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Review Article

Cardiology Update 2017: The Third Quarter

Sridharan Umapathy, Sunil Kumar Verma
Department of Cardiology, AIIMS, New Delhi, India

Abstract
In the third quarter of 2017, culprit only percutaneous coronary intervention (PCI) fares better in acute myocardial infarction with shock,
guided de‑escalation antiplatelet therapy seems noninferior, drug‑eluting stent (DES) better in elderly patients undergoing PCI, DES with
ultrathin struts proves superior, atrial fibrillation ablation improves left ventricular function in idiopathic cardiomyopathy, and edoxaban
beneficial in preventing cancer‑associated venous thromboembolism.

Keywords: 2017, review, update cardiology

Acute Coronary Syndrome
In CULPRIT‑SHOCK trial, 706 patients who had multivessel
coronary artery disease (CAD) and acute myocardial infarction
with cardiogenic shock were studied and it showed that 30‑day
risk of a composite of death or severe renal failure leading
to renal replacement therapy was lower among those who
initially underwent percutaneous coronary intervention (PCI)
of the culprit lesion only than among those who underwent
immediate multivessel PCI.[1] STEMI and NSTEMI were
equally distributed in both the groups.
EARLY‑MYO trial showed that in patients with STEMI presenting
≤6 h after symptom onset and with an expected PCI-related delay
(≥90 min), a pharmacoinvasive strategy with half-dose alteplase
and timely PCI offers more complete epicardial and myocardial
reperfusion when compared with primary PCI with no significant
difference in major bleeding events.[2]
TROPICAL‑ACS trial showed that guided de‑escalation of
antiplatelet therapy (1‑week prasugrel followed by 1‑week
clopidogrel and platelet function testing‑guided maintenance
therapy with clopidogrel or prasugrel from day 14 after hospital
discharge) was noninferior to standard treatment with prasugrel
at 1 year after PCI in terms of net clinical benefit.[3]
Coronary Artery Disease
In SENIOR trial involving elderly patients aged ≥75 years
who had PCI, it has been shown that usage of drug‑eluting
stent and a short duration of dual antiplatelet therapy
(DAPT) (1 month for stable CAD and 6 months for unstable
presentation) are better than bare metal stent and a similar
duration of DAPT with respect to the occurrence of all‑cause
mortality, myocardial infarction, stroke, and ischemia‑driven
target lesion revascularization.[4]
In ORBITA trial involving 200 patients with medically treated
angina and severe coronary stenosis (≥70%), PCI did not
increase exercise time by more than the effect of a placebo
procedure.[5] This small (though well‑done) study enrolled
very stable patients with angina lasting ~9 months, employed
very intensive medical optimization, but had only 6 weeks of
follow‑up. These findings do not imply that patients should
never undergo PCI for stable angina and do not apply to acute
coronary syndromes, for which PCI has well‑proven benefits.
In BIOFLOW V trial involving 4772 patients undergoing
PCI of de novo native coronary lesions, ultrathin
(strut thickness 60 µm), bioresorbable polymer sirolimus-
eluting stent performed better over the durable polymer
everolimus-eluting stent with respect to primary endpoint of
target lesion failure.[6]
In ABSORB III trial, 3‑year adverse event rates were higher
with bio vascular scaffolds than everolimus eluting stents,
Address for correspondence: Dr. Sunil Kumar Verma,
Department of Cardiology, AIIMS, New Delhi, India.
E‑mail: ksunilverma02@gmail.com

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DOI:
10.4103/jpcs.jpcs_61_17 How to cite this article: Umapathy S, Verma SK. Cardiology update 2017:
The third quarter. J Pract Cardiovasc Sci 2017;3:139-42.

© 2018 Journal of the Practice of Cardiovascular Sciences | Published by Wolters Kluwer - Medknow 139
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Umapathy and Verma: Cardio Update
particularly target vessel MI (8.6% vs. 5.9%; P = 0.03) and
device thrombosis (2.3% vs. 0.7%; P = 0.01).[7]
In BIONICS trial, ridaforolimus eluting stent was found to
be noninferior to zotarolimus‑eluting stents for the primary
end‑point of target lesion failure at 12 months and had similar
measures of late lumen loss.[8]
A study evaluating the learning curve of transradial
percutaneous coronary angioplasty with a team of operators
trained with transfemoral coronary angioplasty demonstrated
the ease of transradial technique with similar results. [9]
Although the study was done in acute STEMI setting (a more
demanding scenario), the results can be applicable to elective
cases also.
In DKCRUSH‑V trial involving 482 patients, PCI of true
distal left main bifurcation lesions using a planned double
kissing (DK) crush 2‑stent strategy resulted in a lower rate
of target lesion failure at 1 year than provisional stenting
strategy (5% vs. 10.7%). DK crush also resulted in lower
rates of target vessel myocardial infarction I (2.9% vs.
0.4%; P = 0.03) and definite or probable stent thrombosis
(3.3% vs. 0.4%; P = 0.02).[10]
PRESERVE trial showed that in patients at high risk for renal
complications who were undergoing angiography, there was
no benefit of intravenous sodium bicarbonate over intravenous
sodium chloride or of oral acetylcysteine over placebo for
the prevention of death, need for dialysis, or persistent
decline in kidney function at 90 days or for the prevention of
contrast‑associated acute kidney injury.[11]
Atherosclerosis
A post hoc analysis from the WOSCOPS trial (West of
Scotland Coronary Prevention Study) provides robust novel
evidence for the short‑ and long‑term benefits of lowering
low‑density lipoprotein cholesterol (LDL‑C) for the primary
prevention of cardiovascular disease among individuals
with primary elevations of LDL‑C ≥190 mg/dL. Among
individuals with LDL‑C ≥190 mg/dL, pravastatin reduced
the risk of coronary heart disease by 27% (P = 0.033) and
major adverse cardiovascular events by 25% (P = 0.037)
during the initial trial phase and the risk of coronary heart
disease death, cardiovascular death, and all‑cause mortality
by 28% (P = 0.020), 25% (P = 0.009), and 18% (P = 0.004),
respectively, over a total of 20 years of follow‑up.[12]
Heart Failure
CAMERA‑magnetic resonance imaging (MRI) trial showed
that the restoration of sinus rhythm in patients with idiopathic
cardiomyopathy and chronic atrial fibrillation (AF) by catheter
ablation results in significant improvements in ventricular
function, particularly in the absence of ventricular fibrosis on
cardiac MRI.[13]
140 Journal of the Practice of Cardiovascular Sciences ¦ Volume 3 ¦ Issue 3 ¦ September-December 2017
Hypertension
Dietary approaches to stop hypertension (DASH) sodium
trial showed that the combination of reduced sodium intake
and the DASH diet‑lowered systolic blood pressure (BP)
throughout the range of pre and stage 1 hypertension, with
progressively greater reductions at higher levels of baseline
systolic BP. BP reductions in adults with the highest levels
of systolic BP (≥150 mmHg) were striking and reinforce the
importance of both sodium reduction and the DASH diet in
this high‑risk group.[14]
Electrophysiology
In five patients suffering from refractory ventricular
tachycardia, noninvasive electrophysiology‑guided cardiac
radioablation (stereotactic body radiation therapy) markedly
reduced the burden of ventricular tachycardia over a period of
46 patient months with no reduction in mean left ventricular
(LV) ejection fraction.[15]
About 1500 patients with “legacy devices” (pacemakers or
automated implantable cardioverter defibrillators that are
considered to be non‑MRI conditional) were subjected to about
2000 thoracic and nonthoracic MRIs of 1.5 tesla strength in
a prospective, nonrandomized study[16] reported no clinically
significant long‑term adverse events. About 3%–4% of the
patients developed changes in lead parameters (decrease in
P‑wave amplitude, increase in atrial capture threshold, increase
in right ventricular capture threshold, and increase in LV
capture threshold), but were not clinically significant and not
required reprogramming or device revision.
Atrial Fibrillation
The long‑term 5‑year outcomes of the PREVAIL trial,
combined with the 5‑year outcomes of the PROTECT AF trial,
demonstrate that left atrial appendage (LAA) closure with the
Watchman device provides stroke prevention in nonvalvular
AF patients to a similar degree as oral anticoagulation with
warfarin. Furthermore, by virtue of its ability to minimize
major bleeding, particularly hemorrhagic stroke, LAA device
closure results in less disability, or death than warfarin.[17]
Evaluation of records of about 1500 consecutive patients of
HOCM for about 5 years duration to look for the effect of the
development of AF on clinical course and outcome showed
AF is not a major contributor to heart failure morbidity and/or
a cause of sudden arrhythmic death.[18] When treated, it is
associated with low disease‑related mortality, no different than
patients without AF. AF is an uncommon primary cause of
death in HCM virtually limited to embolic stroke, supporting
a low threshold for initiating anticoagulation therapy.
Structural Heart Disease
In a study comparing mechanical and biologic prosthesis for
mitral/aortic valve replacement over a period from 1996 to
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Umapathy and Verma: Cardio Update
2013, the long‑term mortality benefit that was associated with a
mechanical prosthesis, as compared with a biologic prosthesis,
persisted until 70 years of age among patients undergoing
mitral‑valve replacement and until 55 years of age among
those undergoing aortic‑valve replacement. The incidence of
reoperation was significantly higher with biologic prosthesis,
and bleeding risk was higher with mechanical prosthesis.[19]
In a single institutional analysis of ROSS procedure
between January 1990 and December 2014, overall survival
was excellent at 10 and 20 years being 94.1% and 83.6%
respectively. However, long‑term survival was lower in Ross
patients compared with age‑ and sex‑matched subjects.[20]
In a retrospective study involving persons who had sudden
cardiac arrest during participation in a sport, the incidence of
sudden cardiac arrest was found to be 0.76 cases per 100,000
athlete years. Only three cases of sudden cardiac arrest that
occurred during participation in competitive sports were
determined to have been potentially identifiable if the athletes
had undergone preparticipation screening.[21]
In patients undergoing cardiac surgery who were at
moderate‑to‑high risk for death (EUROSCORE I ≥ 6), a
restrictive strategy regarding red‑cell transfusion (transfuse only
if Hb <7.5 g%) was noninferior to a liberal strategy (transfuse
if Hb <9.5 g%) with respect to the composite outcome of death
from any cause, myocardial infarction, stroke, or new‑onset
renal failure with dialysis, with less blood transfused.[22]
Venous Thromboembolism
In cancer‑associated venous thromboembolism (VTE), oral
edoxaban was shown to be noninferior to subcutaneous
dalteparin with respect to the composite outcome of recurrent
VTE or major bleeding. The rate of recurrent VTE was lower;
however, the rate of major bleeding was higher with edoxaban
than with dalteparin.[23]
ATTRACT trial showed that in patients with acute proximal
deep‑vein thrombosis, the addition of pharmacomechanical
catheter‑directed thrombolysis to anticoagulation did not result
in a lower risk of the postthrombotic syndrome but did result
in a higher risk of major bleeding over 24‑month follow‑up
period.[24]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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142 Journal of the Practice of Cardiovascular Sciences ¦ Volume 3 ¦ Issue 3 ¦ September-December 2017