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The use of beta-blockers after an episode of myocardial infarction is well-established in clinical practice in the last few decades.

However, most trials that have shown a benefit of beta-blocker treatment after myocardial infarction included patients with large myocardial infarctions and were conducted in an era before modern biomarker-based diagnosis of myocardial infarction and treatment with percutaneous coronary intervention. Also, antithrombotic agents and high-potency statins have managed to significantly improve the prognosis of coronary artery disease patients.

In a recent trial, which included more than 5000 patients, it is demonstrated that if systolic function is maintained after an episode of myocardial infarction the use of beta blockers may be reconsidered.

Specifically, in those with acute myocardial infarction who underwent early coronary angiography and had a preserved left ventricular ejection fraction (≥50%), long-term beta-blocker treatment did not show any comparative therapeutic benefit opposed to the group of patients who did not received beta- blockers.

Reference:
The New England Journal of Medicine
Beta-Blockers after Myocardial Infarction and Preserved Ejection Fraction
N. Engl. J. Med 2024 Apr 07


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Iron replacement therapy in patients with heart failure.

Most patients with heart failure and anemia demonstrate iron deficiency, which is often accompanied by anemia. Iron deficiency is generally defined as having a serum ferritin level <100 µg/L or, provided that ferritin level was >300 µg/L, a transferrin saturation (TSAT) <20%.

The IRONMAN randomized trial showed that, overall, for patients with heart failure who fulfilled the above definition of iron deficiency, IV iron increased hemoglobin levels, improved quality of life, and reduced the rates of hospitalization for heart failure but did not improve walking distance or reduce mortality.

According to a recent publication, the clinical response appears even greater in certain individuals with anemia with TSAT < 20% and ferritin > 100 µg/L.

This might identify a specific group of heart failure patients, who may obtain a significant benefit from intravenous iron.

Reference:
European Heart Journal
Intravenous iron for heart failure, iron deficiency definitions, and clinical response: the IRONMAN trial
Eur Heart J 2024 Mar 06


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Treatment of Severe Symptomatic Aortic Valve Stenosis Using Noninvasive Ultrasound Therapy

Calcific aortic stenosis is commonly treated using surgical or transcatheter aortic valve replacement.

However, many patients are not considered suitable candidates for these interventions due to severe comorbidities.

A recently published study aimed to assess the safety of non-invasive ultrasound therapy and its ability to improve valvular function by softening calcified valve tissue. This prospective, multicentre, single-arm series enrolled 40 adult patients with severe symptomatic aortic valve stenosis at three hospitals in France, the Netherlands, and Serbia between March 13, 2019, and May 8, 2022.

Improved valve function was confirmed up to 6 months, reflected by a 10% increase in mean aortic valve area and a 7% decrease in mean pressure gradient. At 6 months, the New York Heart Association score had improved or stabilised in 24 (96%) of 25 patients, and the mean Kansas City Cardiomyopathy Questionnaire score had improved by 33%.

It is interesting to see if his revolutionary therapeutic approach manages in the near future to be established in daily clinical practice. Until then further research need to be done, in order to confirm its safety and efficacy.

Reference:
The Lancet
Treatment of severe symptomatic aortic valve stenosis using non-invasive ultrasound therapy: a cohort
study
Lancet 2023 Dec 16;402(10419)2317-2325, E Messas, A Ijsselmuiden, D Trifunović-Zamaklar, B Cholley, E
Puymirat, J Halim, R Karan, M van Gameren, D Terzić, V Milićević, M Tanter, M Pernot, G Goudot


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The use of coronary artery calcium (CAC) as predictor of cardiovascular events

Coronary artery calcium (CAC) can be quickly quantified on a computed tomography (CT) and enables screening for subclinical atherosclerosis.

In a recent study it is demonstrated that among 5678 asymptomatic adults, 52% had a calcium score above zero. Those with CAC above 100 are estimated to have a 10 year-risk for acute cardiovascular events of about 24%.

Individuals with an increased CAC should be addressed with aggressive management of all cardiovascular risk factors. Statins should be initiated, as they have been documented to stabilize atheromatous plaques and reduce the progression of the disease.

It is interesting that in the study, only 26% of those with an increased CAC (above 100) were on statins.

Lifestyle modification, including smoking cessation, daily physical activity and nutrition optimization are also fundamental in the management of subclinical atherosclerosis.

Reference:
Journal of the American College of Cardiology
Association of Coronary Artery Calcium Detected by Routine Ungated CT Imaging With Cardiovascular
Outcomes J Am Coll Cardiol 2023 Sep 19;82(12)1192-1202, AW Peng, R Dudum, SS Jain, DJ Maron, BN Patel, N Khandwala, D Eng, AS Chaudhari, AT Sandhu, F Rodriguez


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Severe aortic stenosis is a quite common clinical condition, particularly among individuals older than 70 years. It is usually accompanied by symptoms such as chest pain, easy fatigue, dyspnea and fainting attacks. However due to the timing of clinical presentation, symptoms are often attributed to other co-morbidities or simply the age of patient.

Physical examination is sometimes misleading in guiding diagnostic thinking, since the most expected physical findings are not always present. Diagnosis is easily made with echocardiography, a simple, convenient and non-invasive diagnostic procedure. With the use of ultrasound the physician is able to accurately determine the severity of aortic valve stenosis and also evaluate the function of other valves and the contractility of the heart. This echocardiographic evaluation is of paramount importance for the final decision regarding any therapeutic intervention.

Several medications have been used in order to regress or even delay the worsening of this condition, but none was found to be successful. The only way to manage this form of valvulopathy is surgical replacement of the pathologic valve. Each patient needs to be evaluated thoroughly in order to assess the surgical risk and the expected benefit from such intervention.

In general, a patient should be referred for surgery when the severity of aortic valve stenosis is documented (aortic valve area < 1cm2) and also when symptoms are present. For patients who are considered to be at high risk for a traditional surgical operation there is now the option of a transcutaneous procedure (TAVI).

After a successful replacement of the aortic valve the patient will be able to resume back to the normal daily activities without any restrictions, and most importantly without symptoms.


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Catheter ablation of atrial fibrillation is an invasive therapeutic option for individuals with AF. It was first introduced in the late 1980s and has now emerged as a quite common procedure in many hospitals. Accumulated clinical experience as well as data from several prospective randomized trials confirm that catheter ablation of AF is superior to antiarrhythmic drug therapy in controlling AF.

AF ablation is suggested to be particularly beneficial for patients with the paroxysmal form of AF without other severe comorbidities. Catheter ablation is indicated for treatment of patients with symptomatic AF in whom one or more attempts with antiarrhythmic drug (class I or III) therapy have failed.

In the recent guidelines for management of AF, catheter ablation is reasonable to be implemented as a first-line therapy in selected patients; however it is more practical in clinical practice to initiate a non-invasive pharmaceutical intervention first.

This procedure has made a remarkable progress in the last years mostly due to novel technological improvements and packed clinical experience and skills. Finally it should be noted that catheter ablation is very rarely associated with potentially life-threatening complications, such as an atriooesophageal fistula, stroke, and cardiac tamponade.



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Είναι αδύνατο να ξέρει την ιατρική, αυτός που δεν ξέρει ακριβώς τι είναι ο άνθρωπος. ΙΠΠΟΚΡΑΤΗΣ




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It is impossible for one to know medicine if he doesn’t know what a human being is. HIPPOCRATES






Copyright by Dr Yiannis Panayiotides 2018. All rights reserved.



Copyright by Dr Yiannis Panayiotides 2018. All rights reserved.