Cardiology

Parwani, P., A. D. Choi, J. Lopez-Mattei, S. Raza, T. Chen, A. Narang, E. D. Michos, J. P. Erwin, 3rd, M. A. Mamas and M. Gulati (2019). “Understanding Social Media: Opportunities for Cardiovascular Medicine.” J Am Coll Cardiol 73(9): 1089-1093.

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Cardiology professionals have used social media platforms such as Twitter to gain exposure to new research, network with experts, share opinions, and engage in scientific debates. The power of social media to communicate openly, with wide-reaching access worldwide, and at a rate faster than ever before makes it a formidable force and voice. However, evolving individual and institutional use has resulted in uncertainty for all parties on how to optimally advance this newer digital frontier. Thus, the purpose of this paper is to: 1) introduce the basics of social media usage (with the focus on Twitter); 2) provide perspective on best social media practices in academic and clinical cardiovascular medicine; and 3) present a vision for social media and the future of cardiovascular medicine.

Packer, M. (2019). “What Have We Learned From Randomized Controlled Trials of Catheter Ablation for Atrial Fibrillation in Patients With Chronic Heart Failure?” Circ Arrhythm Electrophysiol 12(4): e007222.

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Six trials have evaluated the effects of catheter ablation for atrial fibrillation (AF) in chronic heart failure (HF) (Table). Four compared catheter ablation to medical therapy directed at rate-control. These studies primarily enrolled patients with long-standing AF, and the control groups received atrioventricular nodal blocking drugs. In contrast, 2 trials compared catheter ablation to medical therapy primarily directed at rhythm control. These studies generally enrolled patients with paroxysmal or nonpermanent AF, and the control groups received membrane-active antiarrhythmic drugs . . . The totality of evidence suggests that catheter ablation for AF may have benefits on EF and functional capacity in chronic HF. However, the trials have been small and largely focused on patients with minimal or mild HF and only modest impairment of left ventricle function. In patients with meaningful degrees of HF and low EF, little efficacy has been observed, and the complication rate has been high. Because of the sparse number of events, the large number of patients with excluded or missing data, the lack of balance at randomization, and the use of comparator groups who were treated with cardiotoxic antiarrhythmic drugs to achieve rhythm control, it is not possible to suggest that a benefit of catheter ablation on morbidity and mortality has been demonstrated. Although the results of the 6 randomized trials of catheter ablation have been combined in numerous meta-analyses, summary estimates cannot overcome the inherent limitations of the component trials. Importantly, the available evidence from the 6 trials was not persuasive to the writers of the most recent guideline, which provided its weakest possible positive recommendation for the use of catheter ablation in patients with AF and chronic HF. . . Therefore, additional randomized controlled trials are needed to understand the range of potential responses to this procedure. (Excerpt from text, p. 1, 2-3; no abstract available.)

Packer, M. (2019). “Electrophysiological interventions in the treatment of chronic heart failure: a comparison of the strength of evidence supporting cardiac resynchronization for electrical conduction delay and catheter ablation for atrial fibrillation.” Eur J Heart Fail 21(4): 398-401.

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In patients with a meaningful electrical conduction delay, the evidentiary support for the benefits of cardiac resynchronization is robust and strikingly consistent and is based on a large number and broad range of patients (n ≅ 10 000) enrolled in definitely‐powered trials. Many of these were specifically designed to evaluate the effects of treatment on morbidity and mortality, and they demonstrated meaningful reductions in the risk of death and hospitalizations for heart failure. In contrast, in patients with atrial fibrillation, the available trials of catheter ablation are small and have reported only sparse data. Reports of favourable effects on exercise tolerance and quality of life are difficult to interpret because of the open‐label design of the studies; changes in ejection fraction have been assessed by unreliable methods and have been inconsistent; and the reported decreases in morbidity and mortality have been observed in trials that had significant methodological limitations and/or used potentially cardiotoxic membrane‐active agents as a comparator. In addition, it is noteworthy that cardiac resynchronization follows a standardized approach, whereas the technique for catheter ablation varies considerably by physician. If catheter ablation is to be adopted as an appropriate therapy for large numbers of patients with chronic heart failure, it is important to develop a persuasive evidentiary base that approaches that of cardiac resynchronization therapy or pharmacological treatments for heart failure. This is particularly true, given its invasive nature and its considerable expense. (Excerpt from text, p. 400; no abstract available.)

Myhre, P. L., M. Vaduganathan, B. Claggett, M. Packer, A. S. Desai, J. L. Rouleau, M. R. Zile, K. Swedberg, M. Lefkowitz, V. Shi, J. J. V. McMurray and S. D. Solomon (2019). “B-Type Natriuretic Peptide During Treatment With Sacubitril/Valsartan: The PARADIGM-HF Trial.” J Am Coll Cardiol 73(11): 1264-1272.

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BACKGROUND: Natriuretic peptides are substrates of neprilysin; hence, B-type natriuretic peptide (BNP) concentrations rise with neprilysin inhibition. Thus, the clinical validity of measuring BNP in sacubitril/valsartan-treated patients has been questioned, and use of N-terminal pro-B-type natriuretic peptides (NT-proBNP) has been preferred and recommended. OBJECTIVES: The purpose of this study was to determine the prognostic performance of BNP measurements before and during treatment with sacubitril/valsartan. METHODS: BNP and NT-proBNP were measured before and after 4 to 6 weeks, 8 to 10 weeks, and 9 months of treatment with sacubitril/valsartan in the PARADIGM-HF (Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial. We assessed the association of levels of these natriuretic peptides with the subsequent risk of cardiovascular death or hospitalization for HF. RESULTS: Median BNP concentration (before treatment: 202 ng/l [Q1 to Q3: 126 to 335 ng/l]) increased to 235 ng/l (Q1 to Q3: 128 to 422 ng/l) after 8 to 10 weeks of treatment. BNP concentrations doubled in 141 (18%) patients and tripled in 49 (6%) patients during the first 8 to 10 weeks of sacubitril/valsartan. In contrast, such striking increases in NT-proBNP following the use of the neprilysin inhibitor were extremely rare. Treatment with sacubitril/valsartan caused a rightward shift in the distribution of BNP when compared with NT-proBNP, but both peptides retained their prognostic accuracy (C-statistics of 63% to 67% for BNP and C-statistics of 64% to 70% for NT-proBNP) with no difference between the 2 biomarkers. Increases in both BNP and NT-proBNP during 8 to 10 weeks of sacubitril/valsartan were associated with worse outcomes (p = 0.003 and p = 0.005, respectively). CONCLUSIONS: Circulating levels of BNP may increase meaningfully early after initiation of sacubitril/valsartan. In comparison, NT-proBNP is not a substrate of neprilysin inhibition, and thus may lead to less clinical confusion when measured within 8 to 10 weeks of drug initiation. However, during treatment, either biomarker predicts the risk of major adverse outcomes in patients treated with angiotensin receptor-neprilysin inhibitors. (Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure [PARADIGM-HF]; NCT01035255).

Hamandi, M., R. L. Smith, W. H. Ryan, P. A. Grayburn, A. Vasudevan, T. J. George, J. M. DiMaio, K. A. Hutcheson, W. Brinkman, M. Szerlip, D. O. Moore and M. J. Mack (2019). “Outcomes of Isolated Tricuspid Valve Surgery Have Improved in the Modern Era.” Ann Thorac Surg Apr 2. [Epub ahead of print].

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BACKGROUND: Surgery for isolated tricuspid valve (TV) disease remains relatively infrequent due to significant patient comorbidities and poor surgical outcomes. We reviewed our experience with isolated TV surgery in the current era to determine if outcomes have improved. METHODS: From 2007 through 2017, 685 TV operations were performed in a single institution of which 95 (13.9%) were isolated TV surgery. Patients were analyzed for disease etiology, risk factors, operative mortality and morbidity and long term survival. RESULTS: 95 patients underwent isolated TV surgery, an average of 9 patients/year increasing from an average of 5/year to 15/year during the study period. Surgery was reoperative in 41% (38/95), including 11.6% (11/95) with prior CABG and 29.4% (28/95) with prior valve surgery (9 tricuspid, 11 mitral, 2 aortic, 5 mitral/aortic and 1 mitral/tricuspid).Repair was performed in 71.6% (68/95) and replacement in 28.4% (27/95). Operative mortality was 3.2% (3/95) with no mortality in the most recent 73 patients over the last 6 years. Stroke occurred in 2.1% (2/95), acute kidney injury requiring dialysis in 5.3% (5/95) and need for new permanent pacemaker in 16.8% (16/95). CONCLUSIONS: In the current era with careful patient selection and periprocedural management, isolated TV surgery can be performed with lower morbidity and mortality than has traditionally been reported with good long term survival. These outcomes can also serve as a benchmark for catheter-based tricuspid valve intervention outcomes.