Cardiology Digest podcast: Episode #13

Study #1

First, we explore a study from JAMA Internal Medicine that sheds light on the intricate relationship between chronic inflammation and cardiovascular health in patients with rheumatoid arthritis (RA). The big question is whether there’s a link between RA and the development of aortic stenosis, and if so, what does it mean for the future of patient care? 

"Aortic stenosis is characterized by a narrowing of the opening between the left ventricle and the aorta, and can lead to serious heart complications…a study was published…in JAMA Internal Medicine that looked at whether there was a connection between rheumatoid arthritis and aortic stenosis. They looked at approximately 73 000 patients diagnosed with rheumatoid arthritis and 639 000 controls who were not."

Johnson, TM, Mahabir, CA, Yang, Y,  et al. 2023. Aortic stenosis risk in rheumatoid arthritis. JAMA Intern Med. 9: 973–981. (https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2807944)

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Study #2

Next, we tackle a meta-analysis from the British Journal of Sports Medicine that reveals practical insights about the best form of exercise to reduce blood pressure. The conclusion may surprise you, offering a fresh perspective on exercise regimens and their role in combating hypertension. But to grasp the full scope of these revelations, you'll have to tune in.

"Given how common hypertension is, and the fact that it’s the number one risk factor for stroke and cardiovascular disease, this is an important question. Edwards and his team did a large-scale pairwise and network meta-analysis that looked at 270 randomized controlled trials including almost 16 000 people. They assessed five exercise regimens for lowering blood pressure."

Edwards, JJ, Deenmamode, AHP, Griffiths, M, et al. 2023. Exercise training and resting blood pressure: A large-scale pairwise and network meta-analysis of randomized controlled trials. Br J Sports Med. 20: 1317–1326. (https://bjsm.bmj.com/content/57/20/1317)

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Study #3

Lastly, we discuss a study that assesses the risks associated with subsequent pregnancies in women who have experienced peripartum cardiomyopathy (PPCM). We find out the magnitude of the potential for adverse events, including death.

"A 2023 single-center retrospective review published by Pachariyanon and colleagues in the Journal of the American College of Cardiology provides us with some answers…They followed 45 patients who had PPCM (most diagnosed in the postpartum period), who later became pregnant again…PPCM is a form of heart failure that occurs during the late stages of pregnancy or shortly after delivery."

Pachariyanon, P, Bogabathia, H, Jaisingh, K, et al. 2023. Long-term outcomes of women with peripartum cardiomyopathy having subsequent pregnancies. J Am Coll Cardiol. 1: 16–26. (https://www.jacc.org/doi/10.1016/j.jacc.2023.04.043)

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Please note that these timestamps are auto-generated and may be approximate.

Nora [00:00:04]:

Welcome to Medmastery’s Cardiology Digest, where expert insights are unleashed! I'm your host, Nora, and alongside my co-host Peter, we dive deep into the heart of medicine, bringing clinicians the most groundbreaking scientific findings in the field of cardiology. First up, we discuss a compelling piece from JAMA Internal Medicine, exploring whether there’s a link between rheumatoid arthritis and the development of aortic stenosis, and if so, what does it mean for the future of patient care? Next, we shift gears to a meta-analysis from the British Journal of Sports Medicine, which may challenge what you think you know about exercise and blood pressure. And we finish with a Journal of the American College of Cardiology paper that assesses peripartum cardiomyopathy and the risks associated with subsequent pregnancies. The findings crystallize the risks for us, providing crucial information for our patients’ decision-making. So, whether you’re on your way to work, taking a break, or just in the mood to learn, take a few minutes to join us as we unravel these topics, and get you the insights you need for clinical practice. 

Nora [00:01:10]:

And as always, don't forget to subscribe so you never miss an episode. Now let’s get into it! What have you got for us Peter?

Peter [00:01:18]:

Ok, so this study examines the potential link between rheumatoid arthritis and aortic stenosis. This is important because anywhere from 0.25–1% of the world’s population is estimated to have rheumatoid arthritis and we regularly see patients living with this disease. If rheumatoid arthritis is linked to aortic stenosis, we need to know about it. As you’ll recall, aortic stenosis is characterized by a narrowing of the opening between the left ventricle and the aorta, and can lead to serious heart complications. Last year a study was published by Johnson and colleagues in JAMA Internal Medicine that looked at whether there was a connection between rheumatoid arthritis and aortic stenosis. The study's cohort was made up of patients matched by sex and age. 87% of study participants were male, with an average age of around 62 years. 

Peter [00:02:02]:

They looked at approximately 73 000 patients diagnosed with rheumatoid arthritis and 639 000 controls who were not. They defined aortic stenosis as a composite of inpatient and outpatient diagnoses, replacement of the aortic valve, and aortic stenosis-related death. After accounting for possible confounders, they saw that patients who had rheumatoid arthritis faced a 48% higher risk of aortic stenosis. They also had a 26% higher risk of dying from causes relating to aortic stenosis, and a 34% higher risk of needing an aortic valve replacement. Also, risks were higher still for rheumatoid arthritis patients who had an elevated erythrocyte sedimentation rate and C-reactive protein, as well as those who were prescribed glucocorticoids and certain disease-modifying antirheumatic drugs. So, the key takeaway is that yes, patients with rheumatoid arthritis have a higher risk of aortic stenosis. An expert reflecting on the study said we should monitor our rheumatoid arthritis patients accordingly. They also said that this study adds to previous evidence regarding how chronic inflammation can take a toll on the heart. 

Peter [00:03:06]:

Needless to say, this study serves as an important reminder of the intertwined nature of inflammatory conditions and cardiovascular health, urging ongoing vigilance when we manage these patients. Now we’re going to shift gears and look into the impact of exercise on blood pressure. Over to you Nora!

Nora [00:03:21]:

Thanks Peter! This is a great study from the July 2023 issue of the British Journal of Sports Medicine. Edwards and colleagues looked at what kind of exercise regimen does the best job of lowering blood pressure. Given how common hypertension is, and the fact that it’s the number one risk factor for stroke and cardiovascular disease, this is an important question. Edwards and his team did a large-scale pairwise and network meta-analysis that looked at 270 randomized controlled trials including almost 16,000 people. They assessed five exercise regimens for lowering blood pressure. And it turns out that all of them were effective. But do you want to take a guess at which was the best?

Here are the five options:

1. Aerobic exercise
2. Dynamic resistance training
3. A combination of aerobic exercise and dynamic resistance training
4. High-intensity interval training
5. Isometric exercise 

Okay, ready to find out the winning regimen? It’s isometric exercise! With isometric exercise, you’re contracting the muscles without movement… so think of exercises like planking or holding a squat position.

Nora [00:04:30]:

Isometric exercise routines lowered systolic blood pressure by just over 8mmHg, and lowered diastolic blood pressure by 4mmHg. The runner up was combined routines that consisted of both aerobic exercise and dynamic resistance training. So it’s great to know which regimens were best, but we can’t let that distract us from the key point, which is that all 5 options effectively lowered blood pressure and differences in results weren’t so major that we need to be picky about what type of exercise regimen we recommend to our patients. In other words, as an expert in the field said, it’s probably more important to advise patients to do whatever exercise routine they like best, rather than trying to push them to do a specific type. The expert also pointed out that there were limitations in this meta-analysis. For example, the study designs were fairly heterogeneous. Other factors that could have impacted results were variations in training duration, compliance, and patient characteristics. So, doing more high quality studies would give us additional clarity on this issue.

Peter [00:06:42]:

Now let’s turn our attention to peripartum cardiomyopathy! 

Nora [00:06:48]:

Thanks Peter! This next study looks at maternal health and the heart, specifically, peripartum cardiomyopathy (PPCM) and the long term outcomes for women who go on to have another pregnancy. A 2023 single-center retrospective review published by Pachariyanon and colleagues in the Journal of the American College of Cardiology provides us with some answers. The study was titled "Long-term outcomes of women with peripartum cardiomyopathy having subsequent pregnancies". They followed 45 patients who had PPCM (most diagnosed in the postpartum period), who later became pregnant again. They were primarily African American, and uninsured or on Medicaid. But before we dive into the study results, let’s do a quick refresher on PPCM. As you may recall, PPCM is a form of heart failure that occurs during the late stages of pregnancy or shortly after delivery. And when people have PPCM, their left ventricular ejection fraction (LVEF) is less than 45%. 

Nora [00:07:48]:

In contrast, a normal LVEF is 50–70%. And the findings of this study were really interesting. First, the good news. Overall, ⅔ of patients eventually had their LVEF get back into the normal range. But the detailed findings are concerning. At diagnosis, the average LVEF for these women was just under 26%. By a median 17-month follow-up, LVEF improved quite a bit, to approximately 45%. But that’s still abnormally low. And what happened when they became pregnant again? LVEF decreased by a lesser amount that time, to about 41%. And at the median two-year follow-up, it again rebounded back to approximately 45%. 

Nora [00:08:30]:

So what were the long-term consequences? Results were sobering. Within five years, about 53% of patients whose LVEF remained below normal experienced negative maternal outcomes. In contrast, those occurred in only 20% of patients with a normal LVEF. The negative outcomes included relapse of PPCM, a thromboembolic event, cardiogenic shock, symptoms of heart failure, placement of a left ventricular assist device or implantable cardioverter-defibrillator placement, or death. All-cause mortality was 13.3% for women with  abnormally low LVEF, versus only 3.3% in women with an LVEF in the normal range. By the eight year mark, there were no significant differences in adverse outcomes between groups—all-cause mortality was 20% in both groups.

Nora [00:09:29]:

So what’s the key takeaway? Even if the LVEF recovers, outcomes are still poor. An expert commenting on the study underscored the heightened risk of negative outcomes, including death, for women with peripartum cardiomyopathy who are considering another pregnancy. This risk persists regardless of whether their ejection fraction improves, painting a stark picture of the challenges and decisions faced by these women and their healthcare providers. The study also draws attention to the disproportionate impact of peripartum cardiomyopathy on Black women, prompting further reflection on the underlying causes and necessary support.

Peter [00:10:09]:

Thank you for that Nora! So that’s the end of our studies for today! We hope you enjoyed this episode, and please don’t forget to subscribe. If you have feedback for us, please shoot us an email at [email protected]—we’d love to hear from you! And in case you’re new here, here’s some quick info about Medmastery. We’re a multiple award winning medical education company that’s highly commended by the British Medical Association and consistently rated excellent by users on Trustpilot. We’ve provided internationally accredited CME courses to hundreds of thousands of physicians and other clinicians around the globe. 

Peter [00:10:43]:

And 21% of our paying members said our courses helped them save at least one life. Our courses will help you refresh old knowledge, learn new skills, and pursue your career goals with confidence. To find out more, use the link in the episode description to get a trial account and browse our courses. We’d love to see you inside! 

Nora [00:11:03]:

Thanks for that overview Peter! Now before we sign off for today, I have a really quick favor to ask. Medmastery is passionate about bringing you the latest in medical innovation and education. If our podcast has helped keep you updated in cardiology, or enhanced your clinical knowledge, please consider leaving us a review. It’s a simple way to support our goal of spreading critical medical education that can make a difference in patient care. As always, we hope you enjoyed this episode. Thanks again for listening, everyone, and bye for now!