The edition · Cardiology
Anticoagulation after TAVI halved leaflet thrombosis without costing safety
ACASA-TAVI found NOAC monotherapy cut hypoattenuated leaflet thickening from 28.6% to 16.2% and was non-inferior for bleeding and death, four doses of dapagliflozin around cardiac surgery nearly halved acute kidney injury, and evolocumab started in the cath lab hit every lipid target while changing no outcome at a year.
The edition in brief
Three randomised trials worth acting on, and one worth not acting on. ACASA-TAVI randomised 360 patients aged 65-80 after transcatheter aortic valve implantation to twelve months of NOAC or aspirin monotherapy. Leaflet thrombosis on blinded core-lab CT at twelve months occurred in 16.2% on NOAC against 28.6% on aspirin (risk ratio 0.55, 95% CI 0.37-0.82). The safety composite of bleeding, thromboembolism and death was 7.5% against 10.6%, meeting non-inferiority. This is a subclinical imaging endpoint, not a clinical one, but it is the first randomised signal that anticoagulation after TAVI protects the valve without a bleeding penalty in this age group. In 784 patients undergoing elective cardiac surgery, four doses of dapagliflozin starting the day before operation reduced acute kidney injury over seven days from 52% to 28% (relative risk 0.54, 95% CI 0.45-0.65). Atrial fibrillation and reoperation rates were identical. For a complication with no established prophylaxis, an effect this large from four tablets deserves attention. AMUNDSEN is the cautionary one. Evolocumab given before percutaneous coronary intervention in 2,161 patients with high-risk myocardial infarction got 82% to the LDL target against 40% with standard care, with median LDL of 16 mg/dL at six weeks. All-cause death or unplanned cardiovascular hospitalisation at one year was 14.6% against 15.4% (odds ratio 0.94). Reaching the number faster did not help within a year. Pulmonary-artery denervation cut clinical worsening in heart-failure-related pulmonary hypertension (hazard ratio 0.49). No new drug regulation today; the AHA published a scientific statement on caffeine.
NOAC monotherapy after TAVI halved leaflet thrombosis without a safety penalty
In TAVI patients aged 65-80, twelve months of NOAC monotherapy cut leaflet thrombosis on CT from 28.6% to 16.2% with no excess bleeding or death, making anticoagulation a defensible option where valve durability is the priority.
Four doses of dapagliflozin nearly halved kidney injury after cardiac surgery
Four perioperative doses of dapagliflozin reduced acute kidney injury after elective cardiac surgery from 52% to 28%, the first drug to show this, though the trial population was healthier and less diverse than most surgical lists.
Evolocumab in the cath lab hit every lipid target and changed nothing at a year
Starting evolocumab before PCI got four in five patients to the LDL target against two in five on standard care, but produced no difference in death or cardiovascular hospitalisation at one year, so there is no reason to start it acutely.
Pulmonary-artery denervation cut clinical worsening in heart-failure pulmonary hypertension
Pulmonary-artery denervation halved clinical worsening in pulmonary hypertension from left heart disease, but the trial was open-label with a partly subjective endpoint, so treat it as a reason to watch the field rather than to refer.
No new cardiovascular drug actions today; the AHA has published on caffeine
No new cardiovascular drug regulation today, but the AHA's caffeine statement supports reassuring moderate coffee drinkers while separating that advice clearly from energy drinks, where the limited evidence suggests harm.
Ask which caffeine, not how much
Before telling a patient with palpitations to stop coffee, ask what they drink and what their monitor shows: coffee is associated with less atrial fibrillation but more ectopy, and energy drinks are a different exposure entirely.
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