Meeting the Press at ESC: Notes on news from Amsterdam
Preventive PCI in ST-segment elevation MI significantly reduces CV events
Preventive therapy works, but preventive interventions? Current guidelines give a class III indication for nonculprit vessel PCI in the setting of ST-segment elevation myocardial infarction (STEMI). However, this is based mostly on observational studies. The PRAMI trial compared outcomes between nonculprit vessel PCI in addition to PCI of the infarct-related artery (IRA) versus primary PCI of the IRA alone in patients with STEMI who had multiple stenoses.
“The outcome was actually quite clear. There were approximately 50 events in the group who were randomized not to receive preventive PCI and less than half that number in the group who did receive preventive PCI. So preventive PCI that unblocks additional coronary arteries, instead of culprit-only PCI, reduces the risk of cardiac death, subsequent MI, or angina resistant to medical therapy by about two-thirds in [STEMI] patients.”—David Wald, MD, Wolfson Institute of Preventive Medicine, London
ACCOAST shows prasugrel pretreatment increases bleeding risk and has no benefit
Current guidelines recommend pretreatment with clopidogrel in patients with non–ST-segment elevation acute coronary syndrome (NSTE-ACS) undergoing an invasive approach. In TRITON-TIMI 38, prasugrel administered following coronary angiography significantly reduced the incidence of ischemic endpoints. ACCOAST sought to study if pretreatment with prasugrel in all patients would be superior to prasugrel given selectively post-angiography in patients undergoing PCI.
“The expectation was that patients would have benefitted from pretreatment with prasugrel but our results contradicted the hypothesis. There was absolutely no benefit on the ischemic side which was the primary endpoint of the study, and there was an excess of bleeding. We need to reevaluate our guidelines and our practice and imagine now a way to see the coronaries before treating patients with one of these drugs.”—Gilles Montalescot, MD, Pitie-Salpetriere University Hospital, Paris
Pacemakers implanted for slow heart rhythm restore life expectancy to normal
Previous studies describing the survival of pacemaker patients used data that are more than 20 years old and can no longer be used for patient counseling and benchmarking. Given the considerable changes in pacemaker technology, and in the profile of pacemaker patients, a new reference point of prognosis in modern day cardiac pacing was needed. Enter FOLLOWPACE.
The results suggest that the prognosis of today’s pacemaker patient is primarily determined by whether or not they also have cardiovascular disease rather than the rhythm disorder itself. “Patients who have heart failure or CAD when a pacemaker is implanted have the highest risk of death while those without cardiovascular disease at the time of implantation have a survival that’s comparable to the survival of the general population.”—Erik Udo, MD, UMC Utrecht, Utrecht, Netherlands
No safety signal nor benefit in DPP-4 inhibitor trials
Two studies of drugs from a new class of selective dipeptidyl peptidase 4 (DPP-4) inhibitors that lower glucose—EXAMINE (alogliptin in patients with type 2 diabetes and recent ACS) and SAVOR-TIMI 53 (saxagliptin in patients with type 2 diabetes and high risk for a CV event)—both showed disappointing results.
“I would say the overall results from EXAMINE and SAVOR-TIMI 53 are more similar than dissimilar. Both trials were powered for a primary endpoint of ischemic events and neither found an excess, neither found a benefit. And I would be reasonably comfortable extrapolating these results to the entire class of DPP-4 inhibitors.”—Deepak L. Bhatt, MD, MPH, co-author SAVOR-TIMI 53, Brigham and Women’s Hospital, Harvard Medical School, Boston
Losartan reduces rate of aortic enlargement, prevents aortic dissection in Marfan syndrome patients
Patients with Marfan syndrome often have elevated levels of transforming growth factor (TGF)-beta and a pair of studies suggests losartan blocks its effects. The results of the COMPARE trial indicate that losartan reduces the rate of aortic root enlargement versus placebo in patients and was equally beneficial whether or not these patients were on beta-blocker therapy. Also, this simple approach prevented aortic dissection.
“Marfan syndrome is a deadly disease that goes undiagnosed in many cases, so to have a drug that prevents dissection of the aorta is an important advance. In addition, the drug is very inexpensive, which is also important for our health care system.”—Lina Badimon, MD, Cardiovascular Research Center, Autonomous University of Barcelona, Spain
Smoke-free policies proven to have long-lasting effects on STEMI reduction
Clearing the air of tobacco smoke seems to be a good long-term strategy. “Previous studies have focused on short-term effects of a smoking ban so they only analyzed 6 months or 1 year after implementation of the ban. The strength of our study is the 3-year follow-up, which really supports the hypothesis that there are long-lasting effects from smoke-free policies in decreasing the incidence of STEMI.”—Alessandra Pia Porretta MD, Ospedale San Giovanni, Bellinzona, Switzerland
Mortality much lower in elite Tour de France athletes than non-cycling countrymen
Let’s face it: elite athletes are a fairly self-selected lot, so not sure what this means for the average two-wheeler, but it’s good news for those who’ve kept the Tour de France going for a century.
“As medical doctors, we often tell patients to be careful, that it’s dangerous to exert themselves too strenuously, but this message is wrong. We need to encourage people to exert themselves and to do sports at a good level. Very high level cyclists live 6 years longer than the general population and death from all causes is much lower among Tour de France cyclists except from trauma.”—Xavier Jouven, MD, PhD, Sudden Death Expertise Center, Paris
You can be fit and fat, but that belly may be a big problem in MI survivors
Having a big belly increases the risk of death following an MI and a large registry study suggests lifestyle interventions in heart attack patients should focus on losing abdominal fat.
“You may have a high BMI and still be a fit person because you do a lot of sport and have a high muscle mass and … still you’re very fit. That is why I think the upper level of waist circumference is a much better indicator of being fit or not fit rather than the BMI. From a public health perspective, we need to focus on the more severe forms of obesity as well as abdominal obesity rather than being overweight or mildly obese in patients who’ve had a heart attack.”—Tabassome Simon, MD, Hôpital St Antoine, Paris
Delayed-enhancement MRI helps predict treatment success prior to ablation
Delayed-enhancement magnetic resonance imaging (DE-MRI) has been a very effective modality in identifying fibrotic and scarred cardiac tissue in patients with atrial fibrillation before treatment. In addition, post-ablation DE-MRI effectively demonstrates the degree of left atrial tissue injury and has shown a significant direct relationship of the degree of enhancement and successful clinical outcomes. Despite reproducible, high success rates, recurrences after radiofrequency ablation remain a common event.
“By performing [DE-MRI] before ablative treatment, we can triage patients according to the likelihood of treatment success and avoid ablative procedures in those patients for whom it is unlikely to work. If a patient has late-stage 3 or stage 4 fibrosis, their chance of being cured is only 30-35%, but if they’re in an early stage, their chance of cure is 60-80%.”—Nasir Marrouche, MD, University of Utah, Salt Lake City
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