Cardiology in London
Editor’s Corner | Alfred A. Bove, MD, PhD, MACC
“Look Right Before Crossing” can be read at nearly every curbstone where there is a pedestrian crossing. Of the many characteristics of London, driving on the right side of the road is one that is hard to consistently accommodate during the short stay for the ESC meeting. Likewise, getting into the right front seat in a London taxi puts you in front of the steering wheel, eliciting strange stares from the taxi driver.
In spite of the transposed traffic and a bit of travel from downtown to the ExCel Center, where the ESC annual meeting took place, the atmosphere of the meeting was exciting, a lot of science was presented, and the opportunity to socialize with colleagues from other countries made the meeting quite enjoyable.
More data were presented on IMROVE-IT that support the value of additional lowering of LDL using ezetimibe to reduce the risk of cardiovascular events, challenging the current concept of goalless therapy of hyperlipidemia.
We heard that left atrial appendage isolation is efficacious in eliminating need for anticoagulation in patient with chronic atrial fibrillation (AF) and, as expected, continued discussion about the proper role for novel oral anticoagulants in stroke prevention in AF. We also dove back into the debate on duration of dual antiplatelet therapy. The data from the OPTIDUAL trial suggested that 48 months of DAPT has some advantage in reducing coronary events without increasing bleeding risk. This trial, however, started randomization after 12 months of DAPT, and most of the bleeding occurred within the first 12 months. In short, we are getting more indications that DAPT therapy for more than 36 months provides some advantage in reducing future coronary events.
An interesting observation was the finding that the CHA2DS2-VASc score is useful in predicting stroke in heart failure patients in sinus rhythm, another piece of evidence that embolic stroke is not just the result of the arrhythmia. More detail on how to manage AF patients after catheter ablation was presented, too, as well as another update on FAME suggesting that fractional flow reserve is here to stay in assessing severity of coronary lesions. Some interesting data from Europe and Japan on bioresorbable coronary scaffolds (we don’t call them stents) suggests that this form of scaffold device may find its way into the mainstream of PCI therapy, particularly with the finding that the stented segment reestablishes intima, media, and endothelial integrity, thereby restoring the normal proximal artery response to blood flow.
Another surprising finding came from the SERVE-HF trial, examining the value of synchronized breathing support in heart failure patients with sleep disordered breathing from central sleep apnea. In that study, the mortality rate was higher in subjects who received the synchronized respirator therapy, compared to the usual form of CPAP.
This was a surprise because prior data suggested that this method of respiratory support actually improved the status of patients with heart failure. The data point out the value of doing a randomized trial given that prior nonrandomized and uncontrolled studies suggested a benefit from this therapy.
Many of the studies presented at ESC.15, however, were disappointing in failing to confirm their primary hypothesis. ATTEMPT-CVD, for example, tested the value of angiotensin blockade with telmisartan in preventing cardiovascular disease in patients with hypertension. There was no difference in clinical outcomes, in spite of an improved pattern of biomarkers in the treatment group. Similarly, the ALBATROSS trial provided aldosterone blockade therapy to patient with acute MI and, again, there was no significant change in clinical outcome. One bright spot: in the TECOS trial, sitagliptin, a DPP-4 inhibitor, did not increase risk for heart failure in diabetic patients, a finding that contrasts with several studies of other DPP-4 inhibitors that did heighten HF risk.
I left London without a lot of new ideas for changing my cardiology practice. I will likely continue DAPT for up to 4 years if there are no bleeding complications, but therapy of hypertension, HF, acute MI, hyperlipidemia, and AF will continue as usual. Two new therapeutic options, the PCSK9 inhibitors and the neprolysin inhibitor LCZ696 will gradually make their way into our therapeutic armamentarium, but cost will slow their adoption in the large number of patients who might benefit from their use. With FDA approval of these drugs, their presence at the large meetings has moved from the meeting rooms to the exhibit floor and the next big thing is yet to come.
Alfred A. Bove, MD, PhD, MACC, is professor emeritus of medicine at Temple University School of Medicine in Philadelphia, and former president of the ACC.
< Back to Listings