Cardiology Digest podcast: Episode #12

Study #1

First, we revisit the use of an everyday medication to check if it’s doing more harm than good in the elderly. Aspirin, long touted for its preventative benefits, is under scrutiny for its role in anemia. Should we rethink the use of aspirin in primary prevention, especially among the older population? 

"Trials like ASPREE, ASCEND, and ARRIVE highlighted the fact that among aspirin users, there’s an approximately 1% absolute uptick in episodes of major gastrointestinal bleeding."

McQuilten, ZK, Thao, LTP, Pasricha, S-R, et al. 2023. Effect of low-dose aspirin versus placebo on incidence of anemia in the elderly: A secondary analysis of the Aspirin in Reducing Events in the Elderly trial. Ann Intern Med. 7: 913–921. (https://www.acpjournals.org/doi/10.7326/M23-0675)

Study #2

Then, we shift focus to a comparison of approaches to mitral valve repair: the less-invasive minithoracotomy versus the conventional median sternotomy. Patient outcomes and success rates are put under the microscope, so we can tease apart what truly makes a difference in the final result. Is it the size of the incision or the skill of the hands making it?

"Less invasive surgical approaches are often associated with fewer complications and faster recoveries…But we need to know if that holds true specifically for mitral valve repair…the deciding factor for patients might not be the surgical approach itself…"

Akowuah, EF, Maier, RH, Hancock, HC, et al. 2023. Minithoracotomy vs conventional sternotomy for mitral valve repair: A randomized clinical trial. JAMA. 22: 1957–1966. (https://jamanetwork.com/journals/jama/fullarticle/2805908)

Study #3

Lastly, we wrap up with an insightful discussion on compression stockings after acute DVT, to see if they can prevent post-thrombotic syndrome. Do we have enough evidence to make confident recommendations on the real benefits and drawbacks of compression wearables? And how long should patients use them? We delve into the practical aspects of incorporating the findings of this paper into patient care.

"After experiencing a deep venous thrombosis (DVT), a whopping 20–50% of patients go on to develop the chronic condition known as post-thrombotic syndrome (PTS)...The team did a meta analysis of randomized trials that assessed the effectiveness of compression stockings in preventing PTS after an acute DVT incident."

Meng, J, Liu, W, Wu, Y, et al. Is it necessary to wear compression stockings and how long should they be worn for preventing post thrombotic syndrome? A meta-analysis of randomized controlled trials. Thromb Res. 225: 79–86. (https://www.thrombosisresearch.com/article/S0049-3848(23)00090-7/fulltext)

Cardiac MRI Essentials  (14 CME)

Echo Masterclass: The Valves (3 CME) 

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

Peter [00:00:05]:
Hello and welcome to Medmastery’s Cardiology Digest, where expert insights are unleashed. I'm your host, Peter and alongside me is my colleague Nora, ready to delve into the heart of cardiology's latest scientific findings. And today we’ve got quite the lineup for you. First up, we question a common medication regimen. Aspirin is a staple in preventative care, especially among the elderly, and it’s under the microscope for its potential role in anemia. We explore how the findings impact primary prevention in older adults. Then, we dive into the pages of JAMA to compare two approaches to mitral valve repair: the less-invasive minithoracotomy versus the conventional median sternotomy. 

Peter [00:00:46]:
Which one leads to the best results for our patients? Finally, we wrap up with a critical look at the use of compression stockings after a DVT. Can they actually prevent post-thrombotic syndrome? Stay tuned to get all the answers! But before we begin, please don’t forget to subscribe so you never miss an episode. In 15 minutes or less, we keep you up to date on the latest studies and advancements in cardiology to help you optimize patient outcomes. Now it’s time to get the lowdown on aspirin! Over to you Nora!

Nora [00:01:14]:
Thanks Peter! Given that aspirin is so widely used for prevention of cardiovascular events—for example, in the U.S. over half of older adults say they take it daily—we need to stay on top of the latest info on what it’s doing to them. Is it helping more than it harms? So, now we’re going to take a look at that paper from the Annals of Internal Medicine, “Effect of low-dose aspirin versus placebo on incidence of anemia in the elderly” that was written by McQuilten and colleagues and published in June 2023. It’s a secondary analysis of the ASPREE trial. Trials like ASPREE, ASCEND, and ARRIVE highlighted the fact that among aspirin users, there’s an approximately 1% absolute uptick in episodes of major gastrointestinal bleeding. So naturally, that casts shadows on any purported benefits and makes us wonder about the incidence of anemia. So, McQuilten and her team looked at the ASPREE trial data to further explore the relationship between daily aspirin intake and anemia. 

Nora [00:02:14]:
They analyzed results from over 18,000 healthy adults aged 65 or older, and followed them for at least five years. Patients took either 100mg of aspirin per day, or placebo. Their findings paint a nuanced picture. Anemia and low ferritin levels were more likely to occur in the aspirin group. And although hemoglobin declined in both groups, the decline was larger in the aspirin group. Even excluding those who encountered major bleeding didn't tilt the balance of these outcomes. So, what’s our main takeaway? It’s likely that in a small percentage of patients, taking low-dose aspirin every day will lead to iron deficiency, resulting in anemia. And what do we do with this information? It’s clear that we should be limiting the use of aspirin for primary prevention, particularly in healthy older adults.

Nora [00:03:02]:
An expert emphasizes that in older adults, not only does daily low-dose aspirin increase the risk of major GI bleeding, it’s also likely a contributing factor to higher incidences of iron-deficient anemia and occult bleeding. They also noted that current guidelines do not recommend using aspirin for primary prevention in this population. As we navigate the complexities of preventive healthcare, this study offers a critical lens through which we can assess the benefits and risks associated with routine interventions, particularly in our elderly patients. We have to ensure our preventive strategies don’t inadvertently compromise the overall health and well-being of our patients.

Peter [00:03:41]:
Absolutely Nora! And speaking of the well-being of our patients, let’s talk about more invasive versus less invasive surgical options. Less invasive surgical approaches are often associated with fewer complications and faster recoveries, and who wouldn’t want that, right? But we need to know if that holds true specifically for mitral valve repair. So, today we’re going to turn to the pages of JAMA to find out what turned out to be better: Akowuah and his team compared median sternotomy (the traditional method of mitral valve repair), to the less invasive technique, minithoracotomy. Their study, titled “Minithoracotomy vs conventional sternotomy for mitral valve repair” was a randomized clinical trial that took place across multiple locations in the UK. 330 patients with an average age of 67 years were randomly assigned to undergo either the minithoracotomy or the median sternotomy. So what was the result? The minithoracotomy group benefited from a shorter hospital stay... 

Peter [00:04:38]:
... (the median was one-day shorter). Six weeks post-surgery, the minithoracotomy group was ahead again: they reported a slightly greater engagement in moderate-to-vigorous activities. But as time went on, similarities between the groups became clear: Three months post-surgery, both groups showed similar improvements in their physical function scores. And at the one-year mark, 92% of patients in both groups experienced residual mitral regurgitation that was mild or better. The key takeaway is that there wasn’t much of a difference in outcomes between minithoracotomy and median sternotomy. Overall efficacy and safety was comparable.

Peter [00:05:12]:
Unsurprisingly, the less invasive option, minithoracotomy, provided a marginally quicker recovery and slightly reduced hospital stay. An expert commenting mused that given the fact that efficacy and safety was comparable, the deciding factor for patients might not be the surgical approach itself but rather the surgeon's expertise in performing the procedure. This study serves as an important contribution to the ongoing discourse on optimizing surgical techniques for mitral valve repair, suggesting that while innovation in surgical approaches is crucial, the surgeon’s proficiency and success rate remains vital in achieving the best patient outcomes. But before we reach the point of surgery, we need to understand what we’re dealing with. And Nora, you’ve got some resources for us, am I right?

Nora [00:05:53]:
You bet Peter! So we’ve just talked about ways to fix mitral valve regurgitation… but have you guys ever wished you had a better understanding of how to evaluate it using cardiac imaging? One way to get a look at mitral valve anatomy and help determine the cause of the regurgitation is to use Cardiac Magnetic Resonance (CMR). Medmastery’s Cardiac MRI Essentials course will get you started, and show you how to use CMR to quantify the severity of mitral regurgitation. But why stop there! Did you know that Medmastery also has an Echo Masterclass that focuses entirely on the valves of the heart? It covers a lot of ground, including how to use echocardiography to make accurate decisions based on what you’re seeing, how to recognize an abnormal mitral valve, plus, how to assess and report on mitral valve morphology and function (which of course, includes mitral valve regurgitation!) If being able to use those imaging techniques with confidence sounds good to you, use the link in the episode description to head over to Medmastery.com and sign up for an account. You can either dip your toes in the water with a trial account, or, grab a basic or pro account to fully unlock our entire library of over 120 accredited CME courses and workshops. Full details are on the website!

Nora [00:07:09]:
Now it’s time to turn our attention to post-thrombotic syndrome, and Peter's going to take us through a study on whether using compression stockings after a DVT truly makes a difference.

Peter [00:07:21]:
You bet Nora! This is really important because after experiencing a deep venous thrombosis (DVT), a whopping 20–50% of patients go on to develop the chronic condition known as post-thrombotic syndrome (PTS). Some of the symptoms PTS can cause include swelling of the leg, plus itchy, thickened, and discolored skin. Advanced PTS can even lead to skin ulcers. So, can a low-tech, simple intervention like compression stockings prevent such suffering in our patients? That’s the question Meng and colleagues sought to answer with their May 2023 study published in Thrombosis Research. Their paper is titled "Is it necessary to wear compression stockings and how long should they be worn for preventing post thrombotic syndrome?" Past research results were inconsistent, so current guidelines shy away from routinely recommending compression stockings to help manage acute DVTs. But newer small trials could shift the balance. The team did a meta analysis of randomized trials that assessed the effectiveness of compression stockings in preventing PTS after an acute DVT incident. And one of their findings offers a glimmer of hope to patients dealing with a DVT.

Peter [00:08:24]:
Compression stockings may indeed reduce the risk of developing PTS, with the risk ratio sitting at 0.73. The next question they looked at was whether compression stockings could also reduce the risk of recurrent DVTs or mortality. Unfortunately, the answer was no—compression stockings did not have a significant impact on the rates of recurrent DVTs or mortality. A final question addressed by this paper was whether wearing compression stockings longer would yield more beneficial results. The answer? There was no difference between patients who used these garments for two years versus a year or less. So, what should we do with this information? Well, there appears to be a benefit from wearing compression stockings for a DVT. Granted, stronger data would be preferred because there were significant differences in the control groups and types of compression garments worn. 

Peter [00:09:10]:
It would also be beneficial to study a larger number of patients. Nonetheless, one expert explains that using compression stockings is a reasonable option that’s unlikely to cause serious harm and may have benefits. For that reason, they’re comfortable presenting it to their patients as a potential treatment approach. All in all this study contributes to a critical ongoing discussion in thrombosis management. As we process the implications of this study for post-thrombotic syndrome, it's clear that continuous learning and keeping abreast of the latest research is pivotal. Nora, you’ve got some thoughts on that, am I right?

Nora [00:09:40]:
I sure do, Peter! In the ever-evolving field of medicine, staying updated and enhancing our skills is essential, and Medmastery is here to provide support on that journey. Medmastery has won multiple awards for outstanding digital education, and is highly commended by the British Medical Association, We have a wide range of internationally accredited CME courses, that are trusted by clinicians, residency programs and universities across the globe. Medmastery has an excellent rating from hundreds of users on Trustpilot, and 21% of our paying members report that our courses have helped them save at least one life. And now we want to help you, our listeners, next! Join the hundreds of thousands of clinicians worldwide who have benefited from our courses. Advance your journey towards mastery in medicine today. 

Nora [00:10:29]:
Use the link in the episode description to sign up for a free trial at Medmastery.com. Your next step in medical education starts here.

Peter [00:10:37]:
Thanks to everyone for listing! As always, we hope you’ve enjoyed this episode! And if you have a few seconds to spare, would you be up for leaving us a review? They’re so important to help us grow this podcast and bring this important knowledge to more people! Another option for sharing feedback is to drop us a line via email at support@medmastery.com. We wish you a wonderful week and we hope to see you again for the next episode!