The biggest news from this year's American Heart Association (AHA) 2017 Scientific Sessions in Anaheim, CA will likely be the release of new hypertension guidelines. Two years have passed since the publication of SPRINT.
I am interested in how the guideline writers handle the controversy over BP targets. SPRINT found better outcomes with lower targets—but ACCORD did not. Then there's the simple yet relevant problem of how one takes a blood pressure. SPRINT trialists did it like trialists would: meticulously. That doesn't happen in the real world. Dr Karen Johnson (University of Tennessee, Nashville) will present a late-breaking study on BP measurement in SPRINT.
Few issues in medicine are more complicated than translating hypertension evidence to the bedside. Everyone agrees having high blood pressure is bad. The problem is finding the least harmful and most effective way to control this surrogate marker of risk. It's like preventing stroke with anticoagulants: no one checks into the emergency department to let us know they haven't had a stroke because of good BP control. But clinicians, especially those of us who see the elderly, routinely confront harm wrought by blood-pressure meds.
The other part of the hypertension guideline statements I will listen for is how seriously the experts discuss lifestyle measures. Prash Sanders and his colleagues in Adelaide have shown something we all know: in those patients who are overweight and sedentary, high blood pressure (along with AF, glucose intolerance, dyslipidemia) can be largely vanquished with committed efforts to help patients lose weight and get fit.[3,4] That is hard; pills are easy.
Precision medicine garners an entire daylong summit at AHA. Medscape editor in chief Dr Eric Topol (Scripps Institute, La Jolla, CA) refers to much of modern therapeutics as imprecision medicine. He's right. We are pretty good at understanding how our therapies affect populations and trial participants, but we have much to learn about how these therapies will affect the individual before us. Predicting risk, too, needs improvement. I know some disagree, but I see great hope in using gene risk scores.
I see two frames for precision medicine: one is what it can do for us today: not too much. The other is what it will do for us in the future: a hell of a lot. For instance, I remember where I was the first time someone asked me if I thought it would be possible to place a coronary sinus pacing lead to reverse a LBBB and treat heart failure. I said, no, that would never work. It would be nuts to dismiss precision medicine like I did CRT.
Here are a few AHA late-breaker trials that caught my eye.
BRUISE CONTROL-2 is a randomized controlled trial (RCT) evaluating the best strategy to manage direct acting oral anticoagulants (DOAC) at the time of device surgery. The authors hypothesize that device surgery can be performed safely without interruption of these medications. The original BRUISE CONTROL trial went against decades of dogma when it showed that continuation of warfarin was safer than heparin bridging for patients undergoing cardiac-device surgery. The question now is whether this strategy also applies to patients on DOACs.
TRICS III is an international multicenter RCT studying restrictive vs liberal transfusion strategies after cardiac surgery. The end point is solid: a composite of all-cause mortality, MI, new renal failure requiring dialysis, or new focal neurological deficit.
When to transfuse blood after cardiac surgery is a common question. Observational studies[8,9] suggest harm from liberal transfusion policies, but this has not been confirmed in RCTs. For instance, the adequately powered (n=2007) TITRe2 trial found no significant difference in a composite outcomes between restrictive or liberal transfusion strategies. Bottom line: much uncertainty remains on the best threshold for transfusion.
The PRESERVE trial uses a 2x2 factorial design to compare the effectiveness of intravenous isotonic sodium bicarbonate with intravenous isotonic sodium chloride and oral N-acetylcysteine with oral placebo for the prevention of serious adverse outcomes following angiographic procedures in high-risk patients. Interpretation of these results will have to contend with the provocative AMACING trial, which found no prophylaxis to be noninferior and cost-saving in preventing contrast-induced nephropathy compared with intravenous hydration.
In the PCORI-sponsored DECIDE-LVAD trial, investigators will study the effectiveness and implementation of decision aids in six LVAD centers. The primary outcomes are knowledge and values-treatment concordance. Few therapies could have a greater need for true shared-decision making than the use of LV assist devices. The research team from the University of Colorado are leading developers of decision aids, and I am proud to participate in the soon-to-start DECIDE-ICD study.
In the ABRIDGE J study Japanese investigators compare dabigatran (Pradaxa, Boehringer Ingelheim) vs warfarin before and after AF ablation. Only two studies have addressed the question of DOACs vs warfarin in an RCT format: The RE-CIRCUIT study (uninterrupted dabigatran vs warfarin), and the VENTURE-AF study (uninterrupted rivaroxaban [(Xarelto, Janssen] vs warfarin), and both showed equivalent outcomes for either DOAC vs warfarin. The writing committee of the most recent AF-ablation consensus document felt strong enough about the evidence to give uninterrupted dabigatran and rivaroxaban therapy a class I recommendation as periprocedural anticoagulation strategies. We shall see if the ABRIDGE-J findings confirm or refute the experts' advice.
Much of the late-breaking sessions at the AHA meeting feature further data from some familiar cardiovascular trials, including CANTOS, CANVAS, EXSCEL, EMPA-REG[21 ],COMPASS and RE-DUAL-PCI.
I'm excited to contribute to the meeting. On Monday (14:00), I will cochair a session titled "The YELPifciation of medicine: What do rankings, ratings, and reviews mean for my practice?" The four talks will touch on CMS star rankings for hospitals, online patient reviews of physicians, engaging in social media, and, of course, what Yelp can teach us about measuring hospital quality. Dr C Michael Gibson (Beth Israel Deaconess Medical Center, Boston, MA) is on our schedule. I'm looking forward to getting a selfie with this rock star of cardiology.
We will see you in Anaheim. The news and feature team from the theheart.org | Medscape Cardiology will provide complete and timely news coverage. And look for us on Twitter @theheartorg and on Instagram @Medscape.
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Mandrola Previews AHA 2017 - Medscape - Nov 09, 2017.