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Cardiology Today’s Editorial Board discusses top news of 2018
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There were many noteworthy developments in cardiology in 2018. A number of trials were published that changed practice, and important new guidelines were released.
Cardiology Today asked members of its Editorial Board to expound on what they thought were some of the top stories of the year, and why.
Joseph S. Alpert, MD, University of Arizona Sarver Heart Center
The new high-sensitivity troponin test (Elecsys Troponin T Gen 5 Stat, Roche) will result in a number of changes in the approach to patients with chest discomfort both in the ED and in the hospital. One example is that an individual with chest discomfort who has a normal high-sensitivity troponin 3 hours after the onset of this pain is at very low risk for having a MI and can be sent home from the ED without being admitted. The Europeans and Asians have been using this high-sensitivity test for years. This past year it was approved by the FDA for use in the U.S.
Bradford C. Berk, MD, PhD, University of Rochester Medical Center
Aspirin for primary prevention has become one of the most common practices in America. To convince people not to do it will be difficult given the huge amount of direct-to-consumer advertising. The take-home message is: “Be careful what you wish for and don’t extrapolate from one clinical indication to another.”
Deepak L. Bhatt, MD, MPH , Brigham and Women’s Hospital and Harvard Medical School
The year 2018 provided great insights into the omega-3 story. The use of unregulated over-the-counter supplements is extremely high, as patients mistakenly think they are gaining CV protection. In REDUCE-IT, which I presented at the American Heart Association Scientific Sessions, we now have clear evidence that a large dose of a highly purified ethyl ester of eicosapentaenoic acid (Vascepa, Amarin) can substantially reduce ischemic events, including death due to CV causes. I believe this will open up a whole new approach toward residual CV risk reduction that will only be fully apparent in years to come.
Michael R. Jaff, DO, Newton-Wellesley Hospital and Harvard Medical School
Hypercholesterolemia remains a critically important risk factor for CAD. With the addition of PCSK9 inhibitors, the new guidelines make it significantly more important for clinicians to manage this risk factor.
Robert Roberts, MD, College of Medicine-Phoenix, University of Arizona
A genetic risk score based on the variants for CAD makes it possible to predict CAD for primary prevention from birth or any time after. By using it, one can show who will benefit most from lipid therapy, exercise or a change in lifestyle. There have been 12 publications since 2015 showing the genetic risk score, which has been evaluated in more than 1 million cases and controls, is superior to conventional risk factors such as cholesterol and is about to invade many other chronic diseases. It is more precise and extremely cost-effective.
L. Samuel Wann, MD, Ascension Healthcare Milwaukee
Major strides have been made in the treatment of obstructive coronary disease and therapies combatting the development of atherosclerosis, but heart disease remains the leading cause of death in the world. Further reductions in the impact of atherosclerosis require new pharmacologic approaches and societal attention to diet, exercise and BP control.
Michael A. Weber, MD, SUNY Downstate College of Medicine
I am influenced by exciting progress in preventive cardiology. This has been a fine year for articles on lipid issues, adding further importance to the CV outcomes benefits of tight LDL control. The growing focus on hypertension and diabetes, where certain types of treatment appear to provide outcomes advantages, is also highly meaningful.
Udho Thadani, MD, University of Oklahoma Health Sciences Center and VA Medical Center
It was several years ago that I recall attending a hearing at an FDA meeting, when the topic of aspirin for primary prevention was discussed. And appropriately, the FDA hearing concluded that aspirin was not indicated for primary prevention due to increased risk for intracranial hemorrhage in asymptomatic patients, even in the presence of diabetes or mild to moderate risk for ischemic heart disease. Despite that, several national and international guidelines have recommended the use of low-dose aspirin for primary prevention for patients at risk for ischemic heart disease.
Recent randomized controlled, large outcome trials (ASCEND, ASPREE and ARRIVE) are timely and confirm the FDA standing that aspirin is not indicated for primary prevention in patients with diabetes and those with CV risk factors but no documented evidence of atherosclerotic disease in the coronary, peripheral or carotid vascular beds.
I personally have not and do not prescribe aspirin for primary prevention for the fear of rare but devastating intracranial bleeds in asymptomatic patients.
Nanette K. Wenger, MD, Emory University
The pathophysiology of myocardial ischemia in women is far more complex than in men — in addition to obstructive coronary disease, women are likely to have nonobstructive coronary disease and microvascular disease, rendering the etiologic diagnosis challenging. Recognition of nonobstructive CAD is important in that it is associated with adverse clinical outcomes.
New on the scene for the management of HF in patients with diabetes is a category of drugs used to treat diabetes, the sodium-glucose cotransporter 2 inhibitors, that have favorable effects on HF with reduced ejection fraction. This adds to our spectrum of medications available to treat patients with HFrEF.
Disclosures: Alpert, Berk, Roberts, Thadani, Wann and Wenger report no relevant financial disclosures. Bhatt reports he has financial ties with numerous drug and device companies, including receiving research funding from Amarin. Jaff reports he is a consultant for Abbott Vascular, AOPA, Boston Scientific, Cordis, Medtronic, Micell, Primacea, Silk Road Medical, Vactronix, Venarum and Volcano/Philips and holds equity in Embolitech, Gemini, Janacare, MC10, Northwind Medical, PQ Bypass, Primacea, Sano V and Vascular Therapies. Weber reports he consults for AbbVie, Ablative Solutions, Boston Scientific, Johnson & Johnson, Medtronic, Novartis and ReCor and receives research grants from Ablative Solutions, Astellas, Boehringer Ingelheim, Boston Scientific, Johnson & Johnson, Medtronic, Novartis and ReCor.