Seth Bilazarian, MD


November 13, 2014

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This is Seth Bilazarian, for on Medscape, at the Transcatheter Cardiovascular Therapeutics (TCT) 2014 meeting in Washington, DC. At this TCT meeting. I have learned a lot, but there is an overwhelming sense that progress has stalled in interventional cardiology. Nothing new is coming out. Nothing seems to be on the horizon, so I wanted to briefly comment on that. I spoke with some other people and they share my view that interventional cardiology has stalled.

Is this something to be concerned about, or have we become victims of our own success because we have repeatedly seen exciting new things? We saw bare metal stents move to drug-eluting stents. We saw transcatheter aortic valve replacement. We had great anticipation of renal denervation being the next big area of technological breakthrough. It was a new device that would provide an important therapy. When that fell short, we felt like we had fallen into a lull. This iterative and leapfrogging of new technologies that would fill diagnostic and therapeutic needs has now fallen short and nothing [new] is immediately available to us.

We have had some new drugs in the recent past, such as the novel oral anticoagulants. We had new techniques in the recent past, such as the adoption of transradial approaches, which is now up to 20% [of US catheterizations]. In terms of "next great things" we have catheter-based mitral valve therapies, a potential renewal of renal denervation, and bio-reabsorbable vascular scaffolding, which may or may not come to market. These three things may never make a significant impact on our patients.

We spent most of this meeting talking about how long we should treat with dual antiplatelet therapy. Is bivalirudin or heparin the preferred agent in primary percutaneous coronary intervention? Much time has been spent talking about the appropriate therapies for patients who have both atrial fibrillation and either a drug-eluting stent or an acute coronary syndrome. Should we use triple therapy? Should we use double therapy? Which therapy should be dropped? These are critical questions, so this stalling is perhaps a good opportunity to move from a position where medical progress is constantly outpacing medical knowledge (and practitioners are often criticized for not keeping up and adopting new medical therapies) to adopt the therapies that have come before, without having to focus on new medical progress.

Many areas in both interventional and clinical cardiology have stalled for a very long time. Diastolic dysfunction, and myocardial salvage in myocardial infarction, have not gone anywhere. Mortality rates have dipped with the improvement in door-to-balloon times, but now that we are below 60 minutes, there doesn't seem to be any further improvement. We haven't made any real progress in shock mortality rates. Medical progress is stalled but we can use this as an opportunity to appropriately adopt and integrate the knowledge base we have. Let's try to use these therapies to give patients the best and highest-value care.

There is more talk at this meeting, and almost every meeting, about what the best strategy is for integrating therapy. Is the therapy of good value, both for patients' quality of life and for the healthcare dollar in our healthcare system? Practitioners who aren't health policy decision-makers can use this time to share with colleagues best practices and how to integrate patient care going forward.

I am looking at the silver lining in the gray cloud of slow medical progress in this brief hiatus of major breakthroughs and am using it as an opportunity to do a better job of integrating therapies that are best for our practices.

If you agree that we are in a lull, post a comment. If you agree that this is a good time to take a pause, let me know that as well. This is Seth Bilazarian, from the TCT meeting in Washington.


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