Cardiology Digest podcast: Episode #20

Study #1

See how the new Boston Scientific cryoballoon measures up against the Medtronic balloon. Did the newcomer outshine the veteran, or bring hidden risks? Discover the head-to-head results and what they mean for the future of atrial fibrillation cryoablation. 

"The Medtronic Arctic Front cryoballoon system was unchallenged in its space until 2020 when Boston Scientific's PolarX balloon came onto the market—and was FDA-approved in 2023… This new 2024 study is the first randomized trial to directly compare the safety and efficacy of the Arctic Front to the PolarX."

Reichlin, T, Kueffer, T, Knecht, S, et al. 2024. PolarX vs Arctic Front for cryoballoon ablation of paroxysmal AF: The randomized COMPARE CRYO study. JACC Clin Electrophysiol. Online ahead of print.(https://www.sciencedirect.com/science/article/abs/pii/S2405500X2400255X)

Study #2

We explore the intersection of aging, aortic stenosis, and osteosarcopenia in elderly patients undergoing transcatheter aortic valve replacement. This study highlights a radiographic method that reveals a high-risk subpopulation within this demographic. See how this insight can shape our approach to transcatheter aortic valve replacement.

"Frailty is a risk factor for morbidity and mortality when a person undergoes a transcatheter aortic valve replacement. These researchers wanted to further refine our understanding of those risks in patients with severe aortic stenosis… The study involved over 600 patients. They were 70 years of age or older, with an average age of 83. Almost half were women."

Solla-Suarez, P, Arif, S, Ahmad, F, et al. 2024. Osteosarcopenia and mortality in older adults undergoing transcatheter aortic valve replacement. JAMA Cardiol. 7: 611–618. (https://jamanetwork.com/journals/jamacardiology/article-abstract/2818813)

O'Gara, P, Guduguntla, V, Bonow, R, et al. 2024, Osteosarcopenia and mortality after transcatheter aortic valve replacement. JAMA Cardiol. 7: 618–619. (https://jamanetwork.com/journals/jamacardiology/article-abstract/2818815)

Boost your knowledge of Holter monitoring

Have you ever had patients who’ve needed a Holter monitor for ambulatory ECG monitoring? 

If you’d like to skyrocket your confidence and feel better equipped to use a Holter monitor the next time it’s being considered for one of your patients, Medmastery’s Holter Monitoring Essentials course can help! 

Here’s some of what you’ll learn to do:

• Know when a Holter monitor is indicated
• Choose the best type of ECG monitor
• Maximize diagnostic yield
• Troubleshoot the most common problems
• Correlate your patient’s symptoms with the rhythm strip
• Confidently report your findings 

Ready to jump in? Sign up for a Basic or Pro account to get full access to all of our ECG training, plus over 120 more courses and workshops! Not ready to commit? Take Medmastery for a test drive with a free trial account. 

Study #3

We turn our attention to the pressing issue of hypertensive disorders in pregnancy. Discover why close postpartum monitoring is critical and what the latest research suggests about the persistence of hypertension in new mothers.

"The researchers investigated the frequency and outcomes of sustained hypertension in over 2700 women after delivery, via a remote monitoring program. None of the women had a history of hypertension before pregnancy. But they all developed a hypertensive disorder—such as gestational hypertension or preeclampsia—during their pregnancy."

Hauspurg, A, Venkatakrishnan, K, Collins, L, et al. 2024. Postpartum ambulatory blood pressure patterns following new-onset hypertensive disorders of pregnancy. JAMA Cardiol. Published online. (https://jamanetwork.com/journals/jamacardiology/article-abstract/2820070)

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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 I’ll get you caught up on the most intriguing recent research from top journals that can impact your clinical practice! First up, we compare two balloons for atrial fibrillation cryoablation: The new Boston Scientific balloon versus Medtronic’s. Did the newcomer outshine the veteran, or are there hidden risks to be aware of? We’ll reveal the head-to-head results and discuss what they mean for the future of atrial fibrillation cryoablation. Next, we look at a couple of recent papers from the pages of JAMA Cardiology. The first one navigates the intersection of aging, aortic stenosis, and osteosarcopenia in elderly patients undergoing transcatheter aortic valve replacement. The study highlights a radiographic method that uncovers a high-risk subpopulation. We'll discuss how this insight can reshape our approach to these procedures and improve patient care strategies.

Nora [00:01:00]:

Then we’ll look at a paper published last month, which evaluates the pressing issue of hypertensive disorders in pregnancy. We’ll explore what this new research suggests about the persistence of hypertension in new mothers, and the importance of vigilant postpartum monitoring. Ready to stay ahead in the rapidly evolving world of cardiology? First, subscribe, so you never miss an episode. And keep listening to see how this new research will impact our practice and patients! Today’s first study compares the performance of two cryoballoon ablation systems for treating paroxysmal atrial fibrillation: the Arctic Front (made by Medtronic, and available in the U.S. for well over a decade) versus the relatively new PolarX balloon from Boston Scientific. The results? Efficacy was similar for both. However, there's a potential safety issue with the Boston Scientific system. Let's break down the study. It’s titled “PolarX versus Arctic Front for cryoballoon ablation of paroxysmal AF…

Nora [00:01:59]:

…The randomized COMPARE CRYO study.” Conducted by Reichlin and colleagues, this randomized trial was published in JACC: Clinical Electrophysiology in April 2024, and provides us with the highest level of evidence on our rating scale: Level 1. The Medtronic Arctic Front cryoballoon system was unchallenged in its space until 2020 when Boston Scientific's PolarX balloon came onto the market—and was FDA-approved in 2023.  Earlier nonrandomized studies hinted there could be superior outcomes with this new cryoballoon. But we lacked randomized trial data, until now. This new 2024 study is the first randomized trial to directly compare the safety and efficacy of the Arctic Front to the PolarX. Now, onto the methodology. Researchers studied 201 patients with symptomatic paroxysmal atrial fibrillation who were to undergo pulmonary vein isolation. Patients were randomized to either the Arctic Front cryoballoon or the PolarX. 

Nora [00:03:03]:

Cardiac rhythm was continuously monitored for all patients using an implantable cardiac monitor. The primary endpoint was the first recurrence of atrial tachyarrhythmia within a year, after a blanking period of three months. Using that primary endpoint and based on the results of this study, we can’t say that one balloon is superior to another. But what about safety? Well, one of the predefined safety endpoints was phrenic nerve palsy lasting more than 24 hours—it showed up in none of the patients in the Arctic Front group, but in five of the patients in the PolarX group. Fortunately, all five patients in the PolarX group who had the phrenic nerve palsy eventually recovered—two recovered within a month, two recovered within six months, and one recovered within a year. An expert commenting on the study mentioned that a unique feature of Boston Scientific’s PolarX balloon is its dual diameter capabilities: it can expand to either 28 or 31 mm. The expert said…

Nora [00:04:03]:

… that means it can probably ablate more left atrial tissue and create a wider antral ablation. However, they also highlighted concern about the occurrence of phrenic nerve palsy in patients treated with this system, saying it should be investigated further. This next paper is also from JAMA Cardiology, and showed a concerning finding: after a transcatheter aortic valve replacement, the 1-year mortality risk was three times higher in patients who had both low muscle mass and low bone density. The study, by Solla-Suarez and colleagues, is titled "Osteosarcopenia and mortality in older adults undergoing transcatheter aortic valve replacement." It’s a post hoc analysis that builds on the Frailty in Aortic Valve Replacement (FRAILTY-AVR) prospective multicenter cohort study and McGill extension. Published in May of this year, it fits into a level of evidence category 3…

Nora [00:04:55]:

… (so, in the middle of our rating scale). We know that frailty is a risk factor for morbidity and mortality when a person undergoes a transcatheter aortic valve replacement. These researchers wanted to further refine our understanding of those risks in patients with severe aortic stenosis who need that procedure. So, they zeroed in on the combination of low bone density and low muscle mass, a condition known as osteosarcopenia. The study involved over 600 patients. They were 70 years of age or older, with an average age of 83. Almost half were women. CT scans were used to identify the patients who had osteosarcopenia prior to undergoing their transcatheter aortic valve replacement. So, how did the patients fare after their surgery? The one-year mortality rate was highest (32%) for patients with osteosarcopenia. 

Nora [00:05:46]:

For patients who only had low muscle mass, the one year mortality rate plunged to 14%. Patients who only had low bone density had a one-year mortality rate that was even lower (11%). Finally, patients with normal bone and muscle status had the lowest one-year mortality rate (9%). Even after adjusting for clinical risk factors and other measures of frailty, osteosarcopenia really stood out, bringing a 1-year mortality risk that was about three times higher! Patients with osteosarcopenia were more likely to be men, be older, and have higher rates of frailty. They also had lower body-mass indexes, higher incidences of cognitive impairment, malnutrition, and slower gait speeds. Lastly, they were more likely to have at least one vertebral bone fracture. An expert commenting on the study offered their opinion regarding older patients with severe aortic stenosis who are undergoing transcatheter aortic valve replacement. 

Nora [00:06:45]:

They said that doing a radiographic assessment for osteosarcopenia could be useful to help us identify the high risk subpopulation whose 1-year mortality risk is three times higher. Along with other members of the care team, we could use this information to help guide discussions and shared decision-making with patients. This information could also be used to help us optimize post-surgery nutrition and physical activity interventions. Our next study dives into the issue of hypertension during pregnancy, and what that means for the postpartum prognosis. But before we fully transition away from transcatheter aortic valve replacement, have you ever had patients who’ve had that procedure and then undergone ambulatory ECG monitoring with a Holter monitor? And of course, that’s only one scenario that might involve use of a Holter. If you’d like to skyrocket your confidence and feel better equipped to use a Holter monitor the next time it’s being considered for one of your patients, Medmastery’s Holter Monitoring Essentials course can help! You’ll learn about clinical indications for a Holter monitor, how to choose the best type of ECG monitor, how to maximize diagnostic yield, plus, how to identify and troubleshoot the most common problems. You’ll also learn how to correlate your patient’s symptoms with the rhythm strip and confidently report your findings. 

Nora [00:08:04]:

Ready to jump in? Check out the link in the episode description to sign up for a basic or pro account. You’ll get full access to all of our ECG training, plus, over 120 more courses and workshops! Not ready to commit? Take Medmastery for a test drive with a free trial account. Next, a cohort study published last month in JAMA Cardiology showed that for women who experience hypertension during pregnancy, not only is it quite common for the hypertension to stick around after delivery, but this ongoing hypertension is associated with a higher likelihood of emergency department visits and readmissions to hospital. Titled "Postpartum ambulatory blood pressure patterns following new-onset hypertensive disorders of pregnancy", this study by Hauspurg and colleagues fits into a level of evidence category 3, which is in the middle of our rating scale. Via a remote monitoring program, the researchers investigated the frequency and outcomes of sustained hypertension in over 2700 women after delivery. None of the women had a history of hypertension before pregnancy. But they all developed a hypertensive disorder—such as gestational hypertension or preeclampsia—during their pregnancy. The primary outcomes for the study were emergency department visits and readmissions to hospital within the first six weeks post-delivery. The results? For 82% of the women, hypertension persisted post-discharge. And 14% of women in the study went on to develop severe hypertension, defined as any home blood pressure reading of 160/110 mm Hg or higher.

Nora [00:09:40]:

Almost half of the women were given antihypertensive medication. (In terms of whether they started the medication before or after discharge, it was a pretty even split.) Unsurprisingly, women with normal blood pressure post-discharge had the lowest rates of emergency department visits and hospitalization. Women with nonsevere hypertension had increased rates of emergency department visits (12%) and readmissions (4%). Women with severe persistent hypertension had the highest rates of postpartum emergency department visits (16%) and hospital readmissions (13%). In fact, a multivariate analysis showed that when compared to those with normalized post-discharge blood pressure, those with severe persistent hypertension had almost twice the risk of an emergency department visit and about a sevenfold higher risk of hospital readmission. This study shows that most women who experience a hypertensive disorder during their pregnancy will indeed have the hypertension persist for at least six weeks after they give birth. But an expert commenting on the study said that in their experience, blood pressure will return to normal for many of them, within 3 to 6 months. However, they also said that this study emphasizes the importance of monitoring these patients closely so that we’ll catch it if their hypertension becomes chronic.

Nora [00:11:01]:

So, what did you think of those research papers? If you have any comments or feedback to share, we’d love to hear from you. You can write to us at [email protected]. Next, don’t forget to subscribe so you never miss an episode! New to Medmastery? Please allow me to introduce us! Medmastery has received multiple awards for outstanding digital education and is highly commended by the British Medical Association. With internationally accredited CME courses, Medmastery’s 120+ courses and workshops are used by residency programs and universities around the world to train both clinicians and students. Our faculty, composed of experts in various clinical specialties, practices, teaches, and trains at universities globally. Medmastery has taught hundreds of thousands of clinicians worldwide and is rated excellent by hundreds of users on Trustpilot. 

Nora [00:11:50]:

21% of our paying members say that we've helped them save at least one life, and we’d be honored to help you next!  Ready to see for yourself? Sign up for a free trial at Medmastery.com and start learning today! If you’ve found this podcast helpful, please share it with your colleagues! And if you have a few seconds to spare, please leave us a rating or review on whatever platform you’re using to listen to this episode! Thanks so much for joining me today, and I hope to see you again next time!