Cardiology Digest podcast: Episode #22

Study #1

Brace yourself for insights from a study evaluating rapid uptitration of evidence-based therapies for heart failure. Join us to dissect the feasibility, resource demands, and patient implications! 

"The analysis included almost 1100 study participants hospitalized for acute heart failure. They were randomized to two groups: usual care, or intensive follow-up. The intensive follow-up group received rapid, intensive uptitration of neurohormonal blockers during five post-discharge appointments that were spaced out over 3 months. Which group do you think did better?"

Biegus, J, Mebazaa, A, Davison, B, et al. 2024. Effects of rapid uptitration of neurohormonal blockade on effective, sustainable decongestion and outcomes in STRONG-HF. J Am Coll Cardiol. 4: 323–336. (https://www.sciencedirect.com/science/article/abs/pii/S073510972407400X)

Study #2

A recent paper challenges hospital-centric treatment paradigms for acute pulmonary embolism. Discover how some low-risk patients could benefit from home treatment, and what conditions are essential to ensure their safety and effective care.

"The meta analysis looked at almost 2700 patients who had acute pulmonary embolism, were classified as low risk, and were discharged to home within 24 hours. The researchers looked at adverse events within 30 days after discharge, specifically, major bleeding, recurrent venous thromboembolism, or death."

Luijten, D, Douillet, D, Luijken, K, et al. 2024. Safety of treating acute pulmonary embolism at home: An individual patient data meta-analysis. Eur Heart J. 32: 2933–2950. (https://academic.oup.com/eurheartj/article/45/32/2933/7712560)

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Study #3

Dive into a large cohort study looking at bariatric surgery in obese patients who have obstructive sleep apnea, and see whether losing weight actually had a significant impact on cardiovascular outcomes.

"... obesity puts patients at greater risk of obstructive sleep apnea. And we know obstructive sleep apnea puts them at higher risk of major adverse cardiovascular events. But if a patient with obstructive sleep apnea and obesity intentionally loses weight, how much will it reduce their risk of major adverse cardiovascular events or death?"

Aminian, A, Wang, L, Al Jabri, A, et al. 2024. Adverse cardiovascular outcomes in patients with obstructive sleep apnea and obesity: Metabolic surgery vs usual care. J Am Coll Cardiol. Published online. (https://www.sciencedirect.com/science/article/abs/pii/S0735109724075594)

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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 up to speed on three important studies and advancements in cardiology that can impact your clinical practice! First, get ready for insights on rapid uptitration of evidence-based therapies for heart failure. A paper from the Journal of the American College of Cardiology dives into the feasibility, resource demands, and patient implications of this treatment model. Next, a groundbreaking paper from the European Heart Journal that challenges hospital-centric treatment paradigms for acute pulmonary embolism. Discover how some low-risk patients could benefit from home treatment and what conditions are essential for their safety and effective care. Finally, we explore a large cohort study, also from the Journal of the American College of Cardiology, that examines bariatric surgery in obese patients with obstructive sleep apnea to find out if losing weight significantly impacts cardiovascular outcomes. 

Nora [00:01:05]:
Before we dive in, don't forget to subscribe so you never miss an episode! Now let’s get into it! Today’s first study is a compelling piece of research providing promising insights on an intensive therapeutic approach for the management of heart failure and the resulting impacts on patients’ signs and symptoms of decongestion. Now, let's get into the nitty-gritty of the study, a secondary analysis of the manufacturer-sponsored STRONG-HF trial. The official title is "Effects of rapid uptitration of neurohormonal blockade on effective, sustainable decongestion and outcomes in STRONG-HF." This randomized trial was conducted by Biegus and colleagues and published last month in the Journal of the American College of Cardiology. The study is rated as Level 2 evidence, which is just one step below our gold standard (Level 1). The analysis included almost 1100 study participants hospitalized for acute heart failure. 

Nora [00:01:59]:
They were randomized to two groups: usual care, or intensive follow-up. The intensive follow-up group received rapid, intensive uptitration of neurohormonal blockers during five post-discharge appointments that were spaced out over 3 months. Which group do you think did better? The usual care group? Or the intensive uptitration group? Well here are the study results! At baseline, similar percentages of each group achieved successful decongestion. But differences emerged by the 90-day mark. At 90 days, a significantly higher percentage of the intensive uptitration group—75%— achieved decongestion, whereas only 68% of the usual care group did. In fact, each sign of decongestion—that is, no increase in venous pressure, no pulmonary rales, and no peripheral edema—showed significant improvement in the high-intensity group. Notably, other markers like N-terminal pro–B-type natriuretic peptide levels, orthopnea severity, and weight, also favored the high-intensity group, and that occurred even though they were on lower doses of loop diuretics! The bottom line: the intensive therapeutic approach achieved better decongestion outcomes compared to the usual care. 

Nora [00:03:13]:
And as a reminder, this adds to the benefits noted in the STRONG-HF trial, which showed that in the first 6 months after hospitalization for acute heart failure, an intensive uptitration of evidence-based therapies was associated with a lower risk of death or hospitalization for heart failure. An expert commenting on the study acknowledged that this more intensive treatment approach involves frequent visits and multiple medication adjustments over short periods, which could be taxing for patients and resource-intensive for healthcare systems. But despite that, they said that in settings where frequent follow-ups with nurse practitioners are doable, they usually do use rapid start and up-titration of treatments for heart failure. Our next paper is a great meta analysis looking at low-risk patients with acute pulmonary embolism, which sought to confirm if it’s safe to discharge them from the hospital early and treat them at home instead. The study, titled "Safety of treating acute pulmonary embolism at home: An individual patient data meta-analysis," was led by Luijten and colleagues, and was published last month in the European Heart Journal. It fits into our highest quality category of evidence, Level 1. The meta analysis looked at almost 2700 patients who had acute pulmonary embolism, were classified as low risk, and were discharged to home within 24 hours. The researchers looked at adverse events within 30 days after discharge, specifically, major bleeding, recurrent venous thromboembolism, or death. 

Nora [00:04:45]:
The primary analysis excluded a study on patients who had cancer. The overall findings were quite reassuring: only 1.2% of patients experienced adverse events, and the mortality rate was 0.3%. The tools used to identify low-risk patients—the Hestia criteria and the Pulmonary Embolism Severity Index—were equally effective. At the 30-day mark, patients who had cancer, increased troponin, or increased N-terminal pro–B-type natriuretic peptide were at roughly three times higher risk for adverse events. An expert reviewing the study remarked that home treatment offers clear advantages for selected low-risk patients with pulmonary embolism. They said this meta analysis found a low risk for serious adverse events, and makes a strong case for early discharge to home for treatment, provided there is adequate social support and the patient can immediately begin their anticoagulation therapy. And of course, we need to ensure we educate our patients to report any signs of bleeding or worsening symptoms, and tell them to get prompt medical attention if they experience severe symptoms.

Nora [00:05:50]:
The bottom line? If a validated triage tool is used, this meta-analysis offers robust evidence to support the early home discharge of low-risk patients who have acute pulmonary embolism.

Nora [00:06:51]:
Next up, we'll dive into a significant study that explores cardiovascular outcomes in patients with obstructive sleep apnea and obesity who had bariatric surgery. Do the benefits outweigh the risks? The study is titled "Adverse cardiovascular outcomes in patients with obstructive sleep apnea and obesity: Metabolic surgery vs usual care," conducted by Aminian and colleagues. Published in the Journal of the American College of Cardiology in June of this year, it’s a large cohort study rated as level 3 category evidence (which is in the middle of our quality rating scale). What made them do this study? Well, we already know obesity puts patients at greater risk of obstructive sleep apnea. And we know obstructive sleep apnea puts them at higher risk of major adverse cardiovascular events. But if a patient with obstructive sleep apnea and obesity intentionally loses weight, how much will it reduce their risk of major adverse cardiovascular events or death? To explore this question, researchers retrospectively looked at outcomes for 970 patients who had a BMI of 35 to 70, moderate or severe obstructive sleep apnea, and underwent bariatric surgery. 

Nora [00:08:21]:
Their outcomes were compared with over 12,000 similar patients who didn’t get the surgery. The primary endpoint was defined as the first occurrence of a major adverse cardiovascular event, which included atrial fibrillation, cerebrovascular and coronary events, heart failure, and all-cause death. Any guesses on what they found? Here are the results! At the 10-year mark, the mean weight loss was an impressive 33 kg in the surgery group, compared to 7 kg in the non-surgical group. Compared to their non-surgical counterparts, patients who underwent bariatric surgery showed a 25% reduction in the 10-year cumulative incidence of major cardiovascular events and a 31% lower all-cause mortality rate. But even though the surgery group was successful at losing weight, was able to sustain that weight loss, and they had a lower risk of major cardiovascular events and all-cause mortality, the residual risks for those negative outcomes still remained fairly high. So, we need to address that. An expert offered their perspective on these study results!

Nora [00:09:32]:
On the one hand, they mentioned the standard limitations that come with observational studies. But they also pointed out that this study involved a large cohort and the results add to previous evidence showing an association between obesity and negative outcomes. So, they said their plan for helping obese patients with obstructive sleep apnea is to ensure they discuss all available options for weight loss and be mindful of helping the patient to reduce any other risk factors they may have for cardiovascular disease. The bottom line? Bariatric surgery can significantly reduce the incidence of adverse cardiovascular outcomes in patients with obstructive sleep apnea and obesity, but the high remaining risk suggests we can’t stop at surgery. We need to ensure we consider all options for weight-loss and rigorously manage other cardiovascular risk factors. What do you think about today’s papers? Any surprises? If you have any comments you’d like us to share in a future episode, or general feedback about Cardiology Digest, please write to us at [email protected]. We’d love to hear from you! Did you get value from this episode? Can I ask you for a quick favor? We’d like to get this information out to as many people as possible, and reviews are one of the things that helps us do that. So, could you take a few seconds and leave us a rating or review? It would mean the world to us! 

Nora [00:10:55]:
Next, are you new to Medmastery? We’ve received multiple awards for outstanding digital education and are highly commended by the British Medical Association. We’ve helped hundreds of thousands of clinicians with our internationally accredited CME courses, that are also used by residency programs and universities around the world. Rated excellent by hundreds of users on Trustpilot, Medmastery features a faculty representing a wide range of clinical specialties who practice, teach, and train at universities internationally. 21% of our paying members said that Medmastery helped them save at least one life, and we’d love to help you next! Use the link in the episode description to go to Medmastery.com and test us out with a free trial account. Or, unlock all of our 120+ courses and workshops with just one membership! Thank you so much for joining me today, and please don’t forget to subscribe so you can join us again next time!