Editor's Corner | After the Smoke Clears

Our Annual Scientific Session is in the rearview mirror. There’s been time for the smoke to clear for a more considered interpretation of what we heard and saw in Orlando. What are the compelling messages about therapies for our patients? Some important concepts have been supported by clinical trials that provide us with concepts about future cardiology care.

The show stopper was ODYSESSY Outcomes which showed benefit in patients with acute coronary disease or unstable angina, with a 1.6 percent reduction in all-cause mortality with the PCSK9 inhibitor alirocumab. Like the FOURIER trial presented last year, the PCSK9 inhibitor showed a positive statistical result when examining outcomes in stable coronary disease. But the small differences and high cost for both drugs is not generating a rush to these new medications. The controversy and surrounding discussion is pushing patients and physicians to seek lower LDL-C levels using conventional oral therapy. The data so far suggest that patients show improved outcomes by optimizing oral lipid-lowering drugs before resorting to a PCSK9 inhibitor. The task ahead is to determine who benefits the most from PCSK9 inhibitors and focus therapy on these patients.

Further analysis of the CANTOS data showed a positive outcome with anti-inflammatory therapy in patients with chronic renal disease. The initial message from CANTOS was the finding of lower risk for coronary events with the anti-inflammatory monoclonal antibody canakinumab without a reduction in LDL-C. In follow-up of patients with chronic renal disease, the investigators found improved renal function in patients treated with the monoclonal antibody. The important news is the fact that anti-inflammatory therapy has a similar effect on preventing progression of atherosclerotic disease — and lowering lipid levels is only part of the story.

We made some important steps forward in management of heart failure. Despite high interest in heart failure with preserved ejection fraction (HFpEF), the magic bullet for its treatment remains elusive. We learned that HFpEF is a multifactorial disorder and one magic bullet is not likely the answer. With multiple causes of HFpEF, tailored therapy to each etiology is required. An excellent review given by Sanjiv Jayendra Shah, MD, FACC, described three HFpEF phenotypes.

Group 1 has a BNP deficiency syndrome, and patients are obese, with low BNP, increased plasma volume and some pericardial restraint. Group 2 is characterized by obesity, diabetes and metabolic syndrome, with elevated BNP and abnormal diastolic relaxation. The need to manage obesity and metabolic syndrome make this a difficult phenotype. Group 3 constitutes patients with right ventricular failure. These patients have changes in the splanchnic circulation and the gut microflora that lead to renal insufficiency, thereby aggravating right heart failure and leading to HFpEF.

Many older patients have HFpEF with significant left ventricular hypertrophy, but no other overt pathology. These patients usually benefit from vigorous efforts to lower blood pressure (BP). Right heart dysfunction can induce HFpEF that complicates the management of right heart failure and may be complicated by changes in splanchnic hemodynamics and renal insufficiency. Both hypertrophic cardiomyopathy and persistent high cardiac-output syndromes are often accompanied by HFpEF.

Programs are needed that provide periodic motivation to patients to participate in their care with their providers in a system of care.

In contrast, some studies presented at ACC.18 help the management of patients with reduced ejection fraction (HFrEF). We saw benefit in patients who received an implanted pulmonary artery monitor. Prior studies with this device and others demonstrated that early HF decompensation is first seen in elevated pulmonary pressure, before overt symptoms occur. Early detection of this change allows the physician to modify therapy earlier. This is not a device for everyone. But in patients with late-stage HF this early warning system will often avoid a HF admission.

Another interesting device was reported for treating patients with advanced HF. This device establishes a left-to-right shunt at the atrial level to relieve high left atrial (LA) pressure. The study was in 38 patients (30 HFrEF). At the end of 28 months, 17 of the LA shunt devices were patent. In these patients, LA pressure was reduced, NYHA class went from III to II and they were less symptomatic. In patients with functioning shunts, hospitalizations were reduced significantly. The efficacy of this approach requires confirmation in a larger randomized trial, but this offers another promising method for approaching end-stage HF.

Data from a new left ventricular assist system (VAS), Heartmate III, were presented from the MOMENTUM-3 study. Unlike prior continuous flow axial devices, Heartmate III is a centrifugal pump with a pulsatile component that appears to prevent the thrombosis associated with the older axial flow devices. The older devices also had a significant incidence of bleeding due to small A-V malformations associated with the continuous flow milieu and an interaction with von Willebrand factor that increased bleeding. With Heartmate III, the incidence of bleeding was lower than with Heartmate II, but the difference did not reach statistical significance. And, the overall stroke rate was lower and there were fewer pump failures. Alleviation of these complications of VAS therapy is a welcome addition with the Heartmate III and will allow more patients with end-stage HF to receive a VAS as destination therapy.

Well-deserved attention has been given to the barbershop study. Ronald Victor, MD, FACC, designed a study that took the intervention directly to a population with a substantial need: African American men who have a significant incidence of uncontrolled hypertension. The study targeted men with hypertension living in the inner city of Los Angeles. In the intervention group, 132 men in 28 neighborhood barbershops received monthly BP checks and prescription of antihypertensive medication by a specialty-trained pharmacist. In the usual care group, 171 men in 24 barbershops were encouraged by their barber to see their primary care physician and make lifestyle changes. After six months, 63.6 percent of the intervention group reached BP goal, with a 27 mm drop in systolic BP, compared with only 11.7 percent of the usual care group, with a 9 mm Hg average reduction in systolic BP.

The need for motivation as a key component of chronic care is reinforced by these observations, particularly for disorders often not obvious to patients and can be present for long periods without overt symptoms. Programs are needed that provide periodic motivation to patients to participate in their care with their providers in a system of care.

At ACC.18 we saw many technical innovations that brought improved health to many patients with advanced heart disease and we’ve become immersed in the decision to add advanced therapy for hyperlipidemia. The greatest impact may be to teach us once again that continuous engagement of patients with chronic heart disease will succeed in improving health in many millions of patients.

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Alfred A. Bove, MD, PhD, MACC, is professor emeritus of medicine at Temple University School of Medicine in Philadelphia, and a former president of the ACC.

Clinical Topics: Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Atrial Fibrillation/Supraventricular Arrhythmias, Lipid Metabolism, Novel Agents, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Hypertension, Smoking

Keywords: ACC Publications, Cardiology Magazine, Antihypertensive Agents, Blood Pressure, von Willebrand Factor, Metabolic Syndrome X, Hypertrophy, Left Ventricular, Cardiac Output, High, Plasma Volume, Pulmonary Artery, Physicians, Primary Care, Pharmacists, Smoking, Research Personnel, Stroke Volume, Follow-Up Studies, Atrial Fibrillation, Antibodies, Monoclonal, Goals, Heart Failure, Heart Diseases, Obesity, Hypertension, Hospitalization, Renal Insufficiency, Renal Insufficiency, Chronic, Angina, Unstable, Coronary Disease, Thrombosis, Cardiomyopathy, Hypertrophic, Hyperlipidemias, Stroke, Splanchnic Circulation, Life Style, Phenotype, Diabetes Mellitus, Lipids, ACC18, ACC Annual Scientific Session

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