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Top News From AHA 2015: Slideshow

Steve Stiles; Darbe Rotach; Allison Shelley; Michael O'Riordan; Deborah Brauser; Sue Hughes; Veronica Hackethal, MD; Megan Brooks; Fredy Perojo  |  November 23, 2015

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Slide 1

The widely anticipated full results of the SPRINT hypertension trial and a host of other potentially practicing-changing clinical trial results greeted attendees here at the American Heart Association (AHA) 2015 Scientific Sessions, held November 7 to 11, in Orlando, Florida.

Slide 2

In addition to SPRINT, other key trials presented at this year's sessions include:

  • CANOA: Clopidogrel cuts migraine after atrial septal defect closure
  • PRADA: Candesartan may reduce cardiotoxicity in breast-cancer patients
  • EVITA: Varenicline started during ACS hospitalization helps smokers quit
  • NEAT-HFpEF: Activity levels fall on nitrates in preserved-EF HF
  • Time to rethink continuous-compression CPR by EMS: RCT
  • Valve prosthesis tops repair for 2-year durability in ischemic MR
  • Inappropriate PCI on the decline in US
Slide 3

SPRINT: Push BP Target Lower in High-CV-Risk HTN Patients

Full results from the Systolic Blood Pressure Intervention Trial (SPRINT) headlined the meeting this year. Supporting top-line results reported in September, the trial of 9000 US nondiabetic hypertensive patients showed lower rates of cardiovascular events and all-cause mortality when treated to a systolic-blood-pressure target of 120 mm Hg rather than 140 mm Hg. The lower-target group had a 25% lower relative risk of the primary composite end point of MI, ACS, stroke, acute decompensated HF, and CV death vs the standard-target group. The lower-target group also had 27% lower risk of all-cause mortality and 43% lower risk of CV death, but higher adverse events such as hypotension, syncope, and acute kidney injury or failure. While questions remain, many experts agreed the findings have potentially practice-changing implications.

Slide 4

CANOA: Clopidogrel Reduces Migraine After ASD Closure

Three months of clopidogrel added to aspirin significantly reduced the frequency of migraine in patients who had undergone transcatheter closure of an atrial septal defect (ASD) in the CANOA study. Presenter Dr Josep Rodés-Cabau (Quebec Heart and Lung Institute, QC) noted that while some centers are already using clopidogrel on top of aspirin in these patients, others are using aspirin alone. "We believe that with these results clopidogrel should now be given routinely as well as aspirin after ASD closure," he said. The patients will be followed for up to 1 year. "We want to know whether 3 months of treatment is enough. We believe the device is fully endothelialized by 3 months, and it is rare to see migraines at 5 or 6 months, but we are interested in studying in which patients the migraines persist and in whom they disappear," Rodés-Cabau said.

Slide 5

Candesartan May Cut Cardiotoxicity in Breast Cancer Patients

For patients with early breast cancer, taking the angiotensin-receptor blocker candesartan cilexetil (Atacand) may reduce the risk of cardiac dysfunction, a common side effect of radiation and certain cancer medications. The PRADA trial of 120 women showed that those who received a daily 32-mg dose of adjunctive candesartan had a significantly smaller decline in left ventricular ejection fraction from baseline to end of cancer treatment vs those who received placebo (the primary end point, P=0.03). If further research can confirm a sustained, long-term effect of early angiotensin inhibition, "preventive therapy may be indicated as standard care," said lead investigator Dr Geeta Gulati (Akershus University Hospital, Lorenskog, Norway).

Slide 6

Rethink Continuous-Compression CPR by EMS: Randomized Trial

The largest randomized trial ever done in patients with cardiac arrest has shown that, when conducted by emergency medical services (EMS) personnel, CPR with continuous chest compressions and simultaneous ventilation is not better and may actually be worse than interrupting compressions for rescue breathing. "To our surprise, survival and neurologic recovery tended to be worse in the continuous-chest-compression group," said lead author Dr Graham Nichol (University of Washington, Seattle). Ironically, these new data were reported here just days after the AHA updated its resuscitation guidelines which recommend for the first time that continuous chest compressions can be used. This was based on several observational studies with historical controls. The major new randomized data—from a trial in 23,000 patients—is seen as the most definitive information on the issue to date and has led to calls for the new guidelines to be reevaluated as soon as possible.

Image from iStock

Slide 7

Varenicline Started in ACS Hospitalization Helps Smokers Quit

The smoking-cessation drug varenicline (Chantix/Champix), which has been shown to work in patients with stable coronary disease, can also help those hospitalized with acute coronary syndromes to kick the habit, according to the EVITA trial findings. Patients who were smokers and who started on varenicline while hospitalized for ACS were significantly more likely than a control group to be smoking-abstinent 24 weeks later. The smoking-cessation intervention also included low-level counseling, a mean of 46 minutes total for the entire trial. "Our results are important because clinical trials have not examined the efficacy of nicotine-replacement therapy in this patient population and because several trials of bupropion in these patients suggest that it is not efficacious," Dr Mark J Eisenberg (Jewish General Hospital/McGill University, Montreal, QC) and colleagues note in a report published in Circulation to coincide with presentation here.

Slide 8

Extend SPRINT Results to Diabetics: New ACCORD Data

The benefits of intensive blood-pressure lowering to a target of less than 120 mm Hg systolic for nondiabetic patients at high cardiovascular risk, as shown in the SPRINT trial, should be extended to diabetic patients, said ACCORD trial lead investigator Dr William C Cushman (VA Medical Center, Memphis, TN). "The bottom-line message is we don't have level-A evidence to treat diabetics to a target of 120 mm Hg, but taking into account results from the standard-glycemic-control arm of ACCORD, including those from long-term follow-up, and the stroke benefit seen in the main trial, together with the SPRINT results, I would say it is appropriate to include diabetic patients when making recommendations on intensive blood-pressure control. In addition, we have to take into consideration the fact that in most trials the benefits of blood-pressure reduction in diabetics are at least as good if not better than in nondiabetics," he noted.

Slide 9

NEAT-HFpEF: Activity Levels Fall on Nitrates in Preserved-EF HF

Activity levels in patients with heart failure with preserved ejection fraction (HFpEF) fell while they were on isosorbide mononitrate for a month compared with a similar period on placebo, in a small randomized, crossover trial. At the same time, nitrate therapy was not associated with significantly better 6-minute-walk distance, natriuretic-peptide levels, or quality-of-life scores in the 110-patient trial. The trial doesn't support the empiric use of nitrates to improve symptoms in HFpEF, and "it certainly provides a fairly strong signal that it may have adverse effects on activity," noted Dr Margaret M Redfield (Mayo Clinic, Rochester, MN). Dr Clyde Yancy (Northwestern University, Chicago IL) called the adverse effect on activity levels with the nitrate "a very peculiar observation. It could just be the play of chance, it's not a very large study." Or it's possible that the effect was real and related to the specific long-acting nitrate used, for which "nitrate tolerance happens pretty quickly."

Slide 10

Valve Prosthesis Beats Repair for 2-Year Durability in Ischemic MR

Two-year outcome data suggest that patients with severe ischemic mitral regurgitation (MR) fare just as well when the valve is repaired or replaced, at least when it comes to measures of left ventricular reverse remodeling and survival, but that replacing the mitral valve provides a more durable correction of MR. The bottom line, say investigators, is that the 2-year data reveal a divergence in clinical outcomes not evident at 1 year. The deficiency in the durability of correction of MR with surgical repair is "disconcerting," they add, noting that MR recurrence predisposes patients to heart failure, atrial fibrillation, increased hospitalizations, and other adverse outcomes. Dr Daniel Goldstein (Montefiore Medical Center/Albert Einstein College of Medicine, New York) reported the 2-year results here with simultaneous publication in the New England Journal of Medicine.

Slide 11

IVUS-Guided PCI With Xience Stent Reduces Revascularizations

A strategy of using intravascular ultrasound (IVUS) to guide the implantation of an everolimus-eluting stent (Xience Prime) for long lesions led to a significant reduction in major adverse cardiovascular events, reported Dr Sung-Jin Hong (Yonsei University College of Medicine, Seoul, Korea). But Dr Marco Costa (Case Western Reserve University, Cleveland, OH) urged caution in interpreting the results. The trial included a challenging patient population, those with lesions 28 mm and longer, and used very "liberal" IVUS criteria for stent optimization after PCI, criteria that are not standard in clinical practice, at least not in the US, he explained. More important, those who did and did not meet the IVUS criteria for stent optimization had similar rates of adjunct postdilatation, similar final balloon sizes, and similar maximal inflation pressures—three aspects of care that could affect the results—meaning "something else led to this unique positive outcome . . . and should be studied further," Costa commented.

Slide 12

Nitric Oxide Reduces Kidney Injury in Heart-Valve Surgery

In a single-center study of 217 patients undergoing heart-valve surgery, administration of nitric oxide during extended cardiopulmonary bypass significantly reduced acute kidney injury (AKI), defined as a 50% increase in serum creatinine within 7 days of surgery or a 0.3-mg/dL increase in serum creatinine within 2 days of surgery. AKI was reduced 22% among individuals who received nitric oxide, relative to placebo, reported Dr Lorenzo Berra (Massachusetts General Hospital, Boston). Prolonged cardiopulmonary bypass produces high levels of plasma ferrous oxyhemoglobin, which depletes vascular nitric oxide. The administration of exogenous nitric oxide, on the other hand, causes the oxidation of ferrous oxyhemoglobin and would decrease the risk of kidney injury by reducing the plasma depletion of nitric oxide, explained Berra.

Slide 13

Ranolazine May Improve Post-PCI Angina Frequency in Diabetics

Although ranolazine (Ranexa) does not improve quality-of-life measurements in patients with chronic angina who have undergone a PCI with incomplete revascularization overall, the medication may improve angina frequency in diabetes- or severe-angina–specific subgroups, suggests a secondary analysis of the RIVER-PCI trial. The findings show the book shouldn't be completely closed on the medication, said senior author Dr E Magnus Ohman (Duke University, Durham, NC). "Ranolazine did work in some subgroups, as expected from prior trials. However, it's not for everybody, and the durability of treatment effects went away over time," said Ohman. "I think the main message is that we need better therapies for angina," he added.

Image courtesy of Gilead

Slide 14

Inappropriate PCI Is on the Decline, New US Data Show

The proportion of inappropriate PCIs has decreased since publication of the appropriate-use criteria for coronary revascularization in 2009, according to a new study presented by Dr Nihar Desai (Yale School of Medicine, New Haven, CT). "Over a very short period of time, we have seen dramatic reductions in inappropriate PCI, suggesting that the appropriate-use criteria have helped improve patient selection for PCI and have had a significant impact on the practice of interventional cardiology," he said. Over the 5-year period studied, the volume of PCIs for nonacute or elective reasons decreased by 34%, while there was a "highly significant" 50% relative reduction in the proportion of inappropriate PCIs. "This is a testament to professionalism," Desai noted. "Cardiologists deserve a lot of credit for having faced a difficult issue and for making dramatic improvement in clinical care for patients within 5 years."

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