News in brief:  TAVI funded for all patients with severe AS; Starting low dose aspirin is high risk time for GI bleed; Reassurance on testosterone and cardiovascular risk

Thursday, 23 Jun 2022

TAVI funded for all patients with severe AS

Interventional cardiologists are welcoming the imminent extension of Medicare funding of TAVI for all patients with severe aortic stenosis including those at low surgical risk, which comes into effect from 1 July.

As previously reported in the limbic, a new MBS item 38522 will be introduced for the lower-risk patient cohort, with administrative amendments to items 38495 and 38514.

Dr Ronen Gurvitch, a TAVI specialist at the Royal Melbourne Hospital and One Heart Cardiology, Melbourne said the MBS listing would allow more eligible patients to access the minimally invasive, non-surgical treatment as an alternative to surgical aortic valve replacement (SAVR).

“The treatment paradigm for AS has shifted. Traditionally, TAVI was only available to the oldest and frailest patients deemed too high risk to survive open heart surgery. However, data supports the use of TAVI as a therapy option for all patients with severe aortic stenosis,” said Dr Gurvitch.

“TAVI offers significant benefits over surgery, including reduced procedure time, less time in hospital, a shorter recovery period, lower risk of complications, improved quality of life, and extended life expectancy,” he said.

According to Dr Gurvitch, for patients with severe symptomatic aortic stenosis, TAVI results in 46% lower rates of death, stroke and re-hospitalisation within the first year of the procedure, compared to SAVR. And at two years following TAVI shows continued superiority over surgery, with 34% lower rates of death, stroke, and rehospitalisation.

“The MBS expansion of TAVI will better facilitate shared decision-making between Heart Teams and their severe AS patients, enabling us to choose the most suitable treatment based on anatomical factors, latest clinical evidence and patient preferences,” he said.

Starting low dose aspirin is high risk time for GI bleed

The increased risk of gastrointestinal bleeding with low dose aspirin is seen mostly in new users, with less risk seen among long term users, a study has found.

A review of GI bleeding risks in two cohorts of patients from the UK (214,000) and Germany (7700) found that there was no significant association between low-dose aspirin and gastric ulcer overall observed in both cohorts.

Low-dose aspirin showed a weak association with prevalent duodenal ulcer in one cohort. However when looking only at new users of aspirin the hazard ratios for incident gastric and duodenal ulcer disease were 1.82 and 1.66 respectively in the UK cohort and 2.83 and 3.89 in the German cohort.

“The lower gastrointestinal risk observed in prevalent users [of aspirin] is presumably caused by either a physiological adaption to aspirin effects, the sick-stopper bias, or both,” the authors said.

They said the greatest vigilance for GI bleeding risk was needed on initiation of low dose aspirin, whereas once low-dose aspirin therapy is started, adverse events monitoring is recommended to ensure its safe long-term use.

“Individuals already using low-dose aspirin for years, who do not experience unusual gastrointestinal symptoms, may tolerate the drug well,” they added.

Reassurance on testosterone and cardiovascular risk

There is little evidence that testosterone treatment increases the risk of cardiovascular events, according to a systematic review and meta-analysis of the available data.

The meta-analysis comprising more than 3,400 patients with hypogonadism from 17 clinical trials found the rate of cardiovascular events in people treated with testosterone was 7·5% compared to 7·2% in people receiving placebo.

Fewer deaths were reported during testosterone (0·4% v 0·8%) however the numbers were too small to establish whether testosterone reduced mortality risk.

The reassuring findings suggest that men given testosterone to treat hypogonadism are at no greater risk of heart attack, stroke, and other cardiovascular events in the short-to-medium term than men who do not receive testosterone treatment.

Read more in The Lancet Healthy Longevity 

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