Left my Heart in CABANA: TAVRs, Atrial Fibrillation, and Acute Coronary Syndrome
Michael Fralick and John Fralick, both general internists in Toronto, are on The Rounds Table this week. In classic fashion, they are covering four articles in a rapid-fire style. They discuss transcatheter aortic valve replacement (TAVR) in low surgical risk patients, antiplatelet and anticoagulants in atrial fibrillation (AF) and acute coronary syndrome (ACS) with percutaneous coronary intervention (PCI), catheter ablation for AF, and determining the 99th percentile of high sensitivity troponin for a hospital population.
TAVR is superior to surgical valve replacement in high risk surgical patients with severe, symptomatic, aortic stenosis. TAVR is non-inferior in intermediate surgical risk patients. John covers an article examining the safety of TAVR compared to surgical aortic valve replacement in low surgical risk patients.
For patients with AF and ACS requiring PCI, what antithrombotic therapy should they remain on? Mike shares the AUGUSTUS trial examining this population to answer whether these patients should be on apixaban or warfarin, the bleeding risk, and if ASA is necessary in addition to clopidogrel.
AF is the most common tachyarrhythmia. Catheter ablation may be more effective than anti-arrhythmic medications in decreasing frequency of paroxysms in paroxysmal AF. John reviews the CABANA trial: catheter ablation compared to medical therapy in terms of mortality, stroke, bleeding, and cardiac arrest in patients with atrial fibrillation.
Myocardial infarction is defined by an increase or decrease in cardiac troponin concentration, with at least one value greater than the 99th percentile derived from a reference group of healthy individuals. With the high sensitivity troponin assay, the manufacturer quotes a recommended 99th percentile. Mike highlights a cohort study to determine the 99th percentile of high sensitivity troponin for an entire hospital population.
Finally, the Good Stuff segment. John introduces listeners to the Massachusetts Institute of Technology (MIT) open courseware available on the MIT website (see link below). Mike shares an article on how to deal with difficult coworkers in the workplace.
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1. TAVR vs SAVR: https://www.nejm.org/doi/full/10.1056/NEJMoa1816885
4. Troponin in BMJ https://www.bmj.com/content/364/bmj.l729
1. MIT Courseware: https://ocw.mit.edu/index.htm
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