|
 
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| UPDATE SECTION |
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| Year : 2019 | Volume
: 5
| Issue : 3 | Page : 142-145 |
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Cardiology update – Third quarter
Satyavir Yadav
Department of Cardiology, AIIMS, New Delhi, India
| Date of Submission | 31-Oct-2019 |
| Date of Decision | 03-Dec-2019 |
| Date of Acceptance | 21-Nov-2019 |
| Date of Web Publication | 20-Dec-2019 |
Correspondence Address:
Dr. Satyavir Yadav
Room No. 20, 7th Floor, Cardioneuro Center, Department of Cardiology, AIIMS, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jpcs.jpcs_60_19
In continuation of previous updates this article contains some recent trials which includes CAPTURE study that showed benefits of carotid filter in stroke prevention,THEMIS study showed that in stable CAD patients ticagrelor plus aspirin had a lower incidence of ischemic cardiovascular events but a higher incidence of major bleeding than aspirin alone, AMBER study concluded that potassium binder patiromer enabled more patients to continue treatment with spironolactone with less hyperkalaemia.
Keywords: Coronary artery disease, heart failure, percutaneous coronary intervention
How to cite this article:
Yadav S. Cardiology update – Third quarter. J Pract Cardiovasc Sci 2019;5:142-5 |
| Myocardial Viability and Long-Term Outcomes in Ischemic Cardiomyopathy | |  |
The role of assessment of myocardial viability in identifying patients with ischemic cardiomyopathy who might benefit from surgical revascularization remains controversial.
The findings of this study do not support the concept that myocardial viability is associated with a long-term benefit of coronary artery bypass grafting in patients with ischemic cardiomyopathy. The presence of viable myocardium was associated with improvement in left ventricular systolic function, irrespective of treatment, but such improvement was not related to long-term survival.[1]
| Effects of Serelaxin in Patients With Acute Heart Failure (Relax-Ahf-2 Study) | | |
Serelaxin is a recombinant form of human relaxin-2, a vasodilator hormone that contributes to cardiovascular (CV) and renal adaptations during pregnancy. Previous studies have suggested that treatment with serelaxin may result in relief of symptoms and in better outcomes in patients with acute heart failure.
In this trial involving patients who were hospitalized for acute heart failure, an infusion of serelaxin did not result in a lower incidence of death from CV causes at 180 days or worsening heart failure at 5 days than placebo.[2]
| a Percutaneous Permanent Carotid Filter for Stroke Prevention in Atrial Fibrillation: the Capture Trial | | |
High stroke risk atrial fibrillation patients unsuitable to oral anticoagulants require other stroke prevention strategies. A novel permanent coil filter directly placed into both common carotid arteries was designed to capture emboli >1.4 mm diameter.
In a multicenter first-in-human nonrandomized study of 25 patients, it showed that under surface ultrasound guidance, the success of filter placement was 92%, and this was performed without major adverse events. No device-related major adverse events were observed during a mean follow-up of 6 months. There was also clinical evidence that emboli can be successfully captured.[3]
| Restarting Antiplatelet Therapy After Intracerebral Hemorrhage (Restart Study) | | |
This open-label, blinded endpoint trial recruited 537 adults (69–82 years, 33% women) with spontaneous intracerebral hemorrhage and tested whether restarting antiplatelet therapy, in comparison with avoidance, was associated with differences in the frequency of recurrent intracerebral hemorrhage and occlusive vascular events. The results showed a lower point estimate of risk for recurrent spontaneous intracerebral hemorrhage (primary outcome) for patients on antiplatelet therapy compared with those who did not receive this therapy although this result was not significant (adjusted hazard ratio [HR]: 0.51, 95% confidence interval [CI]: 0.25–1.03; P = 0·06).[4]
| Dulaglutide and Cardiovascular Outcomes in Type 2 Diabetes (Rewind Study) | | |
This study assessed the effect of the glucagon-like peptide-1 receptor agonist dulaglutide on major adverse CV events when added to the existing antihyperglycemic regimens of individuals with type 2 diabetes with and without previous CV disease and a wide range of glycemic control.
The primary outcome was the first occurrence of the composite endpoint of nonfatal myocardial infarction (MI), nonfatal stroke, or death from CV causes (including unknown causes).
During a median follow-up of 5·4 years (interquartile range: 5.1–5.9), the primary composite outcome occurred in 594 (12.0%) participants at an incidence rate of 2.4/100 person-years in the dulaglutide group and in 663 (13.4%) participants at an incidence rate of 2.7/100 person-years in the placebo group (HR: 0.88, 95% CI: 0.79–0.99; P = 0·026). All-cause mortality did not differ between the groups (536 [10.8%] in the dulaglutide group vs. 592 [12.0%] in the placebo group; HR: 0.90, 95% CI: 0.80–1.01; P = 0·067).[5]
| Oral Semaglutide and Cardiovascular Outcomes in Patients With Type 2 Diabetes (Pioneer 6 Study) | | |
It assessed CV outcomes of once-daily oral semaglutide in patients at high CV risk (age of ≥50 years with established CV or chronic kidney disease or age of ≥60 years with CV risk factors only).
In this trial involving patients with type 2 diabetes, the CV risk profile of oral semaglutide was not inferior to that of placebo.[6]
| Ticagrelor in Patients With Stable Coronary Disease and Diabetes (Themis Study) | | |
Patients with stable coronary artery disease and diabetes mellitus who have not had a MI or stroke are at high risk for CV events. Whether adding ticagrelor to aspirin improves outcomes in this population is unclear.
In this study, patients who were 50 years of age or older and who had stable coronary artery disease and type 2 diabetes mellitus received either ticagrelor plus aspirin or placebo plus aspirin. Patients with previous MI or stroke were excluded.
Those who received ticagrelor plus aspirin had a lower incidence of ischemic CV events but a higher incidence of major bleeding than those who received placebo plus aspirin.[7]
| Complete Revascularization With Multivessel Percutaneous Coronary Intervention for Myocardial Infarction (Complete Study) | | |
In patients with ST-segment elevation MI (STEMI), percutaneous coronary intervention (PCI) of the culprit lesion reduces the risk of CV death or MI. Whether PCI of nonculprit lesions further reduces the risk of such events is unclear.
Among patients with STEMI and multivessel coronary artery disease, complete revascularization was superior to culprit-lesion-only PCI in reducing the risk of CV death or MI, as well as the risk of CV death, MI, or ischemia-driven revascularization.[8]
| Angiotensin–neprilysin Inhibition in Heart Failure With Preserved Ejection Fraction (Paragon-Hf Study) | | |
The angiotensin receptor–neprilysin inhibitor sacubitril–valsartan led to a reduced risk of hospitalization for heart failure or death from CV causes among patients with heart failure and reduced ejection fraction. The effect of angiotensin receptor–neprilysin inhibition in patients with heart failure with preserved ejection fraction is unclear.
It randomly assigned 4822 patients with New York Heart Association (NYHA) Class II–IV heart failure, ejection fraction of 45% or higher, elevated level of natriuretic peptides, and structural heart disease to receive sacubitril–valsartan (target dose, 97 mg of sacubitril with 103 mg of valsartan twice daily) or valsartan (target dose, 160 mg twice daily).
Sacubitril–valsartan did not result in a significantly lower rate of total hospitalizations for heart failure and death from CV causes.[9]
| Ticagrelor or Prasugrel in Patients With Acute Coronary Syndromes (Isar-React 5 Study) | | |
The relative merits of ticagrelor as compared with prasugrel in patients with acute coronary syndromes for whom invasive evaluation is planned are uncertain. This study assigned patients who presented with acute coronary syndromes and for whom invasive evaluation was planned to receive either ticagrelor or prasugrel. The primary endpoint was the composite of death, MI, or stroke at 1 year. A major secondary endpoint (the safety endpoint) was bleeding.
Among patients who presented with acute coronary syndromes with or without ST-segment elevation, the incidence of death, MI, or stroke was significantly lower among those who received prasugrel than among those who received ticagrelor, and the incidence of major bleeding was not significantly different between the two groups.[10]
| Dapagliflozin in Patients With Heart Failure and Reduced Ejection Fraction (The Dapa-Hf Trial) | | |
In patients with type 2 diabetes, inhibitors of sodium–glucose cotransporter 2 (SGLT2) reduce the risk of a first hospitalization for heart failure, possibly through glucose-independent mechanisms. More data are needed regarding the effects of SGLT2 inhibitors in patients with established heart failure and a reduced ejection fraction, regardless of the presence or absence of type 2 diabetes.
In this study, 4744 patients with NYHA Class II, III, or IV heart failure and an ejection fraction of 40% or less received either dapagliflozin (at a dose of 10 mg once daily) or placebo, in addition to recommended therapy. The primary outcome was a composite of worsening heart failure (hospitalization or an urgent visit resulting in intravenous therapy for heart failure) or CV death.
Among patients with heart failure and a reduced ejection fraction, the risk of worsening heart failure or death from CV causes was lower among those who received dapagliflozin than among those who received placebo, regardless of the presence or absence of diabetes.[11]
| Patiromer Versus Placebo to Enable Spironolactone Use in Patients With Resistant Hypertension and Chronic Kidney Disease (Amber Study) | | |
Spironolactone is effective at reducing blood pressure in patients with uncontrolled resistant hypertension. However, the use of spironolactone in patients with chronic kidney disease can be restricted by hyperkalemia. We evaluated the use of the potassium-binder patiromer to allow more persistent use of spironolactone in patients with chronic kidney disease and resistant hypertension.
In patients with resistant hypertension and chronic kidney disease, patiromer enabled more patients to continue treatment with spironolactone with less hyperkalemia. Persistent spironolactone enablement in this population of patients has clinical relevance for the treatment of resistant hypertension.[12]
| Edoxaban-Based Versus Vitamin K Antagonist-Based Antithrombotic Regimen After Successful Coronary Stenting in Patients With Atrial Fibrillation (Entrust-Af Pci Study) | | |
It was done to assess the safety of edoxaban in combination with P2Y12 inhibition in patients with atrial fibrillation who had PCI.
In patients with atrial fibrillation who had PCI, the edoxaban-based regimen was noninferior for bleeding compared with the Vitamin K antagonist-based regimen, without significant differences in ischemic events.[13]
| Effect of Remote Ischemic Conditioning on Clinical Outcomes in Patients With Acute Myocardial Infarction (Condi-2/eric-Ppci Study) | | |
Remote ischemic conditioning with transient ischemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with STEMI undergoing primary PCI (PPCI). This study was done to investigate whether remote ischemic conditioning could reduce the incidence of cardiac death and hospitalization for heart failure at 12 months.
Remote ischemic conditioning does not improve clinical outcomes (cardiac death or hospitalization for heart failure) at 12 months in patients with STEMI undergoing PPCI.[14]
| a Community-Based Comprehensive Intervention to Reduce Cardiovascular Risk in Hypertension (Hope-4 Study) | | |
Hypertension is the leading cause of CV disease globally. Despite proven benefits, hypertension control is poor. It hypothesized that a comprehensive approach to lowering blood pressure and other risk factors, informed by detailed analysis of local barriers, would be superior to usual care in individuals with poorly controlled or newly diagnosed hypertension. This study tested whether a model of care involving nonphysician health workers, primary care physicians, family, and the provision of effective medications could substantially reduce CV disease risk.
This strategy is effective, pragmatic, and has the potential to substantially reduce CV disease compared with current strategies that are typically physician based.[15]
The ISCHEMIA trial showed that an invasive approach to patients with moderate-to-severe ischemia did not significantly reduce a composite endpoint of MI, CV death, hospitalization for unstable angina or heart failure, and cardiac arrest compared with a conservative medical strategy.[16]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Panza JA, Ellis AM, Al-Khalidi HR, Holly TA. Myocardial viability and long-term outcomes in ischemic cardiomyopathy. N Engl J Med 2019;381:739-48.  |
| 2. | Metra M, Teerlink JR, Cotter G, Davison BA, Felker GM, Filippatos G, et al. Effects of serelaxin in patients with acute heart failure. N Engl J Med 2019;381:716-26. |
| 3. | Reddy VY, Neuzil P, de Potter T, van der Heyden J, Tromp SC, Rensing B, et al. Permanent percutaneous carotid artery filter to prevent stroke in atrial fibrillation patients: The CAPTURE trial. J Am Coll Cardiol 2019;74:829-39. |
| 4. | Ziai WC, Tsiskaridze A. Restarting antiplatelet therapy after intracerebral haemorrhage. Lancet 2019;393:2567-9. |
| 5. | Gerstein HC, Colhoun HM, Dagenais GR, Diaz R, Lakshmanan M, Pais P, et al. Dulaglutide and cardiovascular outcomes in type 2 diabetes (REWIND): A double-blind, randomised placebo-controlled trial. Lancet 2019;394:121-30. |
| 6. | Husain M, Birkenfeld AL, Donsmark M, Dungan K, Eliaschewitz FG, Franco DR, et al. Oral semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med 2019;381:841-51. |
| 7. | Steg PG, Bhatt DL, Simon T, Fox K, Mehta SR, Harrington RA, et al. Ticagrelor in patients with stable coronary disease and diabetes. N Engl J Med 2019;381:1309-20. |
| 8. | Mehta SR, Wood DA, Storey RF, Mehran R, Bainey KR, Nguyen H, et al. Complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med 2019;381:1411-21. |
| 9. | Solomon SD, McMurray JJ, Anand IS, Ge J, Lam CS, Maggioni AP, et al. Angiotensin-neprilysin inhibition in heart failure with preserved ejection fraction. N Engl J Med 2019;381:1609-20. |
| 10. | Schüpke S, Neumann FJ, Menichelli M, Mayer K, Bernlochner I, Wöhrle J, et al. Ticagrelor or prasugrel in patients with acute coronary syndromes. N Engl J Med 2019;381:1524-34. |
| 11. | McMurray JJ, Solomon SD, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, et al. Dapagliflozin in patients with heart failure and reduced ejection fraction. N Engl J Med 2019;381:1995-2008. |
| 12. | Agarwal R, Rossignol P, Romero A, Garza D, Mayo MR, Warren S, et al. Patiromer versus placebo to enable spironolactone use in patients with resistant hypertension and chronic kidney disease (AMBER): A phase 2, randomised, double-blind, placebo-controlled trial. Lancet 2019;394:1540-50. |
| 13. | Vranckx P, Valgimigli M, Eckardt L, Tijssen J, Lewalter T, Gargiulo G, et al. Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST-AF PCI): A randomised, open-label, phase 3b trial. Lancet 2019;394:1335-43. |
| 14. | Hausenloy DJ, Kharbanda RK, Møller UK, Ramlall M, Aarøe J, Butler R, et al. Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI): A single-blind randomised controlled trial. Lancet 2019;394:1415-24. |
| 15. | Schwalm JD, McCready T, Lopez-Jaramillo P, Yusoff K, Attaran A, Lamelas P, et al. A community-based comprehensive intervention to reduce cardiovascular risk in hypertension. Lancet 2019. |
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