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What's new in cardiovascular medicine
Official reprint from UpToDate® ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
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What's new in cardiovascular medicine
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2017. | This topic last updated: Dec 04, 2017.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.


Risk of sudden cardiac death in athletes (November 2017)

While sudden cardiac death (SCD) is the leading medical cause of death in athletes, its exact incidence remains unclear. Until now, best estimates have suggested an incidence of approximately 1 in 50,000 athlete-years. In a new study using 2009 to 2014 data from a Canadian database recording all out-of-hospital sudden cardiac arrests (SCA) in Ontario, Canada, the overall rate of SCA in athletes was 0.76 per 100,000 athlete-years [1]. With 44 percent of patients surviving to hospital discharge following SCA, the overall rate of SCD was 0.42 per 100,000 athlete-years. These data suggest the incidence of SCD in athletes is one-fourth of previous estimates and raise a question about the role of preparticipation screening. (See "Risk of sudden cardiac death in athletes", section on 'Incidence of sudden death'.)

Implantable cardioverter-defibrillators (ICDs) for primary prevention in nonischemic cardiomyopathy (July 2017)

Several trials have shown reduced arrhythmia-related mortality among patients with nonischemic cardiomyopathy who receive an implantable cardioverter-defibrillator (ICD) for primary prevention of sudden death, but no individual trial has shown a benefit in total mortality. Four meta-analyses that included patients receiving a primary prevention ICD from the same six trials (CAT, AMIOVIRT, DEFINITE, SCD-HeFT, COMPANION, and DANISH), demonstrate a significant benefit for all-cause mortality compared with medical therapy alone (19 to 24 percent hazard reduction) [2-5]. ICDs should be used in conjunction with optimal medical therapy to reduce mortality in patients with nonischemic cardiomyopathy. (See "Primary prevention of sudden cardiac death in heart failure and cardiomyopathy", section on 'Meta-analyses of ICD trials in nonischemic cardiomyopathy'.)

ACC/AHA/HRS guideline for the evaluation and management of syncope (July 2017)

In 2017 the American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) published guidelines on evaluation and management of patients with syncope, the first major new syncope guidelines in eight years [6]. The guidelines present an approach to the evaluation and management of patients with syncope that is consistent with the approach advocated by UpToDate experts. Both UpToDate and the ACC/AHA/HRS guidelines emphasize the importance of a detailed medical history, physical examination, and review of an electrocardiogram as the initial evaluation in all patients. An echocardiogram should be performed in patients with known or suspected structural heart disease, with selected additional testing directed by the results of the initial evaluation. (See "Syncope in adults: Clinical manifestations and diagnostic evaluation", section on 'Initial evaluation'.)


Red blood cell transfusion threshold in patients undergoing cardiac surgery (November 2017)

While the optimal red blood cell transfusion threshold for patients undergoing cardiac surgery with cardiopulmonary bypass is not known, experts have generally recommended transfusion for hemoglobin values less than 8 g/dL. In the TRICS III trial, over 5000 adults at high risk of death were randomly assigned to a restrictive red cell transfusion threshold (transfuse if hemoglobin <7.5 g/dL) or a liberal threshold (transfuse if hemoglobin <9.5 g/dL) [7]. There was no difference in the rate of the composite outcome of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis while, as expected, the rate of transfusion was higher in the group with the higher transfusion threshold. This trial confirms findings in smaller randomized trials and supports our practice to transfuse to maintain the hemoglobin level above 8 g/dL, recognizing that individual patient factors may alter this threshold. (See "Early noncardiac complications of coronary artery bypass graft surgery", section on 'Blood transfusion'.)

Five-year survival worse with off-pump compared with on-pump CABG (August 2017)

We perform off-pump coronary artery bypass graft surgery (CABG) in a small minority of patients as the evidence to support its use has been eroding. In the large ROOBY trial, the rate of death at five years was significantly higher with off-pump, compared with on-pump, CABG (15.2 versus 11.9 percent) [8]. (See "Off-pump and minimally invasive direct coronary artery bypass graft surgery: Outcomes", section on 'Comparison to on-pump CABG'.)


Heparin versus bivalirudin in MI patients undergoing PCI (November 2017)

Despite the publication of many randomized trials of anticoagulant therapy in patients with ST-elevation myocardial infarction (STEMI), the preferred agent for anticoagulation is not known. In the VALIDATE-SWEDEHEART trial, over 6000 patients with STEMI or non-ST elevation MI undergoing urgent percutaneous coronary intervention (PCI) and receiving treatment with dual antiplatelet therapy were randomly assigned to bivalirudin or heparin during the procedure [9]. There was no significant difference in the primary outcome of death, MI, or major bleeding at 180 days. For reasons of cost, we choose heparin in most MI patients undergoing urgent PCI. However, bivalirudin is a reasonable choice in some subgroups. (See "Anticoagulant therapy in acute ST elevation myocardial infarction", section on 'UFH compared with bivalirudin'.)

Culprit lesion-only PCI versus multivessel PCI for MI patients with cardiogenic shock (October 2017)

For patients with myocardial infarction (MI) and cardiogenic shock (CS), it has not been known whether to perform culprit lesion-only percutaneous coronary intervention (PCI) or multivessel PCI. The CULPRIT-SHOCK trial randomly assigned 706 patients with CS and either ST or non-ST elevation MI to PCI of the culprit lesion only (with the option of stage revascularization of nonculprit lesions) or immediate multivessel PCI [10]. The combined primary outcome of death or renal replacement therapy occurred less often in the culprit lesion-only group. Based on CULPRIT-SHOCK, we perform culprit-only PCI in these patients. (See "Prognosis and treatment of cardiogenic shock complicating acute myocardial infarction", section on 'PCI'.)

Targeting inflammation to reduce adverse cardiac events in patients with a recent ACS and elevated CRP (September 2017)

Inflammation is believed to be a central component in the pathogenesis of atherosclerosis. An elevated level of C-reactive protein (CRP), an inflammatory biomarker, is an independent predictor of adverse events from atherosclerosis, but no therapy specifically targeting inflammation has previously been shown to reduce atherosclerotic events. The CANTOS trial randomly assigned over 10,000 patients with a recent acute coronary syndrome and CRP ≥2 mg/L to receive placebo or one of three doses of canakinumab, a monoclonal antibody targeting interleukin-1 beta. At a median follow-up of over three years, canakinumab dosed at 150 or 300 mg subcutaneously every three months reduced the primary composite endpoint of cardiac death, nonfatal myocardial infarction, and nonfatal stroke, with no significant impact on lipid levels, but was associated with an increased risk of fatal infections [11]. This is the first study to show that an anti-inflammatory drug with no effect on lipid levels improves the outcome of patients with ACS and systemic evidence of inflammation. However, the role, if any, of anti-inflammatory therapy for patients following ACS remains to be determined. (See "C-reactive protein in cardiovascular disease", section on 'Monoclonal antibodies'.)

No benefit from supplemental oxygen in normoxemic AMI patients (September 2017)

The value of supplemental oxygen in normoxemic patients (oxygen saturation ≥90 percent) with suspected acute myocardial infarction (AMI) has been debated for years. In the DETO2X-AMI trial, over 6500 such patients were randomly assigned to receive supplemental oxygen (delivered through an open face mask) or ambient air [12]. There was no benefit or harm from supplemental oxygen. We do not treat normoxemic AMI patients with supplemental oxygen. (See "Overview of the acute management of ST-elevation myocardial infarction", section on 'Oxygen'.)

Timing of coronary angiography in patients with NSTEACS (August 2017)

Unlike patients with ST-elevation myocardial infarction who should undergo coronary angiography and revascularization within a few hours of symptom onset, the optimal timing of angiography in patients with non-ST elevation acute coronary syndromes (NSTEACS) is not known. A 2017 meta-analysis evaluated mortality in eight randomized trials that compared early to delayed invasive treatment [13]. There was no difference in mortality between the two strategies. However, subgroup analysis suggested benefit from early intervention in patients at high risk. We generally perform coronary angiography in most NSTEACS patients within 24 hours of presentation. (See "Coronary angiography and revascularization for unstable angina or non-ST elevation acute myocardial infarction", section on 'Timing'.)


Low dose rivaroxaban versus aspirin for secondary cardiovascular disease prevention (November 2017)

Rivaroxaban, an oral direct factor Xa inhibitor, has been evaluated for secondary prevention of cardiovascular disease (CVD). In a randomized trial, over 27,000 patients with stable CVD were assigned to a very low dose of rivaroxaban added to aspirin, rivaroxaban alone, or aspirin alone, with a mean follow-up of 23 months [14]. Compared with aspirin alone, rivaroxaban plus aspirin reduced cardiovascular mortality and ischemic stroke but not myocardial infarction. There were more major bleeding events in the rivaroxaban plus aspirin group, while the risk of intracranial hemorrhage was comparable with aspirin. The cardiovascular outcome was not different comparing rivaroxaban alone with aspirin alone, but there was more bleeding with rivaroxaban. Given the long clinical experience with aspirin, we generally prefer aspirin alone for patients with stable CVD. (See "Prevention of cardiovascular disease events in those with established disease or at high risk".)

Randomized trial of PCI in patients with stable single-vessel CAD (November 2017)

While percutaneous coronary intervention (PCI) with stenting has not been shown to improve survival in most patients with stable coronary artery disease (CAD), its ability to reduce anginal burden has been assumed for most subgroups. The ORBITA trial randomly assigned 230 patients with stable Canadian Cardiovascular Society class II and III angina and severe single-vessel stenosis (≥70 percent) to stenting or a placebo procedure, both performed after six weeks of optimized medical therapy that was continued through the trial [15]. The study was novel in that patients and caregivers were blinded to which treatment had been allocated. At six weeks postprocedure there was no difference in the primary end point of exercise duration nor in patient-reported angina symptoms, although there was a trend to improved exercise duration in the PCI group. Limitations of this trial (including small sample size, short time to follow-up, and patients with fewer comorbidities than seen in usual practice) raise questions about the applicability of these findings to clinical practice. (See "Stable ischemic heart disease: Indications for revascularization", section on 'Relief of angina'.)


Urgency of diuretic therapy in patients with acute heart failure (August 2017)

Only retrospective data have been available, until now, to evaluate the importance of time to initiation of diuretic therapy for management of acute heart failure. A multicenter, prospective observational study of 1291 patients with acute heart failure treated with intravenous furosemide within 24 hours of arrival in an emergency department found that treatment within one hour was associated with a lower in-hospital mortality than later treatment [16]. Thus, the expeditious initiation of an intravenous loop diuretic regimen may improve in-hospital outcomes, in addition to controlling symptoms of volume overload. (See "Treatment of acute decompensated heart failure: Components of therapy", section on 'Diuretics'.)

Vitamin D and all-cause mortality in patients with advanced heart failure (August 2017)

Some, but not all, observational studies suggest that low 25-hydroxyvitamin D levels (especially <10 to 20 ng/mL [25 to 50 nmol/L]) are associated with higher mortality. There are few randomized trials of vitamin D supplementation with mortality as a primary endpoint. In one such trial, vitamin D supplementation (4000 international units daily for three years) compared with placebo did not reduce overall mortality in patients with advanced heart failure and baseline vitamin D levels <30 ng/dL (75 nmol/L) [17]. (See "Vitamin D and extraskeletal health", section on 'Mortality'.)

Declining rate of sudden death in heart failure with reduced ejection fraction (July 2017)

Evidence-based medical therapy for heart failure with reduced ejection fraction (HFrEF) reduces both overall mortality rates and risk of sudden death. The trend in risk of sudden death was examined by an analysis of data from over 40,000 patients with HFrEF enrolled in 12 clinical trials of medical therapy with study periods spanning 1995 through 2014 [18]. There was a significant decline in the rate of sudden death across the trials. The cumulative incidence of sudden death at 90 days after trial randomization was 2.4 percent in the earliest trial and 1.0 percent in the most recent trial. (See "Prognosis of heart failure", section on 'Cause of death'.)


Anacetrapib, a CETP inhibitor, improves cardiovascular outcomes (September 2017)

Cholesteryl ester transfer protein (CETP) inhibitors raise high density lipoprotein cholesterol (HDL-C) and lower low density lipoprotein cholesterol (LDL-C). However, previous randomized clinical trials of four different CETP inhibitors, for the most part, have found no benefit and some potential harm. In the recent REVEAL trial, over 30,000 adults with atherosclerotic vascular disease who were receiving intensive statin therapy were randomly assigned to receive the CETP inhibitor anacetrapib once daily or placebo [19]. During a median follow-up of over four years, fewer cardiovascular events occurred in the treatment group and there was no evidence of serious adverse events with anacetrapib. Most of the benefit could be attributed to LDL-C lowering. Further investigation is required to determine the role of CETP inhibitors in the management of dyslipidemia. (See "HDL cholesterol: Clinical aspects of abnormal values", section on 'CETP inhibition'.)

Statin awareness and reported muscle-related adverse events (August 2017)

In clinical practice, side effects with statins are common, which could be related in part to a heightened awareness of adverse reactions traditionally attributed to the drugs. In a randomized double-blind, placebo-controlled trial involving over 10,000 patients, atorvastatin therapy did not increase the rate of muscle-related adverse events (AEs) [20]. By contrast, in the non-randomized, non-blinded extension of the study, muscle-related AEs were reported more often in patients taking atorvastatin compared with placebo. These results suggest that some muscle-related AEs attributed to atorvastatin are not causally linked to the drug. (See "Statins: Actions, side effects, and administration", section on 'Side effects'.)


Fulminant myocarditis associated with adverse outcomes (August 2017)

Fulminant myocarditis is defined as myocarditis with new onset severe heart failure requiring parenteral inotropic or mechanical circulatory support. Older reports have suggested that patients with fulminant myocarditis may have better outcomes than those with acute nonfulminant myocarditis. In contrast, a new study of 187 patients with acute myocarditis found that individuals with a fulminant presentation had lower rates of heart transplant-free survival both during their initial hospitalization and at nine years compared with patients with nonfulminant myocarditis [21]. The differences in study results are likely due to inclusion of milder cases in the later study as the diagnostic evaluation of acute myocarditis has evolved. (See "Treatment and prognosis of myocarditis in adults", section on 'Fulminant myocarditis'.)

Methamphetamine use and cardiomyopathy (June 2017)

Cardiovascular complications, particularly cardiomyopathy, are the leading causes of death among individuals using methamphetamine, yet there are few data on cardiomyopathy outcomes among methamphetamine users. In a study of 30 methamphetamine users with reduced left ventricular ejection fraction (LVEF) who were followed for a mean of nearly three years, cessation of use compared with continuing use was associated with better cardiac function and a trend toward reduced cardiac symptoms [22]. The extent of myocardial fibrosis was associated with the duration of methamphetamine use and may serve as a marker of irreversible ventricular changes. (See "Methamphetamine use disorder: Epidemiology, clinical manifestations, course, assessment, and diagnosis", section on 'Cardiovascular disease'.)


Risk factor differences for peripheral artery disease versus coronary heart disease (November 2017)

Risk factors for the development of peripheral artery disease (PAD) are generally similar to those that promote coronary heart disease (CHD). However, some differences were identified in the Scottish Heart Health Extended Cohort, which followed over 15,000 men and women (free of PAD or CHD) for up to 25 years [23]. For PAD, markers associated with inflammation and tobacco smoking predominated, while total cholesterol and body mass were less important. The highest ranked adjusted hazard ratios in PAD were age, high-sensitivity C-reactive protein, systolic blood pressure, expired carbon monoxide, cotinine, socioeconomic status, and lipoprotein(a). Diabetes mellitus was also an important risk factor but not the most common cause of PAD. The differences in risk factors for CHD versus PAD may indicate subtle differences in pathophysiology but do not warrant a change in clinical care. (See "Epidemiology, risk factors, and natural history of peripheral artery disease", section on 'Epidemiology and risk factors'.)

Enhanced MRI does not improve prediction of AAA outcomes (September 2017)

Progression of abdominal aortic aneurysm (AAA) is associated with infiltration of inflammatory cells into the wall of the aorta. Such inflammation can be identified by ultrasmall superparamagnetic particles of iron oxide (USPIO)-enhanced magnetic resonance imaging (MRI). In a multicenter study of 342 individuals with AAA ≥4 cm, USPIO uptake was present in 42.7 percent and was associated with increased rates of aneurysm expansion (3.1 versus 2.5 mm per year) and aneurysm rupture/repair (47.3 versus 35.6 percent) [24]. However, baseline AAA diameter and current smoking also predicted aneurysm rupture/repair, and the addition of USPIO uptake did not improve prediction of adverse AAA-related events over clinical features alone. (See "Epidemiology, risk factors, pathogenesis, and natural history of abdominal aortic aneurysm", section on 'Inflammation and the Th2 response'.)


Insufficient sleep and cardiometabolic risk (November 2017)

Short sleep duration has been associated with a variety of adverse cardiovascular outcomes in cross-sectional and small prospective studies. In the largest prospective study to date of over 160,000 healthy, nonobese adults, self-reported sleep duration <6 hours per day was associated with the development of multiple cardiometabolic risk factors over an 18-year follow-up period, including central obesity, elevated fasting glucose, hypertension, low high-density lipoprotein cholesterol, hypertriglyceridemia, and metabolic syndrome [25]. Increases in relative risk ranged from 6 to 12 percent for each individual factor. Healthy sleep behavior is recommended by the American Heart Association and others to promote optimal cardiac health. (See "Insufficient sleep: Definition, epidemiology, and adverse outcomes", section on 'Cardiovascular morbidity'.)


Exercise-based rehabilitation in heart transplant recipients (June 2017)

Most cardiac transplant recipients experience improvement in functional capacity post transplant compared with their preoperative condition, but exercise capacity generally remains below normal. The effect of exercise-based rehabilitation post cardiac transplantation was assessed by a systematic review of 10 randomized controlled trials with a total of 300 participants and median 12 weeks of follow-up [26]. Exercise-based rehabilitation improved exercise capacity compared with no exercise but had no effect on health-related quality of life (HRQoL). We continue to recommend exercise-based cardiac rehabilitation for cardiac transplant recipients, although further studies are needed to determine its long-term effects. (See "Rehabilitation after cardiac transplantation", section on 'Exercise capacity and rehabilitation post-transplantation'.)


Choice of mechanical or bioprosthetic surgical aortic or mitral valve (November 2017)

For patients undergoing surgical aortic or mitral valve replacement, the choice between a mechanical or bioprosthetic valve is based upon multiple factors related to valve durability, risk of thromboembolic and bleeding complications, and the risk of mortality following valve replacement. The largest long-term observational study of patients receiving contemporary surgical prosthetic valves included over 25,000 patients [27]. This study found that the impact of age on long-term survival rates for patients receiving prosthetic versus mechanical valves was different for aortic and mitral valve replacement. Among patients undergoing aortic valve replacement, the 15-year mortality rate was lower with a mechanical valve versus a bioprosthetic valve for patients less than 54 years old but not for older patients. Among patients undergoing mitral valve replacement, the 15-year mortality rate was lower with a mechanical valve for patients less than 69 years old but not for older patients. Given these findings, we now include age <55 years old as a factor favoring a mechanical rather than bioprosthetic aortic valve and include age <70 years old as a factor favoring a mechanical rather than bioprosthetic mitral valve. (See "Choice of prosthetic heart valve for surgical aortic or mitral valve replacement", section on 'Late mortality rates'.)

An investigational transcatheter mitral valve repair system (September 2017)

Many patients with severe mitral regurgitation do not meet anatomic criteria for transcatheter mitral valve repair with the widely available MitraClip device. The investigational PASCAL transcatheter mitral valve repair system was developed to reduce the anatomical requirements for transcatheter valve repair. The feasibility of PASCAL mitral valve repair was evaluated in 23 patients with symptomatic severe mitral regurgitation, most of whom were not candidates for MitraClip repair [28]. Among the 20 patients alive at 30 days of follow-up, nearly all had improved functional status. (See "Transcatheter mitral valve repair", section on 'Investigational technologies'.)

Global variation in prevalence of rheumatic heart disease (August 2017)

The Global Burden of Disease study estimated that there were 33.4 million cases of rheumatic heart disease worldwide in 2015 [29]. The prevalence varied widely among countries from near zero in developed countries to over 1 percent in developing countries in Oceania, central sub-Saharan Africa, and South Asia. While the global mortality burden of rheumatic heart disease has decreased from 1990 to 2015, significant rates of disease persist in some lesser developed regions. (See "Natural history, screening, and management of rheumatic heart disease", section on 'Epidemiology'.)


Acetylcysteine does not prevent contrast nephropathy (November 2017)

Radiocontrast media may cause acute kidney injury (AKI) among high-risk patients. Earlier studies have been inconsistent but indicated that the administration of oral acetylcysteine may decrease the risk of AKI, and led to our previous suggestion to administer acetylcysteine before and the day of angiography to patients at risk of contrast nephropathy. A recent randomized trial in over 5000 patients at increased risk for nephropathy who were undergoing scheduled angiography found that oral acetylcysteine, compared with placebo, did not prevent death, need for dialysis, or decline in kidney function [30]. The trial was a 2 by 2 factorial design and also compared intravenous sodium bicarbonate with isotonic saline, finding no benefit for sodium bicarbonate. UpToDate recommends giving isotonic saline rather than sodium bicarbonate and now suggests not giving acetylcysteine prior to angiography. (See "Prevention of contrast nephropathy associated with angiography", section on 'Acetylcysteine'.)

Patent foramen ovale (PFO) device closure for prevention of recurrent ischemic stroke (October 2017)

Treatment for patients with a cryptogenic stroke who have a patent foramen ovale (PFO) has been controversial. In earlier randomized controlled trials, point estimates suggested that percutaneous device closure of a PFO in patients ≤60 years of age was more effective than antiplatelet therapy for reducing recurrent stroke, but the findings did not reach statistical significance. However, the results of three recent randomized trials, RESPECT extended follow-up [31], REDUCE [32], and CLOSE [33], provide stronger evidence that device closure of a PFO plus antiplatelet therapy is more effective than antiplatelet therapy alone for preventing recurrent ischemic stroke in such patients, with absolute risk reductions ranging from 2.2 to 6 percent. Based upon these results, we now suggest percutaneous PFO closure in addition to antiplatelet therapy for patients who meet all of the following criteria: age ≤60 years, embolic-appearing cryptogenic ischemic stroke (ie, no evident source of stroke despite a comprehensive evaluation), and a PFO with a right-to-left interatrial shunt detected by bubble study. (See "Treatment of atrial septal abnormalities (PFO, ASD, and ASA) for prevention of stroke in adults", section on 'Percutaneous closure of PFO'.)

Updated guidelines for management of coronary artery abnormalities in Kawasaki disease (September 2017)

The American Heart Association (AHA) updated its guidelines for management of Kawasaki disease (KD) [34]. New recommendations for evaluating and managing coronary artery abnormalities (CAAs) include an updated risk stratification schema based on CAA size (table 1), which is used to guide antithrombotic therapy (algorithm 1) and long-term follow-up. The guidelines panel concluded that patients with KD and no history of CAAs are probably not at increased risk for cardiovascular disease compared with the general pediatric population and can be managed with routine preventive counseling alone. Our recommendations for management of cardiovascular sequelae of KD are generally consistent with the 2017 AHA guidelines. (See "Cardiovascular sequelae of Kawasaki disease: Management and prognosis", section on 'Management'.)

High sensitivity cardiac troponin test results in the general population (August 2017)

The blood test for cardiac troponin (cTn) is used most commonly to evaluate patients who may have acute myocardial infarction. With the development of increasingly sensitive troponin tests, it has become clear that many presumably healthy individuals in the general population have an elevated cTn level. The best available data on the prevalence of elevated troponin in the general population and the impact on prognosis comes from a large 2017 observational study [35]. High-sensitivity cTn was detectable in 80 percent of individuals, and the relative risks of major adverse cardiovascular outcomes were significantly increased in a comparison of patients in the top and bottom tertiles for troponin level. However, we do not interpret these findings as evidence in support of screening healthy individuals. (See "Elevated cardiac troponin concentration in the absence of an acute coronary syndrome", section on 'Prognosis'.)

Confirmatory data on idarucizumab for dabigatran reversal (July 2017)

Idarucizumab (pronounced "I-dare-you-cizumab") is a monoclonal antibody fragment against dabigatran that can reverse the anticoagulant effect within minutes. A preliminary report suggested good efficacy in patients with dabigatran-associated bleeding or those undergoing emergency surgery. In a new report of over 500 patients treated with idarucizumab, most had cessation of bleeding or underwent surgery without abnormal bleeding [36]. We continue to suggest idarucizumab for clinically significant bleeding or emergency surgery in patients on dabigatran with a history or laboratory testing that suggest they are actively anticoagulated. (See "Management of bleeding in patients receiving direct oral anticoagulants", section on 'Dabigatran reversal'.)

Radiation for nonmetastastic breast cancer and cardiovascular risk (June 2017)

Many women treated for nonmetastatic breast cancer receive radiation therapy after surgical resection. In a meta-analysis of 39 studies involving almost 1.2 million patients with breast cancer, the risk of coronary artery disease and cardiac death was somewhat increased (relative risk 1.3 and 1.38, respectively) for those who received radiotherapy relative to those who did not [37]. However, absolute risks for these complications were low (76 and 126 cases, respectively, per 100,000 person-years). For appropriately selected patients, adjuvant radiation remains a safe and effective treatment for nonmetastatic breast cancer. (See "Cardiotoxicity of radiation therapy for breast cancer and other malignancies", section on 'Meta-analyses and randomized trials'.)

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