ISHKEMIA-CKD EXTEND – Clinical Outcomes at 5 years of Follow-up
- Largest treatment strategy trial of SIHD and advanced CKD.
- At 5 years, in ISHKEMIA-CKD patients, high rates of death (~39%) and CV death (~28%) were observed.
- An initial invasive and conservative strategy resulted in similar survival at a median of 5 years follow-up.
15-Month results of the MASTER DAPT trial
- APT intensity (DAPT vs SAPT or SAPT vs no APT) was also influenced by perceived ischemic risk or prior ischemic events, but not by bleeding risk or prior bleeding events.
- Majority of patients in the prior standard continued DAPT beyond 12 months despite the absence of prior ischemic events.
- NACE and MACCE remained similar and MCB was low at 15 months suggesting no ischemic or fatal events and at least persistent bleeding with abbreviated compared to the standard treatment after Ultimaster stent implantation in unselected HBR patients.
PARADISE-MI Trial – Win ratio analysis
- The PARADISE-MI trial demonstrated that Sacubitril/Valsartan was superior than Ramipril in high-risk survivors of MI.
- Win ratio analysis can be a useful adjunct to the conventional time-to-first event analysis for trials with composite outcomes, where the ranking of the clinical importance of the different types of events is considered relevant.
- This analysis can inform the design of future CV trials in population.
PANTHER – P2Y12 inhibitor versus aspirin monotherapy in patients with coronary artery disease
- P2Y12 inhibitor monotherapy was associated with lower risks of CVD, MI, and resulting in a reduced risk of net adverse clinical events.
- The incidence of major bleeding was similar, but GI bleeding and haemorrhagic stroke were lower with P2Y12 inhibitor monotherapy.
- Long-term P2Y12 inhibitor monotherapy is better than long-term aspirin monotherapy for secondary prevention in patients with CAD.
FOURIER-OLE primary results
- Long-term use of Evolocumab with a median follow-up of more than 7 years appears to be safe and well-tolerated.
- Early initiation of Evolocumab is beneficial for CVD and CVD mortality over several years.
- FOURIER-OLE study results argue for early initiation of marked and sustained LDL-C reduction for maximum clinical effect.
FIDELITY: Causes of mortality
- Finerenone not only reduced the risk of all-cause and CV mortality but also reduced the risk of sudden cardiac death.
- The effect of Finerenone on mortality outcomes was more pronounced in patients with higher baseline eGFR.
- Finerenone improves prognosis even in well-managed patients.
Management concepts of plaque erosion
- Plaque erosion was found in 25-40% of ACS.
- In vivo diagnosis of plaque erosion became possible.
- Conservative management with prolonged anti-platelet therapy be an option for patients with ACS caused by erosion.
Plaque erosion and its role in acute coronary syndrome
- Plaque erosion is more frequent in NSTEMI than STEMI.
- Potential differences in plaque erosion and plaque rupture in terms of gender and age groups, triggers, and plaque composition.
- Better prognosis than ACS associated with plaque rupture.
Blood pressure treatment targets: what do the guidelines say?
- The updated NICE guideline continues to recommend a treatment range and target BP of 140/90 mmHg, in contrast to the following treatment targets recommended by the ESC/ESH.
- Individualized studies after considering age, frailty, co-morbidity, baseline BP and tolerance of BP lowering drugs reveal that the optimal BP target is not the same for every patient.
- Efforts to reduce CV risk in hypertensive patients should make full use of various BP measures, in routine care or through self-monitoring, in conjunction with treatment regimens to achieve high TITREs.
How to achieve blood pressure targets in clinical practice?
- Inadequate preparation, incorrect BP measurement (home or office), lack of adherence to medical visits, lifestyle changes, and medications are some of the factors that make achieving and maintaining BP goals in the real world difficult.
- The optimum antihypertensive strategy should be based on an individual’s CV risk profile, as well as BP levels and drug tolerance.
- A healthy lifestyle (low salt consumption, moderate to vigorous aerobic activity, or the DASH diet) may prevent or delay the onset of hypertension and lower CV risk. It also improves the effectiveness of antihypertensive medication.
SGLT2 inhibitors in HFpEF – Light at the end of the tunnel
- SGLT2i was first intended to treat diabetes, but studies have shown that it is also useful in the prevention and treatment of HF.
- In individuals with HFpEF or HFmrEF, dapagliflozin treatment decreases the risk of the primary composite outcome of CV death or worsening HF.
- The EMPEROR-Preserved study showed that empagliflozin outperforms placebo in improving HF outcomes in patients with symptomatic stable HFpEF on good baseline GDMT, regardless of diabetes status.
SGLT2 inhibitors across the spectrum of heart failure
- ACEi/ARBs, Neprilysin inhibitors, BBs, MRAs, and SGLT2i are the “living five” or “fantastic/fab four” live-saving therapies for HFrEF.
- According to the DELIVER trial, dapagliflozin reduced the combined risk of worsening HF or CV death in patients with HFmrEF or HFpEF.
- The SOLOIST-WHF study concluded that the primary end goal of the total number of CV fatalities, hospitalizations, and urgent visits for HF was considerably lower with the SGLT2 and SGLT1 inhibitor sotagliflozin compared with placebo in patients with diabetes who had worsening HF.
Practical considerations for treating HF with mildly reduced and preserved EF
- In the absence of AF or valve disease, LA enlargement reflects chronically elevated LV filling pressure.
- The ASIAN-HF registry showed that very young HFpEF patients had a 3-fold higher mortality and twice the hypertrophy than the control group.
- In Paragon-HF, mortality rates were comparable across all regions, despite regional variations in patient characteristics and HF hospitalization rates. Similarly, subsequent analysis of I-Preserve and Charm-P tests showed no change in mortality across regions.
Implementing best practices across the spectrum of heart failure
- To avoid morbidity, patients with HFpEF and HTN should be administered titrated drugs to achieve their BP targets, in accordance with recognized clinical practice recommendations.
- SGLT2i is an ideal cardio-renal-metabolic therapy for HF, as one pill/day significantly improves survival, prevents hospitalization, and improves QoL and functional status.
- According to one study, in a 55-year-old patient with HFrEF, comprehensive therapy (with ARNI+BB+MRA+SGLT2i) provided an overall 6.3 additional years compared to conventional therapy (ACE/ARB+BB).
COVID-PACT – Antithrombotic therapy in critically Ill COVID-19 patients
- To lower the risk of VTE in critically ill patients who do not have COVID-19, thromboprophylaxis is recommended.
- According to current guidelines, SDPAC should be used instead of FDAC in severely sick COVID-19 patients.
- In order to reduce thrombotic problems in a subset of critically sick COVID-19 patients, FDAC should be taken into consideration while balancing the risk of thrombosis and hemorrhage.
ACT Outpatient Trial: Colchicine and Aspirin in community patients with COVID-19
- The year 2021 saw an estimated 3.8 billion people infected with COVID-19 and nearly 18 million deaths.
- Antiplatelet medication may benefit patients with severe COVID-19 through a variety of mechanisms, including inhibition of platelet aggregation and reduction of platelet-derived inflammation.
- Colchicine, high-dose aspirin, and rivaroxaban are being studied as possible COVID-19 modulators in individuals who have not improved with standard therapy.
ACT Inpatient Trial: Colchicine and Rivaroxaban plus Aspirin in patients hospitalized with COVID-19
- One out of every five patients in the ward with COVID-19 died in the ACT inpatient trial (high mortality rate).
- Colchicine did not give a mortality advantage in the ACT study, regardless of whether the patient is on MV or has previously been vaccinated, or if the patient has long or short duration of symptoms.
- A meta-analysis of intensified anticoagulation in inpatients showed a clear 40% decrease in VTE, although this reduction does not give advantage in terms of mortality reduction.