Cardiology Today Editorial Board reacts to top stories of 2017

Cardiology Today asked its Editorial Board Members to name the top stories in cardiology in 2017; the results can be seen in the January 2018 print edition. As might be expected, the hypertension guideline released in November by the American College of Cardiology, the American Heart Association and nine other societies was a frequent response, but other topics of interest ranged from new data on positive CV outcomes for diabetes drugs to the controversial ORBITA trial finding little difference between PCI and a sham procedure for certain short-term outcomes in patients with stable, single-vessel CAD.
Here are their thoughts on some of the most important issues of 2017. Send your feedback on your top stories of 2017 in cardiology by emailing the editors at Cardiology@Healio.com.

New hypertension guideline

Hypertension is now defined as systolic BP 130 mm Hg/diastolic BP 80 mm Hg, which will lead to a new diagnosis in approximately 14% more Americans, according to a newly released, long-awaited guideline published by the American Heart Association, the American College of Cardiology and nine other societies.

“The new BP guidelines are a comprehensive document that emphasizes the importance of lifestyle changes to obtain < 130 mm Hg systolic/80 mm Hg diastolic. They rely more on observational data and the SPRINT trial results, while the American College of Physicians/American Academy of Family Physicians guidelines did not encourage pharmacologic treatment in older adults if their systolic BP was less than 150 mm Hg.”

- Roger S. Blumenthal, MD; Johns Hopkins Ciccarone Center for the Prevention of Heart Disease

“The management of systemic hypertension by dietary and pharmacologic means has had a major impact on CV events with reductions in the risk for stroke, MI, HF (both systolic and diastolic), renal dysfunction and cognitive disorders. At this time, all the drugs for the treatment of hypertension are generic, inexpensive and, for the most part, well tolerated, making cardiac protection a cost-effective intervention for the American population. Having stricter guidelines for treatment, that are evidence-based, will go a long way in reducing CV risk even further in the years to come.”

- William H. Frishman, MD; New York Medical College and Westchester Medical Center

“The definition and treatment of hypertension has proven very controversial. The differing opinions of experts has sown confusion in the minds of the medical community and the public at large. The attendant inaction or undertreatment of hypertension jeopardizes the public health. The 2017 AHA/ACC guideline goes a long way to remedying the confusion and brings the U.S. guidelines in closer conformance with those in other jurisdictions. Resolving some of the controversies that surrounded the previous U.S. statements should dispel confusion and improve the management of this important risk factor.”

- Peter Libby, MD; Brigham and Women’s Hospital and Harvard Medical School

“The new hypertension guidelines will have a tremendous impact on clinical practice and patient outcomes. I particularly like the recommended first approach for most patients, which is lifestyle modification. While not entirely new, lifestyle modification is often overlooked.”

- Douglas L. Mann, MD; Barnes-Jewish Hospital and Washington University in St. Louis

“The importance of hypertension as the No. 1 cause of CVD has been unappreciated. The new guideline focuses on this important risk factor.”

- Keith C. Ferdinand, MD; Tulane University School of Medicine

“The new hypertension guidelines now take a more aggressive and rational approach to the management of hypertension. The lower level for defining hypertension should help alert physicians to become more active in managing patients with BP elevations that they chose to follow in the past. This should translate to a reduction in CV morbidity and mortality over time.”

- Barry Greenberg, MD; University of California, San Diego

ORBITA

The ORBITA trial, presented at TCT 2017, raised questions about the advantages of PCI in patients with stable angina on optimal medical therapy. Compared with a sham procedure, PCI did not improve exercise time at 6 weeks in patients with medically managed angina and single-vessel CAD. Some experts questioned whether PCI should be performed in lower-risk patients, while others said the trial was too small and too short-term to draw firm conclusions.

“The ORBITA trial shows us the power of placebo when we do procedures and the importance of having a sham control, so we can avoid attributing the placebo benefit to a procedure. The FDA should require such high-quality evidence before device approvals, as it is hard for people to accept even high-quality evidence once patterns are established, such as for PCI.”

- Rita Redberg, MD; University of California, San Francisco

“Importantly, ORBITA reaffirms the effectiveness of medical therapy, showing that many patients with stable CAD and single-vessel disease can achieve angina relief with medication. Limitations include its lack of generalizability due to its very select patient population and the fact that some patients with normal fractional flow reserve underwent PCI, The latter is not optimal for a trial in which criteria must be strict so as to achieve cleaner results that are easier to interpret.”

- David P. Faxon, MD; Brigham and Women’s Hospital and Harvard Medical School

Plant-based diet

In 2017, evidence for CV benefits of plant-based diets continued to mount, including a study that linked healthful plant-based diets to reduced risk for CHD.

“The vegan diet has increased 500% in the past 3 years, but high-fat and high-calorie meals still plague the majority of Americans and underpin the epidemic of obesity, hypertension and diabetes. We have therapies for each, but treating this growing population is weighing heavily on the health care budget.”

- Kim Allan Williams Sr.; MD, Rush University Medical Center

Diabetes drugs and CV risk

More was learned in 2017 about the CV benefits and risks of diabetes drugs, including canagliflozin (Invokana, Janssen) reducing risk for CVD and kidney disease but increasing risk for amputation, and empagliflozin (Jardiance, Boehringer Ingelheim) receiving a new indication for reduction of CV death in patients with type 2 diabetes and showing CV benefits in patients with peripheral artery disease and diabetes.

“Positive efficacy outcomes from a series of large randomized trials of type 2 diabetes drugs have revolutionized the care of these high-risk patients. We finally have therapeutic options that go far beyond glucose control and actually reduce CV risk.”
- Darren McGuire, MD, MHSc; University of Texas Southwestern Medical Center

COMPASS

Patients with stable atherosclerotic vascular disease who were treated with 2.5 mg of rivaroxaban (Xarelto, Janssen) plus aspirin had improved CV outcomes vs. aspirin alone, although they had more major bleeding events, according to the COMPASS study presented at the European Society of Cardiology Congress in Barcelona, Spain. Results were similar in a substudy of patients with PAD.

“The COMPASS trial has great potential to be practice changing for a large percentage of patients with coronary or peripheral artery disease.”

- Deepak L. Bhatt, MD, MPH; Brigham and Women’s Hospital and Harvard Medical School

Disclosures: Blumenthal, Frishman, Greenberg, Libby, Mann, Redberg and Williams report no relevant financial disclosures. Bhatt reports financial ties with multiple pharmaceutical and device companies. Ferdinand reports he is a consultant for Amgen, Boehringer Ingelheim, Novartis, Quantum Genomics and Sanofi. McGuire reports he received personal fees for clinical trial leadership from AstraZeneca, Boehringer Ingelheim, Eisai, GlaxoSmithKline, Janssen Research and Development LLC, Lexicon, Lilly USA, Merck Sharp and Dohme, Novo Nordisk and Takeda Pharmaceuticals and personal consultant fees from Merck Sharp and Dohme, Novo Nordisk, Regeneron and Sanofi Aventis Group.