What's new in cardiovascular medicine: Part II
- HEART FAILURE
- Semaglutide for the treatment of heart failure with preserved ejection fraction (September 2024 LANCET)
There is growing evidence that pharmacologic treatments that target metabolic pathways may reduce the burden of cardiovascular outcomes in patients with heart failure with preserved ejection fraction (HFpEF). In a recent meta-analysis that included over 3700 patients with HFpEF and obesity, treatment with the glucagon-like peptide (GLP-1) receptor agonist semaglutide lowered the rate of worsening HF events compared with placebo . A subgroup analysis suggested that patients with body mass index (BMI) ≥35 kg/m2 were more likely to benefit from semaglutide than those with lower BMI.
Conclusion: In patients with HFpEF and obesity, we suggest therapy with a GLP-1 receptor agonist and lifestyle interventions for weight loss rather than lifestyle interventions alone; patients with a higher BMI may benefit more from GLP-1 agonist therapy than those with lower BMI. - Cardiac rehabilitation for heart failure at home (July 2024 COCHRANE DATA BASE REVIEW)
Cardiac rehabilitation is beneficial for patients with heart failure, but it remains unclear whether newer methods of cardiac rehabilitation (eg, home-based programs) are as effective as programs delivered in a dedicated rehabilitation center (eg, hospital). In a recent meta-analysis that included over 2000 patients who mostly had ejection fraction <45 percent, cardiac rehabilitation reduced the rate of all-cause hospitalizations and improved quality of life at six months. The location of rehabilitation did not significantly affect the benefit of cardiac rehabilitation on these outcomes. - Aficamten therapy for hypertrophic cardiomyopathy and symptomatic left ventricular outflow tract obstruction (July 2024 NEJM)
Patients with hypertrophic cardiomyopathy (HCM) may develop dyspnea or other symptoms caused by left ventricular outflow tract (LVOT) obstruction that were historically treated with negative inotropic drugs or septal reduction therapy (eg, surgical myectomy). In a randomized trial in nearly 300 patients with HCM and symptoms of LVOT obstruction, patients receiving aficamten (an investigational oral cardiac myosin inhibitor) had fewer severe heart failure symptoms and improved quality of life compared with those receiving placebo. Although there was concern that myosin inhibitors could increase the risk of atrial fibrillation (AF), rates of AF in this trial were similar between the groups. - Acoramidis for the treatment of transthyretin cardiac amyloidosis (May 2024 NEJM)
In patients with transthyretin (ATTR) cardiac amyloidosis and heart failure (HF) symptoms, treatment with an agent that prevents cleavage of ATTR tetramers has been shown to improve survival. In a recent trial in over 600 patients with ATTR cardiac amyloidosis and HF symptoms, patients randomly assigned to treatment with the ATTR stabilizer acoramidis had a lower rate of hospitalization over 30 months compared with placebo. In contrast with tafamidis, a drug with a similar mechanism of action, acoramidis did not reduce mortality compared with placebo.
Conclusion: For patients with ATTR cardiac amyloidosis and HF symptoms, we recommend treatment with tafamidis. - Intravenous iron in heart failure (April 2024 EHJ META ANALYSIS)Individuals with heart failure (HF) and iron deficiency should be treated, but expert groups differ on the perceived benefits. In a new meta-analysis that included over 4500 patients participating in randomized trials, intravenous iron reduced the rate of cardiovascular hospitalizations compared with placebo; all-cause mortality was not reduced. This supports our suggested approach of using intravenous iron, although oral iron may be reasonable. Iron supplementation should be stopped once stores are repleted, as excess iron deposition is cardiotoxic.
- Semaglutide for the treatment of heart failure with preserved ejection fraction (September 2024 LANCET)
- PREVENTIVE CARDIOLOGY
- Biomarkers for 30-year cardiovascular risk stratification (September 2024 NEJM)
The use of 10-year risk estimates to guide primary prevention of atherosclerotic cardiovascular disease (ASCVD) is well established; however, evidence supporting 30-year ASCVD risk assessment is less robust. An analysis of a cohort of almost 28,000 middle-aged females without ASCVD found that baseline levels of high-sensitivity C-reactive protein, low-density lipoprotein cholesterol, and lipoprotein(a) were each independently associated with increased risks of major ASCVD events at 30-year follow-up. Elevated levels of all three biomarkers conferred the highest ASCVD risk. The analysis did not compare the accuracy of biomarker-based risk stratification with ASCVD risk calculator estimates of 30-year risk. - The PREVENT risk calculator for cardiovascular risk (July 2024 JAMA INTERN MED)
There are concerns that earlier atherosclerotic cardiovascular disease (ASCVD) risk calculators overestimate the risk of incident ASCVD in contemporary United States (US) populations. In a study of a nationally representative US cohort, the 2023 PREVENT calculator produced a lower mean estimated 10-year ASCVD risk compared with the 2013 pooled cohort equations (PCEs; 4.3 versus 8.0 percent). Lower 10-year risk estimates occurred across all age, sex, and racial subgroups. Differences were largest for Black adults and individuals ages 70 to 75 years. The PREVENT calculator likely provides an important downward correction to the 2013 PCEs’ ASCVD risk estimates and is an appropriate tool for cardiovascular risk stratification in US populations.
- Biomarkers for 30-year cardiovascular risk stratification (September 2024 NEJM)
- VALVULAR HEART DISEASE
- Oral anticoagulants in patients undergoing transcatheter aortic valve implantation (September 2024 NEJM)
Many patients undergoing transcatheter aortic valve implantation (TAVI) for aortic stenosis have an indication for chronic oral anticoagulation due to concomitant disease (most commonly atrial fibrillation). An open-label randomized trial in over 850 patients receiving oral anticoagulants and undergoing TAVI found that patients continuing the oral anticoagulant had similar rates of thromboembolic events and stroke as those interrupting the oral anticoagulant for the procedure. Bleeding was more frequent in the continuation group than in the interruption group, although major bleeding rates were similar. These findings inform the choice of whether to continue or interrupt oral anticoagulants in patients undergoing TAVI. - TAVI versus SAVR in patients with severe aortic stenosis with low or intermediate surgical risk (August 2024 NEJM)
Data are lacking on the optimal strategy for valve intervention in patients with symptomatic severe aortic stenosis (AS) and low surgical risk. In a trial in over 1400 patients with severe AS at low or intermediate surgical risk who were randomly assigned to transcatheter aortic valve implantation (TAVI; balloon-expandable or self-expanding at the clinician’s discretion) or to surgical aortic valve replacement (SAVR), the incidence of death or stroke at one year was higher with SAVR. After TAVI, new-onset atrial fibrillation was less frequent, but permanent pacemaker implantation was more frequent. - Choice of transcatheter valve for patients with severe aortic stenosis and small aortic annulus (August 2024 NEJM)
Patients with a small aortic annulus and severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) are at high risk for bioprosthetic valve dysfunction. To investigate the effect of prosthetic valve type on this complication, over 700 patients with severe AS with a small aortic annulus were randomly assigned to receive a self-expanding supra-annular valve or a balloon-expandable valve. At 12 months, rates of the composite outcome of death, disabling stroke, or rehospitalization for heart failure were similar between the groups, but the risk of bioprosthetic valve dysfunction was lower in the group receiving the self-expanding supra-annular valve. For patients with severe AS with a small aortic annulus undergoing TAVI, a self-expanding supra-annular valve is generally preferred. - Long-term outcomes after intervention for severe aortic stenosis (August 2024 NOTION TRIAL EHJ)
Limited data are available comparing long-term outcomes after transcatheter aortic valve (TAVI) versus surgical aortic valve replacement (SAVR) for severe aortic stenosis (AS). In a recent trial in 280 patients with severe AS who were randomly assigned to receive a bioprosthetic valve via TAVI or SAVR, mortality rates at 10 years were similar between the two groups. Severe valve deterioration was less common after TAVI, but rates of bioprosthetic valve failure were similar with TAVI and SAVR. - Cardioselective beta-blockade in patients at high risk for COPD exacerbation (May 2024 BICS TRIAL JAMA)
Observational studies have suggested that cardioselective beta-blocker use may decrease the risk of death and COPD exacerbations in patients with COPD; however, a randomized trial in patients without cardiac indications suggested a possible increase in severe COPD exacerbations. In a new multicenter trial, 515 patients with moderate-severe COPD and frequent exacerbations (≥2 per year) were randomly assigned to receive bisoprolol titrated up to 5 mg per day or placebo. Patient-reported moderate to severe COPD exacerbations and COPD hospitalizations were nearly identical in the two treatment groups. Serious adverse events were also similar. These data suggest that in patients with COPD but without a cardiovascular indication, cardioselective beta-blockade is likely safe but not beneficial in reducing COPD exacerbations. - RSV-associated cardiac events in adults (June 2024 JAMA INTER MED)
Although respiratory syncytial virus (RSV) infection in adults is typically mild, it can have severe outcomes in some. In a cross-sectional study that spanned five RSV seasons, the weighted prevalence of an acute cardiac event among over 6000 hospitalized adults >50 years old with laboratory-confirmed RSV was 22 percent. The most frequent cardiac events were acute heart failure and acute ischemic heart disease. Although most events occurred in patients with cardiovascular disease, 8.5 percent were in those without known cardiovascular disease. These results underscore the potential benefits of preventive measures for RSV, especially for adults with cardiovascular disease
- Oral anticoagulants in patients undergoing transcatheter aortic valve implantation (September 2024 NEJM)
