'Why we do What we do in Cardiology'

Bishnu Subedi
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I am Dr. Bishnu Subedi. I am a cardiologist in the United States. In the era of evidence-based medicine, our practice is usually guided by a scientific study, expert society statements, or clinical guidelines. In this podcast series, I intend to highlight some of these practice-changing articles in the field of cardiology from past and present.

  1. 06/24/2024

    REDUCE-AMI Trial: Diminishing Role of Beta-Blockers in ACS with preserved LVEF

    1. The REDUCE-AMI trial showed no significant benefit of beta-blockers in reducing all-cause mortality or future myocardial infarction in patients with acute myocardial infarction and preserved left ventricular ejection fraction. 2. The trial included 5,020 patients who were randomized to either beta-blockade with metoprolol or bisoprolol or usual care, with follow-up over a median of 3.5 years. 3. Primary and secondary outcomes showed no significant differences between the beta-blocker and usual care groups. 4. Safety outcomes were similar between groups, and there was significant crossover and varying adherence to beta-blocker therapy over time. 5. The findings suggest a need to re-evaluate the routine use of beta-blockers in this patient population, emphasizing personalized treatment approaches and further research.

    4 min

  2. 06/22/2024

    Improving Left Ventricular Ejection Fraction in Heart Failure Patients: Insights from the HF-OPT Study

    The HF-OPT study investigated the improvement of left ventricular ejection fraction (LVEF) beyond 90 days in patients with newly diagnosed heart failure with reduced ejection fraction (HFrEF). In this prospective, multicenter observational study, 1,300 patients with HFrEF (LVEF ≤35%) were initially enrolled. Participants wore a wearable cardioverter-defibrillator (WCD) and received guideline-directed medical therapies (GDMT). LVEF was measured at 0, 90, 180, and 360 days. By day 90, 46% had an LVEF >35%; this increased to 68% by day 180 and 77% by day 360. High GDMT usage was noted, with 97% on beta-blockers, 94% on ACE inhibitors/angiotensin-receptor blockers/ARNI, and 62% on mineralocorticoid antagonists by day 180. Achieving target doses of all three GDMT classes was associated with significant LVEF improvement. The study recorded low rates of ventricular arrhythmias beyond the initial 90 days. These results underscore the potential benefits of continuous GDMT optimization. They suggest that delayed implantable cardioverter-defibrillator (ICD) implantation may be reasonable for selected patients, allowing for further LVEF improvement. This emphasizes the importance of optimal dosing and continuous GDMT for effective heart failure management, highlighting the need for expedited GDMT titration and a tailored approach to heart failure care. Reference: European Heart Journal, ehae334, https://doi.org/10.1093/eurheartj/ehae334

    5 min

  3. 06/21/2024

    AI in Cardiovascular Medicine: JACC Review

    Overview: This review discusses the use and future directions of AI in cardiology, focusing on areas like electrocardiography, telemetry and wearables, echocardiography, CMR, nuclear cardiology, CT, electrophysiology studies, coronary angiography, and genetics or multiomics. AI Glossary: Includes key terms such as algorithms, AUC, artificial intelligence, neural networks, classification, CNNs, deep learning, features, foundation models, joint embedding, labels, large language models, machine learning, preprocessing, reinforcement learning, segmentation, semi-supervised learning, structured data, supervised learning, unstructured data, unsupervised learning, and wearables. Deep Learning in Cardiology: Applied to physiologic waveform, imaging, and multiomics data with clinical applications. Studies reviewed using MeSH terms in PubMed. ECG and AI: Deep learning techniques like CNNs show promise in arrhythmia classification and predicting conditions like LV systolic dysfunction, hypertrophic cardiomyopathy, and cardiac amyloidosis. AI in Echocardiography: Improves image acquisition and interpretation, helping automate measurements and enhancing variability and disease diagnosis. AI in CMR Imaging: Enhances image reconstruction, segmentation, and quantification. AI applications in nuclear cardiology and CT include improved prognostication and plaque burden quantification. AI in Electrophysiology: Aids preprocedural planning, intraprocedural guidance, and postprocedural predictions, improving ablation target identification and therapy response prediction. AI in Coronary Angiography: Automates stenosis detection, plaque characterization, and fractional flow reserve computation, enhancing accuracy and procedural efficiencies. Machine Learning in Genomics: Improves risk prediction, variant interpretation, pathogenicity identification, and integration into clinical care. Future of AI in Cardiovascular Medicine: Promises enhanced disease screening, imaging data integration, and accurate diagnoses. Focuses on data quality, diversity, model generalizability, and promoting AI adoption in clinical practice. AI Potential: Significant potential to enhance patient care through improved diagnostics, risk stratification, and personalized treatment plans, supporting clinicians in delivering better cardiovascular care. Reference: J Am Coll Cardiol. 2024 Jun, 83 (24) 2472–2486

    7 min

  4. 05/31/2024

    2024 ACC Peripheral Artery Disease (PAD) Guidelines

    Collaborative vascular care is emphasized to address health disparities, gaps in medical therapy, structured exercise, and good foot care along with appropriate revascularization to prevent limb loss. The new guidelines update the 2016 guidelines and call for broad implementation of the Peripheral Artery Disease (PAD) National Action Plan to improve outcomes. Emphasis on rigorous medical therapy for all patients with PAD, regardless of clinical subset. Introduction of new medical therapies: Low-dose rivaroxaban combined with low-dose aspirin for symptomatic PAD and post-revascularization patients. SGLT2 inhibitors and GLP-1 receptor agonists for diabetes patients to prevent major adverse cardiovascular events (MACE). PCSK9 inhibitors and ezetimibe for patients with high low-density lipoprotein cholesterol (LDL-C). Recognition of depression as a prevalent comorbidity in PAD with recommendations to use the Geriatric Depression Score (GDS) and Patient Health Questionnaire-9 (PHQ-9) for assessment. Expanded focus on health disparities and social determinants of health affecting PAD across race, ethnicity, and income level. Emphasis on longitudinal follow-up and broad adoption of quality measures for PAD care to reduce amputation rates by 20 percent by 2030. Expanded exercise recommendations: Supervised exercise therapy (SET) for chronic symptomatic PAD, with or without revascularization. Structured community-based exercise programs with behavioral change techniques. New emphasis on foot care across the spectrum of PAD, including preventive foot care and the role of foot care professionals in managing chronic limb-threatening ischemia (CLTI). Consistent theme of collaborative vascular care, particularly team-based care for CLTI to improve patient outcomes.

    6 min

  5. 05/21/2024

    2024 ACC/AHA Guidelines on Hypertrophic Cardiomyopathy

    2024 HCM Guidelines Focus on Cardiac Myosin Inhibitors and Exercise Mavacamten: Class 1 recommendation for symptomatic obstructive HCM. Exercise: Now allows for "vigorous" activity; competitive level still limited. Pediatric Section: Separate guidelines with new risk-prediction tools. Atrial Fibrillation: Enhanced monitoring is recommended. Future Research: Needed on nonobstructive HCM and cardiac myosin inhibitors' long-term effects.

    9 min

  6. 01/29/2024

    DOACs: When direct oral anticoagulants should not be used?

    Key Points: Positive Aspects of DOACs: DOACs are acknowledged for their convenience, efficacy, and safety in conditions like atrial fibrillation (AF) and venous thromboembolism (VTE). The review supports their use in stroke prevention, AF, recent acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI), valve disease (with exceptions), VTE management, cancer-associated thrombosis, stable atherosclerotic cardiovascular disease, and peripheral-artery revascularization. Conditions Where DOACs Are Not Recommended: DOACs are cautioned against in specific medical settings, including mechanical heart valves, rheumatic AF, transcatheter aortic valve implantation (TAVI), embolic stroke of undetermined cause (ESUS), left ventricular assist devices, heart failure with reduced LV systolic function without AF, and thrombotic antiphospholipid syndrome (APS). Areas of Uncertainty and Need for Research: The paper identifies areas where the benefit of DOACs remains uncertain due to a lack of dedicated trials or inconclusive results. These include left ventricular thrombus, catheter-associated deep vein thrombosis (DVT), cerebral venous sinus thrombosis, and splanchnic vein thrombosis. The need for further research, especially in catheter-induced DVT, is emphasized. Reference: J Am Coll Cardiol. 2024 Jan, 83 (3) 444–465

    5 min

  7. 01/26/2024

    Cath: NPO vs Eating before Heart Cath

    Background: Traditional practice requires fasting before cardiac catheterization, but there's no evidence to support it. Objective: This study compared a heart-healthy pre-procedure diet with fasting to determine best practices. Methods: 197 patients were randomly assigned to either a heart-healthy diet or fasting before their cardiac catheterization. Results: Satisfaction: Patients on the heart-healthy diet were significantly more satisfied than those who fasted. Symptoms: Those in the diet group reported less thirst and hunger before and after the procedure. Safety: No difference in complications (pneumonia, aspiration, intubation, hypoglycemia) was observed between groups. Other outcomes: Fatigue, glucose levels, gastrointestinal issues, and antiplatelet medication doses were similar between groups. Conclusion: Providing a heart-healthy diet before cardiac catheterization is safe and improves patient satisfaction without increasing complications. Future Considerations: Larger, multicenter studies are encouraged to validate and replicate these findings. The study prompts a reconsideration of fasting protocols for other procedural situations beyond cardiac catheterization. Reference Link: https://doi.org/10.4037/ajcc2024115

    4 min

  8. 01/22/2024

    Stable CAD and Angina: PCI without medical therapy as first treatment (ORBITA-2)

    Key Points In patients not taking antianginal meds, PCI alleviated some—but not all—symptoms Background: Percutaneous coronary intervention (PCI) is commonly used to alleviate stable angina symptoms. Uncertainty exists regarding whether PCI is more effective than a placebo procedure in patients not using antianginal medication. Methods: A double-blind, randomized, placebo-controlled PCI trial was conducted in stable angina patients. Patients underwent a 2-week symptom assessment phase after stopping antianginal medications. Randomized 1:1, patients received either PCI or a placebo, with a 12-week follow-up. The primary endpoint was the angina symptom score, calculated based on daily angina episodes, antianginal medications, and clinical events. Results: 301 patients were randomized (151 PCI, 150 placebo), with a mean age of 64 and 79% men. Ischemia was present in 80% of one cardiac territory, 17% in two, and 2% in three territories. At 12 weeks, the mean angina symptom score was significantly lower in the PCI group (2.9) than in the placebo group (5.6). The odds ratio for improved scores with PCI was 2.21 (95% CI, 1.41 to 3.47; P0.001). One patient in the placebo group had unacceptable angina leading to unblinding. Acute coronary syndromes occurred in 4 patients in the PCI group and 6 in the placebo group. Conclusions: In stable angina patients not using antianginal medication and with objective evidence of ischemia, PCI resulted in a lower angina symptom score compared to a placebo procedure. Indicates an improved health status concerning angina following PCI. Link to article: DOI: 10.1056/NEJMoa2310610

    3 min
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I am Dr. Bishnu Subedi. I am a cardiologist in the United States. In the era of evidence-based medicine, our practice is usually guided by a scientific study, expert society statements, or clinical guidelines. In this podcast series, I intend to highlight some of these practice-changing articles in the field of cardiology from past and present.

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