Melissa Walton-Shirley, MD

Disclosures

March 21, 2017

Many attendees at the American College of Cardiology (ACC) 2017 Scientific Sessions have commented on how exciting the meeting has been. Perhaps because the molecules discussed had "real" names.  Perhaps it's because there were more studies in real-world patients with digestible and  translatable data.  "There's so much positive energy here," one  attendee said with glee. I agree. 

Here are a few points on some of the trials I liked and a few thoughts moving forward:

FOURIER

Amid the excitement that anything that lowers refractory LDL-C levels might help coronary heart disease patients, I hold out hope that the data reported thus far affirm short-term safety and hint at long-term benefit.

  • The back story: the drug C6242H9648N1668O1996S56 (evolocumab, Amgen), a chemical with a slick marketing name (Repatha), managed to get on European markets, then the US and Canadian markets in 2015.  How this happened with so much uncertainty regarding mortality benefit and a $14K price tag for a year's worth of treatment, we may never know (but we should ask).

  • In the future, all regulatory agencies should hold off on the approval of any lipid drugs until they prove mortality benefit paired with cost-effectiveness.

  • It remains to be seen whether we have won or lost a very expensive craps hoot while window-dressing lipid levels.  For the sake of CAD patients everywhere, we should all hope it will eventually deliver on mortality. 

Cerebral protection for SAVR

  • Yikes, 61% of us dump debris into our brains during surgical aortic-valve replacement. Fortunately, only 4% of patients develop moderate to severe CVA deficits.

  • Many cerebral insults go undetected, despite concerns that they could be linked to late-term cognitive defects.

  • We've tried to catch these gaseous and particulate entities with sophisticated cheesecloth equivalents. We may dance with glee when we flush out goo onto a 4x4, but this study and others show it hasn't really changed anything clinically.

  • In addition, with a shortage of neurologists in this country, even the presenter admitted it's difficult to obtain a much-needed in-patient neurology consultation. We nonneurologists can't often detect deficits.

  • If President Trump really wants to do something good for this country's health, among other things, he should grow us some neurologists and reimburse them for their work.

Subclinical leaflet thrombosis in transcatheter aortic-valve replacement (TAVR)

  • 10% to 15% of TAVR valves develop subclinical leaflet thrombosis, and that's not acceptable.  

  • We can't see those gunked-up leaflets with a transthoracic echocardiogram (TTE), so the problem is going undetected. We need to increase availability of 4D computed tomography (CT).

  • When I heard that novel oral anticoagulants (NOACs) beat dual antiplatelet therapy (DAPT) for prevention and treatment, I mourned the needless cc's of endogenous adrenalin I spent worrying about giving NOACs instead of DAPT for my TAVR patients with atrial fibrillation.

  • The bigger picture? More elderly patients are going to need full-on anticoagulation. Tight aortic stensosis is associated with angiodysplastic bleeders, and increasing age invites bleeding. Someone needs to get busy developing better and less clotty TAVR platforms. Carbon anyone?

VISION: High-sensitivity troponins for noncardiac surgery

  • I learned a new term, MINS (myocardial injury after noncardiac surgery), although I've been diagnosing and treating MINS for 30 years.

  • These new high-sensitivity troponins are coming for us all, so we might as well learn how to use them.

  • Almost 30% of patients with the highest peak hsTnT (≥1000 ng/L) died 30 days postoperatively, and 13.8% of patients with postop hsTnT elevations peaked their troponin Ts preoperatively. This tells me that surgeons need to get a preop cardiology consult in moderate- to high-risk patients.

  • If you aren't going to call a consult preoperatively, at least make baseline troponin levels part of your preop orders on riskier patients, so when you call me I'm not fumbling around in the dark trying to play catch-up.

SPAIN

  • Finally a hint toward the right direction for patients with really refractory vasovagal syncope.

  • A DDD closed-loop stimulation (CSL) pacing algorithm significantly decreased the incidence of the burden of syncope compared with sham, so perhaps we can look forward to more helpful data.

  • Congratulations to the SPAIN investigators for pioneering help for these very sick patients.

Well, those were my picks for ACC 2017.  It was a pleasure to interview and network with researchers and clinicians around the globe.  So many of you came up and introduce yourselves at this meeting. We appreciate your kind words! 

Follow Melissa Walton-Shirley on Twitter.

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