'Why we do What we do in Cardiology'

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: o Amputation-free survival at 6 months: 66.1%, exceeding the 54% performance goal. o Limb salvage: 76.0%. o Wound healing: 25% completely healed, 51% in progress. o Safety: 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: 1. 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. 2. 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. 3. 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. 4. 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. 5. 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) favoured 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: The TRISCEND II trial found that Evoque valve + therapy offered near-complete TR elimination and symptom improvements, which was 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