Dr. Frank Talamantes, Ph.D. - What's new in cardiovascular medicine.pdf

8/20/2019 Dr. Frank Talamantes, Ph.D. - What's new in cardiovascular medicine.pdf

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Dr. Frank Talamantes, [email protected]

Wednesday, November 04, 2015 11:19 PM

What's new in cardiovascular medicine

Authors Gordon M Saperia, MD, FACC Susan B Yeon, MD, JD, FACC Brian C Downey, MD, FACC

Disclosures: Gordon M Saperia, MD, FACC Nothing to disclose. Susan B Yeon, MD, JD, FACC Nothing todisclose. Brian C Downey, MD, FACC Nothing to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed byvetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.

Conflict of interest policy

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

Dabigatran reversal agent approved (October 2015)

The lack of a specific reversal agent for the direct thrombin inhibitor dabigatran has been a persistent

concern in its use for patients with atrial fibrillation or venous thromboembolism. Idarucizumab (Praxbind)

is a reversal agent for dabigatran that was approved by the US Food and Drug Administration in October

2015 to reverse dabigatran effect in the setting of life-threatening or uncontrolled bleeding or emergency

surgery [1,2]. Approval was based on studies in healthy volunteers and an interim analysis of the RE-

VERSE AD trial, which included a cohort of 90 older adult patients who had clinically significant bleeding

or the need for an urgent invasive procedure while taking dabigatran for atrial fibrillation [3]. Idarucizumab

produced rapid normalization of clotting times and/or surgical hemostasis; there were five thrombotic

events and 18 deaths. Without a control group it is unclear how these outcomes would compare with

similar patients who did not receive idarucizumab. For patients with life-threatening bleeding, we would

use idarucizumab, if available, along with other measures to decrease bleeding risk, but we would not

combine idarucizumab with procoagulant products such as an activated prothrombin complex concentrate

(aPCC). Idarucizumab is an antibody-based therapy and does not have known activity against direct

factor Xa inhibitors or other anticoagulants. (See "Management of bleeding in patients receiving direct

oral anticoagulants", section on 'Dabigatran reversal'.)

Leadless cardiac pacing for single ventricle VVI pacing (September 2015)

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Currently available transvenous and epicardial permanent cardiac pacemaker systems are associated

with both early and long-term complications. Many of the complications, including infection, venous

thrombosis, and lead malfunction resulting in device failure, relate to the presence of indwelling

transvenous leads or the need to surgically place epicardial leads. In LEADLESS II, a prospective, non-

randomized, multicenter study of a miniaturized self-contained leadless pacemaker, both the primary

efficacy endpoint (acceptable pacing capture threshold and sensing amplitude) and the primary safetyendpoint (freedom from device-related adverse events) were achieved at six-month follow-

up [4]. Leadless cardiac pacing holds promise as an option for patients requiring long-term single

ventricle (right ventricle only, VVI) pacing. However, leadless pacing systems remain investigational and

longer-term follow-up is needed to assess the safety and efficacy of these devices along with the potential

for any long-term deleterious effects of RV-only pacing. (See "Permanent cardiac pacing: Overview of

devices and indications", section on 'Leadless systems'.)

Radiofrequency catheter ablation for atrial fibrillation (September 2015)

Up to 50 percent of patients with atrial fibrillation (AF) who undergo radiofrequency catheter ablation (CA)

require a second procedure to treat recurrent symptoms. A contact force (CF)-sensing catheter improves

the efficacy of energy delivery and thus may reduce the recurrence of symptomatic episodes. TheTOCCASTAR study randomly assigned 300 patients with paroxysmal AF to radiofrequency CA with a CF-

sensing catheter or a non-CF catheter [5]. There was no significant difference in the primary end point of

freedom from recurrent symptomatic atrial arrhythmia off antiarrhythmic drug therapy or the need for a

second ablation procedure at 12 months (67.8 and 69.4 percent, respectively). In a post hoc analysis, the

primary outcome was significantly improved (75.9 versus 58.1 percent) in patients who received a higher

force (≥10 grams) with the CF catheter. Based on TOCCASTAR, we suggest using a CF-sensing catheter

with force ≥10 grams in most patients with paroxysmal AF undergoing radiofrequency CA. However,

additional evidence from a prospective study supporting the use of this catheter is needed before we

recommend using it in all patients. (See "Catheter ablation to prevent recurrent atrial fibrillation: Technical

considerations", section on 'Circumferential pulmonary vein isolation'.)

Modified Valsalva maneuver for treatment of hemodynamically stable supraventricular

tachycardia (September 2015)

For both diagnostic and therapeutic purposes, the Valsalva maneuver is commonly used in patients with

suspected supraventricular tachycardia (SVT). In a randomized trial of vagal maneuvers for the treatment

of hemodynamically stable SVT, patients were assigned to perform the standard Valsalva maneuver

(strain generating 40 mmHg pressure for 15 seconds while in a semirecumbent position) with or without

supine repositioning and passive leg raise for 15 seconds following the strain phase [6]. Patients

performing the modified Valsalva maneuver with supine repositioning and passive leg raise were

significantly more likely to have restoration of sinus rhythm at one minute. For patients with

hemodynamically stable SVT who are able to effectively perform the maneuver, we recommend the

modified Valsalva maneuver as the initial treatment. (See "Atrioventricular nodal reentrant tachycardia",

section on 'Vagal maneuvers'.)

Adenosine-guided pulmonary vein isolation for patients with AF (July 2015)

In patients with paroxysmal atrial fibrillation (AF) who undergo catheter ablation (CA) for symptom control,

AF reoccurs in up to 50 percent at one year. Studies have shown that the intravenous administration of

adenosine (within 20 minutes of ablation) can unmask dormant conduction in patients who are otherwise

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felt to have had a successful procedure. In the ADVICE study, 534 patients with paroxysmal AF

underwent standard catheter ablation using radiofrequency energy followed by the administration of

intravenous adenosine [7]. The 284 patients with unmasked conduction were randomly assigned

to additional ablation or to no additional ablation. Freedom from symptomatic atrial tachycardia at one

year occurred more often with adenosine-guided additional ablation (69 versus 42 percent). Based on the

ADVICE study, we suggest that most patients with paroxysmal AF undergoing radiofrequency CA receiveadenosine to provoke dormant AF. (See "Catheter ablation to prevent recurrent atrial fibrillation: Clinical

applications", section on 'Use of adenosine-guided pulmonary vein isolation'.)

Safety and efficacy of remote cardiac device monitoring (June 2015)

For several decades, follow-up evaluation of cardiac implantable electronic devices (CIEDs) required in-

person assessment, but current technology enables comprehensive and safe remote monitoring for

nearly all types of CIEDs. In a 2015 systematic review and metaanalysis of nine randomized trials, which

compared remote monitoring and in-office follow-up after implantable cardioverter-defibrillator placement,

patients assigned to remote monitoring had nonsignificant reductions in total mortality, cardiovascular

mortality, and hospitalizations, along with significantly fewer inappropriate shocks [8]. These data reaffirm

the safety and efficacy of a remote monitoring approach for the follow-up of patients withCIEDs. (See "Cardiac implantable electronic devices: Patient follow-up", section on 'Office-based versus

remote follow-up'.)

Arrhythmogenic substrate in Brugada syndrome (June 2015)

The clinical manifestations of Brugada syndrome, most prominently syncope and sudden cardiac arrest

caused by ventricular arrhythmias, are thought to result from a variety of factors including right ventricular

(RV) myocardial abnormalities, mutations in the cardiac sodium channel SCN genes, autonomic tone,

fever, and the use of psychotropic drugs. In the RV outflow tract, there is a prominent transient outward

current, called I(to), which shortens the action potential in the setting of reduced sodium inflow. In

addition, noninvasive electrocardiogram mapping of the RV outflow tract has identified an arrhythmogenic

substrate which may predispose to local reentry and ventricular arrhythmias [9]. This substrate

exhibits delayed activation, slow conduction, and steep repolarization gradients between the RV outflow

tract and the rest of the right ventricle. The diagnostic and therapeutic implications of this newly identified

arrhythmogenic substrate have yet to be clearly identified. (See "Brugada syndrome", section on 'Sodium

channel genes'.)

Catheter ablation procedure for patients with persistent AF (May 2015)

Catheter ablation to prevent recurrent atrial fibrillation (AF) is recommended for many patients with

symptomatic paroxysmal AF who have failed a course of antiarrhythmic drug therapy. However,

outcomes with this invasive procedure have been less favorable in patients with persistent AF and

different ablation strategies have been evaluated in an attempt to improve the long-term success rate. In

the STAR AF II trial, 589 patients with persistent AF were randomly assigned to ablation with pulmonary

vein (PV) isolation alone, PV isolation plus ablation of electrograms showing complex fractionated activity,

or PV isolation plus additional linear ablation across the left atrial roof and mitral valve isthmus [10]. At 18

months, there was no significant difference in the rate of recurrence of AF (59 versus 49 versus 46

percent, respectively). For patients undergoing catheter ablation of persistent AF, we recommend

a standard PV isolation procedure rather than more complicated procedures. (See "Catheter ablation to

prevent recurrent atrial fibrillation: Clinical applications", section on 'Patients with persistent AF' .)

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CORONARY ARTERY BYPASS GRAFT SURGERY

Prophylactic glucocorticoid not beneficial at the time of cardiopulmonary bypass (September

2015)

Cardiopulmonary bypass used at the time of cardiac surgery leads to a systemic inflammatory state. The

SIRS trial randomly assigned 7507 patients to receive high-dose methylprednisolone or placebo andfound no difference in the risk of death or a combined end point of death and major morbidity at 30 days

[11]. We do not recommend the use of prophylactic glucocorticoids to lower the risk of clinically important

outcomes at the time of cardiac surgery with cardiopulmonary bypass. (See "Medical therapy to prevent

complications after coronary artery bypass graft surgery", section on 'Glucocorticoid therapy'.)

CORONARY HEART DISEASE, ACUTE

New societal guidelines on primary PCI (October 2015)

The American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography

and Interventions has published a focused update on primary percutaneous coronary intervention (PCI)

for patients with ST-elevation myocardial infarction [12,13]. Prior recommendations for the use of non-culprit artery revascularization and aspiration thrombectomy have been revised. The 2015 update,

consistent with recommendations in UpToDate, recommends non-culprit artery PCI prior to discharge and

advises against routine aspiration thrombectomy. (See "Primary percutaneous coronary intervention in

acute ST-elevation myocardial infarction: Non-culprit lesions", section on 'Recommendations of

others' and "Suboptimal reperfusion after primary percutaneous coronary intervention in acute ST

elevation myocardial infarction", section on 'Thrombectomy'.)

Optimal dose of beta blocker after acute MI (October 2015)

While beta blocker therapy is recommended for all patients with acute myocardial infarction (MI), the

optimal dose is not known. This issue was evaluated using data in a multicenter registry (OBTAIN study)

[14]. At two years, there was no difference in survival between patients who received at least 50 percentof the dose used in randomized trials and those who received less. Our approach is to prescribe doses

used in the randomized trials. (See "Acute myocardial infarction: Role of beta blocker therapy", section on

'Dose'.)

Cyclosporine not effective in improving outcomes after acute STEMI (September 2015)

Ischemic reperfusion injury accounts for a significant percent of final infarct size in patients with acute ST-

elevation myocardial infarction (STEMI). Cyclosporine has been shown to reduce infarct size, perhaps by

reducing reperfusion injury. The CIRCUS trial randomly assigned 970 patients with an anterior STEMI

undergoing primary percutaneous coronary intervention to an injection of intravenous cyclosporine or

placebo before coronary recanalization [15]. There was no difference between the groups in the primary

composite clinical outcome. Despite the absence of benefit in this study, research directed at reducing

reperfusion injury is ongoing and includes studies with cyclosporine. (See "Ischemic reperfusion injury of

the heart", section on 'Cyclosporine'.)

Coronary artery embolism as the cause of acute MI (July 2015)

Atherosclerotic coronary artery obstruction is the cause of myocardial infarction (MI) in the overwhelming

majority of patients. However, no obstructive coronary atherosclerosis is found in approximately 5 percent

of patients; multiple possible causes have been identified. The relationship between MI and coronary

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artery embolism (CE) due to atrial fibrillation (AF) was evaluated in a study of 1776 patients who

presented with an acute MI [16]. The prevalence of CE was about 3 percent and atrial fibrillation was the

most likely cause in three quarters of these. In patients with acute MI who do not have obstructive

atherosclerotic coronary artery disease as the likely cause, undiagnosed or untreated atrial fibrillation with

CE may be the explanation. (See "Myocardial infarction with no obstructive coronary atherosclerosis",

section on 'Coronary artery embolism'.)

Optimal dose of aspirin after acute MI with stenting (July 2015)

The optimal dose of aspirin for patients with acute myocardial infarction (MI) who undergo stenting is not

known. The TRANSLATE-ACS study evaluated outcomes in a non-randomized series of 10,123 patients

who were discharged on dual antiplatelet therapy that included either 325 or 81 mg of aspirin [17]. At six

months after discharge, the higher dose of aspirin was associated with an increased rate of minor

bleeding not requiring hospitalization, although the rate of major adverse events was similar. We suggest

that MI patients undergoing stenting be discharged on 75 to 81 mg of aspirin rather than higher

doses. (See "Antiplatelet agents in acute ST elevation myocardial infarction", section on 'Aspirin for all

patients'.)

Oxygen not helpful in normoxic STEMI patients (June 2015)

Small studies have raised the possibility of harm from supplemental oxygen in patients with ST-elevation

myocardial infarction (STEMI). In the AVOID study, 441 normoxic patients with confirmed STEMI were

randomly assigned to either supplemental oxygen (8 L/min) or no oxygen [18]. The trial showed no

improvement in the primary end point of a diminution in infarct size with oxygen and perhaps evidence of

a larger infarct. For STEMI patients who are not hypoxic, we suggest not administering supplemental

oxygen. (See "Overview of the acute management of ST elevation myocardial infarction", section on

'Oxygen'.)

HEART FAILURE

Angiotensin receptor-neprilysin inhibitor for heart failure with reduced ejection fraction (July

2015)

Sacubitril-valsartan, an angiotensin receptor-neprilysin inhibitor, has been approved in the United States

by the US Food and Drug Administration for use in patients with chronic New York Heart Association

(NYHA) functional class II to IV heart failure with reduced ejection fraction (HFrEF) [19]. In a randomized

trial, sacubitril-valsartan reduced mortality and morbidity compared with angiotensin converting enzyme

(ACE) inhibitor therapy, when used in combination with other standard heart failure therapies. However,

less than 1 percent of patients in the trial had NYHA class IV heart failure. We suggest use of sacubitril-

valsartan in place of the ACE inhibitor (or single agent ARB) component of therapy, in patients with stable

mild to moderate HFrEF (LVEF ≤40 percent), an elevated natriuretic peptide level or hospitalization for HF

in the past 12 months, a systolic blood pressure ≥100 mm Hg, and eGFR ≥30 mL and who have toleratedhigh-doses of ACE inhibitor or ARB therapy for ≥4 weeks. This recommendation is likely to evolve with

time as more data become available and experience with sacubitril-valsartan develops. (See "Use of

angiotensin II receptor blocker and neprilysin inhibitor in heart failure with reduced ejection fraction",

section on 'Indication'.)

Ivabradine for rate control in heart failure with reduced ejection fraction (July 2015)

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Ivabradine slows the sinus rate through inhibition of the f-channels. For patients with chronic stable heart

failure with left ventricular ejection fraction (LVEF) ≤35 percent, in sinus rhythm with a resting heart rate

≥70 beats per minute (bpm), and who are either on a maximum tolerated dose of a beta blocker or who

have a contraindication to beta blocker use, we suggest treatment with ivabradine, as approved in the

United States [20] and previously approved in Europe. In such patients, ivabradine has been shown to

reduce the risk of hospitalization for worsening heart failure. (See "Use of beta blockers and ivabradine inheart failure with reduced ejection fraction", section on 'Our recommendations'.)

Increased mortality in heart failure patients treated with adaptive servo-ventilation for central

sleep apnea (May 2015)

Adaptive servo-ventilation (ASV) is a type of noninvasive positive airway pressure therapy that is

sometimes used in patients with symptomatic central sleep apnea (CSA) who fail or do not tolerate

continuous positive airway pressure (CPAP). However, results of a randomized trial indicate that

increased caution is now warranted when considering use of ASV in patients with CSA, particularly those

with CSA associated with Cheyne-Stokes breathing due to symptomatic heart failure [21]. In the SERVE-

HF trial, 1325 patients with moderate to severe CSA due to symptomatic heart failure (ejection fraction

≤45 percent) were randomly assigned to ASV plus standard medical therapy or medical therapy alone.While the study found no difference in the primary outcome of time to all-cause mortality, lifesaving

cardiovascular intervention, or unplanned hospitalization due to heart failure, there was a 6 percent

increase in the absolute risk of all-cause mortality in patients randomly assigned to ASV (35 versus 29

percent). Cardiovascular mortality was also increased. Based on these results, we recommend not using

ASV to treat CSA due to heart failure with reduced ejection fraction; in such patients, supplemental

oxygen during sleep may be the next best option to CPAP. (See "Central sleep apnea: Treatment",

section on 'Adaptive servo-ventilation (ASV)'.)

LIPID DISORDERS

CETP inhibition in dyslipidemic patients (August 2015)

The role of cholesterol ester transfer protein (CETP) inhibition in the treatment of patients with

dyslipidemia is under investigation. In the phase 2 dose escalating TULIP trial, 364 patients with mild

dyslipidemia and without cardiovascular disease were randomly assigned to one of five doses of TA-8995

(a novel CETP inhibitor) alone, statin alone, TA-8995 and a statin, or placebo [22]. TA-8995 significantly

lowered low-density lipoprotein cholesterol and raised high-density lipoprotein cholesterol levels in a

dose-dependent manner. No safety issues were identified in the 12-week trial. Trials evaluating clinical

end points are ongoing and the potential role for CETP inhibitors in the treatment of dyslipidemia remains

to be determined. (See "Treatment of drug-resistant hypercholesterolemia", section on 'CETP inhibition' .)

Antisense therapy for hypertriglyceridemia (July 2015)

A randomized trial of an inhibitor of APOC3 messenger RNA in patients with elevated triglyceride levelsdemonstrated large reductions in levels both in patients not receiving other therapies and in patients also

being treated with fibrates [23]. This antisense agent or other therapies directed at apolipoprotein C3

may be of value in the future. (See "Approach to the patient with hypertriglyceridemia", section on 'Other'.)

MYOPERICARDIAL DISEASE

Presentation and outcomes of stress (takotsubo) cardiomyopathy (October 2015)

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Limited information is available on the presentation and outcome of stress (takotsubo) cardiomyopathy.

Among the 1759 patients in an International Takotsubo Registry study, 71.5 percent had a physical

trigger, an emotional trigger, or both. [24]. Although dramatic recovery of left ventricular systolic function

was observed in most patients, cardiogenic shock occurred in 10 percent and in-hospital death occurred

in 4 percent; these complication rates were similar to those in a matched cohort of patients with acute

coronary syndrome. (See "Clinical manifestations and diagnosis of stress (takotsubo) cardiomyopathy",section on 'History' and "Management and prognosis of stress (takotsubo) cardiomyopathy", section on

'Prognosis'.)

Antitrypanosomal therapy for Chagas heart disease (September 2015)

Limited evidence is available on the efficacy of antitrypanosomal therapy in patients with established

Chagas heart disease. The multicenter, double-blind BENEFIT trial randomly assigned 2854 patients

with chronic Chagas cardiomyopathy to receive either benznidazole or placebo for up to 80 days with

mean 5.4-year follow-up [25]. Although benznidazole reduced serum parasite detection compared with

placebo, it did not reduce the primary outcome (the first of the following events: death, resuscitated

cardiac arrest, sustained ventricular tachycardia, insertion of a pacemaker or implantable cardioverter-

defibrillator, cardiac transplantation, new heart failure, stroke, or other thromboembolic event). Despitethe neutral overall result, all components of the composite end point were nominally less frequent in the

treated group than in the placebo group, and the number of hospitalizations for cardiovascular causes in

the benznidazole group was significantly reduced. We suggest antitrypanosomal therapy to treat patients

with early chronic CD including those with mild cardiomyopathy, but not in those with more

advanced stages of Chagas cardiomyopathy. (See "Chagas heart disease: Treatment and prognosis",

section on 'T. cruzi infection'.)

PERIPHERAL VASCULAR DISEASE

Repeat intervention for restenosis following carotid endarterectomy (June 2015)

When re-intervention for restenosis of the carotid artery after carotid endarterectomy (CEA) is indicated,whether redo CEA or carotid artery stenting (CAS) is the preferred intervention is unknown. In a

systematic review of observational studies that included over 4000 individuals who underwent repeat

intervention for restenosis following CEA, there were no differences between CAS and redo CEA with

regards to 30-day mortality, stroke, and transient ischemic attack rates [26]. Redo CEA was associated

with an increased incidence of cranial nerve injury compared with CAS, but most patients recovered

within three months. Although CAS avoided complications related to redo neck surgery, CAS patients

developed restenosis more easily than redo CEA with long-term follow-up. Thus, the choice between the

procedures depends, in part, on the life-expectancy of the patient. Younger patients may be more likely

to opt for redo CEA. (See "Complications of carotid endarterectomy", section on 'CEA versus CAS for

recurrent stenosis'.)

Prevalence of cardiovascular disease among those with small abdominal aortic aneurysm (June

2015)

Patients with abdominal aortic aneurysm (AAA) have an increased risk for cardiovascular disease. In a

systematic review of individuals with small (


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small AAA. (See "Management of asymptomatic abdominal aortic aneurysm", section on 'Medical risk

assessment' and "Secondary prevention of cardiovascular disease".)

PREVENTIVE CARDIOLOGY

PCSK9 antibodies for cardiovascular risk reduction (September 2015)

Monoclonal antibodies that inhibit proprotein convertase subtilisin kexin 9 (PCSK9-abs) reduce LDL-

cholesterol levels by as much as 70 percent. Randomized trials with small numbers of events and limited

follow-up suggest that at least two of these agents, alirocumab and evolocumab, substantially reduce

cardiovascular events and mortality when used for secondary prevention, both as monotherapy and in

combination with statin therapy [28,29]. (See "Lipid lowering with drugs other than statins and fibrates",

section on 'PCSK9 inhibitors'.)

PCSK9-abs are becoming available for clinical use. The agents require subcutaneous injection every

two to four weeks and are very expensive. While awaiting greater experience with these agents, we

would use them in situations where the expected reductions in cardiovascular events are likely to

outweigh any as yet unknown adverse events from a new therapy. These include using them in

combination with statin therapy in very high-risk patients such as those in the proposed NCEP guidelines

(table 1), and as monotherapy in high-risk and very high-risk patients who are intolerant of statin

therapy. (See "Intensity of lipid lowering therapy in secondary prevention of cardiovascular disease",

section on 'Stable CVD'.)

Cardiovascular mortality and modifiable risk factors (August 2015)

Cardiovascular disease (CVD) remains the leading cause of death in the United States (US). Improved

risk factor modification can decrease CVD mortality. In descriptive data from a nationally representative

survey, five modifiable risk factors for CVD (elevated cholesterol, diabetes, hypertension, obesity, and

smoking) accounted for one-half of CVD deaths in US adults aged 45 to 79 from 2009 to 2010 [30]. Thepreventable fraction of CVD mortality associated with these risk factors was 54 percent for men and 50

percent for women. (See "Overview of primary prevention of coronary heart disease and stroke", section

on 'Rationale'.)

REVASCULARIZATION

Treatment of intracoronary stent restenosis (September 2015)

Intracoronary stent restenosis (ISR) is a challenging clinical problem that is commonly treated with repeat

percutaneous coronary intervention (PCI). A 2015 network meta-analysis of treatment for ISR

compared PCI with the everolimus-eluting stent (EES) with other devices and found that PCI with

EES was associated with a significantly larger luminal diameter at angiographic follow-up than bare metalstents, other drug-eluting stents, drug-eluting balloons, and other interventions [31]. We place an EES in

most cases of ISR. (See "Intracoronary stent restenosis", section on 'Choice of device'.)

Duration of dual antiplatelet therapy after coronary stenting (June 2015)

The optimal duration of dual antiplatelet therapy (DAPT) for patients who have received a drug-eluting

intracoronary stent is not known. All randomized trials have found an increased rate of major bleeding

and a lower rate of myocardial infarction with longer therapy. A 2015 meta-analysis confirmed a finding of

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an increase in all-cause mortality seen in some of the trials, although the magnitude of this increase was

small [32]. For patients who have tolerated 12 months of DAPT, we suggest continuing it for at least an

additional 18 months. (See "Antiplatelet therapy after coronary artery stenting", section on 'Drug-eluting

stents'.)

VALVULAR HEART DISEASE

New American and European guidelines on endocarditis (October 2015)

The American Heart Association (AHA) and European Society of Cardiology (ESC) have each issued

new guidelines on management of infective endocarditis (IE) that provide updated information on

antimicrobial therapy for IE [33,34]. Daptomycin has been added as an alternative agent for treatment of

staphylococcal IE, and gentamicin is no longer recommended for treatment of staphylococcal native valve

IE. Regimens for treatment of enterococcal IE now include double beta-lactam therapy with ampicillin and

high-dose ceftriaxone. In addition, high-dose daptomycin (with or without a beta-lactam) and linezolid are

included as potential alternative regimens for managing IE caused by enterococci resistant to penicillin,

aminoglycosides, and vancomycin. (See "Antimicrobial therapy of native valve

endocarditis" and "Antimicrobial therapy of prosthetic valve endocarditis".)

Subclinical bioprosthetic leaflet thrombosis (October 2015)

Limited evidence is available on the frequency and clinical significance of subclinical bioprosthetic aortic

valve leaflet thrombosis. The prevalence and clinical correlates of reduced leaflet motion detected by

computed tomography (CT) were evaluated in a study of 187 patients with bioprosthetic aortic valves

(including 55 patients in a clinical trial of an investigational transcatheter heart valve and 132 patients in

two clinical registries of patients with transcatheter and surgically implanted valves) [35]. Most of the

patients (160) had transcatheter heart valves. Reduced leaflet motion was detected in 40 percent of

patients in the clinical trial and in 13 percent of the patients in the registries. Among patients who were re-

evaluated by CT, the condition resolved in all 11 patients receiving anticoagulation and in 1 of 10 patients

not receiving anticoagulation. Further investigation is required to determine the incidence ofsubclinical bioprosthetic valve leaflet thrombosis, its clinical significance, and appropriate management.

(See "Transcatheter aortic valve replacement: Outcomes and complications", section on 'Valve leaflet

thrombosis'.)

Balloon-expandable versus self-expandable transcatheter heart valves for aortic stenosis (August

2015)

Data comparing clinical outcomes in patients with aortic stenosis treated with balloon-expandable versus

self-expandable valves are limited. One year follow-up of 241 high-risk patients with aortic

stenosis randomly assigned to balloon- or self-expandable valves revealed nominal differences in

mortality (17 versus 13 percent), rates of stroke (9 versus 3 percent), and repeat hospitalization for heart

failure (7 versus 13 percent), but these differences were not statistically significant [36]. More than mildparavalvular regurgitation was significantly more frequent in the self-expandable group (1 versus 12

percent). Further study including adequately powered trials is needed to compare the safety and efficacy

of available transcatheter heart valve devices during long-term follow-up. (See "Transcatheter aortic valve

replacement: Outcomes and complications", section on 'Balloon-expandable versus self-expanding valves

for aortic stenosis'.)

Transcatheter valve-in-valve implantation for failed bioprosthetic aortic valve (June 2015)

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Surgically implanted bioprosthetic valves are at risk for failure (stenosis, regurgitation, or both). While

reoperation is the standard treatment for bioprosthetic valve failure, repeat cardiac valve surgery is

associated with significant risks. The US Food and Drug Administration has approved a transcatheter

heart valve for valve-in-valve use as a less invasive option for patients with surgical bioprosthetic aortic

valve failure who are judged by a heart team, including a cardiac surgeon, to be at high or greater risk for

open surgical therapy [37]. Two devices are approved for valve-in-valve use in Europe.(See "Transcatheter aortic valve replacement: Indications and periprocedural management", section on

'For bioprosthetic aortic valve failure'.)

Five-year outcomes for transcatheter aortic valve replacement in aortic stenosis (June 2015)

Data on long-term outcomes after transcatheter aortic valve replacement (TAVR) for severe aortic

stenosis are emerging. Five-year results of a randomized trial confirmed shorter-term

reports that TAVR was more beneficial than standard therapy (including balloon aortic valvuloplasty) for

inoperable aortic stenosis though mortality rates for both types of treatment are high (71.8 versus 93.6

percent) [38]. Five-year results of a randomized trial comparing TAVR and surgical aortic valve

replacement (SAVR) in high surgical risk patients with aortic stenosis confirmed shorter-term

reports showing similar outcomes for the two treatment groups (mortality 67.8 versus 62.4 percent) [39].These findings demonstrate that TAVR is more beneficial than standard therapy for patients with

inoperable aortic stenosis and that TAVR is an alternative to surgery for patients with aortic stenosis with

high surgical risk. However, the mortality rate in these patient populations is high. (See "Transcatheter

aortic valve replacement: Outcomes and complications", section on 'TAVR versus medical therapy in

inoperable patients'.)

Transcatheter aortic valve replacement for aortic stenosis with low or intermediate surgical risk

(June 2015)

Transcatheter aortic valve replacement (TAVR) is recommended for patients with aortic stenosis requiring

valve replacement who have prohibitive surgical risk and as an option for patients with high surgical risk.

The role of TAVR in lower risk patients is uncertain. In a randomized trial comparing TAVR versus

surgical aortic valve replacement (SAVR) in patients with low and intermediate surgical risk, the

composite primary outcome (death, stroke, or myocardial infarction at one year) was similar in the two

groups [40]. The TAVR group had greater improvement in effective valve orifice but more aortic valve

regurgitation, more residual exertional dyspnea, and more frequently required pacemaker implantation,

whereas the SAVR group had more frequent major or life-threatening bleeding, cardiogenic shock, acute

kidney injury, and early post-procedural atrial fibrillation. Further data are needed to determine the best

strategy for valve replacement in patients with aortic stenosis with low and intermediate surgical risk.

(See "Transcatheter aortic valve replacement: Outcomes and complications", section on 'In low- and

intermediate-risk patients'.)

Trends in infective endocarditis incidence in the United States (May 2015)

The epidemiology of infective endocarditis (IE) has changed over time because of changes in the

prevalence of risk factors, as well as improved diagnostic tools and management. A study using the

Nationwide Inpatient Sample database, which included 457,052 hospitalizations for IE in the United

States between 2000 and 2011, found a steady increase in IE incidence over this time [41]. The trends in

hospitalization rates overall from 2000 to 2007 and from 2008 to 2011 were not significantly different, but

there was a steeper increase in hospitalization rates for streptococcal IE, specifically, after 2007. It has

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been postulated that this reflects reduced antimicrobial IE prophylaxis after the American College

of Cardiology/American Heart Association (ACC/AHA) recommended a narrower range of indications for

prophylaxis in 2007. However, in the absence of controlled data, a causal connection is uncertain. Given

the available evidence, we continue to recommend an approach to IE prophylaxis consistent with

the ACC/AHA guidelines. (See "Epidemiology, risk factors, and microbiology of infective endocarditis",

section on 'Epidemiology' and "Antimicrobial prophylaxis for bacterial endocarditis", section on 'Trends inendocarditis incidence'.)

OTHER CARDIOLOGY

SPRINT trial on goal blood pressure halted early (September 2015)

Goal blood pressure in most hypertensive patients is


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thromboembolism during interruption of chronic anticoagulation. (See "Perioperative management of

patients receiving anticoagulants", section on 'Whether to use bridging'.)

DP

Dr. Frank Talamantes, Ph.D. - What's new in cardiovascular medicine.pdf

Documents

Transcript of Dr. Frank Talamantes, Ph.D. - What's new in cardiovascular medicine.pdf