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Top News From ACC 2016: Slideshow

Steve Stiles; Darbe Rotach; Patrice Wendling; Deborah Brauser; Marlene Busko; Megan Brooks; John Gress; Jeff Haynes  |  April 28, 2016

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Slide 1

The windy city of Chicago hosted the American College of Cardiology (ACC) 2016 Scientific Sessions, held April 2 to 4, which featured more than 2400 original research presentations. Population health, with emphasis on lifestyle and prevention, was a theme the college showcased this year.

Slide 2

Among the key studies presented:

  • HOPE-3: Statins cut CV events in intermediate-CHD-risk patients
  • GAUSS-3: Evolocumab cuts LDL-C in statin-intolerant patients
  • Rhythm vs rate control: A toss-up for postoperative AF
  • Selective valve repair at CABG in moderate ischemic MR
  • Simple shared decision-making tool helpful in low-risk chest pain patients
  • Cryoablation on par with radiofrequency ablation in paroxysmal AF
  • Stem-cell therapy improves clinical outcomes in heart failure
Slide 3

HOPE-3: Statins Lower CV Events in Intermediate-CHD-Risk Patients

Cholesterol-lowering therapy alone and with blood-pressure (BP)–lowering treatment may prevent CV events in patients considered at "intermediate risk" for CHD—but BP lowering alone doesn't do the trick unless BP was high to begin with, hint primary results from the Heart Outcomes Prevention Evaluation-3 (HOPE-3) trial, which included almost 13,000 participants without CVD. "It's interesting that statins are not a new antihypertensive. It very clearly showed that it had no effect on blood pressure—but it stopped the events in the hypertensive people," said ACC president Dr Kim Alan Williams (Rush University Medical Center, Chicago, IL). "To see that half of the benefit was in that group with the statin and half in antihypertensive treatment, that's not something people thought of before," said Williams. "We don't need to give dyslipidemic people an antihypertensive. But we may need to give antihypertensive therapy and statins to those who are hypertensive."

Slide 4

GAUSS-3: Evolocumab Cuts LDL-C in Statin-Intolerant Patients

Taking the PCSK9 inhibitor evolocumab (Repatha, Amgen) for 6 months dramatically reduced LDL cholesterol in patients with both uncontrolled LDL-C levels and statin intolerance in the Goal Achievement After Utilizing an Anti-PCSK9 Antibody in Statin Intolerant Subjects 3 (GAUSS-3) trial. "This is important because it means we have established that you can use PCSK9 inhibitors successfully in people with well-documented statin intolerance," said lead investigator Dr Steven E Nissen (Cleveland Clinic, OH). The coauthors of an editorial, published with the study in JAMA to coincide with presentation here, said balancing the symptoms of muscle aches with the proven benefits of statins for reducing CV events "can be a difficult clinical challenge." While several questions remain, someone at high risk for a CV event and intolerable muscle ache even with a low-dose statin "should be considered a candidate for this treatment." However, "less than 1% of all 'statin-intolerant' patients might belong in this group," the editorialists wrote.

Slide 5

Rhythm vs Rate Control: A Toss-up for Postoperative AF

Atrial fibrillation developing after heart surgery responds similarly to either rate-control or rhythm-control measures, according to a randomized trial of >500 patients assigned to one or the other strategy in conjunction with CABG, valve surgery, or both. The two groups each experienced an average of about 5 days of hospitalization, including emergency-department visits, during the 60 days after the index surgery, which was the primary end point of the study exploring a common postoperative problem for which there is little consensus on therapy. Rates of persistent AF and of complications were also similar at 60 days. "There's no clear advantage of one treatment strategy over the other in terms of hospital days or complications," said lead author Dr A Marc Gillinov (Cleveland Clinic Foundation, OH). "Most of the time, more than 90% of the time, most of the atrial fibrillation is going to be gone by 60 days no matter what we do." But, he said, "I personally would favor rate control."

Slide 6

Selective Valve Repair at CABG in Moderate Ischemic MR

For patients with moderate ischemic mitral regurgitation (MR) who are candidates for surgery, adding mitral-valve repair to CABG won't improve survival, cardiac structure, or function, nor will it boost quality-of-life scores over 2 years compared with CABG alone, according to an extended follow-up of 301 such patients that mostly confirms results seen at 1 year. But the results deserved a more nuanced interpretation and support an individualized approach, the investigators said. Strictly speaking, overall in the cohort there was "no meaningful advantage" to the addition of mitral repair, whether in terms of the study's primary end point of change in left ventricular end-systolic volume index, reflecting reverse ventricular remodeling, or in secondary clinical end points. The latter included mortality, major adverse cardiac events, and hospitalization over 2 years, reported Dr Robert E Michler (Montefiore Medical Center–Albert Einstein College of Medicine, New York).

Slide 7

Shared Decision Making in Low-Risk Chest Pain: Safe, Fewer Tests

A single-page shared decision-making tool helps low-risk chest-pain patients who present to the emergency department better understand their health status and options and may reduce the use of stress tests and imaging, possibly cutting costs, all without increasing risk, a study suggests. The four-part decision aid was developed at the Mayo Clinic using patient-friendly language and graphics to educate and facilitate discussion on how heart attack is ruled out, explain stress testing and coronary CT angiography, provide personal risk evaluation, and detail options for follow-up testing. Videotaping revealed use of the Chest Pain Choice (CPC) aid added just 1.3 minutes to the patient encounter, reported study author Dr Erik Hess (Mayo Clinic, Rochester, MN). The Chest Pain Choice Trial was conducted at six emergency departments in five states and involved >900 adults presenting with chest pain and under consideration for further testing who were randomized to treatment using the CPC or standard care.

Slide 8

Cryoablation Matches RF Ablation in Paroxysmal Atrial Fibrillation

Cryoballoon ablation efficacy and safety was on par with radiofrequency catheter (RFC) ablation for the treatment of paroxysmal atrial fibrillation (PAF) in the FIRE and ICE trial. "I think they are great results from a practical point of view, from a physician's point of view, and, in particular, from the patient's point of view, because it will allow more patients to get access to catheter ablation; that's what we really need," said lead author Dr Karl-Heinz Kuck (Asklepios Klinik St Georg, Hamburg, Germany). Altogether, 762 PAF patients were randomized to pulmonary-vein isolation by cryoballoon ablation with phrenic-nerve pacing or RFC ablation with 3D electroanatomical mapping. The primary efficacy end point of time to first recurrence of AF >30 s, atrial flutter, or atrial tachycardia, use of antiarrhythmic drugs, or reablation occurred in 34.6% of the cryoablation group and 35.9% of RFC patients. Kuck is working on the third update to the Heart Rhythm Society consensus statement and said he expects the FIRE and ICE trial to become a part of the new guidelines.

Slide 9

Stem-Cell Therapy Improves Clinical Outcomes in Heart Failure

Stem-cell therapy injected into the myocardium significantly reduced clinical cardiac events in patients with ischemic heart failure. At 1 year, patients treated with ixmyelocel-T had a 37% relative reduction in the risk of all-cause mortality, CV-related hospital admissions, and unplanned clinic visits to treat acute decompensated heart failure. But the multicellular therapy had no effect on the secondary end points of LVEF or LV volumes, said Dr Timothy D Henry (Cedars Sinai Heart Institute, Los Angeles, CA). Henry said the greater effect on clinical events than LVEF is actually consistent with other cell-therapy trials. "Ixmyelocel-T appears to be an attractive option for NYHA class 3/4 patients with ischemic heart failure who have exhausted optimal medical and device therapy," he said. Ixmyelocel-T involves extracting bone-marrow cells and expanding them over 2 weeks to increase two key types of mononuclear cells: CD90+ mesenchymal stem cells and CD45+ and CD14+ macrophages, Henry explained.

Slide 10

Very High LDL Seldom Caused by FH Gene Variants

Only a small fraction of those with very high LDL-C levels carry one of the known genes that cause familial hypercholesterolemia (FH), a new study finds. However, for any two individuals with the same LDL level, those with these gene variants have a significantly increased risk for coronary artery disease. Gene sequencing in more than 26,000 individuals with LDL-C 190 mg/dL or higher revealed that only 1.7% had a known FH mutation, a low diagnostic yield. "However, with respect to clinical importance, for any given LDL, we demonstrate largely for the first time, that the risk of coronary disease is substantially higher in those who have an FH mutation, and we think this is likely related to cumulative exposure to LDL," said study presenter Dr Amit V Khera (Massachusetts General Hospital, Boston). From his perspective, "one of the most interesting results" was a substantial increase in coronary risk even at normal LDL-cholesterol levels, less than 130 or the 130–160 range. "So I think this cumulative exposure issue is real, and it's relevant, even at normal levels of observed LDL," Khera said.

Slide 11

Empowered Pharmacists Lower Patients' Cardiac Risk in RxEACH

A community-based pharmacist intervention in Alberta, Canada—where authorized pharmacists can prescribe and adjust medications and doses—reduced the estimated risk for CV events by 21% in 3 months. These benefits were seen in the RxEACH study of 700 high-risk patients who had at least one uncontrolled risk factor (hypertension, hyperglycemia, hyperlipidemia, smoking) and were randomized to usual pharmacist care or a targeted intervention designed to lower CVD risk. "We think [this] represents a new paradigm of community-based cardiovascular risk reduction," said study presenter Dr Ross T Tsuyuki (University of Alberta, Edmonton). "Engaging pharmacists could bring another 450,000 'helping hands' in the US and Canada to help reduce the burden of cardiovascular disease," according to Tsuyuki and colleagues. "We would encourage policy makers to consider broadening the scope of practice of pharmacists (as in Alberta) and for pharmacists and pharmacy professional organizations to seize these opportunities for the betterment of patient care," they conclude.

Slide 12

Patients Often Unaware of ICD Issues Near End of Life

Many patients with ICDs across the world don't realize that device shocks are common in the final hours of life and that deactivation is an option, suggests a new study, with the researchers saying cardiologists need to do a better job of explaining these issues. Dr Dilek Yilmaz (Leiden University Medical Center, the Netherlands) and colleagues assessed 328 ICD patients who attended an educational symposium in the Netherlands. They found that 27% didn't know their ICDs could be deactivated, 36% didn't know about shock risks near end of life, and 50% hadn't thought about end-of-life ICD therapy at all. And only 12% of the participants had discussed any of this with their caregivers. The investigators say while the findings show that patient awareness of the issues is somewhat "reasonable" overall, there's definitely room for improvement—and that frank talks between patients and cardiologists and/or ICD nurses "remain limited."

Slide 13

Calls for Higher Heparin-Dosing Caps in Obese With ACS

A small, single-center analysis suggests that it may be time to increase the recommended maximum, weight-based unfractionated-heparin bolus and infusion doses for patients with ACS so as to extend optimal anticoagulation to the growing number of these patients who are obese. In this study of 197 patients who mostly had NSTEMI or unstable angina, in which more than half weighed over 80 kg (176 lbs), patients treated with a more aggressive IV heparin-dosing protocol (that allowed for higher-than-guideline-recommended maximal weight-based heparin doses) were more likely to quickly reach a therapeutic INR range than patients who were treated with a guideline-based protocol—without any increased bleeding risk. "We need to readjust our current strategy and dosing for heparin because it doesn't take into account the [more overweight and obese] population that we're treating . . . in the United States now," said lead author Dr Barbara S Wiggins (Medical University of South Carolina, Charleston).

Image from iStock

Slide 14

Morphine at Acute MI May Blunt Short-Term Antiplatelet Response

Among patients who presented with an acute STEMI who were about to undergo PCI, those who had received morphine to ease severe chest pain had a weakened response to antiplatelet agents compared with other patients, in a small study. Blood tests showed that the patients who had received morphine in the ambulance en route to the hospital had worse measures of platelet activity within an hour of receiving a loading dose of aspirin plus ticagrelor or clopidogrel, but this difference disappeared within 48 hours. "Morphine has been widely used to alleviate chest pain and anxiety of patients suffering from an acute MI, but it is also known that this drug can delay gastric emptying and reduce the absorption of other oral medications," said Dr Nikolaos Spinthakis (East and North Hertfordshire NHS Trust, UK). This study showed that "opioid treatments can reduce the antiplatelet effect of ADP-receptor antagonists." Until large clinical trials confirm this finding, "caution should be exercised in the use of IV morphine and consideration given to other intravenous medication if morphine treatment is to be used," Spinthakis said.

Image from iStock

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