If I had to pick one word to recap the American Heart Association (AHA) 2014 Scientific Sessions it would be incremental. There were simply no game-changers. Perhaps we are approaching the limits of our human biology.
That's it for grand philosophy. Here are some closing thoughts on the meeting.
We learned a little about the use of antiplatelet drugs after a stent. Acute intervention for MI is surely one of cardiology’s greatest achievements. But it's not new. What would be more exciting, futuristic even, would be a breakthrough that freed us from our reliance on a focal strategy—squishing and stenting—for the systemic disease of atherosclerosis.
In having Dick Cheney at a press conference, we learned that sometimes the fury of cardiology unleashed in a motivated, gritty patient works well. One wonders how his case would have turned out if Cheney had awakened to health a decade before his first heart attack.
In the surgical realm, we learned that more surgery, in the form of mitral-valve repair, isn't universally helpful when combined with bypass in patients with moderate mitral regurgitation. But is it a surprise that the less-is-more approach also applies to treating a patient with an open chest?
In the realm of prevention, we learned that ezetimibe together with simvastatin reduces cardiac events but not death. Some called the absolute gains of 2% in post-ACS patients moderate. A number needed to treat of 50 means 49 out of 50 patients who take the drug get no benefit. So we can wrestle about the modifier of benefit. I would argue it's less than moderate. But one thing is for sure. Gains are gains. See this Tweet:
Colleague says the day after IMPROVE-IT announced at #aha14, they had #vytorin-sponsored lunch. The machine roars!— John Mandrola, MD (@drjohnm) November 20, 2014
IMPROVE-IT was a trial that looked at intervening in high-risk patients. The TACT trial also looked at a high-risk group of diabetic patients with atherosclerosis. This tweet, by Dr Jay Schloss, amplifies the incremental nature of ezetimibe and tempts us to rethink our biases about chelation:
Two #AHA14 trials in the pic. Guess which one is getting all of the attention? I wonder why? @drjohnm @GLamasMD pic.twitter.com/UIGds9ya7k— Edward J Schloss MD (@EJSMD) November 17, 2014
The MagnaSafe registry released compelling data that upends the current dogma that one needs an MRI-safe device to undergo an MRI scan. It is way past time that medical leaders dip into their bag of courage and right this wrong.
A lecture on drugs at #aha14. Overflowing. People taking pics. The session on exercise is near empty. #TheProblem pic.twitter.com/hOjI9tfhdx— John Mandrola, MD (@drjohnm) November 16, 2014
The above Tweet tells the story of modern-day cardiology. I snapped the photo right after attending a superb session on the value of exercise in preventing and treating heart disease. I heard Dr Carl (Chip) Lavie make a strong case for using physical activity and fitness as a vital sign. That room was nearly empty. On my way back to the main hall, I came across a room that was overflowing with attendees. They were standing on their toes and furiously snapping photos of slides. The session was on some sort of drug—I didn't see which one. I used the hashtag #TheProblem.
Smaller Abstracts That Deserve Notice
On the last day of the AHA meeting, Dr Pugazhendhi Vijayaraman (Geisinger Valley, Wilkes-Barre, PA) presented a small series of patients with bundle branch block (BBB) who underwent His bundle pacing. Remarkably, the permanent pacing lead was able to normalize the conduction delay. I'd encourage you to take a look at this abstract, for two reasons: one is that it elegantly confirms a 1970s-era thesis that says committed fibers exist in the proximal His bundle. Second, and more important, the ability to pace the bundle of His and normalize the QRS has great relevance to the field of cardiac resynchronization therapy (CRT). What if we could correct a left bundle branch block (LBBB) without a third lead? That is something. I'm looking into this topic for a future report here. Stay tuned.
I met a young man from Wisconsin who presented a small study on the ability of a 5-minute (nonrecorded) echocardiogram to screen athletes. They were able to pick up a small number of significant abnormalities. It was a single-center study, but the idea of point-of-care ultrasound is disruptive. Why can't an ultrasound beam be an extension of our physical exam? Why does it have to be a procedure with a 5-page report that includes downslope velocities of this and that?
I also saw a nifty pilot study on the use of the iPhone ECG for QT monitoring in patients taking dofetilide (Tikosyn, Pfizer). The short story was that it worked in most patients. Although it was a small pilot study of inpatients, it heralds a change in the way we monitor patients. Why limit it to QT monitoring? Mobile ECG monitoring might be useful in measuring QRS width with IC drugs (propafenone and flecainide), heart-rate response in patients in persistent AF, and in the diagnosis of palpitations, among other things. Mobile is coming.
I bet you knew monocytes/macrophages enhance revascularization during ischemia by promoting blood-vessel growth, extracellular matrix remodeling, and dead-tissue removal. You also probably knew that resolvins are a family of lipid mediators generated by macrophages during the resolution phase of inflammation. An abstract given on the last day of AHA demonstrated that resolvins promoted arteriogenesis in mice with critical limb ischemia. Since we can't seem to stop humans from inflaming themselves, we may as well keep working on means to harness the restorative power of inflammation.
I'll close with a thought-provoking population study from the UK. Researchers discovered an increased incidence of infective endocarditis that (temporally) associated with a guideline-directed reduction in antibiotic use before dental work. Although such findings may seem mundane to a cardiology audience, it's a relevant health study. Antibiotic overuse is fueling the spread of resistant pathogens—which is no small thing. So it seemed a good idea for NICE to curtail antibiotic use before dental work. This data, though not causal, suggests rethinking that decision, or at least conducting further research.
That's it for AHA 2014.
See you soon.
Cite this: AHA 2014: Inching Forward - Medscape - Nov 20, 2014.