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 Table of Contents  
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 81-85

Cardiology update 2nd quarter

Department of Cardiology, AIIMS, New Delhi, India

Date of Submission23-Jul-2019
Date of Decision28-Jul-2019
Date of Acceptance28-Jul-2019
Date of Web Publication19-Aug-2019

Correspondence Address:
Dr. Satyavir Yadav
Department of Cardiology, AIIMS, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcs.jpcs_44_19

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This update includes some landmark trials which were published in the last 3 months. Myocardial perfusion cardiovascular magnetic resonance imaging has shown some initial promise in trials, rivaroxaban reduced thromboembolic events in heart failure with coronary artery disease, drug-coated balloons show superiority to bare metal stents in patients with high bleeding risk, and various studies are also published to improve cardiac resynchronization therapy pacemaker response.

Keywords: Atrial fibrillation, coronary artery disease, percutaneous coronary intervention

How to cite this article:
Yadav S. Cardiology update 2nd quarter. J Pract Cardiovasc Sci 2019;5:81-5

How to cite this URL:
Yadav S. Cardiology update 2nd quarter. J Pract Cardiovasc Sci [serial online] 2019 [cited 2023 Jun 8];5:81-5. Available from: https://www.j-pcs.org/text.asp?2019/5/2/81/264634

  Magnetic Resonance Perfusion or Fractional Flow Reserve in Coronary Disease (Mr-Inform Study) Top

In patients with stable angina, two strategies are often used to guide revascularization: one involves myocardial perfusion cardiovascular magnetic resonance imaging (MRI) and the other involves invasive angiography and measurement of fractional flow reserve (FFR). Whether a cardiovascular MRI-based strategy is noninferior to an FFR-based strategy with respect to major adverse cardiac events has not been established.

This study found that in patients with stable angina and risk factors for coronary artery disease (CAD), myocardial perfusion cardiovascular MRI based treatment decision were associated with a lower incidence of coronary revascularization than FFR and were noninferior to FFR with respect to major adverse cardiac events.[1]

Five-Year Clinical Outcomes and Intracoronary Imaging Findings of the Comfortable Ami Trial: Randomized Comparison of Biodegradable Polymer-Based Biolimus-Eluting Stents With Bare Metal Stents in Patients With Acute St-Segment Elevation Myocardial Infarction

Compared with bare metal stent (BMS), the implantation of biodegradable polymer-coated biolimus-eluting stent resulted in a lower 5-year rate of major advanced cardiac event in patients with ST-elevation myocardial infarction (MI) undergoing primary percutaneous coronary intervention (PCI). At 13 months, vascular healing in treated culprit lesions was almost complete irrespective of stent type.[2]

Platelet Reactivity and Clinical Outcomes in Acute Coronary Syndrome Patients Treated With Prasugrel and Clopidogrel: a Prespecified Exploratory Analysis from the Testing Responsiveness to Platelet Inhibition on Chronic Antiplatelet Treatment for Acute Coronary Syndrome Trial

The value of platelet function testing (PFT) in predicting clinical outcomes and guiding P2Y12-inhibitor treatment is uncertain. A study in ACS patients assessed ischemic and bleeding risks according to high platelet reactivity (HPR) and low platelet reactivity (LPR) to adenosine diphosphoribose pyrophosphatase (ADP) in patients receiving uniform prasugrel versus PFT-guided clopidogrel or prasugrel.

Based on this substudy of a randomized trial, selecting prasugrel or clopidogrel based on PFT resulted in similar ischemic outcomes as uniform prasugrel therapy without HPR. Although infrequent, HPR on prasugrel was associated with increased risk of ischemic events. LPR was a strong and independent predictor of bleeding both on prasugrel and clopidogrel.[3]

  Safety and Efficiency of a Common and Simplified Protocol for Pacemaker and Defibrillator Surveillance Based on Remote Monitoring Only: a Long-Term Randomized Trial Top

This trial aimed to evaluate the safety and efficiency of a common and simplified protocol for the surveillance of cardiac implantable electronic devices based on remote monitoring (RM) in patients with pacemakers (PMs) and implantable cardiac defibrillators (ICDs) for at least 24 months.

The RM-A long-term randomized trial protocol common for ICD and PM surveillance, consisting of RM + RI every 6 months, has proven safe and efficient in reducing hospital visits and staff workload.[4]

  Race 7 Acwas Top

Patients with recent-onset atrial fibrillation (AF) commonly undergo immediate restoration of sinus rhythm by pharmacologic or electrical cardioversion. However, whether immediate restoration of sinus rhythm is necessary is not known since AF often terminates spontaneously.

In patients presenting to the emergency department with recent-onset, symptomatic AF, a wait-and-see approach was noninferior to early cardioversion in achieving a return to sinus rhythm at 4 weeks.[5]

  The Circa-Dose Study Top

It randomized 346 patients with paroxysmal AF to contact-force-guided radiofrequency ablation versus cryoablation with 2 × 4 min freezes versus 2 × 2 min freezes and found no difference in arrhythmia recurrence documented by an implantable loop recorder (and an impressive reduction in median AF burden of around 99% compared to baseline). This study confirms findings of the FIRE and ICE trial, using more recent tools.[6]

  the Avatar-Atrial Fibrillation Study Top

It randomized 321 patients with paroxysmal AF to antiarrhythmics, conventional cryoablation, or a protocol with 2 × 3 min freezes (guided by testing of vein occlusion) without pulmonary vein mapping and with same-day discharge. The primary endpoint was time to hospital episodes (including outpatient consultation) related to treatment for atrial arrhythmias. At 1 year from the first intervention, significantly fewer patients had reached the primary endpoint in the AVATAR protocol arm compared to drug therapy (21% vs. 76%, P < 0.0001, hazard ratio 0.156; 95% confidence interval 0.097–0.250, P < 0.0001). There was no significant difference between the AVATAR protocol arm and the conventional cryoballoon ablation arm (21% vs. 18%, P = 0.6). The study is quite provocative as it dispenses with the need to prove electrical isolation of the pulmonary veins and also uses a clinical endpoint which relates to healthcare use rather than arrhythmia recurrence per se.[6]

  the Raise Cardiac Resynchronization Therapy Trial Top

It randomized 172 patients with ischemic heart disease and a standard indication for cardiac resynchronization therapy-D (CRT-D) to image-guided speckle-tracking radial strain echocardiography left ventricular (LV) lead placement versus usual practice. The primary endpoint was the reduction in LV end-systolic volume, which was similar in both groups as was clinical outcome. This negative study highlights the need to find new strategies to improve response rate with CRT.[6]

  the Electrocardiac Resynchronization Therapy Trial Top

It randomized 122 patients undergoing CRT implantation to an imaging-guided strategy (targeting latest mechanically activated nonscarred myocardial segment defined by speckle tracking, cardiac computed tomography venography, and positron emission tomography) versus an electrically guided strategy toward latest activated segment combined with postimplant interventricular pacing delay optimization to achieve narrowest QRS complex. At 6 months' follow-up, the primary endpoint, absolute increase in LV ejection fraction, was greater in the electrical group compared to the imaging group (11% ± 10% vs. 7% ± 11%, P = 0.03). This study provides a relatively simple strategy at implantation for improving response to CRT.[6]

  Does Pregnancy Complication History Improve Cardiovascular Disease Risk Prediction? Findings from the Hunt Study in Norway Top

To evaluate whether history of pregnancy complications (pre-eclampsia, gestational hypertension, preterm delivery, or small for gestational age [SGA]) improves risk prediction for cardiovascular disease (CVD).[6]

It concluded that pre-eclampsia independently predicted CVD after controlling for established risk factors; however, adding pre-eclampsia, gestational hypertension, preterm delivery, and SGA made only small improvements to CVD prediction among this representative sample of parous Norwegian women.

  Open Versus Endovascular Repair of Abdominal Aortic Aneurysm: the over Veterans Affairs Cooperative Study Top

Elective endovascular repair of an abdominal aortic aneurysm results in lower perioperative mortality than traditional open repair; but, after 4 years, this survival advantage is not seen; in addition, results of two European trials have shown worse long-term outcomes with endovascular repair than with open repair. Long-term results of a study we conducted more than a decade ago to compare endovascular repair with open repair are unknown.[7]

Long-term overall survival was similar among patients who underwent endovascular repair and those who underwent open repair. A difference between groups was noted in the number of patients who underwent secondary therapeutic procedures. Results were not consistent with the findings of worse performance of endovascular repair with respect to long-term survival that was seen in the two European trials.

  Association of Rivaroxaban With Thromboembolic Events in Patients With Heart Failure, Coronary Disease, and Sinus Rhythm: a Post Hoc Analysis of the Commander Hf Trial Top

The COMMANDER HF randomized clinical trial evaluated the effects of adding low-dose rivaroxaban to antiplatelet therapy in patients with recent worsening of chronic HF with reduced ejection fraction, CAD, and sinus rhythm. Although the primary end point of all-cause mortality, MI, or stroke did not differ between rivaroxaban and placebo, there were numerical advantages favoring rivaroxaban for MI and stroke.

In this study, thromboembolic events occurred frequently in patients with HF, CAD, and sinus rhythm. Rivaroxaban may reduce the risk of thromboembolic events in this population, but these events are not the major cause of morbidity and mortality in patients with recent worsening of HF for which rivaroxaban had no effect. While consistent with other studies, these results require confirmation in prospective randomized clinical trials.[8]

  Association of Patisiran, an Rna Interference Therapeutic, With Regional Left Ventricular Myocardial Strain in Hereditary Transthyretin Amyloidosis: the Apollo Study Top

Patients with cardiac amyloidosis demonstrate reduced myocardial strain with associated sparing of the cardiac apex. In the APOLLO randomized clinical trial, patisiran, an RNA interference therapeutic that inhibits transthyretin synthesis, improved LV global longitudinal strain compared with placebo in patients with hereditary transthyretin-mediated (hATTR) amyloidosis with polyneuropathy and evidence of cardiac involvement.

These findings highlight a potential role of the LV basal longitudinal strain as a sensitive marker to evaluate the association with cardiac manifestation in hATTR amyloidosis.[9]

  Association of Initial and Serial C-Reactive Protein Levels With Adverse Cardiovascular Events and Death After Acute Coronary Syndrome: a Secondary Analysis of the Vista-16 Trial Top

In this secondary analysis of the VISTA-16 randomized clinical trial that included 5145 patients, baseline and longitudinal high-sensitivity C-reactive protein levels were independently associated with increased risk of a major adverse cardiac event, cardiovascular death, and all-cause death during the 16-week follow-up.

It means monitoring high-sensitivity C-reactive protein levels in patients after ACS may help better identify patients at greater risk for recurrent cardiovascular events or death.[10]

  Two-Year Outcomes After Transcatheter Aortic Valve Replacement With Mechanical Versus Self-Expanding Valves: the Reprise Iii Randomized Clinical Trial Top

REPRISE III is the first large randomized comparison of 2 different transcatheter aortic valve replacement platforms: the mechanically expanded Lotus valve (Boston Scientific) and self-expanding CoreValve (Medtronic).

After 2 years, all-cause mortality rates, mortality, or disabling stroke were similar between Lotus and CoreValve. Disabling stroke, functional class, valve migration, and favored the Lotus arm whereas valve hemodynamics, thrombosis, and new PM implantation favored the CoreValve arm.[11]

  Drug-Coated Balloon for Treatment of De Novocoronary Artery Lesions in Patients With High Bleeding Risk (Debut): a Single-Blind, Randomized, Noninferiority Trial Top

The optimal technique of PCI in patients at high bleeding risk is not known. The hypothesis of the DEBUT trial was that PCI with drug-coated balloons is noninferior to PCI with BMSs for this population.[12]

PCI with drug-coated balloon was superior to BMSs in patients at bleeding risk. The drug-coated balloon-only coronary intervention is a novel strategy to treat this difficult patient population. Comparison of this approach to the new generation drug-eluting stents is warranted in the future.

  Safety and Efficacy of a Sirolimus-Eluting Coronary Stent With Ultra-Thin Strut for Treatment of Atherosclerotic Lesions (Talent) a Prospective Multicenter Randomized Controlled Trial Top

Supraflex is a sirolimus-eluting stent with a biodegradable polymer coating and ultra-thin struts. It aimed to compare Supraflex with the standard of care, Xience, an everolimus-eluting stent with a durable polymer coating, regarding clinical outcomes with a randomized trial in an all-comer population.[13]

The Supraflex stent was noninferior to the Xience stent for a device-oriented composite clinical endpoint at 12 months in an all-comer population. Supraflex seems a safe and effective alternative drug-eluting stent to other stents in clinical practice.

  Effect of Catheter Ablation Versus Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest among Patients With Atrial Fibrillation: the Cabana Randomized Clinical Trial Top

Among patients with AF, the strategy of catheter ablation, compared with medical therapy, did not significantly reduce the primary composite end point of death, disabling stroke, serious bleeding, or cardiac arrest. However, the estimated treatment effect of catheter ablation was affected by lower-than-expected event rates and treatment crossovers, which should be considered in interpreting the results of the trial.[14]

  Association between Warfarin Control Metrics and Atrial Fibrillation Outcomes in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation Registry Top

In this cohort study of 51,830 visits among 10,137 patients with AF, historical international normalized ratio variance was associated with future bleeding events; but, no historical international normalized ratio metrics were associated with future stroke risk.[15]

Meaning – the findings suggest that physicians should be cautious when using historical international normalized ratio control measures to assess the likelihood of future bleeding or thrombotic events in patients with AF taking warfarin.

  Vitamin D Supplementation and Cardiovascular Disease Risks in More Than 83,000 Individuals in 21 Randomized Clinical Trials: A Meta-Analysis Top

Observational studies have reported an association between low serum Vitamin D levels and elevated risk of CVD events, but such studies cannot prove causation because of possible unmeasured confounding.

In this updated meta-analysis, Vitamin D supplementation was not associated with reduced major adverse cardiovascular events, individual CVD end points (MI, stroke, and CVD mortality), or all-cause mortality. The findings suggest that Vitamin D supplementation does not confer cardiovascular protection and is not indicated for this purpose.[16]

2019 American Heart Association/american College of Cardiology/heart Rhythm Society-Focused Update of the 2014 American Heart Association/american College of Cardiology/heart Rhythm Society Guideline for the Management of Patients With Atrial Fibrillation: a Report of the American College of Cardiology/american Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society

The scope of this focused update of the 2014 AF guideline includes revisions to the section on anticoagulation (because of the approval of new medications and thromboembolism protection devices), revisions to the section on catheter ablation of AF, revisions to the section on the management of AF complicating ACS, and new sections on device detection of AF and weight loss.[17]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Nagel E, Greenwood JP, McCann GP, Bettencourt N, Shah AM, Hussain ST, et al. Magnetic resonance perfusion or fractional flow reserve in coronary disease. N Engl J Med 2019;380:2418-28.  Back to cited text no. 1
Räber L, Yamaji K, Kelbæk H, Engstrøm T, Baumbach A, Roffi M, et al. Five-year clinical outcomes and intracoronary imaging findings of the COMFORTABLE AMI trial: Randomized comparison of biodegradable polymer-based biolimus-eluting stents with bare-metal stents in patients with acute ST-segment elevation myocardial infarction. Eur Heart J 2019;40:1909-19.  Back to cited text no. 2
Aradi D, Gross L, Trenk D, Geisler T, Merkely B, Kiss RG, et al. Platelet reactivity and clinical outcomes in acute coronary syndrome patients treated with prasugrel and clopidogrel: A pre-specified exploratory analysis from the TROPICAL-ACS trial. Eur Heart J 2019;40:1942-51.  Back to cited text no. 3
García-Fernández FJ, Asensi JO, Romero R, Lozano IF, Larrazabal JM, Ferrer JM, et al. Safety and efficiency of a common and simplified protocol for pacemaker and defibrillator surveillance based on remote monitoring only: A long-term randomized trial (RM-ALONE). Eur Heart J 2019;40:1837-46.  Back to cited text no. 4
Pluymaekers NA, Dudink EA, Luermans JG, Meeder JG, Lenderink T, Widdershoven J, et al. Early or delayed cardioversion in recent-onset atrial fibrillation. N Engl J Med 2019;380:1499-508.  Back to cited text no. 5
Burri H, Zeppenfeld K. What was hot at the EHRA2019 congress. Eur Heart J 2019;40:1749-51.  Back to cited text no. 6
Lederle FA, Kyriakides TC, Stroupe KT, Freischlag JA, Padberg FT Jr., Matsumura JS, et al. Open versus endovascular repair of abdominal aortic aneurysm. N Engl J Med 2019;380:2126-35.  Back to cited text no. 7
Greenberg B, Neaton JD, Anker SD, Byra WM, Cleland JG, Deng H, et al. Association of rivaroxaban with thromboembolic events in patients with heart failure, coronary disease, and sinus rhythm: A Post hoc analysis of the COMMANDER HF trial. JAMA Cardiol 2019;4:515-23.  Back to cited text no. 8
Minamisawa M, Claggett B, Adams D, Kristen AV, Merlini G, Slama MS, et al. Association of Patisiran, an RNA interference therapeutic, with regional left ventricular myocardial strain in hereditary transthyretin amyloidosis: The APOLLO study. JAMA Cardiol 2019;4:466-72.  Back to cited text no. 9
Mani P, Puri R, Schwartz GG, Nissen SE, Shao M, Kastelein JJ, et al. Association of initial and serial C-reactive protein levels with adverse cardiovascular events and death after acute coronary syndrome: A secondary analysis of the VISTA-16 trial. JAMA Cardiol 2019;4:314-20.  Back to cited text no. 10
Reardon MJ, Feldman TE, Meduri CU, Makkar RR, O'Hair D, Linke A, et al. Two-year outcomes after transcatheter aortic valve replacement with mechanical vs. self-expanding valves: The REPRISE III randomized clinical trial. JAMA Cardiol 2019;4:223-29.  Back to cited text no. 11
Rissanen TT, Uskela S, Eränen J, Mäntylä P, Olli A, Romppanen H, et al. Drug-coated balloon for treatment of de novo coronary artery lesions in patients with high bleeding risk (DEBUT): A single-blind, randomised, non-inferiority trial. Lancet 2019;394:230-9.  Back to cited text no. 12
Zaman A, de Winter RJ, Kogame N, Chang CC, Modolo R, Spitzer E, et al. Safety and efficacy of a sirolimus-eluting coronary stent with ultra-thin strut for treatment of atherosclerotic lesions (TALENT): A prospective multicentre randomised controlled trial. Lancet 2019;393:987-97.  Back to cited text no. 13
Mark DB, Anstrom KJ, Sheng S, Piccini JP, Baloch KN, Monahan KH, et al. The CABANA randomized clinical trial. JAMA 2019;321:1275-85.  Back to cited text no. 14
Pokorney SD, Holmes DN, Thomas L, Fonarow GC, Kowey PR, Reiffel JA, et al. Association between warfarin control metrics and atrial fibrillation outcomes in the outcomes registry for better informed treatment of atrial fibrillation. JAMA Cardiol 2019. doi: 10.1001/jamacardio.2019.1960. [Epub ahead of print].  Back to cited text no. 15
Barbarawi M, Kheiri B, Zayed Y, Barbarawi O, Dhillon H, Swaid B, et al. Vitamin D supplementation and cardiovascular disease risks in more than 83,000 individuals in 21 randomized clinical trials: A meta-analysis. JAMA Cardiol 2019. doi: 10.1001/jamacardio.2019.1870. [Epub ahead of print].  Back to cited text no. 16
January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC Jr., et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2019;74:104-32.  Back to cited text no. 17


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