov VV, Alvaro G, Lobreglio R, Pisano A, Guarracino F, et al. Levosimendan for hemodynamic support after cardiac surgery. N Engl J Med 2017;376:2021-31. [ PUBMED] |
| 3. | Shen L, Jhund PS, Petrie MC, Claggett BL, Barlera S, Cleland JG, et al. Declining risk of sudden death in heart failure. N Engl J Med 2017;377:41-51. |
| 4. | Townsend RR, Mahfoud F, Kandzari DE, Kario K, Pocock S, Weber MA, et al. Catheter-based renal denervation in patients with uncontrolled hypertension in the absence of antihypertensive medications (SPYRAL HTN-OFF MED): A randomised, sham-controlled, proof-of-concept trial. Lancet 2017. pii: S0140-6736(17) 32281-X. |
| 5. | Rolnik DL, Wright D, Poon LC, O'Gorman N, Syngelaki A, de Paco Matallana C, et al. Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia. N Engl J Med 2017;377:613-22. |
| 6. | Lincoff AM, Nicholls SJ, Riesmeyer JS, Barter PJ, Brewer HB, Fox KA, et al. Evacetrapib and cardiovascular outcomes in high-risk vascular disease. N Engl J Med 2017;376:1933-42. |
| 7. | HPS3/TIMI55–REVEAL Collaborative Group, Bowman L, Hopewell JC, Chen F, Wallendszus K, Stevens W, et al. Effects of anacetrapib in patients with atherosclerotic vascular disease. N Engl J Med 2017;377:1217-27. |
| 8. | Dewey FE, Gusarova V, Dunbar RL, O'Dushlaine C, Schurmann C, Gottesman O, et al. Genetic and pharmacologic inactivation of ANGPTL3 and cardiovascular disease. N Engl J Med 2017;377:211-21. |
| 9. | Graham MJ, Lee RG, Brandt TA, Tai LJ, Fu W, Peralta R, et al. Cardiovascular and metabolic effects of ANGPTL3 antisense oligonucleotides. N Engl J Med 2017;377:222-32. [ PUBMED] |
| 10. | Neal B, Perkovic V, Mahaffey KW, de Zeeuw D, Fulcher G, Erondu N, et al. Canagliflozin and cardiovascular and renal events in type 2 diabetes. N Engl J Med 2017;377:644-57. [ PUBMED] |
| 11. | Holman RR, Bethel MA, Mentz RJ, Thompson VP, Lokhnygina Y, Buse JB, et al. Effects of once-weekly exenatide on cardiovascular outcomes in type 2 diabetes. N Engl J Med 2017;377:1228-39. [ PUBMED] |
| 12. | Ridker PM, Everett BM, Thuren T, MacFadyen JG, Chang WH, Ballantyne C, et al. Antiinflammatory therapy with canakinumab for atherosclerotic disease. N Engl J Med 2017;377:1119-31. [ PUBMED] |
| 13. | Giugliano RP, Pedersen TR, Park JG, De Ferrari GM, Gaciong ZA, Ceska R, et al. Clinical efficacy and safety of achieving very low LDL-cholesterol concentrations with the PCSK9 inhibitor evolocumab: A prespecified secondary analysis of the FOURIER trial. Lancet 2017. [Epub ahead of print]. |
| 14. | Dehghan M, Mente A, Zhang X, Swaminathan S, Li W, Mohan V, et al. Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): A prospective cohort study. Lancet 2017. [Epub ahead of print]. |
| 15. | Erlinge D, Omerovic E, Fröbert O, Linder R, Danielewicz M, Hamid M, et al. Bivalirudin versus heparin monotherapy in myocardial infarction. N Engl J Med 2017;377:1132-42. |
| 16. | Hofmann R, James SK, Jernberg T, Lindahl B, Erlinge D, Witt N, et al. Oxygen therapy in suspected acute myocardial infarction. N Engl J Med 2017;377:1240-9. [ PUBMED] |
| 17. | Grangner. Education and feedback improve use of stroke prevention drugs in atrial fibrillation (IMPACT-AF).LBCT session at ESC Congress 28 August 2017. |
| 18. | Rienstra M. The routine versus aggressive upstream rhythm control for prevention of early persistent atrial fibrillation in heart failure study. LBCT session at ESC Congress 27 August 2017. |
| 19. | Shroyer AL, Hattler B, Wagner TH, Collins JF, Baltz JH, Quin JA, et al. Five-year outcomes after on-pump and off-pump coronary-artery bypass. N Engl J Med 2017;377:623-32. [ PUBMED] |
| 20. | Cannon CP, Bhatt DL, Oldgren J, Lip GYH, Ellis SG, Kimura T, et al. Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation. N Engl J Med. 2017 19;377:1513-1524. doi: 10.1056/NEJMoa1708454. Epub 2017 Aug 27. |
| 21. | Eikelboom JW, Connolly SJ, Bosch J, Dagenais GR, Hart RG, Shestakovska O, et al. Rivaroxaban with or without aspirin in stable cardiovascular disease. N Engl J Med 2017;377:1319-30. [ PUBMED] |
| 22. | Watkins DA, Johnson CO, Colquhoun SM, Karthikeyan G, Beaton A, Bukhman G, et al. Global, regional, and national burden of rheumatic heart disease, 1990-2015. N Engl J Med 2017;377:713-22. [ PUBMED] |
| 23. | Morrouche, Brachmann J. Catheter ablation improves outcomes in patients with heart failure and atrial fibrillation. Late breaking trials. Europian society of cardiology congress. 27 August 2017. |
| 24. | Søndergaard L, Kasner SE, Rhodes JF, Andersen G, Iversen HK, Nielsen-Kudsk JE, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 2017;377:1033-42. |
| 25. | Mas JL, Derumeaux G, Guillon B, Massardier E, Hosseini H, Mechtouff L, et al. Patent foramen ovale closure or anticoagulation vs. Antiplatelets after stroke. N Engl J Med 2017;377:1011-21. [ PUBMED] |
| 26. | Saver JL, Carroll JD, Thaler DE, Smalling RW, MacDonald LA, Marks DS, et al. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med 2017;377:1022-32. [ PUBMED] |
| 27. | Praz F, Spargias K, Chrissoheris M, Büllesfeld L, Nickenig G, Deuschl F, et al. Compassionate use of the PASCAL transcatheter mitral valve repair system for patients with severe mitral regurgitation: A multicentre, prospective, observational, first-in-man study. Lancet 2017;390:773-80. |
| 28. | Dokainish H, Teo K, Zhu J, Roy A, AlHabib KF, ElSayed A, et al. Global mortality variations in patients with heart failure: Results from the international congestive heart failure (INTER-CHF) prospective cohort study. Lancet Glob Health 2017;5:e665-e672. [ PUBMED] |
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