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| REVIEW ARTICLE |
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| Year : 2016 | Volume
: 2
| Issue : 3 | Page : 142-145 |
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Cardiology update 2017
Sunil Kumar Verma1, Harish Gupta2, Abhishek Gupta1
1 Department of Cardiology, AIIMS, New Delhi, India
2 Department of Medicine, CSM Medical University (KGMC), Lucknow, Uttar Pradesh, India
| Date of Web Publication | 2-Mar-2017 |
Correspondence Address:
Sunil Kumar Verma
Department of Cardiology, Suite No. 24, 7th Floor, CTC, AIIMS, Ansari Nagar, New Delhi - 110 029
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jpcs.jpcs_4_17
In the latter half of 2016, the Danish study evaluated the need of automatic implantable cardioverter-defibrillator in nonischemic cardiomyopathies group of heart failure population. HOPE-3 in 2016 expanded the dimension of statin use. Novel age, biomarker, and clinical history stroke risk score for atrial fibrillation was validated. Success of Phase 2b clinical trial for CSL112 was one more step to reduce the ischemic events in the postmyocardial infarction period. On the one hand, NORSTENT study compared the bare-metal stents with drug-eluting stent, and on the other hand, 3-year follow-up data of ABSORB II trail discussed the performance of bioresorbable scaffolds. NOBLE and EXCEL trials evaluated the coronary intervention with coronary artery bypass graft in the left main coronary artery disease. Reduction of major adverse cardiac event with low-density lipoprotein cholesterol <50 mg/dl was analyzed with alirocumab. Fractional flow reserve was tested as a tool to decide treatment modality in patients with stable coronary artery disease. Natural history of rheumatic heart disease in the current era was described in REMEDY study. A few technological advancements in cardiac resynchronization therapy defibrillator technology were also approved by the Food and Drug Administration. Birth prevalence and pattern of congenital heart disease in North India were presented. Keywords: Acute coronary syndrome, congenital heart disease, heart failure
How to cite this article:
Verma SK, Gupta H, Gupta A. Cardiology update 2017. J Pract Cardiovasc Sci 2016;2:142-5 |
| Heart Failure | |  |
The Danish study [1] assessed the prophylactic use of an implantable cardioverter-defibrillator in patients with symptomatic systolic heart failure due to causes other than coronary artery disease. With left ventricular (LV) ejection fraction (EF) of ≤35%, 556 patients received automatic implantable cardioverter-defibrillator (AICD) and 560 patients received usual clinical care for this indication. The primary outcome was death from any cause, and the secondary outcome was sudden cardiac death and cardiovascular (CV) death. In both groups, 58% of the patients received cardiac resynchronization therapy (CRT). Median follow-up period was 67.6 months. The trial concluded that the prophylactic use of AICD implantation in patients with symptomatic systolic heart failure not caused by coronary artery disease was not associated with a significantly lower long-term rate of death from any cause than being the usual clinical care.
The link between Alzheimer's disease (AD) and heart failure in aging population was first provided by imaging and proteomics approach in a retrospective cross-sectional study [2] from a cohort of 22 patients with AD and 35 age-matched controls. Echocardiographic measurements of myocardial function suggest that patients with AD present with an anticipated diastolic dysfunction. As in the brain, amyloid beta (Aβ) protein Aβ40 and Aβ42 are present in the heart, their expression is increased in AD.
| Hypertension | | |
A common perception is that ambulatory blood pressure (ABP) is usually lower than clinic blood pressure (CBP). ABP is consistently superior to CBP as a CV mortality and morbidity risk. An untreated employer-based US population of 888 healthy, employed, middle-aged (mean ± standard deviation age, 45 ± 10.4 years) individuals with screening blood pressure (BP) <160/105 mmHg and not taking antihypertensive medications completed three separate clinic BP assessments and a 24-h ABP recording.[3] The results of the study showed that patients with elevated CBP, ABP is usually not lower than CBP, at least not among healthy, employed individuals. In addition, a substantial proportion of otherwise healthy individuals with nonelevated CBP have masked hypertension.
| Primary Prevention | | |
HOPE-3 investigators [4] tested the hypothesis of extended benefits of statin therapy to intermediate-risk, ethnically diverse population without CV disease. About 12,000 individuals from 21 countries constituted the 2 × 2 factorial design of the trial. The inclusion criteria were women aged >60 years and men >55 years, at least one additional CV risk factor, including (1) waist/hip ratio ≥0.90 in men and ≥0.85 in women,(2) history of current or recent smoking (regular tobacco use within 5 years), (3) low high-density lipoprotein cholesterol (HDL-C), (4) dysglycemia, (5) renal dysfunction, (6) family history of premature congenital heart disease in the first-degree relatives. The tested statin was rosuvastatin 10 mg. The first coprimary outcome was the composite of death from CV causes, nonfatal myocardial infarction (MI), or nonfatal stroke, and the second coprimary outcome additionally included revascularization, heart failure, and resuscitated cardiac arrest. The median follow-up was 5.6 years. The HOPE-3 investigators concluded that the treatment with rosuvastatin at a dose of 10 mg/day resulted in a significantly lower risk of CV events than placebo in an intermediate-risk, ethnically diverse population without CV disease.
Atrial fibrillation
Oldgren et al.[5] tried to validate a recently proposed novel stroke risk score for patients with atrial fibrillation (AF) called ABC (age, biomarker [high-sensitivity troponin and N-terminal fragment B-type natriuretic peptide] and a clinical history of prior stroke/transient ischemic attack [TIA]). They also compared the performance of ABC with CHA2 DS2-VASc and Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) risk scores. This validation was based on about 8000 patients, 16,137 person-years of follow-up, and 219 adjusted stroke or systemic embolic events in anticoagulated patients with AF in the RE-LY study. The biomarker-based ABC score was well calibrated and consistently performed better than both CHA2 DS2-VASc and ATRIA stroke scores.
| Acute Coronary Syndromes | | |
CSL112 is a plasma-derived apolipoprotein A-I, the primary functional component of HDL. It causes a significant dose-dependent increase in plasma apolipoprotein A-I and enhances cholesterol efflux capacity and can reduce ischemic events in post-MI patients. AEGIS-I trial [6] tested CSL112 with placebo in about 1250 patients of acute coronary syndrome (both ST-elevation myocardial infarction [STEMI] and non-STEMI within the last 4 days) in 16 countries in two doses (2 g and 6 g weekly infusion for four consecutive weeks) to characterize its safety, efficacy, tolerability, pharmacodynamics, and pharmacokinetics. This dose-ranging Phase 2b clinical trial demonstrated that CSL112 infusions are feasible and well tolerated and not associated with any significant alterations in liver or kidney function or other safety concern. The ability of CSL112 to acutely enhance cholesterol efflux was confirmed.
| Coronary Artery Disease | | |
NORSTENT study [7] compared the long-term outcomes related to contemporary drug-eluting stent (DES) with contemporary bare-metal stents (BMS) in about 9000 patients with stable or unstable coronary artery disease undergoing percutaneous coronary intervention (PCI). The primary outcome was a composite of death from any cause and nonfatal spontaneous MI at a median follow-up of 5 years. Repeat revascularization, stent thrombosis, and quality of life were secondary outcome measures. The study demonstrated that there was no significant difference between DES and BMS in primary outcomes. However, they reported lower repeat revascularization in the group receiving DES.
Intervention in the left main coronary artery was compared with coronary artery bypass graft (CABG) in two trials and we got some opposing results.
One of them was EXCEL trial, published in NEJM [8] which involved 1905 patients with the left main coronary artery disease with low to intermediate SYNTAX score and given either PCI (with fluoropolymer-based, cobalt-chromium everolimus-eluting XIENCE stents, n = 948) or CABG (n = 95) with a 3-year follow-up. At the end of 3 years, PCI group was found noninferior to CABG group with respect to the composite end-point of death, stroke, and MI.
Another one was NOBLE, published in the Lancet [9] which involved 1201 patients with left main coronary artery disease. A total of 598 patients were treated with PCI (predominantly a blemish eluting stent, BioMatrix Flex) and 603 were treated with CABG with a 5-year follow-up. At 5 years, there was no significant difference in all-cause mortality between the two treatment modalities. The rate of nonprocedural MI and repeat revascularization were significantly higher among PCI-treated patients as compared to patients treated with CABG. A surprising finding was higher stroke rate in PCI group, but the difference was not statistically significant at 5 years. The investigators suggested that CABG might be superior to PCI in the treatment of the left main stem coronary artery disease.
The 3-year-follow-up data of ABSORB-II trail [10] failed to show the superior vasomotor reactivity and noninferior late lumen loss for the everolimus-eluting bioresorbable scaffold (ABSORB) with respect to everolimus-eluting metallic stent (XIENCE). A higher rate of periprocedural MI was observed in ABSORB group.
Alirocumab-treated patients can achieve low-density lipoprotein cholesterol (LDL-C) <50 mg/dl. Currently, statins and add-on lipid therapies can reduce the LDL-C up to ~54 mg/dl. The relationship between LDL-C <50 mg/dl and reduction in major adverse cardiac event (MACE) is not clear. A post hoc analysis [11] of ten randomized trials of ODYSSEY trial program with information on 6699 patient-years of exposure tested relationship between additional LDL-C, non-HDL-C, and apolipoprotein-B100 reduction and MACE among alirocumab with control (placebo/ezetimibe), mainly as add-on therapy to maximal tolerated dose of statin. Results showed that greater percentage reduction in LDL-C and lower on-treatment LDL-C was associated with lower MACE including very low levels of LDL-C (<50 mg/dl). For every 39 mg/dl lower achieved LDL-C, the risk of MACE appeared to be 24% lower.
The extent of reversible myocardial ischemia is an important determinant of clinical outcome in patients with stable coronary artery disease. Fractional flow reserve (FFR) values were used as a tool to assess the MACE at 2 years in 607 patients with stable coronary artery disease, in whom all the stenosis were assessed by FFR and were treated with medical therapy alone.[12] An average decrease in MACE per 0.05-unit increase in FFR was statistically significant even after adjustment for all clinical and angiographic features. The strongest increase in MACE occurred for FFR values between 0.80 and 0.60. In patients with stable coronary artery disease, stenosis as assessed by FFR is a major and independent predictor for lesion-related outcome.
Rheumatic heart disease
The latest data about the natural history of rheumatic heart disease (RHD) in most recent time are now from the REMEDY [13] study, and it demonstrated still a high mortality and morbidity. Enrollment of the 3343 patients of the RHD was done in between 2010 and 2012 in 25 centers in 14 low- and middle-income African and Asian countries and follow-up was done for 2 years. Median age of the patients was 28 years. Two-thirds of the patients were female. The 2-year case fatality rate was 16.9%. The mortality rate was 116.3/1000 patient-years and 65.4/1000 patient-years for the 1st and 2nd year, respectively, with 28.7 years as median age of death. Independent predictor of mortality in decreasing order of hazards ratio was severe valvular heart disease, congestive heart failure (CHF), the New York Heart Association functional Class III/IV, AF, and older age. Postprimary education and female sex were associated with lower risk of death. Incidence rates per 1000 patients per year were 38.42 for CHF, 8.45 for stroke or TIA, 3.49 for acute rheumatic fever, and 3.65 for infective endocarditis. Older age and previous stroke were independent predictors of stroke/TIA or systemic embolism.
Antiplatelet therapy
Multicenter, randomized academic PRAGUE-18[14] study did head-to-head comparison of efficacy and safety between prasugrel and ticagrelor in patient with acute MI undergoing primary PTCA as treatment strategy. About 1200 patients participated in the study. Although the study was of small sample size, it concluded that among the tested two newer P2Y12 receptor antagonists, no one is safer and effective in preventing ischemic and bleeding events in acute phase of MI treated with primary or intermediate PCI.
| Electrophysiology | | |
Investigational device exemption (IDE)[15] clinical study showed the results of multipoint pacing (MPP) in CRT-defibrillator and CRT-pacemakers. This MPP technology has recently got the US-Food and Drug Administration (FDA) approval. MPP is claimed to have better response rate and reduced rehospitalization rate because of electrical benefit (recruitment of a greater portion of the LV than traditional biventricular pacing, resulting in reduced activation times and QRS duration), mechanical benefit (reduced mechanical dyssynchrony), and hemodynamic benefit (improved acute LV contractility and improved EF and end-systolic volume at 6 months). Five hundred patients at 49 centers were given quadripolar pacing device in this prospective, randomized, multicenter, double-blinded noninferiority clinical study. Biventricular pacing was given to all patients for the first 3 months of the study. Then, for the next 6 months, patients were randomized to receive either standard biventricular pacing or MPP programming. The primary safety end-point was met with a 93.2% freedom from device-related complications. The primary efficacy end-point of the IDE clinical study demonstrated noninferiority of response rate in MPP technology group compared to biventricular pacing group at 9 months compared to at 3 months. Response rate reported by MPP technology was 87%.
Similarly, early in the year 2016, the US FDA approved ACUITY™ X4 Quadripolar LV leads for cardiac resynchronization therapy on the basis of results of NAVIGATE X4 study.[16] The novel family of ACUITY™ X4 Quadripolar LV leads is engineered with four electrodes along with a unique three-dimensional shape. These LV leads are designed to pace from the nonapical regions of the LV with low pacing capture threshold. The NAVIGATE X4 study was a prospective, multicenter, nonrandomized clinical trial that enrolled 764 patients. This study successfully met the primary safety and efficacy end-points through 6 months of follow-up. These leads demonstrated low pacing thresholds, particularly from proximal electrode, a high incidence of pacing from nondistal electrode, and low likelihood of dislodgement or phrenic nerve stimulation requiring surgical intervention.
Results and outcomes of catheter ablation of ventricular tachycardia (VT) in nonischemic dilated cardiomyopathy were discussed by Muser et al.[17] A total of 282 consecutive patients (mean age 59 ± 15 years, 80% males) after a failed median of two antiarrhythmic drugs including amiodarone in 166 (59%) patients were studied. Epicardial ablation was performed in 90 (32%) of the patients because of the recurrent VT or persistent inducibility after endocardial only ablation. Overall, VT-free survival was 69% at 60-month follow-up. Transplant-free survival was 76% and 68% at 60- and 120-month follow-up, respectively. At the last follow-up, 128 (45%) patients were only on beta-blockers or no treatment, 41 (30%) were on sotalol or Class I antiarrhythmic drugs, and 62 (22%) were on amiodarone.
| Congenital Heart Disease | | |
In a cross-sectional study, over a 3-year period involving of 20,307 newborns over a specific 8-h period of the day with clinical examination, pulse oximetry followed by screening echocardiography showed the statistics of birth prevalence and pattern of CHD in a community hospital in North India.[18] The study demonstrated CHD prevalence similar to reported worldwide birth prevalence. The birth prevalence of significant CHDs was 8.07 per 1000 live births (out of them about 80% were acyanotic, and about 20% were cyanotic). Ventricular septal defect was most common acyanotic CHD (5.7/1000 live birth). Transposition of the great arteries was the most common cyanotic CHD (0.34/1000 live birth).
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Conflicts of interest
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