The edition · Cardiology
Stress testing standards rewritten, and a heart failure risk model for the patients you already follow
ASNC replaces its 2016 stress testing guideline; a fatty liver meta-analysis argues for looking harder at HFpEF; and SMART2-HF puts a number on heart failure risk in established atherosclerotic disease.
The edition in brief
The American Society of Nuclear Cardiology has replaced its 2016 stress testing guideline with a beginning-to-end standard covering patient selection and preparation, stress modalities and protocols, safety, and reporting for both SPECT and PET perfusion imaging. A meta-analysis of three observational studies covering 899,629 people found clinically diagnosed heart failure with preserved ejection fraction in 2.2% of those with metabolic dysfunction-associated steatotic liver disease against 1.85% without, a pooled odds ratio of 1.35 with no heterogeneity, but an absolute difference of only 0.35%; the authors call it hypothesis-generating. A post hoc analysis of the TARGET trial found CT-derived fractional flow reserve guidance reduced angiography without obstructive disease mainly in men, while two-year major adverse cardiovascular events were lower in women (adjusted hazard ratio 0.48, 95% CI 0.27 to 0.87) with no significant interaction by sex. In a first-in-human phase 1 trial, a single subcutaneous dose of the small interfering RNA Kylo-11 lowered lipoprotein(a) by a median 96 to 97% at 48 weeks at doses of 225 mg and above, with no serious or drug-related adverse events in 70 healthy adults. The practice-changer is SMART2-HF, a model that predicts incident heart failure in people with established atherosclerotic cardiovascular disease, developed in 7,698 patients and externally validated in 240,741 across six data sources with a pooled C-statistic of 0.696 and calibration matching observed incidence. Incident heart failure is not part of current guideline-recommended risk assessment in this group, and it is now a number you can give.
ASNC replaces its stress testing standard after ten years
Audit your lab's stress protocol, patient preparation sheet and reporting template against the new ASNC standard — the first replacement in ten years.
Fatty liver and HFpEF: a real association, a small absolute difference
Let a MASLD diagnosis lower your threshold for assessing breathlessness as HFpEF — but not low enough to screen people without symptoms.
CT-FFR in stable disease worked differently in women and men
Nothing to change in practice — but worth knowing that the benefit of CT-FFR may not arrive by the same route in women as in men.
A single injection cut lipoprotein(a) by 97% at forty-eight weeks
Keep measuring lipoprotein(a) and treating everything else; the drugs aimed at it are coming, but no outcome data exist yet.
Settle the stressor before the patient is on the table
Decide exercise versus pharmacological stress at booking, and re-ask about caffeine and methylxanthines on arrival — a blunted study reads as a normal one.
You can now put a heart failure number on your ASCVD patients
In a patient with established vascular disease, estimate incident heart failure risk explicitly rather than assuming the atherothrombotic risk score covers it.
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