Laurie Scudder, DNP, NP


April 22, 2016

ACC 2016: The Messages for Primary Care

A number of studies presented at the American College of Cardiology (ACC) 2016 meeting can and will affect primary care practice. Keeping up on relevant research presented at specialty conferences is a good idea, but it's virtually impossible to do in the hectic, information-saturated world in which primary care is practiced. So Medscape asked John Mandrola, MD, a clinical electrophysiologist and chief cardiology correspondent at Medscape, to provide this quick tour of the five key takeaways from this year's meeting, with implications for primary care practice.

1. HOPE for Intermediate-Risk CVD Patients

The Heart Outcomes Prevention Evaluation-3 (HOPE-3) trial[1] was an industry-funded study involving almost 13,000 adults from 21 countries. Patients were randomly assigned to candesartan/hydrochlorothiazide or placebo, rosuvastatin or placebo, or the combination of both or placebo. Median follow-up was 5.6 years. HOPE-3 was published in three separate papers in the New England Journal of Medicine.[1,2,3]

The major results:

  1. In the blood pressure (BP) study, candesartan/hydrochlorothiazide treatment induced a significant drop in BP (average, 6 mm Hg) but did not reduce the frequency of the primary outcome, a composite of cardiovascular (CV)-related death, nonfatal myocardial infarction (MI), nonfatal stroke, heart failure, cardiac arrest, or revascularization.

  2. In the cholesterol-reduction study, patients randomly assigned to rosuvastatin compared with placebo experienced 1.1% fewer CV events (3.7% vs 4.8%), a significant difference.

  3. In the combination study, patients who received both antihypertensive and statin drugs experienced 1.4% fewer CV events (3.6% vs 5.0%), again a statistically significant reduction.

What does this mean for use of polypills that combine an antihypertensive with a statin? Coinvestigator Eva M. Lonn, MD, told Medscape that "in an intermediate-risk population, it appears that everybody benefits from statins and that statins are safe." Jennifer Robinson, MD, the director of the Prevention Intervention Center at the University of Iowa, noted in an interview on Medscape that "we probably do not want to be using a polypill in primary prevention on the basis of age only." Melissa Walton-Shirley, MD, a clinical cardiologist, observed that the rosuvastatin-only group derived these positive outcomes with "no LDL levels at baseline and no frequent BP checks," a simplified approach with enormous potential population-wide benefits.

Dr Mandrola agreed that a major strength of HOPE-3 was its pragmatic nature. He said the study's major weakness was the lack of an intensive lifestyle-modification arm. "We know from the LEGACY trial that BP- and lipid-lowering can be done with fewer—not more—drugs."

On the clinical translation of HOPE-3, Dr Mandrola said the study confirms what many studies on statins have shown: When the drugs are used for primary prevention, you have to treat more than 90 individuals to prevent one cardiac event. Whether that statistical benefit is significant enough to warrant taking a daily pill is a question best answered by patients, not doctors. The challenge lies in helping patients understand the gamble.

2. Low-Risk Chest Pain: Is Less Better?

Can a one-page shared decision-making tool reduce the use of diagnostic testing in low-risk patients who present to the emergency department (ED) with chest pain? The workup of such patients is often low-yield. False-positive results occur frequently. This can lead to excess costs, unnecessary radiation exposure, and hospitalization. The Chest Pain Choice (CPC) Trial[4] was conducted at six EDs in five states. Adults with chest pain who were considered for ED observation for stress testing or coronary CT angiography (CTA) were randomly assigned to treatment using the decision aid or to standard care.

The results were positive. Patients treated with the decision aid were more knowledgeable about their risks for acute coronary syndrome and management options. Physicians viewed the information as "extremely clear," and two thirds said they would recommend the aid to other clinicians. Patients who used the decision aid underwent fewer cardiac tests. Of note, no differences between groups were noted in major adverse coronary events (MACE). Videotaping revealed that use of the decision aid added just 1.3 minutes to the patient encounter.

In other words, what's not to like? Patients are happier, physicians are happier, payers are happier, and the cost was less than 2 minutes of clinician time. As Dr Mandrola noted in a commentary about the study, if "shared decision-making can happen in busy emergency departments, it can happen in most places."


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