The edition · Cardiology
Ablation lost to a sham procedure, and exercise echo alone still cannot diagnose HFpEF
PVI-SHAM-AF randomised 262 patients to pulmonary vein isolation or a sham and found a 2.6-point difference in quality of life at six months, confidence interval crossing zero. Meanwhile a 482-patient study shows the non-invasive HFpEF pathway most units now use has a sensitivity of 55 to 60%.
The edition in brief
Five findings and a pearl for the cardiology desk. The lead item is diagnostic: in 482 patients with unexplained dyspnoea who underwent invasive haemodynamic exercise testing with simultaneous echocardiography, the recommended non-invasive scores combined with exercise echo detected HFpEF with sensitivity of only 55 to 60% and accuracy of 61 to 67%. Adding resting left atrial compliance and using separate rule-in and rule-out cut points raised sensitivity to 95 to 99% among definitively classified patients and cut the proportion needing invasive testing from about 60% to about 30% - a triage tool, not a replacement for catheterisation. An individual patient data meta-analysis of six prospective prehospital studies covering 5,239 patients found HEART-derived risk scores with point-of-care troponin identified low-risk suspected NSTE-ACS with 99.8% negative predictive value for 30-day mortality and 97.2% for MACE, with the explicit caveat that this holds in well-organised EMS systems with reliable follow-up. SCORE2-HF, derived in 611,778 people and validated in 1.3 million, predicts incident heart failure with C-indices of 0.83 to 0.87 in people without prior cardiovascular disease. A head-to-head meta-analysis of 35 trials found rosuvastatin lowers CRP marginally more than atorvastatin, by 0.16 mg/L, and only after an outlier is removed; no difference for IL-6, TNF-alpha or adiponectin. The practice-changer is PVI-SHAM-AF: 173 patients randomised to catheter ablation and 89 to a sham procedure, with a between-group AFEQT difference at six months of 2.6 points (95% CI -2.7 to 8.0, p=0.36). Both arms improved substantially. Plus a pearl on measuring orthostatic blood pressure properly.
The non-invasive HFpEF pathway misses four in ten - unless you add atrial strain and change the cut points
Stop treating a normal exercise echo as a negative HFpEF result; add resting LA compliance and report indeterminate studies as indeterminate.
Prehospital HEART scoring with point-of-care troponin ruled out 30-day death with 99.8% negative predictive value
A HEART-derived score with point-of-care troponin is safe enough to rule out low-risk chest pain prehospitally only where follow-up for non-conveyed patients actually exists.
SCORE2-HF puts a number on heart failure risk before any cardiovascular disease exists
Treat SCORE2-HF as a way of ranking who in the clinic is heading for heart failure, not as a calibrated probability for a South Asian patient.
Rosuvastatin versus atorvastatin on CRP: a difference of 0.16 mg/L, and only after an outlier goes
Nothing here should change a statin prescription: the CRP difference is a tenth of a milligram per litre with no outcome attached.
Most orthostatic blood pressures are measured at the wrong moment
Take the standing pressure at one and three minutes with heart rate recorded, after five minutes supine - one reading at two minutes finds neither pattern.
Catheter ablation did not beat a sham procedure on quality of life at six months
When ablation is being offered purely for symptoms, quote a blinded between-group benefit of 2.6 AFEQT points (95% CI -2.7 to 8.0) rather than the improvement seen in open series.
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