DeMaria: Several recent trials have implications for clinical practice

Anthony DeMaria

WASHINGTON — Some of the top studies in 2018 that may have implications on clinical practice include those that focus on patients with mitral regurgitation, HF, high triglycerides and hypertension, according to a presentation at Cardiovascular Research Technologies.

Anthony DeMaria, MD, professor of medicine and Judith and Jack White Chair in Cardiology at the University of California, San Diego School of Medicine, and editor-in-chief of Structural Heart: The Journal of the Heart Team, discussed several trials that have had a major effect on his practice. The following is a list he provided of those studies that touch on topics that relate to both medications and interventional treatment of several conditions.

MITRA-FR: In patients with HF with reduced ejection fraction and secondary mitral valve regurgitation, percutaneous mitral valve repair plus medical therapy offered no advantage over medical therapy alone. Read more

COAPT: Patients with HF with moderate to severe or severe functional mitral regurgitation who underwent transcatheter mitral valve repair reduced the risk for HF hospitalization and mortality compared with patients treated with medical therapy alone.

“For degenerative mitral regurgitation, the MitraClip (Abbott) is good, but surgery is to be preferred,” DeMaria said. “We need to revisit this concept that functional mitral regurgitation is a disease of the left ventricle and that treating the mitral valve can’t be of any benefit. ... I look forward to the RESHAPE-HF2 data and for the 5-year follow-up [for COAPT]. At the moment, I’m a bit cautious and I would only apply the MitraClip for functional mitral regurgitation in patients who fit the clinical profile that was enrolled in COAPT.” Read more

ODYSSEY Outcomes: Reducing LDL to very low levels with the PCSK9 inhibitor alirocumab (Praluent, Sanofi/Regeneron) lowered risk for MACE and all-cause mortality in patients with ACS on statin therapy.

“Why am I talking about ODYSSEY when FOURIER showed a benefit,” DeMaria said. “The biggest reason is that they re-established LDL targets. Their LDL targets were 25 mg/dL to 50 mg/dL. That has really brought LDL targets back. Personally, I always thought they should have been. They had a slightly greater benefit in patients with LDL over 100 mg/dL, indicating that there might be even a better mortality benefit there, and a reduction in death is provocative, but exploratory.” Read more

REDUCE-IT : In patients with elevated triglycerides at high CV risk despite statin therapy, icosapent ethyl was superior to placebo for reducing risk for ischemic events.

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“It was a large study, but a bit surprising because there’s been some 40 studies on fish oils, and other than JELLIS done in Japan, none of the other studies really were positive,” DeMaria said. “The mechanism remains uncertain, unlikely due to the triglyceride or the antiplatelet effects. It’s intriguing that it may be related to membrane stabilization.” Read more

ATTR-ACT: Treatment with tafamidis (Pfizer) reduced risk for all-cause mortality and CV-related hospitalizations in patients with hereditary and wild-type transthyretin amyloid cardiomyopathy.

“We haven’t had any treatment, so this is a major breakthrough,” DeMaria said. “Now we have something to offer these patients not only to prolong life, but to improve quality of life. There was an 18-month delay in the mortality benefit. That raises some intriguing possibilities as to whether or not the amyloid fibrils are being removed. An important factor in this study is that it was most effective in patients with relatively mild disease, class 1 and class 2 patients, stressing the importance of early diagnosis.” Read more

CABANA: In patients with atrial fibrillation, catheter ablation conferred better outcomes compared with drug therapy in on-treatment and per-protocol analyses, but not in an intention-to-treat analysis.

“It’s about time,” DeMaria said. “This was welcome. The patients weren’t blinded to therapy, and of course that’s a major issue. It’s inherent in devices. Ablation turned out to be safer than we thought.” Read more

Black Barbershop Study: Health promotion in a barbershop setting was a useful intervention to target uncontrolled hypertension in the shops’ black male patrons.

“Simple things can be powerful, and pharmacists can be very useful,” DeMaria said. “Remember the pharmacists weren’t blinded, and they took the blood pressure. They were shooting for lower blood pressure than the community. Nevertheless, two-thirds of all these black hypertensives were brought to control.” Read more – by Darlene Dobkowski

Reference:

DeMaria A. PCI 2019: Controversies and Hot Topics in Interventional Cardiology. Presented at: Cardiovascular Research Technologies; March 2-5, 2019; Washington, D.C.

Disclosure : DeMaria reports no relevant financial disclosures.

Editor’s Note: This article was updated on March 13, 2019 to correct a transcription error in Dr. DeMaria’s comments on REDUCE-IT. The Editors regret the error.