COMMENTARY

Feb 28, 2020 This Week in Cardiology Podcast

John M. Mandrola, MD

Disclosures

February 28, 2020

Please note that the text below is not a full transcript and has not been copyedited. For more insight and commentary, subscribe to the This Week in Cardiology podcast.

Podcast Highlights

For the week ending Feb 28, 2020 John Mandrola, MD comments on the following cardiology news [and features] stories.

Social Media Tension

Noted meta-researcher, Dr Shazeb Khan has published a provocative paper in JACC Case Reports on the Kardashian Index or K-Index. The K-index is the number of followers a physician has on Twitter, divided by the number of followers a physician should have, based on that physician’s number of citations. A higher K-index suggests that a physician may be over-celebrated due to his or her active presence on social media.

Dr. Kahn and colleagues found that most cardiologists are not on Twitter and of those who are, scant few have imbalances between their Twitter following and citations. The accompanying editorial from Dr Robert Califf, a true giant in the field of cardiology, was provocative. Among other things, he said, “The K-index is an oblique way of addressing an issue that is bothersome to researchers who have paid the hard price of designing, conducting, analyzing, and publishing research.

Dr Califf’s accomplishments do not mean we cannot respectfully oppose his take on social media. In my view, social media offers another way to conduct peer review. While the wisdom of the crowds is not perfect, neither is the secretive insular peer review that is ongoing now.

Hopeful News From Centers for Medicare & Medicaid Services

CMS director Seema Verma presented hopeful news at the CMS Quality Conference. She said that the agency’s new plans aim to reduce physician fatigue and frustration.

Verma emphasized that in CMS’s “Patients Over Paperwork” initiative, evaluation and management codes have been reformed to simplify documentation. She says this move will save the country billions dollars and save docs millions of hours of burden.

Another area of change Verma talked about was improving the merit based incentive payment system. This, too, is complex and confusing. Verma says future quality measures will be more specialty specific.

Finally, no quality measure could be more farcical than the meaningful use measure of how much one used a terrible EHR system. Here’s hoping CMS’s Meaningful Measures 2.0 will actually allow clinicians to report quality measures without lifting a finger.

New Cholesterol Drug

This week, FDA approved the inhibitor of ATP citrate lyase (ACLY), bempedoic acid for adults with heterozygous familial hypercholesterolemia or established atherosclerotic cardiovascular disease who require additional LDL-c lowering.

Last March, the New England Journal of Medicine published the Clear Harmony Trial, an RCT of patients with heart disease or heterozygous family history who had an LDL of at least 70 mg/dL while taking maximally dosed statins. The magnitude of LDL reductions was similar to reductions from ezetimibe added to statins. The incidence of adverse effects was similar in both groups, but the incidence of adverse effects leading to discontinuation of the regimen was higher in the bempedoic acid group than in the placebo group.

In the same issue of NEJM, Dr. Brian Ference and colleagues presented a Mendelian Randomization study looking at ACLY and future heart disease. Here patients with genetic inhibition of ACLY were followed for cardiac events.

Patients with ACLY and HMG-CoA reductase looked similar. Genetic variants that mimic the effect of ACLY inhibitors and statins appeared to lower plasma LDL cholesterol levels by the same mechanism of action and were associated with similar effects on the risk of cardiovascular disease per unit decrease in the LDL cholesterol.

But recall that an LDL level is a mere risk factor for disease. Having a high LDL level is not the same as having a disease. Statins have been so important not because they reduce LDL but because they reduce cardiac events.

Carotid Interventions

An important study presented at the International Stroke Conference in Los Angeles combined data from two RCTs of carotid stenting (CAS) vs carotid endarterectomy (CEA; CREST and ACT 1) and asked: How does carotid stenting compare to CEA in older patients without symptoms?

The primary outcome the researchers used for their analysis was the incidence of periprocedural stroke, MI, or death, plus the incidence of ipsilateral stroke during 4 years of follow-up post procedure. Among patients who underwent CAS, this outcome occurred in roughly 9% of patients aged 75-79 years and in about 3% of those younger than 65 years. Patients who underwent CEA showed no similar relationship between age and outcome. The incidence of the primary outcome among the CEA patients was roughly the same, about 3.5%, regardless of their age.

But neither CAS nor CEA may be the best treatment for patients with carotid disease who have no symptoms. Recall that the evidence for doing any carotid intervention stems from very weak data from very old trials—before the era of high potency statins. The rate of CEA for asymptomatic disease in Denmark and Canada are very low–almost zero—while the rate of CEA for asymptomatic disease in the United States is high, yet cardiac outcomes in Denmark and Canada are no different from those in the United States.

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