COMMENTARY

Feb 14, 2020 This Week in Cardiology Podcast

John M. Mandrola, MD

Disclosures

February 14, 2020

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

Podcast Highlights

Cardiac Stents

First, we have to give kudos to the authors for publishing such sobering data.

Second, this data highlights a basic premise in medicine: stuff isn’t free. Intervention comes with a cost.

A stent trades a flow-limiting lesion for a metal cage in the artery—you know, the place where platelets flow by.

At the stent site, the vessel tries to heal—that’s inflammation, and then late, focal disease can occur—that’s given the funny name neo-atherosclerosis.

So, when you are having an MI, the PCI and stent are great, because you are going to lose heart muscle, and maybe die; but when you are stable, every shred of evidence we have shows that PCI does not reduce hard outcomes.

Could this observation, the very late steady increase in events possibly explain the superiority of bypass surgery over PCI in patients with left main disease, seen in NOBLE and EXCEL?

My hope is that someday, we can find a way to convince society that the clogged-pipe frame of treating chronic vascular disease is flawed. Unlike the editorialists, I don’t think iterations of stents or balloons with solve the problem of vascular disease.

Cardio-oncology

I am seeing more and more of this: While oncology has made great strides in the treatment of many cancers, there are now new challenges for cardiologists.

One reason MACE might have been lower is selection bias. If you are trying to get a drug approved, you want to minimize bad events, and thus, either consciously or unconsciously, you choose healthier patients to be in trials. (This is actually a very key point in using evidence at the bedside; patients in trials are generally healthier than real-world patients)

Another reason MACE events were so low, is that cardiac toxicity takes longer to develop; the editorialists in JACC make this point. It’s a worthy editorial.

A point made in the news story was that we all have to get past the dated notion that cardiac toxicity is only from anthracyclines and radiation. A quote from a breast cancer oncologist: “The checkpoint inhibitors are so unbelievably different in terms of their toxicities that many people simply didn't even know what they were getting into at first.”

Also cited in the news piece was cardio-oncologist Javid Moslehi from Vandy, who said the majority of MACE seen today is vascular, metabolic, arrhythmogenic and inflammatory. Echo misses the big and increasingly complex picture, he added.

His group has just reported a paper describing 303 CV deaths from ibrutinib

One type of surveillance does not fit all—what’s relevant for the breast cancer patient may not be relevant for the prostate cancer patient.

VT Ablation

First, this was a tough comparison. The protocol called for the deferred strategy to wait for three ICD shocks before doing VT ablation. Many operators broke protocol and ablated after one or two ICD shocks. That is quite reasonable as having three shocks is rough.

The ablation did seem to reduce VT—a secondary endpoint; this is similar to prior studies. But remember VT ablation is not free, there are potential complications.

This is why outcomes trials of VT ablation are important. You can’t just say—ablation reduces shocks and VT so let’s do it. It has to reduce VT and icd shocks and also improve outcomes and not harm people.

The higher rate of HF admissions in the preventive arm did not reach sig but the signal trended in the harm direction. That is concerning.

Final comment from me: VT ablation is very reasonable intervention but I see overzealous use. Berlin VT should cool our enthusiasm for preventive ablation, and remember in the seminal VT ablation trial, VANISH, the best RCT in this space, ALL patients enrolled in the trial had medical therapy and the choice was ablation or acceleration of medical therapy. VT ablation did modestly better.

Acute AF Strategies

This study highlights a crucial teaching point: procainamide is an underrecognized and underused drug for acute conversation of tachyarrhythmia.

Procainamide is a type IA drug, a sodium channel blocker primarily, but also with effects on K+ channels so it slows conduction and prolongs the ERP. It is given IV over 20-30 minutes

A Spanish RCT, published in European Heart Journal, which I will reference, showed it was much better than IV amiodarone for conversion of wide complex tachycardia. In fact, the OR for conversion vs amiodarone was 3.3, though with wide confidence interval due small numbers.

What’s weird is that in my place few people know about it. IV amiodarone is the go-to drug. Things get established in medicine, nurses, docs get comfortable, and that’s what happened with amiodarone. (A similar situation occurred with IV diltiazem rather than betablocker)

But procainamide is extremely easy to use, safe if given slowly and probably more effective. In this study, the fact that half the time, proc infusion converted is fantastic for patients –because they can avoid being sedated and shocked.

Two final comments on this study are the notion of acute conversion. A very important Dutch study published in NEJM in 2019 (link below) showed that delayed cardioversion—a conservative approach—for AF was noninferior to acute cardioversion. In that study, 67% of patients converted with time. Just wait. You don’t have to convert AF in the ED. You can wait. Most AF stops on its own. And you avoid AAD and a shock.

Second important point—while there were no strokes in this group at 14 days, it was a small sample to look at that endpoint, strokes are low-outcome events.

All it takes is one young person with AF with a stroke after cardioversion and you will never forget that case. I am extremely conservative about choosing patients for acute cardioversion—especially when they are not on AC.

References

Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study.

Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation

An Interview With Lisa Rosenbaum

In his podcast, Robert A. Harrington, MD, from Stanford University, here on theheart.org and Medscape Cardiology delves into current science topics and health policy topics. He also tries to introduce the listener to some of the people in cardiovascular medicine who may be approaching the world of medicine from a different vantage point as opposed to a strictly scientific/research vantage point or a clinical observation standpoint.

In this podcast, Dr Harrington talks with Dr Lisa Rosenbaum, a national correspondent for the New England Journal of Medicine (NEJM). She is also an assistant professor of medicine at Harvard Medical School and a practicing cardiologist at Brigham and Women's Hospital in Boston.

They cover how she got into medicine, and then into writing. And how she started writing for the NEJM and eventually The New Yorker. Dr Rosenbaum has a unique take on burnout, finding joy in medical practice, conflicts of interest, and other tough topics.

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