At the ESC meeting in Paris, Gerhard Schuler from Leipzig reviewed the current indications for Transcatheter Aortic Valve Implantation (TAVI). TAVI is considered appropriate for: Inoperable patients with severe aortic stenosis with a baseline 1-year mortality risk of 50%.  Patients with severe aortic stenosis and a surgical risk of greater than 15%. Valve-in-valve implantation for degenerated bioprosthetic valves with severe aortic stenosis. Specific patient types suitable for TAVI include those with porcelain aorta, general frailty, poor pulmonary function from COPD or pulmonary fibrosis, open bypass grafts at risk during re-operation,… Continue Reading

There’s an old maxim in medicine that one shouldn’t be the first to prescribe a new drug, nor the last. A fascinating debate between Michael Ezekowitz from the U.S. and Felicita Andreotti from Italy highlighted the differences between warfarin and the newer oral anticoagulants (NOACs) apixaban, rivaroxaban, and dabigatran. Even Dr. Ezekowitz, the warfarin protagonist for purposes of the debate, had to concede the superiority of the NOACs, now supported as safer and more effective in three clinical trials: RE-LY, ROCKET-AF, and ARISTOTLE. In general, the factor Xa inhibitors prevent… Continue Reading

How can we manage a patient with atrial fibrillation and contraindications to warfarin therapy such as recurrent severe bleeding — a common scenario in clinical practice? Data from the manufacturer-sponsored ASAP study (ASA Plavix Feasibility Study with WATCHMAN Left Atrial Appendage Closure Technology) provides some hope, beyond what we had learned from the Protect AF trial. Annkathrin Braut, of the Frankfurt Cardiovascular Center, presented preliminary results from ASAP. This feasibility study of Watchman device implantation enrolled 125 high-risk atrial fibrillation patients from the Czech Republic and Germany. All had contraindications… Continue Reading

Just as the great voleur Willie Sutton robbed banks because “that’s where the money is,” why don’t we just look for coronary artery disease (CAD) directly in the coronary arteries? At the ESC meeting today in Paris, Bharati Shivalkar of Belgium reviewed the assessment of CAD utilizing coronary CT angiography (anatomical)  vs. the usual standard of care, stress testing (physiological). Several studies, including CT-STAT and ROMICAT, have demonstrated cost and time savings — as well as safety — using an initial strategy of coronary CT angiography (64-slice or better) in the emergency room for the… Continue Reading

As we make clinical decisions every day, we assess probabilities in a subjective fashion. And in doing so, we tend to fall into very predictable traps — traps we can get better at avoiding if we learn about how they ensnare us. That requires familiarizing ourselves with a bit of history. Several decades ago Casscells and colleagues published the results of an interesting experiment (N Engl J Med 1978; 299:999). They asked 60 Harvard medical students, residents, and attending physicians the following question: “If a test to detect a disease… Continue Reading

An analysis of recent health news coverage in the mainstream media: “Exit complexity. Enter stupidity.”

Drs. Paul Ridker and Sanjay Kaul offer their perspectives on a new coronary artery calcium/C-reactive protein study, published in the Lancet, and three of the study authors respond. The study showed that people with low LDL levels and high CRP levels may benefit from CAC scans to identify the folks who are most likely to benefit from statin therapy. Data came from 950 people enrolled in the Multi-Ethnic Study of Atherosclerosis (MESA) who had met the entry criteria for the JUPITER study. We invite you to read the discussion—and then… Continue Reading

The possibilities — and the limits — of giving medical advice online

Today on CardioExchange, we launch a new mini-series of blog posts on decision making in cardiology. Dr. John E. Brush explores the conscious and unconscious mental strategies that cardiologists use in their everyday work and asks you to examine your own decision-making processes. The aim: to foster a rich dialogue about how we do what we do so that we ultimately improve the care of patients. A 60-year-old man with systolic heart failure is admitted to the hospital for shortness of breath. You are making rounds when the nurse calls out… Continue Reading

Editor’s Note: In an article published in the New England Journal of Medicine, three members of the FDA’s Endocrinologic and Metabolic Drugs Advisory Committee (Allison Goldfine, Sanjay Kaul, and William Hiatt) offer their perspective on the May 19 committee meeting to review the controversial ACCORD-Lipid Study. Here, one of those authors, Sanjay Kaul, provides his own account of the session for CardioExchange members. After reviewing data from the ACCORD Lipid Study, the 13-person Endocrinologic and Metabolic Drugs Advisory Committee (EMDAC) of the FDA has voted unanimously to request that Abbott… Continue Reading