TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of Texas Tech Health El Paso, look at the top medical stories of the week.
This week’s topics include treatment for pulmonary embolism (PE), quality of life outcomes for atrial fibrillation (Afib) ablation, preserving cognitive function, and EKG monitoring and syncope.
Program notes:
0:44 EKG monitoring and syncope
1:45 No difference when monitored
2:45 Why not try monitoring?
3:13 Catheter-directed thrombolysis in PE
4:14 Composite of death from any cause
5:14 Assessment for intermediate or high risk
6:16 Treatment not onerous
6:45 Afib ablation versus sham
7:45 Did not improve quality of life
8:45 Preprocedure assessment of psychological state?
9:13 Digital intervention to protect cognitive health
10:13 Verbal reasoning at 12 months
11:13 As long as internet is available
12:15 What happens at 5-year follow-up
13:09 End
Transcript:
Elizabeth: Can we protect cognitive health in older people who already have cognitive impairment?
Rick: In individuals with atrial fibrillation, does catheter ablation improve their quality of life?
Elizabeth: Speaking of catheters, can we use them for thrombolysis in intermediate- and high-risk pulmonary embolism?
Rick: And in individuals who have fainted, does continuous EKG monitoring prevent further fainting?
Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: And I’m Rick Lange, president of Texas Tech Health El Paso.
Elizabeth: OK. Rick, let’s turn to the New England Journal of Medicine, and you were talking about fainting, otherwise known in the parlance as syncope. What about that?
Rick: Syncope, that’s when people have had a loss of consciousness and they spontaneously recover. Approximately 1.2 million emergency department visits in the U.S. annually because of this.
It’s usually caused from one of three things. It’s either neurocardiogenic, also called vasovagal syncope. It can be due to postural hypotension — the blood pressure goes down when people stand up. Or it can be due to cardiac syncope, due to structural heart disease. Unfortunately, about 50% of the people that present to the emergency department, no cause is found. If you take those individuals that are presented to the emergency department — you can’t identify a cause there — does placing a 14-day monitor help detect cardiac arrhythmias, and subsequently, that treatment reduce subsequent syncopal episodes?
They had almost 2,000 patients that presented to the emergency department. These are adults who they couldn’t explain the syncope, and half of them received a 14-day continuous EKG monitor, and the other half just usual care. And unfortunately, what they discovered is there was no difference between the two. The use of the monitor did not detect cardiac arrhythmias that precipitated treatment that prevented future syncopal episodes.
About 22% of the individuals had a cardiac arrhythmia that was felt to be significant. Rarely does antiarrhythmic therapy or medications effectively treat that. More commonly, the only thing that helps is when someone has a very low heart rate, have pauses, in which case a pacemaker may be helpful. About 5% that was detected; a pacemaker was put in.
There appeared to be, in a secondary analysis, a lower risk of death. About 3% of individuals that did not have the cardiac monitor experienced death over the next year versus about 1.5%. Whether it’s related or not is difficult to say, but the data are pretty clear. The monitor did not prevent recurrent syncope over the next year.
Elizabeth: Those monitors, of course, are fairly benign, so I would be inclined, I think, to say, why not try this just to see if we can discern some more information and whether there’s a condition that exists, such as bradycardia, that might benefit from having the placement of a pacemaker?
Rick: Does it reveal things that cause one to provide medications that, in fact, do have side effects? We’re trying to reduce syncope, but, in fact, it didn’t help at all. So despite the fact that the monitors are relatively harmless, they just don’t seem to be relatively useful.
Elizabeth: Let’s stay in the New England Journal of Medicine and talk about catheter-directed thrombolysis in people who have intermediate/high-risk pulmonary embolism. Pulmonary embolism, those clots in the lungs, are really not good to have. And I’ve always wondered why catheter-directed thrombolysis as very much what we do when somebody has a stroke that’s due to a clot, why aren’t we going in there and getting rid of them, IV medicines to try to break up the clot gradually? It seems like it just takes a very long time.
What they did in this interesting study in the Czech Republic is they had 558 patients who were randomized, 280 to a thrombolysis group and 278 to the standard-care group, just using medicines to try to break up the clot. They either got the catheter-directed thrombolysis with alteplase plus the anticoagulation therapy or anticoagulation therapy alone, their standard-care group. Their primary outcome, composite of death from any cause, recurrence of PE, cardiorespiratory decompensation or collapse within 7 days after randomization. And they also looked at secondary outcomes, including clinically relevant bleeding and intracranial hemorrhage.
One of their primary outcome events occurred in two patients, or 0.7%, in the thrombolysis group, and in 6.8% in the standard-care group. This difference was driven mainly by lower incidence of cardiorespiratory decompensation or collapse in the thrombolysis group. Clinically relevant bleeding occurred about as often in both groups. They had one patient in the thrombolysis group die within 30 days, and four patients in the standard group died. Hmm, sounds like we ought to be using this strategy for folks who have this condition.
Rick: Well, certainly in those who have intermediate or high risk, and they assess that by looking at a severity index. Did it involve the right ventricle? Was there a dysfunction? And was there evidence of cardiac damage, as assessed by biomarkers? If those three things were present, it put someone at a moderate or high risk of either having death, recurrent pulmonary emboli, or cardiovascular collapse. In that group, the use of catheter-directed thrombolysis was beneficial.
Statistically, it didn’t really reduce death, it didn’t really reduce recurrent PE, but it did reduce cardiovascular collapse, about a 90% reduction. It does require a hospital that can do the procedure. It requires expertise. It is invasive. It is costly. When patients present to a hospital that doesn’t have the capability, we need to provide a rapid transport to a place that does.
Elizabeth: I would note that as far as treatment goes in the thrombolysis group, their median time from randomization to initiation of catheter-directed thrombolysis was 76 minutes. They were able to successfully place the catheter and initiate the alteplase infusion in almost 100%, 99.6%, of the patients. And their mean duration of alteplase infusion was 9.3 hours. So it doesn’t seem that onerous to me.
Rick: No. Well, it doesn’t if you have the expertise to do it. And importantly, the study revealed it wasn’t associated with any increased bleeding risk compared to just giving thrombolytic therapy intravenously. This is a very well-done study that I think will change the way that we treat individuals that are intermediate or high risk with pulmonary emboli.
Elizabeth: Let’s move from here to The Lancet.
Rick: Atrial fibrillation — we’ve talked about this multiple times in different aspects — Afib ablation is recommended for individuals to either improve their quality of life or to maintain them into a regular rhythm.
The recent guidelines were published in 2024, the European Society of Cardiology guidelines, point to the fact that even though we recommend it for improving quality of life in people with atrial fibrillation, we’ve never really compared it to a sham procedure. This study did. It took 260 patients, randomized them 2:1 to either have catheter ablation or sham, and they followed these individuals over 6 months — ultimately, it’s going to be a 12-month study — and they assess atrial fibrillation effect on the quality of life questionnaire.
Six months after the procedure or the sham procedure was performed, catheter ablation did not, let me repeat it, did not demonstrate superiority over a sham procedure for improving atrial fibrillation-related quality of life at 6 months. These people were more likely to either be or remain in a regular rhythm, but it did not improve the quality of life, which is pretty surprising.
Elizabeth: It reminds me of other studies we’ve covered over the years that have been also employing this sham technique and demonstrating that, gosh, when we take a look at outcomes, oops, we’re not getting the outcome we thought we were going to get.
Rick: Yeah. I mean, it did do some things. It reduced the atrial fibrillation burden, atrial fibrillation recurrence, but it did not improve quality of life. That would imply that the quality of life is influenced in many individuals, not by atrial fibrillation, but for some other reasons. It may be that the quality of life is influenced by symptom perception. Having a procedure done could just improve anxiety and depression that these people oftentimes have. But it doesn’t appear that the reduction in atrial fibrillation burden alone fully accounts for all the changes in the patient-reported quality of life.
Elizabeth: Does this suggest to you, and I’m thinking here about bariatric surgery, for example, where before somebody has such a procedure, there’s an assessment of their psychological state and how that might be impacting. I’m wondering if this might be appropriate.
Rick: If we’re going to recommend Afib ablation for improving quality of life, we need to identify those patients in whom that will actually occur. At this particular time, we don’t know who those individuals are. And the other question is, this is just 6 months. We’ll have a 1-year follow-up, and it’ll be interesting to see whether the results at 1 year are the same as at 6 months.
Elizabeth: OK. So remaining in The Lancet then, this last study we’re going to talk about takes a look at whether a digital intervention to protect cognitive health in folks who already have some degree of cognitive impairment can help to preserve it.
This open-label trial occurred among adults 60 to 85 years of age with internet access and low cognitive scores. And that would be greater than or equal to one standard deviation below normal on the Baddeley verbal reasoning test, which is the cognitive criteria for age-associated cognitive decline. They randomized folks into one of three groups. That was something called the Active Brains website, which supports physical activity, a Mediterranean diet, and cognitive exercises. Active Brains plus brief support (three email or telephone sessions that constituted that brief support). Or a control group, which was just evidence-based advice for cognitive health. Their primary outcome was this Baddeley verbal reasoning score at 12 months. They’re going to have a follow-up for a coprimary outcome of dementia at 5 years. They had just shy of 12,000 participants from 670 practices. The 12-month data are available for their primary outcome for about 80% of their controls, 67% of their Active Brains, and 67% of their Active Brains plus.
Their verbal reasoning score was 18.3 in the control group, 18.7 in the Active Brains group, and 19.2 in the Active Brains-plus-the-support group. They say a substantial minority of folks in these groups, they showed that there was an improvement. And in fact, this improvement was enough to take them off of having this notion that they did have mild cognitive impairment, so they didn’t have that anymore. They feel that this is an effective strategy. It’s not very resource-intensive. As long as you have internet access, you can go ahead and do this on your own. It’s likely to help a certain subset of these people to preserve their cognitive function or even improve it slightly.
Rick: I found this pretty interesting. They either gave someone just a piece of paper saying, here’s what you do to keep your brain healthy, or they involved them in this online interactive Active Brains. And then the third group was they did that plus they had three consultations.
All three groups got better. The ones that had the Active Brains [did] slightly better, 32% or 33% of them moved off of mild cognitive impairment to being normal, as opposed to 28% just handed a sheet of paper. But in essence, just paying attention, and they all got somewhat better. And there were some that declined, and there were fewer of those in the Active Brains-plus group than in the control group.
But this tells me that what they’ve done is they’ve selected a group of individuals that were motivated, and even though they didn’t participate in the online, just handing them a sheet of paper, instructing them what to do to get better helped. I’ll be interested in seeing what happens at the 5-year follow-up to see whether this helps to reduce the incidence of dementia over the long term.
Elizabeth: The other thing that the authors note is that there were similar estimates of effect for older age groups, female participants, ethnic minorities, and areas of relatively higher deprivation. So that’s also a good outcome.
Rick: Now, there were some people that were randomized but didn’t participate. The reason for that is primarily because they had a lack of access to the internet; that was about 37%. And there were some that just weren’t interested. That was another 34%. So it works if you have access to internet and you’re motivated as well.
Elizabeth: And on that note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.
