![\"\"](\"https:\/\/blogs.bmj.com\/bmj\/files\/2018\/09\/alex_nowbar.jpg\")
<\/a>\nJAMA<\/b><\/p>\n
Atrial Fibrillation ablation and outcomes<\/u><\/p>\n
The CABANA trial looked at whether ablation for atrial fibrillation reduces mortality compared <\/span>with<\/span> drug therapy. It didn\u2019t. In two simultaneous<\/a> reports on the trial<\/a>, which randomised over 2000 patients, ablation improved quality of life (using <\/span>quality of life scores<\/span> <\/span>specific <\/span>for <\/span>atrial fibrillation<\/span>) and reduced cardiovascular hospitalisations. But with these two outcomes comes the warni<\/span>ng that the trial was unblinded. Staff and patients kne<\/span>w what intervention the patients had<\/span>,<\/span> and this has an undeniable impact. The absence of blinding skews those outcomes<\/span>,<\/span> and thus the true effect of ablation on those outcomes has not been measured. The le<\/span>sson is that interventional trials, like drug trials, requ<\/span>ire placebo control with double <\/span>blinding.<\/span><\/p>\n Lancet<\/b><\/p>\n 3D fetal hearts<\/u><\/p>\n Thes<\/span>e researchers developed an open <\/span><\/a>source, motion<\/span> <\/span>correction technique for imaging the fetal cardiovas<\/span>cular system with <\/span>magnetic resonance imaging (<\/span>MRI<\/span>)<\/span> and assessed it in 85 cases. It is intended for use <\/span>in <\/span>pregnancies <\/span>with a fetus with known or suspected congenital heart disease. The researchers found it was reliable (using <\/span>echocardiography <\/span>as the standard)<\/span>,<\/span> and the visual and diagnostic qua<\/span>lity were better than the <\/span>two dimensional, <\/span>uncorrected MRI. In particular, the vascular structures could be seen better<\/span>,<\/span> and in 10 cases<\/span> the new technique identified anatomical features that weren\u2019t previously known about. This could provide <\/span>useful <\/span>information <\/span>in preparation<\/span> for the birth and postnatal care.<\/span><\/p>\n NEJM<\/b><\/p>\n Antithrombotic regimens for patients with atrial fibrillation<\/u><\/p>\n For treatment of cardiovascular disease, the base <\/span>drug <\/span>is usually aspirin. For acute coronary syndrome <\/span>or stenting<\/span>,<\/span> this usually gets topped up with clopidogrel<\/span>,<\/span> ticagrelor, or<\/span>,<\/span> less commonly, prasugrel. But <\/span>if <\/span>the patient has atrial fibrillation, <\/span>they <\/span>will <\/span>also need anticoagulation. Should they be <\/span>given <\/span>warfarin or the <\/span>\u201c<\/span>xabans<\/span>\u201d<\/span>? Dual or triple therapy? The AUGUSTUS trial elegantly<\/a> used 2<\/span>\u00d7<\/span>2 factorial design to address both questions. Over 4000 patients were<\/span> randomised to apixaban or a vitamin<\/span> <\/span>K antagonist (which was open <\/span>label) and <\/span>to either aspirin or ma<\/span>tched placebo (which was double <\/span>blinded). And they all received a P2Y12 inhibitor such as clopidogrel. The strategy with the best outcomes was a P2Y12 <\/span>inhibitor and apixaban without aspirin. <\/span><\/p>\n Angiography for arrests<\/u><\/p>\n Percutaneous coronary intervention for STEMI is one of the few medical interventions nearing parachutism (a parachute being a metaphor for a treatment without which the chance of death is near 100%). No one honestly thinks PCI will be that critical for any other condition but, of course, it can still be a good treatment. Since ischaemic heart disease is the commonest cause of cardiac arrest, Lemkes et al investigated<\/a> whether immediate versus delayed angiography for patients with an out-of-hospital cardiac arrest with an initial shockable rhythm. They randomised 552 patients to either immediate angiography (with PCI if needed) or angiography delayed until neurologic recovery. There was no statistically significant difference in mortality at 90 days between groups, nor in any of the other endpoints other than it taking longer for the immediate angiography patients to reach target temperature. Over a third of patients had no clinically significant coronary disease. \u00a0<\/span><\/p>\n Cardioversion for recent-onset symptomatic atrial fibrillation<\/u><\/p>\n Pluymaekers et al randomised 437 patients<\/a> to early or delayed cardioversion in a non-inferiority trial. The delayed approach was non-inferior for restoration of sinus rhythm. This is a really useful practical result for the medical community. Spontaneous conversion was common and if it happens then electrical cardioversion will have been avoided which is preferably. This study allays fears that not cardioverting early on and thus remaining longer in atrial fibrillation might be bad because electrical cardioversion might be less effective at restoring sinus rhythm at this later stage. It was just as effective at the later stage in terms of the proportion of patients achieving sinus rhythm. The authors also explain that the theoretical risk of stroke in the period of delay to cardioversion is probably mitigated by the use of anticoagulant therapy.<\/span><\/p>\n A new era for aortic stenosis <\/u><\/p>\n Surgical aortic valve replacement has been trumped by transcatheter valve replacement for low-risk patients in the PARTNER-3 trial and the Evolut Low Risk Trial.\u00a0<\/span><\/p>\n PARTNER-3 looked at the balloon-expandable valve<\/a>. In this non-inferiority randomised trial of 1000 patients, the headline finding was the much lower rate of death, stroke, or rehospitalisation (which together formed the primary endpoint) in the transcatheter group. The transcatheter group also had less atrial fibrillation and shorter stays. Follow-up was for a year which is reasonable for a mortality assessment but patients will also be interested in the longevity of their new valve.<\/span><\/p>\n The Evolut Low Risk trial<\/a> looked at the self-expanding valve. The primary endpoint was death or disabling stroke. Again, it was non-inferior to surgical valve replacement. In the context of being able to avoid these major outcomes through the transcatheter approach, the outcome of being more likely to have a pacemaker implanted (as was shown for the self-expanding valve) does not seem hugely problematic but will be relevant to patients.<\/span><\/p>\n BMJ<\/b><\/p>\n Game of Troponins<\/u><\/p>\n For this study<\/a>, a Southampton-based team of researchers got ethical approval to test the blood of 20,000 patients without their consent. The blood had been taken from patients for biochemistry testing for a clinical reason (for a minority this was chest pain). The researchers put these samples through their troponin assay to work out the \u201ctrue\u201d normal range of troponins in patients (as opposed to the healthy people used by the assay manufacturer).<\/span><\/p>\n They found that the 99<\/span>th<\/span> centile of troponin level of the cohort of 20,000 was several times higher than that reported by the manufacturer for 300 healthy men and 300 healthy women. Well, it was a different population, a population selected for the unique bundle of things that made people in the summer of 2017 get into different hospital areas and end up with a blood test. They repeated their analysis after excluding actual myocardial infarctions. But the amount of and reliability of the data on what else was going on with these patients was limited by the observational methodology which is a shame.<\/span><\/p>\n If centiles aren\u2019t your preferred concept, their results also showed that 5% of people with the unique bundle of things had a higher troponin level than 99% of the healthy people the manufacturer will have tested. It would have been weird if only 1% of their cohort had a higher troponin level than 99% of healthy people because then they would have matched the group of healthy people. But sometimes it\u2019s good for research to confirm obvious things, i.e. don\u2019t use a troponin in isolation to diagnose myocardial infarction. <\/span><\/p>\n Risk of miscarriage<\/u><\/p>\n