Westby Fisher, MD on the lack of clinical evidence supporting the ABIM’s MOC program.

Electrophysiology

Questioning the Cath Lab for Arrhythmia Risk Management

Many arrhythmia patients take a trip to the cath lab before they end up in the EP lab, but a pair of new studies suggest that many of these “risk management” cath lab procedures are unnecessary – and might even increase risks.

PCI Before ICD – Patients with ischemic left ventricular dysfunction often undergo PCI procedures before receiving implantable cardioverter defibrillators (ICDs) based on the belief that it reduces the risk of fatal ventricular arrhythmias. However, an AHA study using data from the REVIVED-BCIS2 trial suggests that this step might be unnecessary.

Researchers analyzed 700 patients in the UK who either underwent PCI with optimal therapy or only received optimal therapy over a 41-month median follow up period, finding that…

• The PCI and optimal therapy groups had comparable rates of all-cause death or aborted sudden death (41.6% vs. 40.2%) – the primary outcome
• The two groups also had comparable secondary outcomes related to mortality, arrhythmias, or ICD therapies 

This is a study that could (and maybe should) lead to guideline changes, noting that current guidelines recommend waiting 90 days after revascularization before making ICD decisions.

Exams Before Monomorphic VT – A JACC study stated a solid case against performing routine exams to rule out CAD or ischemia as the cause of patients’ monomorphic VT storm before sending them in for ablation – a conclusion that might be more obvious to EPs than other specialists.

The analysis of 97 Cleveland Clinic patients with monomorphic VT storm and no acute coronary syndrome found that…

• 45% underwent ischemic or coronary evaluations via: coronary angiography (10%), noninvasive myocardial perfusion (26%), or both (9%)
• Patients who did and didn’t undergo CAD/ischemia tests had no significant differences in short-term ablation efficacy and outcomes, or 2-year revascularization and mortality rates

The study’s message for non-EPs who often make these evaluation decisions is that routine testing for CAD or ischemia on patients with monomorphic VT and no ASC doesn’t improve ablation effectiveness, but they can delay care and increase risks. 

The Takeaway

Although the patients and procedures evaluated in these two studies are quite different, they both suggest that angiography and PCI might play an unnecessarily large role before common EP procedures – potentially increasing healthcare costs, care delays, and risk of adverse events.

The First Step to Coronary Artery Disease Diagnosis

HeartFlow’s new RoadMap Analysis solution allows CT readers to accurately, efficiently, and consistently identify stenoses in the coronary arteries. See how RoadMap Analysis’ visual and quantitative insights into the narrowing of all major coronary arteries helps readers evaluate coronary CT angiograms before determining the need for an FFRCT.

Accurately Measuring Heart Rate Variability

Heart rate variability measurement and analysis involves two critical elements – the ability to accurately discern the R wave in noisy environments, and using the correct analysis method for a given application. Check out how Monebo’s Kinetic HRV ECG Algorithm excels at both of these essential tasks.

The Wire

• MedArrive & Heartbeat’s Home Cardiology Alliance: Home care provider MedArrive is expanding to virtual cardiology through a new Medicaid-targeted alliance with Heartbeat Health. MedArrive can now connect its CVD patients with Heartbeat Health’s virtual cardiologists, while MedArrive’s providers can coordinate care with Heartbeat cardiologists and health plan case management teams. This partnership seems on-trend for both companies, as MedArrive has launched similar alliances for virtual maternal and ophthalmology care and Heartbeat Health has signed patient-targeted partnerships with Cleerly and Caption Health.

• Cuff Size Matters: A JAMA Internal Medicine study found that one-size-fits-all blood pressure cuffs often produce inaccurate readings. In the Cuff(SZ) trial with 195 participants using one-size-fits-all cuffs, patients who would have required a small cuff had lower systolic BP readings (mean difference: -3.6 mm Hg), while users who normally fit into large or extra-large cuffs had higher readings (mean differences: 4.8 mm Hg and 19.5 mm Hg).

• ABIM Pressure Intensifies: What started out as a grassroots fight against the American Board of Internal Medicine’s Maintenance of Certification program is apparently becoming more formal, after the Society for Cardiovascular Angiography and Interventions and the EP Advocacy Foundation spoke out against the ABIM’s MOC policies. Both groups cited the MOC’s unnecessary costs and burdens, while calling for the ABIM to stop requiring MOC participation to maintain certification.

• How Many Steps for Heart Health? It could be less than you think. A large meta-analysis showed that the more daily steps you take the better, though a smallish number also helps. Among roughly 227k people in 17 studies, adding 1,000 steps daily reduced all-cause mortality by 15% while a 500-step boost cut the risk of CV death by 7%. What’s more, the study found that just 3,867 steps daily reduces all-cause mortality and only 2,337 daily steps reduces the risk of cardiovascular death.

• CathVision’s EP AI Clearances: Electrophysiology analytics startup CathVision announced the FDA clearance and commercial availability of its PVI Analyzer and Signal Complexity AI algorithms, making CathVision’s ECGenius the first AI-integrated EP ablation recording system. CathVision’s PVI Analyzer is a signal-based AI algorithm used to confirm PVI isolation during complex arrhythmia ablation, while its new Signal Complexity algorithm helps physicians visualize and quantify AF complexity parameters in patients with persistent AF. The clearance and launch comes just a few weeks after CathVision completed a $9M funding round.

• MRI Radiomics for Cardiac Amyloidosis: A cardiac MRI radiomics score excelled in predicting all-cause mortality in cardiac amyloidosis patients. China-based researchers developed the CMRI Rad-score, which combines radiomics features from late gadolinium enhancement (LGE) MRI scans. Among 120 cardiac amyloidosis patients, Rad-score predicted mortality better than LGE total enhancement mass and LGE extent (AUCs: 0.77 vs. 0.54 & 0.53), while Rad-score combined with Mayo stage was more accurate than Mayo stage alone (0.86 vs. 0.81).

• Consumers Turn to Telehealth for GLP-1s: A Trilliant Health analysis found that among the 3.6M people who received a new GLP-1 prescription in 2022, only 53% also had a medical visit claim within three days. That suggests that 1.7M Americans likely went to a direct-to-consumer telehealth company instead of going through a doctor to get their GLP-1 prescription, an important number to keep an eye on given the medication’s impact on weight and CVD.

• HeartBeam’s VECG Occlusion Detection: A study in JAMA Advances highlighted HeartBeam’s compact 3-lead vector electrocardiogram (VECG) technology’s ability to detect coronary occlusions. Among 66 patients with coronary artery disease, VECG-derived ST segment shifts showed similar accuracy to standard 12-lead ECG data, while VECG’s new “normal baseline” monitoring feature improved interpretation accuracy (AUC: 0.72 to 0.95).

• United Cuts Prior Auth Requirements: United Healthcare is moving forward with plans to drop prior authorization requirements for a number of popular procedures, including at least 12 cardiology codes. Starting September 1, United will begin the phase out across a “vast majority” of its plans, with the removals representing 20% of its overall prior auth volume. There’s recently been a brighter spotlight on the administrative burden that prior auths place on overworked clinicians, prompting Cigna and Aetna to announce similar rollbacks.

• TPP for Circulatory Shock: Clinicians treating ICU patients with circulatory shock might eventually have a new method for measuring their blood pressure. The new tissue perfusion pressure (TPP) method calculates the difference between mean arterial pressure and critical closing pressure, and was able to predict mortality, length of hospital stay, and peak blood lactate levels when tested using data from 6k Mass General patients and 864 patients from an external hospital.

• CVD Technology Gap: A new Yale study (n=16k, 2017-2020) found that 42% of U.S. adults who have or are at risk of developing cardiovascular disease use their smart devices to monitor their health. That’s less than the overall population (46%), and people with the highest CVD risks are least likely to use health apps. Older and poorer individuals, men, and cigarette smokers were all less likely to use smart devices for health monitoring, prompting the authors to warn that this “technology gap” could worsen CVD health disparities.

AI to Democratize Echo

Us2.ai published what might be the most comprehensive paper we’ve seen on AI echo, detailing the benefits of AI-automated echocardiography, the global need for more scalable and flexible CVD assessments, and how its technology is fit for the future. If you’re focused on the echo, echo AI, or echo accessibility and efficiency, this paper is worth checking out.

Staging Coronary Artery Disease

Believe it or not, there’s been no clinically relevant atherosclerosis staging system used to characterize heart disease — until now. Check out Cleerly’s four-stage system for evaluating atherosclerotic plaque burden, which is the direct cause of coronary artery disease (CAD).

The Resource Wire

• With the advent of advanced imaging technologies like CCTA come added burdens to technologists and diagnostic imaging centers. See how PIA can relieve the burden of post-processing, saving you time while helping your bottom line.

• Join us on August 22 at 8:00 p.m. ET for the highly anticipated live master class with esteemed expert, Dr. Hemal Gada. Renowned for his expertise, he’ll walk you through the intricacies of the Cusp Overlap Technique in patients with pre-existing rhythm disorders over the course of 55 minutes. Don’t miss it!

• When Change Healthcare set out to design its next-generation Cardiology Hemo monitoring system, they put behavior science at the heart of its product strategy. See how Change’s UX designers applied its behavioral science team’s findings to improve its Hemodynamics solution to help make physicians and technicians even more efficient.