Left Atrial Appendage Occlusion vs Oral Anticoagulation—No Free Lunch
https://jamanetwork.com/journals/jamacardiology/fullarticle/2853343
Atrial fibrillation (AF) is a leading cause of ischemic stroke. Moreover, strokes due to AF are more likely to have larger infarct volume, more frequent hemorrhagic transformation, and more severe disability and mortality. Oral anticoagulation (OAC) is recommended in individuals with AF who are at increased risk for stroke. Although OAC is highly effective at reducing the risk of stroke, adherence to OAC is challenging due to the risk of bleeding, adverse effects like bruising, and financial cost. Transesophageal echocardiography and autopsy data suggest that approximately 90% of embolic strokes in individuals with nonrheumatic AF are due to thrombi that originate in the left atrial appendage. Thus, in theory, percutaneous left atrial appendage occlusion (LAAO) should reduce the risk of ischemic stroke and reduce the risk of bleeding if patients can discontinue OAC. Yet as with any procedure, LAAO has risks, including procedural complications, incomplete seal, device-related thrombus, and a need for postprocedural antithrombotic therapy. The 2023 American College of Cardiology (ACC)/American Heart Association (AHA)/American College of Clinical Pharmacy (ACCP)/Heart Rhythm Society (HRS) guidelines state that percutaneous LAAO may be a reasonable alternative to OAC based on patient preference in those with AF who have a high risk of major bleeding (class 2b).
https://jamanetwork.com/journals/jamacardiology/fullarticle/2853343
Atrial fibrillation (AF) is a leading cause of ischemic stroke. Moreover, strokes due to AF are more likely to have larger infarct volume, more frequent hemorrhagic transformation, and more severe disability and mortality. Oral anticoagulation (OAC) is recommended in individuals with AF who are at increased risk for stroke. Although OAC is highly effective at reducing the risk of stroke, adherence to OAC is challenging due to the risk of bleeding, adverse effects like bruising, and financial cost. Transesophageal echocardiography and autopsy data suggest that approximately 90% of embolic strokes in individuals with nonrheumatic AF are due to thrombi that originate in the left atrial appendage. Thus, in theory, percutaneous left atrial appendage occlusion (LAAO) should reduce the risk of ischemic stroke and reduce the risk of bleeding if patients can discontinue OAC. Yet as with any procedure, LAAO has risks, including procedural complications, incomplete seal, device-related thrombus, and a need for postprocedural antithrombotic therapy. The 2023 American College of Cardiology (ACC)/American Heart Association (AHA)/American College of Clinical Pharmacy (ACCP)/Heart Rhythm Society (HRS) guidelines state that percutaneous LAAO may be a reasonable alternative to OAC based on patient preference in those with AF who have a high risk of major bleeding (class 2b).
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Inequities in Age-Related Perinatal Cardiometabolic Risk
https://jamanetwork.com/journals/jamacardiology/fullarticle/2853335
This cross-sectional study quantifies disparities in age-related risk of perinatal cardiometabolic conditions at the intersection of race and ethnicity and socioeconomic status.
https://jamanetwork.com/journals/jamacardiology/fullarticle/2853335
This cross-sectional study quantifies disparities in age-related risk of perinatal cardiometabolic conditions at the intersection of race and ethnicity and socioeconomic status.
Vutrisiran and Transthyretin Amyloidosis With Cardiomyopathy
https://jamanetwork.com/journals/jamacardiology/fullarticle/2853333
This post hoc analysis of a randomized clinical trial investigates the association of right ventricular (RV) function with clinical outcomes and evaluates the effect of vutrisiran on measures of RV function.
https://jamanetwork.com/journals/jamacardiology/fullarticle/2853333
This post hoc analysis of a randomized clinical trial investigates the association of right ventricular (RV) function with clinical outcomes and evaluates the effect of vutrisiran on measures of RV function.
Left Atrial Systolic Collapse in Cardiac Tamponade
https://jamanetwork.com/journals/jamacardiology/fullarticle/2853341
This case report discusses cardiac tamponade identified through left atrial collapse in a woman in her late 60s with a history of hypertension and diabetes who presented with progressive dyspnea and chest pain.
https://jamanetwork.com/journals/jamacardiology/fullarticle/2853341
This case report discusses cardiac tamponade identified through left atrial collapse in a woman in her late 60s with a history of hypertension and diabetes who presented with progressive dyspnea and chest pain.
Bleeding and Stroke Prevention After Left Atrial Appendage Occlusion
https://jamanetwork.com/journals/jamacardiology/fullarticle/2853340
To the Editor Schmidt et al provide informative, long-term data on major bleeding (MB) after left atrial appendage occlusion (LAAO). However, several aspects merit further discussion in the context of the evolving use of LAAO and contemporary postprocedural management.
https://jamanetwork.com/journals/jamacardiology/fullarticle/2853340
To the Editor Schmidt et al provide informative, long-term data on major bleeding (MB) after left atrial appendage occlusion (LAAO). However, several aspects merit further discussion in the context of the evolving use of LAAO and contemporary postprocedural management.
Venous Thromboembolism Risk and Lipid-Lowering Therapy
https://jamanetwork.com/journals/jamacardiology/fullarticle/2853339
To the Editor The post hoc analysis of the CLEAR Outcomes trial by Spiazzi and colleagues provides a clinically stimulating observation: bempedoic acid was associated with a 42% relative reduction in venous thromboembolism (VTE) among statin-intolerant patients at high cardiovascular risk or with established cardiovascular disease. This quantitative signal is particularly relevant because VTE, encompassing deep vein thrombosis and pulmonary embolism, remains a frequent and potentially severe condition, associated with substantial morbidity, mortality, recurrence, and health care burden.
https://jamanetwork.com/journals/jamacardiology/fullarticle/2853339
To the Editor The post hoc analysis of the CLEAR Outcomes trial by Spiazzi and colleagues provides a clinically stimulating observation: bempedoic acid was associated with a 42% relative reduction in venous thromboembolism (VTE) among statin-intolerant patients at high cardiovascular risk or with established cardiovascular disease. This quantitative signal is particularly relevant because VTE, encompassing deep vein thrombosis and pulmonary embolism, remains a frequent and potentially severe condition, associated with substantial morbidity, mortality, recurrence, and health care burden.
Revised Supplement 2
https://jamanetwork.com/journals/jama/fullarticle/2853352
The Original Investigation titled “Estimated Glomerular Filtration Rate, Albuminuria, and Adverse Outcomes: An Individual-Participant Data Meta-Analysis,” published on October 3, 2023, was corrected to update Supplement 2. In the original supplement, eTable 21 and eTable 22 were identical and did not have the correct information. This article was corrected online.
https://jamanetwork.com/journals/jama/fullarticle/2853352
The Original Investigation titled “Estimated Glomerular Filtration Rate, Albuminuria, and Adverse Outcomes: An Individual-Participant Data Meta-Analysis,” published on October 3, 2023, was corrected to update Supplement 2. In the original supplement, eTable 21 and eTable 22 were identical and did not have the correct information. This article was corrected online.
Cannabinoid Hyperemesis Syndrome
https://jamanetwork.com/journals/jama/fullarticle/2853351
This JAMA Insights discusses cannabinoid hyperemesis syndrome, including pathophysiology, clinical presentation, and the epidemiology and risk factors.
https://jamanetwork.com/journals/jama/fullarticle/2853351
This JAMA Insights discusses cannabinoid hyperemesis syndrome, including pathophysiology, clinical presentation, and the epidemiology and risk factors.
Amoxicillin-Clavulanate vs Amoxicillin for Sinusitis
https://jamanetwork.com/journals/jama/fullarticle/2853350
To the Editor The retrospective cohort study by Dr Savage and colleagues compared outcomes of narrow- vs broader-spectrum antibiotics for acute sinusitis. Although the authors’ findings support use of amoxicillin when antibiotics are prescribed, the underlying assumption that most patients truly had acute bacterial sinusitis warrants closer scrutiny.
https://jamanetwork.com/journals/jama/fullarticle/2853350
To the Editor The retrospective cohort study by Dr Savage and colleagues compared outcomes of narrow- vs broader-spectrum antibiotics for acute sinusitis. Although the authors’ findings support use of amoxicillin when antibiotics are prescribed, the underlying assumption that most patients truly had acute bacterial sinusitis warrants closer scrutiny.
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Amoxicillin-Clavulanate vs Amoxicillin for Sinusitis
https://jamanetwork.com/journals/jama/fullarticle/2853349
To the Editor Dr Savage and colleagues reported no difference in treatment failure between standard-dose amoxicillin-clavulanate and amoxicillin among adults aged 18 to 64 years treated for outpatient acute sinusitis, whereas amoxicillin-clavulanate was associated with higher risks of yeast infection and Clostridioides difficile infection. These findings are important for antimicrobial stewardship and support narrower-spectrum therapy when antibiotics are indicated for uncomplicated acute sinusitis.
https://jamanetwork.com/journals/jama/fullarticle/2853349
To the Editor Dr Savage and colleagues reported no difference in treatment failure between standard-dose amoxicillin-clavulanate and amoxicillin among adults aged 18 to 64 years treated for outpatient acute sinusitis, whereas amoxicillin-clavulanate was associated with higher risks of yeast infection and Clostridioides difficile infection. These findings are important for antimicrobial stewardship and support narrower-spectrum therapy when antibiotics are indicated for uncomplicated acute sinusitis.
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Parental Support Package for Pregnant and Postpartum Trainees
https://jamanetwork.com/journals/jama/fullarticle/2853368
To the Editor The recent article on a pragmatic parental support package to mitigate burnout among pregnant and postpartum trainees addressed a real and underrecognized problem. However, the proposed parental support package did not address the structural determinants of burnout in this population, and framing it as a meaningful solution risks diverting attention from reforms with greater demonstrated impact.
https://jamanetwork.com/journals/jama/fullarticle/2853368
To the Editor The recent article on a pragmatic parental support package to mitigate burnout among pregnant and postpartum trainees addressed a real and underrecognized problem. However, the proposed parental support package did not address the structural determinants of burnout in this population, and framing it as a meaningful solution risks diverting attention from reforms with greater demonstrated impact.
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Parental Support Package for Pregnant and Postpartum Trainees—Reply
https://jamanetwork.com/journals/jama/fullarticle/2853367
In Reply We share the conviction of Dr Patek and colleagues that parental leave is critically important for the well-being of childbearing trainees. We believe, however, that burnout among childbearing trainees is multifactorial, and the empirical evidence does not support paid parental leave as the single most important intervention to reduce burnout in this population. While foundational, leave policies do not address many stressors that emerge during pregnancy or after trainees return to clinical work. As Patek and colleagues note, regardless of leave duration, trainees ultimately transition back to work, and support is needed when they do.
https://jamanetwork.com/journals/jama/fullarticle/2853367
In Reply We share the conviction of Dr Patek and colleagues that parental leave is critically important for the well-being of childbearing trainees. We believe, however, that burnout among childbearing trainees is multifactorial, and the empirical evidence does not support paid parental leave as the single most important intervention to reduce burnout in this population. While foundational, leave policies do not address many stressors that emerge during pregnancy or after trainees return to clinical work. As Patek and colleagues note, regardless of leave duration, trainees ultimately transition back to work, and support is needed when they do.
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ADVOCATing for Patients With Heart Failure
https://jamanetwork.com/journals/jama/fullarticle/2853366
The ADVOCATE initiative and how autonomous AI agents could help patients with heart failure are discussed by JAMA+ AI Editor in Chief Roy Perlis, MD, MSc, and Haider Warraich, MD, a cardiologist and the program manager at ARPA-H, for the JAMA+ AI Conversations podcast.
https://jamanetwork.com/journals/jama/fullarticle/2853366
The ADVOCATE initiative and how autonomous AI agents could help patients with heart failure are discussed by JAMA+ AI Editor in Chief Roy Perlis, MD, MSc, and Haider Warraich, MD, a cardiologist and the program manager at ARPA-H, for the JAMA+ AI Conversations podcast.
Nomenclature
https://jamanetwork.com/journals/jama/fullarticle/2853365
In this narrative medicine essay, a maternal-fetal medicine physician trained to use clinical terms for developmental stages of pregnancy as an emotional stay against an uncertain outcome experiences tension between clinical and lived language during his wife’s miscarriage.
https://jamanetwork.com/journals/jama/fullarticle/2853365
In this narrative medicine essay, a maternal-fetal medicine physician trained to use clinical terms for developmental stages of pregnancy as an emotional stay against an uncertain outcome experiences tension between clinical and lived language during his wife’s miscarriage.
AI and Echocardiography
https://jamanetwork.com/journals/jamacardiology/fullarticle/2853494
There is a burden of undiagnosed aortic stenosis (AS) in the community—1% of older individuals—which is small but important. This problem has increased with population aging, and the desirability of detection has increased with access to percutaneous management of AS. The limitations of current practice—based on case finding by symptoms, examination findings, or known risk factors—are reflected in the patients who present in extremis from undiagnosed AS and with cardiac damage from prolonged pressure load. However, efforts to screen for AS have been stymied by variability in auscultation accuracy. While the enhancement of electrocardiography by artificial intelligence (AI) might help, this technique is still in development and validation. A combined approach of AI-guided transthoracic echocardiography (TTE) acquisition and interpretation might provide an inexpensive initial screening test that triages no significant AS from possible or uncertain AS, which then leads to comprehensive TTE, surveillance, and intervention.
https://jamanetwork.com/journals/jamacardiology/fullarticle/2853494
There is a burden of undiagnosed aortic stenosis (AS) in the community—1% of older individuals—which is small but important. This problem has increased with population aging, and the desirability of detection has increased with access to percutaneous management of AS. The limitations of current practice—based on case finding by symptoms, examination findings, or known risk factors—are reflected in the patients who present in extremis from undiagnosed AS and with cardiac damage from prolonged pressure load. However, efforts to screen for AS have been stymied by variability in auscultation accuracy. While the enhancement of electrocardiography by artificial intelligence (AI) might help, this technique is still in development and validation. A combined approach of AI-guided transthoracic echocardiography (TTE) acquisition and interpretation might provide an inexpensive initial screening test that triages no significant AS from possible or uncertain AS, which then leads to comprehensive TTE, surveillance, and intervention.
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AI-Enabled Aortic Stenosis Screening
https://jamanetwork.com/journals/jamacardiology/fullarticle/2853493
This diagnostic study develops and validates a deep learning algorithm to detect moderate or greater aortic stenosis and prospectively evaluates its performance using artificial intelligence–guided focused cardiac ultrasound acquired by novice operators.
https://jamanetwork.com/journals/jamacardiology/fullarticle/2853493
This diagnostic study develops and validates a deep learning algorithm to detect moderate or greater aortic stenosis and prospectively evaluates its performance using artificial intelligence–guided focused cardiac ultrasound acquired by novice operators.
Implantable Cardioverter-Defibrillators for Patients With an LVEF >35%
https://jamanetwork.com/journals/jama/fullarticle/2853396
The implantable cardioverter-defibrillator (ICD) remains a cornerstone therapy for the prevention of sudden cardiac death. Randomized clinical trials have demonstrated a survival benefit with ICDs for primary prevention in patients with a left ventricular ejection fraction (LVEF) of 35% or less; therefore, professional guideline recommendations on ICDs are based on this LVEF cutoff. However, most individuals who experience a sudden cardiac arrest do not have significant left ventricular dysfunction. Admittedly, these LVEF cutoffs are arbitrary, and the risk of sudden cardiac death is not dichotomous.
https://jamanetwork.com/journals/jama/fullarticle/2853396
The implantable cardioverter-defibrillator (ICD) remains a cornerstone therapy for the prevention of sudden cardiac death. Randomized clinical trials have demonstrated a survival benefit with ICDs for primary prevention in patients with a left ventricular ejection fraction (LVEF) of 35% or less; therefore, professional guideline recommendations on ICDs are based on this LVEF cutoff. However, most individuals who experience a sudden cardiac arrest do not have significant left ventricular dysfunction. Admittedly, these LVEF cutoffs are arbitrary, and the risk of sudden cardiac death is not dichotomous.
CMR to Guide Defibrillator Implantation for LVEF
https://jamanetwork.com/journals/jama/fullarticle/2853395
This randomized clinical trial compares the effects of an implantable cardioverter-defibrillator vs an implantable loop recorder on sudden cardiac death risk or hemodynamically significant ventricular arrhythmia in patients with a left ventricular ejection fraction of 36% to 50% and a myocardial scar.
https://jamanetwork.com/journals/jama/fullarticle/2853395
This randomized clinical trial compares the effects of an implantable cardioverter-defibrillator vs an implantable loop recorder on sudden cardiac death risk or hemodynamically significant ventricular arrhythmia in patients with a left ventricular ejection fraction of 36% to 50% and a myocardial scar.
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Cardiovascular Magnetic Resonance to Guide Defibrillator Implantation for LVEF of 36% to 50% Research Summary
https://jamanetwork.com/journals/jama/fullarticle/2853394
This trial tested whether implantable cardioverter-defibrillators (ICDs) reduce sudden cardiac death (SCD) or hemodynamically significant ventricular arrhythmia (HSVA) in patients with a left ventricular ejection fraction (LVEF) of 36% to 50% and myocardial scar.
https://jamanetwork.com/journals/jama/fullarticle/2853394
This trial tested whether implantable cardioverter-defibrillators (ICDs) reduce sudden cardiac death (SCD) or hemodynamically significant ventricular arrhythmia (HSVA) in patients with a left ventricular ejection fraction (LVEF) of 36% to 50% and myocardial scar.