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ACC 2011 research highlights:
A slideshow presentation
ACC 2011 Research Highlights
                                                          The American College of Cardiology (ACC) 2011 Scientific Sessions took
                                                          place in New Orleans, LA, from April 2 through April 5, 2011.

                                                          Key trials presented at the sessions include:

                                                          PARTNER cohort A: Transcatheter valves noninferior to surgery
                                                          PARTNER cohort B cost analysis: TAVI cost-effective treatment in
                                                          surgery-ineligible patients
                                                          RIVAL: Radial RIVALs femoral access for invasive ACS treatment, but
                                                          doesn't beat it
                                                          STICH: "Hypothesis one" results support CABG in HF patients despite
                                                          missing primary end point
                                                          STICH substudy: Viability testing didn't affect treatment outcomes
                                                          MAGELLAN: Rivaroxaban prevents VTE in medical patients, but bleeding
                                                          an issue




OSCAR: Antihypertensive choice in elderly should be guided by underlying disease
EVEREST II: MitraClip less effective but safer than surgery
PRECOMBAT: PCI noninferior to CABG for left main disease, but questions linger
RESOLUTE: New zotarolimus stent data flesh out efficacy, safety
PLATINUM: Novel everolimus-eluting stent noninferior to Xience V stent
ISAR CABG: Drug-eluting stents reduce repeat revascularization in saphenous vein grafts
EXCELLENT: Some patients can stop DAPT after six months following drug-eluting-stent implantation

View our complete ACC coverage here.
PARTNER (Placement of Aortic Transcatheter Valve Trial) cohort A

                                Results: Transcatheter-valve implantation was just as good as
                                surgery in surgery-eligible patients for the primary end point of
                                mortality, but major strokes were higher in the TAVI-treated
                                patients, both at 30 days and one year. In a combined end point
                                of all stroke or transient ischemic attack (TIA), the difference
                                between groups was statistically significant.

                                "These results indicate that [transcatheter aortic-valve
                                replacement] TAVR is an acceptable alternative to AVR in
                                selected high-risk operable patients," concluded principal
                                investigator Dr Craig Smith (Columbia University, New York,
                                NY). "Future randomized studies should focus on lower-risk
                                patients who are candidates for operation."

                                See: PARTNER cohort A: Transcatheter valves noninferior to
                                surgery
PARTNER (Placement of Aortic Transcatheter Valve Trial) cohort B:
cost analysis
                                Results: Transcatheter aortic-valve implantation is a cost-
                                effective treatment strategy in surgery-ineligible patients with
                                severe aortic disease, with incremental costs per life-year
                                gained within commonly accepted ranges for other
                                cardiovascular technologies, according to a cost-effectiveness
                                analysis presented at the American College of Cardiology 2011
                                Scientific Sessions.

                                "There is a lot of cost up front now to do this, with the facility,
                                the team, all the imaging techniques that we need to have, so
                                this is only going to be done in major centers that can assemble
                                teams like this, once the device gets approved," said Dr
                                Michael Crawford (University of California, San Francisco),
                                who is not affiliated with the PARTNER trial. "It's hoped that as
                                we gain experience with this technique, this up-front cost will
                                actually go down and the cost-effectiveness will actually get
                                better."

                                See: TAVI cost-effective treatment in surgery-ineligible patients:
                                PARTNER cohort B cost analysis
RIVAL (Radial vs Femoral Access for Coronary Intervention) trial

                                 Results: A head-to-head comparison of radial vs femoral access
                                 for the treatment of patients with acute coronary syndromes has
                                 shown that treatment via the radial artery did not reduce the
                                 rate of death, MI, stroke, or non-coronary artery bypass graft
                                 (CABG)-related major bleeding at 30 days. Transradial access,
                                 however, did result in a 63% reduction in the risk of large
                                 vascular-access complications.

                                 "Interventional cardiologists should feel reassured that both
                                 radial and femoral procedures are safe and effective in the
                                 current era," said lead investigator Dr Sanjit Jolly (McMaster
                                 University, Hamilton, ON). "The second take-home point is that
                                 experience and expertise do matter, and the more procedures
                                 you do the better you get. Clinicians and patients may decide,
                                 with similar PCI efficacy, to use radial access because of the
                                 lower rates of vascular complications."

                                 See: Radial RIVALs femoral access for invasive ACS treatment,
                                 but doesn't beat it
Spotlight on Health Information Technology
                   he Health Information Technology (IT) Spotlight at the ACC 2011
                   Scientific Sessions took place on Sunday, April 3, 2011.

                   The session focused on opportunities and challenges in launching an
                   electronic health record (EHR).

                   Highlights included:
                   The James T Dove Lecture: Meaningful Use from the Perspective of the
                   Office of the National Coordinator for Health IT
                   Presented by Farzad Mostashari, Washington, DC

                   Meaningful use: Eligible providers and hospital compliance
                   Presented by James E Tcheng, Durham, NC

                   Meaningful use: Electronic quality reporting
                   Presented by Floyd Eisenberg, Washington, DC
STICH (Surgical Treatment for Ischemic Heart Failure)

                            Results: The five-year results of a randomized comparison of
                            medical therapy with or without bypass surgery for ischemic
                            heart disease in patients with LV systolic dysfunction found that
                            CABG did not beat medical therapy alone in the primary end
                            point of all-cause death. There was, however, a slight
                            advantage for CABG in cardiovascular-specific causes of death
                            and in some of the composite secondary end points.

                            "The take-home message for me is that the STICH trial
                            supports bypass surgery on top of best medical therapy vs
                            medical therapy alone to reduce cardiovascular morbidity and
                            mortality and that many patients who are now treated for heart
                            failure without ever being assessed for the potential of having
                            angiographic coronary disease should be evaluated for that,
                            because [coronary disease] does not present the same way in
                            every patient," said Dr Eric Velazquez (Duke Clinical Research
                            Institute, Durham, NC).

                            See: Docs say STICH "hypothesis one" supports CABG in HF
                            patients despite missing primary end point
STICH (Surgical Treatment for Ischemic Heart Failure):
Viability substudy
                            Results: A substudy of STICH found that: overall, substantial
                            viable myocardium evident at baseline imaging had no
                            independent bearing on all-cause mortality over five years; and
                            such viability didn't influence the relative effectiveness of the
                            two treatment strategies, either for all-cause mortality or the
                            secondary end points of CV mortality and CV hospitalization.

                            During a press conference on the STICH presentations,
                            interventionalist Dr Ted Feldman (Evanston Hospital, IL), who
                            was not connected with the trial, said: "I don't take away from
                            this [study] that viability testing doesn't help. What I take away
                            is, if there's viability, I really want to be sure to revascularize.
                            But prior to seeing these results, I was inclined to say if there
                            isn't viability, [do not] revascularize. And the results of the trial
                            challenge that historic bias."

                            See: STICH substudy: Viability testing didn't affect treatment
                            outcomes
MAGELLAN (Venous Thromboembolic Event [VTE]
Prophylaxis in Medically Ill Patients)
                        Results: Taking the new oral anticoagulant rivaroxaban (Xarelto,
                        Bayer/Johnson & Johnson) once daily for 35 days was
                        associated with a reduction in the risk of venous thrombosis,
                        compared with standard 10-day treatment with enoxaparin
                        (Lovenox, Sanofi-Aventis) by subcutaneous injection, in acutely
                        ill medical patients. But bleeding rates were significantly
                        increased with rivaroxaban, and the new factor Xa inhibitor did
                        not show a net clinical benefit across the whole population.

                        "The drug has been shown to be noninferior to standard
                        treatments in other settings, and this was what was seen in the
                        first part of this trial. Also, since the extended-treatment arm
                        compared the drug with placebo, it is not surprising that
                        bleeding complications were increased. A better comparison
                        would have been to extend treatment with enoxaparin or
                        warfarin," said Dr Roy Silverstein (Cleveland Clinic, OH).

                        See: MAGELLAN: Rivaroxaban prevents VTE in medical
                        patients, but bleeding an issue
Poster sessions
                                               The Best Fellows-in-Training Poster Awards included:

                                               Heterogeneous upregulation of apamin-sensitive currents (IKAS) in failing human ventricles.
                                               Po-Cheng Chang et al, Indiana University School of Medicine, Indianapolis, IN

                                               Is the gender-specific risk of ischemic stroke in atrial fibrillation related to differences in
                                               anticoagulation?
                                               Renee Sullivan et al, University of Iowa Hospitals and Clinics, and University of Birmingham, UK

                                               Enhanced external counter pulsation improves endothelial function, inflammatory markers and
                                               depression.
                                               Deepak Hooda et al, West Virginia University Heart Institute, Morgantown, WV

Molecular Imaging demonstrates ID3 modulates B lymphocyte homing to atherosclerosis-prone regions of the aorta.
Michael Lipinski et al, University of Virginia Health System, Charlottesville, VA

Use Of 320-detector computed-tomography coronary angiography for evaluating patients with chest pain in the emergency department:
Impact on duration of stay and coronary artery disease detection.
David E Winchester et al, University of Florida, Gainesville

Reverse-use dependence of antiarrhythmic drugs: Role of late sodium current.
Chinmay Patel et al, Lankenau Medical Center and Lankenau Institute of Medical Research, Wynnewood, PA

Influence of myocardial ischemia on outcomes in patients with systolic versus nonsystolic heart failure.
Thomas E Vanhecke et al, William Beaumont Hospital, Royal Oak, MI

The correlation of fragmented QRS complexes on 12-lead ECG and myocardial infarct size determined by cardiac magnetic resonance
imaging.
Waddah Maskoun et al, Medical College of Wisconsin, Milwaukee, and Northwestern University Feinberg School of Medicine, Chicago, IL
OSCAR (Olmesartan and Calcium Antagonists
Randomized Study)
                         Results: Treating elderly hypertensive patients with a
                         combination of an angiotensin receptor blocker (ARB) and a
                         calcium antagonist is better at reducing BP than using a high
                         (double) dose of an ARB alone, particularly if they have CV
                         disease, according to a new study.

                         "The OSCAR study provides the first evidence showing that a
                         standard dose of ARB plus CCB combination is superior to
                         high-dose ARB in reducing adverse events in elderly
                         hypertensive patients with cardiovascular disease," said study
                         investigator Dr Hisao Ogawa (Kumamoto University, Japan).

                         See: OSCAR: Antihypertensive choice in elderly should be
                         guided by underlying disease
EVEREST II (Pivotal Study of a Percutaneous Mitral Valve
Repair System)
                                                                               Results: One- and two-year results show that
                                                                               percutaneous repair of the mitral valve with the
                                                                               MitraClip (Abbott) device was significantly less
                                                                               effective at reducing mitral regurgitation than
                                                                               surgery, but the procedure was associated with
                                                                               superior safety and similar improvements in
                                                                               clinical outcomes.




"It looks as though the MitraClip might be an alternative strategy for reducing regurgitation in older people with lots of
comorbidities who are not good candidates for surgery. With the two-year data we have just seen, I would say the clip is
fine for an 80-year-old with heart failure, but a younger patient needs a 20-year fix, and we get this from surgery," said Dr
Robert Bonow (Northwestern University, Chicago, IL). "We don't know if we get this from the clip. Perhaps patients can
tolerate low levels of regurgitation long term. Perhaps not."

See: Latest from EVEREST II: MitraClip less effective but safer than surgery
PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty
Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease)

                                        Results: Either PCI using a sirolimus-eluting stent or coronary
                                        artery bypass graft (CABG) surgery for unprotected left main
                                        coronary artery stenosis yield similar rates of major adverse
                                        cardiac or cerebrovascular events at one year, although study
                                        investigators acknowledge that the study was underpowered as
                                        a result of unexpectedly low event rates.

                                        "Overall, this trial is a modest advance on what we already
                                        recognize from the existing—and limited—randomized data
                                        and, more broadly, the observational data of left main PCI," said
                                        Dr David Kandzari (Piedmont Heart Institute, Atlanta, GA).
                                        "That is, we have a remarkable consistency across trials of
                                        equipoise with regard to the so-called hard end points—death,
                                        myocardial infarction, and stroke—and at the same time we
                                        have seemingly consistent data showing that with existing drug-
                                        eluting stents, at least first-generation drug-eluting stents,
                                        repeat revascularization is still higher when compared with
                                        bypass surgery."

                                        See: PRECOMBAT: PCI noninferior to CABG for left main
                                        disease, but questions linger
Real World Cases in Sports Cardiology
                     The Clinical Cardiology Spotlight at the ACC 2011 Scientific
                     Sessions focused on "Real-World Cases in Sports Cardiology."

                     Four cases were presented:

                     Case I: Abnormal ECG in a 17-year old from the major league
                     soccer screening program
                     Presented by Ira Smith, Toronto, ON

                     Case II: Adolescent athlete with exertional syncope/chest pain
                     Presented by Wayne J Franklin, Houston, TX

                     Case III: Collegiate athlete with ICD
                     Presented by Renee Sullivan, Iowa City, IA

                     Case IV: 20-Yyar-old with aortic disease wants to continue to
                     swim at NCAA level
                     Presented by Sandeep Mangalmurti, Chicago, IL

                     Spotlight panelists included: Christine Lawless, Chicago, IL;
                     Rachel Lampert, New Haven, CT; Barry Maron, Minneapolis,
                     MN; Luigi Padeletti, Florence, Italy; Paul Thompson, Hartford,
                     CT; and Jeffrey Towbin, Cincinnati, OH.
RESOLUTE
           RESOLUTE US
           Results: The single-arm study shows the new Resolute stent to
           yield lower rates of restenosis at one year than historical
           controls made up of studies testing the predecessor stent,
           Endeavor, also made by Medtronic.

           RESOLUTE AC
           Results: At two years, rates of "patient-related outcomes" and
           "stent-related outcomes" were no different between patients
           randomized to the Resolute or to the Xience everolimus-eluting
           stent, nor were rates of any major clinical events different
           between the two groups. Stent-thrombosis rates at one year
           were reportedly higher for Resolute stent than for the Xience.

           "No matter how you look at these data, from effectiveness or
           safety, they're very, very strong. They're as good as we've seen
           with a next-generation drug-eluting stent, and it's also a platform
           that physicians like using; they like using the driver platform,"
           said Dr Martin Leon (Columbia University, New York, NY).

           See: New Resolute zotarolimus stent data flesh out efficacy,
           safety
PLATINUM (Clinical Trial to Assess the PROMUS Element Stent
System for Treatment of De Novo Coronary Artery Lesions)
                               Results: A novel everolimus-eluting stent containing a new
                               metallic alloy, platinum, as part of a modified design has been
                               shown to be noninferior to the widely used Xience V stent
                               (Abbott Vascular)—also known as Promus (Boston Scientific)—
                               in a pivotal trial presented during a late-breaking clinical-trials
                               session at the American College of Cardiology 2011 Scientific
                               Sessions.

                               "Our procedures continue to get safer; our equipment and
                               devices are getting better. New stents will have to be as safe as
                               approved devices, and when it comes to deciding which stent is
                               better than another, it will come down to nuanced aspects, and
                               these don't come to light until you are using these devices in
                               lots and lots of people, not in these small trials designed for
                               regulatory approval. This is the sort of information you get from
                               large registries and from feedback from operators," said Dr
                               Edward J McNulty (University of California, San Francisco).

                               See: Everolimus-eluting stent performs well in PLATINUM
ISAR CABG (Is Drug-Eluting Stenting Associated With Improved
Results in Coronary Artery Bypass Grafts)
                               Results: Drug-eluting stents (DES) reduced repeat
                               revascularization compared with bare-metal stents in
                               saphenous vein grafts (SVGs) for high-risk patients with at least
                               one lesion in a previously implanted saphenous vein bypass
                               graft.

                               The ISAR-CABG trial was designed to compare DES and bare-
                               metal stents in SVGs with a large enough study population to
                               provide information on clinical end points, explained study
                               investigator Dr Julinda Mehilli (Technische Universität Munich,
                               Germany). Although many interventionalists already use DES in
                               SVGs, most drug-eluting-stent trials have excluded SVGs, and
                               the only two previous randomized trials of comparing DES and
                               bare-metal stents in SVGs were very small and produced
                               conflicting mortality results, said Mehilli.

                               See: ISAR CABG: Drug-eluting stents reduce repeat
                               revascularization in saphenous vein grafts
EXCELLENT (Efficacy of Xience/Promus Versus Cypher in Reducing
Late Loss After Stenting)
                               Results: Patients with coronary artery disease were randomized
                               to dual antiplatelet therapy for six months or dual antiplatelet
                               therapy for one year. Regarding the primary end point of target
                               vessel failure (TVF), a composite of cardiac death, MI, or target
                               vessel revascularization at 12 months, investigators observed
                               no statistically significant difference between those treated for
                               six months and those treated with for one year, suggesting that
                               some patients can stop clopidogrel after just six months
                               following drug-eluting-stent implantation.

                               "The take-home message from our study is that, at least in low-
                               risk, nondiabetic patients treated with second-generation drug-
                               eluting stents, we can safely discontinue clopidogrel at about six
                               months, especially if the patient is at high risk for bleeding or is
                               anticipating some surgery," said lead investigator Dr Hyeon-
                               Cheol Gwon (Sungkyunkwan University School of Medicine,
                               Seoul, Korea) during a morning press conference announcing
                               the results.

                               See: EXCELLENT results for stopping DAPT at six months, but
                               others say bigger trials are needed
Opinions and review
                                           Cutting-edge dialogues with Drs Tim Gardner and Mat Williams
                                           Surgeons and interventionalists partner to ensure best care
                                           Heart failure and transplantation with Dr Ileana Piña
                                           STICH: Focusing on the "crossover" patients
                                           Private practice with Dr Seth Bilazarian
                                           Shaking up the DES arena with safer, more efficacious newcomers
                                           Radial didn't beat its rival
                                           PARTNER A: Evaluating "important but different hazards"
                                           Clotblog with Dr Samuel Goldhaber
                                           MAGELLAN trial passes "proof-of-principle" test

                                                                        Trials and PIs
                                                                        Rivaroxaban vs enoxaparin for the Prevention of Venous
Heartfelt with Dr Melissa Walton-Shirley                                Thromboembolism in Acutely Ill Medical Patients with...
MAGELLAN on VTE, EXCELLENT on antiplatelets and OSCAR on                PROTECTION-AMI with Dr Michael Lincoff
antihypertensives                                                       NAGOYA HEART Study with Dr Murohara
STICH, EVEREST, RIVAL, and top interventional trials from ACC 2011      EXCELLENT with Dr Hyeon-Cheol Gwon
TAVI vs surgery: Mortality data and cost-effectiveness in PARTNER A     PRECOMBAT with Dr Seung-Jung Park
and B                                                                   Surgical Treatment for Ischemic Heart Failure Trial with Dr Robert
Discussing science, anecdote, and opinion: Up in arms after RIVAL?      Bonow
ACC Day 1: Dr Ralph Brindis and the doctrine of cardiovascular          EVEREST II: Two-year outcomes with Dr Ted Feldman
                                                                        TAVI vs SAVR in PARTNER with Dr Craig Smith
ecumenism
                                                                        RIVAL with DrSanjit Jolly
This week in cardiology from heartwire
                                                                        REMEDIAL II with Dr Carlo Briguori
#84: TAVI matches surgery in PARTNER cohort A; PARTNER B cost-
                                                                        Surgical Treatment of Ischemic Heart Failure Trial with Dr Eric
effectiveness; MAGELLAN on rivaroxaban in...                            Velazquez
#83: Hot topics at ACC 2011; noninvasive CV imaging for subclinical     RAPS with Dr Stephen Fremes
disease; Elizabeth Taylor and...                                        PARTNER (cohort B) with Dr Matthew Reynolds
For more information
                       ACC Scientific Sessions

                       ACC 2011 coverage on theheart.org

                       ACC 2011 on Medscape
Credits and disclosures
                                                        Editor:
                                                        Shelley Wood
                                                        Managing Editor, heartwire
                                                        Kelowna, BC
                                                        Disclosure: Shelley Wood has disclosed no relevant financial relationships.

                                                        Contributor:
                                                        Steven Rourke
                                                        Manager, Editorial Programming
                                                        theheart.org
                                                        Montreal, QC
                                                        Disclosure: Steven Rourke has disclosed no relevant financial relationships.


Journalists:
Lisa Nainggolan, theheart.org                                                Michael O'Riordan, theheart.org
London, UK                                                                   Toronto, ON
Disclosure: Lisa Nainggolan has disclosed no relevant financial              Disclosure: Michael O'Riordan has disclosed no relevant financial
relationships.                                                               relationships.

Sue Hughes, theheart.org                                                     Steve Stiles, theheart.org
London, UK                                                                   Fremont, CA
Disclosure: Sue Hughes has disclosed no relevant financial relationships.    Disclosure: Steve Stiles has disclosed no relevant financial

Reed Miller, theheart.org
Bethesda, MD
Disclosure: Reed Miller has disclosed no relevant financial relationships.
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ACC 2011 research highlights: A slideshow presentation

  • 1. ACC 2011 research highlights: A slideshow presentation
  • 2. ACC 2011 Research Highlights The American College of Cardiology (ACC) 2011 Scientific Sessions took place in New Orleans, LA, from April 2 through April 5, 2011. Key trials presented at the sessions include: PARTNER cohort A: Transcatheter valves noninferior to surgery PARTNER cohort B cost analysis: TAVI cost-effective treatment in surgery-ineligible patients RIVAL: Radial RIVALs femoral access for invasive ACS treatment, but doesn't beat it STICH: "Hypothesis one" results support CABG in HF patients despite missing primary end point STICH substudy: Viability testing didn't affect treatment outcomes MAGELLAN: Rivaroxaban prevents VTE in medical patients, but bleeding an issue OSCAR: Antihypertensive choice in elderly should be guided by underlying disease EVEREST II: MitraClip less effective but safer than surgery PRECOMBAT: PCI noninferior to CABG for left main disease, but questions linger RESOLUTE: New zotarolimus stent data flesh out efficacy, safety PLATINUM: Novel everolimus-eluting stent noninferior to Xience V stent ISAR CABG: Drug-eluting stents reduce repeat revascularization in saphenous vein grafts EXCELLENT: Some patients can stop DAPT after six months following drug-eluting-stent implantation View our complete ACC coverage here.
  • 3. PARTNER (Placement of Aortic Transcatheter Valve Trial) cohort A Results: Transcatheter-valve implantation was just as good as surgery in surgery-eligible patients for the primary end point of mortality, but major strokes were higher in the TAVI-treated patients, both at 30 days and one year. In a combined end point of all stroke or transient ischemic attack (TIA), the difference between groups was statistically significant. "These results indicate that [transcatheter aortic-valve replacement] TAVR is an acceptable alternative to AVR in selected high-risk operable patients," concluded principal investigator Dr Craig Smith (Columbia University, New York, NY). "Future randomized studies should focus on lower-risk patients who are candidates for operation." See: PARTNER cohort A: Transcatheter valves noninferior to surgery
  • 4. PARTNER (Placement of Aortic Transcatheter Valve Trial) cohort B: cost analysis Results: Transcatheter aortic-valve implantation is a cost- effective treatment strategy in surgery-ineligible patients with severe aortic disease, with incremental costs per life-year gained within commonly accepted ranges for other cardiovascular technologies, according to a cost-effectiveness analysis presented at the American College of Cardiology 2011 Scientific Sessions. "There is a lot of cost up front now to do this, with the facility, the team, all the imaging techniques that we need to have, so this is only going to be done in major centers that can assemble teams like this, once the device gets approved," said Dr Michael Crawford (University of California, San Francisco), who is not affiliated with the PARTNER trial. "It's hoped that as we gain experience with this technique, this up-front cost will actually go down and the cost-effectiveness will actually get better." See: TAVI cost-effective treatment in surgery-ineligible patients: PARTNER cohort B cost analysis
  • 5. RIVAL (Radial vs Femoral Access for Coronary Intervention) trial Results: A head-to-head comparison of radial vs femoral access for the treatment of patients with acute coronary syndromes has shown that treatment via the radial artery did not reduce the rate of death, MI, stroke, or non-coronary artery bypass graft (CABG)-related major bleeding at 30 days. Transradial access, however, did result in a 63% reduction in the risk of large vascular-access complications. "Interventional cardiologists should feel reassured that both radial and femoral procedures are safe and effective in the current era," said lead investigator Dr Sanjit Jolly (McMaster University, Hamilton, ON). "The second take-home point is that experience and expertise do matter, and the more procedures you do the better you get. Clinicians and patients may decide, with similar PCI efficacy, to use radial access because of the lower rates of vascular complications." See: Radial RIVALs femoral access for invasive ACS treatment, but doesn't beat it
  • 6. Spotlight on Health Information Technology he Health Information Technology (IT) Spotlight at the ACC 2011 Scientific Sessions took place on Sunday, April 3, 2011. The session focused on opportunities and challenges in launching an electronic health record (EHR). Highlights included: The James T Dove Lecture: Meaningful Use from the Perspective of the Office of the National Coordinator for Health IT Presented by Farzad Mostashari, Washington, DC Meaningful use: Eligible providers and hospital compliance Presented by James E Tcheng, Durham, NC Meaningful use: Electronic quality reporting Presented by Floyd Eisenberg, Washington, DC
  • 7. STICH (Surgical Treatment for Ischemic Heart Failure) Results: The five-year results of a randomized comparison of medical therapy with or without bypass surgery for ischemic heart disease in patients with LV systolic dysfunction found that CABG did not beat medical therapy alone in the primary end point of all-cause death. There was, however, a slight advantage for CABG in cardiovascular-specific causes of death and in some of the composite secondary end points. "The take-home message for me is that the STICH trial supports bypass surgery on top of best medical therapy vs medical therapy alone to reduce cardiovascular morbidity and mortality and that many patients who are now treated for heart failure without ever being assessed for the potential of having angiographic coronary disease should be evaluated for that, because [coronary disease] does not present the same way in every patient," said Dr Eric Velazquez (Duke Clinical Research Institute, Durham, NC). See: Docs say STICH "hypothesis one" supports CABG in HF patients despite missing primary end point
  • 8. STICH (Surgical Treatment for Ischemic Heart Failure): Viability substudy Results: A substudy of STICH found that: overall, substantial viable myocardium evident at baseline imaging had no independent bearing on all-cause mortality over five years; and such viability didn't influence the relative effectiveness of the two treatment strategies, either for all-cause mortality or the secondary end points of CV mortality and CV hospitalization. During a press conference on the STICH presentations, interventionalist Dr Ted Feldman (Evanston Hospital, IL), who was not connected with the trial, said: "I don't take away from this [study] that viability testing doesn't help. What I take away is, if there's viability, I really want to be sure to revascularize. But prior to seeing these results, I was inclined to say if there isn't viability, [do not] revascularize. And the results of the trial challenge that historic bias." See: STICH substudy: Viability testing didn't affect treatment outcomes
  • 9. MAGELLAN (Venous Thromboembolic Event [VTE] Prophylaxis in Medically Ill Patients) Results: Taking the new oral anticoagulant rivaroxaban (Xarelto, Bayer/Johnson & Johnson) once daily for 35 days was associated with a reduction in the risk of venous thrombosis, compared with standard 10-day treatment with enoxaparin (Lovenox, Sanofi-Aventis) by subcutaneous injection, in acutely ill medical patients. But bleeding rates were significantly increased with rivaroxaban, and the new factor Xa inhibitor did not show a net clinical benefit across the whole population. "The drug has been shown to be noninferior to standard treatments in other settings, and this was what was seen in the first part of this trial. Also, since the extended-treatment arm compared the drug with placebo, it is not surprising that bleeding complications were increased. A better comparison would have been to extend treatment with enoxaparin or warfarin," said Dr Roy Silverstein (Cleveland Clinic, OH). See: MAGELLAN: Rivaroxaban prevents VTE in medical patients, but bleeding an issue
  • 10. Poster sessions The Best Fellows-in-Training Poster Awards included: Heterogeneous upregulation of apamin-sensitive currents (IKAS) in failing human ventricles. Po-Cheng Chang et al, Indiana University School of Medicine, Indianapolis, IN Is the gender-specific risk of ischemic stroke in atrial fibrillation related to differences in anticoagulation? Renee Sullivan et al, University of Iowa Hospitals and Clinics, and University of Birmingham, UK Enhanced external counter pulsation improves endothelial function, inflammatory markers and depression. Deepak Hooda et al, West Virginia University Heart Institute, Morgantown, WV Molecular Imaging demonstrates ID3 modulates B lymphocyte homing to atherosclerosis-prone regions of the aorta. Michael Lipinski et al, University of Virginia Health System, Charlottesville, VA Use Of 320-detector computed-tomography coronary angiography for evaluating patients with chest pain in the emergency department: Impact on duration of stay and coronary artery disease detection. David E Winchester et al, University of Florida, Gainesville Reverse-use dependence of antiarrhythmic drugs: Role of late sodium current. Chinmay Patel et al, Lankenau Medical Center and Lankenau Institute of Medical Research, Wynnewood, PA Influence of myocardial ischemia on outcomes in patients with systolic versus nonsystolic heart failure. Thomas E Vanhecke et al, William Beaumont Hospital, Royal Oak, MI The correlation of fragmented QRS complexes on 12-lead ECG and myocardial infarct size determined by cardiac magnetic resonance imaging. Waddah Maskoun et al, Medical College of Wisconsin, Milwaukee, and Northwestern University Feinberg School of Medicine, Chicago, IL
  • 11. OSCAR (Olmesartan and Calcium Antagonists Randomized Study) Results: Treating elderly hypertensive patients with a combination of an angiotensin receptor blocker (ARB) and a calcium antagonist is better at reducing BP than using a high (double) dose of an ARB alone, particularly if they have CV disease, according to a new study. "The OSCAR study provides the first evidence showing that a standard dose of ARB plus CCB combination is superior to high-dose ARB in reducing adverse events in elderly hypertensive patients with cardiovascular disease," said study investigator Dr Hisao Ogawa (Kumamoto University, Japan). See: OSCAR: Antihypertensive choice in elderly should be guided by underlying disease
  • 12. EVEREST II (Pivotal Study of a Percutaneous Mitral Valve Repair System) Results: One- and two-year results show that percutaneous repair of the mitral valve with the MitraClip (Abbott) device was significantly less effective at reducing mitral regurgitation than surgery, but the procedure was associated with superior safety and similar improvements in clinical outcomes. "It looks as though the MitraClip might be an alternative strategy for reducing regurgitation in older people with lots of comorbidities who are not good candidates for surgery. With the two-year data we have just seen, I would say the clip is fine for an 80-year-old with heart failure, but a younger patient needs a 20-year fix, and we get this from surgery," said Dr Robert Bonow (Northwestern University, Chicago, IL). "We don't know if we get this from the clip. Perhaps patients can tolerate low levels of regurgitation long term. Perhaps not." See: Latest from EVEREST II: MitraClip less effective but safer than surgery
  • 13. PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease) Results: Either PCI using a sirolimus-eluting stent or coronary artery bypass graft (CABG) surgery for unprotected left main coronary artery stenosis yield similar rates of major adverse cardiac or cerebrovascular events at one year, although study investigators acknowledge that the study was underpowered as a result of unexpectedly low event rates. "Overall, this trial is a modest advance on what we already recognize from the existing—and limited—randomized data and, more broadly, the observational data of left main PCI," said Dr David Kandzari (Piedmont Heart Institute, Atlanta, GA). "That is, we have a remarkable consistency across trials of equipoise with regard to the so-called hard end points—death, myocardial infarction, and stroke—and at the same time we have seemingly consistent data showing that with existing drug- eluting stents, at least first-generation drug-eluting stents, repeat revascularization is still higher when compared with bypass surgery." See: PRECOMBAT: PCI noninferior to CABG for left main disease, but questions linger
  • 14. Real World Cases in Sports Cardiology The Clinical Cardiology Spotlight at the ACC 2011 Scientific Sessions focused on "Real-World Cases in Sports Cardiology." Four cases were presented: Case I: Abnormal ECG in a 17-year old from the major league soccer screening program Presented by Ira Smith, Toronto, ON Case II: Adolescent athlete with exertional syncope/chest pain Presented by Wayne J Franklin, Houston, TX Case III: Collegiate athlete with ICD Presented by Renee Sullivan, Iowa City, IA Case IV: 20-Yyar-old with aortic disease wants to continue to swim at NCAA level Presented by Sandeep Mangalmurti, Chicago, IL Spotlight panelists included: Christine Lawless, Chicago, IL; Rachel Lampert, New Haven, CT; Barry Maron, Minneapolis, MN; Luigi Padeletti, Florence, Italy; Paul Thompson, Hartford, CT; and Jeffrey Towbin, Cincinnati, OH.
  • 15. RESOLUTE RESOLUTE US Results: The single-arm study shows the new Resolute stent to yield lower rates of restenosis at one year than historical controls made up of studies testing the predecessor stent, Endeavor, also made by Medtronic. RESOLUTE AC Results: At two years, rates of "patient-related outcomes" and "stent-related outcomes" were no different between patients randomized to the Resolute or to the Xience everolimus-eluting stent, nor were rates of any major clinical events different between the two groups. Stent-thrombosis rates at one year were reportedly higher for Resolute stent than for the Xience. "No matter how you look at these data, from effectiveness or safety, they're very, very strong. They're as good as we've seen with a next-generation drug-eluting stent, and it's also a platform that physicians like using; they like using the driver platform," said Dr Martin Leon (Columbia University, New York, NY). See: New Resolute zotarolimus stent data flesh out efficacy, safety
  • 16. PLATINUM (Clinical Trial to Assess the PROMUS Element Stent System for Treatment of De Novo Coronary Artery Lesions) Results: A novel everolimus-eluting stent containing a new metallic alloy, platinum, as part of a modified design has been shown to be noninferior to the widely used Xience V stent (Abbott Vascular)—also known as Promus (Boston Scientific)— in a pivotal trial presented during a late-breaking clinical-trials session at the American College of Cardiology 2011 Scientific Sessions. "Our procedures continue to get safer; our equipment and devices are getting better. New stents will have to be as safe as approved devices, and when it comes to deciding which stent is better than another, it will come down to nuanced aspects, and these don't come to light until you are using these devices in lots and lots of people, not in these small trials designed for regulatory approval. This is the sort of information you get from large registries and from feedback from operators," said Dr Edward J McNulty (University of California, San Francisco). See: Everolimus-eluting stent performs well in PLATINUM
  • 17. ISAR CABG (Is Drug-Eluting Stenting Associated With Improved Results in Coronary Artery Bypass Grafts) Results: Drug-eluting stents (DES) reduced repeat revascularization compared with bare-metal stents in saphenous vein grafts (SVGs) for high-risk patients with at least one lesion in a previously implanted saphenous vein bypass graft. The ISAR-CABG trial was designed to compare DES and bare- metal stents in SVGs with a large enough study population to provide information on clinical end points, explained study investigator Dr Julinda Mehilli (Technische Universität Munich, Germany). Although many interventionalists already use DES in SVGs, most drug-eluting-stent trials have excluded SVGs, and the only two previous randomized trials of comparing DES and bare-metal stents in SVGs were very small and produced conflicting mortality results, said Mehilli. See: ISAR CABG: Drug-eluting stents reduce repeat revascularization in saphenous vein grafts
  • 18. EXCELLENT (Efficacy of Xience/Promus Versus Cypher in Reducing Late Loss After Stenting) Results: Patients with coronary artery disease were randomized to dual antiplatelet therapy for six months or dual antiplatelet therapy for one year. Regarding the primary end point of target vessel failure (TVF), a composite of cardiac death, MI, or target vessel revascularization at 12 months, investigators observed no statistically significant difference between those treated for six months and those treated with for one year, suggesting that some patients can stop clopidogrel after just six months following drug-eluting-stent implantation. "The take-home message from our study is that, at least in low- risk, nondiabetic patients treated with second-generation drug- eluting stents, we can safely discontinue clopidogrel at about six months, especially if the patient is at high risk for bleeding or is anticipating some surgery," said lead investigator Dr Hyeon- Cheol Gwon (Sungkyunkwan University School of Medicine, Seoul, Korea) during a morning press conference announcing the results. See: EXCELLENT results for stopping DAPT at six months, but others say bigger trials are needed
  • 19. Opinions and review Cutting-edge dialogues with Drs Tim Gardner and Mat Williams Surgeons and interventionalists partner to ensure best care Heart failure and transplantation with Dr Ileana Piña STICH: Focusing on the "crossover" patients Private practice with Dr Seth Bilazarian Shaking up the DES arena with safer, more efficacious newcomers Radial didn't beat its rival PARTNER A: Evaluating "important but different hazards" Clotblog with Dr Samuel Goldhaber MAGELLAN trial passes "proof-of-principle" test Trials and PIs Rivaroxaban vs enoxaparin for the Prevention of Venous Heartfelt with Dr Melissa Walton-Shirley Thromboembolism in Acutely Ill Medical Patients with... MAGELLAN on VTE, EXCELLENT on antiplatelets and OSCAR on PROTECTION-AMI with Dr Michael Lincoff antihypertensives NAGOYA HEART Study with Dr Murohara STICH, EVEREST, RIVAL, and top interventional trials from ACC 2011 EXCELLENT with Dr Hyeon-Cheol Gwon TAVI vs surgery: Mortality data and cost-effectiveness in PARTNER A PRECOMBAT with Dr Seung-Jung Park and B Surgical Treatment for Ischemic Heart Failure Trial with Dr Robert Discussing science, anecdote, and opinion: Up in arms after RIVAL? Bonow ACC Day 1: Dr Ralph Brindis and the doctrine of cardiovascular EVEREST II: Two-year outcomes with Dr Ted Feldman TAVI vs SAVR in PARTNER with Dr Craig Smith ecumenism RIVAL with DrSanjit Jolly This week in cardiology from heartwire REMEDIAL II with Dr Carlo Briguori #84: TAVI matches surgery in PARTNER cohort A; PARTNER B cost- Surgical Treatment of Ischemic Heart Failure Trial with Dr Eric effectiveness; MAGELLAN on rivaroxaban in... Velazquez #83: Hot topics at ACC 2011; noninvasive CV imaging for subclinical RAPS with Dr Stephen Fremes disease; Elizabeth Taylor and... PARTNER (cohort B) with Dr Matthew Reynolds
  • 20. For more information ACC Scientific Sessions ACC 2011 coverage on theheart.org ACC 2011 on Medscape
  • 21. Credits and disclosures Editor: Shelley Wood Managing Editor, heartwire Kelowna, BC Disclosure: Shelley Wood has disclosed no relevant financial relationships. Contributor: Steven Rourke Manager, Editorial Programming theheart.org Montreal, QC Disclosure: Steven Rourke has disclosed no relevant financial relationships. Journalists: Lisa Nainggolan, theheart.org Michael O'Riordan, theheart.org London, UK Toronto, ON Disclosure: Lisa Nainggolan has disclosed no relevant financial Disclosure: Michael O'Riordan has disclosed no relevant financial relationships. relationships. Sue Hughes, theheart.org Steve Stiles, theheart.org London, UK Fremont, CA Disclosure: Sue Hughes has disclosed no relevant financial relationships. Disclosure: Steve Stiles has disclosed no relevant financial Reed Miller, theheart.org Bethesda, MD Disclosure: Reed Miller has disclosed no relevant financial relationships.
  • 22. More slideshows AHA 2010 research highlights: A slideshow presentation TCT 2010 research highlights: A slideshow presentation ESC 2010 research highlights: A slideshow presentation
  • 23. Become a member of http://www.theheart.org Become a fan on Facebook: http://www.facebook.com/theheartorg Follow us on Twitter: http://www.twitter.com/theheartorg theheart.org is the leading online source of independent cardiology news. We are the top provider of news and opinions for over 100 000 physicians.