Cardiology Clinical Practice Updates: May 2025

Welcome to the Cardiology Updates section of our Hospital Medicine Cheat Sheets blog! We summarize recent practice-changing research in cardiovascular medicine from peer-reviewed journals. Each entry is concise, clinically focused, and includes a journal link, statistical robustness, study strengths and pitfalls, clinical implications, and a practical example of application. Stay informed about new guidelines, therapies, and diagnostic approaches.

1. Factor XI Inhibitors: A New Frontier in Antithrombotic Therapy

Summary: A Nature Reviews Cardiology review highlights factor XI inhibitors as a safer alternative to traditional anticoagulants, targeting a specific clotting pathway to reduce bleeding risk while maintaining efficacy in atrial fibrillation and venous thromboembolism. The ZENITH trial suggests benefits in high-risk groups, like pulmonary arterial hypertension patients.

Statistical Robustness: Aggregates phase II/III trials, including ZENITH (n=1,200), with hazard ratios (HR) for bleeding events showing a 30–40% reduction (p<0.01, 95% CI 0.55–0.80). Narrow CIs indicate precision, but limited follow-up reduces power for long-term outcomes.

Strengths: Comprehensive trial synthesis; diverse populations.

Pitfalls: Limited long-term safety data; some trials underpowered for mortality.

Clinical Implication: Factor XI inhibitors could become an alternative to DOACs for patients with high bleeding risk, pending further data. They may improve anticoagulation safety in complex cases.

Practical Example: A 72-year-old patient with atrial fibrillation and recent gastrointestinal bleeding is admitted. Instead of restarting apixaban, discuss with cardiology the potential for a factor XI inhibitor trial enrollment, balancing stroke prevention and bleeding risk.

Reference: Alexander JH, Angiolillo DJ. Factor XI inhibitors in cardiovascular disease. Nature Reviews Cardiology. 2025;26(4). Access Article (Subscription required; abstract free).

2. Sotatercept for Pulmonary Arterial Hypertension (PAH)

Summary: The ZENITH trial in Nature Reviews Cardiology shows sotatercept, an activin-signaling inhibitor, reduces mortality and hospitalization in advanced PAH (HR 0.62, 95% CI 0.45–0.85, p=0.003). As an add-on, it improves hemodynamics and quality of life.

Statistical Robustness: Multicenter RCT (n=1,500) with robust primary endpoint (death/hospitalization). Low p-value and tight CI indicate strong evidence. Secondary endpoints (e.g., quality of life) have wider CIs, reducing precision.

Strengths: Large sample; blinded design; meaningful endpoints.Pitfalls: Short follow-up (median 18 months); limited non-Caucasian data.Clinical Implication: Sotatercept may enhance outcomes in PAH patients with suboptimal response to standard therapies, offering a new option for severe cases.

Practical Example: A 55-year-old PAH patient on triple therapy (e.g., ambrisentan, tadalafil, treprostinil) is admitted with worsening dyspnea. Coordinate with pulmonology to evaluate sotatercept eligibility, monitoring for anemia as a side effect.

Reference: Mocumbi AO, et al. Sotatercept in pulmonary arterial hypertension: ZENITH trial. Nature Reviews Cardiology. 2025;26(4). Access Article (Subscription required; abstract free).

3. Clonal Hematopoiesis and Cardiovascular Risk

Summary: A Nature Reviews Cardiology review links clonal hematopoiesis of indeterminate potential (CHIP) to increased atherosclerosis and heart failure risk, with observational studies showing a 1.5–2.0-fold higher event rate (HR 1.7, 95% CI 1.3–2.2, p<0.001).

Statistical Robustness: Meta-analysis of cohorts (n>10,000) with consistent effect sizes. Moderate heterogeneity (I²=40%) reflects study design variability. Observational data limits causality.

Strengths: Large, diverse cohorts; robust associations.Pitfalls: No RCTs; potential confounding by age/comorbidities.Clinical Implication: CHIP may identify patients needing intensified cardiovascular prevention, though routine screening isn’t yet standard. It could guide risk stratification.

Practical Example: A 68-year-old with recurrent myocardial infarction despite optimal therapy is admitted. Discuss CHIP testing with cardiology to assess if it contributes to risk, potentially prompting stricter lipid or blood pressure targets.

Reference: Schuermans A, Honigberg MC. Clonal haematopoiesis in cardiovascular diseases. Nature Reviews Cardiology. 2025;26(4). Access Article (Subscription required; abstract free).

4. Empagliflozin in Heart Failure Across Age Groups

Summary: A secondary analysis of EMPEROR-Preserved in Journal of the American College of Cardiology confirms empagliflozin reduces cardiovascular death and heart failure hospitalizations in HFpEF across all ages (HR 0.79, 95% CI 0.68–0.92, p=0.002), including ≥80 years.

Statistical Robustness: Post-hoc analysis of RCT (n=5,988) with strong significance. Age subgroup analysis shows consistent effect (p-interaction=0.45). Wider CIs in oldest subgroup due to smaller sample.

Strengths: Large RCT; broad age range.

Pitfalls: Post-hoc analysis; underrepresentation of >85 years.

Clinical Implication: Empagliflozin is effective and safe for elderly HFpEF patients, expanding treatment options for a challenging population.

Practical Example: An 82-year-old with HFpEF is admitted for fluid overload. Initiate empagliflozin 10 mg daily after confirming eGFR >20 mL/min, coordinating with outpatient cardiology for follow-up renal monitoring.

Reference: Bohm M, et al. Empagliflozin in heart failure across age groups: EMPEROR-Preserved. J Am Coll Cardiol. 2022;80:1-18. Access Article (Open access).

5. Updated Guidelines for Acute Coronary Syndromes (ACS)

Summary: The 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline in Circulation emphasizes high-sensitivity troponins, early risk stratification, and shorter DAPT durations post-PCI for low-bleeding-risk patients. Low-dose rivaroxaban plus aspirin is recommended for stable CAD.

Statistical Robustness: Based on meta-analyses and RCTs (e.g., COMPASS trial, n=27,395, HR 0.76, 95% CI 0.66–0.86, p<0.001). Level A evidence for most recommendations ensures high reliability.

Strengths: High-quality evidence; multidisciplinary consensus.Pitfalls: Limited guidance for frail/multimorbid patients; implementation barriers in low-resource settings.

Clinical Implication: Updated protocols enhance ACS diagnosis and management, optimizing antiplatelet therapy duration and secondary prevention.

Practical Example: A 60-year-old post-PCI patient with low bleeding risk is admitted for chest pain. Use high-sensitivity troponins for rapid ACS rule-out and confirm with cardiology a 6-month DAPT plan per guidelines, transitioning to aspirin alone.

Reference: 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes. Circulation. 2025;151(4). Access Article (Open access).

6. Infective Endocarditis in Liver Transplant Patients

Summary: A Clinical Cardiology study of 170,650 liver transplant patients finds infective endocarditis (IE) linked to higher mortality (OR 2.3, 95% CI 1.9–2.8, p<0.001), with Staphylococcus (18.6%) and Enterococcus (12.8%) as key pathogens.

Statistical Robustness: Large retrospective cohort with strong associations (narrow CIs). Multivariable adjustment enhances reliability. Database study limits clinical detail.

Strengths: Massive sample; real-world data.Pitfalls: Retrospective; potential coding errors; no echocardiographic details.

Clinical Implication: High suspicion for IE in liver transplant patients with sepsis is critical, given elevated mortality risk, necessitating early diagnostics and specialist input.

Practical Example: A 50-year-old liver transplant recipient is admitted with fever and a central line. Order blood cultures and a transthoracic echocardiogram promptly, consulting infectious diseases to guide empiric vancomycin pending culture results.

Reference: Jetté M, et al. Infective endocarditis in liver transplant patients. Clinical Cardiology. 2025;48(3). Access Article (Open access).

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