The edition · Cardiology
Three months of anticoagulation after TAVI buys a CT finding and costs blood
NOTION-4 abolishes leaflet thickening at three months and loses it again by twelve, while harm accumulates; scar corridors and genotype beat ejection fraction for arrhythmic risk; and a simple protocol gets more post-ACS patients to target than good intentions do.
The edition in brief
Four findings for the cardiology desk, plus one regulatory action. NOTION-4 randomised 347 patients without an indication for oral anticoagulation after successful TAVI to lifelong single antiplatelet therapy or three months of a direct oral anticoagulant followed by antiplatelet therapy. Hypoattenuated leaflet thickening at three months fell from 31.8% to 12.1%, but by twelve months, nine months after the drug stopped, the difference had gone: 32.2% versus 28.3%, risk difference -3.9% (95% CI -14.4 to 6.6), P=0.54. The composite of death, stroke or major bleeding at twelve months was 2.3% with antiplatelet therapy alone and 8.2% with the anticoagulant strategy (risk difference 5.9%, 95% CI 1.2 to 10.6). In 925 patients with non-ischaemic dilated cardiomyopathy from 22 European centres, the number of late gadolinium enhancement corridors and a high-risk genotype each independently predicted major ventricular arrhythmia after adjustment for ejection fraction and scar burden. A stepwise algorithm using scar, four or more corridors and genotype clearly outperformed the guideline threshold of ejection fraction 35% or less (5-year AUC 0.72 versus 0.57, P=0.001). TARGET-D titrated vitamin D3 in 630 patients after myocardial infarction to a 25-hydroxyvitamin D level above 40 ng/mL. Major adverse cardiovascular events were 15.7% versus 18.4% with usual care (HR 0.85, 95% CI 0.58-1.24, P=0.40): negative, despite achieving the target that earlier trials were accused of missing. BRIDGE cluster-randomised ten centres to a protocol-based lipid pathway after acute coronary syndrome. LDL cholesterol below 70 mg/dL at six months was reached by 86.4% versus 73.7%, and below 55 mg/dL by 60.8% versus 34.5%. The FDA approved a supplement to an existing generic carvedilol application on 27 August.
After TAVI, three months of a DOAC clears the CT and leaves the patient no better
Three months of a DOAC after TAVI reduced leaflet thickening while it was being taken but not at twelve months (28.3% vs 32.2%, P=0.54), and the composite of death, stroke or major bleeding was higher with it, so do not anticoagulate for this finding alone.
Scar corridors and genotype beat ejection fraction for arrhythmic risk in dilated cardiomyopathy
In non-ischaemic dilated cardiomyopathy, four or more late gadolinium enhancement corridors and a high-risk genotype predict major ventricular arrhythmia independently of ejection fraction and clearly outperform the 35% threshold (5-year AUC 0.72 vs 0.57).
Vitamin D after myocardial infarction fails even when the target is reached
Titrating vitamin D3 to a 25-hydroxyvitamin D level above 40 ng/mL after myocardial infarction did not reduce major adverse cardiovascular events (15.7% vs 18.4%, HR 0.85, 95% CI 0.58-1.24), so treat deficiency for bone, not for the heart.
FDA clears a supplement to a generic carvedilol application
This is an administrative approval of a supplement to a generic carvedilol application, not a label change or safety action, and it does not alter how carvedilol should be prescribed or monitored.
A rising gradient on a transcatheter valve is thrombosis until proved otherwise
A transcatheter aortic valve gradient that has risen from the patient's own baseline within the first year should trigger a cardiac CT for leaflet thrombosis, which is treatable, before anyone considers structural failure.
A written protocol gets post-ACS patients to LDL target; good intentions do not
Attach a written escalation algorithm and a four-week lipid recheck to every acute coronary syndrome admission: it raised the proportion reaching LDL cholesterol below 55 mg/dL at six months from 34.5% to 60.8% using drugs you already have.
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