Cardiology Digest podcast: Episode #19

Study #1

We explore safety outcomes for carotid artery stenting and see how this could impact your clinical discussions and decision-making. And if you practice in the U.S., now that Medicare and Medicaid cover this procedure for a broader range of patients, this info will prove to be especially important. 

"The 9792 patients studied had carotid artery stenosis and underwent carotid artery stenting… Previous trials showed carotid artery stenting is noninferior to carotid endarterectomy. But because of reimbursement limitations in the United States, we lacked real-world data on mortality and adverse procedural events."

Uchida, K, Sakakibara, F, Sakai, N, et al. 2024. Real-world outcomes of carotid artery stenting in symptomatic and asymptomatic patients with carotid artery stenosis. JACC Cardiovasc Interv. 9: 1160–1162. (https://www.sciencedirect.com/science/article/abs/pii/S1936879824005764)

Study #2

Next, we tackle a common cardiology conundrum: significant coronary artery disease lesions discovered incidentally in patients with severe aortic stenosis who are undergoing transcatheter aortic valve replacement. Should we treat it ahead of time, or not? We'll probe the debate, highlighting the potential implications of this new data.

"Our decision of whether or not to treat these lesions can impact our choice of prosthesis for transcatheter aortic valve replacement due to its impact on future access to the coronary vessels."

Colaiori, I, Paolucci, L, Mangiacapra, F, et al. 2024. Natural history of coronary atherosclerosis in patients with aortic stenosis undergoing transcatheter aortic valve replacement: The role of quantitative flow ratio. Circ Cardiovasc Interv. Online ahead of print. (https://www.ahajournals.org/doi/10.1161/CIRCINTERVENTIONS.123.013705)

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Study #3

Lastly, we sip our way through the nuances of coffee consumption and its impact on blood pressure and cardiac arrhythmias. A new study lets us know whether our patients' daily caffeine fix can be left off the list of cardiac concerns.

"Researchers adjusted for potential confounders, and after that, the only significant difference between the three groups was not what one might expect… that finding remained the same at baseline and follow-up."

Trevano, FQ, Vela-Bernal, S, Facchetti, R, et al. 2024. Habitual coffee consumption and office, home, and ambulatory blood pressure: Results of a 10-year prospective study. J Hypertens. 6: 1094–1100. (https://journals.lww.com/jhypertension/fulltext/2024/06000/habitual_coffee_consumption_and_office,_home,_and.21.aspx)

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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! I'm your host, Nora, and 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. In today's episode, we dive into some fascinating topics: First, we explore a  new study from one of the Journal of the American College of Cardiology family of journals that digs into safety outcomes for carotid artery stenting and see how this could impact your clinical discussions and decision-making. Next, a paper from Circulation: Cardiovascular Interventions tackles a common conundrum: how to handle significant coronary artery disease lesions discovered incidentally in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement. Is it better to treat these lesions beforehand, or is there a more effective strategy? Lastly, we sip our way through the nuances of coffee consumption and its impact on blood pressure and cardiac arrhythmias. Can your patients' daily caffeine fix be left off the list of cardiac concerns? A new study from the Journal of Hypertension provides insights that could shape your patient consultations.

Nora [00:01:12]:

Before we get into it, don't forget to subscribe so you never miss an episode. Now let's get started! Our first study for today is from JACC: Cardiovascular Interventions. This evaluation of registry data from almost 9800 patients in Japan found that carotid artery stenting was safe, with a low complication rate at the 30-day mark. Titled "Real-world outcomes of carotid artery stenting in symptomatic and asymptomatic patients with carotid artery stenosis," this nationwide retrospective registry study was conducted by Uchida and colleagues and published a couple of months ago. The study fits into a Level 3 category of evidence, which is right in the middle of our rating scale. The patients studied had carotid artery stenosis and underwent carotid artery stenting. The cohort had a mean age of 74 years and most of them were male (86%). 

Nora [00:02:07]:

A little over half of the patients were symptomatic and embolic protection devices were used in almost all— 99%—of cases. Here’s some background on why this study is important for patients with carotid artery stenosis. Previous trials showed carotid artery stenting is noninferior to carotid endarterectomy. But because of reimbursement limitations in the United States, we lacked real-world data on mortality and adverse procedural events. In this particular study, the primary outcome was a composite of ischemic stroke and all-cause death within 30 days of the carotid artery stenting procedure. There was no significant difference in primary outcome rates between the symptomatic and asymptomatic groups. Secondary outcomes that were significantly more common in the symptomatic group were acute in-stent occlusion, intracranial hemorrhage, and hypoperfusion syndrome. However, rates were still under 2% for both groups.

Nora [00:03:05]:

The scarcity of U.S. data on carotid artery stenting procedures is largely due to reimbursement  previously being limited to patients who are at high surgical risk. But now the U.S. Centers for Medicare and Medicaid Services recently widened their coverage for this procedure. And one expert said these new findings provide the confidence we need to discuss the option of carotid artery stenting with our patients. However, it's worth calling attention to a big obstacle: operator experience. That being said, that situation will improve over time as clinicians do increasing numbers of carotid artery stenting procedures. The expert also suggested that we discuss the option of transcarotid artery revascularization with our patients, as that’s also a proven treatment option. This next paper came out last month in Circulation: Cardiovascular Interventions. Results showed that quantitative coronary flow reserve was better than traditional angiography for predicting outcomes in patients with coronary artery disease.

Nora [00:04:04]:

These results can impact how we handle coronary artery disease in patients who have severe aortic stenosis and are undergoing transcatheter aortic valve replacement. Titled "Natural history of coronary atherosclerosis in patients with aortic stenosis undergoing transcatheter aortic valve replacement: The role of quantitative flow ratio," this research was a retrospective multicenter study conducted in Italy by Colaiori and colleagues. It falls within a Level of Evidence rating of 3, right in the center of our rating scale. To better understand the results, let’s dive into how the study was conducted. Researchers analyzed mortality predictions for over 300 patients with aortic stenosis who were being treated with transcatheter aortic valve replacement. The median patient age was 84, and a bit over half were female. Noteworthy patient risk factors for coronary artery disease included hypertension, diabetes, and/or a previous myocardial infarction. Researchers assessed the severity of the aortic stenosis in two ways: quantitative coronary flow reserve measured angiographically without a wire versus traditional visual angiographic estimates. 

Nora [00:05:12]:

So what were the results? Using visual angiographic estimates, mortality rates were similar for patients with and without significant coronary artery disease (which was defined as ≥70% diameter stenosis). However, the situation was very different when using quantitative coronary flow reserve. Patients with an abnormal quantitative coronary flow reserve (≤0.80) experienced a significantly higher mortality rate. In fact, a multivariate analysis showed that abnormal quantitative coronary flow reserve independently predicted all-cause death with a hazard ratio of 5.31. An expert commenting on the study said that a common dilemma before doing a transcatheter aortic valve replacement is whether to treat incidental lesions from coronary artery disease in patients who have severe aortic stenosis but no chest pain. Some cardiologists treat these lesions, others don’t. Our decision of whether or not to treat these lesions can impact our choice of prosthesis for transcatheter aortic valve replacement due to the impact on future access to the coronary vessels. This particular expert said that prior to doing a transcatheter aortic valve replacement, they usually do treat proximal lesions within major vessels, even though there wasn’t yet proof that there’s a clinical benefit to doing so. 

Nora [00:06:36]:

While we await randomized trials, this new study shows the potential benefits of more physiologically-based decisions in clinical practice, and quantitative coronary flow reserve may be more prognostic than using visual angiographic assessments of stenosis severity. 

Nora [00:07:58]:

Alright, now let’s move onto the impact of coffee. This next study from the Journal of Hypertension will be good news for coffee drinkers: It showed that 10 years of coffee consumption seems to have no significant impact on blood pressure. This complements previous research that showed coffee consumption was also not linked to any increased risk of cardiac arrhythmias. Titled “Habitual coffee consumption and office, home, and ambulatory blood pressure: Results of a 10-year prospective study,” this research was led by Trevano and colleagues, published last month, and classified as Level 3 evidence (so, in the middle of our rating scale). Conducted in Italy, the study followed over 1,400 participants categorized based on their self-reported daily intake of coffee: heavy (3 or more cups), moderate (1-2 cups), or none. 

Nora [00:08:49]:

Researchers measured blood pressure in the office, at home, and via 24-hour ambulatory blood pressure at the start of the study, and again after 10 years. They adjusted for potential confounders, and after that, the only significant difference between the three groups was not what one might expect: mean office systolic blood pressure in heavy coffee consumers was slightly lower than that of moderate and non-consumers—that finding remained the same at baseline and follow-up. There was no difference in the incidence of new hypertension either. An expert said based on these results, habitual coffee consumption probably doesn’t raise the risk of clinically significant changes in blood pressure or a new diagnosis of hypertension. So, whether our patients are coffee aficionados or occasional consumers, they can likely continue their habits without worries about their blood pressure.

Nora [00:09:41]:

Before I continue, just a quick reminder to subscribe so you don’t miss any future episodes. Also, have you got any feedback for us? Or maybe today’s research reminded you of a clinical encounter you’ve had that you’d like to share with us? We’d love to hear from you, so please write to us at [email protected]! Next, are you new to Medmastery? Here’s what you need to know about us! Medmastery has won multiple awards for outstanding digital education and is highly commended by the British Medical Association. We offer internationally accredited CME courses, and have served hundreds of thousands of clinicians. We’re also a trusted resource for residency programs and universities around the world. Our faculty practices, teaches, and trains at esteemed universities globally. Medmastery is rated excellent by hundreds of users on Trustpilot, and 21% of our paying members have reported that we’ve helped them save at least one life. 

Nora [00:10:35]:

We’d love to help you next. Use the link in the episode description to sign up now for a free trial at Medmastery.com and get started. That’s it for today—thanks for tuning in, and I’ll see you next time!