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What's new in cardiovascular medicine

What's new in cardiovascular medicine
Authors:
Todd F Dardas, MD, MS
Nisha Parikh, MD, MPH
Susan B Yeon, MD, JD, FACC
Literature review current through: Nov 2022. | This topic last updated: Dec 14, 2022.

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'.)

CORONARY HEART DISEASE, STABLE

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 [4]. 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 [5]. 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 [6]. 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'.)

Improved outcomes and adherence with a polypill in older patients with myocardial infarction (September 2022)

In patients with recent myocardial infarction (MI), a polypill strategy may simplify treatment and improve treatment adherence, but its efficacy in preventing a secondary cardiovascular event is uncertain. In a trial that randomly assigned nearly 2500 older patients with an MI in the prior six months to either a polypill (containing aspirin, ramipril, and atorvastatin) or usual care, those receiving a polypill had a lower rate of a composite of cardiovascular events (death, nonfatal MI, nonfatal ischemic stroke, or urgent revascularization; 9.5 versus 12.7 percent) over a mean of 36 months [7]. Blood pressure, low-density lipoprotein cholesterol levels, and adverse events were similar between the two groups, and medication adherence was higher in the polypill group. While these results are promising, further studies are needed to confirm these findings. (See "Prevention of cardiovascular disease events in those with established disease (secondary prevention) or at very high risk", section on 'Polypill'.)

Efficacy of moderate-dose statin plus ezetimibe for secondary prevention of cardiovascular disease (September 2022)

The long-term efficacy of combination therapy with ezetimibe plus a moderate-dose statin for the secondary prevention of cardiovascular disease (CVD) has not been well studied. In the RACING trial, which randomly assigned nearly 3800 patients with CVD to combination therapy with moderate-dose rosuvastatin plus ezetimibe or high-dose rosuvastatin monotherapy, rates of a composite of cardiovascular death, major cardiovascular events, or nonfatal stroke at three years were similar between the treatment groups (9.1 versus 9.9 percent, respectively) [8]. Patients receiving combination therapy were more likely to have low-density lipoprotein cholesterol <70 mg/dL, and discontinuation or dose reduction of the study drug was less frequent in the combination versus monotherapy group. In patients with CVD, ezetimibe plus a moderate-dose statin may be an alternative to high-dose statin therapy, particularly in those with an intolerance to high-dose statins. (See "Management of low density lipoprotein cholesterol (LDL-C) in the secondary prevention of cardiovascular disease", section on 'Combination therapies'.)

HEART FAILURE

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 [9]. 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 [10]. 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 [6]. 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'.)

Acetazolamide in patients with diuretic-resistant heart failure (October 2022)

In patients hospitalized with acutely decompensated heart failure (HF) who are resistant to loop diuretic therapy, the safety and efficacy of augmenting diuresis with another class of diuretic agent is unknown. In a recent trial in which 500 patients hospitalized with HF and on moderate doses of an oral loop diuretic were randomly assigned to receive standardized intravenous loop diuretic therapy plus either acetazolamide or placebo, rates of death or readmission within three months were similar between the groups [11]. Rates of worsening kidney function and adverse events were also comparable between the groups, while patients receiving acetazolamide had a shorter length of stay (9 versus 10 days). In patients hospitalized with HF who are refractory to initial diuretic therapy, we increase the dose of loop diuretics before adding a nonloop diuretic to augment diuresis. (See "Use of diuretics in patients with heart failure", section on 'Refractory congestion'.)

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 [12]. 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'.)

No reduction in heart failure readmission risk with remote monitoring and financial incentives (June 2022)

In patients with heart failure (HF) who were recently discharged from the hospital, insufficient support from the health care system has been linked to a higher risk of readmission, and systems-based interventions designed to reduce the risk of readmission have questionable efficacy. In a recent trial, over 550 patients recently discharged with HF were randomly assigned to usual care or a complex intervention that included remote scales and electronic pill bottles that generated alerts to clinicians, as well as financial incentives for adherence [13]. Despite more than 3700 alerts generated by the complex intervention, rates of readmission or death were similar between the two groups. The role of telemonitoring in reducing hospital readmission for HF remains unclear; optimal therapy with evidence-based medications is the strategy most likely to reduce the risk of readmission. (See "Systems-based strategies to reduce hospitalizations in patients with heart failure" and "Overview of the management of heart failure with reduced ejection fraction in adults" and "Treatment and prognosis of heart failure with preserved ejection fraction".)

LIPID DISORDERS

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 [5]. 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) [14]. 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 [15]. 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 [4]. 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

Improved outcomes and adherence with a polypill in older patients with myocardial infarction (September 2022)

In patients with recent myocardial infarction (MI), a polypill strategy may simplify treatment and improve treatment adherence, but its efficacy in preventing a secondary cardiovascular event is uncertain. In a trial that randomly assigned nearly 2500 older patients with an MI in the prior six months to either a polypill (containing aspirin, ramipril, and atorvastatin) or usual care, those receiving a polypill had a lower rate of a composite of cardiovascular events (death, nonfatal MI, nonfatal ischemic stroke, or urgent revascularization; 9.5 versus 12.7 percent) over a mean of 36 months [7]. Blood pressure, low-density lipoprotein cholesterol levels, and adverse events were similar between the two groups, and medication adherence was higher in the polypill group. While these results are promising, further studies are needed to confirm these findings. (See "Prevention of cardiovascular disease events in those with established disease (secondary prevention) or at very high risk", section on 'Polypill'.)

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) [14]. 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'.)

Efficacy of moderate-dose statin plus ezetimibe for secondary prevention of cardiovascular disease (September 2022)

The long-term efficacy of combination therapy with ezetimibe plus a moderate-dose statin for the secondary prevention of cardiovascular disease (CVD) has not been well studied. In the RACING trial, which randomly assigned nearly 3800 patients with CVD to combination therapy with moderate-dose rosuvastatin plus ezetimibe or high-dose rosuvastatin monotherapy, rates of a composite of cardiovascular death, major cardiovascular events, or nonfatal stroke at three years were similar between the treatment groups (9.1 versus 9.9 percent, respectively) [8]. Patients receiving combination therapy were more likely to have low-density lipoprotein cholesterol <70 mg/dL, and discontinuation or dose reduction of the study drug was less frequent in the combination versus monotherapy group. In patients with CVD, ezetimibe plus a moderate-dose statin may be an alternative to high-dose statin therapy, particularly in those with an intolerance to high-dose statins. (See "Management of low density lipoprotein cholesterol (LDL-C) in the secondary prevention of cardiovascular disease", section on 'Combination therapies'.)

Gout flare and risk of subsequent cardiovascular event (August 2022)

Gout is known to be associated with cardiovascular disease; however, the temporal association of cardiovascular events after an acute gout flare had not previously been studied. In a case-control study that included over 62,500 patients with gout in a longitudinal primary care database, of whom nearly 10,500 experienced a cardiovascular event (ie, stroke or myocardial infarction), acute gout flare was associated with increased risk of a cardiovascular event in the next 0 to 60 days (adjusted odds ratio [aOR] 1.93) and 61 to 120 days (aOR 1.57) [16]. These findings highlight the importance of managing cardiovascular risk factors among patients with gout. (See "Lifestyle modification and other strategies to reduce the risk of gout flares and progression of gout", section on 'Treatment of comorbidities'.)

Remote monitoring of self-measured blood pressure and blood pressure control (July 2022)

Self-measurement of blood pressure (at home) may improve blood pressure control in patients with hypertension, especially if integrated with other supportive interventions. In a meta-analysis of 18 randomized trials, blood pressure self-measurement combined with mobile or web-based telemonitoring led to greater decreases in systolic and diastolic blood pressure compared with usual care,, possibly due to increased patient engagement and adherence [17]. Patients who are interested in self-monitoring should be provided with adequate training in the machine's use, and the device should be checked for accuracy approximately once yearly. (See "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring", section on 'Possible improvement in blood pressure control with SMBP'.)

TRANSPLANTATION

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 [18]. 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

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 [19,20]. 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 [21]. 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'.)

Anticoagulation for rheumatic mitral stenosis with atrial fibrillation (September 2022)

Limited data have been available to guide anticoagulant choice in patients with rheumatic mitral stenosis and atrial fibrillation. A randomized trial enrolling over 4500 adults with rheumatic heart disease and atrial fibrillation found that the mortality and stroke rates were higher with rivaroxaban than with a vitamin K antagonist (VKA), and major bleeding rates were similar [22]. Based on these findings, for patients with rheumatic mitral stenosis and atrial fibrillation, we now recommend a VKA rather than a direct oral anticoagulant such as rivaroxaban. (See "Rheumatic mitral stenosis: Overview of management", section on 'Choice of anticoagulant'.)

Adverse prognosis with tricuspid regurgitation (August 2022)

There has been growing recognition of the prognostic significance of tricuspid regurgitation (TR). In a study from the National Echocardiography Database of Australia of nearly 440,000 adults, 29 percent had at least mild TR [23]. After adjustment for clinical factors, grades of TR from mild to severe were associated with increasing risk of all-cause mortality and cardiovascular mortality; even mild TR was an independent predictor of increased mortality. These findings highlight the importance of follow-up in patients with TR. (See "Management and prognosis of tricuspid regurgitation", section on 'Prognosis'.)

Role of surgery for large left-sided cardiac valve vegetation (July 2022)

Patients with left-sided native valve infective endocarditis with a large (>10 mm) vegetation are at high risk for mortality, but a benefit from early valve surgery in this setting has not been established. An observational study of over 700 patients with left-sided infective endocarditis found that although patients with large vegetations had a high early mortality rate, vegetation size was not an independent predictor of mortality [24]. Among patients with large vegetations without heart failure or uncontrolled infection, the mortality rate was similar with or without valve surgery. For patients with large vegetations, we perform an individualized risk-benefit assessment comparing early surgery with expectant management based upon multiple factors including response to antibiotic therapy, presence of embolic events, and surgical risk. (See "Surgery for left-sided native valve infective endocarditis", section on 'Vegetation characteristics and risk of embolization'.)

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 [25]. 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'.)

Blood pressure and oxygen targets following sudden cardiac arrest (September 2022)

Supporting data to guide specific blood pressure and oxygen targets after sudden cardiac arrest (SCA) are limited, and practice is variable. In a recent open-label, two-by-two factorial trial, 789 patients with SCA were randomly assigned to a high versus low mean arterial pressure (MAP) target (77 versus 63 mmHg) as well as a restrictive versus liberal arterial oxygen tension (PaO2) target (68 to 75 versus 98 to 105 mmHg) [26,27]. At 90 days, rates of death or severe disability/coma at discharge were similar across all groups. Although the trial had limitations and confidence intervals were wide, these results do not support aggressive MAP goals or overly restrictive oxygenation in the care of patients after cardiac arrest, pending future studies. (See "Intensive care unit management of the intubated post-cardiac arrest adult patient", section on 'Hemodynamic monitoring and goals'.)

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Topic 8353 Version 11627.0

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