The edition · Cardiology
Genes sharpen arrhythmic risk in dilated cardiomyopathy, and immediate multivessel PCI in STEMI meets a mortality signal
A registry of 2,660 genotyped patients with dilated cardiomyopathy, an occlusion-focused triage trial in chest pain without ST elevation, a mediation analysis of SELECT, and a meta-analysis that questions doing non-culprit PCI at the index procedure.
The edition in brief
In 2,660 genotyped adults with dilated cardiomyopathy from an international registry, a pathogenic variant in a high-arrhythmic-risk gene (LMNA, DSP, FLNC, RBM20, PLN, SCN5A, DES, TMEM43) carried a hazard ratio of 3.25 (95% CI 2.63 to 4.01) for major ventricular arrhythmia against gene-elusive patients, and the excess persisted when ejection fraction was 50% or more (HR 2.36, 1.59 to 3.51). A substudy of the DIFOCCULT-3 cluster trial in 4,398 patients without ST elevation found that an occlusion-focused approach led to early invasive management in 45.4% against 13.6%, and to earlier identification of adjudicated coronary occlusion (35.1% vs 16.7%); clinical outcomes were not reported in the abstract. A mediation analysis of SELECT could not attribute semaglutide's 20% reduction in cardiovascular events to known risk factors with any certainty. A meta-analysis of four randomised trials (2,651 patients) found higher one-year all-cause death with immediate rather than staged complete revascularisation in STEMI with multivessel disease (HR 1.50, 95% CI 1.02 to 2.21), a fragile result built on few deaths. The pearl covers repeat ECGs and posterior leads in ongoing chest pain.
Gene group predicts arrhythmia in dilated cardiomyopathy, even with preserved ejection fraction
Consider genetic testing in dilated cardiomyopathy and use a high-risk gene result as one input to arrhythmia risk assessment alongside ejection fraction and imaging.
An occlusion-focused triage approach sent more non-ST-elevation patients to early angiography
Consider adding occlusion-pattern recognition to ECG review, and treat the outcome benefit as unproven until clinical endpoints are reported.
Known risk factors explain little of semaglutide's cardiovascular benefit in SELECT
Do not assume weight loss is the route to the cardiovascular benefit; the mechanism remains uncertain.
Chest pain that persists deserves another ECG
In ongoing chest pain, repeat the ECG and compare; consider posterior leads when anterior ST depression is present.
Immediate non-culprit PCI in STEMI linked to higher one-year mortality
Consider staging non-culprit PCI in stable STEMI patients with multivessel disease rather than treating everything at the index procedure.
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