AHA18

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What Can Cardiology Learn from Impressionism?

Akl Fahed, MD, MPH

A Sunday on La Grande Jatte — 1886 Georges Seurat

At the end of three inspiring days at the American Heart Association Scientific Sessions (AHA18) in Chicago, I took advantage of my late night return flight to spend the afternoon at the Art Institute of Chicago. The museum has one of the finest collections of impressionist paintings, and I’m a big fan.

Impressionist artists in the mid-1870s in France challenged the artistic traditions of their predecessors. They depicted spontaneity in their paintings by capturing moments of daily life of regular people, focusing on nature, and using bright colors and rapid brush strokes.

The mid-1880s marked the end of Impressionism. Fathers of the movement started challenging the very basic conventions they helped establish. Claude Monet, for example, traveled outside Paris and instead of painting spontaneous moments, his paintings started reflecting thoughtful and deliberate approach with series of paintings of the same subject to reflect all the level of detail. In the last impressionist exhibition in Paris in 1886, Georges Seurat exhibited A Sunday a La Grande Jatte which used pointillism, a scientific technique of painting deliberately distinct from the more intuitive approach of impressionists. It was a challenge to the impressionist movement and marked its end and the start of a post-impressionist era.

The American Heart Association brings breakthrough science in cardiovascular disease to the art of cardiology practice. At the Scientific Sessions every year, you get to see practice-changing clinical trials, which are often the result of at decade or more of pre-clinical and clinical development. Despite that excitement, adoption of new evidence-based therapies remains slow.  While economic, drug-specific, and prescriber-specific characteristics play a role, we are sometimes shackled by our habits.

Impressionists revolted on the habits of the past and brought a whole new approach to painting. When they no longer needed it a decade later, they evolved quickly into new techniques. One painting, A Sunday a La Grande Jatte, marked the end of an era.

We can learn from that.

If new anti-diabetic drugs such as GLP-1 receptor agonists and SGLT2 inhibitors are showing cardiovascular benefits, maybe we should take more ownership of diabetes management.   If the new cholesterol guidelines recommended lower LDL cut-offs for statin initiation, we should be more proactive about re-evaluating all our clinic patients. And if angiotensin receptor-neprolyhsin inhibitor reduces death in heart failure compared to ACE inhibitor, then we should probably we using it more.   There is often a delay in diffusion of scientific sessions research to clinical practice. We should be always conscious that any delay of implementing new scientific findings to patient care is a  missed opportunity to save lives.

When AHA was founded in 1925, Dr. Paul Dudley White, one of the co-founders, commented, “We were living in a time of almost unbelievable ignorance about heart disease.”  Thankfully nowadays, we have gone so far from that, as we even discuss cutting edge cardiovascular science such as systems-based approaches to drug development, nanotech monitoring in the ICU, and development of an anti-atherosclerosis vaccine.

Like the impressionists, we should continue to challenge the past and present every day, but also free ourselves of habit when necessary,  as we strive “to be a relentless force for a world of longer, healthier lives.”

 
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Live Streaming Into Scientific Sessions 2018

Trupti Shetty

AHA Scientific Sessions 2018 was a unique experience for me – unable to attend the meeting, I live-streamed the sessions (first time ever for a conference!). Two of my most favorite sessions this year were the panel discussion for advanced heart failure (HF) patients, “The Metabolic Face of Heart Failure,” and the mini-symposium on “Cutting Edge in Cardiovascular Science.”

One of the main highlights in the session Metabolic Face of HF, moderated by Dr Lynne Stevenson, was the talk by cardiovascular stalwart Dr. E. Braunwald, Brigham and Women’s Hospital. Dr. Braunwald spoke of the significance and latest practices in the use of Sodium-Glucose Cotransporter-2 (SGLT2) inhibitors, a class of FDA-approved drugs for type-2 diabetes. He indicated how SGLT2 inhibitors should be explored beyond diabetes treatment and these class of drugs can benefit HF patients as well. “I had to learn about blood clotting 30 years ago, which was difficult,” he modestly admitted as he clarified the renal effects of SGLT2 inhibition. His views also seemed to resonate with Dr. Subodh Verma, St. Michael’s Hospital, Toronto and Dr. John McMurray, Glasglow University, as they covered SGLT2 inhibitors in HF, as well.

Other speakers at this session, Dr. Neha Pagidipati, Duke University and Dr. Lewandowski, Ohio State University, touched upon aspects of stroke and metabolism regulating HF, respectively. While Dr. Pagidipati compared the risk of cardiovascular diseases and stroke with the risks of diabetes, Dr. Lewandowski explained how metabolic regulator PPAR-a (transcriber of genes in fat metabolism) could be a player explored in targeted therapy.

The session ‘Cutting Edge in Cardiovascular Science’ had presenters covering diverse strategies in dealing with cardiovascular therapy, ranging from computational screening to identifying small molecule compounds, to decoding neurovascular networks and the gut microbiome. Dr. Stanley Hazen from Cleveland Clinic presented his work on understanding the microbes in the gut and their role in driving cardiovascular diseases. Dr. Hazen explained how food like red meat, which are rich in components like phosphatidyl serine, activates the gut microbiome. He described the significance of trimethylamine N-oxide (TMAO) pathway in liver and its association with HF, stroke and cardiovascular diseases. He also strategized the use of enzyme in TMAO pathway as targets of small molecule inhibitors.

Dr. Joseph Loscalzo, Brigham and Women’s Hospital, explained how repurposing drugs and finding drug targets computationally could help precision medicine vastly. He also offered his expertise and tools as open access to AHA members. Finally, Dr. Costantino Iadecola, Cornell, elaborated on the heart-brain connectome. He brought attention to the fact that dementia, known to cause hardening of arteries, led to Alzheimer’s, but we all forgot about the vascular complications of this. He bridged this connection between neurovascular dysfunction and cognitive impairment and went on to explain his research on the intake of high salt in diet caused dementia in mice models. To learn of such versatile range of topics in a session was illuminating, to say the least!

Researchers must spend time thinking about applications of their current projects beyond their own niche – this is the only way we can widen our horizons with existing tools.

 
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Feel Like An Imposter? Strategies For Dealing With Early Career Self-Doubt

Allison Webel, PhD

As we were wrapping up our first editorial meeting for the AHA Early Career Bloggers on Saturday at Scientific Sessions 2018, the new bloggers were given this advice: “Over the next three days, do something [at Scientific Sessions] outside of your comfort zone.” This year’s Scientific Sessions offered some novel experiences –  augmented reality in the Cath Lab, network analysis for high throughput data, and machine learning for dummies. But the thing that made me the most uncomfortable was having my research recognized by my council.

If you have read my World AIDS Day blog, you know that most of my research and clinical work has been in the field of HIV. I came to the cardiovascular space out of necessity because my patients living with HIV were developing cardiovascular disease at higher rates than those without HIV. I never worked as a CICU nurse or in cardiac rehabilitation, and I still get confused about the many different types of antihypertensive medications. I could reasonably be considered a cardiovascular carpetbagger. Yet I work hard to understand cardiovascular science and practice guidelines because I know it is important to helping people living with HIV enjoy the healthiest life possible. Knowing this, about five years ago, my mentors pushed me to get more involved with the American Heart Association which has led me attend various AHA conferences, review abstracts, and apply for (and receive) AHA Research funding.

This year at Scientific Sessions, I was honored with the Council on Cardiovascular and Stroke Nursing (CVSN) Research Article of the Year Award. It is an incredible honor recognizing work that I am proud of. And while I am grateful to the CVSN and the sponsor for this award, my first thoughts after receiving the notification of award  were, “Wow, this is amazing,” quickly followed by, “Why me? Why an article on improving cardiovascular health in people living with HIV? Maybe they didn’t get other nominations.”  I felt undeserving and uncomfortable being honored for work I invested the last three years of my life in and I could not understand why.

Imposter Phenomenon, or Imposter Syndrome, first defined in 1979 by Clance and Imes, are feelings of fraudulence by high achievers who “do not attribute their success to their own abilities despite their many achievements and accolades.”  Recent research suggests most professionals can relate to these feelings, but it can be especially prevalent as new roles are taken on, especially in first jobs or new challenges. While Impostor Syndrome is associated with academic success, it is also associated with poor mental health outcomes including anxiety, depression, psychological distress, and minority student status stress.  There is also  evidence that Imposter Syndrome can make one reluctant to seek out new professional opportunities. Thus, Imposter Syndrome may be especially stunting to early career scientists and clinicians.

Strategies for Managing Imposter Syndrome

  • Recognize that many people have the same feelings of self-doubt at some point in their career
  • Talk about it and ask your trusted mentors and colleagues about their own feelings of being an imposter
  • Write down your strengths and how those led to your accomplishments
  • Develop a strong, safe social support network to share your feelings of self-doubt
  • Read about/listen to others talking about imposter syndrome, there are many great resources available which can help you contextualize your experiences
  • Be present for others who are going through similar experiences

The strategies for managing Imposter Syndrome are timeless but seem hard to achieve. A recent paper by Dr. LaDonna and colleagues in Academic Medicine suggests that having senior colleagues speak openly about their own experiences with self-doubt can have a positive effect. In addition to open discussion about self-doubt, is the importance of a strong support network the importance of perspective and reflection on their own strengths in order to expel “negative views of their own flaws”.

While such strategies may seem contradictory to social media which often highlights success but rarely failures, a recent twitter discussion on Imposter Syndrome (hosted by Emma Clayton of NHS Women Leaders) did just that. This discussion reveled many useful strategies and resources and created a space for people to share their experiences with imposter syndrome with others who had similar struggles. Emma is currently building a website designed to serve as a hub for women to come together and mentor each other as they seek new leadership roles, which should be up later this month.  In reading through her thread, I realized that my feelings of unworthiness can be a double-edged sword and that in the end I just need own it. I need to let my discomfort with my success drive me, not distress or diminish me; motivate, not isolate, me; and above all else,  never let it hold me back from confidently, passionately,  pursuing my goals.

As you reflect back upon your accomplishments in 2018, I hope that you have not feelings of being an imposter stop you from enjoying those successes or thwart progress toward your own goals. But if you are one of the many of us who have, this new year resolve to lessen the negative impact of the imposter and advance confidently in the direction of your dreams.

Photo by Paul Joyce on flikr

 
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Practice Change & CME

Mirvat Alasnag, MD

There are many scientific sessions happening around the globe that issue continuous medical education (CME) credits. Although the AHA Scientific Sessions 2018 covered a wide breadth of topics, I took particular interest in how the new Lipid Management Guidelines apply to women. My previous blog ended by citing a clinic encounter with a female patient. When I see how, as a woman cardiologist, I gained a newer perspective on hyperlipidemia, I realize these CME hours don’t capture the actual impact and changes in practice effected by presented data. Most busy clinicians don’t read every page of published guidelines. The lipid guidelines were summarized into ten key take home messages.

These points didn’t include women as a special population. I avail this opportunity to highlight two very different clinic visits: one before AHA Scientific Sessions 2018 & the second soon after it.

 

October 2018:

This is a 42-year-old female whose cardiovascular risk factors include poorly controlled Type II Diabetes, obesity and hypertension. She suffered an acute inferior myocardial infarction 3 months ago for which primary Percutaneous Intervention was performed with a second-generation drug eluting stent. She was on dual antiplatelet therapy, Lisinopril, Bisoprolol and Atorvastatin 40mg daily. She had not repeated any blood works since discharge (HbA1C 11.1 g/dL & LDL 162 mg/L). Her physical examination was unremarkable aside from weight gain (82 Kg to 85 Kg).

Me: Any chest pain or dyspnea?

She: No

Me: Why did your weight increase?

She: Shrug

Me: Ok I’ll get a dietician and educator to discuss this with you. You need to see your diabetologist. Continue DAPT. We need to drop your LDL, so I’d like to increase the dose of statin.

 

November 2018:

This is a 45-year-old female whose cardiovascular risk factors include Type II Diabetes, obesity and hypertension. She had a positive myocardial perfusion scan performed for angina. A coronary angiogram revealed non-obstructive coronary artery disease in January 2018. She was on aspirin, oral hypoglycemic agents, Bisoprolol and Atorvastatin 40mg daily. Her HbA1C 8 g/dL & LDL 118 mg/L. Her physical examination was unremarkable (weight 71 Kg).

Me: Any chest pain or dyspnea?

She: No, I’m feeling well.

Me: You’re only 45 years old. How many children do you have? Do you plan on having anymore?

She: Why? Will I have a heart attack if I do?

Me: I’m asking because of the statin. We need to discuss contraception if you aren’t planning anymore or alternatives if you do.

She: How about aspirin? Can I stop it now?

Me: …

 

As my mentor always told me, “If you don’t know what to look for, you won’t see what you should.” If I wasn’t directed through the AHA Scientific Sessions to search for the topic of women and statin therapy, I would have failed my second patient as I did my first.

But the second encounter sparked a different discussion related to cardiovascular disease prevention in women: What is the role of Aspirin in prevention? This too was discussed at Scientific Sessions 2018.

The Physicians Health Study published in 1989 demonstrated a 44% reduction in myocardial infarctions with aspirin therapy. The evidence for stroke reduction and cardiovascular deaths was inconclusive.1 The Women’s Health Study published in 2005 demonstrated a 17% reduction in stroke.2 This was primarily ischemic with an insignificant increase in hemorrhagic stroke. There was no net effect on fatal and nonfatal myocardial infarctions or overall cardiovascular deaths. The US Preventive Services’ latest statement (see link) recommends low dose aspirin for individuals between 50-59 years with a > 10% 10- year ASCVD risk and a life expectancy of at least 10 years for the primary prevention of cardiovascular disease and colorectal cancer.

Neither of my patients fit the age group; nevertheless, it is worth the pause. Would my second patient qualify in 5 years?

This year three trials on the role of aspirin in prevention were published and all conflict with these recommendations: ASPREE, ASCEND, ARRIVE. ASCEND in particular is relevant to my second patient who is diabetic rendering her ACVD risk > 20%. There was a small reduction in major adverse cardiac events and a significant increase in bleeding.3 How do we reconcile these differences. Subjects in the earlier trials had an important additional risk factor: smoking. The use of statin therapy was also significantly lower in the earlier studies. Perhaps the impact of the two accounts for the conflicting results in the more recent trials.

Is there any role for aspirin in primary prevention? Preliminary data from MESA suggests that high coronary artery calcium score and high plasma lipoprotein (a) may warrant aspirin therapy.4

Scientific Sessions offers CME. However, what we take back to our patients is far more…Aspirin or not, Statin or not, CACs or not. All these were thought provoking discussions this year.

 

I thank both my patients for consenting to using their information in this blog.

 

REFERENCES:

  1. Steering Committee of the Physicians’ Health Study Research Group. N Engl J Med 1989; 321: 129-35
  2. Ridker P, et al. A Randomized Trial of Low-Dose Aspirin in the Primary Prevention of Cardiovascular Disease in Women. N Engl J Med 2005; 352: 1293-1304.
  3. The ASCEND Study Collaborative Group N Engl J Med 2018; 379: 1529-39.
  4. Chasman D, et al. Polymorphism in the apolipoprotein (a) gene, plasma lipoprotein(a), cardiovascular Disease and Low-dose Aspirin Therapy. Atherosclersosis: 2009 Apr; 203 (2):371-6.

 

 
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Is There An Intervention For Reducing All Cardiovascular-Related Diseases?

Saurav Chatterjee, MD

What ‘intervention’ reduces risk for all-cause and cardiovascular mortality, cardiac and cerebrovascular events, hypertension, type 2 diabetes, lipid disorders, and cancer of the bladder, breast, colon, endometrium, esophagus, kidney, stomach, and lung? As an interventional cardiologist and outcomes researcher, I would have been happy to attribute this to the latest device/procedure or a cure-all pill. But the answer is ‘none of the above’. The the answer is probably one of the biggest take aways from AHA Scientific Sessions 2018 for me.

As the AHA18 meeting drew to a close, amidst all the ‘buzz’ of the late-breaking clinical trials and other remarkable research, a largely less publicized session celebrated physical activity and their favorable impact on health outcomes.The ‘Physical Activity Guidelines Advisory Committee’ under the auspices of the Department of Health and Human Services (HHS) came out with a systematic review and proposed recommendations for physical activity for the American public:

  • A significant change since the 2008 Physical Activity Guidelines for Americans is that previously, aerobic physical activity for adults had to be accumulated in bouts, or sessions, that lasted at least 10 minutes to count toward meeting the key guidelines. Current evidence shows that the total volume of moderate-to-vigorous physical activity is related to many health benefits; bouts of a prescribed duration are not essential. Sufficient physical activity is defined as at least 150 minutes of moderate-intensity aerobic physical activity and 2 days per week of muscle-strengthening activity for adults and at least 60 minutes of moderate-intensity aerobic physical activity and 3 days per week of muscle-strengthening activity for youth.
  • Preschool-aged children (ages 3-5 years) should be physically active throughout the day to enhance growth and development. Increased physical activity is associated with improvements in bone health and weight status. Children and adolescents ages 6-17 years should do 60 minutes or more of moderate-to-vigorous physical activity daily. Increased physical activity is associated with improvements in bone health, weight status, cardiorespiratory fitness, and cardiometabolic health. Additional benefits include improved cognitive function and reduced risk of depression.
  • Adults should do at least 150-300 minutes a week of moderate-intensity, or 75-150 minutes a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. Adults should perform muscle-strengthening activities on 2 or more days a week. Older adults should do multicomponent physical activity that includes balance training as well as aerobic and muscle-strengthening activities. Benefits of increased physical activity include lower risk of mortality including cardiovascular mortality, lower risk of cardiovascular events and associated risk factors (hypertension and diabetes), and lower risk of many cancers (including bladder, breast, colon, endometrium, esophagus, kidney, lung, and stomach). Additional improvements have been seen in cognition, risk of dementia, anxiety and depression, improved bone health, lower risk of falls, and associated injuries.
  • Adults with chronic conditions or disabilities, who are able, should follow the key guidelines for adults and do both aerobic and muscle-strengthening activities. Pregnant and postpartum women should do at least 150 minutes of moderate-intensity aerobic activity a week.
  • Recommendations emphasize that moving more and sitting less will benefit nearly everyone. Individuals performing the least physical activity benefit most by even modest increases in moderate-to-vigorous physical activity. Both aerobic and muscle-strengthening physical activity are beneficial. Some health benefits begin immediately after exercising, and even short episodes or small amounts of physical activity are beneficial.
  • Technology, such as step counters or other wearable devices or fitness apps, can provide physical activity feedback directly to the user. Technology can be used alone or combined with other strategies, such as goal setting and coaching, to encourage and maintain increased physical activity. (Adapted from https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2018/11/14/14/37/the-physical-activity-guidelines-for-americans)

As an interventional cardiologist, I feel that these interventions or recommendations, if observed, could have significant positive impact on the health and well-being of the US population, and I will try my best to incorporate these in my practice and encourage peers to do the same.

 

 
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Management of Stroke Patients: A One Man Show or A Tag-Team?

Reem Waziry, MD, MPH, PhD

Atrial fibrillation (AF) increases risk of stroke up to 5 folds, resulting in considerable physical, cognitive impairment and high mortality1. Thus, AF related strokes are very expensive to treat compared to non-AF strokes2. Oral anticoagulation is a well-established therapy in the majority of stroke cases3. Warfarin reduces the risk of stroke by 64% and mortality by 30% compared to placebo3.

Recent data from the pinnacle registry presented by ‘Roopinder Sandhu, Edmonton, AB, Canada’ at the Scientific Sessions 2018, highlighted three key challenges in anti-coagulants management in stroke patients4. Data from a national outpatient registry reported over 700,000 patients had a diagnosis of atrial fibrillation5. Although oral anticoagulation use increased over time, around 40% of patients who are eligible for anti-coagulation never got started on therapy5. The second gap is sub-therapeutic dosing. Recent data from the orbit registry evaluated over 5700 patients who were recently started on a new drug and reported that one in eight patients were either underdosed or overdosed6. Further, there was a higher rate of adverse events in patients who had dosing that was sub therapeutic. The third gap is non-adherence. Data from administrative claims based on a large U.S. commercial insurance database, calculated adherence based on the fill date and the days of supply on the pharmacy claims over a median of 1.1 years7. Less than half of patients who were started on a drug therapy reached the threshold of proportion days covered of 80% or higher. This proportion was less for patients who were on Warfarin.

Given the public health consequences of untreated AF, it is necessary to evaluate different strategies to deliver stroke prevention therapy. Data from 30 randomized clinical trials evaluating the impact of pharmacists, versus standard care, showed superior results in the pharmacist care group in reducing systolic blood pressure (by 8 mm HG), diastolic blood pressure (by 4 mm HG) and total cholesterol (by 17 milligrams DL) and LDL (by 13 mg DL)10. This was done through educational intervention and identification of drug related problems followed by early feedback to the treating physician.

Roopinder added a few possible explanations to what could be driving such impact in the Canadian setting. Typically, a general practitioner would be dealing with patients with a higher evidence of chronic diseases. Further, patient demands often exceed the available physician capacity.

While these results collectively suggest that pharmacist led strategies may be a promising way forward because of their accessibility, drug expertise and their ability to build a trusted relationship. A few key things should be considered. First, that anticoagulation remains to be a complicated problem when it comes to individual patients, with many factors playing a role in the decision process including; medical history (as prior bleeding) and patient preferences. Second, while these interventions seem beneficial in the short-term it may lead to the same shortcomings in the long-term with the increase in demand on the pharmacists as the main provider.

Finally, a key question remains, would a collaborative approach between physicians and pharmacists yield better outcomes through reducing the burden on both providers and simultaneously increasing the time allocated to stroke patients on a case-by-case basis?

 

REFERENCES

  1. Developed with the special contribution of the European Heart Rhythm Association (EHRA), Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS), Authors/Task Force Members, Camm, A. J., Kirchhof, P., Lip, G. Y., … & Al-Attar, N. (2010). Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). European heart journal, 31(19), 2369-2429.
  2. Stewart, S., Murphy, N., Walker, A., McGuire, A., & McMurray, J. J. V. (2004). Cost of an emerging epidemic: an economic analysis of atrial fibrillation in the UK. Heart, 90(3), 286-292.
  3. Ruff, C. T., Giugliano, R. P., Braunwald, E., Hoffman, E. B., Deenadayalu, N., Ezekowitz, M. D., … & Yamashita, T. (2014). Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. The Lancet, 383(9921), 955-962.
  4. Sandhu, R. K., Guirguis, L. M., Bungard, T. J., Youngson, E., Dolovich, L., Brehaut, J. C., … & McAlister, F. A. (2018). Evaluating the potential for pharmacists to prescribe oral anticoagulants for atrial fibrillation. Canadian Pharmacists Journal/Revue des Pharmaciens du Canada, 151(1), 51-61.
  5. Marzec, L. N., Wang, J., Shah, N. D., Chan, P. S., Ting, H. H., Gosch, K. L., … & Maddox, T. M. (2017). Influence of direct oral anticoagulants on rates of oral anticoagulation for atrial fibrillation. Journal of the American College of Cardiology, 69(20), 2475-2484.
  6. Steinberg, B. A., Peterson, E. D., Kim, S., Thomas, L., Gersh, B. J., Fonarow, G. C., … & Piccini, J. P. (2015). Use and outcomes associated with bridging during anticoagulation interruptions in patients with atrial fibrillation: findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF). Circulation, 131(5), 488-494.
  7. Yao, X., Abraham, N. S., Alexander, G. C., Crown, W., Montori, V. M., Sangaralingham, L. R., … & Noseworthy, P. A. (2016). Effect of adherence to oral anticoagulants on risk of stroke and major bleeding among patients with atrial fibrillation. Journal of the American Heart Association, 5(2), e003074.
  8. Santschi, V., Chiolero, A., Burnand, B., Colosimo, A. L., & Paradis, G. (2011). Impact of pharmacist care in the management of cardiovascular disease risk factors: a systematic review and meta-analysis of randomized trials. Archives of internal medicine, 171(16), 1441-1453.

 
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Antithrombotic Medications: Is More Better?

Siddharth Sehgal, MD

During Scientific Sessions 2018, I was able to remotely attend several great and informative lectures pertaining to the management of cardiovascular diseases. I was especially interested in the sessions related to antithrombotic therapy as this directly applies to my daily practice of Vascular Neurology. One of those sessions focused on management of tricky situations in post PCI patients. Dr. Roxana Mehran discussed the management of patients with atrial fibrillation and a recent PCI.

Antiplatelet medications are used for secondary prophylaxis in patients with coronary artery disease and ischemic stroke. Patients are routinely prescribed dual antiplatelet therapy (DAPT), usually a combination of aspirin with a P2Y12 inhibitor such as clopidogrel, ticagrelor or prasugrel. This is usually continued for six to 12 months after a PCI.

Results from the recently published POINT (1) trial showed reduced risk of recurrent ischemic stroke in the  short term but an increased risk of hemorrhage with long term use of DAPT for patients with a recent TIA or minor stroke. Data from the SPS-3 (2) trial showed increased risk of hemorrhage with no clear benefit of using DAPT when compared to monotherapy in secondary stroke prevention for patients with a history of lacunar stroke. Therefore, patients who have experienced a recent transient ischemic attack or minor stroke are prescribed a short course of DAPT for 21-30 days.

DAPT has been shown to be inferior to warfarin for embolic stroke prophylaxis, with similar bleeding risk in atrial fibrillation(3). Therefore oral anticoagulants are the treatment of choice for atrial fibrillation. The AHA/ASA guidelines recommend against using DAPT in place of warfarin for atrial fibrillation in high bleeding risk patients.

About 5-10% of patients who undergo PCI are also taking an oral anticoagulant for atrial fibrillation. This creates a tricky situation where they need to be on triple therapy with DAPT and an oral anticoagulant. The triple therapy regimen has been associated with a significantly elevated risk of hemorrhage. WOEST (4) study data showed that using the combination of clopidogrel and an oral anticoagulant after PCI can reduce this risk as compared to the triple therapy regimen. The triple therapy arm 44.4% patients experienced a bleeding episode as compared to 19.4% in the double therapy arm (p<0.001). Moreover there was a higher rate of recurrent bleeding in the triple therapy group at 12% vs. 2.2% in the double therapy cohort. Most importantly, the double therapy did not cause an increase in the incidence of stent thrombosis or recurrent myocardial infarction. These data are encouraging and there are ongoing trials comparing various combination regimens of direct anticoagulants with antiplatelets in this difficult clinical scenario. These much awaited trials will hopefully provide some clarity regarding the optimal combination and duration of treatment. For now, we do have some evidence supporting the use of these triple therapy regimens for the shortest durations possible and periodically assessing the indications for continuing these combination regimens for our patients. When it comes to antithrombotic medications, more may not always be better.

 

References

  1. Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. N Engl J Med 2018; 379:215-225
  2. Effects of Clopidogrel Added to Aspirin in Patients with Recent Lacunar Stroke. N Engl J Med 2012; 367:817-825
  3. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet. 2006 Jun 10;367(9526):1903-12
  4. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet. 2013 Mar 30;381(9872):1107-15

 
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Late Breaking Trials: Scientific Sessions – Chicago 2018

Fawaz Alenezi, MD, MSc


Cardiovascular risk assessment is a process, not just a calculation! This year, I was very pleased to attend the 2018 guidelines for cholesterol management at the American Heart Association (AHA) Scientific Sessions – Chicago 2018. I highly recommend that you check the guidelines as there are many changes that may impact your daily practice. Here, I’m summarizing the late breaking trials that were presented at the last AHA and encouraging you to join us at the next AHA Scientific Sessions meeting – Philadelphia 2019.

 

Critical Questions in Cardiovascular Prevention:

The VITamin D and OmegA-3 TriaL (VITAL): Principal Results for Vitamin D and Omega-3 Fatty Acid Supplementation in the Primary Prevention of Cardiovascular Disease and Cancer.

  • RESULTS: Major CVD events and total invasive cancer not significantly reduced by Omega-3 or vitamin D3. Omega-3 significantly reduced total MI, especially in African Americans and those with lower baseline fish intake.

The Primary Results of the REDUCE-IT Trial.

  • RESULTS: High-dose icosapent ethyl vs. placebo in at-risk patients significantly reduced the composite CVD endpoint: risk of CV death, MI, stroke, coronary revascularization, and unstable angina.

Ezetimibe in Prevention of Cerebro- and Cardiovascular Events in Middle- to High-Risk, Elderly (75 Years Old or Over) Patients with Elevated LDL-Cholesterol: A Multicenter, Randomized, Controlled, Open-Label Trial.

  • RESULTS: Ezetimibe monotherapy + diet counselling vs diet counselling alone for primary prevention (elevated LDL-C; no history of CAD) in an over-75 y/o Japanese population significantly prevented cerebral and cardiovascular events.

Cost-Effectiveness of Alirocumab Based on Evidence from a Large Multinational Outcome Trial: The ODYSSEY OUTCOMES Economics Study.

  • RESULTS: For the patients in the ODYSSEY OUTCOMES trial (post-ACS and LDL-C ≥100 mg/dL), alirocumab was found to be cost effective.

 

Novel Approaches to CV Prevention:

The Dapagliflozin Effect on Cardiovascular Events (DECLARE)-TIMI 58 Trial.

  • RESULTS: Dapagliflozin compared to placebo in patients with T2DM was safe, reduced the composite of CV death or hospitalization for heart failure, but did not impact MACE.

The Cardiovascular Inflammation Reduction Trial (CIRT): Low Dose Methotrexate for the Prevention of Atherosclerotic Events.

  • RESULTS: Low dose methotrexate compared to placebo in patients with prior MI or multivessel CVD and either type 2 diabetes or metabolic syndrome, did not reduce inflammatory markers, and CV events weren’t lower than placebo.

Safety and Efficacy of AKCEA-APO(a)-LRx to Lower Lipoprotein(a) Levels in Patients with Established Cardiovascular Disease: A Phase 2 Dose-Ranging Trial.

  • RESULTS: Dose-dependent lowering of Lp(a) levels by AKCEA-APO(a)-LRx were seen in patients with pre-existing CV disease or PAD in this phase 2 trial

 

Harnessing Technology and Improving Systems for Global Health:

Effects of a Multifaceted Intervention to Narrow the Evidence-Based Gap in the Treatment of High Cardiovascular Risk Patients: The BRIDGE CV Prevention Cluster Randomized Trial.

  • RESULTS: Adherence to evidence-based therapies (antiplatelets, statins and ACE inhibitors) for high CV risk Brazilian patients was improved with use of a multifaceted quality improvement educational intervention vs routine practice.

Alert-Based Computerized Decision Support to Increase Anticoagulation Prescription Prevents Stroke and Myocardial Infarction in High-Risk Hospitalized Patients with Atrial Fibrillation: A Randomized, Controlled Trial.

  • RESULTS: Alert-based computerized decision support in high-risk hospitalized AF patients increased prescribing of anticoagulation for stroke prevention and reduced major adverse cardiovascular events, MI and stroke.

Efficacy of Electronic Clinical Decision Support in Atrial Fibrillation: Results of the Integrated Management Program Advancing Community Treatment of Atrial Fibrillation (IMPACT-AF).

  • RESULTS: An online, evidence-based computer decision support system did not significantly affect the number of patients experiencing the unplanned cardiovascular hospitalization and/or AF-related emergency room visit at 12 months.

 

Preserving Brain & Heart in Acute Care Cardiology:

Pre-Hospital Resuscitation Intra-Arrest Cooling Effectiveness Survival Study – The Princess Trial.

  • RESULTS: Survival with good neurologic outcome 90 days after cardiac arrest was not statistically different for pre-hospital trans-nasal evaporative intra-arrest cooling compared to standard care.

Early Goal-Directed Hemodynamic Optimization in Comatose Survivors After Out-of-Hospital Cardiac Arrest: The Neuroprotect Trial.

  • RESULTS: A higher mean arterial pressure (MAP) in the ICU during the first 36 hours after cardiac arrest improved cerebral perfusion and oxygenation but did not decrease anoxic brain damage or improve functional outcome compared to the lower MAP target of 65mmHg.

A Randomized, Double Blind, Placebo-Controlled, Parallel Group, Multicenter Clinical Trial of Low-Dose Adjunctive Alteplase During Primary PCI (T-TIME).

  • RESULTS: Compared to placebo, microvascular obstruction was not different for low-dose alteplase during primary PCI for acute STEMI.

Optimal Timing of Intervention in Non St-Elevation Acute Coronary Syndromes Without Pretreatment.

  • RESULTS: In not pre-treated intermediate and high-risk NSTEACS patients, a very early (<2 hours) invasive intervention strategy compared to a delayed one (≥12-72 hours) was highly significant for reduction in CV death or recurrent ischemic events @ 30 days.

Mechanically Unloading the Left Ventricular and Delaying Reperfusion in Patients with Anterior ST-Segment Elevation Myocardial Infarction: The Door to Unload Pilot Trial.

  • RESULTS: In patients with anterior STEMI, mechanical unloading of the left ventricle followed by either immediate vs delayed reperfusion found no difference in MACCE between the two groups and no increase in 30-day infarct size in the delayed group.

 

Hot News in HF:

Angiotensin Receptor-Neprilysin Inhibition in Patients Hospitalized with Acute Decompensated Heart Failure: Primary Results of the PIONEER-HF Randomized Controlled Trial.

  • RESULTS: This comparison of sacubitril/valsartan to enalapril in patients hospitalized with HFrEF found that sacubitril/valsartan resulted in significantly more reduction in NT-proBNP levels.

Withdrawal of Pharmacological Heart Failure Therapy in Recovered Dilated Cardiomyopathy – A Randomised Controlled Trial (TRED-HF).

  • RESULTS: Withdrawal of therapy in ‘recovered’ dilated cardiomyopathy patients resulted in relapse for 40% compared to 0% relapse for those who remained on therapy. “Recovered’ patents are in remission.

Effects of Rivaroxaban on Thrombotic Events in Heart Failure Patients with Coronary Disease and Sinus Rhythm.

  • RESULTS: Low-dose rivaroxaban use in HF significantly reduced the risk for thromboembolic events in the COMMANDER HF trial population.

EMPA-HEART Cardiolink-6 Trial: A Randomized Trial Evaluating the Effect of Empagliflozin on Left Ventricular Structure, Function and Biomarkers in People with Type 2 Diabetes (T2D) and Coronary Heart Disease.

  • RESULTS: In patients with T2DM and stable CAD, LV mass was significantly reduced by empagliflozin compared to placebo.

 

Coronary Revascularization:

Endoscopic Vein Harvest for Coronary Bypass Surgery in a Randomized Multicenter Trial with Long-Term Follow-Up.

  • RESULTS: Late findings for endoscopic vs open SVG harvesting for CABG found MACE rates were similar @ 2.7 years’ follow-up.

Long-Term Survival Following Multivessel Revascularization in Patients with Diabetes: The FREEDOM Follow-On Study.

  • RESULTS: At the 8-year FREEDOM trial follow-up, CABG showed lower rate of all-cause mortality over 8-year follow-up compared to PCI in patients with diabetes and multivessel coronary artery disease.

TiCAB: A Randomized, Double-Blind Study of Ticagrelor versus Aspirin in Patients Undergoing Coronary Bypass Surgery.

  • RESULTS: In patients having CABG, major CV events and bleeding rates were not significantly reduced with ticagrelor monotherapy compared to aspirin.

Ten-Year Clinical Outcomes After Coronary Drug-Eluting Stents with Biodegradable or Permanent Polymer Coating: Results from the Randomized ISAR-TEST 4 Trial.

  • RESULTS: 10-year CV outcomes were superior for three limus-eluting stents with different polymer coatings compared to early-generation stents.

Intramyocardial Injection of Mesenchymal Precursor Cells in Left Ventricular Assist Device Recipients: Impact on Myocardial Recovery and Morbidity.

  • RESULTS: Successful temporary LVAD weans over 6 months and 1-year mortality were similar for intramyocardial mesenchymal precursor cell injection vs sham injection.

 
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Beyond Embargoes: A Vision for Future Scientific Sessions

Nosheen Reza, MD

At my first two AHA Scientific Sessions, I sat in the Main Event Hall, shoulder-to-shoulder with my co-fellows, eagerly awaiting the results of the Late Breaking Clinical Trials and guideline updates. I remember whispers cascading across the room after the presentation of NEAT-HFpEF in 2015 and the hundreds of cellphones in the air snapping pictures of the hypertension guideline release in 2017. This year as an AHA Early Career Blogger, I learned the results of the Late Breaking Clinical Trials with other news writers at embargoed media briefings. These intimate press conferences are routinely offered to health care journalists at major medical meetings and by top medical journals. Members of the media receive early access to manuscripts and data and discuss trial findings with investigators and outside experts with the understanding that nothing should be published until after trial results are publicly released. Generally, media pieces are published very soon after the embargo is lifted. At my first embargoed briefing, I heard one reporter’s question that has spurred me to imagine a new, more inclusive future for scientific meetings.

On Sunday of Sessions, I joined other health care reporters for the VITAL and REDUCE-IT presentations. In VITAL, 1 gram/day of omega-3 fatty acid supplementation (containing 460 mg of eicosapentaenoic acid [EPA] and 380 mg of docosahexaenoic acid [DHA]) was not effective for primary prevention of cardiovascular events in healthy middle-aged adults. In REDUCE-IT, icosapent ethyl (a purified EPA) at a dose of 2 grams twice daily reduced cardiovascular events among patients at risk for or with known cardiovascular disease and with high triglycerides already on statin therapy with good LDL-C control. After both trials were presented, one news writer probed the primary investigators’ thoughts on communicating these results to patients. The reporter wondered if the trials could be interpreted as sending mixed messages about the cardiovascular benefits of omega-3 fatty acids to the general public. Both trials’ primary investigators acknowledged this concern and systematically reviewed the differences in drug composition, patient populations, and study goals that, in their estimation, led to the outcomes. Multiple panelists implored the journalists to integrate these differences into their stories with hopes that consumers and potential patients would be able to understand the distinctions on their own.

After the briefing, I walked to the Main Event Hall to re-experience the Late Breaking Clinical Trials and thought about how we translate these breakthroughs, frequently announced at scientific meetings, to the public and our patients. Recent data suggest that the use of social media at cardiovascular conferences, a key approach to broadcasting late-breaking scientific developments, is rapidly growing. At these meetings, physicians comprise the largest group of Tweeters and compose nearly half of all tweets.1 Identifying the full scope of our social media audience, though, is more elusive. Ensuring veracity in scientific communication has become progressively challenging as the attitudes and tools to perpetuate misinformation have spread. We know that across multiple information domains, false news spreads faster, farther, and deeper than the truth.2 Just this week, Dictionary.com chose “misinformation” as the 2018 word of the year.3 Clinicians and scientists are now especially vulnerable to this insidious erosion of public trust.

How do we combat the propagation of falsehood while encouraging this new democratization of science? I have thought about how the importance of trust was so admirably exemplified in a recent study of blood pressure reduction in black barbershops.4 What if we could leverage our meetings to spread science to where our patients are and with trusted people delivering the message? The AHA has recognized this opportunity and does have programs in place, like “Students at Sessions”, to share Scientific Sessions with non-medical communities.5 Can we imagine a future state of Scientific Sessions where internationally recognized clinicians and scientists deliver a talk at a barbershop or civic center in the host city, where community leaders are invited to participate in panels and plenaries, where large scale cardiovascular risk screenings happen just outside our conference center doors?

The 2019 Scientific Sessions will be held in my current home base of Philadelphia, Pennsylvania. I am looking forward to learning the results of the next round of Late Breaking Clinical Trials and guideline updates in the Main Event Hall, but next year, I hope to sit shoulder-to-shoulder not only with my cardiology colleagues, but with my fellow citizens, community leaders, and patients.

 

References:

  1. Tanoue MT, Chatterjee D, Nguyen HL, et al. Tweeting the Meeting: Rapid Growth in the Use of Social Media at Major Cardiovascular Scientific Sessions From 2014-2016. Circ Cardiovasc Qual Outcomes. 2018;11:e005018.
  2. Vosoughi S, Roy D, Aral S. The spread of true and false news online. Science. 2018;359:1146–1151. doi: 10.1126/science.aap9559.
  3. Italie, Leanne. “Dictionary.com Chooses ‘Misinformation’ as Word of the Year.” Associated Press, 26 Nov. 2018, https://www.apnews.com/e4b3b7b395644d019d1a0a0ed5868b10.
  4. Victor RG, Lynch K, Li N, et al. A Cluster-Randomized Trial of Blood-Pressure Reduction in Black Barbershops. N Engl J Med. 2018;378(14):1291-1301.
  5. “High schoolers enjoy peek into world of cardiovascular science.” American Heart Association News. 21 Nov. 2017. https://newsarchive.heart.org/high-schoolers-enjoy-peek-into-world-of-cardiovascular-science/.

 
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Mentorship and Inspiration at Scientific Sessions

Omid Amidi, MD

Life as a resident physician can be demanding at times. The long hours, the difficult task of cross covering multiple wards, and the emotional toll of caring for sick patients are all factors that can make residency a difficult road to travel.  It can be easy to lose sight of the bigger picture and in the process, your empathy. It is important to keep track of where you have been, and more importantly, who you want to become. This is why I believe that mentorship and inspiration play a critical role in medical training. A great mentor can guide you, can celebrate your victories with you, and also, pick you up when you are down. At the same time, inspiration helps you push through difficult times. As residents, we need to identify with and become inspired by those that have gone through the path we are on so that we may fight burnout.

With that in mind, I would like to make the plea to students, residents, and fellows at any level of training to attend the AHA Scientific Sessions next year. Here is why, given my experience this past year at AHA18:

First and foremost, walking into Sessions, you will feel connected to something larger than yourself. You will find thousands of people from different fields of study and walks of life in attendance who have traveled many miles in the name of their dedication to reducing the burden of cardiovascular disease and strokes. This part of the experience really changed how I viewed my own training as a resident, and I began to see my role in the bigger picture.

Second, Sessions provides an opportunity for professional development. Whether you are attending an activity in the Early Career Lounge, or watching a lecture in the main auditorium, you end up meeting influential clinicians and scientists at every turn. You learn more about the challenges they faced in their training, their work ethic, and their inspirations. I found that many had gone through the same uphill battles as me: balancing research and clinical duties, family and work, down to even grasping difficult concepts in cardiology. This resonated with me.

These face-to face interactions help you not only address your own challenges, but also plan out the next steps in your career. Whenever possible, I took the opportunity to discuss a research idea or career choices with the mentors I met at AHA. Whether they supported the idea or played devil’s advocate, they helped me view these ideas in a different way. At the same time, I was able to pitch in my experiences as a resident and a former medical student to help those going through training.

Setting aside time from clinical duties to attend conferences can at times be a difficult endeavor, but I believe that experiencing a national conference such as Scientific Sessions can aid your career. It will help you identify mentors, role models, and potential collaborators.