Melissa Walton-Shirley


March 14, 2015

There were only two late-breakers today: PROMISE, which examined CTA vs functional stress testing in intermediate-risk chest-pain patients, and PEGASUS, which compared aspirin-treated patients with ticagrelor (Brilinta, AstraZeneca) vs placebo.

Dr Patrick O'Gara, the current ACC president, opened the ACC 2015 session after a Walt-Disney-meets-Francis-Scott-Key musical score. As our hands respectfully covered our hearts, we experienced the hair-blowing thrill of a roller coaster ride along with the pride of the patriotism of a newly birthed American. Dr O'Gara spoke about innovations and the future of cardiology. He also gently slammed electronic health records (EHR) in the first few minutes of his excellent talk.

Then there was a fantastic, uplifting, and heart-rending lecture by Dr Abraham Verghese on the decaying physician-patient interaction as driven by EHR (second slam in an hour and rightly so).

Later, I attended a really excellent review by Dr Gregg Stone on the latest on bivalirudin (Angiomax, the Medicines Company).

At the end of the day, there was plenty of fodder for discussion, but I left with lots of questions. With the recent change from Daylight Savings Time to Pacific Coast Time, combined with the weight of the day, this Kentucky girl just might have another fitful night.


The Point

There was a 15% lower risk of the primary end point of MI, stroke, or CV death at a median of 30 months with ticagrelor therapy in prior MI patients compared with patients who received placebo plus aspirin.

The Questions

1. Should we reduce our typical 90-mg twice-daily ticagrelor dosing down to a similarly efficacious 60 mg twice-daily at 1 year?

2. Is the 6.4% incidence of shortness of breath worth the benefit?

3. As we see an uptake in this drug utilization on the heels of this trial, will shortness of air in patients treated early in their disease process affect cost or necessitate more procedures like recath or stress testing or increase readmit rates?

The Quip

Dr Bob Harrington stated in postpresentation commentary, "Now that we've seen DAPT trial results on stented patients, it seems pretty clear there is not a time you should ever come off the dual platelet therapy."

My Take

Pointing to a lack of discontinuance of drug doesn't make me feel any more confident when the dyspneic patient is sitting in front of me in the exam room. In addition, although clopidogrel was mentioned in the discussions, nary a word was spoken about prasugrel (Effient, Lilly/Daiichi-Sankyo). Methinks there was an elephant in the room.


The Point

In this trial, 10 000 intermediate-risk chest pain patients were randomized to either a CTA or functional stress test. There was no significant difference in the 3% occurrence of death, MI, procedural complications, or hospital admission at nearly 2 years in either group.

The Questions

1. How many small hospitals have access to competent CTA interpretation acutely?

2. Would troponin I levels have accurately predicted outcomes as well?

3. Are we shifting back to our former obsession with fixed obstructive disease hunting instead of the quest for the milieu of the sticky prothrombotic plaque rupture?

The Quip

Dr Valentin Fuster commented, "If both tests are equal—ie, direct visualization vs indirect stress testing—I wonder if it's not just better to know what you have."

My Take

With hard calcified obstruction, we still can't estimate the degree of acutely vulnerable plaque, so I'm not sure we know what we have when we have it . . . or something like that.

On Bivalirudin

The Point

In the session, "Debates in optimal pharmacologic management of PCI," Dr Gregg Stone reviewed bivalirudin use in both elective and ACS therapy. He acknowledged concerns regarding sudden acute thrombosis (SAT) rates in earlier trials in STEMI patients. He reviewed data in which 3- to 4-hour low-dose postprocedure bivalirudin infusions in BRIGHT and EUROMAX abolished the SAT concern.

The Questions

1. Why isn't bivalirudin used more often?

2. Will interventionalists ever get over the early SAT concerns raised against this compound?

3. Will we be any closer to incorporating bivalirudin in our cath labs 100 studies from now?

The Quip

Dr Stone stated, "In a total of 127 000 ACS patients, we see a (staggering) 49% reduction in mortality."

My Take

Only aspirin in ACS has performed better than that, so why not pair the two? Second, radialists, you aren't off the hook. Bivalirudin decreases non–access-site bleeding that is most usually from a GI source.

The "I Carry Your Heart" Lecture by Dr Abraham Verghese

The Point

The physician-patient relationship is adulterated by EHR, decreasing reimbursement and the "need" to see more patients.

The Questions

1. Although we couldn't help but cringe at the "outing" of the lies that are recorded every minute of the day in EHRs around the world, will any of us "do" anything about it?

2. Will we insist that EHR be used for archiving but not for acute patient care?

3. Will we ever see the benefit of allowing doctors to spend more time with the acutely ill?

4. After a predictable future uptick in poor outcomes, will we see the wisdom in hiring scribes to do the busywork in the acute setting?

The Quip

Dr Verghese: "The real heart awaits you the next time you see a patient. It will come with the other heart for which you have tracings and other kinds of data. When you listen and touch with skill your own heart, your head and heart will be fulfilled."

My Take

I hope we can trend back to our focus on the patient history, eye contact, and the physical exam. I long for colleagues to ask, "How is the patient doing?" before asking, "When can they go home?"

Only then will we see more heart at the heart of medicine and only then will I sleep a whole lot better.


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