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

Beta blocker therapy for Marfan syndrome (November 2022)

Patients with Marfan syndrome (MFS) are treated with an angiotensin II receptor blocker (ARB) or beta blocker to reduce the risk of aortic aneurysm, but data comparing a beta blocker with no treatment for MFS are limited. The effects of beta blocker therapy versus control were estimated in an individual patient data meta-analysis that compared the effects of an ARB versus control (placebo or open control) with the effects of an ARB versus a beta blocker on the rate of change of aortic root dimension in patients with MFS [1]. The indirect estimate of the effect of beta blocker therapy was similar to the direct effect of an ARB. For adults with MFS and aortic aneurysm, we recommend a beta blocker or ARB. (See "Management of Marfan syndrome and related disorders", section on 'Beta blocker outcomes'.)

ARRHYTHMIAS

Alternative sites for cardiac resynchronization pacing (November 2022)

For patients with heart failure and reduced ejection fraction (HFrEF) who have left bundle branch block, cardiac resynchronization therapy (CRT) with pacing in the coronary sinus can improve functional status and reduce mortality, but alternative pacing sites may be more physiologic and superior. In a recent trial in 40 patients with HFrEF, CRT with a left bundle branch area pacing (LBBAP) lead resulted in greater improvement in left ventricular ejection fraction at six months compared with CRT with a coronary sinus lead [2]. However, other important markers of CRT effectiveness (eg, left ventricular end-diastolic dimension, six-minute walk time) were similar between the two groups. For patients with HFrEF who have an indication for CRT, we suggest initial placement of a CRT system with a coronary sinus lead; in selected patients who cannot undergo coronary sinus lead placement, CRT may be established with conduction system pacing (eg, LBBAP, His bundle pacing). (See "Cardiac resynchronization therapy in heart failure: Indications and choice of system", section on 'Choice of CRT system'.)

Motor vehicle crash risk in patients with syncope and other conditions (November 2022)

Studies of the risk of motor vehicle crash in patients with history of syncope have generally compared this risk with that in the general population. In a study that compared motor vehicle crash risk in over 9000 patients with "syncope and collapse" and over 34,000 patients visiting emergency departments with conditions other than syncope, the crash rates in the patient populations were similar and higher than that in the general population [3]. As a practical matter, patients were diagnosed with "syncope and collapse," which is not the same as an established diagnosis of syncope. The study suggests that motor vehicle crashes are likely to be similarly increased among patients with acute illness of sufficient severity to cause them to seek emergency department evaluation. (See "Syncope in adults: Management and prognosis", section on 'Driving restrictions'.)

CONGENITAL HEART DISEASE, ADULT

Incidence and predictors of Fontan-associated liver disease (February 2023)

Patients who have undergone a Fontan operation are at risk for liver disease (Fontan-associated liver disease [FALD]), but data on the incidence and risk factors for this complication are limited. In a retrospective study of over 1000 post-Fontan patients, liver cirrhosis developed in 13 percent and hepatocellular carcinoma in 1 percent at 20 years after Fontan operation [4]. High central venous pressure and severe atrioventricular valve regurgitation were risk factors for the development of cirrhosis or hepatocellular carcinoma. These data suggest potential targets for surveillance and prevention of FALD. (See "Management of complications in patients with Fontan circulation", section on 'Liver disease'.)

Long-term risk of ventricular septal defect (January 2023)

Limited data are available on long-term outcomes in adults with congenital ventricular septal defects (VSDs). In a population-based cohort study comparing 8000 patients with VSDs with over 80,000 matched controls for a median of more than 20 years, the risks of heart failure, arrhythmia, infectious endocarditis, and pulmonary hypertension were elevated in patients with unrepaired or surgically repaired VSDs [5]. Among patients with unrepaired VSDs, the risk of morbidity accelerated after age 40 years, and at a younger age in patients with repaired VSDs. These findings underscore the importance of long-term clinical follow-up in adults with VSDs. (See "Management and prognosis of congenital ventricular septal defect in adults", section on 'Long-term prognosis'.)

CORONARY HEART DISEASE, ACUTE

Bivalirudin or heparin for anticoagulation during percutaneous coronary intervention for myocardial infarction (November 2022)

Despite large trials, the optimal agent for anticoagulation during percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) remains unclear. In a recent trial in over 6000 patients with STEMI who underwent PCI and were randomly assigned to anticoagulation with either bivalirudin before and after PCI or to a single dose of unfractionated heparin (UFH) prior to PCI, those receiving bivalirudin had lower risks of mortality (3 versus 4 percent) and major bleeding (2.1 versus 2.6 percent) [6]. However, these small differences in efficacy and safety are of unclear clinical significance. In patients with STEMI who undergo revascularization with PCI, we suggest either UFH or bivalirudin for anticoagulation. (See "Acute ST-elevation myocardial infarction: Management of anticoagulation", section on 'Evidence in primary PCI'.)

CORONARY HEART DISEASE, STABLE

Increased cardiac events in Black females with ischemia with no obstructive coronary arteries (March 2023)

Black females with ischemia with no obstructive coronary arteries (INOCA) have a higher cardiovascular risk burden, more atypical symptoms, and delayed diagnosis and treatment compared with females of other races and ethnicities. In a study of nearly 600 females with INOCA, of whom 17 percent were Black, Black females had a higher risk of major adverse cardiovascular events and cardiovascular mortality compared with females of other races and ethnicities [7]. Patient and provider education about INOCA symptoms, diagnosis, and treatment may be needed to prevent these disparities. (See "Myocardial infarction with no obstructive coronary atherosclerosis", section on 'Prognosis'.)

Fractional flow reserve versus intravascular ultrasound to guide percutaneous coronary intervention (December 2022)

Fractional flow reserve (FFR) and intravascular ultrasound (IVUS) are both commonly used during coronary angiography to guide decisions about percutaneous coronary intervention (PCI), but data comparing their effects on clinical outcomes are lacking. In the FLAVOUR trial, in which over 1600 patients with intermediate coronary lesions (40 to 70 percent stenosis) were randomly assigned to an FFR- or IVUS-guided procedure, the risks of death, myocardial infarction, or revascularization at two years were similar between the groups [8]. Fewer patients in the FFR group were guided to PCI compared with the IVUS group (44 versus 65 percent), and patient-reported angina was similar in the two groups. We use FFR to guide PCI in patients with intermediate-risk coronary disease and reserve IVUS as a complementary modality to assess plaque anatomy. (See "Chronic coronary syndrome: Indications for revascularization", section on 'Severity of coronary artery disease'.)

Long-term outcomes with evolocumab for secondary prevention of cardiovascular disease (November 2022)

Among patients with cardiovascular disease (CVD) who are on effective statin therapy, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors reduce low-density lipoprotein cholesterol (LDL-C) and short-term risk of cardiovascular events. However, long-term outcomes are uncertain. In an open-label extension study of the FOURIER trial, over 6600 patients with CVD on statin therapy who had been originally assigned to the PCSK9 inhibitor evolocumab or placebo were treated with open-label evolocumab [9]. At a median of five years, patients originally assigned to evolocumab had a lower risk of a composite of major adverse cardiovascular events and a lower risk of cardiovascular death than those originally assigned to placebo; adverse events were similar between the groups. These findings suggest that patients with CVD receiving combination therapy with a statin and a PCSK9 inhibitor may derive long-term benefits with treatment. (See "PCSK9 inhibitors: Pharmacology, adverse effects, and use", section on 'Clinical effect'.)

Revascularization or medical therapy for ischemic cardiomyopathy (October 2022)

In patients with ischemic cardiomyopathy (ICM), it is unclear whether revascularization of coronary artery disease (CAD) is superior to optimal medical therapy alone. In a trial that included 700 patients with multivessel CAD and reduced left ventricular ejection fraction who were randomly assigned to receive percutaneous coronary intervention (PCI) with optimal medical therapy or optimal medical therapy alone, rates of death or rehospitalization were similar between the groups [10]. However, important factors that are commonly used to guide treatment decisions (eg, patient eligibility for coronary artery bypass grafting and correlation between stress testing and clinical findings) were not reported, limiting the trial's broader application to clinical practice. Revascularization is usually indicated for patients with ICM who have signs or symptoms of obstructive CAD, while optimal medical therapy may be appropriate for patients who do not have a clear association between clinical findings and obstructive CAD or who have advanced heart failure. (See "Treatment of ischemic cardiomyopathy", section on 'Choosing CABG, PCI, or no revascularization'.)

HEART FAILURE

Thiazide diuretics to augment diuresis in heart failure (February 2023)

In patients hospitalized with heart failure (HF), the simultaneous use of a loop diuretic and a thiazide diuretic may augment diuresis, but the safety and efficacy of this approach is unknown. In a trial that included over 300 inpatients with acutely decompensated HF who were receiving treatment with a loop diuretic, patients randomly assigned to receive additional therapy with hydrochlorothiazide (HCTZ) or placebo had similar changes in patient-reported dyspnea scores after 72 hours of therapy [11]. Patients assigned to HCTZ had more weight loss but a greater decrease in kidney function and a higher risk of hypokalemia. We typically attempt combination diuretic therapy with a thiazide or other nonloop diuretic agent in patients with acutely decompensated HF who are refractory to high doses of loop diuretics (eg, furosemide equivalent of 200 mg/day). (See "Use of diuretics in patients with heart failure", section on 'Management options'.)

Changes to heart failure therapy in patients recently hospitalized for heart failure (February 2023)

Patients with heart failure (HF) benefit from optimal medical therapy, but it is unclear whether patients recently hospitalized with HF can safely undergo rapid changes to their pharmacologic regimen. In a trial in nearly 1100 patients hospitalized with HF who were randomly assigned to high-intensity care (drug adjustment to target within two weeks of discharge and clinical surveillance) or to usual care, patients assigned to high-intensity care were more likely to achieve target doses of primary therapies for HF with reduced ejection fraction (eg, sacubitril-valsartan, beta blockers) and had a lower risk of hospital readmission by 180 days [12]. Although overall adverse effects were more frequent in the high-intensity care group, rates of serious adverse events were similar between the groups. In highly selected inpatients scheduled for discharge who can reliably undergo frequent observation in the outpatient setting, HF medications can be added or adjusted toward their target doses. (See "Treatment of acute decompensated heart failure: Specific therapies", section on 'Approach to long-term therapy in hospitalized patients'.)

Torsemide or furosemide for diuresis after heart failure hospitalization (January 2023)

Torsemide and furosemide have different pharmacologic properties, but it is unknown whether one agent is superior to the other in patients with heart failure (HF). In a trial in nearly 2900 patients hospitalized with HF who were randomly assigned to treatment with furosemide or torsemide prior to discharge, the rates of all-cause mortality and all-cause hospitalization at 12 months were similar between the groups [13]. However, immediate crossover between treatments and the open-label design may have obscured differences in diuretic efficacy. In patients recovering from acutely decompensated HF without known resistance to a specific diuretic, furosemide and torsemide are reasonable options for outpatient diuresis. (See "Use of diuretics in patients with heart failure", section on 'Choice of loop diuretic'.)

Alternative sites for cardiac resynchronization pacing (November 2022)

For patients with heart failure and reduced ejection fraction (HFrEF) who have left bundle branch block, cardiac resynchronization therapy (CRT) with pacing in the coronary sinus can improve functional status and reduce mortality, but alternative pacing sites may be more physiologic and superior. In a recent trial in 40 patients with HFrEF, CRT with a left bundle branch area pacing (LBBAP) lead resulted in greater improvement in left ventricular ejection fraction at six months compared with CRT with a coronary sinus lead [2]. However, other important markers of CRT effectiveness (eg, left ventricular end-diastolic dimension, six-minute walk time) were similar between the two groups. For patients with HFrEF who have an indication for CRT, we suggest initial placement of a CRT system with a coronary sinus lead; in selected patients who cannot undergo coronary sinus lead placement, CRT may be established with conduction system pacing (eg, LBBAP, His bundle pacing). (See "Cardiac resynchronization therapy in heart failure: Indications and choice of system", section on 'Choice of CRT system'.)

Treatment of iron deficiency in patients with heart failure (November 2022)

Patients with heart failure (HF) who are iron deficient should receive iron replacement, but the benefit of this therapy in patients who are not anemic is unclear. In a recent trial in nearly 1900 patients with HF who had an ejection fraction ≤45 percent, hemoglobin ≥9 g/dL, and evidence of iron deficiency (ie, low ferritin or low transferrin saturation), patients assigned to receive intravenous ferric derisomaltose had lower rates of mortality and hospitalization that did not reach statistical significance when compared with placebo [14]. However, in aggregate, trials of iron replacement in similar patients suggest a favorable effect on reducing hospital admissions. Thus, for most patients with HF and iron deficiency (with or without anemia), we suggest iron replacement with intravenous iron. (See "Evaluation and management of anemia and iron deficiency in adults with heart failure".)

Routine display of a risk estimate in patients with heart failure (October 2022)

Routine risk stratification of patients with heart failure (HF) may lead to improved care, but it is unclear whether this strategy alters physician behavior or improves health outcomes. In a recent trial that included over 3100 patients with HF who were randomly assigned to routine display of a one-year mortality estimate to their clinician via the electronic health record or to usual care, the risk of one-year mortality and 30-day hospital readmission was similar between the groups [15]. In addition, clinician behavior, as measured by the use of guideline-directed medical therapy or advanced HF therapies (eg, cardiac transplantation), was also similar between the groups. The use of a risk model in patients with HF is indicated when the information may help to more accurately convey prognosis to the patient but should not be routinely used to guide therapy. (See "Predictors of survival in heart failure with reduced ejection fraction", section on 'Predictive models'.)

Revascularization or medical therapy for ischemic cardiomyopathy (October 2022)

In patients with ischemic cardiomyopathy (ICM), it is unclear whether revascularization of coronary artery disease (CAD) is superior to optimal medical therapy alone. In a trial that included 700 patients with multivessel CAD and reduced left ventricular ejection fraction who were randomly assigned to receive percutaneous coronary intervention (PCI) with optimal medical therapy or optimal medical therapy alone, rates of death or rehospitalization were similar between the groups [10]. However, important factors that are commonly used to guide treatment decisions (eg, patient eligibility for coronary artery bypass grafting and correlation between stress testing and clinical findings) were not reported, limiting the trial's broader application to clinical practice. Revascularization is usually indicated for patients with ICM who have signs or symptoms of obstructive CAD, while optimal medical therapy may be appropriate for patients who do not have a clear association between clinical findings and obstructive CAD or who have advanced heart failure. (See "Treatment of ischemic cardiomyopathy", section on 'Choosing CABG, PCI, or no revascularization'.)

Guidelines for perioperative management of patients with pulmonary hypertension and right heart failure (September 2022)

Pulmonary hypertension with right heart failure is a risk factor for perioperative morbidity and mortality. In a recently published consensus statement, the International Society for Heart and Lung Transplantation recommended a multidisciplinary approach to preoperative assessment to ensure that the indication and benefits of surgery are reasonable and that the patient's condition is optimal for surgery [16]. Intraoperative considerations include use of invasive monitoring for higher-risk cases, use of slowly titrated epidural or spinal neuraxial anesthesia as appropriate, and induction of general anesthesia with etomidate with appropriate use of vasopressors. Vigilant postoperative monitoring is necessary for early recognition and treatment of complications. (See "Anesthesia for noncardiac surgery in patients with pulmonary hypertension or right heart failure", section on 'Risks of anesthesia and surgery'.)

LIPID DISORDERS

Bempedoic acid lowers cardiovascular events in patients intolerant to statins (March 2023)

Statins are the preferred therapy for most patients requiring treatment of dyslipidemia, but nearly 10 percent of patients have statin intolerance. In a trial in which nearly 14,000 patients at high risk for cardiovascular disease who were unable or unwilling to take statins due to adverse effects were randomly assigned to oral bempedoic acid or placebo, patients receiving bempedoic acid had a lower risk of major adverse cardiovascular events (11.7 versus 13.3 percent) [17]. However, the incidences of gout, cholelithiasis, and increases in serum creatinine, uric acid, and hepatic enzymes were slightly higher with bempedoic acid than with placebo. Bempedoic acid may be used in statin-intolerant patients who require modest lipid lowering, but side effects must be monitored. (See "Low-density lipoprotein cholesterol lowering with drugs other than statins and PCSK9 inhibitors", section on 'Bempedoic acid'.)

Long-term outcomes with evolocumab for secondary prevention of cardiovascular disease (November 2022)

Among patients with cardiovascular disease (CVD) who are on effective statin therapy, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors reduce low-density lipoprotein cholesterol (LDL-C) and short-term risk of cardiovascular events. However, long-term outcomes are uncertain. In an open-label extension study of the FOURIER trial, over 6600 patients with CVD on statin therapy who had been originally assigned to the PCSK9 inhibitor evolocumab or placebo were treated with open-label evolocumab [9]. At a median of five years, patients originally assigned to evolocumab had a lower risk of a composite of major adverse cardiovascular events and a lower risk of cardiovascular death than those originally assigned to placebo; adverse events were similar between the groups. These findings suggest that patients with CVD receiving combination therapy with a statin and a PCSK9 inhibitor may derive long-term benefits with treatment. (See "PCSK9 inhibitors: Pharmacology, adverse effects, and use", section on 'Clinical effect'.)

Novel gene variant associated with familial combined hypocholesterolemia (September 2022)

A number of rare genetic variants cause low levels of low-density lipoprotein cholesterol (LDL-C) and are associated with a reduced risk of atherosclerotic cardiovascular disease (ASCVD). Recently, a novel gain-of-function genetic variant in hepatic lipase (called LIPC-E97G) was identified in a family with combined hypocholesterolemia (low LDL-C, low high-density lipoprotein cholesterol, normal triglyceride and apolipoprotein B concentrations) [18]. The index case developed ASCVD at age 61 despite having low LDL-C levels (40 mg/dL or 1 mmol/L); other affected family members did not have ASCVD. Additional studies are needed to better understand the biological and clinical significance of this genetic variant. (See "Low LDL-cholesterol: Etiologies and approach to evaluation", section on 'Other genetic conditions'.)

PERIPHERAL ARTERIAL DISEASE

Surgical bypass or endovascular revascularization for chronic limb-threatening ischemia (November 2022)

The BEST-CLI trial randomly assigned two cohorts of patients (over 1800 patients in total) with chronic limb-threatening ischemia (CLTI) to surgical bypass or endovascular revascularization [19]. All patients in the first cohort had a single segment of suitable great saphenous vein (GSV) on ultrasound. At a mean 2.7 years follow-up, surgery reduced the composite outcome of major adverse limb events or all-cause death in this cohort (43 versus 57 percent). No patient in the second cohort had a suitable GSV, and the composite outcome was not significantly different for surgery versus endovascular revascularization in this cohort. For patients with CLTI judged to be suitable candidates for either approach, we suggest a bypass-first strategy when a single segment of suitable GSV is available. Otherwise, a bypass-first or endovascular-first approach is appropriate. (See "Management of chronic limb-threatening ischemia", section on 'Approach to revascularization'.)

PERCUTANEOUS CORONARY INTERVENTION

Fractional flow reserve versus intravascular ultrasound to guide percutaneous coronary intervention (December 2022)

Fractional flow reserve (FFR) and intravascular ultrasound (IVUS) are both commonly used during coronary angiography to guide decisions about percutaneous coronary intervention (PCI), but data comparing their effects on clinical outcomes are lacking. In the FLAVOUR trial, in which over 1600 patients with intermediate coronary lesions (40 to 70 percent stenosis) were randomly assigned to an FFR- or IVUS-guided procedure, the risks of death, myocardial infarction, or revascularization at two years were similar between the groups [8]. Fewer patients in the FFR group were guided to PCI compared with the IVUS group (44 versus 65 percent), and patient-reported angina was similar in the two groups. We use FFR to guide PCI in patients with intermediate-risk coronary disease and reserve IVUS as a complementary modality to assess plaque anatomy. (See "Chronic coronary syndrome: Indications for revascularization", section on 'Severity of coronary artery disease'.)

PREVENTIVE CARDIOLOGY

Bempedoic acid lowers cardiovascular events in patients intolerant to statins (March 2023)

Statins are the preferred therapy for most patients requiring treatment of dyslipidemia, but nearly 10 percent of patients have statin intolerance. In a trial in which nearly 14,000 patients at high risk for cardiovascular disease who were unable or unwilling to take statins due to adverse effects were randomly assigned to oral bempedoic acid or placebo, patients receiving bempedoic acid had a lower risk of major adverse cardiovascular events (11.7 versus 13.3 percent) [17]. However, the incidences of gout, cholelithiasis, and increases in serum creatinine, uric acid, and hepatic enzymes were slightly higher with bempedoic acid than with placebo. Bempedoic acid may be used in statin-intolerant patients who require modest lipid lowering, but side effects must be monitored. (See "Low-density lipoprotein cholesterol lowering with drugs other than statins and PCSK9 inhibitors", section on 'Bempedoic acid'.)

Novel gene variant associated with familial combined hypocholesterolemia (September 2022)

A number of rare genetic variants cause low levels of low-density lipoprotein cholesterol (LDL-C) and are associated with a reduced risk of atherosclerotic cardiovascular disease (ASCVD). Recently, a novel gain-of-function genetic variant in hepatic lipase (called LIPC-E97G) was identified in a family with combined hypocholesterolemia (low LDL-C, low high-density lipoprotein cholesterol, normal triglyceride and apolipoprotein B concentrations) [18]. The index case developed ASCVD at age 61 despite having low LDL-C levels (40 mg/dL or 1 mmol/L); other affected family members did not have ASCVD. Additional studies are needed to better understand the biological and clinical significance of this genetic variant. (See "Low LDL-cholesterol: Etiologies and approach to evaluation", section on 'Other genetic conditions'.)

TRANSPLANTATION

New guidelines for management of heart transplant recipients (January 2023)

Updated guidelines on the management of heart transplant recipients were recently published by the International Society for Heart and Lung Transplantation [20]. These guidelines provide new content on the safe use of hearts from donors with hepatitis C infection, technological requirements for centers wishing to use hearts from donors declared dead after circulatory arrest, and management issues related to the ongoing COVID-19 pandemic. In addition, the guidelines review an array of new diagnostic tests for allograft rejection and acknowledge that routine surveillance for rejection is increasingly performed with noninvasive testing rather than with endomyocardial biopsy. (See "Heart transplantation in adults: Donor selection and organ allocation", section on 'Criteria for cardiac donors' and "Heart transplantation in adults: Donor selection and organ allocation", section on 'Donation after circulatory death' and "Heart transplantation in adults: Diagnosis of allograft rejection", section on 'Approaches to evaluating for rejection'.)

Donor hearts procured after circulatory death (December 2022)

There is increasing experience with transplantation of hearts donated after circulatory death (DCD, also called donation after circulatory determination of death), but concerns remain that DCD hearts can be severely injured between cessation of life support and declaration of circulatory death. In a recent study that evaluated outcomes among nearly 230 recipients of a DCD heart and nearly 7300 recipients of a donor heart acquired after declaration of brain death (DBD), the one-year risk of mortality was similar with DCD or DBD transplantation [21]. In all DCD donors, an ex vivo perfusion device (eg, "heart in a box") or normothermic regional perfusion technique (eg, resuscitation of the heart in situ after excluding the cerebral circulation) was used to assess the donor heart for injury prior to transplantation. The use of DCD hearts has expanded the donor pool for heart transplantation, but the need to assess DCD heart function after circulatory arrest requires additional surgical experience and specialized equipment that may limit the broad use of DCD hearts. (See "Heart transplantation in adults: Donor selection and organ allocation", section on 'Donation after circulatory death'.)

VALVULAR HEART DISEASE

Five-year outcomes of transcatheter mitral repair for secondary mitral regurgitation (March 2023)

Transcatheter edge-to-edge repair (TEER) reduces secondary mitral regurgitation (MR), but the durability of clinical benefit has not been established. Five-year outcomes were recently reported from a randomized trial that compared TEER with medical therapy alone in over 600 patients with moderate-to-severe or severe (3+ or 4+) secondary MR and symptomatic heart failure despite maximal medical therapy [22,23]. At five years, TEER reduced all-cause mortality and hospitalization for heart failure compared with medical therapy alone. For selected patients with moderate-to-severe to severe secondary MR who are symptomatic despite optimum medical therapy, we suggest TEER. (See "Management and prognosis of chronic secondary mitral regurgitation", section on 'Transcatheter edge-to-edge repair'.)

Early surgical valve replacement versus conservative management for asymptomatic severe aortic stenosis (February 2023)

Management options for patients with asymptomatic severe aortic stenosis include surgical aortic valve replacement (SAVR), transcatheter aortic valve implantation, and conservative management. In a meta-analysis that included two randomized controlled trials and 10 observational studies (over 4000 patients) comparing early SAVR with conservative management, early SAVR was associated with lower all-cause mortality, cardiovascular mortality, and heart failure hospitalization [24]. The risks of stroke and myocardial infarction were similar with early SAVR and conservative management. These findings support a role for early SAVR in selected patients with asymptomatic severe aortic stenosis. (See "Indications for valve replacement for high gradient aortic stenosis in adults", section on 'Asymptomatic severe aortic stenosis'.)

Prognostic factors for isolated severe tricuspid regurgitation (January 2023)

Patients with severe tricuspid regurgitation (TR) commonly have left-sided valve disease that impacts prognosis, but prognostic data in patients with isolated severe TR and no significant left-sided valve disease are limited. In a study of over 600 patients with isolated severe TR, 23 percent died and 10 percent were hospitalized for heart failure over a median of 26.5 months [25]. Adverse prognostic factors included pulmonary hypertension, elevated blood urea nitrogen levels, decreased albumin levels, and left atrial enlargement. These data may help guide risk-stratified management of isolated severe TR. (See "Management and prognosis of tricuspid regurgitation", section on 'Prognosis of severe TR'.)

Cerebral embolic protection for transcatheter aortic valve implantation (November 2022)

Cerebral embolic protection (CEP) systems are designed to capture or deflect debris released during transcatheter aortic valve implantation (TAVI), but a clinical benefit from this approach has not been established. A meta-analysis of seven randomized trials of four CEP devices in a total of 3000 patients undergoing TAVI found similar rates of stroke with or without CEP [26,27]. In the largest included trial, there were similar rates of stroke with or without CEP, but the rate of disabling stroke was slightly lower with CEP. Thus, the role of CEP devices is uncertain and may be clarified with the addition of results of a larger randomized trial currently in progress. (See "Transcatheter aortic valve implantation: Periprocedural and postprocedural management", section on 'Role of cerebral embolic protection'.)

Antibiotic prophylaxis against endocarditis before invasive dental procedures (September 2022)

The efficacy of antibiotic prophylaxis for prevention of infective endocarditis (IE) has not been established. A case-crossover analysis and cohort study performed in nearly 8 million individuals identified an association between invasive dental procedures (particularly extractions and oral surgery) and subsequent IE in individuals at high IE risk [28]. Antibiotic prophylaxis was associated with reduced risk of IE after these procedures. These findings support administration of antibiotic prophylaxis to individuals with high IE risk undergoing invasive dental procedures. (See "Prevention of endocarditis: Antibiotic prophylaxis and other measures", section on 'Impact of procedures on risk of endocarditis'.)

OTHER CARDIOLOGY

No role for statin therapy in preventing anthracycline cardiotoxicity (December 2022)

Cardiac toxicity caused by anthracycline-based chemotherapy is a major complication of cancer treatment, and there is an unmet need to identify therapies that attenuate this toxicity. In a recent trial that included nearly 300 patients who were treated with doxorubicin for either lymphoma or breast cancer and who had normal left ventricular ejection fraction (LVEF), patients randomly assigned to statin therapy or to placebo had similar decreases in LVEF after 24 months [29]. The trial used the gold standard of cardiovascular magnetic resonance imaging to quantify LVEF but was limited by missing LVEF values in more than one-third of participants. These findings do not support a role for statin therapy in preventing anthracycline-induced left ventricular systolic dysfunction; our approach to mitigating anthracycline cardiotoxicity includes limiting the cumulative dose of anthracycline and monitoring for early signs of toxicity with echocardiography. (See "Risk and prevention of anthracycline cardiotoxicity", section on 'Primary prevention with cardiovascular drugs'.)