The following represent additions to UpToDate since the last version of What's New that were considered by the authors and editors to be of particular interest.
ARRHYTHMIAS
Epinephrine for out-of-hospital cardiac arrest — Epinephrine is frequently used as a vasopressor in patients with out-of-hospital cardiac arrest, although data showing improved outcomes with epinephrine are sparse. In a prospective observational study of over 417,000 adults with out-of-hospital cardial arrest that compared return of spontaneous circulation (ROSC), survival, and neurologic outcome in patients who did (15,030 patients, 3.6 percent) or did not (402,158 patients, 96.4 percent) receive epinephrine, there was significantly greater ROSC in the epinephrine group [1]. However, this improvement in ROSC did not translate into improved survival, as patients receiving epinephrine had significantly lower rates of overall and neurologically intact survival. Although this study is limited by its observational nature, the results call into question the routine use of epinephrine in the treatment of out-of-hospital cardiac arrest and should serve as an impetus for randomized controlled trials of this issue. (See "Supportive data for advanced cardiac life support in adults with sudden cardiac arrest", section on 'VF or VT arrest and vasopressors'.)
Dronedarone in permanent atrial fibrillation — Dronedarone is contraindicated in atrial fibrillation (AF) patients with New York Heart Association class III or IV heart failure (or a left ventricular ejection fraction <35 percent). On the basis of recent findings, it is now recognized that dronedarone should not be used in patients with permanent AF. The PALLAS trial of nearly 10,000 patients with permanent AF who were randomly assigned to receive either dronedarone or placebo was stopped early after a significantly increased risk of cardiovascular events was observed in the dronedarone arm [2]. (See "Antiarrhythmic drugs to maintain sinus rhythm in patients with atrial fibrillation: Recommendations", section on 'Concerns about dronedarone'.)
Ventricular arrhythmias post-myocardial infarction — Most of the data analyzing the incidence of ventricular arrhythmias post-myocardial infarction (MI) come from cohort studies performed in the era prior to early percutaneous coronary intervention and prior to the introduction of several classes of medications that are now standard therapy post-MI. In the current era of more aggressive therapy, approximately 25 percent of patients with a non-ST elevation acute coronary syndrome experience ventricular tachycardia (VT) within the initial seven days [3]. Patients who have an episode of VT are at a significantly greater risk of dying compared to patients without VT. (See "Clinical features and treatment of ventricular arrhythmias during acute myocardial infarction", section on 'Incidence'.)
Exercise testing to diagnose long QT syndrome — A prolonged corrected QT interval (QTc) on a resting electrocardiogram has limited sensitivity for the detection of long QT syndrome. A multicenter study found that a prolonged QTc during exercise recovery provided greater sensitivity [4]. A screening algorithm based upon resting and exercise-recovery QTc performed well in derivation and validation cohorts. (See "Diagnosis of congenital long QT syndrome", section on 'Exercise-recovery QTc'.)
CORONARY HEART DISEASE
Coronary CT angiography — The value of coronary computed tomographic angiography (CCTA) as compared to traditional care for the management of low to intermediate risk patients with possible acute coronary syndrome presenting to the emergency department was evaluated in a multicenter randomized trial enrolling 1370 patients [5]. Lengths of stay were shorter, rates of discharge from the emergency department were higher and there was a higher rate of detection of coronary disease in patients undergoing CCTA. One percent of patients in each group had a myocardial infarction and there were no cardiac deaths within 30 days after presentation. (See "Noninvasive imaging and stress testing in patients with suspected acute coronary syndrome", section on 'Coronary computed tomographic angiography'.)
Vorapaxar as adjunctive antiplatelet therapy in stable patients — Long-term antiplatelet therapy with aspirin reduces the risk of cardiovascular events in patients with stable and unstable coronary artery disease. The addition of a second antiplatelet agent reduces the risk in patients with unstable disease or those who have undergone percutaneous coronary intervention with stenting. In the PRA 2P-TIMI 50 trial of patients with stable cardiovascular disease, the addition of vorapaxar (a competitive inhibitor of a major thrombin receptor on platelets) to at least one other antiplatelet drug lowered the combined rate of cardiovascular death, MI, or stroke at three years compared to placebo [6]. However, the rate of moderate or severe bleeding occurred significantly more often with vorapaxar. Vorapaxar is not available for clinical use. (See "Secondary prevention of cardiovascular disease", section on 'Vorapaxar'.)
Glucose-insulin-potassium in patients with acute coronary syndromes — Although there has been no conclusive evidence of benefit from the infusion of a glucose-insulin-potassium (GIK) solution in patients with suspected or diagnosed acute coronary syndromes (ACS), concerns have persisted that, in the relevant studies, the infusion had not been given early enough. The issue of timing was addressed in the IMMEDIATE trial, which randomly assigned 871 patients with suspected ACS to intravenous GIK or 5 percent glucose placebo; study drug was administered by paramedics in the pre-hospital setting [7]. There was no difference in the rate of progression to MI at 24 hours or the rate of death at 30 days between the two groups. (See "Overview of the acute management of unstable angina and non-ST elevation myocardial infarction", section on 'Intravenous glucose-insulin-potassium'.)
Statins and monitoring liver function tests — In 2012, the US Food and Drug Administration revised its labeling information on statins to only recommend liver function testing prior to initiation of statin therapy and to only repeat such testing for clinical indications [8]. We agree that routine monitoring of liver function tests in patients receiving statin therapy is not necessary. (See "Statins: Actions, side effects, and administration", section on 'Hepatic dysfunction'.)
Lovastatin drug interactions — New manufacturer recommendations for lovastatin state that the medication is contraindicated in patients treated with most strong CYP3A4 inhibitors (table 1), and that there are dose limitations or recommendations to avoid lovastatin when used in conjunction with a number of other medications [8]. The metabolism of a number of other statins is affected by CYP3A4 inhibitors and manufacturer information for some other statins also includes restrictions and dose limitations when used with specific other medications. (See "Muscle injury associated with lipid lowering drugs", section on 'Concurrent drug therapy'.)
Rivaroxaban in acute coronary syndromes — A role for warfarin has not been established in patients with acute coronary syndrome (ACS) who do not have another indication for chronic oral anticoagulation, such as atrial fibrillation. In the ATLAS 2 ACS-TIMI 51 trial, over 15,000 patients with recent ACS treated with dual antiplatelet therapy were randomly assigned to either rivaroxaban (2.5 or 5 mg) or placebo [9]. After a mean duration of treatment of 13.1 months, rivaroxaban significantly reduced the rate of the primary efficacy end point (a composite of death from cardiovascular causes, MI, or stroke). (See "Chronic anticoagulation after acute coronary syndromes", section on 'Rivaroxaban'.)
High sensitivity troponin assays in acute coronary syndromes — The role of high sensitivity (hs) troponin assays in the evaluation of patients with possible acute coronary syndromes (ACS) continues to evolve. In a study of 413 patients who presented to emergency departments with symptoms suggestive of an ACS and were ultimately diagnosed with acute myocardial infarction (MI), the use of an hs troponin assay allowed for a “rule in” or ”rule out” of MI by three hours in over 98 percent of patients [10]. However, because of concerns that the optimal clinical use of these tests has not been well defined, additional data are needed before we suggest the routine use of high sensitive troponin assays. (See "Troponins and creatine kinase as biomarkers of cardiac injury", section on 'Clinical considerations'.)
HEART FAILURE
Bedside assessment of filling pressures — Accurate estimation of cardiac filling pressures is essential to the diagnosis and management of heart failure. A study of patients undergoing catheterization found that physical examination was moderately accurate in estimating right and left heart filling pressures [11]. The accuracy of bedside assessment was greater for staff cardiologists than for trainees. Exposure to the results of noninvasive cardiac testing did not improve the accuracy of estimates of filling pressures. (See "Evaluation of the patient with suspected heart failure", section on 'Diagnostic accuracy of clinical features'.)
Diagnosis of heart failure — A study evaluated the diagnostic value of elements of the initial clinical assessment in diagnosing heart failure [12]. A combination of three items from history plus six elements from the physical examination had strong diagnostic value. N-terminal pro B-type natriuretic peptide (NT-proBNP) level was the most helpful supplementary test. (See "Evaluation of the patient with suspected heart failure", section on 'Diagnostic rules'.)
Cardiopulmonary exercise testing — Prognostication is a major challenge in the management of patients with heart failure. More sophisticated cardiopulmonary exercise testing parameters (eg, the oxygen update efficiency plateau [13]) may offer greater prognostic value than currently used measures, but require further validation. (See "Exercise capacity and VO2 in heart failure", section on 'Oxygen uptake efficiency parameters'.)
Optimal medical therapy prior to ICD implantation — Prior to placement of an implantable cardioverter-defibrillator (ICD) for primary prevention, patients should be treated with optimal medical therapy directed toward the management of heart failure and the underlying cardiomyopathy. Usually this optimal medical therapy includes a beta blocker and either an angiotensin converting enzyme inhibitor (ACE inhibitor) or angiotensin II receptor blocker (ARB). In a large cohort of first-time ICD recipients, 25.7 percent of ICD recipients without a documented contraindication were not receiving optimal medical therapy at the time of ICD implantation, including 18.7 percent who were not receiving an ACE inhibitor or ARB and 10.7 percent who were not receiving a beta blocker [14]. (See "Secondary and primary prevention of sudden cardiac death in heart failure and cardiomyopathy", section on 'Optimal medical therapy'.)
INTERVENTIONAL CARDIOLOGY
Primary percutaneous coronary intervention without on-site surgery — Although concerns exist regarding the safety of primary percutaneous coronary intervention (PPCI) in patients with ST-elevation myocardial infarction (STEMI) when performed at hospitals without on-site surgery, a 2011 meta-analysis found no difference in the rate of in-hospital mortality between hospitals with and those without on-site surgery [15].
For most patients with STEMI, clinical trials have demonstrated the superiority of PPCI to fibrinolysis. The issue of whether PPCI improves outcomes compared to fibrinolysis at hospitals without on-site surgery was addressed by the C PORT trial, which randomly assigned 451 patients to one of these two reperfusion strategies [16]. Patients undergoing PPCI had a significantly lower incidence of the composite end point (death, recurrent MI, and stroke) at six months, primarily due to a lower rate of recurrent MI. (See "Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome", section on 'PCI without on-site cardiac surgery'.)
Switching from heparin to bivalirudin in acute myocardial infarction — Anticoagulation with bivalirudin is preferred to heparin in patients with acute coronary syndromes and planned percutaneous coronary intervention, as it has a comparable efficacy profile but is associated with lower rates of major bleeding. (See "Anticoagulant therapy in acute ST elevation myocardial infarction", section on 'Summary and recommendations'.)
In a prespecified analysis of the HORIZONS AMI trial, bivalirudin maintained its efficacy and safety profile, compared to heparin, in the subgroup of patients who were initially treated with heparin [17]. (See "Anticoagulant therapy in acute ST elevation myocardial infarction", section on 'Switching from heparin to bivalirudin'.)
Same-day discharge after elective percutaneous coronary intervention — Many of the adverse outcomes after percutaneous coronary intervention (PCI) are seen within the first 48 hours, leading to the common practice of overnight observation in hospital following PCI. In an observational study of over 107,000 patients undergoing elective PCI, same-day discharge was not associated with an increased risk of death or hospitalization at 30 days [18]. (See "Periprocedural complications of percutaneous coronary intervention", section on 'Early discharge in low risk patients'.)
RenalGuard System may decrease contrast nephropathy — The RenalGuard system is a fluid management device that guides fluid replacement by providing a real-time display of urine and replacement fluid volumes. Two studies have suggested that furosemide-induced diuresis and matched saline infusion that is guided by the RenalGuard system may decrease the risk of contrast nephropathy among high risk patients undergoing angiography [19,20]. (See "Prevention of contrast-induced nephropathy", section on 'RenalGuard system'.)
Acetylcysteine and contrast nephropathy — The Acetylcysteine for the prevention of Contrast-induced Nephropathy (ACT) trial showed no benefit over placebo of acetylcysteine (1200 mg orally twice daily) on the incidence of contrast nephropathy among 2308 high-risk patients who were undergoing angiography [21]. The trial was underpowered to exclude a potential benefit of acetylcysteine among patients with severe kidney insufficiency. (See "Prevention of contrast-induced nephropathy", section on 'Acetylcysteine'.)
Clopidogrel hypersensitivity reactions — Hypersensitivity reactions develop in 1 to 4 percent of patients who receive clopidogrel following a coronary artery stenting procedure. Management options include stopping clopidogrel and changing to another antiplatelet agent, restarting the clopidogrel using a desensitization procedure, or continuing the drug while treating the patient with systemic glucocorticoids and antihistamines (ie, “treating through”). An observational study reported outcomes for a series of 62 patients with mild to moderate clopidogrel reactions who were managed by “treating through” and also evaluated with various allergy tests to define the nature of their reactions [22]. Hypersensitivity signs and symptoms included generalized macular rash, localized skin reaction, and isolated urticaria or angioedema. All patients received a 20-day course of prednisone, during which 95 percent had resolution of symptoms by a mean of five days. All patients were able to complete the minimum desired period of clopidogrel treatment (ie, 1 to 12 months). (See "Antithrombotic therapy for intracoronary stent implantation: General use", section on 'Hypersensitivity'.)
MYOPERICARDIAL DISEASE
Titin mutations causing dilated cardiomyopathy — More than 30 genes have been identified harboring mutations that cause dilated cardiomyopathy. The TTN gene encodes titin, a key component of sarcomeric force generation. A study of three referred populations of patients with idiopathic dilated cardiomyopathy identified TTN truncating mutations in 25 percent of familial cases and 18 percent of sporadic cases [23]. Thus truncations of titin are the most common known genetic cause of dilated cardiomyopathy (table 2). (See "Genetics of dilated cardiomyopathy", section on 'Sarcomere genes'.)
Cardiac magnetic resonance imaging in constrictive pericarditis — Cardiac magnetic resonance (CMR) imaging, specifically the degree of late gadolinium enhancement (LGE) of the pericardium, appears promising as a way to predict which patients with constrictive pericarditis will have reversal or resolution of the process. In a retrospective cohort study of 29 patients with constrictive pericarditis who underwent CMR prior to initiating therapy, 14 of the 29 patients ultimately had resolution of constrictive pericarditis [24]. LGE pericardial thickness ≥3 mm predicted reversibility of constriction with 86 percent sensitivity and 80 percent specificity. We suggest using CMR imaging in patients being considered for pericardiectomy to provide additional information that might alter the decision to proceed with surgery. (See "Constrictive pericarditis", section on 'Transient constrictive pericarditis'.)
Safety of endomyocardial biopsy in arrhythmogenic right ventricular cardiomyopathy — The safety of endomyocardial biopsy (EMB) when targeting non-septal locations in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) has been a concern, given the thinner right ventricular (RV) free wall and apical myocardium. However, in a cohort of 482 patients with cardiomyopathy of uncertain etiology that underwent 3777 EMB samples taken from six different RV locations, there was no significant difference in the rate of cardiac perforation resulting in pericardial effusions between patients with ARVC and those with a diagnosis other than ARVC [25]. These results suggest that, in experienced hands, it is safe to perform EMB targeted to areas of the RV likely to yield a higher rate of diagnostic biopsies for ARVC. (See "Diagnosis of arrhythmogenic right ventricular cardiomyopathy", section on 'Endomyocardial biopsy'.)
VALVULAR HEART DISEASE
Transcatheter aortic valve replacement — Transcatheter aortic valve replacement (TAVR) has been developed as a treatment for patients with severe symptomatic aortic stenosis with high risk for surgical aortic valve replacement. Benefits and limitations of TAVR are illustrated by results from the following two trials:
Valve surgery for endocarditis complicated by heart failure — Prompt valve surgery is recommended for patients with endocarditis who have valve dysfunction leading to heart failure. Support for this approach comes from a prospective multicenter observational study including 1359 patients with endocarditis and heart failure [28]. Valve surgery during the initial hospitalization was independently associated with lower mortality. (See "Surgery for native valve endocarditis", section on 'Heart failure'.)
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.
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