Editor’s Corner: The AHA in New Orleans 2016 | Alfred A. Bove, MD, PhD, Editor-in-Chief, CardioSource WorldNews
CardioSource WorldNews | I was proud to see Dr. Steven Houser’s lead-off Presidential Address at the AHA this year. Dr. Houser is a long-time colleague and friend whose compelling talk at the opening ceremony tracked his personal and scientific journey.
His 25 years in research have been to advance the science in cardiology that could have prolonged his father’s life. What his dad thought was a chest cold was, in fact, a myocardial infarction, which led to severe heart failure and death when he was just 51.
In his quarter century of subsequent research, Dr. Houser has made many contributions to the field of cardiovascular science. His work now is impacting new methods to improve heart muscle function in the failing heart.
Advancements in Care
At AHA.16, we also heard about quite a number of clinical trials that provided insight into new and established therapies of heart disease. In a study from the Mayo Clinic, investigators compared an objective measure of exercise, functional aerobic capacity (FAC), as a measure of fitness to the incidence of atrial fibrillation. Over 11 years, a higher FAC was correlated with an 11% lower risk of AF. Greater gains were found in the less fit, but all ranges of fitness benefited. The findings again underscore the important role of moderate exercise in maintaining cardiovascular health.
Everyone wants to be best, but again this year there were plenty of examples of comparative trials with neutral results. In a study involving more than 30,000 subjects in the PRECISION trial, the investigators found small, but non-significant differences in safety when comparing celecoxib to ibuprofen and naproxen. The study was designed to examine differences in safety between these drugs in patients with high-risk cardiovascular disease. The population, however, ended up with many subjects at intermediate risk, many of whom were also taking aspirin. All of the trial patients were also taking esomeprazole to reduce gastric side effects. With the small, non-significant differences in safety outcomes, it will be hard to convince patients to stock their medicine cabinet with celecoxib in place of either ibuprofen or naproxen for their day-to-day needs to treat minor musculoskeletal pain, headaches, or other minor discomforts, given the expected difference in cost for these medications.
Should we recommend dual internal mammary bypasses in patients with multivessel CAD? Data from the ART trial indicate no advantage to using dual mammary artery grafts to improve 5-year coronary outcomes, and there is a higher incidence of early sternal wound complications when using both mammary arteries for coronary bypass. We have been concerned for several years that bilateral mammary artery bypass would leave the sternum at risk for ischemia and poor wound healing. The data from ART support this long-held concern; dual mammary artery bypass surgery does, in fact, increase the rate of sternal wound complications in the first few months after bypass surgery. That’s a limiting feature, for sure, when you consider that 5-year clinical outcomes were the same with single or dual mammary artery bypass.
Use of antiplatelet therapy extends beyond coronary disease, and this therapy is also of interest in treating patient with peripheral artery disease. The EUCLID trial compared the effects of ticagelor to clopidogrel on cardiovascular death, MI or ischemic stroke in patients with PAD. The study showed no differences in outcome between these 2 drugs in this patient population.
We also saw no benefit in measuring fractional flow reserve in patients undergoing coronary angiography in the FUTURE trial. Indeed, after 1 year, mortality increased from 2% to 4% in patients whose care was guided by FFR versus coronary angiography interpretation.
We continue to seek therapies for acute HF to improve long-term survival , such as a new drug, ularitide, for treating acute decompensated heart failure. Although the patients in the TRUE-HF trial felt better in the first 48 hours of therapy, their long-term survival was not improved with this new agent. Neither troponin nor BNP was able to predict long-term mortality, suggesting that injury to the myocardium that occurs with ADHF has a long-lasting effect that might require methods to detect heart failure progression long before the decompensation phase to prevent permanent injury to the myocardium that results from ADHF.
There are some important lessons to take home from this meeting. First, we need to look out multiple years to fully understand the effects of our therapies; the initial observations of an effect may not tell the entire story. Many of the studies that showed no differences in outcome when comparing 2 therapies leave us with some reassurances that our current therapies are effective, and many of the newer therapies, while efficacious, are not adding a significant incremental effect to care.
We also learned that population health is a concept that needs to come to our practices. Long-term care and prevention of chronic diseases – like hypertension, hyperlipidemia, and diabetes – need a broader approach for both treatment and prevention, and this is best achieved with a team of care providers that can range from a physician to a trained health aid. Team care and motivation for patients to participate in their health care is needed to achieve better health in communities and these concepts need to be applied even to children and adolescents if we want better health for our youth, just as much as we do for our peers and the elderly. Considering population health as part of our responsibility means that we not only provide care for a single patient, but also should be participating in care systems that look at a broader perspective of prevention and chronic disease management. This year’s AHA meeting was both enjoyable and informative with enough valuable take-home messages to make attendance worthwhile.
Alfred A. Bove, MD, PhD, is professor emeritus of medicine at Temple University School of Medicine in Philadelphia, and former president of the ACC.
|Read the full December issue of CardioSource WorldNews at ACC.org/CSWN|
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