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Review Article

Cardiology Update 2017

Sunil Kumar Verma, Harish Gupta1, Abhishek Gupta
Department of Cardiology, AIIMS, New Delhi, 1Department of Medicine, CSM Medical University (KGMC), Lucknow, Uttar Pradesh, India

Abstract
In the latter half of 2016, the Danish study evaluated the need of automatic implantable cardioverter‑defibrillator in nonischemic
cardiomyopathies group of heart failure population. HOPE‑3 in 2016 expanded the dimension of statin use. Novel age, biomarker, and
clinical history stroke risk score for atrial fibrillation was validated. Success of Phase 2b clinical trial for CSL112 was one more step to
reduce the ischemic events in the postmyocardial infarction period. On the one hand, NORSTENT study compared the bare‑metal stents with
drug‑eluting stent, and on the other hand, 3‑year follow‑up data of ABSORB II trail discussed the performance of bioresorbable scaffolds.
NOBLE and EXCEL trials evaluated the coronary intervention with coronary artery bypass graft in the left main coronary artery disease.
Reduction of major adverse cardiac event with low‑density lipoprotein cholesterol <50 mg/dl was analyzed with alirocumab. Fractional
flow reserve was tested as a tool to decide treatment modality in patients with stable coronary artery disease. Natural history of rheumatic
heart disease in the current era was described in REMEDY study. A few technological advancements in cardiac resynchronization therapy
defibrillator technology were also approved by the Food and Drug Administration. Birth prevalence and pattern of congenital heart disease
in North India were presented.

Keywords: Acute coronary syndrome, congenital heart disease, heart failure

Heart Failure controls. Echocardiographic measurements of myocardial

The Danish study[1] assessed the prophylactic use of an
implantable cardioverter‑defibrillator in patients with
symptomatic systolic heart failure due to causes other than
coronary artery disease. With left ventricular (LV) ejection
fraction  (EF) of  ≤35%, 556  patients received automatic
implantable cardioverter‑defibrillator (AICD) and 560 patients
received usual clinical care for this indication. The primary
outcome was death from any cause, and the secondary
outcome was sudden cardiac death and cardiovascular (CV)
death. In both groups, 58% of the patients received cardiac
resynchronization therapy (CRT). Median follow‑up period
was 67.6 months. The trial concluded that the prophylactic use
of AICD implantation in patients with symptomatic systolic
heart failure not caused by coronary artery disease was not
associated with a significantly lower long‑term rate of death
from any cause than being the usual clinical care.
The link between Alzheimer’s disease (AD) and heart failure
in aging population was first provided by imaging and
proteomics approach in a retrospective cross‑sectional study[2]
from a cohort of 22 patients with AD and 35 age‑matched
function suggest that patients with AD present with an
anticipated diastolic dysfunction. As in the brain, amyloid
beta (Aβ) protein Aβ40 and Aβ42 are present in the heart,
their expression is increased in AD.
Hypertension
A common perception is that ambulatory blood pressure (ABP)
is usually lower than clinic blood pressure (CBP). ABP
is consistently superior to CBP as a CV mortality and
morbidity risk. An untreated employer‑based US population
of 888 healthy, employed, middle‑aged (mean ± standard
deviation age, 45 ± 10.4 years) individuals with screening
blood pressure (BP) <160/105 mmHg and not taking
antihypertensive medications completed three separate clinic
BP assessments and a 24‑h ABP recording.[3] The results
Address for correspondence: Dr. Sunil Kumar Verma,
Department of Cardiology, Suite No. 24, 7th Floor, CTC, AIIMS, Ansari Nagar,
New Delhi ‑ 110 029, India.
E‑mail: ksunilverma02@gmail.com

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DOI:
10.4103/jpcs.jpcs_4_17 How to cite this article: Verma SK, Gupta H, Gupta A. Cardiology update
2017. J Pract Cardiovasc Sci 2016;2:142-5.

142 © 2017 Journal of the Practice of Cardiovascular Sciences | Published by Wolters Kluwer - Medknow
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Verma, et al.: Cardio 2017
of the study showed that patients with elevated CBP, ABP
is usually not lower than CBP, at least not among healthy,
employed individuals. In addition, a substantial proportion
of otherwise healthy individuals with nonelevated CBP have
masked hypertension.
Primary Prevention
HOPE‑3 investigators[4] tested the hypothesis of extended
benefits of statin therapy to intermediate‑risk, ethnically diverse
population without CV disease. About 12,000 individuals
from 21 countries constituted the 2 × 2 factorial design of
the trial. The inclusion criteria were women aged >60 years
and men >55 years, at least one additional CV risk factor,
including  (1) waist/hip ratio  ≥0.90 in men and  ≥0.85 in
women,(2) history of current or recent smoking (regular
tobacco use within 5 years), (3) low high-density lipoprotein
cholesterol (HDL-C), (4) dysglycemia, (5) renal dysfunction,
(6) family history of premature congenital heart disease in
the first‑degree relatives. The tested statin was rosuvastatin
10  mg. The first coprimary outcome was the composite of
death from CV causes, nonfatal myocardial infarction (MI), or
nonfatal stroke, and the second coprimary outcome additionally
included revascularization, heart failure, and resuscitated
cardiac arrest. The median follow‑up was 5.6 years. The
HOPE‑3 investigators concluded that the treatment with
rosuvastatin at a dose of 10 mg/day resulted in a significantly
lower risk of CV events than placebo in an intermediate‑risk,
ethnically diverse population without CV disease.
Atrial fibrillation
Oldgren et  al.[5] tried to validate a recently proposed novel
stroke risk score for patients with atrial fibrillation (AF) called
ABC (age, biomarker [high‑sensitivity troponin and N‑terminal
fragment B‑type natriuretic peptide] and a clinical history
of prior stroke/transient ischemic attack [TIA]). They also
compared the performance of ABC with CHA2DS2‑VASc and
Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA)
risk scores. This validation was based on about 8000 patients,
16,137 person‑years of follow‑up, and 219 adjusted stroke or
systemic embolic events in anticoagulated patients with AF
in the RE‑LY study. The biomarker‑based ABC score was
well calibrated and consistently performed better than both
CHA2DS2‑VASc and ATRIA stroke scores.
Acute Coronary Syndromes
CSL112 is a plasma‑derived apolipoprotein A‑I, the primary
functional component of HDL. It causes a significant
dose‑dependent increase in plasma apolipoprotein A‑I
and enhances cholesterol efflux capacity and can reduce
ischemic events in post‑MI patients. AEGIS‑I trial [6]
tested CSL112 with placebo in about 1250 patients of
acute coronary syndrome (both ST‑elevation myocardial
infarction [STEMI] and non‑STEMI within the last 4 days)
in 16 countries in two doses (2 g and 6 g weekly infusion for
four consecutive weeks) to characterize its safety, efficacy,
Journal of the Practice of Cardiovascular Sciences  ¦ Volume 2 ¦ Issue 3 ¦ September-December 2016
tolerability, pharmacodynamics, and pharmacokinetics. This
dose‑ranging Phase 2b clinical trial demonstrated that CSL112
infusions are feasible and well tolerated and not associated
with any significant alterations in liver or kidney function or
other safety concern. The ability of CSL112 to acutely enhance
cholesterol efflux was confirmed.
Coronary Artery Disease
NORSTENT study[7] compared the long‑term outcomes related
to contemporary drug‑eluting stent (DES) with contemporary
bare‑metal stents (BMS) in about 9000 patients with stable
or unstable coronary artery disease undergoing percutaneous
coronary intervention (PCI). The primary outcome was a
composite of death from any cause and nonfatal spontaneous
MI at a median follow‑up of 5 years. Repeat revascularization,
stent thrombosis, and quality of life were secondary outcome
measures. The study demonstrated that there was no significant
difference between DES and BMS in primary outcomes.
However, they reported lower repeat revascularization in the
group receiving DES.
Intervention in the left main coronary artery was compared
with coronary artery bypass graft (CABG) in two trials and
we got some opposing results.
One of them was EXCEL trial, published in NEJM[8] which
involved 1905 patients with the left main coronary artery
disease with low to intermediate SYNTAX score and given
either PCI (with fluoropolymer‑based, cobalt‑chromium
everolimus‑eluting XIENCE stents, n = 948) or CABG (n = 95)
with a 3‑year follow‑up. At the end of 3 years, PCI group
was found noninferior to CABG group with respect to the
composite end‑point of death, stroke, and MI.
Another one was NOBLE, published in the Lancet[9] which
involved 1201 patients with left main coronary artery disease.
A total of 598 patients were treated with PCI (predominantly
a blemish eluting stent, BioMatrix Flex) and 603 were treated
with CABG with a 5‑year follow‑up. At 5 years, there was no
significant difference in all‑cause mortality between the two
treatment modalities. The rate of nonprocedural MI and repeat
revascularization were significantly higher among PCI‑treated
patients as compared to patients treated with CABG.
A surprising finding was higher stroke rate in PCI group, but
the difference was not statistically significant at 5 years. The
investigators suggested that CABG might be superior to PCI
in the treatment of the left main stem coronary artery disease.
The 3‑year‑follow‑up data of ABSORB‑II trail[10] failed
to show the superior vasomotor reactivity and noninferior
late lumen loss for the everolimus‑eluting bioresorbable
scaffold (ABSORB) with respect to everolimus‑eluting
metallic stent (XIENCE). A higher rate of periprocedural MI
was observed in ABSORB group.
Alirocumab‑treated patients can achieve low‑density
lipoprotein cholesterol (LDL‑C) <50 mg/dl. Currently,
statins and add‑on lipid therapies can reduce the LDL‑C up
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Verma, et al.: Cardio 2017
to ~54 mg/dl. The relationship between LDL‑C <50 mg/dl and
reduction in major adverse cardiac event (MACE) is not clear.
A post hoc analysis[11] of ten randomized trials of ODYSSEY
trial program with information on 6699 patient‑years of
exposure tested relationship between additional LDL‑C,
non‑HDL‑C, and apolipoprotein‑B100 reduction and MACE
among alirocumab with control (placebo/ezetimibe), mainly
as add‑on therapy to maximal tolerated dose of statin. Results
showed that greater percentage reduction in LDL‑C and
lower on‑treatment LDL‑C was associated with lower MACE
including very low levels of LDL‑C (<50 mg/dl). For every
39 mg/dl lower achieved LDL‑C, the risk of MACE appeared
to be 24% lower.
The extent of reversible myocardial ischemia is an important
determinant of clinical outcome in patients with stable coronary
artery disease. Fractional flow reserve  (FFR) values were
used as a tool to assess the MACE at 2 years in 607 patients
with stable coronary artery disease, in whom all the stenosis
were assessed by FFR and were treated with medical therapy
alone.[12] An average decrease in MACE per 0.05‑unit increase
in FFR was statistically significant even after adjustment for
all clinical and angiographic features. The strongest increase
in MACE occurred for FFR values between 0.80 and 0.60.
In patients with stable coronary artery disease, stenosis as
assessed by FFR is a major and independent predictor for
lesion‑related outcome.
Rheumatic heart disease
The latest data about the natural history of rheumatic
heart disease (RHD) in most recent time are now from the
REMEDY[13] study, and it demonstrated still a high mortality
and morbidity. Enrollment of the 3343 patients of the
RHD was done in between 2010 and 2012 in 25 centers in
14 low‑ and middle‑income African and Asian countries and
follow‑up was done for 2 years. Median age of the patients
was 28 years. Two‑thirds of the patients were female. The
2‑year case fatality rate was 16.9%. The mortality rate was
116.3/1000 patient‑years and 65.4/1000 patient‑years for the
1st and 2nd year, respectively, with 28.7 years as median age of
death. Independent predictor of mortality in decreasing order
of hazards ratio was severe valvular heart disease, congestive
heart failure (CHF), the New York Heart Association functional
Class III/IV, AF, and older age. Postprimary education and
female sex were associated with lower risk of death. Incidence
rates per 1000 patients per year were 38.42 for CHF, 8.45 for
stroke or TIA, 3.49 for acute rheumatic fever, and 3.65 for
infective endocarditis. Older age and previous stroke were
independent predictors of stroke/TIA or systemic embolism.
Antiplatelet therapy
Multicenter, randomized academic PRAGUE‑18[14] study
did head‑to‑head comparison of efficacy and safety between
prasugrel and ticagrelor in patient with acute MI undergoing
primary PTCA as treatment strategy. About 1200 patients
participated in the study. Although the study was of small
sample size, it concluded that among the tested two newer
144 Journal of the Practice of Cardiovascular Sciences  ¦  Volume 2  ¦  Issue 3  ¦  September-December 2016
P2Y12 receptor antagonists, no one is safer and effective in
preventing ischemic and bleeding events in acute phase of MI
treated with primary or intermediate PCI.
Electrophysiology
Investigational device exemption (IDE)[15] clinical study showed
the results of multipoint pacing  (MPP) in CRT‑defibrillator
and CRT‑pacemakers. This MPP technology has recently
got the US‑Food and Drug Administration (FDA) approval.
MPP is claimed to have better response rate and reduced
rehospitalization rate because of electrical benefit (recruitment
of a greater portion of the LV than traditional biventricular
pacing, resulting in reduced activation times and QRS duration),
mechanical benefit (reduced mechanical dyssynchrony), and
hemodynamic benefit (improved acute LV contractility
and improved EF and end‑systolic volume at 6 months).
Five hundred patients at 49 centers were given quadripolar
pacing device in this prospective, randomized, multicenter,
double‑blinded noninferiority clinical study. Biventricular
pacing was given to all patients for the first 3 months
of the study. Then, for the next 6 months, patients were
randomized to receive either standard biventricular pacing
or MPP programming. The primary safety end‑point was met
with a 93.2% freedom from device‑related complications.
The primary efficacy end‑point of the IDE clinical study
demonstrated noninferiority of response rate in MPP
technology group compared to biventricular pacing group at
9 months compared to at 3 months.  Response rate reported
by MPP technology was 87%.
Similarly, early in the year 2016, the US FDA approved
ACUITY™ X4 Quadripolar LV leads for cardiac
resynchronization therapy on the basis of results of NAVIGATE
X4 study.[16] The novel family of ACUITY™ X4 Quadripolar
LV leads is engineered with four electrodes along with a
unique three‑dimensional shape. These LV leads are designed
to pace from the nonapical regions of the LV with low
pacing capture threshold. The NAVIGATE X4 study was a
prospective, multicenter, nonrandomized clinical trial that
enrolled 764 patients. This study successfully met the primary
safety and efficacy end‑points through 6 months of follow‑up.
These leads demonstrated low pacing thresholds, particularly
from proximal electrode, a high incidence of pacing from
nondistal electrode, and low likelihood of dislodgement or
phrenic nerve stimulation requiring surgical intervention.
Results and outcomes of catheter ablation of ventricular
tachycardia (VT) in nonischemic dilated cardiomyopathy
were discussed by Muser et al.[17] A total of 282 consecutive
patients (mean age 59 ± 15 years, 80% males) after a failed
median of two antiarrhythmic drugs including amiodarone
in 166 (59%) patients were studied. Epicardial ablation was
performed in 90 (32%) of the patients because of the recurrent
VT or persistent inducibility after endocardial only ablation.
Overall, VT‑free survival was 69% at 60‑month follow‑up.
Transplant‑free survival was 76% and 68% at 60‑  and
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Verma, et al.: Cardio 2017
120‑month follow‑up, respectively. At the last follow‑up,
128 (45%) patients were only on beta‑blockers or no treatment,
41 (30%) were on sotalol or Class I antiarrhythmic drugs,  and
62 (22%) were on amiodarone.
Congenital Heart Disease
In a cross‑sectional study, over a 3‑year period involving of
20,307 newborns over a specific 8‑h period of the day with
clinical examination, pulse oximetry followed by screening
echocardiography showed the statistics of birth prevalence
and pattern of CHD in a community hospital in North
India.[18] The study demonstrated CHD prevalence similar to
reported worldwide birth prevalence. The birth prevalence of
significant CHDs was 8.07 per 1000 live births (out of them
about 80% were acyanotic, and about 20% were cyanotic).
Ventricular septal defect was most common acyanotic
CHD (5.7/1000 live birth). Transposition of the great arteries
was the most common cyanotic CHD (0.34/1000 live birth).
Financial support and sponsorship
Nil
Conflicts of interest
There are no conflicts of interest.
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