Cardiology: What You May Have Missed in 2023.

Cardiology and all its subspecialties continue to push the envelope in developing new treatment strategies for a wide variety of diseases. After screening more than 1300 articles, we highlight a selection of important cardiology articles published in 2023. Starting with prevention, we note articles that look at the effect of semaglutide in patients with obesity as well as a first-in-class drug, bempedoic acid, on cardiovascular outcomes. We have also examined new evidence comparing conservative management with invasive management of frail, older patients with non-ST-segment elevation myocardial infarction (NSTEMI). In patients with cardiac arrest secondary to NSTEMI, another article examines the rationale for expedited transfer to a cardiac arrest center. The STREAM-2 (Strategic Reperfusion in Elderly Patients Early After Myocardial Infarction) trial builds on looking at half-dose thrombolysis in older populations with STEMI. Emphasis is placed on guideline-directed medical therapy before hospital discharge in those with heart failure. In addition, in patients with stable symptomatic coronary artery disease, initial noninvasive testing using coronary computed tomography angiography may be a viable option compared with invasive strategies. More details have emerged on anticoagulation strategies in those with device-detected atrial fibrillation. Finally, transcatheter approaches to treat both mitral and tricuspid regurgitation have also been included.

Systemic arterial response to exercise in patients with aortic valve stenosis.

BACKGROUND: Systemic arterial hemodynamics play an important role in the assessment of the severity and hemodynamic consequences of aortic valve stenosis (AVS). METHODS AND RESULTS: Systemic vascular resistance, total arterial compliance, effective arterial elastance, and aortic characteristic impedance were derived from high-fidelity catheter recordings of ascending aortic pressure and blood flow velocity at rest and with supine bicycle exercise in 18 patients with AVS and 11 control subjects. Mean aortic pressure was similar between groups. At rest, systemic vascular resistance (AVS patients, 1426+/-318 dynes . s . cm(-5); control subjects, 107+/-228 dynes . s . cm(-5); P<0.01), arterial elastance (AVS patients, 1.38+/-0.36 mm Hg/mL; control subject, 0.99+/-0.15 mm Hg/mL; P<0.002), and aortic characteristic impedance (AVS patients, 107+/-23 dynes . s . cm(-5); control subjects, 76+/-30 dynes . s . cm(-5); P<0.01) were increased, whereas total arterial compliance was lower (AVS patients, 0.737+/-0.19x10(-3) cm(5)/dyne; control subjects, 1.155+/-0.27x10(-3) cm(5)/dyne; P<0.001) in AVS. With exercise, total arterial compliance increased in control subjects (rest, 1.155+/-0.27x10(-3) cm(5)/dyne; exercise, 1.421+/-0.49x10(-3) cm(5)/dyne; P<0.05) but did not change in AVS patients (rest, 0.737+/-0.19x10(-3) cm(5)/dyne; exercise, 0.769+/-0.21x10(-3) cm(5)/dyne; P=0.2). Arterial elastance increased on exercise in AVS patients (rest, 1.38+/-0.36 mm Hg/mL; exercise, 1.57+/-0.44; P<0.01). Aortic characteristic impedance remained elevated on exercise (AVS patients, 122+/-30 dynes . s . cm(-5); control subjects, 80+/-43 dynes . s . cm(-5); P=0.01). Stroke flow increased significantly in both AVS patients (rest, 229+/-69 mL/s; exercise, 256+/-78 mL/s; P<0.01) and control subjects (rest, 230+/-37 mL/s; exercise, 406+/-69 mL/s; P<0.001), although the increment was much attenuated in AVS. On multiple regression, the increase in stroke flow was related to the decrease in systemic vascular resistance (P=0.03), increase in total arterial compliance (P=0.03), and decrease in arterial elastance (P=0.02). CONCLUSIONS: These results indicate a pressure-independent increase in the steady and pulsatile components of the arterial load in patients with AVS under resting conditions. Persistent "stiffening" of the arterial system is an important contributor to the diminished stroke output response to exercise in AVS.

ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance: endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine.

The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 Appropriateness Criteria for Stress Echocardiography. A report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine.

The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine.

The American College of Cardiology Foundation (ACCF) and the American Society of Echocardiography (ASE) together with key specialty and subspecialty societies, conducted an appropriateness review for stress echocardiography. The review assessed the risks and benefits of stress echocardiography for several indications or clinical scenarios and scored them on a scale of 1 to 9 (based upon methodology developed by the ACCF to assess imaging appropriateness). The upper range (7 to 9) implies that the test is generally acceptable and is a reasonable approach, and the lower range (1 to 3) implies that the test is generally not acceptable and is not a reasonable approach. The midrange (4 to 6) indicates a clinical scenario for which the indication for a stress echocardiogram is uncertain. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Use of stress echocardiography for risk assessment in patients with coronary artery disease (CAD) was viewed favorably, while routine repeat testing and general screening in certain clinical scenarios were viewed less favorably. It is anticipated that these results will have a significant impact on physician decision making and performance, reimbursement policy, and will help guide future research.

Method for coronary angiography in morbidly obese patients.

Cardiac catheterization in morbidly obese patients is difficult. In addition to problems regarding vascular access and radiographic penetration of the chest, the engineering parameters and physical limitations of the table and its supporting structures may limit these patients' ability to undergo clinically indicated coronary angiography. We describe a method for cardiac catheterization in which much of the obese patient's body weight is supported on a stretcher placed at right angles to the catheterization table, with only the thorax on the table under the image intensifier. Using this method, five consecutive successful diagnostic procedures and one coronary stent procedure have been performed without complication. Limitations of this procedure include inability to achieve the normal variety of angiographic views due to constraints on image intensifier rotation and skew.