2011 Game Changers in Cardiology

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1. Eplerenone for mild heart failure: EMPHASIS-HF trial showed that aldosterone antagonist eplerenone produced large reductions in both the risk for death and the risk for hospitalization compared with placebo in patients with systolic heart failure and mild symptoms. Its role in moderate and sever heart failure is already known.
2. COURAGE Findings Are Not Being Implemented: In 2007, the landmark COURAGE study found that in patients with stable coronary artery disease, optimal medical therapy was just as good at preventing future events as receiving a stent on top of optimal medical therapy. Still cardiologists are not following it.
3. FDA Approves Rivaroxaban for Stroke Prevention in Atrial Fibrillation: Based on ROCKET-AF trial following dabigatran, rivaroxaban is the second in a surge of novel oral anticoagulants to go before the FDA’s advisors for the atrial fibrillation/stroke indication.
4. AIM-HIGH: Results Raise Controversy Over Early Discontinuation: The AIM-High study showed that raising HDL using extended-release niacin (1500-2000 mg) was not beneficial in patients who had been treated with statin therapy for elevated low-density lipoprotein cholesterol levels. There was also a small, unexplained increase in ischemic stroke in the niacin group. However, the final results of the trial that were presented at AHA 2011 and published in The New England Journal of Medicine suggest that the signal of increased ischemic stroke with niacin could have been the play of chance.
5. The NICE Hypertension Guidelines: A Monitoring Revolution: The new NICE guidelines formally recommend ambulatory blood-pressure monitoring as a “key priority” in diagnosing suspected hypertension, particularly if a clinic blood pressure reading is 140/90 mm Hg or higher.
6. PARTNER Cohort A: TAVI Non inferior to Surgery: PARTNER cohort A, results showed that transcatheter valve replacements (TAVR) in severe aortic stenosis, is an acceptable alternative to aortic valve replacement in selected high-risk operable patients.
7. DOSE Trial Published: How to Give Intravenous Diuretics in Acute Heart Failure: The DOSE trial suggested that aggressive decongestion is a critical part of achieving good outcomes in acute decompensated heart failure. It may seem to come at the cost of transient worsening renal function, but that doesn’t seem to be a major problem, as long as it’s monitored carefully.
8. STICH “Hypothesis One” Supports CABG in Heart Failure: Results of NIH sponsored STICH showed that CABG was associated with an early risk of death as a result of the surgical intervention, but this disadvantage for surgery disappeared 2 years after the procedure. Over a median follow-up of 56 months, 41% of the medical therapy group and 36% of the CABG group died.
9. STICH: Viability Testing Didn’t Affect Treatment Outcomes: STICH published in The New England Journal of Medicine was a randomized comparison of CABG surgery and medical therapy alone in 1212 patients with a left ventricular ejection fraction less than 35% and coronary artery disease amenable to CABG. The sub study found that overall, substantial viable myocardium evident at baseline imaging studies had no independent bearing on all-cause mortality over 5 years; and such viability didn’t influence the relative effectiveness of the 2 treatment strategies. It questions the value of assessing myocardial viability with perfusion scans or other functional imaging methods to predict benefit from coronary revascularization in such patients.
10. Death Rates Diverge but no Change in Advice: SYNTAX: The SYNTAX results show that in LMCA/TVD bypass surgery was better than PCI using Taxus drug-eluting stent at 3 years.