Five Cardiology Practice Changing Trials in 2019 of Importance to CMAAO Countries

Five Cardiology Practice Changing Trials in 2019 of Importance to CMAAO Countries

Dr KK Aggarwal

President CMAAO and HCFI

ISCHEMIA Trial: Chronic coronary artery disease is not a time bomb in the chest but a condition that should be treated with reassurance, lifestyle changes, and medical therapy.

DAPA-HF trial: Dapagliflozin, a SGLT2 inhibitor reduces CV death, worsening heart failure, and overall death when used on top of optimal medical therapy in patients with heart failure due to a reduced ejection fraction.

The ISCHEMIA-CKD: The best thing a cardiologist can do for a patient with advanced kidney disease is to resist the urge to do procedures. The trial despite great efforts to reduce contrast-induced kidney injury, the invasive approach was not associated with a reduction in CV death or MI. The safety endpoint of death or dialysis was 48% higher in the invasive arm, and stroke rates were nearly fourfold higher.

 RACE 7 ACWAS: no need for early cardioversion for recent-onset AF. Wait for 48 hours. 69% of patients in the delayed-cardioversion group converted spontaneously within 48 hours. Most patients we cardiovert in the emergency department for acute-onset AF could be spared an anesthetic and high-voltage shock if clinicians would simply give peace a chance and wait 48 hours.

ISAR-REACT 5 study showed that prasugrel trounced ticagrelor for the reduction of death, myocardial infarction, or stroke at 1 year. And prasugrel achieved this superiority without an increase in major bleeding.

Other trials

• AUGUSTUS: Antithrombotic Therapy After Acute Coronary Syndrome or PCI in Atrial Fibrillation
• DECLARE-TIMI 58: Dapagliflozin Effect on Cardiovascular Events–Thrombolysis in Myocardial Infarction 58
• EMPA-REG OUTCOME: Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients
• EVAPORATE: Effect of Icosapent Ethyl on Progression of Coronary Atherosclerosis in Patients With Elevated Triglycerides on Statin Therapy
• REDUCE-IT: Reduction of Cardiovascular Events With Icosapent Ethyl–Intervention Trial
• STOP-DAPT 2: Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-2

• VITAL: Vitamin D and Omega-3 Trial

Medications as effective as stents or bypass for stable heart blockages: A must for Asian countries

Breaking Trial

Medications as effective as stents or bypass for stable heart blockages

Dr KK Aggarwal

President CMAAO and HCFI

The ISCHEMIA trial, a new study reported at November’s American Heart Association meeting, suggests that for most, managing heart blockages with optimal drugs alone is as safe and effective as putting a stne tor doing a bypass surgery.

The trial followed over 5,000 patients with significant narrowing in one or more heart arteries. Half of the patients were randomly selected to receive optimal medical therapy (OMT) and lifestyle changes. The other half were given OMT and also sent for cardiac catheterization or a bypass surgery.

The group that received stents did report greater relief of angina, or chest pain but, there was no significant difference between the two groups in terms of rates of heart attack, death, or hospitalization for worsening heart pain.

OMT makes more sense because it addresses all the arteries in the heart, not just the small section of narrowing addressed by a stent that may be causing angina.

However, stents remain an effective at relieving angina in patients who continue to experience symptoms despite being on appropriate medicines.

Unlike unstable angina, patients with stable angina have more predictable, chronic symptoms that can be managed with medications. Stable angina worsens with exertion or sometimes with emotional stress, and improves with rest. Reduction of stable angina involves improving the mismatch between oxygen supply and demand. This can be accomplished either by lowering demand or improving supply.

Demand can be reduced with optimal drug therapy, which may include beta blockers, which slow down the heart rate, or nitroglycerin, which decreases the work of the heart by relaxing blood vessels. Statins and aspirin are another important components as they help to stabilise the blockage.

Accurate perfusion assessment is very important in patients with critical limb ischemia

Dr KK Aggarwal

The American Heart Association (AHA) has published a new scientific statement on critical limb ischemia. Published online August 12 in the journal Circulation, the statement emphasizes upon the importance of early diagnosis and treatment of critical limb ischemia.

Critical limb ischemia is the most severe form of peripheral artery disease (PAD), which can lead to gangrene and amputations if blood flow is not returned to the limbs.

In the statement, critical limb ischemia has been defined as “the presence of ischemic rest pain, nonhealing wound/ulcer, or gangrene for >2 weeks with associated evidence of hypoperfusion as measured by ankle-brachial index (ABI), ankle pressure, toe-brachial index (TBI), toe systolic pressure, transcutaneous oximetry (TcPo2 ), or skin perfusion pressure (SPP).”

Accurate perfusion assessment is critically important as it not only allows timely revascularization but also reduces unnecessary invasive procedures in patients with adequate blood flow or among those with other causes for ulcers, including venous, neuropathic, or pressure changes.

·         The most commonly used perfusion method is the ankle brachial index (ABI); but, it has limited utility in patients with CLI.

·         Toe pressure has been suggested as a better predictor of major adverse limb events and tibial disease in patients with CLI, especially among those with isolated below-knee disease.

·         Imaging modalities such as computed tomography (CT) angiography, magnetic resonance imaging (MRI) angiography, and duplex ultrasound can accurately measure blood flow in the lower extremities; however, these are only surrogate markers for tissue perfusion.

·         Perfusion CT and MRI, specifically arterial spin labeling (ASL) and blood oxygen level–dependent (BOLD) imaging, can better quantify lower-extremity tissue perfusion, although these techniques are not routinely performed for clinical evaluation of PAD.

·         Evaluation of regional perfusion and oxygenation is of potential importance for evaluating disease severity and planning revascularization strategy, as well as assessing the benefit of medical therapy or arterial revascularization.

(Circulation, Published online August 12, 2019). 

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Hillary Clinton being treated for transverse sinus venous thrombosis

1.   Cerebral (brain) venous thrombosis is uncommon occurring in 1/lac population

2.   It is more common in neonates and children than in adults. In adults it is more common in women than men.

3.   The mean age of onset is 39 years old.

4.   Thrombosis of cerebral veins or dural sinus leads to increased venous and capillary pressure, which in turn leads to brain swelling, venous hemorrhage, and/or ischemia with cytotoxic edema.

5.   Occlusion of dural sinus causes decreased brain cerebrospinal fluid absorption and elevated brain pressure.

6.   Risk factors are hypercoagulable states, oral contraceptives, pregnancy, cancer, infection and head injury.

7.   The onset can be acute, subacute, or chronic.

8.   Headache is the most frequent symptom, occurring in 90% cases

9.   Other symptoms are focal neurologic deficits, focal or generalized fits, altered mental status, stupor, or coma.

10.       Brain MRI with MR venography is diagnostic

11.       Head CT scan is normal in up to 30 percent of  cases

12.             CT venography is a useful alternative to MR venography.

13.       There is complete recovery in 80 percent of patients.

14.       5% die in acute illness and 10% die over a period of time

15.       The main cause of acute death is brain herniation.

16.       Recurrence rate is 2 to 4 percent.

17.            Treatment is blood thinners initially with subcutaneous low molecular weight heparin or intravenous heparin followed with oral warfarin for 3-12 months

Dr KK Answers: Should I opt for surgery of angioplasty in left main lesion?

In patients with left main coronary artery disease bypass surgery is the golf standard. Angioplasty is increasingly being used as an alternative. The PRECOMBAT trial, randomly assigned 600 such patients to either drug-eluting stents or bypass surgery. At one year, the rate of major adverse cardiac or cerebrovascular events (death from any cause, heart attack, paralysis, or ischemia-driven target vessel revascularization) was similar in both groups. 

Source: N Engl J Med 2011; 364:1718.