'Why we do What we do in Cardiology‪'‬ Bishnu Subedi

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






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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








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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; P0.001).

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




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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




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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



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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




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