Key Points

• Cardiovascular risk mitigation strategies such as the recommendation to engage in a more active lifestyle are common in primary care and cardiovascular clinics, yet more nuanced data gauging the association between lifelong endurance exercise and coronary atherosclerosis is lacking
• In this study, investigators examined the association between lifelong endurance exercise with the incidence of coronary plaque as compared to late-onset endurance exercise and a non-athletic lifestyle
• The study showed that lifelong endurance sport participation was not associated with a more favorable coronary plaque composition; however, this group was found to have less vulnerable plaque as assessed by coronary computed tomography

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Key Points

• Appropriate lipid management is of critical importance in preventing further cardiac events in patients with atherosclerotic cardiovascular disease, yet different approaches exist to achieving lipid control
• In this study, investigators sought to assess whether a treat-to-target LDL strategy is noninferior to a strategy of high-intensity statins for long-term clinical outcomes in patients with coronary artery disease
• A targeted approach to reducing LDL-C was noninferior to the high-intensity statin strategy in terms of a 3-year composite outcome of all-cause death, myocardial infarction, stroke, or any coronary revascularization.

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Key Points:
 The prognostic significance of the V122I variant (associated with wt-ATTR) in Black women has not yet been established.
 A substudy of the WHI aimed to establish the association of the V122I variant with a composite of CVD and all-cause mortality in Black Women.
 The V122I variant was associated with increased composite CVD and all-cause mortality in Black women; this association was particularly significant for women age 60+.

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Key Points:

• Two-year results showed improved outcomes with the MitraClip device but long-term results had not been reported; TEER was allowed in the control arm only after the 2-year primary endpoint assessment.
• At 5 years, the annual rate of hospitalization for HF was 33.1%/year in the device group and 57.2%/year in the control group (HR 0.53; 95% CI 0.41-0.68).
• All- cause mortality through 5 years was lower at 57.3% in the device group and 67.2% in the control group (HR 0.72; 95% CI 0.58-0.89). MitraClip was safe and led to a lower rate of hospitalization for HF and lower all-cause mortality through 5 years of follow-up as compared with medical therapy alone.

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Key Points:

– Pulsed field ablation (PFA) is a novel ablation technology which utilizes electrical pulses to deliver irreversible electroporation and induce thermal cardiac cell death and has shown high cardiac tissue selectivity and safety in preclinical data.

-Over 1 year of follow-up, treatment with PFA to achieve pulmonary vein isolation, achieved freedom from atrial arrhythmias in up to two-thirds of patients.

-Pulse field ablation appears to have an excellent safety profile with only one adverse event occurring in each of the two patient cohorts, for an adverse event rate of 0.7%.

-Patients with both paroxysmal and persistent AF had significant and meaningful improvements in quality of life following their index ablation.

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Key Points

• Evidence-based therapies that reduce cardiovascular risk remain underused among individuals with type 2 diabetes and cardiovascular disease
• The COORDINATE-Diabetes cluster-randomized clinical trial included 43 cardiology clinics treating individuals with type 2 diabetes and atherosclerotic cardiovascular disease and randomized them to a multifaceted intervention of assessment, education, and feedback or usual care. The primary outcome was the proportion of participants who were prescribed all three recommended groups of preventative medications (high-intensity statins, ACEIs or ARBs, and SGLT2 inhibitors and/or GLP-1RAs) at the last follow-up visit (either 6-month or 12-month).
• The coordinated, multifaceted intervention increased the prescription of all three therapies as compared to usual care (37.9% vs 14.5%, respectively) in individuals with T2D and atherosclerotic cardiovascular disease

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Key Points

• Cardiac device monitoring is a repetitive, long term activity that can be resource intensive.
• The Global Cardiovascular Carbon Footprint (GCCF) project sought to evaluate the extent to which remote cardiac device monitoring can reduce greenhouse gas emissions.
• Compared to in-person visits, remote monitoring resulted in a net reduction of nearly 12600 metric tons of CO2 among 67 sites over 2 years, the equivalent of 2 million gallons of gasoline or nearly 15,000 acres of forest land saved.

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Key Points:

• There have been limited data regarding the biomarkers that may predict the development and severity of preeclampsia.
• hs-cTnI was significantly elevated in pregnant women who would later develop preeclampsia starting at 14 weeks. A cutoff hs-cTnI value of >2.2pg/ml at 14 weeks and >2.6pg/ml at 26 weeks had a combined 100% negative predictive value for predicting severe preeclampsia in women at high a prior risk.

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Key Points

• While transcatheter edge-to-edge repair (TEER) is FDA approved for treatment of degenerative mitral regurgitation (MR) in patients at high surgical risk, outcomes in this population are not well described.
• This study used registry data to report clinical endpoints including mortality and procedure success over time for patients undergoing TEER for degenerative MR in the United States.
• The safety profile of MitraClip for degenerative MR was excellent despite advanced age (82 years) and significant comorbidities Succesful repair was achieved in 89% of the patients.

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Key Points:

• Pharmaco-invasive (PI) strategy with half-dose tenecteplase (TNK) is compared to routine primary percutaneous coronary intervention (pPCI) in STEMI patients over 60 years of age who presented within 3 hours and unable to undergo pPCI within 1 hour.
• Primary efficacy endpoints were the percentage of patients with ≥ 50% ST-segment resolution after TNK and before and after PCI, the need for rescue PCI, and the combined clinical endpoint of death, cardiogenic shock, re-infarction, and heart failure at 30 days.
• Composite outcome at 30 days (death, heart failure, MI, shock), for pharmaco-invasive therapy vs. primary PCI, was: 12.8% vs. 13.3% (relative risk 0.96, 95% confidence interval 0.62-1.48)
• The findings of the study suggest that using a pharmaco-invasive strategy with half-dose tenecteplase (TNK) is both secure and efficient in contrast to primary percutaneous coronary intervention (PCI) in older individuals with ST-segment elevation myocardial infarction (STEMI) who could not obtain timely primary PCI within an hour.

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Key Points

• Despite the proven benefits of annual influenza (flu) vaccination among patients with cardiovascular disease (CVD), uptake remains suboptimal.
• The NUDGE-FLU implementation trial randomized all Danish citizens ages 65 and older with access to the official Danish electronic letter system to usual care (no letter) or one of 9 active arms utilizing electronic letters (E-letter) with a different nudging strategy for flu vaccination. One of the nudges specifically mentioned the potential cardio benefits of the vaccine. The primary endpoint was receipt of the flu vaccine.
• Electronically delivered letters highlighting potential cardiovascular benefits of influenza vaccination or sent again as a reminder significantly increased vaccination uptake across Denmark, and they especially effective in those who had not been vaccinated the previous season.
• This is likely one of the largest randomized implementation trials in history; while the magnitude of effect was not very large, this study demonstrated that an automated, inexpensive and scalable intervention can help make modest but real gains in public health.

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Key Points

• Over half of the patients with HFpEF suffer from exercise intolerance, which may be often due to inability to augment heart rate (HR). As such, rate-adaptive atrial pacing may offer an innovative approach to improve their quality of life.

• In the single center RAPID-HF trial, 29 patients with HFpEF received a transvenous pacemaker and were randomized to to atrial rate responsive pacing or no pacing first for 4 weeks, followed by a 4-week washout period and then crossover for an additional 4 weeks.

• Despite a statistically and clinically significant increase in mean HR during exercise between the pacer-on phase or a pacer-off phase, there was no statistically significant improvement in the primary outcome of the trial, oxygen consumption (VO₂) at the anaerobic threshold, nor in any of the secondary endpoints. As such, the RAPID-HF trial does not support the use of rate-adaptive atrial pacing to treat patients with HFpEF and chronotropic incompetence

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Key Points

• Despite guideline recommendations, both statin use overall and high intensity statin (HIS) use specifically remains low in patients with established atherosclerotic cardiovascular disease (ASCVD). Both therapeutic inertia (TI) and concerns for statin associated side effects (SASE) have been identified as contributors to under-prescribing.
• In this cluster randomized controlled trial performed in the Department of Veterans Affairs (VA), clinicians at the intervention sites received individualized electronic reminders created using natural language processing (NLP) and structured chart data that included information on the patient’s statin use, SASE, ASCVD history, and statin fill history.  Those in the control sites,  usual care, had access to a patient dashboard displaying compliance with statin therapy..
• Centrally processed individualized statin specific reminders, when compared to usual care, lead to a modest yet statistically significant increase in HIS use and statin adherence in VA patients with ASCVD.

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Key Points

• Cost related medication non-adherence is a common problem among patients with cardiovascular disease and is associated with poor clinical outcomes. Whether eliminating co-payments for a large number of medications meant to treat a broad set of chronic diseases would translate into improved clinical outcomes is unknown.
• ACCESS was a randomized controlled trial in Canada in which the copayment of 15 medication classes commonly used to reduce cardiovascular events was waived in the intervention group and the cost was unchanged in the control group.
• Copayment elimination did not reduced the primary composite outcome of death, myocardial infarction, stroke, coronary revascularization, or cardiovascular-related hospitalization over 3 years of follow up.  Adherence to statins was significantly higher in the intervention group.

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Key Points:

• Polygenic scores (PGS) give insights into a patient’s inherited risk for coronary artery disease (CAD) but it is unclear how this information should inform clinical care.
• Participants in this study had their lifetime risk of major coronary events (MCS) estimated by a PGS and were then divided into deciles based on that risk. A causal AI algorithm that integrated data from Mendelian randomization studies as well as randomized trials was used to estimate the reduction in LDL or systolic blood pressure (SBP) needed in each decile to reduce their risk to that of the participants with the average PGS.  These estimated were then validated against the observed events in each group.
• This study found that most patients could overcome their polygenic risk for CAD with small lifetime reductions in LDL and systolic blood pressure (SBP), however the later in life that therapy is initiated, the more that lipids and blood pressure needed to be lowered to achieve the same effect.

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Key points :

1. Mitral valve surgery via sternotomy is associated with significant disadvantages, including an increased risk of bleeding, difficult valve access due to the incision’s location, and a 2-3% risk of wound infections that can result in significant morbidity and mortality.

2. Recovery from sternotomy can take up to 3 months, during which patients must significantly limit their activity to reduce the risk of complications, which can prolong recovery and limit their ability to return to usual activities.

3. Minimally invasive approaches to mitral valve surgery have been shown to be safe and effective, with lower rates of morbidity and mortality than conventional sternotomy, including in high-risk patients such as the elderly.

4. Emerging evidence suggests that minimally invasive surgery may be less costly than conventional sternotomy, with cost savings driven by reduced hospital stay and the need for blood transfusion. The UK Mini Mitral trial aims to assess whether minimally invasive surgery is associated with improvements in physical functioning, a return to usual activities, and cost-effectiveness compared to conventional surgery.

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Key Points

• Many patients with heart failure with reduced ejection fraction (HFrEF) are not on optimal guideline directed medical therapy (GDMT), especially mineralocorticoid receptor antagonists (MRAs), despite their strong evidence base in improving clinical outcomes. GDMT under-prescribing is a cause of potentially preventable morbidity and mortality.
• It is unknown whether electronic clinical decision support (CDS) is able to improve MRA prescribing, and if so, what type of CDS is most effective.
• This was a pragmatic, cluster-randomized trial trial that included HFrEF patients, no active prescription of MRA, and an outpatient cardiologist in a large health system. Patients were cluster-randomized by cardiologist (60 per arm) into: automated EHR alerts  automated EHR message and usual care.
• Patients randomized to the intra-visit BPA arm resulted in a significantly higher MRA prescription rate as compared to the monthly message or usual care.
• An automated, patient specific, visit based alert in the electronic medical record can increase appropriate GDMT prescription for HFrEF patients.

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Key Points

• Both transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) procedures offer options for intervention in patients with aortic stenosis
• High-surgical risk has guided the use of a transcatheter approach, but data on its application in patients at low-surgical risk remains an area to be fully explored
• An update to the outcomes at 3-year follow up of the Evolut Low Risk Trial provide reassurance that TAVR is as safe as SAVR with respect to all-cause mortality or disabling stroke in low surgical risk patients

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Key Points:

• There have been limited data examining the safety and efficacy of transcatheter tricuspid repair systems.
• In the TRILUMINATE study, Tri-Clip was compared against medical therapy in patients with severe symptomatic TR.
• Tri-Clip implantation reduced severity of TR and improved quality of life. Tri-Clip was safe and resulted in only a 1.7% rate of major adverse events.

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Key Points:

• Mortality in high-risk PE remains unacceptably high (25%) despite advances in medical and interventional therapies.
• The FLAME study was a prospective, multi-center non-randomized observational study to describe the outcomes of patients undergoing mechanical thrombectomy and other modern therapies and generate evidence in high-risk PE. The primary outcome was a composite of all-cause mortality, bailout to alternate thrombus removal strategy, clinical deterioration, and major bleeding.
• Compared with a pre-established performance goal of 32%, patients treated with Flowtriever had a significant reduction in the primary endpoint. There was also significant reduction in in-hospital mortality (1.9% compared to 28.5%). There was no increase in adverse events in the FlowTriever group.
• Randomized evidence will be required to follow-up this observational study, but FlowTriever appears to be a safe, effective treatment which may reduce mortality in high-risk PE.

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