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Susan Jeffrey; Steve Stiles; Patrice Wendling; Fredy Perojo; Marlene Busko; Megan Brooks; Kristy Walker | November 30, 2017
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Top News From AHA 2017: Slideshow
Susan Jeffrey; Steve Stiles; Patrice Wendling; Fredy Perojo; Marlene Busko; Megan Brooks; Kristy Walker | November 30, 2017 | Contributor Information
Highly anticipated new recommendations on hypertension with a new definition that calls 130 to 139 mm Hg systolic or 80 to 89 mm Hg stage 1 hypertension, as well as a host of key clinical trials, greeted attendees here at the American Heart Association (AHA) 2017 Scientific Sessions, held November 11 to 15, in Anaheim, California.
Top News From AHA 2017: Slideshow
Susan Jeffrey; Steve Stiles; Patrice Wendling; Fredy Perojo; Marlene Busko; Megan Brooks; Kristy Walker | November 30, 2017 | Contributor Information
In addition to the new ACC/AHA hypertension guidelines, key studies presented at this year's sessions include:
PRESERVE: No Benefit From Bicarbonate, Acetylcysteine Postangiography
TRICS-3 Disputes 'Liberal' RBC Transfusions at Cardiac Surgery
BRUISE CONTROL-2: DOACs Can Continue During Cardiac-Device Surgery
POISE-2: PCI Patients May Benefit From Perioperative Aspirin
GATEWAY: Bariatric Surgery Can Lead to HTN 'Remission' in Obese
Top News From AHA 2017: Slideshow
Susan Jeffrey; Steve Stiles; Patrice Wendling; Fredy Perojo; Marlene Busko; Megan Brooks; Kristy Walker | November 30, 2017 | Contributor Information
New ACC/AHA Hypertension Guidelines Make 130 the New 140
The American College of Cardiology (ACC) and the American Heart Association (AHA) released new guidelines on hypertension with a new definition that will call 130 to 139 mm Hg systolic or 80 to 89 mm Hg stage 1 hypertension. While the definition of normal blood pressure hasn't changed, the new guidelines eliminate the classification of prehypertension and divide those blood-pressure levels previously called prehypertension into elevated BP, with a systolic pressure between 120 and 129 and diastolic pressure less than 80 mm Hg, and stage 1 hypertension, now systolic 130 to 139 or diastolic 80 to 89 mm Hg. There is also now a strong emphasis on blood-pressure measurement, both accuracy of blood-pressure measurements and using the average of measures taken over several visits, as well as an emphasis on out-of-office blood-pressure measurements, "which is relatively new for a blood-pressure guideline," note Dr Paul Whelton (Tulane University School of Public Health and Tropical Medicine, New Orleans, LA), chair of the 2017 Hypertension Practice Guidelines.
Top News From AHA 2017: Slideshow
Susan Jeffrey; Steve Stiles; Patrice Wendling; Fredy Perojo; Marlene Busko; Megan Brooks; Kristy Walker | November 30, 2017 | Contributor Information
PRESERVE: No Benefit From Bicarbonate, Acetylcysteine Postangiography
Neither intravenous (IV) sodium bicarbonate nor oral N-acetylcysteine (NAC) significantly reduced adverse outcomes in patients at high risk for renal complications undergoing angiography in the PRESERVE trial of nearly 5000 high-risk patients scheduled for angiography. All were randomly assigned to receive IV 1.26% sodium bicarbonate or IV 0.9% sodium chloride plus NAC or placebo. The primary outcome was a composite of death, need for dialysis, or an increase over baseline of at least 50% in serum-creatinine level 90 days postangiography. At a prespecified interim analysis, there were no significant benefits found from either study agent, and the trial was prematurely stopped. Secondary outcomes, including contrast-associated acute kidney injury and persistent kidney impairment up to 90 days, also did not differ significantly between the groups. "These interventions were not effective at all compared with their comparators in patients with chronic kidney disease undergoing these procedures," said lead author Dr Steven D Weisbord (Veterans Affairs Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, PA). "The findings should immediately impact how providers perform angiograms in this patient population."
Top News From AHA 2017: Slideshow
Susan Jeffrey; Steve Stiles; Patrice Wendling; Fredy Perojo; Marlene Busko; Megan Brooks; Kristy Walker | November 30, 2017 | Contributor Information
TRICS-3 Disputes 'Liberal' RBC Transfusions at Cardiac Surgery
No advantages, clinical or otherwise, were seen from liberal use of red blood cell (RBC) transfusions to keep hemoglobin levels up in patients undergoing on-pump cardiac surgery, in a randomized noninferiority trial with more than 4800 patients. "We've definitely shown that you can transfuse more sparingly and maintain patient safety and patient outcomes, while saving blood and its associated costs," said Dr C David Mazer (University of Toronto and St Michael's Hospital, Toronto, ON). The rate of the primary clinical composite end point, which included new-onset renal failure, was 11.4% in the patients managed according to a "restrictive" strategy that allowed transfusions only at hemoglobin levels that were lower than for liberal transfusions, where the rate was 12.5% (P<0.0001 for noninferiority). The international third Transfusion Requirements in Cardiac Surgery (TRICS-3) trial is noteworthy for "the remarkable consistency of the results through various subgroup and sensitivity analyses," Mazer said. "I think that strengthens the message."
Top News From AHA 2017: Slideshow
Susan Jeffrey; Steve Stiles; Patrice Wendling; Fredy Perojo; Marlene Busko; Megan Brooks; Kristy Walker | November 30, 2017 | Contributor Information
Direct Oral Anticoagulants Can Continue During Cardiac-Device Surgery
Continuing direct oral anticoagulants (DOACs) did not reduce hematoma rates in patients at moderate to high risk of thromboembolism undergoing cardiac-device surgery in the BRUISE CONTROL-2 trial. The rate of clinically relevant hematoma was identical at 2.1% with continued or interrupted anticoagulation with dabigatran (Pradaxa), rivaroxaban (Xarelto), or apixaban (Eliquis). Further, there was no difference between the two strategies in all secondary outcomes, including stroke/transient ischemic attack. "Operating with continued DOACs should not be considered specifically as a strategy to reduce hematoma rates, but I think the take-home message for clinicians is that either strategy may be reasonable depending on the clinical scenario," said co–principal investigator Dr David H Birnie (Ottawa Heart Institute, ON). This "gives physicians and patients options for management."
Top News From AHA 2017: Slideshow
Susan Jeffrey; Steve Stiles; Patrice Wendling; Fredy Perojo; Marlene Busko; Megan Brooks; Kristy Walker | November 30, 2017 | Contributor Information
POISE-2: PCI Patients May Benefit From Perioperative Aspirin
Perioperative low-dose aspirin may reduce the risk of death and nonfatal MI after noncardiac surgery for patients who have undergone a prior PCI, hints a subgroup analysis of the POISE-2 trial. The effect, which was not seen among patients without prior PCI, was driven by a lower risk of MI in these patients. "For every 1000 patients with prior PCI, perioperative aspirin will prevent 59 myocardial infarctions but cause eight major bleeds," said Dr Michelle M Graham (University of Alberta and Mazankowski Alberta Heart Institute, Edmonton). "Among those with prior PCI undergoing noncardiac surgery, perioperative aspirin may be more likely to benefit than to harm patients," said Graham. The findings have to be regarded as hypothesis generating, but the numbers are "quite persuasive," commented Dr Bernard Gersh (Mayo Clinic, Rochester, Minnesota). "The numbers are small, but the effect size is large, and it's biologically plausible—I can perfectly understand why aspirin would be beneficial in the perioperative period, which is a prothrombotic state in patients undergoing noncardiac surgery."
Top News From AHA 2017: Slideshow
Susan Jeffrey; Steve Stiles; Patrice Wendling; Fredy Perojo; Marlene Busko; Megan Brooks; Kristy Walker | November 30, 2017 | Contributor Information
PRAGUE-18 Hints at Risk-Based Personalized DAPT After STEMI-PCI Discharge
Switching to clopidogrel postdischarge after starting on a more potent P2Y12 inhibitor as part of dual antiplatelet therapy (DAPT) after primary PCI apparently doesn't lead to a greater risk of ischemic events over 1 year, at least in selected low-risk patients, according to a secondary finding in a 12-month follow-up report of PRAGUE-18, which had primarily compared prasugrel (Effient, Efient) vs ticagrelor (Brilinta, Brilique, Possia) in DAPT after PCI for STEMI. Also at 1 year, there was no significant difference between the two agents for the primary clinical end point, a composite of reinfarction, urgent target vessel revascularization, stroke, bleeding requiring transfusion, or prolonged hospitalization. Importantly, the PRAGUE-18 protocol allowed a postdischarge switch to clopidogrel for patients unwilling to pay out-of-pocket for costlier long-term prasugrel or ticagrelor, subject case-by-case to the approval of trial physicians. That is, they went with clopidogrel for "economic" reasons and tended to be at low enough risk that their doctors agreed to it, noted Dr Zuzana Motovska (Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic).
Top News From AHA 2017: Slideshow
Susan Jeffrey; Steve Stiles; Patrice Wendling; Fredy Perojo; Marlene Busko; Megan Brooks; Kristy Walker | November 30, 2017 | Contributor Information
High-sensitivity C-reactive protein (hs-CRP) testing after a single dose of canakinumab appears to identify patients with atherosclerotic cardiovascular disease most likely to benefit from treatment, according to a secondary analysis of the CANTOS trial. The primary results provided critical proof of concept that targeting inflammation with the monoclonal antibody reduces CV event rates independent of LDL cholesterol. But treatment with the orphan drug is costly, associated with a small but significant increase in fatal infections, and delivered what some regarded as an underwhelming 15% reduction in major adverse coronary events (MACE) in the entire CANTOS population. This secondary analysis revealed no baseline characteristics that predicted patients more or less likely to benefit from canakinumab. However, patients who achieved hs-CRP <2 mg/L at 3 months had an adjusted 25% relative risk reduction in MACE and 31% risk reduction in CV death and all-cause mortality. For those with an hs-CRP above this threshold, canakinumab had minimal effects on these outcomes. These observations have "clinical importance not only for the pathophysiology of inflammation and future drug development, but also for patient selection, cost-effectiveness, and personalized medicine," said Dr Paul Ridker (Brigham and Women's Hospital, Boston, MA).
Top News From AHA 2017: Slideshow
Susan Jeffrey; Steve Stiles; Patrice Wendling; Fredy Perojo; Marlene Busko; Megan Brooks; Kristy Walker | November 30, 2017 | Contributor Information
Bariatric Surgery Can Lead to HTN 'Remission' in Obese: GATEWAY
Bariatric surgery can allow obese people on numerous antihypertensive meds to cut way back on them, so their blood pressure is maintained in the normal range with only one agent or even without drugs, a study found. The patients, who had a body-mass index (BMI) of 30 to <40 kg/m2 and were on at least two BP–lowering agents at baseline, underwent laparoscopic Roux-en-Y gastric-bypass surgery plus meds or medical therapy alone. Within a year, those who had the surgery were more than six times as likely to have cut back on their number of BP meds by about a third. Half of the surgical patients didn't need antihypertensive meds to maintain their BP under 140/90 mm Hg. But all of the standard-care patients needed antihypertensives to keep BP that low, and half of them needed at least three. Moreover, in a post hoc analysis of the study known as GATEWAY, about 20% of patients who underwent bariatric surgery achieved the more ambitious systolic BP target of <120 mm Hg. Simply put, bariatric surgery "made it easy to treat hypertension in these patients," said Dr Carlos Aurelio Schiavon (Research Institute, Heart Hospital, São Paulo, Brazil).
Top News From AHA 2017: Slideshow
Susan Jeffrey; Steve Stiles; Patrice Wendling; Fredy Perojo; Marlene Busko; Megan Brooks; Kristy Walker | November 30, 2017 | Contributor Information
DACAB: Ticagrelor Plus Aspirin Improves CABG Graft Patency
The combination of aspirin plus ticagrelor led to significant improvement in saphenous vein graft (SVG) patency at 12 months vs aspirin alone in patients undergoing CABG in the DACAB trial. Patency was better with ticagrelor plus aspirin compared with either agent alone, although the results were only statistically significant for dual therapy vs aspirin. "Ticagrelor plus aspirin combination therapy significantly improves SVG patency 1 year after CABG when compared with aspirin monotherapy, and the risk of major bleeding was minimal," lead author Dr Qiang Zhao (Ruijin Hospital, Shanghai, China) concluded. Invited discussant John H Alexander (Duke Clinical Research Institute, Durham, NC) was not yet entirely convinced by these results. The DACAB trial "established an effect of ticagrelor on saphenous vein graft patency, and their findings are compelling, but they will be insufficient to drive changes in practice," Alexander said. "And that's because the effects on major adverse cardiac events and the bleeding trade-off for this vein graft patency have not been adequately assessed in this study."
Top News From AHA 2017: Slideshow
Susan Jeffrey; Steve Stiles; Patrice Wendling; Fredy Perojo; Marlene Busko; Megan Brooks; Kristy Walker | November 30, 2017 | Contributor Information
Botox Injections to the Heart May Tamp Down Postop AF
Epicardial botulinum toxin injections may reduce postoperative atrial fibrillation (POAF). When injected near cardiac autonomic nerves in epicardial fat pads, botulinum toxin acts in an anticholinergic fashion on the atrium, shortening atrial effective refractory periods and blocking induction of AF, explained Dr Nathan Waldron (Duke University School of Medicine, Durham, NC). The novel strategy showed promise in a prior first-in-human study, reducing the risk of recurrent AF after CABG in patients with paroxysmal AF compared with saline when injected into the four major epicardial fat pads. Based on these results, the TNT-POAF study randomized a larger, higher-risk cohort of 130 patients undergoing CABG, valve surgery, or both to receive either 50 U of onabotulinum toxin A (Botox, Allergan) or 1-mL sterile saline injected into five epicardial fat pads. The risk of POAF during hospitalization was numerically lower in patients receiving botulinum toxin rather than saline (36.5% vs 47.8%), but the difference failed to reach statistical significance in unadjusted or multivariate adjusted analysis. The duration of the first episode of POAF was lower with the neurotoxin, although overall POAF burden, treatment of POAF with amiodarone or cardioversion, and length of stay were not significantly different.
Top News From AHA 2017: Slideshow
Susan Jeffrey; Steve Stiles; Patrice Wendling; Fredy Perojo; Marlene Busko; Megan Brooks; Kristy Walker | November 30, 2017 | Contributor Information
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Susan Jeffrey
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London, Ontario
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San Diego, California
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