John Mandrola


November 03, 2015

There is nothing Mickey Mouse about the upcoming American Heart Association 2015 Scientific Sessions in Orlando, FL.

I always enjoy the AHA meeting because it's so massive. For the curious, AHA is a delight. This year, organizers separated the meeting by three basic tracts: basic, clinical, and population science. Each category includes breakdowns of all areas of cardiology.

A subcategory within population science that will garner great attention this year is big data and digital health. In fact, an entire day is dedicated to digital health. In the past, attendees might have been given free pens and other trinkets; the swag this year will likely include free wearables.

The big show starts on Saturday November 7 with the Resuscitation Science Symposium. Bystander CPR, AED availability, CPR training in the community, prognostic indicators, and, of course, the role of mobile technology are some of the featured topics.

I am drawn to resuscitation science because it's the purest of medicine: patients with circulatory collapse need intervention—and often not from professionals but from whomever is nearby. I am especially looking forward to a series of studies on novel ways to improve community awareness of early CPR and AED use. You can call this the teach-a-man-to-fish category.

The most anticipated news from AHA has to be the formal announcement of the SPRINT trial results. Recall that SPRINT compared an aggressive BP-lowering strategy to a less aggressive one. In a controversial press conference, one that was called to announce premature termination of the trial, investigators told us that patients in the aggressive BP-treatment arm had significantly fewer cardiovascular events.

In giving only the relative benefits, SPRINT researchers offered conclusions without results. At AHA, we learn the details. These (absolute) numbers will be key to applying the findings to clinical practice. With the entirety of mainstream media awaiting the news, it won't be easy sorting through the nuance on the fly. Beware of early reports. In the same way that slow medicine is good medicine, slow interpretation of this trial will be the wise choice.

If SPRINT isn't enough to challenge journalists covering this year's AHA, the long list of late-breaking clinical trials (LBCTs) and registry studies surely will.

In the first LBCT session, we learn about new drugs and systems of care for patients with heart failure. The most interesting of these studies involves the use of the glucagonlike peptide-1 (GLP-1) liraglutide (Victoza, Novo Nordisk) for high-risk heart-failure patients with reduced ejection fraction. I'm keen on this trial because cardiac metabolism may be a good target for treating the energy-starved failing heart.[1] Isn't that the reason beta-blockers are beneficial in heart failure?

The second day of late breakers features five studies on how best to decrease the global burden of disease. In a sign of the times, and a hopeful one at that, only two of the five prevention trials involve drugs. More interesting to me are the three studies that investigate peer groups, mobile technology, and the disclosure of genomic risks as means for reducing cardiac disease.

Also on day 2 of AHA, we learn the 2-year results of the mitral-valve repair vs mitral-valve replacement trial for patients with severe ischemic mitral regurgitation (MR). The 1-year results of this trial, which were published in the New England Journal of Medicine,[2] showed no difference in left ventricular remodeling or survival. Patients who had replacement, however, had more durable correction of MR, so I wonder whether 2-year results may diverge.

The five late breakers on day 3 of AHA address acute coronary syndromes and PCI. In this area, there is no way to avoid drugs or devices. Ultrasound guidance of stents, long-term use of ticagrelor (Brilinta, AstraZeneca), duration of dual antiplatelet therapy, and ranolazine are all featured topics. The PROACT trial is the outlier. This Canadian study seeks to determine whether early diagnosis and risk stratification acquired through prehospital clinical assessment, ECG, and point-of-care biomarkers will facilitate enhanced triage and treatment in patients with presumed non-ST-segment-elevation acute coronary syndromes (NSTEMI).

The last day of a meeting is usually a quiet one. Not at AHA; meeting organizers offer seven late-breakers on the final half-day. Novel therapies, including hydrogel implants for the failing LV, a first-in-human study of the beta-3 adrenoreceptor agonist in patients with heart failure, MRI scans for preventing cardiac dysfunction during adjuvant chemotherapy for breast cancer, renal preservation with nitric oxide during cardiopulmonary bypass, and ranolazine in coronary microvascular dysfunction. In addition, a new phase 1 study of a proprotein convertase subtilisin-kexin type 9 (PCSK9) drug given quarterly or twice yearly will be presented. While reductionists rejoice about the LDL-cholesterol lowering of the newly approved PCSK9 drugs, empiricists await the outcomes trial. I'm with the latter, but the PCSK9 train has both mass and velocity—momentum. I'll try not to dwell on the tracks. Clinicians will focus on part 2 of the ANNEXA-R trial, in which we learn more about andexanet alfa, a universal antidote for factor Xa inhibitors.

In its mission statement, the AHA says it seeks to build healthier lives, free of cardiovascular disease. You can love molecular biology, physiology, anatomy, and technology, but if you aim to (really) influence heart disease, you have to go further upstream. And there is plenty of upstream stuff at AHA. I found studies on obesity in children, walkable neighborhoods, public transportation, home-cooked meals, physical activity, and most important, inequality of care based on gender and economic status.

In my field of electrophysiology, I look forward to studies on his-bundle pacing, left atrial appendage closure, and atrial substrate changes in patients with AF. Dr Rajeev Pathak (University of Adelaide and Royal Adelaide Hospital, Australia), who is up for yet another young investigators award, will present substrate-specific data from the ARREST-AF[3] cohort. This could be another key finding from the group that has changed our approach to patients with AF.

I'll close with a certainty: on Medscape team will work hard to bring you the best possible coverage. Each of us will keep the Twitter feed and live blog buzzing with news.

See you in Orlando.



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