COMMENTARY

Feb 7, 2020 This Week in Cardiology Podcast

John M. Mandrola, MD

Disclosures

February 07, 2020

Please note that the text below is not a full transcript and has not been copyedited.

Podcast Highlights

Correction: On the last podcast, I mistakenly said the IMPROVE-IT trial (which was simvastatin/ezetimibe) when I meant REDUCE-IT (icosapent ethyl). Sorry for that.

NEJM Retraction

From the original editorialists: "The take-home message from this study is that ambulatory blood-pressure monitoring is a valuable tool in the assessment of the most important and treatable factor worldwide contributing to premature death and disability, namely, blood pressure."

Well, no. The take-home message from this study, which has been cited 190 times, is that based on concerns raised by the senior authors, the data is not reliable. And so this study does not tell us the value of ambulatory BP. Also, the conclusions the editorialists and authors made about white-coat hypertension being ominous is also fraught.

TAVR at Five Years

I understand why patients love transcatheter aortic valve replacement (TAVR). Our coordinator told me that many patients referred to the valve team want TAVR... even before they hear any opinions.

This is where we—the cardiology community---have to be careful. Yes, the TAVR valve is better now, so is sizing, but the widening Kaplan Meier curves over time in PARTNER 2a are worrisome. The differential and massive loss to followup should decrease our confidence in the data. (Yet I don't sense much lack of confidence among TAVR proponents.)

Keep in mind that the 2 low risk studies are super super short term. When we do TAVR in patients in their 80s, long term data are less relevant, but as this technique goes to lower-risk, younger patients, performance at 5-10 years is highly relevant.

Targeting ICD Therapy

The implantable cardioverter-defibrillator (ICD) did not affect all-cause mortality, for either patients with late gadolinium enhancement (or scar) or for patients without scar. (P for interaction was not even close.)

What's provocative about this small observational trial is that it goes against many other previous observational studies showing an association between scar on MRI and higher risk of ventricular arrhythmia and thus benefit from the ICD.

Long QT Syndrome (LQTS)

The study, from a genetic consortium, went back to the actual evidence and found that more than half the genes annointed as causing LQTS have limited or disputed evidence.

These new findings further strengthen the idea that phenotype must be the driving reason to do gene testing. Always have a good reason to do the gene test.

Remember, these are the simplest conditions to deal with genetically, as they are single-gene diseases. But atherosclerotic heart disease, diabetes, obesity, and cancer are polygenetic. Cracking the genetic basis of disease caused by many genes is going to be significantly harder.

Screening for Disease

The Nelson trial on lung cancer screening makes the podcast because lung cancer screening represents a best case scenario for screening. It's low hanging fruit.

High-risk people. Deadly disease. Early detection would allow surgical removal. But no, it did not work.

So, if you cannot extend the life of high-risk people by early detection of lung cancer, how are you going to extend life by screening for something far less deadly like AF or far more slow growing like atherosclerotic vascular disease?

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