 Check out the latest coverage of the European Society of Cardiology Congress 2020

ESC Congress 2020

New data from an analysis of the CoreValve High-Risk Trial is detailing the effects of transcatheter and surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis.

Results from the 5-year follow-up in the study suggest high-risk patients saw early benefit from transcatheter aortic valve replacement (TAVR) but identified no long-term differences in health status between SAVR and TAVR.

With TAVR proving to be one of the most impactful advances in cardiovascular medicine in recent decades, many have been waiting anxiously to see how this approach might benefit patients with severe symptomatic aortic stenosis. While the results of the CoreValve High-Risk Trial suggest those undergoing TAVR had greater rates of survival, data that has been published since the original results were released suggests this effect dissipates by 5 years.

CoreValve High-Risk was designed as a randomized clinical trial of 795 high-risk aortic stenosis patients randomized to TAVR or SAVR. In the trial, patients randomized to SAVR were treated using conventional open-heart techniques with the use of cardiopulmonary bypass and were administered aspirin at a dose of at least 81 mg daily indefinitely following the procedure.

Those randomized to TAVR received the CoreValve self-expanding prosthesis. Patients randomized to TAVR were recommended to dual antiplatelet therapy with aspirin and clopidogrel before the procedure and for 3 months following the procedure. Following the 3-month period, trial design recommended TAVR patients receive aspirin or clopidogrel monotherapy at the same dose indefinitely. At 1 year, results of the original trial indicated a significantly lower rate of all-cause mortality (14.2% vs 19.1%) among patients randomized to TAVR than those randomized to SAVR.

Of the 795 included in CoreValve High-Risk, 713 patients had baseline health status data available and were included in the current analysis. Of the 713 included in the study, 53% were men, the mean age of the group was 83 (7) years, and the mean Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary (OS) score was 46.7 (22.8). In total, 377 patients in the current analysis were randomized to TAVR and 336 were randomized to SAVR—investigators pointed out these groups were well-matched other than an increased prevalence of diabetes in the SAVR arm.

At 1-month, investigators noted TAVR was associated with greater improvements in health status compared to SAVR with results indicating a mean 1-month difference in KCCQ OS score of 16.8 points (95% CI, 12.4-21.2). At 6 months, this difference was no longer evident and there were no significant differences in health status between study arms after that point. When assessing data at 5 years, investigators found 44% (134 of 305) of the patients who underwent TAVR and 39% (105 of 266) of the patients who underwent SAVR were still alive.

Of those who survived and had health status data available, 61% (48 of 79) in the TAVR group and 65% (46 of 71) in the SAVR group had a KCCQ overall summary score greater than 60 (

=.61). Investigators also pointed out there were no significant differences between TAVR and SAVR among noniliofemoral patients included in the study.

“In light of concerns about potential deleterious effects of TAVR-related complications, including paravalvular leak, need for permanent pacing, leaflet thrombosis, or structural valve deterioration (each of which could adversely affect health status), our findings are reassuring that there were no long-term differences in health status by treatment, despite differential rates of complications,” wrote study investigators.

Five-Year Health Status After Self-expanding Transcatheter or Surgical Aortic Valve Replacement in High-risk Patients With Severe Aortic Stenosis

Articles

A prespecified analysis of a clinical trial in high-risk aortic stenosis patients found no differences in health status at 5 years among patients undergoing SAVR vs TAVR. 

No Difference in 5-Year Health Status Among High-Risk Patients Undergoing TAVR or SAVR

A female in her early 50’s with prior cardiac ablation for AV nodal reentrant tachycardia presents to the ED for 3 days of constant palpitations and chest pressure. She has had the same symptoms frequently for over 6 months and two ablations have not helped. She states that her heart rate is normally in the 120s at rest but recently has been in the 140s-150s. She denies fever, syncope, leg pain or swelling or other complaints.

: Vital signs are normal except for a pulse of 155. Exam is otherwise normal.

Atrial Flutter with rapid ventricular response

Our latest Emergency Department Minute Quiz from Brady Pregerson, MD. Can you determine the correct diagnosis?

Emergency Department Minute Quiz: Palpitations and Chest Pressure

In the wake of the coronavirus disease 2019 (COVID-19) pandemic, remote patient monitoring and implementation of telemedicine approaches have gone from fringe topics to centerstage. While, for most, the revelation during this unique time period has been that telemedicine options provide a viable alternative for many patients, there are certain specialties that are more difficult to transfer into a digital space.

Without regard to specialty, this time period has led to stringent evaluations and reevaluations of thousands of medical procedures and routines. A major topic of discussion in the realm of telemedicine even before the pandemic was home monitoring of patients with cardiovascular diseases. In a study presented at a conference earlier in 2020, Kazem Rahimi, MD, and a team examined the effects of home monitoring on quality of life in patients with heart failure. Rahimi refers to the trial as one of the rigorous, in terms of design and criteria, to examine the topic and, while it failed to reach statistical significance, provided valuable insight into what else is needed in terms of technology and home monitoring to make this a viable option for all patients.

Videos

Kazem Rahimi, MD, discusses the prospect of home monitoring for heart failure patients and how technology needs to improve before it is a viable option for most patients.

Kazem Rahimi, MD: Home Monitoring for Cardiology Patients

A century ago if one were to seek out a physician, they would likely have had only two specialties to choose from, a surgeon or a medical doctor. Even earlier those two would be one and the same. Now, the medical profession consists of dozens of specialties and likely over a hundred subspecialties.

The argument for subspecialization is sound and exists in its purest form within the old saying, a jack of all trades is a master of none. However, some would claim that too many subspecialties only serve to dilute or minimize the parent specialty negating the foundational work already done. So, what is the answer and how much is too much?

The most common and valid reason to create a new subspecialty is to address newly discovered disease categories that may benefit from a more focused approach within an established specialty. It is well known that diabetes, heart disease, and obesity are increasing globally. It is further known that this cluster, known as the metabolic syndrome, increases the risk for cardiovascular (CV) events and death.

Classically, diabetes is managed by endocrinologists who are sub-specialists of internal medicine. Likewise, cardiologists treat patients with heart conditions and are also subspecialists of internal medicine. There is a clear intersection between the work of endocrinologists and cardiologists. However, this is true of most specialties and subspecialties in medicine. So, what would warrant either discipline claiming dominion over patients with cardiometabolic disease?

Recent investigations have led to a discussion with regards to creating a cardiometabolic medical subspecialty. Research has revealed that drugs used to treat diabetes are independently associated with improved cardiovascular outcomes and reduced mortality related to CV disease.

In particular the glucagon-like peptide-1 receptor agonist (GLP-1) class of drugs and the sodium-glucose co-transporter 2 (SGLT2) inhibitors have been shown to improve CV risk, mortality, and heart failure.

 The question becomes, who should manage the patient with type 2 diabetes and a glycosylated hemoglobin (HbA1c) of 9% who has been admitted for a non-ST elevation myocardial infarction (NSTEMI)?

I believe that there is a strong argument for cardiologists taking a bigger role in managing patients with cardiometabolic disease. While endocrinologists and diabetologists are focused on managing blood sugar and minimizing the risk of diabetes-related complications, the most deleterious complications from diabetes remain cardiovascular disease and death from cardiac events. As such, once an obese, diabetic patient develops cardiovascular disease, they will come under the care of a cardiologist. Andrew Krentz, MD, and colleagues in the UK believe that the cardiologist, as the cardiometabolic specialist, should take the lead in coordinating care aimed at reducing cardiovascular risk including management of metabolic disease in patients with established cardiovascular risk.

 Robert Eckel, MD, would agree and go further by calling for a cardiometabolic subspecialty training program with its home in cardiology.

While many find the idea of a cardiometabolic specialty appealing, others do not. Turf wars are common in medicine even without the specter of business being funneled away or diminished authority over a body of work. Endocrinologists would argue that there is no need for a cardiometabolic subspecialty since they have been leading that work for some time. Further, creating a new subspecialty that largely deals with endocrine disorders that coincide with cardiovascular disease would further diminish the number of physicians going into endocrinology—an already underrepresented group. Cardiology itself has become a procedure driven specialty creating more revenue than specialties that classically treat chronic medical conditions, a fact adding to the resistance from endocrinologists.

So, who is right? The answer is neither and both. 

There is no doubt that we need more endocrinologists. Cardiologists are not going to be managing obese 18-year-old patients without cardiovascular disease just as endocrinologists will not be performing cardiac catheterizations on their diabetic clients.

In my opinion, there exists plenty of red meat to be had by all. The benefit of developing a cardiometabolic subspecialty lies in the spotlight it would create leading to research and advancements specific to the interplay of CV risk and the metabolic syndrome. The argument that doing so would detract from either endocrinology or cardiology could be satisfied by including both specialties in the training programs. Allowing both cardiologists and endocrinologists pathways to certification in a cardiometabolic subspecialty solves most of the problems with regards to marginalization eliminating the tendency for specialties to silo medical conditions into their own domain. Further, combining specialties may foster more collaboration and a more patient-centered approach. After all, at the end of the day, it is really about the patients, not about our specialty’s numbers or recognition for our efforts.

Gregory Weiss, MD, reflects on the idea of creating a cardiometabolic subspecialty. 

Gregory Weiss, MD: Has the Time Come for a Cardiometabolic Subspecialty?

A simple solution could cut time and streamline care for stroke patients, according to results of a randomized controlled trial conducted in Germany.

In the study, use of a large display alarm clock in a hospital’s computed tomography (CT) room contributed to more streamlined care—suggesting implementation of such an approach could help to achieve the American Heart Association/American Stroke Association’s target recommendation of 60 minutes or less from the time a 

 patient arrives to the hospital to the time of clot-busting treatment.

"Time is brain. Minutes are easily lost in acute stroke management, despite standard protocols," said study author Klaus Fassbender, MD, professor of neurology at Saarland University Medical Center in Homburg, Germany, 

. "The stroke alarm clock is a low-cost intervention and an efficient way to quickly deliver life-saving treatment to acute stroke patients."

With the goal of identifying cost-effective means of improving acute stroke management, Fassbender and more than a dozen colleagues sought to determine whether a feedback-demanding stroke clock could help streamline care. With this in mind, investigators designed a randomized controlled study to assess whether a large display alarm clock installed in the CT room, which is where admission, diagnostic work-up and intravenous thrombolysis occurred, at the Saarland University Medical Center.

The alarm clock installed in the room was designed to provided alarms at the end of 3 specific time periods. The first time period lasted 15 minutes, the second lasted 20, and the third lasted 30 minutes. The first time period marked the amount of time it should take to complete the neurological exam, the second time period represented the amount of time it should take to complete CT scanning and international normalized ratio determination by point-of-care (POC) laboratory, and the third time period represented the time it should take to begin intravenous thrombolysis.

Physicians were required to provide feedback in the form of pressing a button when the alarm sounded. Investigators pointed out the alarm could be avoided by pressing the button prior to the time period ending.

The primary end point of the study was time to therapy decision, which investigators defined as the end of all guideline-recommended diagnostic work-up required for decision-making for or against reanalyzing treatments. Secondary end points for the study included time for door-to-end of neurological examination, end-of-POC laboratory, end-of-native CT, end-of-CT angiography, and, if indicated, start of intravenous thrombolysis and thrombectomy, and achievement of recanalization.

In total, 107 patients were included in the trial. Of these, 56 were randomized to the alarm clock group and 51 were randomized to standard care. Investigators pointed out demographic and medical characteristics, including final diagnoses, were similar between the study arms.

Upon analysis, results indicated time from door to end of all indicated diagnostic work-up (treatment decision time; 16.73 vs 26.00 minutes, 

 <.001), end of neurological examination (7.28 vs 10.00 minutes, 

 <.001), end of CT (11.17 vs 14.00 minutes, 

=.002), end of CT angiography (14.00 vs 17.17 minutes, 

=.001), end-of-POC laboratory testing (12.14 vs 20.00 minutes, 

<.001), and start of intravenous thrombolysis (18.83 vs 47.00 minutes, 

=.016) were improved for patients randomized to the alarm clock group.

However, investigators noted the there was no significant difference in time to start of thrombectomy and functional outcomes at day 90 between the study arms. In the aforementioned statement, Fassbender noted the study was not designed to evaluate long-term outcomes and noted the need for larger studies to confirm the effect of the clock on outcomes.

"A limitation of this study was its size. We need more patients to determine whether accelerated acute stroke management with the clock translates to less death and disability long-term,” Fassbender added.

Effects of a Feedback-Demanding Stroke Clock on Acute Stroke Management

Could an alarm clock in the room where stroke care is performed contribute to more streamlined care?

"Stroke Clock" Could Help Streamline Care of Acute Stroke Patients

New research from a George Institute for Global Health-led team suggests rates of recurrent heart attacks have declined but also revealed the declines seen in recent years were not equal between sexes.

While results indicated rates of recurrent events have declined from 2008-2017, data indicates the decline among men was slower than that among women and the risk for recurrent events and death remain high in 

"We expected to see a decline in the rate of events, however, we did not expect the rates to differ between the sexes,” said lead investigator Sanne A. E. Peters, PhD, senior lecturer at The George Institute for Global Health, 

. “It may be that the improvements in men were achieved before our study period, leaving less room for improvement in the most recent decade. It could also be that the attention paid to heart disease in women over recent years has resulted in the greater gains.”

With significant advances in care and management of cardiovascular health in recent decades, investigators sought to further our understanding of declines in events between men and women who had suffered a previous event. To do so, they designed their study as an analysis of data from the MarketScan and Medicare databases between 2008-2017.

In total, investigators identified 770,408 women and 700,477 men who had a myocardial infarction during the aforementioned time frame for analysis. To avoid including duplicate patients, investigators excluded beneficiaries in the Marketscan database 65 years and younger and beneficiaries 66 years of age or older from the Medicare database. Inclusion criteria for the study were an overnight hospitalization for myocardial infarction of less than 30 days, live in the US, and have continuous coverage from 365 days prior to their admission date through the discharge date.

For the purpose of the analysis, investigators chose recurrent myocardial infarction, recurrent coronary heart disease (CHD) event, heart failure hospitalization, or death within 365 days of hospitalization. Investigators used Poisson regression models to estimate women-to-men risk ratios (RR) for each outcome in each calendar year. Of note, these models were adjusted for age, sex/ethnicity, region of residence, Medicare-Medicaid dual eligible, diabetes and use of insulin, history of CHD, history of stroke, history of heart failure prior to hospitalization, incident heart failure during the hospitalization, and a slew of other factors.

Upon analysis, the age-standardized recurrent myocardial infarction rates per 1000 person-years decreased from 89.2 to 72.3 in women from 2008-2017 and from 94.2 to 81.3 among men during that same time frame (

 <.001). For recurrent CHD event rates, investigators noted declines from 166.3 to 133.3 in women and from 198.1 to 176.8 in men during that same time period (

For heart failure hospitalization, rates decreased from 177.4 to 158.1 in women and from 162.9 to 156.1 among men (

.001). For all-cause mortality, investigators observed rates decreased from 403.2 to 389.5 in women and from 436.1 to 417.9 in men (

=.82). Additionally, investigators found rate ratios of 0.90 (0.86-0.93) for recurrent myocardial infarction, 0.80 (0.78-0.82) for recurrent CHD events, 0.99 (0.96-1.01) for heart failure hospitalization, and 0.82 (0.80-0.83) for all-cause mortality when comparing risk for women versus men.

“Regardless of the improvements, the rates of recurrent events in people who survived a heart attack are still very high in both sexes. Patients should speak with their doctors to ensure that the get the right treatments to prevent secondary events and must make sure that they adopt or maintain a healthy lifestyle," added Peters.

Trends in Recurrent Coronary Heart Disease Following Myocardial Infarction Among US Women and Men Between 2008 and 2017

While rates of recurrent events have declined, the rates of decline have not been equal between sexes and risk of recurrent events still pose a serious risk to heart attack survivors.

Recurrent Events Declining, But Remain a Serious Risk for Heart Attack Survivors

An unspoken concern for many following a heart attack, new research suggests resumption of sexual activity following a heart attack was associated with increased chances for long-term survival.

An analysis of nearly 500 patients aged 65 or younger, results suggest those who maintained or increased their frequency of sexual activity following a heart attack reduced their risk of death by 35% compared to those who decreased or abstained from sexual activity following their heart attack.

“Sexuality and sexual activity are markers of wellbeing,” said lead investigator Yariv Gerber, PhD, professor of epidemiology at Tel Aviv University , 

. “Resumption of sexual activity soon after a heart attack may be a part of one’s self-perception as a healthy, functioning, young and energetic person. This may lead to a healthier lifestyle generally.”

For many the idea of returning to vigorous physical activity after myocardial infarction can be intimidating. While previous studies have examined a link between resuming sexual activity and improvements in survival following myocardial infarction, investigators pointed out they failed to assess the impact of resuming sexual activity in the period immediately after the event.

With this in mind, Gerber and a team of colleagues designed the current study with the goal of assessing the impact of resuming or abstaining sexual activity within the first 6 months following acute myocardial infarction. Pulling data from the Israel Study of First Acute Myocardial Infarction, investigators identified 495 patients who met their inclusion criteria for the study.

The Israel Study of First Acute Myocardial Infarction enrolled more than 1600 patients from 1992-1993, however for inclusion in the analysis, patients needed to provide information related to sexual activity before hospitalization and during a second interview 3-6 months detailing sexual activity after hospitalization. In total, 560 patients met these criteria but 65 were eliminated as they reported no sexual activity at baseline.

Of the 495 patients included, 90% were men and the mean age was 53±8 years. From the interviews, investigators determined 73% of patients were sexually active at least once a week prior to the index event. Additionally, 88% of patients resumed sexual activity after the event but only 60% of the total cohort reported similar frequency of sexual activity before and after the event. Based on these results, investigators categorized 263 patients into a group defined by maintained or increased frequency of sexual activity 3-6 months following myocardial infarction and 232 into a group defined by a decrease or entirely abstaining from sexual activity following myocardial infarction.

During the follow-up period, which had a median length of 22 years, 43% of patients included in the current study died. Upon analysis, investigators found maintaining or increasing sexual activity frequency was inversely associated with all-cause mortality (HR, 0.65; 95% CI, 0.48-0.88) when compared against abstaining or reducing frequency. Furthermore, results revealed the inverse association was more robust for non-cardiovascular mortality (HR, 0.56; 95% CI, 0.36-0.85) than cardiovascular mortality (HR, 0.90; 95% CI, 0.53-1.51).

In the aforementioned statement, Gerber noted the observational nature of the study prevents investigators from drawing direct conclusions on the link between sexual activity and increased survival and, because of this, cautions against overinterpretation of results.

“Numerous physical and psychosocial health parameters are required for maintaining regular sexual activity,” Gerber added. “In light of this, the net benefit of sexual activity itself is still a matter of debate.”

Resumption of sexual activity after acute myocardial infarction and long-term survival,

European Journal of Preventive Cardiology.

New data suggest resuming or increasing sexual activity shortly after myocardial infarction could reduce risk of mortality. 

Resuming Sexual Activity Post-Heart Attack Could Increase Survival 

: A man in his 70’s w/ ESRD on peritoneal dialysis, type 2 diabetes, and diastolic heart failure presented to the emergency department for a 2-day history of dyspnea worse than his baseline dyspnea that started yesterday around 4 pm. He takes torsemide for CHF and denies any missed doses. His baseline is dyspnea after walking for 5 minutes, but today and yesterday he felt dyspneic walking between rooms at home. He endorses some mild abdominal distension, but denies any abdominal pain, fever, chills, new leg swelling, chest pain, or other complaints.

Vital signs are normal except for a pulse ox of 92% on room air

LUNGS: labored respirations. Bibasilar rales. No wheezing.

HEART: Normal rate. Regular. Normal heart sounds.

ABDOMEN: Soft, non-tender. No guarding. No rebound. 

T-wave abnormality, consider lateral ischemia

Emergency Department Minute Quiz: Chest Pain in CAPD Patient

This video features an interview examining cholesterol management with Guy Mintz, MD, director of cardiovascular health and lipidology at Sandra Atlas Bass Heart Hospital, North Shore University Hospital and board member of the National Lipid Association. With the backdrop of National Cholesterol Education Month, the following interview is centered around the challenges of cholesterol education and the current state of 

While statins have been a mainstay for decades, new agents have recently received approval and our beginning to cement their roles in treatment algorithms. Still, even with this progress, cholesterol management remains a challenge and, for many patients, the issue can be traced back to misunderstanding the role cholesterol plays in cardiovascular risk. For more on the subject, we reached out to Mintz for his perspective.

Chief member of Practical Cardiology's editorial advisory board discusses his approach to cholesterol education and the current state of cholesterol management in 2020. 

Guy Mintz, MD: National Cholesterol Education Month 2020

A study assessing the effects of smoking on health from a population of more than 16k pairs of twins details the effects of smoking on risk of fatal bleeding events in the brain.

Results of the study, which included more than 800k person-years of follow-up data, suggest those who identified as heavy or moderate smokers had a 3 times greater risk of 

 and even those considered light smokers found themselves at 2.8 times greater risk of fatal brain bleeds than their twins who did not smoke.

“Our study provides further evidence about the link between smoking and bleeding in the brain,” said corresponding researcher Ilari Rautalin, BM, a sixth-year medical and PhD student at the University of Helsinki in Finland, in a statement.

After a recent study of twins found SAH was mainly of nongenetic origin, a team of investigators from the University of Helsinki sought to further their understanding of the effect environmental factors have on SAH. With a hypothesis that smoking causes SAH, investigators designed their study using data from the Finnish Twin Cohort study.

From the Finnish Twin Cohort Study, which was initiated in 1974, investigators obtained information related to 16,282 same-sex twin pairs enrolled between 1976-2018. Participants identified for inclusion completed baseline surveys that collected data related to smoking status, hypertension, leisure-time physical activity, body max index, education level, and alcohol use. For the purpose of the current analysis, smokers were categorized as smokers and non-smokers—smokers were further categorized based on number of cigarettes smokers per day defined as light (less than 10), moderate (10-19), or heavy smokers (20 or more).

Participants were followed through the end of 2018 or until death, migration out of Finland, or death. Investigators ascertained deaths from SAH through the use of a nationwide cause-of-death registry. Additionally, pairs of twins were classified as monozygotic, dizygotic, or of unknown zygosity.

In total, 869,469 person-years of follow-up data were included in the investigators’ analyses. During this period, they were able to identify 116 discordant and 2 concordant twin pairs for fatal SAH. Of these, 25 of the discordant pairs were monozygotic. Upon analysis, investigators found smoking was associated with increased risk of SAH death when compared to patients who were considered never smokers (HR, 3.33; 95% CI, 2.24-4.95). Additionally, both heavy (HR, 3.01; 95% CI, 1.58-5.73) and moderate smokers (HR, 3.98; 95% CI, 2.44-6.49) appeared to have a greater risk for fatal SAH than light smokers (HR, 2.83; 95% CI, 1.64-4.9).

In pairwise analyses, investigators found the twin who smoked was at more than a 6 times greater risk for fatal SAH (HR, 6.33; 95% CI, 1.87-21.4) than their nonsmoking twin when assessing discordant pairs. Further analysis indicated this apparent association was consistent regardless of the twin pairs’ zygosity or sex.

“This long-term study in twins helps to confirm the link between subarachnoid hemorrhage and smoking,” said Rose Marie Robertson, MD, FAHA, the American Heart Association (AHA)’s deputy chief science and medical officer and co-director of the AHA Tobacco Center for Regulatory Science, in a 

 “Not smoking or quitting if you've already started, is an essential component of primary prevention.”

Smoking Causes Fatal Subarachnoid Hemorrhage

Results of the analysis offer further clarity on the detrimental impact of smoking on overall and cerebrovascular health.

No Difference in 5-Year Health Status Among High-Risk Patients Undergoing TAVR or SAVR

Emergency Department Minute Quiz: Palpitations and Chest Pressure

Kazem Rahimi, MD: Home Monitoring for Cardiology Patients

Gregory Weiss, MD: Has the Time Come for a Cardiometabolic Subspecialty?

"Stroke Clock" Could Help Streamline Care of Acute Stroke Patients

ESC Congress 2020

"Stroke Clock" Could Help Streamline Care of Acute Stroke Patients

Recurrent Events Declining, But Remain a Serious Risk for Heart Attack Survivors

Resuming Sexual Activity Post-Heart Attack Could Increase Survival

Emergency Department Minute Quiz: Chest Pain in CAPD Patient

Guy Mintz, MD: National Cholesterol Education Month 2020

Study of Twins Sheds Light on Smoking and Risk of Fatal Subarachnoid Hemorrhage