Cardiovascular disease prevention in 2033

  • Cardiovascular disease prevention can be done by targeting modifiable causes of disease.
  • Use of AI /digital platform for personalized health promotion or guiding health management through predict, prescribe and prevent may work better.
  • Personalizing diet and lifestyle GUIDANCE by conducting digital ‘personalized’ n-of-1 trials on the platform to ‘learn’ the best way in which each person can minimize the exposure to the cause of disease.


How will we approach coronary artery disease in 2033?

  • Multi-slice spiral computed tomography will be the new sole diagnostic tool for bypass grafting, FASTTRACK CABG trial without using conventional invasive cine angiography.
  • The use of Hologram will be prevalent and the use of blended therapy will be normal in PCI.
  • Aspirin will be replaced by monotherapy of a specific anti-platelet.


Management of Valvular Heart Disease in 2033

  • The screening of VHD will be done by Artificial Intelligence/ Machine learning (ECGs) in the future.
  • Bioprosthetic valve platforms will be introduced: Edwards Resilia tissue valve, Anteris DurAVR and Foldax TRIA polymer valve.
  • TAVR will be the dominant technology for AVR and most AS anatomic scenarios.


Screening, prevention, and treatment of AF: what we will be doing in 2033?

  • For individualized risk prediction for AF, new algorithms will be utilized.
  • AF will be screened via contact-free optical screening or a smart wearable.
  • In 2033, new medications will prevent strokes, and ablation technology will manage the rate and rhythm of AF.


Management of Heart Failure in 2033: My predictions

  • Patients will manage their own volume status with a patient self-management approach directed by a physician and congestion will be measured by AI or smart wearables.
  • Extracellular vesicles will be used as a biomarker in understanding the pathophysiology and in therapy.
  • Focus will be on, why women are more prone to HFpEF than men to understand HFpEF and how to prevent it.


Digital cardiology & Artificial Intelligence- Where will it take us in 2033?

  • AI will increase convenience for patients and staff.
  • The AI won’t replace doctors but will help them.
  • Lot of companies have FDA- cleared machine learning products for cardiology.


Implementing ESC 2021 Guideline-recommended HF care: where do we stand now?

  • Initiate standard therapies as soon as possible and titrate every 2-4 weeks to target or maximallyntolerated dose over 3-6 months
  • The ESC/HFA society recommends personlized approach for treatment of heart failure.
  • Real-world data suggest better outcomes with simultaneous vs sequential prescription of Ivabradine and Sacubitril/Valsartan in patients with HFrEF.


Individualized approach in HF management: What more can we do?

  • A personlized approach, adjusting guideline-directed medical therapy to patient profile, may allow to achieve a better and more comprehensive therapy for each individual patient than the more traditional, forced titration of each drug class before initiating treatment with the next.
  • As per the 2021 ESC consensus on HF patient profiling for tailoring medical therapy, achieing better and more comprehensive therapy for each indivual patient is a must.
  • Ivabradine can be added in patients who have low BP and elevated HR and are currently taking SGLT2i, MRA, diuretics, BB.


INVICTUS – Rivaroxaban versus VKA for rheumatic atrial fibrillation

  • Rheumatic heart disease (RHD) affects more than 40 million people worldwide, primarily young people and people living in low-middle income countries, and about 20% of symptomatic RHD patients also suffer from AF (or elevated stroke risk).
  • An anticoagulant that does not require monitoring would be of great benefit to RHD-AF patients.
  • According to the INVICTUS trial, in RHD-AF patients, VKA reduced ischemic stroke and mortality without increasing the risk of major bleeding. This trial also showed a reduction in mortality with VKA.


PACIFIC-AMI – Efficacy and safety of factor XIa inhibitor asundexian on top of dual antiplatelet therapy after acute myocardial infarction

  • Patients with AF are known to be at an increased risk of stroke due to their tendency to develop atrial thrombi.
  • After acute myocardial infarction, antiplatelet therapy with aspirin and a P2Y12 inhibitor (DAPT) is considered the standard of care.
  • According to the Pacific-AMI study, asundexion (an oral factor XIa inhibitor) was well tolerated in the Phase 1 trial and its 50 mg daily dosage resulted in almost complete (>90%) suppression of factor XIa activity.


GLP-1 RAs: more than just glucose-lowering agents

  • Globally, approximately 10% of cardiologists, endocrinologists, or HCPs are using GLP-1 RA for the management of diabetes.
  • GLP-1RAs target both fasting and postprandial glycemia, in general by increasing insulin and decreasing glucagon levels.
  • In patients with T2D at high cardiovascular risk, studies (such as LEADER, SUSTAIN-6, Harmony Outcomes, REWIND, or AMPLITUDE-O) have revealed that GLP-1-RA significantly reduces 3-P MACE (composite of CV death, nonfatal MI, or nonfatal stroke) compared to placebo.


The Evolution of T2D and CV Guidelines

  • In accordance with AHA/ASA 2021, in patients with established ASCVD, including stroke, GLP-1-RA should be added to metformin regardless of baseline HbA1c.
  • Lifestyle modification, glucose targeting, BP control, dyslipidemia management (LDL-C), antiplatelet therapy, weight control, and anti-inflammatory therapy are considered multifactorial approaches to T2D management.
  • Interventions for glucose management (pre-diabetes and diabetes) will reduce the risk of neurocognitive and discrete stroke events.


Real-world evidence: a bridge between trials and clinical practice

  • The ESC guidelines on management of AF recommend structured characterization and a better care (ABC) approach.
  • NOACs are generally recommended as first line therapy (Class I, Level A).
  • Real-world evidence builds on data from RCTs to demonstrate the safety and effectiveness profile of NOACs in the real world.


Practical considerations for the use of GLP-1-RAs in the clinic

  • Although GLP-1-RAs have shown cardiovascular benefits in people with T2D at high risk of CV events, they are not frequently used by cardiologists.
  • GLP-1-RAs have a more pronounced effect on ASCVD than SGLT2i. Whereas, SGLT2i shows a more pronounced effect on HHF and CKD than GLP-1-RAs.
  • GLP-1-RAs do not increase the risk of hypoglycemia when combined with other glucose-lowering therapies (e.g. metformin, SGLT2i, and thiazolidinediones).


GLORIA-AF: New Phase III data from this innovative registry program

  • Dabigatran showed significant relative risk reduction of major bleeding by 39% and all-cause death by 22% vs VKA.
  • Dabigatran was associated with a 41% lower relative risk of major bleeding vs rivaroxaban.
  • There were similar risks of clinical outcomes with dabigatran vs apixaban.


What do real-world analyses tell us about NOACs?

  • In a large, real-world FDA/MCS analysis, each NOAC was associated with reduced risk of thromboembolic stroke vs warfarin.
  • As per GARFIELD-AF study, NOACs were associated with significantly lower rates of major bleeding and all-cause death vs VKA.
  • As per GARFIELD-AF registry, dabigatran was the only NOAC with significant reduction in major bleeding and all-cause mortality vs VKA.