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.

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 cardiac arrest remained stable over time, cardiac arrest mortality declined by nearly 50 percent [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, Black race and "other" (ie, non-Black and non-White) race were associated with lower survival [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'.)

Cardiac magnetic resonance for risk stratification in nonischemic dilated cardiomyopathy (November 2024)

Cardiac magnetic resonance (CMR) is often performed on patients with nonischemic dilated cardiomyopathy (DCM) to quantify the left ventricular ejection fraction (LVEF) and identify the presence and pattern of late gadolinium enhancement (LGE), which indicates fibrosis, infiltration, or inflammation. In a recent meta-analysis of 103 studies comprising nearly 30,000 patients with nonischemic DCM, the presence and extent of LGE were associated with all-cause mortality, cardiovascular mortality, and arrhythmic events, while LVEF was not [6]. These data suggest that CMR may be a useful tool in the risk assessment of patients with nonischemic DCM. (See "Primary prevention of sudden cardiac death in patients with cardiomyopathy and heart failure with reduced LVEF", section on 'Myocardial fibrosis on cardiac magnetic resonance'.)

Timing of anticoagulation after acute ischemic stroke in patients with atrial fibrillation (November 2024)

The timing of anticoagulation after acute ischemic stroke in patients with atrial fibrillation (AF) is controversial. Because of concern for intracranial hemorrhage, the start of anticoagulation is often delayed by one to two weeks for certain patients, such as those with large infarcts. However, recent findings from the OPTIMAS randomized trial and the CATALYST meta-analysis challenge this approach [7-9]. In a meta-analysis of patient-level data on over 6700 patients from trials (including OPTIMAS) evaluating the timing of direct oral anticoagulant (DOAC) initiation in patients with stroke and AF, rates of symptomatic intracranial hemorrhage were similarly low for both early (≤4 days from stroke onset) and late (≥5 days) DOAC administration, and the composite outcome of stroke or hemorrhage with early initiation was marginally lower at 30 but not 90 days [8]. Approximately 15 percent of patients had large or severe infarcts in the three largest trials. These data support the safety of early DOAC administration in patients with AF and ischemic stroke, but whether earlier DOAC treatment reduces the risk of recurrent ischemic stroke remains to be settled. (See "Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack", section on 'Timing of anticoagulation after acute ischemic stroke or TIA in patients with atrial fibrillation'.)

Efficacy of catheter ablation for atrial fibrillation (November 2024)

Catheter ablation (CA) for atrial fibrillation (AF) improves AF symptoms in most patients, but AF commonly recurs and anticoagulation is commonly required to mitigate the risk of stroke associated with AF. These issues were illustrated by a double-blind trial in which over 120 patients with symptomatic AF were randomly assigned to undergo either CA or a sham procedure [10]. At six months, the CA group had greater improvement in AF symptoms and greater reduction in frequency of AF than the sham group, although AF was common in both groups. These findings inform decisions regarding CA for AF as well as the approach to monitoring and anticoagulation after the procedure. (See "Atrial fibrillation: Catheter ablation", section on 'Effect on symptoms and AF burden'.)

Threshold for potassium repletion to prevent atrial fibrillation after cardiac surgery (November 2024)

General management to reduce the risk of atrial fibrillation (AF) after cardiac surgery includes treatment of hypokalemia; however, the optimum threshold for potassium replacement therapy in this setting has not been established. In a trial in which 1700 patients undergoing coronary artery bypass graft surgery were randomly assigned to potassium supplementation at a potassium concentration trigger of <4.5 mEq/L or <3.6 mEq/L, rates of at least one AF episode after cardiac surgery and inpatient mortality were similar between the groups [11]. These results support the use of a standard potassium threshold (<3.6 mEq/L) for treatment of post-operative hypokalemia. (See "Atrial fibrillation and flutter after cardiac surgery", section on 'General measures'.)

Catheter ablation for electrical storm and incessant ventricular tachycardia (November 2024)

Catheter ablation is an effective treatment for electrical storm and incessant ventricular tachycardia; however, the impact of ablation on mortality is unclear. In a multicenter observational study of nearly 600 patients with electrical storm, catheter ablation was associated with higher rates of survival at 1 and 3 years and lower rates of recurrence at 1 year compared with medical therapy alone [12]. Catheter ablation for electrical storm and incessant ventricular tachycardia is a complex, potentially risky procedure that should be performed only in experienced centers. (See "Electrical storm and incessant ventricular tachycardia", section on 'Catheter ablation'.)

CORONARY HEART DISEASE, ACUTE

Red blood cell transfusion in patients with acute coronary syndromes (April 2025)

Previous evidence suggests a possible benefit with use of a liberal red blood cell transfusion threshold (hemoglobin <10g/dL) in patients with acute myocardial infarction (MI). In a recently published meta-analysis of over 4300 patients from four trials, patients randomly assigned to a liberal or restrictive (hemoglobin <7 to 8 g/dL) transfusion threshold had similar rates of mortality and recurrent MI after 30 days [13]. In patients with acute MI and anemia who do not have signs of shock, ongoing ischemia, blood loss, or symptoms of anemia, the approach to transfusion is individualized. (See "Overview of the acute management of non-ST-elevation acute coronary syndromes", section on 'Anemia'.)

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 [14]. 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 [15]. 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'.)

Duration of beta blocker therapy after acute myocardial infarction (December 2024)

Most patients with a myocardial infarction (MI) are treated with a beta blocker indefinitely, although this practice is based on data obtained prior to modern advances in MI management such as stenting, dual antiplatelet therapy, and statin therapy. In a recent trial in nearly 3700 patients with a history of acute MI who had already received beta blocker therapy for at least six months (median 2.9 years) and had no other indication for beta blocker therapy (eg, reduced left ventricular systolic function), patients randomly assigned to discontinue beta blocker therapy had similar rates of mortality and recurrent MI after four years compared with those who continued such therapy [16]. Quality-of-life scores were also similar between the groups, suggesting that discontinuing beta blocker therapy did not noticeably impact quality of life. For patients treated with a beta blocker for at least three years after MI and who have no other indication to continue a beta blocker, clinicians should discuss the potential benefits and risks of continued therapy. (See "Acute myocardial infarction: Role of beta blocker therapy", section on 'Duration'.)

Choice of management strategy in older patients with non-ST-segment elevation myocardial infarction (December 2024)

In patients with non-ST-segment elevation myocardial infarction (NSTEMI), the approach to management typically includes early coronary angiography and appropriate percutaneous coronary intervention (PCI), but the efficacy and safety of this approach in older patients are unclear. In a recent trial in over 1500 patients ≥75 years old with NSTEMI, patients randomly assigned to an invasive management strategy (ie, coronary angiography and PCI) had a lower rate of recurrent myocardial infarction but a similar rate of all-cause death when compared with those assigned to a conservative management strategy [17]. The rate of non-fatal bleeding was not significantly higher in the invasive management group. In patients with NSTEMI, we suggest invasive coronary angiography rather than other management strategies. (See "Non-ST-elevation acute coronary syndromes: Selecting a management strategy", section on 'Evidence of infarction (NSTEMI)'.)

HEART FAILURE

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 [18]. 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 [19]. 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 [20]; 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) [21]. 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 [22]. 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'.)

Point-of-care-ultrasound in patients with shock (January 2025)

Point-of-care-ultrasound (POCUS) is increasingly being used in patients with shock to assess etiology and monitor treatment response. A recent meta-analysis of 18 randomized trials in patients with shock found that POCUS-guided resuscitation reduced the duration of vasoactive medication (mean difference -0.73 days), and may reduce 28-day mortality and the need for kidney replacement therapy (relative risk 0.88 and 0.80, respectively; borderline statistical significance) [23]. The use of POCUS did not impact the administration of fluids or inotropes, length of stay, or need for mechanical ventilation. We continue to encourage the use of POCUS when managing patients with shock of unclear etiology. (See "Evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock", section on 'Point-of-care ultrasonography'.)

Weight loss treatment in patients with heart failure with preserved ejection fraction and obesity (December 2024)

In patients with heart failure with preserved ejection fraction (HFpEF), treatment with a glucagon-like peptide-1 receptor (GLP-1R) agonist can reduce body weight and decrease the risk of hospitalization. In a randomized trial in more than 700 patients with HFpEF and obesity (body mass index ≥30 kg/m²), treatment with the GLP-1R agonist tirzepatide reduced the rate of heart failure hospitalizations but not mortality compared with placebo [24]. The rate of adverse events was similar between the groups, though more patients stopped tirzepatide treatment due to gastrointestinal intolerance. In patients with HFpEF and obesity, we suggest therapy with a GLP-1R agonist and lifestyle interventions for weight loss rather than lifestyle interventions alone. (See "Treatment and prognosis of heart failure with preserved ejection fraction", section on 'Additional therapy for patients with obesity (GLP-1 agonist)'.)

Gene editing for treatment of cardiac amyloidosis (December 2024)

Transthyretin (TTR) cardiac amyloidosis (ATTR) is caused by mutations in the TTR gene, and disease-specific therapies for ATTR cardiac amyloidosis are directed at stabilizing or decreasing the production of TTR molecules. In a recent phase I study of 36 patients treated with a clustered regularly interspaced short palindromic repeats and associated Cas9 endonuclease (CRISPR-Cas9) therapy that targets the TTR gene in hepatocytes, serum TTR protein levels decreased by 90 percent and symptoms and measures of functional capacity either remained stable or improved in the majority of patients [25]. Treatment-related adverse events included infusion reactions (14 percent) and an increase in aspartate aminotransferase (6 percent). Until larger trials assess the efficacy and safety of this approach to amyloidosis therapy, we recommend therapy with tafamidis. (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 [26]. 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 [27]. 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 [28]. 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 [29]. 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 [30]. 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 [31]. 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) [32]. 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'.)

Atherosclerotic cardiovascular disease (ASCVD) risk factors in adolescence and ASCVD events in adulthood (January 2025)

A growing body of evidence suggests that vascular changes predisposing to adult atherosclerotic cardiovascular disease (ASCVD) begin in childhood. In a recent study using data from seven different longitudinal studies including over 11,000 participants who were followed from adolescence to a mean age of 50 years, the presence of ASCVD risk factors in adolescence (eg, hypertension, obesity, smoking, or hypercholesterolemia) was independently associated with experiencing fatal and nonfatal ASCVD events in adulthood [33]. The risk increased with increasing number of risk factors. These findings highlight the importance of screening for ASCVD risk factors during childhood and adolescence and intervening at a young age. (See "Overview of pediatric risk factors for premature atherosclerotic cardiovascular disease (ASCVD)", section on 'Evidence linking childhood risk factors to ASCVD events in adulthood'.)

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) [34]. 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'.)

Long-term outcomes of paclitaxel-containing devices in peripheral artery disease (November 2024)

Local drug delivery using paclitaxel-coated balloons or stents reduces the rate of re-stenosis after femoropopliteal angioplasty for peripheral artery disease (PAD). Although an early meta-analysis reported increased mortality and possibly an increased risk of amputation with use of paclitaxel-containing devices, longer-term data from premarket trials suggest that these devices may not pose a significant risk. In a new meta-analysis of 19 randomized trials involving over 4000 participants, all-cause mortality and target limb major amputation rates for paclitaxel-containing devices were similar to standard devices up to 60 months after intervention [35]. While these results are reassuring, we extensively discuss the potential benefits and risks before using paclitaxel-containing devices in patients with PAD. (See "Endovascular techniques for lower extremity revascularization", section on 'Femoropopliteal'.)

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 [36]. (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 [37]. 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 [38]. 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) [39]. 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 [40]. 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 [41]. 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'.)

TRANSPLANTATION

Evolocumab therapy for coronary artery vasculopathy after heart transplantation (December 2024)

Coronary artery vasculopathy (CAV) is a common complication of heart transplantation that is difficult to prevent and treat. In a randomized trial in over 100 patients who underwent transplantation four to eight weeks before enrollment and who were receiving pravastatin, treatment with evolocumab (a proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitor) resulted in similar changes in CAV severity (ie, intimal thickness by ultrasound) after 12 months as placebo [42]. Notably, there were no serious adverse events attributable to evolocumab therapy in this population. The effect of intensive low-density lipoprotein (LDL) lowering with PCSK9 inhibitors on CAV prevention remains unclear, but in heart transplant recipients with an indication for lipid-lowering therapy who are not at their goal LDL level, additional therapy with evolocumab is a safe option for therapy. (See "Heart transplantation: Hyperlipidemia after transplantation", section on 'Additional therapy based on risk'.)

VALVULAR HEART DISEASE

Transcatheter tricuspid valve replacement for severe tricuspid regurgitation (November 2024)

For patients with symptomatic severe tricuspid regurgitation (TR), transcatheter tricuspid valve (TV) repair and replacement options have emerged as alternatives to TV surgery. In a trial of 400 symptomatic patients with severe TR, patients randomly assigned to transcatheter TV replacement had improved symptoms and severity of TR compared with those assigned to medical therapy alone [43]. However, safety concerns with transcatheter TV replacement included increased risks of early mortality, severe bleeding, and requiring a permanent pacemaker. For patients with symptomatic severe TR, the choice of intervention for symptom control is based on the available outcomes and safety data, but studies directly comparing interventions are lacking. (See "Tricuspid regurgitation: Management and prognosis", section on 'Transcatheter TV replacement'.)

Transcatheter aortic valve implantation for asymptomatic severe aortic stenosis (November 2024)

A role for transcatheter aortic valve (TAVI) in patients with asymptomatic severe aortic stenosis (AS) has not been determined. In a trial in which over 900 asymptomatic patients aged ≥65 years with severe AS, anatomy suitable for transfemoral TAVI, and low procedural risk were randomly assigned to transfemoral TAVI or routine clinical surveillance, mortality rates were similar in the groups over a median of nearly four years [44]. However, unplanned hospitalizations were less frequent and symptoms were less severe in the TAVI group. Based on these findings, options for asymptomatic patients aged ≥65 years with severe AS, anatomy suitable for transfemoral TAVI, and low procedural risk include transfemoral TAVI or close clinical monitoring. (See "High-gradient aortic stenosis in adults: Indications for valve replacement", section on 'TAVI outcomes'.)

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 [45]. 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 [46]. 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'.)

Seventh World Symposium pulmonary hypertension guidelines (January 2025)

Guidelines were issued by the Seventh World Symposium on Pulmonary Hypertension (PH) [47]. These guidelines highlight the importance of fast-track referral to PH centers. comprehensive baseline risk assessment prior to treatment, initial combination therapy (even for mild pulmonary arterial [PAH]), and the inclusion of sotatercept (a new class of medication that inhibits transforming growth factor-beta) to PAH regimens. The new guidelines also replace the term "acute responders at vasoreactivity testing" with "long-term responders to calcium channel blockers (CCB)," since some acute responders still require treatment with PAH-targeted drugs beyond CCB. We agree with these recommendations. (See "Clinical features and diagnosis of pulmonary hypertension of unclear etiology in adults", section on 'Introduction'.)

Association of myocardial fibrosis with sudden cardiac death risk in children with hypertrophic cardiomyopathy (January 2025)

In children with hypertrophic cardiomyopathy (HCM), growing evidence suggests that the burden of late gadolinium enhancement (LGE; a surrogate for myocardial fibrosis) on cardiac magnetic resonance (CMR) imaging provides valuable information for assessing the risk of sudden cardiac death (SCD). In a recent study of 700 patients <21 years of age with HCM, the risk of SCD events increased with increasing LGE burden, even after adjustment for multiple variables associated with SCD [48]. In patients whose risk of SCD is unclear, incorporating LGE burden into the overall risk assessment may influence the decision to place an internal cardioverter-defibrillator (ICD). (See "Hypertrophic cardiomyopathy in children: Management and prognosis", section on 'Other risk factors'.)