What's new in cardiovascular medicine

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.

AORTIC DISEASE

Timing of prophylactic aortic surgery for patients with bicuspid aortic valve (October 2023)

The optimal timing for prophylactic aortic surgery for patients with a bicuspid valve (BAV) and ascending aorta diameters of 5.0 to 5.4 cm is uncertain. In a retrospective multicenter study including nearly 500 patients with BAV and aortic diameters in this range who were followed for a median of seven years, over one-half of the patients underwent elective aortic surgery, with an operative mortality rate of 1.9 percent [1]. Aortic dissection occurred during surveillance in 1.8 percent of the nearly 500 patients. These findings illustrate the risk trade-offs for early surgery versus surveillance for patients with BAV; a randomized trial is underway to compare these approaches in patients with ascending aorta diameters of 5.0 to 5.4 cm, including patients with BAV. (See "Bicuspid aortic valve: Intervention for valve disease or aortopathy in adults", section on 'Without high-risk features'.)

ARRHYTHMIAS

Pericarditis after catheter ablation for atrial fibrillation (January 2024)

Acute pericarditis is one of the complications of catheter ablation for atrial fibrillation (AF), but its incidence and risk factors have not been well defined. In a series of over 1500 patients who underwent catheter ablation for AF, acute pericarditis was diagnosed in nearly 4 percent with median onset at one day post procedure [2]. The risk of acute pericarditis was higher with radiofrequency ablation than with cryoablation; cardiac tamponade occurred in less than 10 percent of patients with pericarditis. These data help inform risk assessment for patients with AF. (See "Atrial fibrillation: Catheter ablation", section on 'Pericarditis'.)

Anticoagulation for device-detected atrial fibrillation (January 2024)

Device-detected (subclinical) atrial fibrillation (AF) is common in patients with an implanted cardiac rhythm device and associated with an increased risk of ischemic stroke; however, the risks and benefits of anticoagulation in this setting are uncertain. In a meta-analysis of two randomized controlled trials comparing direct oral anticoagulants (edoxaban or apixaban) with placebo or aspirin in patients with device-detected AF, oral anticoagulation reduced the risk of ischemic stroke but increased the risk of major bleeding [3]. These findings will help inform the management of patients with device-detected AF. (See "Atrial fibrillation in adults: Selection of candidates for anticoagulation", section on 'Paroxysmal AF'.)

Sport participation among athletes with increased risk of fatal arrhythmias (October 2023)

In patients who participate in competitive athletics and have a diagnosis that increases the risk of fatal arrhythmias, return to sport participation may provoke an arrhythmia or risk damage to an internal cardioverter-defibrillator (ICD). In a recent single-center report of 76 patients with a genetic cardiomyopathy that increased the risk of sudden death (32 percent with an ICD) who underwent tailored treatment and a shared decision-making process before returning to elite sport participation, there were four arrhythmic events and no fatalities during 200 patient-years of observation [4]. The small study size and nonstandardized approach to risk assessment and counseling limit the generalizability of these findings. In patients with an increased risk of fatal arrhythmias, we advise against participation in competitive sports, but some athletes may choose to participate based on their values and preferences following a shared decision-making process. (See "Athletes with arrhythmias: Treatment and returning to athletic participation", section on 'Athletes with ICDs'.)

Catheter ablation lowers psychological distress in patients with atrial fibrillation (September 2023)

Among patients with symptomatic atrial fibrillation (AF), catheter ablation may improve psychological distress and symptoms of anxiety and depression compared with medical therapy, but randomized trials have been lacking. In a recent trial in which 100 symptomatic patients with AF were randomly assigned to catheter ablation or medical therapy, those in the ablation group had a lower Hospital Anxiety and Depression Scale (HADS) score at 12 months [5]. The prevalence of severe psychological distress was also lower in the ablation group at 12 months. In patients with AF, catheter ablation may be a treatment for psychological distress. (See "Atrial fibrillation: Overview and management of new-onset atrial fibrillation", section on 'Anxiety and depression'.)

Race-ethnic disparities in CPR for out-of-hospital cardiac arrest in the post-COVID-19 era (September 2023)

Pre-COVID-19 pandemic data have shown race-ethnic differences in bystander cardiopulmonary resuscitation (CPR); however, it is uncertain whether these disparities have persisted. In a United States registry of over 64,000 patients with witnessed out-of-hospital cardiac arrest in the post-COVID-19 era, Black and Hispanic persons were less likely to receive bystander CPR than White persons (60 versus 67 percent) [6]. These differences existed regardless of public or private setting, neighborhood income level, or population density. Public health education in bystander CPR should be undertaken to reduce these disparities. (See "Prognosis and outcomes following sudden cardiac arrest in adults", section on 'Race-ethnic differences in out-of-hospital CPR'.)

CORONARY HEART DISEASE, ACUTE

Liberal transfusion strategy for acute myocardial infarction (December 2023)

Restrictive transfusion (transfusing at a lower hemoglobin, typically <7 or 8 g/dL) is appropriate for most patients based on evidence from randomized trials, but trial data for patients with acute myocardial infarction (MI) have been slower to accumulate. In the MINT trial, which randomly assigned 3504 patients with acute MI and anemia to a restrictive or liberal (transfusing for hemoglobin <10 g/dL) strategy, there was a trend toward better outcomes with the liberal strategy without an increased risk of adverse events [7]. We now suggest a liberal strategy for acute MI. A slightly lower hemoglobin may be reasonable for stable, asymptomatic patients, and patients with hemodynamic instability may require a higher hemoglobin. (See "Indications and hemoglobin thresholds for RBC transfusion in adults", section on 'Acute MI'.)

No benefit of routine V-A ECMO in patients with AMI-related cardiogenic shock (September 2023)

Venoarterial extracorporeal membrane oxygenation (V-A ECMO) can increase survival for patients with refractory cardiogenic shock caused by a variety of conditions. However, benefit from the routine use of V-A ECMO for cardiogenic shock due to acute myocardial infarction (AMI) is unproven. In a meta-analysis of four randomized trials (nearly 570 patients with AMI-related cardiogenic shock), routine V-A ECMO use showed no mortality benefit and increased rates of both major bleeding and peripheral vascular ischemia compared with medical care alone [8]. Limitations of this meta-analysis include crossover between groups and a low rate of active left ventricular uploading during ECMO therapy, which may have biased the study in favor of the control group. These findings suggest no meaningful benefit for the routine use of V-A ECMO for patients with AMI-related cardiogenic shock but does not preclude benefit in selected patients who are candidates for salvage procedures such as heart transplant. (See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Refractory cardiogenic shock'.)

Complete revascularization in older patients with acute myocardial infarction (September 2023)

In patients with acute myocardial infarction (MI), revascularization of the culprit artery is the main goal of percutaneous coronary intervention (PCI), but the ideal approach to residual nonculprit lesions in older patients is unclear. In a recent trial in nearly 1500 older patients (mean age 80 years) with acute MI and multivessel coronary artery disease who were not candidates for coronary artery bypass grafting (CABG), patients randomly assigned to PCI of nonculprit lesions (ie, complete revascularization) during the index admission had a lower rate of all-cause death and recurrent MI compared with those assigned to no additional planned PCI [9]. Rates of safety endpoints (eg, bleeding) were comparable between the two groups. In patients with acute MI who undergo PCI and are not candidates for CABG, we suggest complete revascularization of all stenotic lesions prior to discharge, if feasible. (See "Acute coronary syndromes: Approach to nonculprit lesions", section on 'STEMI'.)

Timing of percutaneous coronary intervention of nonculprit lesions in patients with ST-elevation myocardial infarction (September 2023)

Among patients with acute myocardial infarction (MI) and multivessel disease who have undergone percutaneous coronary intervention (PCI) of the culprit vessel, but who have residual nonculprit lesions, some undergo immediate PCI of these lesions, while others undergo delayed or "staged" PCI days to weeks later. In a recent trial in over 400 patients with ST-elevation MI (STEMI) who successfully underwent PCI of a culprit lesion, those randomly assigned to immediate PCI of nonculprit lesions had a lower rate of recurrent MI compared with those assigned to staged PCI of such lesions [10]. Rates of death and heart failure were similar between the two groups. For patients with STEMI who undergo culprit vessel PCI and have residual nonculprit lesions, we suggest PCI of nonculprit lesions during the index admission and preferably during the index procedure rather than planned PCI beyond the index admission. (See "Acute coronary syndromes: Approach to nonculprit lesions", section on 'STEMI'.)

HEART FAILURE

Detection of left ventricular systolic dysfunction by artificial intelligence-based ECG analysis (October 2023)

Artificial intelligence (AI) analysis of electrocardiogram (ECG) images can detect subclinical cardiovascular disease such as asymptomatic left ventricular (LV) systolic dysfunction, but the accuracy of this technology remains unclear. In a recent study of over 380,000 ECGs obtained from more than 116,000 patients, AI-based ECG analysis had moderate accuracy (sensitivity 89 percent, specificity 77 percent) for detection of an LV ejection fraction <40 percent [11]. However, the ECGs were obtained for a variety of clinical indications, and not all patients were truly asymptomatic. In patients in whom AI-based ECG analysis suggests LV systolic dysfunction, further evaluation is required before making the diagnosis and prescribing treatment. (See "Approach to diagnosis of asymptomatic left ventricular systolic dysfunction", section on 'Patients with unexplained signs of cardiac injury or disease'.)

Semaglutide in patients with heart failure with preserved ejection fraction and obesity (September 2023)

In patients with heart failure with preserved ejection fraction (HFpEF), weight loss is likely to improve functional status and quality of life, but achieving weight loss in this group of patients is difficult. In a recent trial of more than 500 patients with HFpEF, patients randomly assigned to treatment with semaglutide had greater improvement in exercise capacity (ie, six-minute walk distance), quality of life, and weight loss (-13 percent mean change in body weight versus -2.6 percent) at 52 weeks than patients assigned to placebo [12]. An exploratory analysis suggested a lower risk of urgent HF hospitalizations in those treated with semaglutide. Similar to other patients with obesity, patients with HFpEF and obesity should receive appropriate management to achieve weight loss. (See "Treatment and prognosis of heart failure with preserved ejection fraction", section on 'Obesity'.)

No benefit of routine V-A ECMO in patients with AMI-related cardiogenic shock (September 2023)

Venoarterial extracorporeal membrane oxygenation (V-A ECMO) can increase survival for patients with refractory cardiogenic shock caused by a variety of conditions. However, benefit from the routine use of V-A ECMO for cardiogenic shock due to acute myocardial infarction (AMI) is unproven. In a meta-analysis of four randomized trials (nearly 570 patients with AMI-related cardiogenic shock), routine V-A ECMO use showed no mortality benefit and increased rates of both major bleeding and peripheral vascular ischemia compared with medical care alone [8]. Limitations of this meta-analysis include crossover between groups and a low rate of active left ventricular uploading during ECMO therapy, which may have biased the study in favor of the control group. These findings suggest no meaningful benefit for the routine use of V-A ECMO for patients with AMI-related cardiogenic shock but does not preclude benefit in selected patients who are candidates for salvage procedures such as heart transplant. (See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Refractory cardiogenic shock'.)

Effect of cardiac resynchronization therapy device programming on clinical outcomes (September 2023)

Among patients with heart failure (HF) and a cardiac resynchronization therapy (CRT) pacemaker, it remains unclear if specific pacemaker programming reduces the risk of clinical events. In a recent trial in over 3600 patients with HF and a CRT device, patients randomly assigned to adaptive CRT programming (ie, timing left ventricular pacing to coincide with normal right ventricular activation) had similar rates of all-cause death and urgent intervention for HF decompensation at a median of 59 months compared with those assigned to traditional CRT programming [13]. In a subgroup analysis, the adaptive CRT programming group was less likely to undergo generator replacement due to battery depletion. In patients with HF and a CRT device, programming with adaptive CRT may help to delay exchange of the pacemaker generator but has no clear effect on clinical outcomes. (See "Cardiac resynchronization therapy and conduction system pacing in heart failure: System implantation and programming", section on 'Other parameters for optimization'.)

Intravenous iron supplementation in heart failure with reduced ejection fraction (September 2023)

Iron deficiency is common in patients with heart failure (HF), but it remains unclear whether iron supplementation reduces mortality or hospitalization in this population. Recently published research on the effects of intravenous (IV) iron supplementation included the following observations:

●In a trial in nearly 3100 patients with HF and reduced ejection fraction (HFrEF), IV iron supplementation improved iron stores but did not clearly reduce the risk of cardiovascular mortality or HF hospitalization [14].

●In a meta-analysis of randomized trials of IV iron in patients with HFrEF, IV iron reduced the risk of HF hospitalization but had an unclear effect on cardiovascular mortality [15].

These data support the use of IV iron to reduce hospitalization in patients with HFrEF who have iron deficiency. (See "Evaluation and management of anemia and iron deficiency in adults with heart failure", section on 'Iron supplementation'.)

Virtual inpatient consultation to optimize medical therapy for heart failure (August 2023)

Patients with systolic heart failure (HF) benefit from a multidrug medical regimen, but barriers to achieving optimal therapy include therapeutic inertia, adverse effects, and polypharmacy. In a recent randomized trial in nearly 200 inpatients with systolic HF, virtual consultation by an HF cardiologist and pharmacist resulted in more appropriate changes to medical therapy than usual care [16]. In particular, compared with the usual care group, more patients in the virtual consultation group had intensification of HF therapy or initiation of new HF medications. Inpatients with HF benefit from specialist review of their medical regimen, which may result in durable changes that lead to lower risks of mortality or future HF hospitalizations. (See "Systems-based strategies to reduce hospitalizations in patients with heart failure", section on 'Decision support'.)

MYOPERICARDIAL DISEASE

Pericardiocentesis risks in patients with pulmonary hypertension (November 2023)

Case series suggest that patients with pulmonary hypertension (PH) may be at risk for hemodynamic collapse during pericardiocentesis, but data are limited and conflicting. A National Inpatient Sample database study of over 95,000 adults (including nearly 8000 with PH) who underwent pericardiocentesis assessed in-hospital outcomes [17]. In patients with PH, pericardiocentesis was associated with higher adjusted rates of in-hospital mortality and postprocedure shock than in patients without PH. These findings suggest that hemodynamic monitoring during pericardiocentesis is particularly important in patients with PH. (See "Pericardial effusion: Approach to management", section on 'Pulmonary hypertension'.)

TRANSPLANTATION

Thyroid hormone administration in deceased organ donors (December 2023)

Thyroid hormone administration has been a longstanding component of some organ procurement protocols due to concern that acute hypothyroidism might contribute to hemodynamic instability and left ventricular dysfunction, reducing heart and other organ procurement; however, evidence for the practice has been inconsistent. In a recent trial of 838 hemodynamically unstable, brain-dead donors assigned to receive a levothyroxine infusion or saline placebo, there was little to no difference in number of hearts transplanted or 30-day cardiac graft survival [18]. Recovery of other organs was similarly unaffected. More cases of severe hypertension or tachycardia occurred in the levothyroxine group than in the saline group. Based on these data, we suggest avoiding thyroid hormone administration in deceased organ donors. (See "Management of the deceased organ donor", section on 'Thyroid hormone'.)

Lower survival among recipients of donor hearts from donors with active COVID-19 (November 2023)

It is unclear whether donor hearts from donors with active COVID-19 have similar survival when compared with those from donors without COVID-19. In a recent study of nearly 5900 patients who underwent heart transplantation, one-year survival was lower among recipients of hearts obtained from donors with active COVID-19 when compared with recipients of hearts from donors without COVID-19 (77 versus 91 percent) [19]. The cause of higher mortality was unclear, and despite adjustment for confounders, the difference in survival could be the result of unmeasured confounders or bias. The decision to accept a donor heart depends on each recipient's ongoing risk of waiting for transplantation and risks associated with the potential donor, including the donor's COVID-19 status at the time of donation. (See "Heart transplantation in adults: Donor selection and organ allocation", section on 'Donors with COVID-19'.)

VALVULAR HEART DISEASE

Choice of intervention for aortic stenosis with low surgical risk (November 2023)

The choice of intervention for severe aortic stenosis (AS) is based upon an individualized assessment by a multidisciplinary heart valve team. Two randomized trials reported outcomes for transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) in selected low surgical risk patients with severe AS [20,21]:

●In one trial in which nearly 1500 patients were randomly assigned to TAVI with a self-expanding valve or SAVR, rates of mortality, disabling stroke, and aortic valve rehospitalization at four years were similar in the two groups.

●In another trial in which 1000 patients were randomly assigned to TAVI with a balloon-expanding valve or SAVR, rates of mortality, stroke, and rehospitalization at five years were similar in the two groups.

These trials indicate generally favorable results for TAVI up to four and five years for selected low surgical risk patients with severe AS and anatomical suitability for TAVI; additional data, including longer-term outcomes, will further inform the choice of intervention in this clinical setting. (See "Choice of intervention for severe calcific aortic stenosis", section on 'In low-risk symptomatic patients'.)

OTHER CARDIOLOGY

Additional experience with mavacamten for obstructive hypertrophic cardiomyopathy (September 2023)

In patients with symptomatic obstructive hypertrophic cardiomyopathy (HCM), recent trials suggest that a new class of drugs, the myosin inhibitors, can reduce symptoms of obstruction. Two new investigations provide additional data on the effects of these agents:

●In one randomized trial, patients with symptomatic obstructive HCM who received treatment with mavacamten had a reduction in symptoms compared with those treated with placebo [22].

●In another randomized trial, patients who were assigned to mavacamten as well as those who initially received placebo for 16 weeks and then switched to mavacamten had a decreased need for cardiac surgery (ie, septal myectomy) at 56 weeks [23].

In patients with symptomatic obstructive HCM, mavacamten may improve symptoms and delay the need for cardiac surgery. (See "Hypertrophic cardiomyopathy: Management of patients with outflow tract obstruction", section on 'Myosin inhibitors'.)

New technique for septal myectomy in patients with hypertrophic cardiomyopathy (August 2023)

In select patients with hypertrophic cardiomyopathy (HCM), septal myectomy performed under cardiopulmonary bypass is a treatment option, but its effectiveness may be limited by poor visualization of the septum and the inability to assess the immediate effect of myectomy while the heart is unloaded; a novel procedure, transapical myectomy, seeks to overcome these limitations. In a recent single-center report of 46 patients with HCM who underwent transapical septal myectomy, 42 patients had a reduction in left ventricular outflow tract (LVOT) gradient without moderate or worse mitral regurgitation, and average six-minute walk distance increased [24]. Complications included one postoperative death, one ventricular septal defect, and one LV apical tear. In patients with HCM and symptoms attributable to severe LVOT obstruction, medical therapy and on-bypass septal myectomy remain the standards of care; further studies are required to define the role of off-bypass septal myectomy. (See "Hypertrophic cardiomyopathy: Management of patients with outflow tract obstruction", section on 'Therapies of limited benefit'.)