The authors explain that by stimulating the His-Purkinje network, His bundle pacing engages electrical activation of both ventricles and may avoid marked dyssynchrony. They also describe recent studies that demonstrated the potential of His bundle pacing in patients with underlying left bundle branch block and cardiomyopathy.

Furthermore, the authors note that His bundle pacing may have a theoretic advantage to conventional cardiac resynchronization therapy since it restores the intrinsic electromechanical activation sequence of the heart. They add that in some studies, patients have demonstrated improved functional status, reduced mitral regurgitation, reduced dyssynchrony, and improved left ventricular ejection fraction after His bundle pacing, on par with what has been shown in cardiac resynchronization therapy responders.

“This technique holds potential and requires further validation in larger studies with longer follow-up,” the authors conclude. “It is also clear that collective and collaborative efforts from physician scientists, industry partners, scientific societies and regulatory authorities will be required to successfully develop this technology and advance our understanding of the physiology of pacing.”

Vijayaraman P, Chung MK, Dandamudi D, et al. J Am Coll Cardiol 2018;72:927-47.

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A total of 1,424 patients received transcatheter heart valves and computed tomography angiography (CTA) was performed in 754 (53 percent) of these patients. LT was found in 120 patients (15.9 percent) who received CTA.

Patients with LT were less likely to be male (36.7 vs. 47.0 percent; p=0.045) and had a lower rate of atrial fibrillation (28.3 vs. 41.5 percent; p=0.008). There were no significant differences in peri- and postprocedural characteristics between patients with and without LT. Mean pressure gradient was similar between groups at the time of CTA (11.3 vs. 12.0 mm Hg; p=0.229). There was no significant difference regarding anticoagulation at discharge (261 [41.2 percent] vs. 51 [42.5 percent]; p=0.840).

The median follow-up for the overall cohort was 406 days. The mortality per year for the entire study cohort was 11.1 percent (n=124); it was 11.1 percent (n=15) and 11.2 percent (n=109) in patients with and without LT. In univariate analysis, neither LT thrombosis (hazard ratio, 0.38; p=0.350) nor the other tested variables (age, male sex, atrial fibrillation) were predictive of stroke or transient ischemic attacks (TIAs). The incidence of stroke or TIA was too low to perform meaningful multivariate analysis.

“[T]he data presented here add to the growing evidence indicating that LT has no impact on short- and medium-term mortality,” the authors write. “The fact that LT represents a relatively benign condition is further supported by comparable rates of stroke in patients with and without LT, in line with previous studies.”

Ruile P, Minners J, Breitbart P, et al. JACC Cardiovasc Interv 2018;11:1164-71.

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After several large cardiovascular outcome trials with mostly neutral results, two studies of SGLT-2 inhibitors – EMPA-REG OUTCOME looking at empagliflozin and CANVAS looking at canagliflozin – reported favorable effects on a composite of MI, stroke and cardiovascular death. In addition, the studies found reductions of hospitalizations for HF and, in the case of empagliflozin, reductions in both cardiovascular and total mortality.

The authors note these beneficial findings have prompted several analyses to clarify the potential application of SGLT-2 inhibitors and initiated large clinical trials in HF patients without T2D. Three large T2D cardiovascular outcome trials, with dapagliflozin, ertugliflozin and sotagliflozin, are underway; results are expected over the next four years.

“The favorable effects of SGLT2i … represent an unexpected bonus of the FDA’s advisory in 2008 to test new glucose agents for cardiovascular safety in large post-marketing trials,” the authors write. “SGLT2i appears to be effective and relatively safe in patients with type 2 diabetes.”

Zelniker TA, Braunwald E. J Am Coll Cardiol 2018;July 31:Epub ahead of print.

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Data from 11,518 patients (5,765 CABG; 5,753 PCI) were pooled. There were 293 strokes and 976 deaths over the mean follow-up of 3.8 years.

The 30-day stroke rate was higher in the CABG than the PCI group (1.1 vs. 0.4 percent; hazard ratio [HR] for PCI, 0.33). In the CABG vs. PCI group, the cumulative five-year stroke rate was higher (3.2 vs. 2.6 percent; HR for PCI, 0.77).

For the period between 31 days and five years, the stroke rate was comparable with PCI and CABG (p=0.72). For patients who had a stroke in the first 30 days, compared with those who did not, the five-year mortality was significantly higher after both PCI (45.7 vs. 11.1 percent) and CABG (41.5 vs. 8.9 percent) (p<0.001 for both).

The increased five-year risk of stroke with CABG was confined to patients with multivessel disease and diabetes. Five-year mortality was high in patients experiencing a stroke within 30 days after both CABG and PCI.

“The differential risks of stroke after PCI and CABG should be considered in the comprehensive assessment of the long-term risk-benefit ratio of these alternative revascularization options,” the authors conclude.

Head SJ, Milojevic M, Daemen J, et al. J Am Coll Cardiol 2018;72:386-98.

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Using the Nationwide Readmission Database, researchers analyzed patients over 18 years who underwent a first PCI within the calendar year between 2010 and 2014 and were discharged against medical advice or discharged home. Patients who died during their initial admission for PCI, who had an elective readmission or who were not discharged against medical advice or home were excluded. In total, 2,021,104 individuals were included in the patient cohort analyzed for 30-day readmissions and reasons for readmissions.

Overall, 0.5 percent (n=10,049) of patients were discharged against medical advice, of whom 16.8 percent were readmitted within 30 days (p<0.001). The readmission rate was 8.5 percent in the patients discharged home (p<0.001). DAMA was the strongest predictor of an unplanned 30-day readmission (odds ratio [OR], 1.89; p<0.001). In a readmission, DAMA, compared with discharge home, was associated with a higher rate of death (3.2 vs. 2.0 percent), in-hospital major adverse cardiac events (6.1 vs. 2.4 percent), and recurrent DAMA (13.9 vs. 1.1 percent).

Patients discharged against medical advice were younger, male, more likely to be smokers and misuse alcohol and drugs, and be in the lowest quartile of income. They were also more likely to be admitted on a weekend, be insured by Medicaid and have comorbidities. Predictors of DAMA were diagnosis of acute myocardial infarction (OR, 1.37), smoking (OR, 1.71), drug abuse (1.82) and alcohol misuse (OR, 1.53) (p<0.001 for all).

Among DAMA patients, the most common noncardiac cause of readmission was neuropsychiatric reasons (8.3 vs. 2.4 percent for discharge home) and acute myocardial infarction for cardiac causes (39.4 vs. 19.5 percent).

“Patients who undergo PCI not only have risks associated with their presenting condition, but there are also risks related to their treatment. When patients discharge against medical advice, there is a breakdown in the care relationship and the patient has chosen to discontinue care,” Mamas says. “This has serious consequences as ongoing care is vital after PCI, from prescribing dual antiplatelet therapy to echocardiograms to assess other, necessary, evidence based therapies or management of newly diagnosed diabetes and more.” The authors write that interventions should be developed to reduce DAMA in high-risk groups and initiate interventions to avoid complications and readmission when it occurs.

Kwok CS, Bell M, Anderson HV, et al. JACC Cardiovasc Interv 2018;11:1354-64.

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