Why we do what we do in Cardiology: Recent Episodes

Bishnu Subedi

I am Dr. Bishnu Subedi. I am a cardiologist in the United States. In the era of evidence-based medicine, our practice is usually guided by a scientific study, expert society statements, or clinical guidelines. In this podcast series, I intend to highlight some of these practice-changing articles in the field of cardiology from past and present.

The REDUCE-AMI trial showed no significant benefit of beta-blockers in reducing all-cause mortality or future myocardial infarction in patients with acute myocardial infarction and preserved left ventricular ejection fraction.
The trial included 5,020 patients who were randomized to either beta-blockade with metoprolol or bisoprolol or usual care, with follow-up over a median of 3.5 years.
Primary and secondary outcomes showed no significant differences between the beta-blocker and usual care groups.
Safety outcomes were similar between groups, and there was significant crossover and varying adherence to beta-blocker therapy over time.
The findings suggest a need to re-evaluate the routine use of beta-blockers in this patient population, emphasizing personalized treatment approaches and further research.

The HF-OPT study investigated the improvement of left ventricular ejection fraction (LVEF) beyond 90 days in patients with newly diagnosed heart failure with reduced ejection fraction (HFrEF).

In this prospective, multicenter observational study, 1,300 patients with HFrEF (LVEF ≤35%) were initially enrolled.

Participants wore a wearable cardioverter-defibrillator (WCD) and received guideline-directed medical therapies (GDMT).

LVEF was measured at 0, 90, 180, and 360 days.

By day 90, 46% had an LVEF >35%; this increased to 68% by day 180 and 77% by day 360.

High GDMT usage was noted, with 97% on beta-blockers, 94% on ACE inhibitors/angiotensin-receptor blockers/ARNI, and 62% on mineralocorticoid antagonists by day 180.

Achieving target doses of all three GDMT classes was associated with significant LVEF improvement.

The study recorded low rates of ventricular arrhythmias beyond the initial 90 days.

These results underscore the potential benefits of continuous GDMT optimization. They suggest that delayed implantable cardioverter-defibrillator (ICD) implantation may be reasonable for selected patients, allowing for further LVEF improvement.

This emphasizes the importance of optimal dosing and continuous GDMT for effective heart failure management, highlighting the need for expedited GDMT titration and a tailored approach to heart failure care.

Reference: European Heart Journal, ehae334, https://doi.org/10.1093/eurheartj/ehae334

Overview: This review discusses the use and future directions of AI in cardiology, focusing on areas like electrocardiography, telemetry and wearables, echocardiography, CMR, nuclear cardiology, CT, electrophysiology studies, coronary angiography, and genetics or multiomics.
AI Glossary: Includes key terms such as algorithms, AUC, artificial intelligence, neural networks, classification, CNNs, deep learning, features, foundation models, joint embedding, labels, large language models, machine learning, preprocessing, reinforcement learning, segmentation, semi-supervised learning, structured data, supervised learning, unstructured data, unsupervised learning, and wearables.
Deep Learning in Cardiology: Applied to physiologic waveform, imaging, and multiomics data with clinical applications. Studies reviewed using MeSH terms in PubMed.
ECG and AI: Deep learning techniques like CNNs show promise in arrhythmia classification and predicting conditions like LV systolic dysfunction, hypertrophic cardiomyopathy, and cardiac amyloidosis.
AI in Echocardiography: Improves image acquisition and interpretation, helping automate measurements and enhancing variability and disease diagnosis.
AI in CMR Imaging: Enhances image reconstruction, segmentation, and quantification. AI applications in nuclear cardiology and CT include improved prognostication and plaque burden quantification.
AI in Electrophysiology: Aids preprocedural planning, intraprocedural guidance, and postprocedural predictions, improving ablation target identification and therapy response prediction.
AI in Coronary Angiography: Automates stenosis detection, plaque characterization, and fractional flow reserve computation, enhancing accuracy and procedural efficiencies.
Machine Learning in Genomics: Improves risk prediction, variant interpretation, pathogenicity identification, and integration into clinical care.
Future of AI in Cardiovascular Medicine: Promises enhanced disease screening, imaging data integration, and accurate diagnoses. Focuses on data quality, diversity, model generalizability, and promoting AI adoption in clinical practice.
AI Potential: Significant potential to enhance patient care through improved diagnostics, risk stratification, and personalized treatment plans, supporting clinicians in delivering better cardiovascular care.

Reference: J Am Coll Cardiol. 2024 Jun, 83 (24) 2472–2486

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

2024 HCM Guidelines Focus on Cardiac Myosin Inhibitors and Exercise

Mavacamten: Class 1 recommendation for symptomatic obstructive HCM.
Exercise: Now allows for "vigorous" activity; competitive level still limited.
Pediatric Section: Separate guidelines with new risk-prediction tools.
Atrial Fibrillation: Enhanced monitoring is recommended.
Future Research: Needed on nonobstructive HCM and cardiac myosin inhibitors' long-term effects.

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Key Points:

Positive Aspects of DOACs: DOACs are acknowledged for their convenience, efficacy, and safety in conditions like atrial fibrillation (AF) and venous thromboembolism (VTE). The review supports their use in stroke prevention, AF, recent acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI), valve disease (with exceptions), VTE management, cancer-associated thrombosis, stable atherosclerotic cardiovascular disease, and peripheral-artery revascularization.

Conditions Where DOACs Are Not Recommended: DOACs are cautioned against in specific medical settings, including mechanical heart valves, rheumatic AF, transcatheter aortic valve implantation (TAVI), embolic stroke of undetermined cause (ESUS), left ventricular assist devices, heart failure with reduced LV systolic function without AF, and thrombotic antiphospholipid syndrome (APS).

Areas of Uncertainty and Need for Research: The paper identifies areas where the benefit of DOACs remains uncertain due to a lack of dedicated trials or inconclusive results. These include left ventricular thrombus, catheter-associated deep vein thrombosis (DVT), cerebral venous sinus thrombosis, and splanchnic vein thrombosis. The need for further research, especially in catheter-induced DVT, is emphasized.

Reference: J Am Coll Cardiol. 2024 Jan, 83 (3) 444–465

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Background: Traditional practice requires fasting before cardiac catheterization, but there's no evidence to support it.

Objective: This study compared a heart-healthy pre-procedure diet with fasting to determine best practices.

Methods: 197 patients were randomly assigned to either a heart-healthy diet or fasting before their cardiac catheterization.

Results:

Satisfaction: Patients on the heart-healthy diet were significantly more satisfied than those who fasted.

Symptoms: Those in the diet group reported less thirst and hunger before and after the procedure.

Safety: No difference in complications (pneumonia, aspiration, intubation, hypoglycemia) was observed between groups.

Other outcomes: Fatigue, glucose levels, gastrointestinal issues, and antiplatelet medication doses were similar between groups.

Conclusion: Providing a heart-healthy diet before cardiac catheterization is safe and improves patient satisfaction without increasing complications.

Future Considerations:

Larger, multicenter studies are encouraged to validate and replicate these findings.

The study prompts a reconsideration of fasting protocols for other procedural situations beyond cardiac catheterization.

Reference Link: https://doi.org/10.4037/ajcc2024115

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Key Points

In patients not taking antianginal meds, PCI alleviated some—but not all—symptoms

Background:

Percutaneous coronary intervention (PCI) is commonly used to alleviate stable angina symptoms.

Uncertainty exists regarding whether PCI is more effective than a placebo procedure in patients not using antianginal medication.

Methods:

A double-blind, randomized, placebo-controlled PCI trial was conducted in stable angina patients.

Patients underwent a 2-week symptom assessment phase after stopping antianginal medications.

Randomized 1:1, patients received either PCI or a placebo, with a 12-week follow-up.

The primary endpoint was the angina symptom score, calculated based on daily angina episodes, antianginal medications, and clinical events.

Results:

301 patients were randomized (151 PCI, 150 placebo), with a mean age of 64 and 79% men.

Ischemia was present in 80% of one cardiac territory, 17% in two, and 2% in three territories.

At 12 weeks, the mean angina symptom score was significantly lower in the PCI group (2.9) than in the placebo group (5.6).

The odds ratio for improved scores with PCI was 2.21 (95% CI, 1.41 to 3.47; P<0.001).

One patient in the placebo group had unacceptable angina leading to unblinding.

Acute coronary syndromes occurred in 4 patients in the PCI group and 6 in the placebo group.

Conclusions:

In stable angina patients not using antianginal medication and with objective evidence of ischemia, PCI resulted in a lower angina symptom score compared to a placebo procedure.

Indicates an improved health status concerning angina following PCI.

Link to article:

DOI: 10.1056/NEJMoa2310610

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Study: STRONG-HF trial examined rapid up-titration of heart failure medications (GDMT) after hospitalization.

Goal: Reach optimal GDMT doses within 2 weeks after discharge.

Findings:

Over 90% of patients achieved medium-to-high GDMT doses within 2 weeks.

Patients with lower blood pressure, more congestion, and higher risk markers received less up-titration.

Higher GDMT doses:

Associated with lower rates of readmission or death for heart failure within 6 months.

Led to greater improvements in quality of life.

Were safe and well-tolerated.

Implications:

Efforts should be made to quickly reach optimal GDMT doses for most patients after hospitalization for heart failure.

Individual factors like blood pressure and congestion may influence up-titration.

This approach offers potential benefits for improving outcomes and quality of life.

Note: This study focused on three main GDMT classes (RAAS inhibitors, beta-blockers, MRAs). Newer drugs like SGLT2 inhibitors were not included but might also benefit from early initiation. Further research is needed on their effectiveness in this context.

Link: doi:10.1001/jamacardio.2023.4553

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Key Points from "Treat to Target or With Intensity? Both Statin Tactics Cut MACE: LODESTAR":

The study compares two strategies for managing LDL cholesterol in coronary artery disease (CAD):

Treat-to-target: aiming for LDL levels between 50-70 mg/dL.

High-intensity statin: prescribing the highest tolerated statin dose regardless of LDL level.

Both strategies are equally effective in preventing major adverse cardiovascular events (MACE) over 3 years:

MACE rate: 8.1% in treat-to-target vs. 8.7% in high-intensity statin (non-inferior).

No significant differences in individual components of MACE (death, MI, stroke, revascularization).

Treat-to-target achieved lower LDL levels initially but the gap closed by year 3.

Safety was similar between groups, but new-onset diabetes trended lower in treat-to-target.

Study limitations:

Open-label design (not blinded).

Limited use of combination therapy (e.g., ezetimibe) with statins.

Implications:

Treat-to-target offers an alternative to the "fire and forget" approach.

May be more patient-centered, allowing dose adjustment based on individual response.

Further research is needed on longer-term outcomes and lower LDL targets.

Additional points:

European guidelines recommend even lower LDL targets (<55 mg/dL) for high-risk patients.

Concerns remain about the potential side effects of high-intensity statin therapy.

Treat-to-target may offer a more cautious and personalized approach.

Link to article: doi:10.1001/jama.2023.2487

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Key Points of the Study:

T-TEER with the TriClip device significantly improved health status in patients with severe tricuspid regurgitation (TR) compared to medical therapy alone.

This improvement was seen in both the short-term (1 month) and long-term (1 year) after the procedure.

T-TEER patients were more likely to be alive and well (defined as good KCCQ score and no decline) at 1 year compared to those on medical therapy.

The benefit of T-TEER was greater for patients with lower baseline health scores (KCCQ).

The health status improvement after T-TEER was likely due to reduced TR and correlated with reduced mortality and heart failure hospitalizations.

In conclusion, T-TEER is a promising treatment for severe TR, leading to significant and sustained improvement in health status and quality of life for patients.

Link to article:

https://doi.org/10.1016/j.jacc.2023.10.008

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Key Points from PROMISE 2 Trial:

•Problem: 20% of CLTI patients have no revascularization options, leading to amputations.

•Solution: Transcatheter arterialization of deep veins creates an artery-to-vein connection, delivering oxygenated blood to the ischemic foot and potentially preventing amputation.

•Study: Analyzed 105 patients with no other treatment options who underwent the procedure with LimFlow Device.

•Results:

oAmputation-free survival at 6 months: 66.1%, exceeding the 54% performance goal.

oLimb salvage: 76.0%.

oWound healing: 25% completely healed, 51% in progress.

oSafety: No unanticipated device-related adverse events.

•Conclusion: Deep-vein arterialization is a safe and effective option for no-option CLTI patients, offering limb salvage, wound healing, and improved survival.

Article Link: DOI: 10.1056/NEJMoa2212754

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Key Points from this trial:

The CLASP IID trial, the first randomized controlled trial comparing the PASCAL system and the MitraClip system in prohibitive-risk patients with significant symptomatic degenerative mitral regurgitation (DMR), aimed to report primary and secondary endpoints along with 1-year outcomes for the full cohort.

In the study, 300 patients were randomized (PASCAL: n = 204; MitraClip: n = 96).

At 1 year, differences in survival, freedom from heart failure hospitalization, and major adverse events (MAE) were nonsignificant (P > 0.05 for all).

The PASCAL system demonstrated noninferiority to the MitraClip system for primary endpoints, with 30-day MAE rates of 4.6% vs. 5.4% and 6-month MR ≤2+ rates of 97.9% vs. 95.7%.

Noninferiority was also met for secondary effectiveness endpoints at 1 year, with MR ≤2+ rates of 95.8% vs. 93.8% and MR ≤1+ rates of 77.1% vs. 71.3%.

Both groups showed sustained improvements in functional classification and quality of life (P < 0.05 for all vs. baseline).

The results affirm the PASCAL system as a beneficial therapy for prohibitive-surgical-risk patients with significant symptomatic DMR.Link to article: https://doi.org/10.1016/j.jcin.2023.10.002

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Key points of the DANPACE II study on atrial pacing and atrial fibrillation in sinus node dysfunction:

Minimizing atrial pacing in pacemakers doesn't prevent atrial fibrillation (AF):

•46% of patients regardless of pacing rate (40bpm or 60bpm) experienced an AF episode lasting over 6 minutes during 2 years.

•No difference in AF rates across age, heart rhythm patterns, or prior AF history.

Safety concerns: Lower pacing rate linked to increased presyncope/syncope (22% vs 13%).

•Some patients initially assigned to 40bpm required device reprogramming to a higher rate due to these issues.

Standard pacing settings (60bpm with rate-adaptive pacing) are recommended unless individual needs require adjustment.

•Rate-adaptive pacing adjusts to activity level, providing adequate heart rate while minimizing unnecessary atrial pacing.

Optimal pacing rate remains under investigation for further minimizing AF and syncope.

•Future studies are needed to identify specific patient groups who might benefit from atrial pacing minimization.

Overall, DANPACE II clarifies pacemaker programming strategies for sinus node dysfunction patients.

•While minimizing atrial pacing isn't generally effective for preventing AF, the study provides valuable insights for optimizing pacemaker settings to ensure patient safety and well-being.

Link to article: https://doi.org/10.1093/eurheartj/ehad564

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Major Trends:

Independent Medical Board: Cardiologists seek a new board separate from the ABIM due to concerns with MOC requirements.
Scope of Practice Debates: Tensions arise over advanced nurse practitioners performing complex procedures like TAVI.
Work-Life Balance in Meetings: Live meetings return, but concerns grow about FOMO and digital fatigue.
AI in Cardiology: ChatGPT and other tools spark discussions about AI authorship in research.
Regulatory Decisions: FDA approves pulsed-field ablation, renal denervation devices, EVICD, LimFlow device, and colchicine for CAD prevention.
Transplantation Advancements: DCD hearts and genetically modified pig hearts show promise for addressing organ shortages.

Additional Notes:

The updated Medicare fee schedule emphasizes community health integration and social determinants of health.
The AMA survey on practice costs is crucial for accurate Medicare physician payments.
Shared services and team-based care with clear roles for different professions are essential.
Quality will become an increasingly important metric for Medicare reimbursement.

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Key Points of Coronary Artery Disease Studies in 2023:

•ORBITA-2: Confirmed PCI's role in relieving angina symptoms for stable patients.

•SELECT: Semaglutide (Ozempic) reduced cardiovascular events in overweight/obese patients with existing CVD.

•Left Main CAD Revascularization: Guidelines downgraded PCI to less strong recommendation for low-risk patients.

•ROMA-Women: Launched to study gender differences in CABG outcomes.

•New Chronic Coronary Disease Guidelines: Recommend SGLT2 inhibitors and GLP-1 agonists in select cases.

•REPRIEVE: Pitavastatin lowered cardiovascular risk in HIV patients on antiretroviral therapy.

•BIOVASC: Immediate PCI was safe and effective as staged procedures in ACS patients.

•Imaging Wars: ILLUMIEN IV showed a limited benefit of OCT, while RENOVATE-COMPLEX-PCI found value in complex cases.

•DAPT Duration: Studies suggest shorter regimens may be beneficial in certain patients.

•DAPA-MI: Mixed results for dapagliflozin in acute MI, but improved cardiometabolic outcomes.

•MINT: No harm seen with liberal transfusion strategy in anemic acute MI patients.

•Oral PCSK9 Inhibitor: Potential future breakthrough for LDL cholesterol control.

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

A quick rundown of the key developments:

Trials:

STEP-HFpEF
CASTLE-HTx
HEART FID
DAPA-MI

Policy and Guidelines:

ESC cardiomyopathy guidelines
Inflation Reduction Act
FDA approvals: dapagliflozin and sotagliflozin

Other Highlights:

The world's second-living patient with end-stage heart failure received a genetically modified pig heart transplant but sadly died after 6 weeks due to transplant rejection.
The ARIES-HCM3 trial
The PUSH AHF trial
The QUEST trial from China
Declining interest in advanced heart failure and transplant cardiology fellowships

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Focus on Valves:

TAVI vs. SAVR: Long-term data showed mixed results. PARTNER 3 (Sapien 3 valve) benefits declined over time, while Evolut Low Risk (CoreValve, Evolut R/PRO) favored TAVI. Experts advise caution in direct comparison.
Aortic Regurgitation: The ALIGN-AR trial demonstrated the success of the Trilogy valve for moderate-to-severe AR, with improved symptoms and quality of life.
Ross Procedure: Analysis showed excellent long-term survival (25 years) for patients undergoing the Ross procedure.
Mitral Regurgitation: The CLASP IID trial showed similar outcomes for MitraClip and Pascal devices in high-risk patients with degenerative MR, with sustained improvements.
Tricuspid Regurgitation: TRILUMINATE Pivotal trial showed significant TR reduction and quality-of-life improvements with TriClip TEER, but no mortality or heart failure hospitalization reductions. Additional analyses provided further insights.
TTVR: TRISCEND II trial found Evoque valve + therapy offered near-complete TR elimination and symptom improvements, hailed as a significant advancement.

Challenges and Future Directions:

Lead Jailing: Electrophysiologists call for improved communication between fields to address potential damage to pacemaker/defibrillator leads during tricuspid interventions.
Areas to hear more in 2024:
Long-term data from low-risk TAVI trials.
TTVR as an alternative treatment option for tricuspid valve disease.
Expanding M-TEER with multiple device options.
Artificial intelligence applications in structural heart interventions.
Novel devices and research, including TAVI-in-TAVI procedures.

Overall, 2023 was a pivotal year for structural heart disease, with advancements in valve interventions and promise for future innovation.

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Key Highlights:

Lodoco is the first anti-inflammatory approved for reducing cardiovascular events in ASCVD patients.
Bempedoic acid offers an alternative for high-risk patients who can't tolerate statins.
Semaglutide has emerged as a powerful tool for reducing cardiovascular events in overweight or obese patients with pre-existing CVD.
Recaticimab is a long-acting injectable PCSK9 inhibitor requiring less frequent dosing than existing options.
Focus on LDL Cholesterol: New data supports the "power of zero" for coronary artery calcium, prioritizing LDL reduction only in those with established atherosclerosis.
Treat-to-Target vs. High-Intensity Statins: A study (LODESTAR) shows the non-inferiority of the treat-to-target approach, adding to ongoing discussions about cholesterol management strategies.

Overall:

Shift towards prevention: 2023 saw a significant focus on research and interventions aimed at preventing cardiovascular disease rather than solely treating established cases.
Emphasis on early intervention: Studies like POP-HT highlight the importance of monitoring and modifying risk factors in young adulthood.

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Key Points of Endovascular Procedures and Devices in 2023:

FDA Actions:

Lifted restrictions on paclitaxel-coated balloons and stents for PAD after updated data showed no increased mortality risk.
Approved coverage of carotid artery stenting for Medicare beneficiaries with severe stenosis.
Approved the LimFlow device for diverting blood flow in severe CLTI patients, offering limb salvage hope.
Approved the Paradise and Symplicity Spyral systems as the first renal denervation devices in the US.

CLTI Debate:

Conflicting data from the BEST-CLI (surgery preferred) and BASIL-2 (endovascular preferred) trials emphasize patient-specific treatment decisions.

Other Developments:

LIFE-BTK trial showed promising results for a new resorbable scaffold in below-the-knee interventions.
PEERLESS II, HI-PEITHO, and STORM-PE trials are investigating advanced therapies for pulmonary embolism.

Future Outlook:

The endovascular field is poised for continued innovation with new technologies and ongoing research.
There is a need for operator training and reimbursement clarity for novel techniques like renal denervation.
Upcoming PE trials are expected to provide level 1 evidence for improved treatment options.

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Heart Rhythm 2023: Innovations in Ablation, Devices, and Conduction System Pacing.

Catheter Ablation and LAAO Advance:

CASTLE-HTx: Ablation for AF proved beneficial in patients with advanced heart failure, potentially paving the way for wider adoption.
Pulsed-field ablation (PFA): PULSED AF and ADVENT trials showed promise for novel PFA technologies like PulseSelect (Medtronic) and Farapulse (Boston Scientific).
Left atrial appendage occlusion (LAAO): WATCH-TAVR confirmed LAAO safety and efficacy alongside TAVI in severe aortic stenosis and AF.
Updated AF guidelines: Both US and European guidelines incorporated advancements in ablation, LAAO, and medications.

Medical Therapies: Mixed Bag:

NOAH-AFNET 6: Edoxaban (Savaysa) increased risks in patients with subclinical AF detected by implanted devices.
ARTESiA: Apixaban (Eliquis) reduced stroke but increased major bleeding in subclinical AF patients.
Meta-analysis: DOACs reduce ischemic stroke but significantly increase major bleeding in subclinical AF.
AZALEA-TIMI 71: Abelacimab (Anthos Therapeutics) showed promise for reducing bleeding compared to rivaroxaban in AF patients.
ReVeRA-201: Etripamil nasal spray effectively reduced ventricular rate in AF with rapid ventricular rate.
FRAIL-AF: Switching frail elderly AF patients from warfarin to DOACs increased bleeding risks.

Pacing and ICDs: Conduction System Pacing Takes Center Stage:

Large observational study: LBBAP outperformed biventricular pacing in CRT patients.
HOT-CRT pilot study: His-bundle pacing improved LV function more than biventricular pacing in CRT candidates.
EHRA consensus statement: Standardized implantation technique for conduction system pacing.
DANPACE II: Reducing atrial pacing in sinus node dysfunction patients did not lower AF risk but increased presyncope/syncope.
US FDA approves first EVICD: Aurora EV-ICD by Medtronic avoids transvenous lead complications.

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Key Points:

Multi-vessel coronary disease (MVD) in acute myocardial infarction (AMI) is still a difficult condition to manage.
Complete revascularization improves outcomes for hemodynamically stable patients without any safety concerns.
A personalized approach and evaluation by a team of heart specialists is recommended for making decisions in complex cases.
More randomized trials are needed to better understand the best timing and guidance strategy for complete revascularization.

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Key findings of the FRAIL-AF trial: * Switching from vitamin K antagonist (VKA) to non-vitamin K antagonist oral anticoagulant (NOAC) therapy was associated with an increased risk of major and clinically relevant bleeding (hazard ratio [HR] 1.69, 95% CI 1.23-2.32). There was no difference in the risk of thromboembolic events between the two groups. The trial included 1,330 patients with atrial fibrillation (AF) who were 75 years of age or older and had at least two of the following frailty criteria: * Self-reported difficulty walking 100 meters * Weight loss of >10% in the past year * Low physical activity * Low grip strength The trial was conducted in 26 centers in the Netherlands and lasted for a median of 2.4 years. The main author of the trial is Linda Joosten, MD, from the University Medical Center Utrecht in the Netherlands. The trial was published in the journal Circulation on September 1, 2023.Link to article: https://doi.org/10.1161/CIRCULATIONAHA.123.066485--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Summary of the STEP-HFpEF trial 2023 published in Nature Medicine

The STEP-HFpEF trial was a study of semaglutide in patients with obesity phenotype of heart failure and preserved ejection fraction (HFpEF).
Semaglutide improved symptoms, physical limitations, exercise function, and reduced body weight in patients with HFpEF and obesity.
The benefits of semaglutide were consistent across obesity categories.
The magnitude of the benefit of semaglutide was directly related to the extent of weight loss.
Patients who received semaglutide had a 16.6-point improvement in their Kansas City Cardiomyopathy Questionnaire-Clinical Summary Score (KCCQ-CSS), compared to an 8.7-point improvement in the placebo group.
Patients who received semaglutide walked an additional 21.5 meters in the 6-minute walk test, compared to 1.2 meters in the placebo group.
Patients who received semaglutide had a 43.5% reduction in their C-reactive protein (CRP) levels, compared to a 7.3% reduction in the placebo group.

Overall, the STEP-HFpEF trial showed that semaglutide is a promising treatment option for patients with the obesity phenotype of HFpEF. Semaglutide improved these patients' symptoms, physical limitations, exercise function, and reduced body weight. The magnitude of the benefit was directly related to the extent of weight loss.

Link to the article: https://doi.org/10.1038/s41591-023-02526-x

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Key points of the FIRE trial:

The study was a randomized trial of complete revascularization vs. culprit-only revascularization in older patients (≥75 years of age) with myocardial infarction and multi-vessel disease.
A total of 1445 patients were enrolled.
The primary outcome was a composite of death, myocardial infarction, stroke, or any revascularization at 1 year.
The key secondary outcome was a composite of cardiovascular death or myocardial infarction.
Safety was assessed as a composite of contrast-associated acute kidney injury, stroke, or bleeding.
The results showed that complete revascularization was associated with a lower risk of the primary outcome (15.7% vs. 21.0%, P=0.01) and the key secondary outcome (8.9% vs. 13.5%, P=0.01).
There was no difference in safety between the two groups.

In conclusion, the study found that complete revascularization is beneficial in older patients with myocardial infarction and multivessel disease. It is associated with a lower risk of death, myocardial infarction, stroke, and any revascularization at 1 year.

Here are some additional details from the study:

The median age of the patients was 80 years.
About 36% of the patients were women.
About 35% of the patients were admitted for ST-segment elevation myocardial infarction.
The safety outcome did not appear to differ between the groups, but the study was not powered to detect differences in safety.

The study findings support the use of complete revascularization in older patients with myocardial infarction and multivessel disease. However, it is important to note that the study was conducted in a single center and the results may not be generalizable to all patients. Further research is needed to confirm the findings of this study.

Link to the article: DOI: 10.1056/NEJMoa2300468

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

These are the key points from this 2023 ACC/AHA guideline in managing chronic coronary disease.

Patients with chronic coronary disease should receive care from a team of healthcare professionals (Team-based, patient-centered care)
All patients with chronic coronary disease should be encouraged to make healthy lifestyle changes (nonpharmacologic therapies).
Patients with chronic coronary disease who can exercise should be encouraged to participate in habitual physical activity.
Sodium-glucose cotransporter two inhibitors and glucagon-like peptide-1 receptor agonists can be helpful for some patients with chronic coronary disease.
Beta-blockers are no longer recommended for all patients with chronic coronary disease except in people who have had a heart attack in the past year, have a left ventricular ejection fraction of less than 50%, or have another condition that requires them to take beta-blockers.
Statins are still the first-line therapy for lowering cholesterol in patients with chronic coronary disease. Consider PCSK9i, inclisiran, and bempedoic acid as alternative or additional therapies.
Shorter durations of dual antiplatelet therapy are safe and effective in many patients with chronic coronary disease.
There is no evidence that nonprescription or dietary supplements benefit patients with chronic coronary disease.
Routine periodic anatomic or ischemic testing is not recommended for risk stratification or to guide therapeutic decision-making in patients with chronic coronary disease.
E-cigarettes increase the likelihood of successful smoking cessation compared with nicotine replacement therapy, but they are not recommended as first-line therapy for smoking cessation. Reference article: https://doi.org/10.1016/j.jacc.2023.06.006

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

The ATTRibute-CM trial was a randomized, double-blind, placebo-controlled trial that evaluated the efficacy and safety of acoramidis in patients with transthyretin amyloid cardiomyopathy (ATTR-CM). The trial enrolled 632 patients with symptomatic ATTR-CM. Patients were randomly assigned to receive either acoramidis 800 mg twice daily or a placebo for 30 months.

The trial's primary endpoint was a hierarchical analysis of all-cause mortality, cardiovascular-related hospitalization, NT-proBNP, and 6-minute walk distance. The trial found that acoramidis was associated with a number of benefits compared to placebo, including:

A 25% reduction in all-cause mortality
A 50% reduction in cardiovascular-related hospitalizations
A 39.64-meter improvement in 6-minute walk distance
A 9.94-point improvement in KCCQ-OS score
A 7.1 mg/dL increase in serum transthyretin levels

Acoramidis was generally well-tolerated. The most common side effects were nausea, vomiting, and diarrhea.

The results of the ATTRibute-CM trial suggest that acoramidis is an effective and safe treatment for ATTR-CM. Acoramidis is a potential alternative to tafamidis, the only other FDA-approved drug tafamidis for treating ATTR-CM.

Here are some additional details about the ATTRibute-CM trial:

The trial was conducted in 40 countries.
The median age of the participants was 78 years.
The majority of the participants were male (90%).
The most common ATTR-CM subtype was wild-type (80%).
The trial was funded by Akcea Therapeutics.

The results of the ATTRibute-CM trial are a major step forward in the treatment of ATTR-CM. Acoramidis offers a new option for patients with this serious condition, and it is likely to be an important treatment option for many years to come.

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Key Points from ARREST trial findings:

The study included 862 patients who were resuscitated after a cardiac arrest.
The patients were randomly assigned to be taken to either a well-resourced cardiac arrest center or the nearest emergency department.
The primary outcome of the study was survival to 30 days. The secondary outcome was survival to 90 days.
There was no difference in the survival rate between the two groups of patients (63% in the cardiac arrest center group vs. 63% in the emergency department group).
The authors of the study say that the results suggest that there is no need to transport patients to a cardiac arrest center after a cardiac arrest if the nearest emergency department can provide the same level of care.

Link to the reference article: https://doi.org/10.1016/S0140-6736(23)01351-X

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

Here is a summary of the key points from the 2023 ESC guidelines for the management of endocarditis:

Prevention: People at high risk of endocarditis should take steps to prevent it, such as taking antibiotics before dental procedures.
Diagnosis: The diagnosis of endocarditis is based on a combination of clinical features, blood cultures, and imaging studies.
Antimicrobial therapy: The duration of antibiotic treatment depends on whether the infection is native valve endocarditis (NVE) or prosthetic valve endocarditis (PVE).
Indications for surgery: Surgery may be indicated in patients with endocarditis who have heart failure, uncontrolled infection, or a high risk of emboli.
Other complications of IE: IE can also lead to other complications, such as neurological problems, infective aneurysms, and myocarditis.
Surgical therapy: Surgery may be necessary to treat complications of IE, such as heart failure or uncontrolled infection.
Outcome after discharge: Patients treated for IE should remain under close surveillance for long-term complications.
Patient-centered care: A recovery plan should be developed for patients treated for IE, considering their individual needs.
Sex differences: Female sex is less common in patients diagnosed with IE.

Link to Reference article: https://doi.org/10.1093/eurheartj/ehad193

--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

This review highlights the following points: There are different ways to prevent blood clots in patients who have undergone LAAO for atrial fibrillation (AF). Taking a direct oral anticoagulant (DOAC) alone is associated with a lower risk of blood clots in the device and death than not taking any antithrombotic medication. For patients who are not at high risk of bleeding, taking a DOAC alone is likely the best way to prevent blood clots after LAAO. This is because it balances the risk of bleeding and blood clots.Link for the article: DOI: 10.1016/j.jacc.2023.08.010--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

The review article was published in the Journal of the American College of Cardiology in August 2023 and was co-authored by Dr. Kyle Nelson, Dr. Valentin Fuster, and Dr. Paul Ridker. The review found that low-grade systemic inflammation, as determined by hsCRP, is a more powerful determinant of recurrent cardiovascular events, cardiovascular death, and all-cause mortality than low-density lipoprotein cholesterol (LDL-C).The review also found that the recent randomized trials of the interleukin-1 inhibitor canakinumab and of the microtubule polymerization inhibitor low-dose colchicine provide evidence that inflammation inhibition safely lowers cardiovascular event rates among statin-treated patients with a magnitude of effect similar to if not greater than that of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, ezetimibe, and other adjunctive lipid-lowering agents.The review concluded that low-dose colchicine (0.5 mg po qd) is an effective and safe therapy for the secondary prevention of CAD. It is particularly beneficial for patients with high hsCRP levels.Reference Article: https://doi.org/10.1016/j.jacc.2023.05.055--- Send in a voice message: https://podcasters.spotify.com/pod/show/dr-bishnu-subedi/message

LM CAD treatment needs sophisticated decision-making. Recent clinical practice standards guide clinicians; however, treating individual individuals might be tough. Anatomy and physiology determine LM CAD manifestations. Recognizing the complexity of LM CAD, which rarely occurs alone and sometimes with multivessel disease, a treatment protocol using medical therapy alone or in combination with PCI or CABG is proposed. It is best to have a strategy for the heart team that takes into account clinical, procedural, operator, and institutional factors and uses collaborative decision-making to meet the needs and clinical situations of each patient.

Link to the original article:

https://www.jacc.org/doi/full/10.1016/j.jacc.2022.09.034

https://www.sciencedirect.com/science/article/pii/S0735109722070267?via%3Dihub

Screening for Asymptomatic Carotid Artery Stenosis in the General Population: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force, published in JAMA on February 2, 2021.

Link for the article: https://jamanetwork.com/journals/jama/fullarticle/2775704

The understanding, diagnosis, and treatment options for transthyretin (TTR) amyloid is rapidly evolving. American Heart Association published a statement titled "Cardiac Amyloidosis: Evolving Diagnosis and Management: A Scientific Statement From the American Heart Association". I have tried to present the key elements of this article.

Link: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000792