The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.
ARRHYTHMIAS
Improved survival after sudden cardiac arrest in competitive athletes (April 2025)
Sudden cardiac arrest (SCA) is a leading cause of death among competitive athletes. Two recent observational studies evaluated outcomes after SCA in athletes:
●A study of over 29 million runners who completed marathons and half-marathons between 2010 and 2023 found that while the incidence of SCA remained stable over time, SCA mortality declined by nearly 50 percent from historical controls (from 0.4 to 0.2 per 100,000) [1].
●Another study of nearly 650 young competitive athletes who experienced SCA between 2014 and 2023 demonstrated a trend towards improved survival over this period; however, there were racial differences in survival that may have been attributable to social determinants of health [2].
While improvements in survival after SCA are likely due to better on-scene medical care (eg, bystander cardiopulmonary resuscitation, automatic external defibrillators), disparities in such care may explain the racial differences in observed outcomes. (See "Athletes: Overview of sudden cardiac death risk and sport participation", section on 'Prognosis of sudden cardiac arrest'.)
Competing risks when resuming direct oral anticoagulants after intracerebral hemorrhage (March 2025)
Patients with atrial fibrillation and intracerebral hemorrhage (ICH) often have long-term competing risks of ischemic stroke and recurrent ICH. Limited data are available to help quantify these risks in patients taking direct oral anticoagulants (DOACs). In an open-label trial of 319 patients with prior ICH and atrial fibrillation who were randomly assigned to treatment with a DOAC or withholding anticoagulation, the subsequent ischemic stroke rate was lower in those assigned to a DOAC (0.8 versus 8.6 per 100 patient-years), but this benefit was partially offset by an increase in ICH recurrence (5 versus 0.8 per 100 patient-years) [3]. All-cause mortality was similar between groups, with wide confidence intervals. These data support the feasibility of resuming anticoagulation with a DOAC in selected patients with ICH but highlight the importance of shared decision-making incorporating these competing risks. (See "Spontaneous intracerebral hemorrhage: Secondary prevention and long-term prognosis", section on 'Therapeutic options'.)
Conduction system pacing as an alternative to right ventricular pacing (March 2025)
Left bundle (LB) and His bundle (HB) pacing, collectively known as conduction system pacing, are alternatives to traditional right ventricular (RV) pacing; while LB pacing has a lower rate of complications than HB pacing, the clinical benefits of LB pacing are uncertain. In a large retrospective study that compared nearly 6200 patients who underwent conduction system pacing with nearly 17,000 patients who underwent traditional RV pacing, conduction system pacing was associated with a lower risk of heart failure hospitalization (hazard ratio [HR] 0.70, 95% CI 0.52-0.94) and all-cause mortality (HR 0.66, 95% CI 0.57-0.77) [4]. LB pacing was associated with comparable clinical outcomes and lower complication rates compared with HB pacing. LB pacing may be a good alternative for patients who are anticipated to require frequent ventricular pacing, such as those with atrioventricular block. (See "Permanent cardiac pacing: Overview of devices and indications", section on 'Conduction system (His or left bundle) pacing'.)
Bleeding risk with direct oral anticoagulants (March 2025)
Direct oral anticoagulants (DOACs) are often preferred to warfarin since they do not require routine monitoring, but bleeding risks are uncertain. A new meta-analysis of data from randomized trials involving over 26,000 individuals prescribed a DOAC or low-dose aspirin reported that bleeding risks with DOACs were similar to low-dose aspirin, which carries a small increased risk [5]. However, clinicians should use caution when comparing bleeding risks between DOACs from different trials, as trial populations may differ and data from direct comparisons are limited. (See "Risks and prevention of bleeding with oral anticoagulants", section on 'Drug class'.)
CORONARY HEART DISEASE, ACUTE
Colchicine after acute myocardial infarction (January 2025)
The efficacy of colchicine for prevention of recurrent myocardial infarction (MI) remains unclear. One previous trial in patients with MI found that colchicine decreased the rate of a composite cardiovascular endpoint compared with placebo, but this effect was largely driven by lower rates of angina and stroke; rates of mortality and recurrent MI were similar. In a more recent trial in over 7000 patients with acute MI, rates of death, recurrent MI, and stroke were comparable among patients treated with colchicine or placebo over a median of three years [6]. In patients with acute MI, we do not routinely treat with colchicine for secondary prevention of cardiovascular events. (See "Overview of the nonacute management of ST-elevation myocardial infarction", section on 'Colchicine'.)
Spironolactone for patients with acute myocardial infarction and normal left ventricular ejection fraction (January 2025)
In patients with heart failure (HF) with reduced ejection fraction (HFrEF), mineralocorticoid receptor antagonists (MRA; eg, spironolactone) reduce the risk of death and worsening HF; however, the efficacy of MRAs in patients with acute myocardial infarction (MI) and normal left ventricular ejection fraction (LVEF) remains unclear. In a recent trial in over 6000 patients with acute ST-elevation MI, normal LVEF, and without HF symptoms, patients treated with spironolactone had similar rates of cardiovascular death, recurrent MI, and new or worsening HF over a median of three years compared with those receiving placebo [7]. In patients without HF or reduced LVEF after acute MI, routine treatment with an MRA is not indicated. (See "Overview of the nonacute management of ST-elevation myocardial infarction", section on 'Mineralocorticoid receptor antagonists'.)
HEART FAILURE
Rheumatoid arthritis and heart failure (June 2025)
Patients with rheumatoid arthritis (RA) have an increased risk of heart failure (HF), but whether they also have an increased risk of poor outcomes from HF is less clear. In a study of over three million index hospitalizations for heart failure, RA was associated with a significantly increased risk of readmission and death during readmission in the 90 days following the index hospitalization (adjusted odds ratio 1.2 and 1.1, respectively) [8]. Older age, rural residence, and higher median household income were all associated with an increased risk of death during readmission. Patients with RA should be monitored carefully following hospitalization for heart failure; the association between mortality and high socioeconomic status among patients with RA and HF warrants further study. (See "Heart failure in rheumatoid arthritis", section on 'Prognosis'.)
Home- or center-based cardiac rehabilitation for patients with heart failure (May 2025)
In patients with heart failure (HF), exercise training is associated with a lower risk of hospital admission and improvement in quality of life, but it remains unclear whether home-based rehabilitation programs are as effective as center-based programs. In a recent trial in more than 100 patients with HF, patients randomly assigned to home-based or center-based cardiac rehabilitation had similar improvements in exercise capacity and quality of life [9]. This finding is consistent with prior studies and trials. For patients with HF who can be adequately supervised using remote or no monitoring, cardiac rehabilitation may be performed at a center or at home. (See "Cardiac rehabilitation in patients with heart failure", section on 'Exercise location'.)
Fluid restriction in patients with stable heart failure (May 2025)
In patients with heart failure (HF), the efficacy of fluid restriction remains uncertain. In a recent trial in over 500 patients with New York Heart Association class II or III HF who were randomly assigned to liberal fluid intake (ie, no maximum per day) or restricted fluid intake (ie, <1500 mL per day), rates of death, all-cause hospitalization, and intravenous loop diuretic use at three months were similar between the groups [10]. Notably, patients in both groups reported daily fluid intake of less than two liters (1764 and 1480 mL in the liberal and fluid restriction groups, respectively), which may have biased the trial toward a null result. Patients with stable HF do not require a specific fluid restriction, but in patients whose fluid intake is associated with HF exacerbation or significant hyponatremia, it is reasonable to provide an individualized and achievable fluid restriction. (See "Heart failure self-management", section on 'Fluid restriction'.)
Intravenous iron supplementation in heart failure (April 2025)
In patients with heart failure (HF) with reduced ejection fraction (HFrEF), iron supplementation reduces the risk of readmissions, but whether sustained iron therapy has additional beneficial effects remains uncertain. In a trial in more than 1100 patients with HFrEF, New York Heart Association class II or III HF symptoms, and iron deficiency who were treated for up to three years with ferric carboxymaltose or placebo, there were similar rates of mortality and HF hospitalizations between the groups [11]. Subgroup analyses, including an analysis by transferrin saturation (ie, 20 percent cutoff), showed similar findings to the main trial results. Despite the results of this trial, patients with HF who have iron deficiency with or without anemia should receive iron and should be evaluated for the cause of the deficiency. (See "Evaluation and management of anemia and iron deficiency in adults with heart failure", section on 'Iron supplementation'.)
Routine intraaortic balloon pump placement for heart failure-related cardiogenic shock (April 2025)
In patients with refractory cardiogenic shock due to chronic heart failure (HF), an intraaortic balloon pump (IABP) is one option for therapy, but the effects of routine IABP use in this population are unknown. In a trial in which over 100 patients with cardiogenic shock related to HF were randomly assigned to early IABP placement or standard care, rates of 60-day survival without heart transplantation or left ventricular assist device placement were similar between the groups [12]; the trial was stopped early for futility. Rates of bleeding and limb ischemia were nonsignificantly higher in the IABP group. In highly selected patients with refractory cardiogenic shock, IABP placement is an option for therapy. (See "Intraaortic balloon pump counterpulsation", section on 'Cardiogenic shock'.)
Society of Critical Care Medicine guidelines on critical care ultrasonography use (March 2025)
The Society of Critical Care Medicine (SCCM) recently updated its guidelines on the use of bedside critical care ultrasonography (CCUS) [13]. The SCCM conditionally recommended CCUS use in patients with septic shock, acute respiratory failure, and acute cardiogenic shock as well as in patients with unclear volume status. It was unable to make a clear recommendation for CCUS use in patients undergoing cardiopulmonary resuscitation. We agree with these recommendations. (See "Indications for bedside ultrasonography in the critically ill adult patient", section on 'Introduction'.)
RNA interference therapy for treatment of transthyretin cardiac amyloidosis (February 2025)
In patients with transthyretin (ATTR) cardiac amyloidosis, one option for therapy is RNA interference, which reduces hepatic production of transthyretin. In a trial in over 650 patients with ATTR cardiac amyloidosis, patients randomly assigned to therapy with vutrisiran, an RNA interference agent, had lower rates of mortality and heart failure (HF) events (ie, hospitalizations, urgent HF visits) after 36 months when compared with placebo [14]. Rates of adverse events were similar between the groups. In patients with wild-type or gene variant ATTR cardiac amyloidosis and New York Heart Association (NYHA) functional class I to III HF symptoms, we recommend treatment with tafamidis, acoramidis, or vutrisiran rather than no disease-specific therapy. (See "Cardiac amyloidosis: Treatment and prognosis", section on 'Disease-specific therapy for ATTR amyloidosis'.)
LIPID DISORDERS
Small interfering RNA reduces lipoprotein(a) (April 2025)
An elevated serum concentration of lipoprotein(a), also known as Lp(a), is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD); however, available lipid-lowering agents have minimal efficacy in lowering Lp(a). In a phase 2 trial in over 300 patients with elevated Lp(a) who were randomly assigned to lepodisiran (subcutaneous injection of 16, 96, or 400 mg), an investigational small interfering RNA that targets hepatic Lp(a) synthesis, or placebo, lepodisiran lowered Lp(a) in a dose-dependent manner from 60 to 180 days after administration [15]. Mild injection-site reactions occurred in up to 12 percent of participants in the highest-dose group. Larger studies are needed to determine whether lepodisiran improves clinical outcomes. (See "Lipoprotein(a)", section on 'Investigational therapies'.)
Improvements in the prognosis of familial hypercholesterolemia (March 2025)
Studies prior to the widespread use of statin therapy found that individuals with heterozygous familial hypercholesterolemia (FH) were at high risk of premature coronary artery disease (CAD); whether their prognosis has improved over the past few decades is uncertain. In an analysis of Danish registry data from 1978 to 2021, the mean age at which individuals with FH (predominantly heterozygous) were diagnosed with CAD increased from 49 in 1978 to 61 in 2021, while the mean age at death increased from 50 to 78 [16]. In 2021, the mean age at CAD diagnosis was seven years younger in individuals with FH compared with those who did not have FH, while the mean age at death was comparable in those with and without FH. The improved prognosis of heterozygous FH likely reflects advancements in the treatment of hypercholesterolemia. (See "Familial hypercholesterolemia in adults: Overview", section on 'Prognosis'.)
Olezarsen for familial chylomicronemia syndrome (February 2025)
Olezarsen, a small interfering RNA that reduces apolipoprotein C-III (APOC3) production and reduces plasma triglycerides (TG), is now approved in the United States as an adjunct to diet for patients with familial chylomicronemia syndrome (FCS) who have severe hypertriglyceridemia and a high risk of acute pancreatitis [17]. Approval was based on a randomized trial in 66 patients with FCS comparing monthly subcutaneous olezarsen (50 or 80 mg) with placebo for 49 weeks [18]. Both doses of olezarsen reduced APOC3 levels and the incidence of acute pancreatitis at 53 weeks, but only the 80 mg olezarsen dose significantly reduced TG levels at six months. The most common adverse reactions with olezarsen were injection site reactions, decreased platelet count, and arthralgias. Based on these results, we recommend olezarsen as a component of treatment for individuals with FCS. (See "Hypertriglyceridemia in adults: Management".)
Effects of exercise on lipoproteins (February 2025)
Although numerous randomized trials document the benefits of exercise on serum lipid profiles, few analyses have compared the effects of different types of exercise on specific lipoproteins. In a meta-analysis of 148 randomized trials, exercise modestly improved total, low-density lipoprotein (LDL), very low-density lipoprotein (VLDL), and high-density lipoprotein (HDL) cholesterol and triglyceride levels, with changes that ranged from 3.5 to 11.7 percent [19]. Interventions combining aerobic and resistance exercise produced optimal reductions in serum lipoproteins. On meta-regression, each extra weekly aerobic session reduced total cholesterol by 7.68 mg/dL (0.2 mmol/L). These results provide important guidance for counseling patients on the benefits of exercise on lipid profiles. (See "Effects of exercise on lipoproteins and hemostatic factors", section on 'Type of exercise'.)
Plozasiran for persistent chylomicronemia (February 2025)
Persistent chylomicronemia is caused by familial chylomicronemia syndrome (FCS) or multifactorial causes and is associated with a risk of acute pancreatitis. The effects of plozasiran, an investigational small interfering RNA that reduces apolipoprotein C3 (APOC3) production and circulating triglycerides (TG), were evaluated in a trial in 75 patients with persistent chylomicronemia (with or without confirmed FCS) randomly assigned to this drug (25 or 50 mg) or placebo every 3 months for 12 months [20]. Patients receiving either dose of plozasiran had a fourfold greater decline in median TG level and a lower incidence of acute pancreatitis (4 versus 20 percent) compared with those receiving placebo; some patients with baseline prediabetes or diabetes developed hyperglycemia with plozasiran. Further study is needed to confirm these findings. (See "Hypertriglyceridemia in adults: Management", section on 'Plozasiran'.)
Cognitive safety of long-term treatment with evolocumab and very low LDL-C levels (January 2025)
Proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors are highly effective at reducing low-density lipoprotein cholesterol (LDL-C), often resulting in very low LDL-C levels; whether this has an adverse impact on cognitive function is unclear. In an open-label extension of a substudy of the FOURIER trial, annual cognitive testing of patients who received treatment with evolocumab for five years revealed stable cognitive function despite the achievement of very low LDL-C levels (median 35 mg/dL) [21]. There was no association between cognitive function and LDL-C levels. Based on these findings, it is unlikely that long-term treatment with evolocumab adversely impacts cognitive function, even if very low LDL-C levels are achieved. (See "PCSK9 inhibitors: Pharmacology, adverse effects, and use", section on 'Neurocognitive toxicity'.)
PERIPHERAL ARTERIAL DISEASE
Ischemic events in giant cell arteritis (February 2025)
Which patients with giant cell arteritis (GCA) may be at highest risk for cranial ischemic events (CIC) is not clear. In a multicenter consortium database study of over 1,900 patients with GCA, 17 percent had CIC (eg, blindness, stroke) [22]. Risk factors for CIC included age at diagnosis and hypertension, whereas anticoagulation (but not antiplatelet agents such as aspirin) was associated with lower risk. This study suggests that traditional cardiovascular risk factors may be associated with CIC in patients with GCA, but whether anticoagulation is protective requires further study and prospective validation. (See "Clinical manifestations of giant cell arteritis", section on 'Risk factors'.)
PERCUTANEOUS CORONARY INTERVENTION
Stepwise de-escalation of antiplatelet therapy after drug-coated balloon angioplasty (April 2025)
For patients at high risk of bleeding who undergo drug-eluting stent (DES) placement, a shorter course of dual antiplatelet therapy (DAPT) is sometimes used; whether this approach might be appropriate for patients undergoing drug-coated balloon (DCB) angioplasty is uncertain. In a trial in which over 1900 patients with acute coronary syndrome treated with paclitaxel DCBs were randomly assigned to stepwise de-escalation of antiplatelet therapy (ie, aspirin plus ticagrelor for one month, then five months of ticagrelor, then six months of aspirin) or standard DAPT (ie, aspirin plus ticagrelor for 12 months), rates of the primary composite endpoint (ie, death, stroke, myocardial infarction, revascularization, Bleeding Academic Research Consortium [BARC] type 3 or 5 bleeding) were similar between the groups. Patients in the de-escalation group experienced less bleeding. For patients undergoing DCB angioplasty, especially those at high bleeding risk, stepwise de-escalation of antiplatelet therapy may be a reasonable alternative to standard DAPT [23]. (See "Patients with high bleeding risk undergoing percutaneous coronary intervention", section on 'Drug-coated balloon angioplasty'.)
Orbital atherectomy of calcified coronary lesions (April 2025)
Orbital atherectomy, like rotational atherectomy, can be performed on heavily calcified coronary lesions prior to drug-eluting stent (DES) placement; while rotational atherectomy has been shown to improve procedural success rates, the impact of orbital atherectomy is uncertain. In a trial of more than 2000 patients with severely calcified coronary lesions who were randomly assigned to orbital atherectomy or balloon angioplasty with cutting and scoring balloons before DES placement, the post-procedural minimal stent area and target vessel failure within one year were similar between the treatment groups [24]. Patients for whom the investigators believed atherectomy was required were excluded from the trial. These data support the continued use of a pretreatment balloon angioplasty strategy for patients with severely calcified lesions who do not require rotational atherectomy. (See "Specialized revascularization devices in the management of coronary artery disease", section on 'Orbital atherectomy'.)
Intravascular lithotripsy for calcified coronary lesions (March 2025)
Intravascular lithotripsy (IVL) is the newest technique for plaque modification of severely calcified coronary lesions; while IVL is in common use, its efficacy compared with the more established technique of rotational atherectomy (RA) is uncertain. In a trial in which over 170 patients with moderate or severe calcified coronary lesions were randomly assigned to RA, IVL, or excimer laser coronary angioplasty (ELCA), IVL was comparable with RA with respect to the percentage of stent expansion measured by optical coherence tomography, while ELCA was inferior to RA [25]. While this study supports the use of IVL for calcified lesions, larger studies are necessary to compare the efficacy of IVL and RA with respect to clinically important endpoints. (See "Specialized revascularization devices in the management of coronary artery disease", section on 'Shockwave intravascular lithotripsy'.)
Preprocedural 3DCT for PCI of the ostial RCA (March 2025)
Ostial right coronary artery (RCA) lesions have a high rate of target lesion failure because of geographic stent-ostium mismatch, which may be partly due to unrecognized vessel foreshortening in the working views selected by interventionalists during percutaneous coronary intervention (PCI); whether three-dimensional computed tomography (3DCT) may be useful for preprocedural planning is uncertain. In a trial in 30 patients with ostial RCA stenosis who were randomly assigned to PCI with preprocedural 3DCT or angiography-guided PCI, there was a trend towards a reduction in geographic mismatch in the 3DCT group (0 versus 33 percent, p = 0.06) [26]. The procedural radiation dose, contrast volume, and duration were lower in those who underwent 3DCT. A larger study is needed to determine whether preprocedural 3DCT may reduce target lesion failure. (See "Percutaneous coronary intervention of specific coronary lesions", section on 'Ostial lesions'.)
PERIOPERATIVE CARDIOLOGY
Prophylactic use of inotropic agents during cardiac surgery in adults (January 2025)
Patients with low ejection fraction undergoing cardiac surgery often receive inotropic agents prophylactically, but whether patients benefit from this practice isn't clear. A 2024 systematic review of randomized trials of prophylactic administration of an inotropic agent during cardiac surgery found inadequate data to suggest any benefit (or harm) for most inotropic agents (ie, milrinone, amrinone, dobutamine, and dopamine) compared with placebo [27]. However, low certainty evidence suggested that prophylactic levosimendan infusion reduces the incidence of low cardiac output syndrome and mortality compared with placebo (risk ratio 0.43 and 0.65, respectively). Levosimendan is not available in the United States, and we do not prophylactically administer any inotropic agent during cardiac surgery. (See "Intraoperative problems after cardiopulmonary bypass", section on 'Vasoactive drug therapy'.)
PREVENTIVE CARDIOLOGY
Home-based cardiac rehabilitation for older patients (February 2025)
Home-based cardiac rehabilitation (CR) using portable electronic devices is an attractive alternative to traditional CR; however, its benefits in older adults are unclear. In a study of 400 patients (median age 71 years, range 65 to 91 years), those who were randomly assigned to home-based CR did not experience clinically meaningful improvements in six-minute walk duration (6MWD) or the ability to perform activities of daily living (ADL) compared with those undergoing usual care [28]. Subgroup analysis showed improved 6MWD in female patients and patients who had undergone coronary artery bypass grafting (CABG). These findings suggest that home-based CR may not be effective for most older adults but may benefit certain subgroups; further studies are needed to confirm these results. (See "Cardiac rehabilitation: Indications, efficacy, and safety in patients with coronary artery disease", section on 'Home-based and hybrid cardiac rehabilitation'.)
VALVULAR HEART DISEASE
Transcatheter edge-to-edge repair for acute mitral regurgitation (May 2025)
Patients with acute severe mitral regurgitation (MR) require prompt mitral valve intervention, but the risk of mitral valve surgery is high; transcatheter edge-to-edge repair (TEER) is a potential alternative to surgery in this setting. In a meta-analysis of 24 studies including over 5000 patients with severe MR, cardiogenic shock, and a high surgical risk score (mean 15.2) treated with TEER, device success (defined as MR reduction by at least 2 grades) was achieved in 86 percent [29]. Thirty-day mortality was higher among patients with acute myocardial infarction (MI) than in those without acute MI (20 versus 13 percent). These data demonstrate the feasibility of TEER in selected patients with acute severe MR, although data comparing outcomes with mitral surgery and TEER in this setting are lacking. (See "Acute mitral regurgitation: Management", section on 'Choice of intervention'.)
OTHER CARDIOLOGY
Anorexia nervosa and cardiovascular conditions (March 2025)
Weight loss and malnutrition in anorexia nervosa can lead to comorbidities, including cardiovascular conditions such as cardiomyopathy and conduction disorders. A recent study found that the incidence of any cardiac condition at the five-year follow-up was nearly two times greater in those with anorexia nervosa compared with controls without any eating disorder [30]. Patients with anorexia nervosa should be monitored for comorbidities, including structural and functional cardiovascular conditions, that may warrant specific management along with nutritional replenishment. (See "Anorexia nervosa in adults and adolescents: Medical complications and their management", section on 'Any cardiovascular condition'.)
Safety of antithrombotic therapy in factor XI deficiency (January 2025)
Spontaneous bleeding is rare in factor XI deficiency, suggesting that anticoagulation or antiplatelet therapy may be safer in these individuals than in those with other bleeding disorders. A new database study evaluated bleeding risk in approximately 50 percent of the general population in Israel [31]. While use of an anticoagulant or antiplatelet agent increased bleeding risk, individuals with factor XI deficiency did not have an appreciably higher rate of bleeding with these treatments than individuals without factor XI deficiency. These results suggest that antithrombotic therapy may be used when needed in individuals with factor XI deficiency, using shared decision-making based on the individual's bleeding phenotype and thrombotic risk. (See "Factor XI (eleven) deficiency", section on 'Anticoagulation or antiplatelet therapy'.)
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