The edition · Cardiology
PCI anticoagulation, ED troponin pathways and a node-ablation trial that fell flat
A large synthesis favours bivalirudin over heparin in ACS PCI, a pragmatic trial finds the 0/1-hour troponin pathway no faster in practice, and CAAN-AF shows atrioventricular node ablation does not improve resynchronisation outcomes.
The edition in brief
Six sections for the cardiology desk. A meta-analysis of 11 randomised trials and 17 cohorts (584,249 patients) found bivalirudin associated with lower in-hospital and 30-day mortality and major bleeding than heparin in acute coronary syndrome PCI, with no difference in ischaemic events; most data were observational, so the signal is hypothesis-generating. A pragmatic randomised trial of 3,543 patients with suspected ACS found the ESC 0/1-hour troponin pathway did not discharge more patients within four hours than a 0/3-hour pathway and was non-inferior but no safer, with laboratory turnaround the real bottleneck. A mediation analysis of SELECT could not attribute semaglutide's 20% reduction in major adverse cardiovascular events to any measured risk factor with certainty, with confidence intervals crossing zero. A HELIOS-B subgroup analysis found vutrisiran's benefit in transthyretin amyloid cardiomyopathy held whether or not patients were on background tafamidis, though the effect looked numerically smaller on a stabiliser. A pearl covers when to suspect ATTR cardiomyopathy. The practice-changer is CAAN-AF: in 143 patients with heart failure, permanent atrial fibrillation and a resynchronisation defibrillator, adding atrioventricular node ablation gave no reduction in death or heart failure events versus medical rate control, and the trial was stopped for futility.
Bivalirudin versus heparin in ACS PCI: a mortality and bleeding signal
Consider bivalirudin as a reasonable alternative to heparin in selected ACS patients undergoing PCI, particularly when bleeding risk is high.
The 0/1-hour troponin pathway did not speed up the emergency department
Do not expect a switch to 0/1-hour troponin sampling to speed up discharge unless laboratory turnaround and department processes can act on the earlier result.
Why does semaglutide cut cardiovascular events? SELECT cannot say
Frame semaglutide's cardiovascular benefit as independent of any single measured factor, including weight, rather than attributing it to one mechanism.
Vutrisiran in ATTR cardiomyopathy: benefit held with or without tafamidis
Vutrisiran can be considered in ATTR cardiomyopathy whether or not a patient is on tafamidis, but do not assume proven added benefit from combining the two.
When to suspect transthyretin cardiac amyloidosis
In an older patient with heart failure and unexplained left ventricular thickening, consider cardiac amyloidosis and screen with a monoclonal-protein workup followed by bone scintigraphy.
CAAN-AF: AV node ablation does not improve CRT outcomes
Do not add atrioventricular node ablation routinely to improve resynchronisation outcomes in HFrEF with permanent AF; reserve it for rate control that medication cannot achieve.
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