Melissa Walton-Shirley, MD


August 29, 2017

On Sunday at the European Society of Cardiology (ESC) 2017 Congress it was as if someone blindfolded me, spun me around, and asked me to pin the tail on the most interesting presentation. I was underwhelmed because I don't share the same enthusiasm as many for the pharmaceutical opportunities of the inflammatory-myocardial–infarction axis presented in CANTOS. I'm certain it will be viewed as heresy that I'd rather reverse inflammation with the proven and less costly prescriptions for daily walking, the Mediterranean diet, avoidance of smoking, and a healthy body-mass index. For many reasons that regimen beats the crap out of the outcome and cost of a $200K/year molecule any day.

As for improved outcomes in stable CAD patients with low-dose rivaroxaban (2.5 mg twice daily) and aspirin (vs aspirin alone) in the COMPASS trial, as enthusiastic as I am about the positive outcome, a part of me is actually a bit ashamed to add to the laundry list of too many and too expensive meds that many of my patients carry around in their purses. We have no qualms about comparing compound x with compound y, but if the words diet and/or exercise were ever presented as a comparator approach, I would literally fall out of my press-room chair.

Monday's presentations were different. Common sense prevailed. These data will change what I actually tell patients and fellow practitioners. Here are a few thoughts on some of the day's most practical trial results.

DETO2X-SWEDEHEART: Supplemental Oxygen in Suspected-AMI Setting

How many times have I figuratively rolled my eyes in the ER at the sight of a 28-year-old nonsmoking male with chest pain? He has absolutely no risk factors and is lying on a gurney with 2 L of supplemental O2 running. I've always said that oxygen in that setting is a great placebo. It's good for the sentiments of patients, healthcare workers, and family members. It's a token of care and attention, like your grandmother's chicken soup, comforting but no mortality benefit.

The DETO2X trial demonstrated absolutely no impact of supplemental oxygen on mortality in patients with ischemic ECG tracings or demonstrated elevated troponins and had O2 sats ≥ 90%. They randomized 6000 patients, and as the presenter, Dr Hofmann of Stockholm, said, "Oxygen isn't expensive but it's not free, when you consider the millions of patients who present with chest pain annually," it adds up. He mentioned an estimated cost of supplemental oxygen at $100/per patient/day in the US. As for the sweating heart-failure patient with a sat of 82%, even I will continue to give oxygen. It's just common sense, albeit another trial for another day.

PRECISION-ABPM: A Prospective Randomized Evaluation of Celecoxib, Naproxen, and Ibuprofen

How many times am I asked each month, "Doc, what can I take for my arthritis?"

I'm a cardiologist, so it's easier for me to say, "Well, it's best if you take nothing." Physicians should hate NSAIDs. They are the stone in David's sling that could sabotage our dual antiplatelet therapy regimen. Interruption of DAPT in a freshly stented patient spells disaster. But my answer to my arthritic patient, although correct, is the right answer for the wrong audience.

Many patients don't respond to acetaminophen, my go-to. My arthritic patients always leave my office empty-handed, defeated, and in pain. The results of this trial in people at increased CV risk who required NSAIDs for 6 months or more were a kind of Goldilocks porridge. Ibuprofen (600 mg thrice daily) was way too hot, with the highest BP elevation, naproxen (375 mg twice daily) was kind of warm and still offending, but celecoxib (100 mg twice daily) was just right with a neutral impact on ambulatory blood pressure.

The presenter, Dr F Ruschitzka from Zurich, cautioned that even a small elevation in BP multiplied by our total number of heartbeats per day spells a huge increase in daily pressure load for our vasculature. He also cautioned that no matter which NSAID you use, "If you use it daily for 2 months, you are going to bleed."  Perhaps my patients can get away with a little celecoxib on the short term for aches and pains, but I will still discourage it.

LAACS: Surgical Closure of the Left Atrial Appendage at Routine CABG

This trial result was an "I-told-you-so" moment for me, and a crowning glory of common sense in the medical world. Patients with or without afib who were undergoing CABG and assigned to LAAC got a double-closure purse string around their dog-eared left atrial appendage and a single running suture closure. These patients enjoyed a marked reduction in yet another hard end point of stroke compared with those who had the standard approach—just the plumbing. We must observe caution, as this was a small trial, but encouraging none the less.

Since one in four humans are going to develop afib, with such little risk of complication, why not exclude the appendage from our patients' circulation? If I could have the attention of all CV surgeons I'd ask them to please lasso, staple, or suture all of my patients' left atrial appendages. Friends and family, feel free to sign that consent form for me as well if I'm incapacitated.

SIOVAC: Sildenafil for Improving Outcomes After Valvular Correction

Should you give sildenafil for secondary pulmonary hypertension postvalvular surgery? In a word, no. Although we are all tempted to treat patients with what we've known to be an effective therapy for primary pulmonary hypertension, don't even think about using sildenafil in patients whose secondary PH didn't correct after valve surgery.

I know it's tempting because we as physicians want to bring down everything that's high and raise up everything that's low, but this was one of the most lopsided negative-outcome trials I've ever witnessed. It was so lopsided there really wasn't much to discuss, kind of like arguing about why it's not such a good idea to jump out of a plane without a parachute. When the primary-outcome slide was shown on the screen, I had to quell the weird urge to jump out of my chair and shout, "Oh hell, no"!

CAAM: Trial of Bag-Mask Ventilation vs Tracheal Intubation

There was no shock here, but some folks whom I suspect were never strong intubaters like to think bag-mask ventilation is just as good as intubation, if you do it right. In this trial it did not meet the noninferiority threshold.

The aspiration risk is massively higher in bag-mask ventilation. The outcome was yet another coup for commonsense thinking. Bottom line, we either need to learn to intubate well or get out of the way and let someone else do it.

VIVA: Viborg Vascular Randomized Screening Trial: AAA and PAD Screening

This information is important not only to patients but also to third-party payers and national health systems. The giant gestalt gained from this trial is that systems are far more motivated by cost savings than outcomes. Fortunately, both patients and systems win here. Middle-aged and elderly men were randomized to screening for AAA and PAD or no screening. If an AAA was >3 cm and or the ABI fell under 0.9 or over 1.4, they were referred for treatment with 75 mg of aspirin and statin daily. Those with AAAs ≥ 5.0 cm were referred for a CT scan and a vascular-surgery appointment. There was an impressive overall 7% reduction in mortality over 5 years in patients who underwent screening.

Think of how many 65- to 74-year-old men we cardiologists see in a day. In many, their bellies are so round that we can't reliably palpate even a large aneurysm. A hand-on-the-belly approach will rarely detect a small aneurysm of 3 cm. How many are sedentary and don't really know they have claudication? This was a down-and-dirty, straightforward approach to screening. I'm all for screening at-risk asymptomatic patients for opportunities for prevention, and this backs that notion.

So, there you have my initial picks of the day for practice-changing or practice-reinforcing trial data. Stay tuned for more coverage from our professional team of journalists and columnists for more late-breaking news.



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