Cardiology Digest podcast: Episode #14

Study #1

First, we turn our attention to the role of GLP-1 agonists in cardiovascular disease prevention among non-diabetic patients who are overweight or obese. With a focus on injectable semaglutide this study examines its cost-effectiveness and potential side effects. The findings might alter how we manage cardiovascular risk in these patients! 

"This industry-sponsored trial analyzed semaglutide's potential in a large cohort of around 18 000 patients. They had a mean body mass index of 33 kg/m², and a history of symptomatic peripheral arterial disease, stroke, or myocardial infarction. They received either a placebo or subcutaneous semaglutide (gradually increased, if tolerated, to 2.4mg once weekly) and were closely monitored for an average of 40 months."

Lincoff, AM, Brown-Frandsen, K,  Calhoun, HM, et al. 2023. Semaglutide and cardiovascular outcomes in obesity without diabetes. N Engl J Med. 24: 2221–2232. (https://doi.org/10.1056/NEJMoa2307563)

Study #2

Next, we’ll explore a compelling meta-analysis that could sway future guidelines and recommendations. They evaluated the outcomes of physiologic guidance and intravascular imaging in percutaneous coronary interventions (PCI), to see if these techniques improve patient outcomes beyond what’s possible with angiographic guidance alone.

"This analysis incorporated data from 32 randomized trials involving over 22 000 patients who were followed for time periods ranging from six months to five years. They defined the primary endpoint as a major adverse cardiac event. Their definition of a major adverse cardiac event included target lesion revascularization, myocardial infarction, and death.

What were the results? Well, when compared to only using angiography, the study found…"

Kuno, T, Kiyohara, Y, Maehara, A, et al. 2023. Comparison of intravascular imaging, functional, or angiographically guided coronary intervention. J Am Coll Cardiol. 23: 2167–2176. (https://doi.org/10.1016/j.jacc.2023.09.823)

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Study #3

Finally, we’re going to examine the nuances of anticoagulation in patients with subclinical atrial fibrillation. The balance between preventing strokes and avoiding bleeding complications is a delicate one. With new data suggesting nuanced approaches, this segment will provide valuable insights for us when we’re prescribing or considering anticoagulation therapies.

"The study involved 4000 patients, averaging 77 years in age, all of whom had a CHA2DS2-VASc score of three or higher. Each patient had experienced one or more episodes of subclinical atrial fibrillation, detected by an implanted device, lasting anywhere from 6 minutes to 24 hours. Patients received either aspirin or apixaban and were followed for an average of 3.5 years…On the one hand, the odds of a patient having a stroke are already lower with…."

Healey, JS, Lopes, RD, Granger, CB, et al. Apixaban for stroke prevention in subclinical atrial fibrillation. N Engl J Med. 2: 107–117. (https://doi.org/10.1056/NEJMoa2310234)

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

Nora [00:00:06]:

Welcome to Medmastery’s Cardiology Digest! In less than 15 minutes we’ll get you up to date on important studies and advancements in cardiology that can impact your clinical practice! I'm your host, Nora, and I'll be guiding you solo today, as Peter is taking a well-deserved break. Today’s studies are from the New England Journal of Medicine and the Journal of the American College of Cardiology. Study number one addresses the role of GLP-1 agonists in cardiovascular disease prevention among non-diabetic patients who are obese or overweight. Researchers examined injectable semaglutide to evaluate its cost-effectiveness and potential side effects. Next, we’ll explore a compelling meta-analysis from the Journal of the American College of Cardiology that evaluates the outcomes of functional guidance and intravascular imaging in percutaneous coronary interventions (PCI)—results could sway future guidelines and recommendations. 

Nora [00:01:01]:

Then we’ll wrap things up with an examination of the nuances of anticoagulation in patients with subclinical atrial fibrillation. The balance between preventing strokes and avoiding bleeding complications is a delicate one, and new data suggests nuanced approaches. Join me to explore the potential impacts of these studies, and the ongoing debates they spark within the cardiology community! And be sure to tap that subscribe button so you never miss an episode!

Today’s first study is from a November 2023 issue of the New England Journal of Medicine. This compelling paper by Lincoff and colleagues explores the cardiovascular effects of semaglutide, a GLP-1 agonist, in patients with cardiovascular disease who are overweight or obese but don’t have diabetes. This industry-sponsored trial analyzed semaglutide's potential in a large cohort of around 18 000 patients. They had a mean body mass index of 33 kg/m², and a history of symptomatic peripheral arterial disease, stroke, or myocardial infarction. 

Nora [00:02:02]:

They received either a placebo or subcutaneous semaglutide (gradually increased, if tolerated, to 2.4mg once weekly) and were closely monitored for an average of 40 months. So what happened? Semaglutide significantly reduced the incidence of major cardiovascular events—specifically stroke, myocardial infarction, or cardiovascular-related deaths. Major cardiovascular events occurred in 8% of placebo recipients, and only 6.5% of semaglutide recipients. Also, patients taking semaglutide experienced more weight loss. However, it wasn't all smooth sailing. Gastrointestinal issues doubled the percentage of patients who dropped out—16.6% in the semaglutide group, versus just 8.2% in the placebo group. So GI issues are going to be a significant consideration in the clinical use of semaglutide. One expert insightfully points out that while semaglutide offers a new avenue for secondary prevention in cardiovascular disease among non-diabetic overweight or obese patients, its high cost poses considerable economic challenges. 

Nora [00:03:10]:

It costs about $17 000 per year, and we’d have to treat approximately 70 patients over three years (a total cost of over 3.5 million dollars) to prevent 1 major event. Additionally, the question remains whether taking semaglutide orally would yield similar benefits in this patient population. To sum it all up, subcutaneous semaglutide has promise for secondary prevention in non-diabetic overweight or obese patients with cardiovascular disease. But costs are a huge challenge, and potential side effects are another issue to bear in mind. We'll have to stay tuned for more updates as further studies build on these findings.

Our next study is a comprehensive meta-analysis recently published in December 2023 in The Journal of the American College of Cardiology, by Kuno and colleagues. They looked at clinical outcomes for three guidance strategies for percutaneous coronary intervention (PCI): angiography-guided (the traditional option), functionally-guided (which is also known as physiologically-guided), and imaging-guided (including techniques like ultrasound (IVUS) or optical coherence tomography (OCT)). Doing this comparison is important for several reasons. 

Nora [00:04:23]:

First, angiography alone often doesn’t fully capture the functional significance of certain coronary lesions. It also can’t necessarily differentiate between anatomic features like precise stent dimensions, calcification, and the presence of untreated dissections that can impact the outcome of PCI. This analysis incorporated data from 32 randomized trials involving over 22,000 patients who were followed for time periods ranging from six months to five years. They defined the primary endpoint as a major adverse cardiac event. Their definition of a major adverse cardiac event included target lesion revascularization, myocardial infarction, and death. What were the results? Well, when compared to only using angiography, the study found a 28% reduction in major cardiovascular adverse events with imaging guidance and a 19% reduction with functional guidance. So, intravascular imaging guidance (IVUS or OCT) is probably the most effective overall of the three options. Now let's look at specific adverse events.

Nora [00:05:26]:

Compared to angiography-guided PCI, imaging guidance was associated with lower rates of target lesion revascularization, stent thrombosis, myocardial infarction and cardiovascular death. Whereas functional guidance was only associated with lower rates of myocardial infarction. What’s the key takeaway? Intravascular imaging and functional guidance are superior to solely using angiographic guidance. An expert commenting on the study said these results should prompt a shift in clinical practice, and they advocated to make imaging guidance a Class I recommendation for nearly all PCI procedures. This study not only underscores the importance of optimizing PCI outcomes through advanced imaging techniques but also highlights a potential shift towards integrating imaging and physiological assessments to achieve the best outcomes for patients with coronary artery disease, whether they present in acute or stable conditions. As we continue to refine our approaches, the combination of these strategies could well represent the future of interventional cardiology.

Our next study dives into the question of what to do about anticoagulation in patients with subclinical atrial fibrillation! 

Nora [00:07:50]:

Run by Healey and colleagues, and published in November 2023, this randomized trial addresses a pressing question—whether the risks associated with anticoagulation outweigh the benefits in patients with transient subclinical atrial fibrillation. The study involved 4 000 patients, averaging 77 years of age, all of whom had a CHA2DS2-VASc score of three or higher. Each patient had experienced one or more episodes of subclinical atrial fibrillation, detected by an implanted device, lasting anywhere from 6 minutes to 24 hours. Patients received either aspirin or apixaban and were followed for an average of 3.5 years. The apixaban group had a significantly lower incidence of systemic embolism or stroke, which translated to one less stroke per 217 apixaban users per year. (Strokes accounted for nearly all the events). But there was a drawback…

Nora [00:09:00]:

Apixaban was associated with a higher incidence of major bleeding events: for each year of treatment, there was an excess of one major bleed per 130 patients. Despite these risks, the mortality rates remained similar in both groups. So what are we to do? The jury’s still out on this one. On the one hand, the odds of a patient having a stroke are already lower with subclinical versus symptomatic atrial fibrillation. But in this study of patients with subclinical atrial fibrillation, 40% of the strokes caused moderate or worse disability, which we’d obviously like to avoid. And most of the excess bleeding events were non-fatal GI bleeds. That caused the study's authors to suggest considering oral anticoagulation in similar cases. 

Nora [00:09:46]:

But other experts reviewing a different meta analysis (which included this study plus the NOAH-AFNET 6 study) leaned towards not treating these patients with anticoagulants. If you’d like to dig into the details more, there are links to both papers in the show notes. Ultimately this study underscores the uncertainties surrounding the treatment of subclinical atrial fibrillation and stresses the importance of weighing the benefits of stroke prevention against the risks of increased bleeding. It's a pivotal consideration for all of us in the field, and one that will undoubtedly influence future guidelines and patient management strategies.

Now I hope you found today’s studies as interesting as I did, and if you like this content, be sure to subscribe! If you have any feedback about this episode, we’d love to hear from you—you can shoot us an email at [email protected] any time.

Nora [00:10:37]:

New to Medmastery? Then please allow me to properly introduce us! We’re a multiple award-winning provider of continuing medical education and highly commended by the British Medical Association. Medmastery’s courses are internationally accredited, and have been used by residency programs and universities worldwide. Our faculty includes experts who practice, teach, and train at leading universities and institutions globally. 21% of Medmastery’s paying members say our training has helped them save at least one life, and we’ve helped hundreds of thousands of clinicians enhance their skills. But don’t just take my word for it… here’s what a recent reviewer had to say about Medmastery: “Superior design and presentation. They manage to break concepts down into such a simple way it almost makes the viewer feel guilty how good it feels being able to just soak up everything so easily. I am so glad I found this. Best investment I made.” We’d love to help you next! Use the link in the episode description to grab an account today at Medmastery.com. A basic or pro account unlocks our entire library, or, you can give us a test drive with a trial account!  Well, that’s all I’ve got for you today.

Nora [00:11:43]:

If you’ve found this podcast to be helpful, please help spread the word by taking a minute to leave a review! Thanks again for listening, I wish you a great week and I hope to see you again next time!