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What's new in cardiovascular medicine

What's new in cardiovascular medicine
Authors:
Susan B Yeon, MD, JD, FACC
Todd F Dardas, MD, MS
Nisha Parikh, MD, MPH
Literature review current through: Feb 2022. | This topic last updated: Feb 24, 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.

ARRHYTHMIAS

Midodrine for recurrent vasovagal syncope (November 2021)

Vasovagal syncope, the most common type of syncope, can be recurrent in some individuals; no therapy has been found to be consistently effective. In a recent trial that randomly assigned over 130 patients with recurrent vasovagal syncope to the vasoconstrictor midodrine or placebo, midodrine reduced the risk of recurrent syncope at one year, and adverse effects were similar between the groups [1]. For patients with recurrent vasovagal syncope despite general preventive measures who do not have an indication for permanent cardiac pacing, we suggest treatment with either midodrine or fludrocortisone. (See "Reflex syncope in adults and adolescents: Treatment", section on 'Midodrine'.)

CONGENITAL HEART DISEASE, ADULT

Patent foramen ovale closure for stroke prevention (December 2021)

Evidence from multiple trials has shown that percutaneous device closure of patent foramen ovale (PFO) is more effective than medical therapy alone for reducing the risk of recurrent stroke in select patients with an embolic-appearing ischemic stroke who have a PFO but no other identified cause of stroke, but the degree of benefit for patient subgroups was unknown. A recent meta-analysis of individual patient data from six randomized trials used the PASCAL classification (table 1) to analyze outcomes based on the estimated probability that stroke was associated with a PFO [2]. PASCAL is based upon the RoPE score (table 2) combined with anatomic and clinical factors (shunt size, presence or absence of atrial septal aneurysm and/or venous thromboembolism) in patients with embolic-appearing infarcts and no other major sources of ischemic stroke. The meta-analysis found that PFO closure was associated with benefit if the stroke was probably or possibly related to the PFO per PASCAL score, but not if stroke was unlikely related to the PFO. These data support the use of PASCAL and RoPE to guide informed decision-making for PFO closure. (See "Treatment of patent foramen ovale (PFO) for secondary stroke prevention", section on 'Benefit'.)

CORONARY HEART DISEASE, ACUTE

Worse outcomes in patients with ST-elevation myocardial infarction infected with COVID-19 (November 2021)

Infection with COVID-19 may complicate the care of patients with ST-elevation myocardial infarction (STEMI), but the magnitude of this effect has not been well described. A new study used a large administrative claims database to assess the impact of COVID-19 on over 76,000 patients with out-of-hospital STEMI (present on admission) and over 4000 patients with in-hospital STEMI (recorded after hospital admission) [3]. In both groups of patients, in-hospital mortality was higher among those infected with COVID-19; while patients with out-of-hospital STEMI infected with COVID-19 were as likely to receive coronary angiography or percutaneous coronary intervention as those without COVID-19, patients with in-hospital STEMI and COVID-19 were less likely to receive these procedures compared with their uninfected counterparts. These results suggest that infection with COVID-19 can alter the management and worsen the prognosis of patients with STEMI. (See "COVID-19: Myocardial infarction and other coronary artery disease issues", section on 'Outcomes in COVID-19 patients'.)

HEART FAILURE

No benefit to interatrial shunt device for heart failure with preserved ejection fraction (February 2022)

In patients with heart failure with preserved ejection fraction (HFpEF), small trials have shown that percutaneous placement of an interatrial shunt device can reduce left atrial pressure at rest and during exercise, but the long-term effects of this procedure are not well described. In a recent trial that randomly assigned nearly 650 patients with HFpEF to receive either an interatrial shunt device or sham procedure, the risks of death, stroke, worsening heart failure, and change in health status were similar between the groups [4]. However, patients in the shunt device group had a higher risk of serious events (ie, cardiac death, myocardial infarction, cardiac tamponade, or cardiac surgery). Given the lack of benefit and possible harm associated with interatrial shunt device placement, we do not routinely perform this procedure in patients with HFpEF. (See "Treatment and prognosis of heart failure with preserved ejection fraction", section on 'Device-based therapies'.)

MYOPERICARDIAL DISEASE

Myocarditis in athletes recovering from COVID-19 (October 2021)

Despite initial concerns about possible myocarditis in older adolescent and young adult athletes recovering from COVID-19, recent studies suggest that the risk of cardiac injury is low. In a prospective, multi-center cohort of over 3,000 US collegiate athletes diagnosed with COVID-19 and undergoing cardiac evaluation, possible cardiac injury was noted in 21 (0.7 percent), including 15 of 119 individuals who underwent cardiac magnetic resonance (CMR) imaging based on preliminary test findings (ECG, cardiac troponin, and/or echocardiography) and 6 of 198 individuals who underwent primary CMR screening [5]. During subsequent surveillance, only one adverse cardiac event occurred, most likely unrelated to COVID-19. These findings may not reflect the frequency of myocarditis after SARS-CoV-2 infection caused by subsequent variants such as the Delta variant. Nevertheless, they provide support for the current approach to cardiac evaluation and return to play in this population (algorithm 1). (See "COVID-19: Return to play or strenuous activity following infection", section on 'Cardiovascular complications in athletes'.)

PERIPHERAL ARTERIAL DISEASE

Carotid stenting versus endarterectomy for asymptomatic carotid stenosis (September 2021)

Earlier trials comparing transfemoral carotid artery stenting (TF-CAS) with carotid endarterectomy (CEA) for asymptomatic carotid stenosis reported that the periprocedural (30-day) stroke or death rate is higher for TF-CAS, while long-term outcomes are similar. In the recent ACST-2 trial, the periprocedural rate of death or any stroke was slightly higher with TF-CAS compared with CEA, but the difference was not statistically significant [6]. This result largely reflected a higher incidence of nondisabling stroke in the TF-CAS group. The five-year rate of periprocedural death or any fatal or disabling stroke was similar for TF-CAS and CEA (3.3 versus 3.5 percent). For medically stable individuals with asymptomatic carotid stenosis of 70 to 99 percent, we advise a shared decision-making approach; either intensive medical therapy alone or intensive medical therapy plus revascularization with CEA are reasonable treatment options. For those with an unacceptably high surgical risk with suitable anatomy, carotid artery stenting is an alternative. (See "Management of asymptomatic extracranial carotid atherosclerotic disease", section on 'Stenting versus endarterectomy trials'.)

PREVENTIVE CARDIOLOGY

Placental abruption and future risk of cardiovascular disease (January 2022)

Accumulating data support the hypothesis that abnormalities of placental development are a harbinger of future maternal cardiovascular disease (CVD). In a meta-analysis of 11 cohort studies including over 6 million pregnancies, nearly 70,000 abruptions, and nearly 50,000 cases of CVD (including stroke), the risk of future morbidity/mortality from CVD was significantly higher among patients with abruption (17 versus 9 per 1000 births) and positively correlated with the number of abruptions [7]. Based on these and other findings, patients who have had an abruption may benefit from postpartum counseling and interventions to mitigate future CVD risk. (See "Placental abruption: Management and long-term prognosis", section on 'Long-term maternal prognosis'.)

VALVULAR HEART DISEASE

Transcatheter aortic valve implantation in low surgical risk patients with bicuspid or tricuspid aortic stenosis (November 2021)

Transcatheter aortic valve implantation (TAVI) has been successfully performed in many patients with bicuspid aortic valve stenosis, but some studies have observed higher risks of stroke and procedural complications in patients with bicuspid valves compared with those with tricuspid valves. A recent registry-based study compared outcomes of over 3000 propensity-matched pairs of patients at low surgical risk who underwent TAVI for bicuspid or tricuspid aortic stenosis [8]. Rates of mortality and stroke at 30 days and one year were comparable between the bicuspid and tricuspid groups, as were rates of procedural complications. These results suggest that TAVI is a reasonable option for selected patients at low surgical risk who require valve replacement for bicuspid aortic stenosis. (See "Bicuspid aortic valve: Intervention for valve disease or aortopathy in adults", section on 'Transcatheter aortic valve implantation'.)

Choice of anticoagulant for atrial fibrillation post-transcatheter aortic valve implantation (September 2021)

Patients post-transcatheter aortic valve implantation (TAVI) commonly have a concurrent indication for long-term anticoagulation (mainly atrial fibrillation [AF]), but the optimal choice of anticoagulation in such patients is unclear. In a recent open-label trial that randomly assigned over 1400 post-TAVI patients with AF to the direct oral anticoagulant (DOAC) edoxaban or a vitamin K antagonist (VKA), rates of mortality and ischemic stroke at a median of 1.5 years were similar between the two treatment groups [9]. Although the overall rate of major bleeding was higher in the edoxaban group, rates of intracranial hemorrhage were comparable between the groups. For patients with AF requiring anticoagulation (including those post-TAVI), we generally prefer a DOAC to VKA. (See "Transcatheter aortic valve implantation: Antithrombotic therapy".)

OTHER CARDIOLOGY

Risk of GI bleeding with DOACs (October 2021)

Direct oral anticoagulants (DOACs) are generally preferred over warfarin in individuals with non-valvular atrial fibrillation or venous thromboembolism. A new study evaluated the risk of gastrointestinal (GI) bleeding in over 5000 individuals taking apixaban, rivaroxaban, or dabigatran [10]. Higher rates of GI bleeding were seen in individuals taking rivaroxaban (3.2 per 100 patient-years) than with the other agents (2.5 for apixaban and 1.9 for dabigatran). The once-daily dosing of rivaroxaban and higher peak levels may explain the higher bleeding risk; the other agents are dosed twice daily. These results may be a consideration when choosing among DOACs. (See "Direct oral anticoagulants (DOACs) and parenteral direct-acting anticoagulants: Dosing and adverse effects", section on 'Differences between factor Xa inhibitors'.)

REFERENCES

  1. Sheldon R, Faris P, Tang A, et al. Midodrine for the Prevention of Vasovagal Syncope : A Randomized Clinical Trial. Ann Intern Med 2021; 174:1349.
  2. Kent DM, Saver JL, Kasner SE, et al. Heterogeneity of Treatment Effects in an Analysis of Pooled Individual Patient Data From Randomized Trials of Device Closure of Patent Foramen Ovale After Stroke. JAMA 2021; 326:2277.
  3. Saad M, Kennedy KF, Imran H, et al. Association Between COVID-19 Diagnosis and In-Hospital Mortality in Patients Hospitalized With ST-Segment Elevation Myocardial Infarction. JAMA 2021; 326:1940.
  4. Shah SJ, Borlaug BA, Chung ES, et al. Atrial shunt device for heart failure with preserved and mildly reduced ejection fraction (REDUCE LAP-HF II): a randomised, multicentre, blinded, sham-controlled trial. Lancet 2022.
  5. Moulson N, Petek BJ, Drezner JA, et al. SARS-CoV-2 Cardiac Involvement in Young Competitive Athletes. Circulation 2021; 144:256.
  6. Halliday A, Bulbulia R, Bonati LH, et al. Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy. Lancet 2021; 398:1065.
  7. Ananth CV, Patrick HS, Ananth S, et al. Maternal Cardiovascular and Cerebrovascular Health After Placental Abruption: A Systematic Review and Meta-Analysis (CHAP-SR). Am J Epidemiol 2021; 190:2718.
  8. Makkar RR, Yoon SH, Chakravarty T, et al. Association Between Transcatheter Aortic Valve Replacement for Bicuspid vs Tricuspid Aortic Stenosis and Mortality or Stroke Among Patients at Low Surgical Risk. JAMA 2021; 326:1034.
  9. Van Mieghem NM, Unverdorben M, Hengstenberg C, et al. Edoxaban versus Vitamin K Antagonist for Atrial Fibrillation after TAVR. N Engl J Med 2021; 385:2150.
  10. Ingason AB, Hreinsson JP, Ágústsson AS, et al. Rivaroxaban Is Associated With Higher Rates of Gastrointestinal Bleeding Than Other Direct Oral Anticoagulants : A Nationwide Propensity Score-Weighted Study. Ann Intern Med 2021; 174:1493.
Topic 8353 Version 10977.0

References

1 : Midodrine for the Prevention of Vasovagal Syncope : A Randomized Clinical Trial.

2 : Heterogeneity of Treatment Effects in an Analysis of Pooled Individual Patient Data From Randomized Trials of Device Closure of Patent Foramen Ovale After Stroke.

3 : Association Between COVID-19 Diagnosis and In-Hospital Mortality in Patients Hospitalized With ST-Segment Elevation Myocardial Infarction.

4 : Atrial shunt device for heart failure with preserved and mildly reduced ejection fraction (REDUCE LAP-HF II): a randomised, multicentre, blinded, sham-controlled trial.

5 : SARS-CoV-2 Cardiac Involvement in Young Competitive Athletes.

6 : Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy.

7 : Maternal Cardiovascular and Cerebrovascular Health After Placental Abruption: A Systematic Review and Meta-Analysis (CHAP-SR).

8 : Association Between Transcatheter Aortic Valve Replacement for Bicuspid vs Tricuspid Aortic Stenosis and Mortality or Stroke Among Patients at Low Surgical Risk.

9 : Edoxaban versus Vitamin K Antagonist for Atrial Fibrillation after TAVR.

10 : Rivaroxaban Is Associated With Higher Rates of Gastrointestinal Bleeding Than Other Direct Oral Anticoagulants : A Nationwide Propensity Score-Weighted Study.