A Personal Take On The Interventional Trials At AHA Scientific Sessions
American Heart Association Scientific Sessions always been inclusive of all cardiology specialties. Despite this breadth of science, each subspecialty in cardiology get enough depth to improve patient’s outcome.
Trials of interventional nature had big presence at the Scientific Sessions 2017. The PRESERVE trial was one of the landmark studies presented at the sessions. The study was run by VA which show the Among patients undergoing coronary angiography with chronic kidney disease, a strategy of IV sodium bicarbonate or oral acetylcysteine yielded no additional benefit for the prevention of death, dialysis or persistent kidney impairment at 90 days. This study put to rest a long debate of IV sodium bicarbonate or oral acetylcysteine use for prevention of acute kidney injury showing no benefit in either strategy. Going forward, interventionalist should feel comfortable not to use either strategies which will decrease complexity of care and cost. This study prove that Veterans Affairs Health System is able to deliver an important study to answer critical and practice changing question.
COMPASS trial is another interventional-related study which has been published before and showed decreased cardiovascular events in patients randomized to ASA plus low dose atherosclerosis versus aspirin alone. in patients with stable atherosclerosis. At the Scientific Sessions, the cost analysis showed decreased cost with ASA plus low dose rivaroxaban compared with ASA alone driven by the lower ischemic events in both CAD and PAD patients, as well the decrease in number of procedures required (i.e. angiogram, intervention, amputations, etc.). However, since the actual cost of this dose of the drug is yet unknown, overall cost savings and cost-effectiveness analyses are unavailable at this time.
Moving along, another important study looking into the antithrombotic regimen for patients with indication for anticoagulation undergoing coronary intervention. The RE-DUAL PCI trial was already published, but what presented at the sessions is sub-group analysis that focused on patients with acute coronary syndrome (ACS) and non-ACS at index event. Majority of patients received clopidogrel, while 12% of the patients received ticagrelor either as part of dabigatran dual therapy or warfarin triple therapy. The dabigatran dual therapy regimen used dabigatran and a P2Y12 platelet antagonist, while warfarin triple therapy combined warfarin, aspirin and a P2Y12 platelet antagonist. In the study, 83% of cases, DES was used, and were similar in patients with ACS and non-ACS. The study showed, that dabigatran with P2Y12 inhibitor is superior to triple antithrombotic strategy. More bleeding, obviously in the triple therapy group with no efficacy in terms of lower ischemic complications.
Another study that provided evidence for what we do in practice was the POISE-2 trials. The goal of the trial was to evaluate perioperative aspirin compared with placebo and perioperative clonidine compared with placebo among patients undergoing non-cardiac surgery. The POISE-2 trial showed that among unselected patients undergoing non-cardiac surgical procedures, neither the perioperative use of aspirin, nor clonidine, was beneficial in reducing the incidence of death or myocardial infarction. However, benefit was observed with aspirin among patients with prior stenting. This is consistent with what most cardiologists are practicing, where they recommend ASA continuation throughout the non-cardiac surgery for patients with previous PCI.
Different studies with different aims related to interventional cardiology presented at the sessions. AHA Scientific Sessions continues to support all cardiovascular specialties bringing science to practicing cardiologist that answer practice-based clinical questions and, more importantly, saves lives.
M Chadi Alraies, MD is an interventional fellow and vice chair of Council on Clinical Cardiology Fellow-In-Training & Early Career Committee of American Heart Association.