Cardiology Digest podcast: Episode #15

A new study could lead to a big change in the care of patients who’ve had an acute myocardial infarction. In a showdown between AI and traditional risk scoring, we see what’s better at predicting cardiac disease! Lastly, the FDA approves new drug-coated balloons for in-stent restenosis.

Franz Wiesbauer, MD MPH
Franz Wiesbauer, MD MPH
17th May 2024 • 8m read
01:17
Potential treatment changes for revascularized patients with normal ejection fraction after a heart attack
03:25
AI tries to predict cardiac risk from a chest x-ray
07:20
Newly approved drug-coated balloons are tested for in-stent restenosis

What are the latest cardiology studies?

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! 

"Traditionally, beta-blockers have been a foundational element of therapy following an acute MI, strongly backed by treatment guidelines. However, the issue is that those guidelines were based on evidence gathered before modern treatment protocols that use…"

Yndigegn, T, Lindahl, B, Mars, K, et al. 2024. Beta-blockers after myocardial infarction and preserved ejection fraction. N Engl J Med15: 1372–1381. (https://www.nejm.org/doi/full/10.1056/NEJMoa2401479)

Steg, PG. 2024. Routine beta-blockers in secondary prevention—On injured reserve. N Engl J Med15: 1434–1436. (https://www.nejm.org/doi/10.1056/NEJMe2402731)

Study #2

The integration of artificial intelligence in healthcare takes center stage, with a groundbreaking approach that uses AI in combination with routine chest x-rays. Could this offer a novel way to assess elevated risks for major adverse cardiovascular events, especially in settings where detailed clinical data might be lacking? The implications could transform patient screenings and prognostic assessments.

"The study gathered data from approximately 40 000 patients who had undergone standard chest x-rays. Then they fed that data to a sophisticated deep learning model for the purpose of training it to predict their cardiac risk. After training the deep learning model, they used it to estimate the 10-year risk of major adverse cardiac events in a separate cohort of about 11 000 patients."

Weiss, J, Raghu, VK, Paruchuri, K, et al. 2024. Deep learning to estimate cardiovascular risk from chest radiographs: A risk prediction study. Ann Intern Med4: 409–417. (https://www.acpjournals.org/doi/10.7326/M23-1898)

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Study #3

We look into an exciting advancement in interventional cardiology with the introduction of drug-coated balloons. Fresh from their recent FDA approval in March of this year, these innovative devices represent a significant breakthrough for treating patients with in-stent restenosis, especially those who haven’t responded well to multiple drug-eluting stents.

"The study’s primary endpoint was a combination of target-vessel myocardial infarction, ischemia-driven target-lesion revascularization, or cardiac death at the 12-month mark… Findings were consistent across various patient subgroups…"

Yeh, RW, Shlofmitz, R, Moses, J, et al. 2024. Paclitaxel-coated balloon vs uncoated balloon for coronary in-stent restenosis: The AGENT IDE randomized clinical trial. JAMA12: 1015–1024. (https://jamanetwork.com/journals/jama/fullarticle/2816073)

Kundu, A and Moliterno, DJ. 2024. Drug-coated balloons for in-stent restenosis—Finally leaving nothing behind for US patients. JAMA12: 1011–1012. (https://jamanetwork.com/journals/jama/fullarticle/2816074)

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Episode transcript

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

Nora [00:00:04]:

Hello and welcome to Medmastery’s Cardiology Digest. I’m your host, Nora, and in less than 15 minutes, I’ll get you up to date on three important studies and advancements in cardiology that can impact your clinical practice. First up, a New England Journal of Medicine paper that raises questions about the routine use of beta-blockers following an acute myocardial infarction in patients with preserved ejection fraction. Are we witnessing the end of an era in how we manage these patients? Join me to find out! Next, we turn to the Annals of Internal Medicine to explore the cutting-edge use of artificial intelligence with routine chest x-rays. You’ll find out if this technology is an improvement when it comes to assessing the risk for major adverse cardiovascular events. And finally, we’ll look at the recent FDA approval of drug-coated balloons.

Nora [00:00:56]:

Newly approved by the FDA in March of this year, these devices offer new hope for patients with in-stent restenosis for whom other treatments failed. A JAMA paper shows us what this means for interventional cardiology. Remember, if you enjoy these discussions, don’t forget to subscribe to stay updated on the latest in cardiology. Now let’s get started! Change is afoot! Last month the New England Journal of Medicine published a really interesting paper that one expert says will probably alter the long-accepted practice of using beta-blockers after an acute myocardial infarction (MI) in patients with a normal left-ventricular ejection fraction. Traditionally, beta-blockers have been a foundational element of therapy following an acute MI, strongly backed by treatment guidelines. However, the issue is that those guidelines were based on evidence gathered before modern treatment protocols that use renin–angiotensin–aldosterone system antagonists, antiplatelet therapy, high-intensity statins, and primary percutaneous coronary intervention. 

Nora [00:02:01]:

So, researchers looked at over 5000 patients who’d experienced an acute MI, had revascularization procedures and had a normal left-ventricular ejection fraction. They were randomized to either receive post-discharge beta blockers, or not, and followed for a median of three-and-a-half years. So what happened? It turned out that there was no significant difference between the two groups when it came to the primary endpoint, which was a new myocardial infarction or death. So does that mean we’re currently prescribing these medications for nothing? Well, then they looked at secondary outcomes like cardiovascular death, all-cause death, new myocardial infarction, and hospitalizations due to heart failure or atrial fibrillation. Comparing the beta-blocker and no-beta blocker groups showed no difference in the rates of those outcomes either. Needless to say, this research definitely challenges the one-size-fits-all approach of prescribing beta-blockers to almost everyone after an acute myocardial infarction. Experts point out that the statistical power of this study was limited because the event rate was too low. So, we can’t say for sure that beta blockers provide zero benefit. But ongoing research should help clarify that issue. 

Nora [00:03:16]:

Despite that bit of uncertainty, experts still think the end is coming for the practice of giving beta-blockers after an MI with preserved ejection fraction.

Next, we’re going to delve into an intriguing study from Harvard that could serve as a preview of the way we’ll practice medicine in future. Published in the Annals of Internal Medicine in March of this year, researchers investigated whether we can use AI to forecast cardiovascular risks from a source you might not expect: chest x-rays. The study gathered data from approximately 40,000 patients who had undergone standard chest X-rays. Then they fed that data to a sophisticated deep learning model for the purpose of training it to predict their cardiac risk. After training the deep learning model, they used it to estimate the 10-year risk of major adverse cardiac events in a separate cohort of about 11,000 patients. About twenty percent of the 11,000 patients had electronic medical records that were complete enough to allow for traditional cardiovascular risk scoring using the ASCVD calculator, in addition to the AI’s predictions based on their chest x-rays. That was very useful for comparing the AI’s performance to traditional risk scoring methods. 

Nora [00:04:29]:

So, how did the AI do? It did fantastic! Whether they used the AI’s assessment of a single chest x-ray, or traditional risk scoring, the same percentage of patients—37%—were categorized as having a 10-year risk of major adverse cardiac events that was ≥7.5% (which classified them as statin-eligible). But here's a striking addition—the study pointed out that the performance of the model based on chest x-rays wasn't just matching the traditional methods. It actually enhanced the predictive capability significantly. It showed that the 10-year incidence of major adverse cardiac events was 88% higher in patients categorized as statin-eligible compared to those who were statin-ineligible, independent of their traditional risk scores. We think one reason why the AI may be able to perform so well is that it can detect calcium deposits that the human eye can’t see. What does this mean for medical practice? Well, first, it’s important to recognize that ordering screening chest x-rays to assess cardiovascular disease risk is not recommended. 

Nora [00:05:35]:

However, experts said healthcare systems should consider using AI to predict risk in situations where we have a pre-existing chest x-ray but don’t have enough information in the electronic medical record to do traditional risk scoring. In summary, this study beautifully demonstrates how a blend of existing medical imaging and cutting-edge technology like deep learning can reshape our approach to predicting heart health risks and enhance patient care.

The next research paper for today looks at the performance of paclitaxel-coated balloons vs uncoated balloons for coronary in-stent restenosis, and the results led to an exciting new FDA approval.

Nora [00:06:52]:

The study, conducted by Yeh and colleagues, focuses on a pressing challenge for patients who receive percutaneous coronary intervention with modern drug-eluting stents: up to 10% of them end up with in-stent restenosis. 

Nora [00:07:40]:

To see if this could be improved, researchers conducted a multicenter, randomized clinical trial titled "Paclitaxel-coated balloon vs uncoated balloon for coronary in-stent restenosis: The AGENT IDE randomized clinical trial." They enrolled 600 patients—average 68 years old—and randomly assigned them to receive either a paclitaxel-coated balloon or a standard uncoated balloon during their PCI procedure. The study’s primary endpoint was a combination of target-vessel myocardial infarction, ischemia-driven target-lesion revascularization, or cardiac death at the 12-month mark. After 12 months, the percentage of patients who experienced the primary endpoint was only 18% in the group treated with the drug-coated balloon, compared to 29% in the uncoated balloon group. And rates of target-lesion revascularization and target-vessel myocardial infarction were almost cut in half for those with the drug-coated balloon. In terms of safety, the trial found that patients who received the drug-coated balloon did not have a significantly increased risk of stent thrombosis. These findings were consistent across various patient subgroups, affirming the broad applicability and potential of paclitaxel-coated balloons in clinical practice. Following the success noted in the study, drug-coated balloons were approved by the FDA in March of this year, making them a valuable new tool for managing patients with in-stent restenosis.

Nora [00:09:08]:

An expert noted that we still need to determine how the drug-coated balloon compares with inserting another drug-eluting stent. But nonetheless, the introduction of the drug-coated balloon is a significant step forward, especially for patients who've had multiple failures with previous drug-eluting stents.

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