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Top News From ACC 2019: Slideshow

Steve Stiles; Patrice Wendling; Sue Hughes; Marlene Busko; Darbe Rotach; Megan Brooks; Susan Jeffrey | March 28, 2019 | Contributor Information

The latest advances in prevention and treatment of cardiovascular disease, including updated guidance on the primary prevention of CVD, greeted attendees at the American College of Cardiology (ACC) 68th Annual Scientific Session held March 16 to 18 in New Orleans.

Top News From ACC 2019: Slideshow

Steve Stiles; Patrice Wendling; Sue Hughes; Marlene Busko; Darbe Rotach; Megan Brooks; Susan Jeffrey | March 28, 2019 | Contributor Information

Transcatheter aortic valve replacement (TAVR) may now be the preferred strategy in patients with severe aortic stenosis at low surgical risk, according to results from two major studies that took center stage at ACC.19. Among other highlights this year:

  • Apple Watch Helps Detect AF: Is This the Future?
  • HoT-PE Supports Home Treatment of Pulmonary Embolism With Rivaroxaban
  • New AHA/ACC CVD Primary Prevention Guideline Curtails Aspirin Use
  • COACT: Delayed Cath Safe in Some Non-STEMI Cardiac Arrest
  • POET: No Late Failure With Oral Antibiotic for Endocarditis
  • INFINITY: Intensive BP Meds in Elderly May Slow Hypertensive Brain Damage
  • WRAP-IT: Antibacterial Pouch Cuts Device Infections

Top News From ACC 2019: Slideshow

Steve Stiles; Patrice Wendling; Sue Hughes; Marlene Busko; Darbe Rotach; Megan Brooks; Susan Jeffrey | March 28, 2019 | Contributor Information

TAVR Low-Risk Studies Get Standing Ovation at ACC

The success of two trials of transcatheter aortic valve replacement (TAVR) in low-surgical-risk patients stole the show on the first day, with the presenters receiving a standing ovation after reporting their data, which showed impressive outcomes compared with surgery. "This is a historic moment, and all of us here should remember it as such," said Eugene Braunwald, MD, Brigham and Women's Hospital, Boston, during the discussion panel immediately after presentation of the trials. "We will talk to our grandchildren about this — that we were here at the time this incredible advance in the care of patients with aortic stenosis was presented," he added. And such was the enthusiasm from the audience that the discussion was interrupted several times with spontaneous applause. Until now, TAVR use has been restricted to patients with severe aortic stenosis at high/intermediate surgical risk, but these new studies open the procedure up to the much larger population of patients at low risk.

Top News From ACC 2019: Slideshow

Steve Stiles; Patrice Wendling; Sue Hughes; Marlene Busko; Darbe Rotach; Megan Brooks; Susan Jeffrey | March 28, 2019 | Contributor Information

PARTNER 3: TAVR Success in Low-Risk Patients

In the PARTNER 3 trial of 1000 patients, TAVR using the SAPIEN 3 system (Edwards Lifesciences) showed a significantly lower rate of the primary end point — a composite of death, stroke, and rehospitalization at 1 year — than surgical valve replacement in patients with severe aortic stenosis at low surgical risk. The index hospitalization was shorter with TAVR than surgery (3 vs 7 days), and patients undergoing TAVR had more rapid improvements in New York Heart Association class, 6-minute walk test distance, and Kansas City Cardiomyopathy Questionnaire (quality of life) score than those who underwent surgery. The results were presented by Martin Leon, MD, Columbia University Medical Center, New York City, with simultaneous publication in the New England Journal of Medicine.

Top News From ACC 2019: Slideshow

Steve Stiles; Patrice Wendling; Sue Hughes; Marlene Busko; Darbe Rotach; Megan Brooks; Susan Jeffrey | March 28, 2019 | Contributor Information

TAVR With Evolut: Interim Results Promising in Low-Risk Patients

The second trial of TAVR in patients with severe aortic stenosis and low surgical risk showed similarly promising results with a different valve device. In this trial, TAVR with a self-expanding bioprosthesis (CoreValve, Evolut R, or Evolut PRO, Medtronic) was noninferior to surgical aortic valve replacement in an interim Bayesian analysis of the primary end point (death from any cause or disabling stroke at 24 months). Patients at low surgical risk "make up 80% of the population treated for aortic stenosis, so they represent a very big piece of the pie, and about half of these patients could be candidates for TAVR," said coauthor Michael Reardon, MD, Houston Methodist DeBakey Heart & Vascular Institute. The results suggest that TAVR might be "a preferred strategy" in this patient population, he said. The study was also published in the New England Journal of Medicine to coincide with presentation.

Top News From ACC 2019: Slideshow

Steve Stiles; Patrice Wendling; Sue Hughes; Marlene Busko; Darbe Rotach; Megan Brooks; Susan Jeffrey | March 28, 2019 | Contributor Information

Real-world Data Support Safety of TAVR in Bicuspid Stenosis

An analysis of registry data showed that TAVR offers patients with bicuspid aortic stenosis survival similar to TAVR patients with tricuspid stenosis, albeit with an uptick in conversion to open-heart surgery, aortic root injury, and 30-day stroke risk. "This analysis suggests that select bicuspid anatomy is amenable to TAVR with current-generation balloon-expandable TAVR technology with acceptable clinical outcomes," said Raj Makkar, MD, Cedars-Sinai Heart Institute, Los Angeles. "These data provide an argument for TAVR to be a reasonable alternative for bicuspid AS patients who are intermediate- or high-risk for surgical aortic valve replacement" and "provide a sound basis to conduct a randomized clinical trial in young patients with bicuspid AS who are at low risk for surgery," he concluded.

Top News From ACC 2019: Slideshow

Steve Stiles; Patrice Wendling; Sue Hughes; Marlene Busko; Darbe Rotach; Megan Brooks; Susan Jeffrey | March 28, 2019 | Contributor Information

Apple Watch Helps Detect AF: Is This the Future?

In the first study of its kind involving more than 400,000 members of the general population, use of an Apple Watch to identify irregular pulse was shown to help in the identification of atrial fibrillation (AF). The watch identified an irregular rhythm in 0.5% of the whole study population, and in those who were subsequently monitored with an electrocardiogram (ECG) patch, it showed a positive predictive value for detecting AF of 0.84, which "supports the ability to correctly identify AF among those notified of an irregular rhythm by the watch," said coprincipal investigator, Marco Perez, MD, Stanford University, California. "A positive notification by the watch could therefore help inform clinical evaluation along with clinical history and examination." Delegates here had widely differing opinions on how this technology should fit into clinical practice.

Top News From ACC 2019: Slideshow

Steve Stiles; Patrice Wendling; Sue Hughes; Marlene Busko; Darbe Rotach; Megan Brooks; Susan Jeffrey | March 28, 2019 | Contributor Information

AUGUSTUS Backs Apixaban 'Double Therapy' in Most AF Post-ACS, PCI

Results from the AUGUSTUS trial could make the risk-vs-benefit quandary of antithrombotic therapy in patients with both atrial fibrillation (AF) and an indication for dual-antiplatelet therapy (DAPT) a little less daunting. The study of people with both AF and recent acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI), all of whom went on a P2Y12 inhibitor, showed that risks of major bleeding and risks for death or hospitalization were both lower with the novel oral anticoagulant apixaban (Eliquis, Bristol-Myers Squibb/Pfizer) than with a vitamin K antagonist such as warfarin. In a separate randomization, DAPT seemed unnecessary and even riskier for major bleeding than a P2Y12 inhibitor alone in most study patients. Taken together, treatment with apixaban on top of a P2Y12 inhibitor seemed to pose the lowest risk for bleeding and clinical events, but neither comparison showed an effect, either way, on risk for ischemic events, said principal investigator Renato D. Lopes, MD, MHS, PhD, Duke Clinical Research Institute, Durham, North Carolina.

Top News From ACC 2019: Slideshow

Steve Stiles; Patrice Wendling; Sue Hughes; Marlene Busko; Darbe Rotach; Megan Brooks; Susan Jeffrey | March 28, 2019 | Contributor Information

New AHA/ACC CVD Primary Prevention Guideline

The 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease was unveiled at the meeting and published in both the Journal of the American College of Cardiology and Circulation. As expected, one of the major changes is a recommendation against the broad use of aspirin in primary prevention, after recently reported results from three trials called the balance of risk and benefit with treatment into question in a variety of populations. Co-chair of the writing committee Donna K. Arnett, PhD, dean and professor of epidemiology at the University of Kentucky College for Public Health, said the guideline uses three "overarching themes."

"The first is that we really need a team-based approach to care for risk factors for ASCVD (atherosclerotic cardiovascular disease). The second recommendation is that all decisions should be shared between the clinician and the patient as they're discussing the best strategies to reduce risk, and finally, we adopted the recommendation that social determinants of health should inform optimal implementation of treatment recommendations for the prevention of ASCVD."

Top News From ACC 2019: Slideshow

Steve Stiles; Patrice Wendling; Sue Hughes; Marlene Busko; Darbe Rotach; Megan Brooks; Susan Jeffrey | March 28, 2019 | Contributor Information

COACT: Delayed Cath Safe in Some Non-STEMI Cardiac Arrest

Immediate coronary angiography may offer no survival advantage over a delayed-angiography approach in adults resuscitated but unconscious after out-of-hospital cardiac arrest with no sign of ST-segment elevation myocardial infarction (STEMI), results of the COACT trial suggest. Survival at 90 days, the primary end point, was similar at about 66% in both the immediate- and delayed-cath groups, with no significant difference in the secondary end point of neurologic status at ICU discharge. Immediate angiography also led to a significant 16% delay in time to achieving target body temperature during induced hypothermia. Sending such patients right to the cath lab "we now know will not improve outcomes, and we saw that it delays a treatment that is one of the cornerstones of treating post-cardiac-arrest patients. I think that's an important finding," said presenter Jorrit S. Lemkes, MD, Amsterdam University Medical Centre.

Image courtesy of Bayer/Janssen Pharmaceuticals

Top News From ACC 2019: Slideshow

Steve Stiles; Patrice Wendling; Sue Hughes; Marlene Busko; Darbe Rotach; Megan Brooks; Susan Jeffrey | March 28, 2019 | Contributor Information

HoT-PE Puts Early Discharge for Low-Risk PE on Front Burner

Low-risk patients with acute pulmonary embolism (PE) can be discharged early after limited or no parenteral therapy and be safely treated at home with oral rivaroxaban (Xarelto, Bayer/Janssen Pharmaceuticals), the Home Treatment of Pulmonary Embolism (HoT-PE) trial suggests. The primary efficacy outcome of recurrent symptomatic venous thromboembolism (VTE) or fatal PE within 3 months occurred in three of 525 patients (0.6%) in the intent-to-treat population. All three events were recurrent PE. A prespecified interim analysis of the 525 ITT patients rejected the null hypothesis of fewer than six events occurring at an α level of 0.004, and the trial was prematurely stopped. Further, just 2.3% of patients were rehospitalized because of suspected recurrent PE or bleeding, reported Stavros Konstantinides, MD, Democritus University of Thrace, Greece. The results support the selection of appropriate PE patients for ambulatory treatment with a direct oral anticoagulant, "helping to reduce hospital-related complications and rationalize the use of healthcare resources," he said.

Top News From ACC 2019: Slideshow

Steve Stiles; Patrice Wendling; Sue Hughes; Marlene Busko; Darbe Rotach; Megan Brooks; Susan Jeffrey | March 28, 2019 | Contributor Information

Deep Dive Into COAPT Echo Results Raises More Questions

An echocardiographic substudy of the COAPT trial failed to identify any baseline echo characteristics to differentiate patients with heart failure (HF) and secondary mitral regurgitation (MR) that would or would not benefit from the MitraClip (Abbott). The MitraClip provided "substantial death and heart failure hospitalization benefits" in all the cohort-adjusted subgroups, regardless of the degree of left ventricular (LV) dysfunction, LV dimensions, pulmonary hypertension, severity of tricuspid regurgitation, or individual MR parameters. There is a possibility that the extremes in the cohort actually did behave differently, noted Federico Asch, MD, Medstar Health Research Institute, Washington, DC. "We did not perform that analysis here. But as of now, the data that we have do not support that we should be cherry-picking patients here. If patients have the criteria to get into the COAPT trial, they should have a clip," said Asch.

Top News From ACC 2019: Slideshow

Steve Stiles; Patrice Wendling; Sue Hughes; Marlene Busko; Darbe Rotach; Megan Brooks; Susan Jeffrey | March 28, 2019 | Contributor Information

POET: No Late Failure With Oral Antibiotic for Endocarditis

Longer-term follow-up of stabilized patients with left-sided infective endocarditis showed no delayed treatment failure with a change from intravenous (IV) to early oral antibiotic treatment, sparing them weeks of in-hospital treatment. Primary findings from the POET trial showed that initial IV therapy followed by a switch to two-drug oral antibiotic therapy was noninferior to IV-only treatment for the composite end point of all-cause death, unplanned cardiac surgery, embolic events, and relapse of bacteremia at 6 months. The findings were consistent across all subgroups. Henning Bundgaard, MD, Copenhagen University Hospital, Denmark, presented an extended analysis looking at outcomes out to a median of 3.5 years. Overall, "we conclude that efficacy and safety of changing to oral antibiotic treatment is noninferior to continued IV antibiotic treatment short-term, and with reassuring — I would say very reassuring — long-term outcomes in stabilized patients with left-sided endocarditis caused by one of these four bacteria," Bundgaard said.

Top News From ACC 2019: Slideshow

Steve Stiles; Patrice Wendling; Sue Hughes; Marlene Busko; Darbe Rotach; Megan Brooks; Susan Jeffrey | March 28, 2019 | Contributor Information

INFINITY: Intensive BP Meds in Elderly May Slow Hypertensive Brain Damage

Intensive drug therapy to lower blood pressure (BP), compared with treatment to a more liberal BP target, seemed to slow the progression of subcortical brain lesions on MRI in the 3-year randomized study of patients 75 years and older. But no improvements in cognitive testing or mobility accompanied gains seen on MRI in the more aggressively managed patients, in whom therapy was aimed at a systolic BP below 130 mm Hg (compared with a target below 145 mm Hg). Patients managed to the lower target had a 76% reduction in major CV events compared with the less-intensively managed group. Results from the INFINITY trial are consistent with other research, which has shown that aggressive BP targets are safe and clinically advantageous compared with more conservative BP goals in older patients with hypertension, said lead investigator William B. White, MD, University of Connecticut School of Medicine, Farmington. But the current trial is rare for showing corresponding MRI confirmation of a benefit against chronic brain damage.

Top News From ACC 2019: Slideshow

Steve Stiles; Patrice Wendling; Sue Hughes; Marlene Busko; Darbe Rotach; Megan Brooks; Susan Jeffrey | March 28, 2019 | Contributor Information

WRAP-IT: Antibacterial Pouch Cuts Device Infections

WRAP-IT, the first randomized trial to evaluate the TYRX absorbable antibacterial envelope (Medtronic), showed that it significantly reduced the risk for major cardiac implantable electronic device (CIED) infections when added to standard infection-prevention strategies. Patients whose device was enclosed in the envelope had a 40% relative risk reduction in the primary outcome — major infection resulting in device extraction or revision, long-term antibiotic therapy with infection recurrence, or death within 1 year — compared with standard care alone. The absolute risk reduction was 0.5%. "This study provides comprehensive data on CIED infection and strong evidence for use of the TYRX envelope for infection prevention in this patient population," concluded lead author Khaldoun Tarakji, MD, MPH, Cleveland Clinic.

Top News From ACC 2019: Slideshow

Steve Stiles; Patrice Wendling; Sue Hughes; Marlene Busko; Darbe Rotach; Megan Brooks; Susan Jeffrey | March 28, 2019 | Contributor Information

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Top News From ACC 2019: Slideshow

Steve Stiles; Patrice Wendling; Sue Hughes; Marlene Busko; Darbe Rotach; Megan Brooks; Susan Jeffrey | March 28, 2019 | Contributor Information

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