Daily Cardiology Research Analysis
Three advances span therapy optimization, biomarker-guided diagnostics, and secondary prevention. Individual-patient data from RALES and EMPHASIS-HF show mineralocorticoid receptor antagonists benefit HFrEF across body weights with greater effect at higher weight. In ischemic stroke, admission NT-proBNP ≥505 pg/mL strongly predicts in-hospital atrial fibrillation detection but performs poorly for post-discharge AF. After AMI, participation in exercise-based cardiac rehabilitation and higher phys
Summary
Three advances span therapy optimization, biomarker-guided diagnostics, and secondary prevention. Individual-patient data from RALES and EMPHASIS-HF show mineralocorticoid receptor antagonists benefit HFrEF across body weights with greater effect at higher weight. In ischemic stroke, admission NT-proBNP ≥505 pg/mL strongly predicts in-hospital atrial fibrillation detection but performs poorly for post-discharge AF. After AMI, participation in exercise-based cardiac rehabilitation and higher physical activity lowered subsequent stroke risk.
Research Themes
- Phenotype-tailored pharmacotherapy in heart failure
- Biomarker-guided detection of atrial fibrillation after stroke
- Rehabilitation and lifestyle to prevent post-MI cerebrovascular events
Selected Articles
1. Mineralocorticoid receptor antagonists in heart failure with reduced ejection fraction according to body weight.
An individual patient data analysis of RALES and EMPHASIS-HF (n=4,386 with weight data) shows MRAs reduce HF hospitalization/cardiovascular death and all-cause mortality across weight strata, with larger benefits at higher body weight. Effects were consistent by sex and across trials.
Impact: This IPD analysis refines patient selection by showing amplified MRA benefit in heavier HFrEF patients, informing precision use without denying therapy to lighter patients.
Clinical Implications: Do not withhold MRAs in obese HFrEF; if anything, prioritize adherence and monitoring given amplified benefit. Weight alone should not deter MRA initiation; monitor hyperkalemia similarly across weights.
Key Findings
- Across 4,386 patients, MRAs reduced the composite of HF hospitalization or cardiovascular death versus placebo irrespective of weight.
- The magnitude of benefit on the primary composite and HF hospitalization increased with higher body weight, both as categorical and continuous variables.
- Trends toward greater reductions in cardiovascular and all-cause mortality with higher body weight; consistent across sexes and within each trial.
Methodological Strengths
- Individual patient data from two randomized, placebo-controlled trials (RALES, EMPHASIS-HF)
- Consistent effects across prespecified subgroups and across separate trial analyses
Limitations
- Post hoc analysis; body weight was not randomized and may proxy for unmeasured adiposity or comorbidities
- No mechanistic biomarkers to explain differential benefit by weight
Future Directions: Prospective, stratified studies by adiposity measures (e.g., visceral fat) and aldosterone signaling; evaluate safety (hyperkalemia) and optimal dosing across weight phenotypes.
2. Role of NT-proBNP for Atrial Fibrillation Detection After Ischemic Stroke: A Time-Dependent Relationship.
Across two prospective cohorts (n=2,292), admission NT-proBNP strongly predicted in-hospital AFDAS (AUROC 0.83); a 505 pg/mL cutoff had 82% sensitivity, 71% specificity, and 96% NPV. Predictive performance for AF detected after discharge was modest (AUROC 0.65), with 20% having normal NT-proBNP at baseline.
Impact: Defines a pragmatic NT-proBNP threshold to triage rhythm monitoring intensity after ischemic stroke, distinguishing in-hospital versus post-discharge detection windows.
Clinical Implications: Use NT-proBNP ≥505 pg/mL to prioritize intensive telemetry/prolonged inpatient monitoring for AF detection; do not rely on NT-proBNP to exclude post-discharge AF—outpatient prolonged monitoring remains necessary for many.
Key Findings
- AFDAS occurred in 16% (374/2,292) within 1 year; 72% were detected during hospitalization and 28% after discharge.
- Admission NT-proBNP predicted in-hospital AFDAS with AUROC 0.83; a 505 pg/mL cutoff yielded 82% sensitivity, 71% specificity, and 96% negative predictive value.
- Predictive performance for post-discharge AFDAS was modest (AUROC 0.65), and 20% had normal NT-proBNP (<125 pg/mL) at admission.
Methodological Strengths
- Pooled analysis of two prospective cohorts with standardized early biomarker measurement (≤24 hours)
- Clear outcome definition (≥30 s AF/flutter) and external validation of cutoff
Limitations
- Observational cohorts; potential heterogeneity between studies and unmeasured confounding
- Did not evaluate serial biomarker trajectories or cost-effectiveness of biomarker-guided monitoring
Future Directions: Randomized strategies allocating monitoring based on NT-proBNP, integration with ECG analytics and other biomarkers, and evaluation of outcomes/costs.
3. Cardiac rehabilitation and physical activity decrease the risk of stroke after acute myocardial infarction: A nationwide cohort study in Sweden.
In a nationwide cohort of 86,637 post-AMI patients, participation in exercise-based cardiac rehab (24 sessions) was associated with lower total stroke risk (aHR 0.85). Self-reported ≥150 min/week of physical activity also reduced risk (aHR 0.79), and six-day-per-week activity was linked to lower intracerebral hemorrhage versus the general population.
Impact: Provides robust, population-scale evidence that EBCR participation and higher physical activity after AMI are associated with stroke risk reduction, supporting stronger implementation of rehab programs.
Clinical Implications: Refer eligible AMI survivors to EBCR and counsel for at least 150 minutes/week of moderate activity; benefits extend to stroke prevention, not just cardiac outcomes.
Key Findings
- EBCR participation after AMI was associated with reduced total stroke risk versus non-participation (aHR 0.85; 95% CI 0.80–0.91).
- Self-reported ≥150 min/week physical activity reduced total stroke risk (aHR 0.79; 95% CI 0.75–0.83).
- Six-day-per-week activity post-AMI conferred no excess total/ischemic stroke risk versus general population and lower intracerebral hemorrhage risk (aHR 0.59; 95% CI 0.35–0.98).
Methodological Strengths
- Nationwide, double-cohort design with matched general population comparators
- Large sample size and time-to-event analyses with adjusted hazard ratios
Limitations
- Observational design with potential residual confounding and selection bias into EBCR
- Physical activity was self-reported, introducing measurement error
Future Directions: Evaluate strategies to increase EBCR uptake and sustained physical activity; assess causal effects via pragmatic trials and study dose–response relationships.