Coronary Artery Disease: Innovation and Optimization

While drug-coated balloons (DCB) initially held promise as a potential alternative, the REC-CAGEFREE I study revealed they were not as effective as drug-eluting stents (DES) in treating uncomplicated coronary artery lesions.

In this study, 2,272 patients were randomized at 43 sites in China to receive paclitaxel-coated balloon angioplasty with the option of rescue stenting due to an unsatisfactory result (DCB group) or intended deployment of second-generation thin-strut sirolimus-eluting stents (DES group).

At 24 months, DCB angioplasty with rescue stenting did not achieve noninferiority compared with intended DES deployment for patients with de novo, noncomplex coronary artery lesions. However, the OCCUPI study offered encouraging news. It demonstrated the significant benefits of optical coherence tomography (OCT) guidance during PCI procedures for complex lesions.

Compared with traditional angiography guidance, OCT guidance resulted in a lower incidence of major adverse cardiac events at one year following the intervention.

The SCOFF trial challenged a long-standing practice by suggesting that fasting might not be necessary before cardiac procedures requiring conscious sedation. This finding has the potential to significantly streamline patient care and improve overall procedural efficiency, offering a promising outlook for the future of cardiac procedures with no significant increase in adverse events or anesthesia-related complications.

New studies were also presented regarding treatment strategies for older adults with NSTEMI. The SENIOR-RITA trial investigated the effectiveness of an invasive approach involving coronary angiography and revascularization. The results revealed that this approach did not offer a clear advantage over medical therapy alone for this specific patient population, especially in hemodynamically stable patients with no active chest pain or signs of cardiogenic shock.

Due to recent interest in complete vs. culprit-only intervention in patients presenting with STEMI and multivessel disease, the EARTH-STEMI meta-analysis explored the comparative benefits of these two revascularization strategies in older adults with STEMI.

Adding more granularity to this challenging patient population, this analysis demonstrated that complete revascularization successfully reduced ischemic events for up to four years after STEMI, offering hope for improved treatments in the future.

Structural Heart Disease: Minimally Invasive Solutions Take Center Stage

The RHEIA trial garnered significant attention by comparing transcatheter aortic valve implantation (TAVI) to surgical aortic valve replacement (SAVR) for women with severe symptomatic aortic stenosis. The study revealed that TAVI provided better clinical outcomes, primarily attributed to a lower rate of hospitalizations in the TAVI group.

For patients grappling with secondary mitral regurgitation (MR), the MATTERHORN and RESHAPE-HF2 trials delved into the efficacy of mitral transcatheter edge-to-edge repair (M-TEER) as an alternative to surgical intervention. Both trials demonstrated that M-TEER was a viable and effective option compared with surgery.

Notably, the RESHAPE-HF2 trial further highlighted that M-TEER offered additional benefits for patients with symptomatic heart failure (HF) and moderate to severe functional MR leading to a reduction in cardiovascular death, HF-related hospitalizations, and an overall improvement in patient health status.

The Tri.fr study focused on tricuspid transcatheter edge-to-edge repair (T-TEER) to treat secondary tricuspid regurgitation (TR). The study yielded promising results, demonstrating that T-TEER significantly reduced the severity of TR while also improving patients' quality of life after one year.

Refining Guidelines and Early Detection

The ESC Congress 2024 unveiled revised guidelines for the management of peripheral arterial and aortic diseases. Although these changes do not reflect the U.S. guidelines, it's worth mentioning since a few changes can affect patient outcomes and trigger earlier screening parameters.

These updated recommendations emphasize the importance of early detection, particularly for abdominal aortic aneurysms (AAA). The guidelines advocate for screening men aged ≥65 years with a history of smoking, all men >75 regardless of smoking status and women aged ≥75 who are active smokers or hypertensive.

Additionally, first-degree relatives of individuals diagnosed with AAA are now recommended to undergo screening with duplex ultrasound. Additionally, the recommendations for postoperative imaging follow-up have been revamped for both open and endovascular repair procedures for AAA.

Furthermore, the new guidelines for patients diagnosed with atherosclerotic peripheral arterial disease set a more ambitious target for LDL-C reduction, aiming for levels <55 mg/dL with a minimum 50% reduction from baseline.

Beyond Core Areas: Expanding Horizons in CV Care

The congress reached beyond these central themes, showcasing additional exciting developments. Semaglutide, a medication originally developed for diabetes management, was found to have broader cardiovascular benefits beyond weight loss. Analysis of existing trials revealed that semaglutide can potentially reduce the risk of death, minimize serious COVID-19 complications, and alleviate symptoms of HF.

The ADMINISTER2 trial explored using digital consultations to improve guideline-directed medical therapy adherence in patients with HF with reduced ejection fraction. The study demonstrated the effectiveness of these digital consultations in enhancing patient adherence with recommended treatment regimens.

Also highlighted was the importance of early intervention in preventing adverse cardiovascular events. The Stop-or-Not trial in France demonstrated that continuing renin-angiotensin system inhibitors (RASIs) before major noncardiac surgery was associated with better postoperative outcomes than discontinuing them. This finding underscores the need for careful consideration when managing patients with preexisting cardiovascular conditions undergoing noncardiac surgery.

Clinical Topics: Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Imaging

Keywords: Cardiology Magazine, ACC Publications, ESC Congress, ESC24, Coronary Artery Disease, London, Shock, Cardiogenic, Tomography, Optical Coherence, Angioplasty, Balloon, Coronary