Advances in HF, hypertrophic cardiomyopathy management among top news of 2022
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The year 2022 was one full of practice-changing advances in cardiology, with new data, drugs and management strategies for everything from HF and hypertension to CVD prevention.
In 2022, researchers presented striking new data on the efficacy and safety of SGLT2 inhibitors in HF across the full range of ejection fraction, in addition to updated HF guidelines and novel approaches to improve the uptake of guideline-directed medical therapy. The FDA approved a first-in-class treatment for obstructive hypertrophic cardiomyopathy, the cardiac myosin inhibitor mavacamten (Camzyos, Bristol Myers Squibb), and the first dual-incretin agonist, tirzepatide (Mounjaro, Eli Lilly), for type 2 diabetes. Novel strategies and updated guidance for BP management, including hypertensive disorders of pregnancy, offer new ways to reduce CV risk. Throughout the year, researchers also conducted important work focused on reducing racial and ethnic disparities in care that persist in cardiology, highlighting the importance of the social determinants of health. This year also marked 2 decades since the first transcatheter aortic valve replacement.
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Healio and Cardiology Today asked leading cardiologists: What was the biggest news of 2022 in cardiology?
Carl J. Pepine, MD, MACC
Clearly, this was a pivotal year of practice-changing developments to better manage a range of CV conditions that were overshadowed by record-breaking development of effective treatments for COVID-19.
However, climate change remains the challenge of our generation, as Martha Gulati, MD, MS, FACC, FAHA, FASPC, FESC, president of the American Society for Preventive Cardiology and professor of medicine at the Smidt Heart Institute at Cedars-Sinai, has pointed out. We now need to urgently replicate the collaboration observed for COVID-19 management into that space. Climate change is an existential threat that may be slowed with greater collaboration. Together, we can foster scientific breakthroughs and accelerate the research-innovation cycle that we saw for COVID-19 for climate change. This is a crucial time in history; actions that we take during the next decade will have lasting impact. Actions need to be taken if we are to keep our planet safe for ourselves and our children; decisive, evidence-based decisions driven through collaborative science.
The SGLT2 inhibitors, once a niche drug class used by endocrinologists to treat type 2 diabetes, fought their way into risk prevention, particularly for HF and CV risk. Results from the DELIVER trial showed dapagliflozin (Farxiga, AstraZeneca) was beneficial in HF with mildly reduced or preserved ejection fraction, reducing risk for CV death and worsening HF compared with placebo, with no attenuation of treatment benefit for patients with the highest EF.
Finerenone (Kerendia, Bayer), a selective nonsteroidal mineralocorticoid receptor antagonist, has been shown to preserve renal function without elevating potassium, a standout among mineralocorticoid blockers.
Mavacamten, a cardiac myosin inhibitor approved in April to treat obstructive hypertrophic cardiomyopathy (HCM), offers hope for many people with this debilitating disease who want improved quality of life.
Then, we have some relevant new guidelines. The inaugural chest pain guidelines from the American College of Cardiology/American Heart Association, published at the end of 2021, redefined how physicians discuss chest pain with patients and serve as a guidepost for a detailed clinical decision pathway for diagnosis and management. I commend the authors of this comprehensive guideline, led by Dr. Gulati, for their hard work on this important topic. Their recommendation to abandon “atypical chest pain” was key towards improving our management approach to patients without ACS.
The American Diabetes Association’s Standards of Care in Diabetes includes relevant cardiology updates for 2023. This adds a recommendation for high-intensity statin therapy in people with diabetes aged 40 to 75 years at higher risk, including those with one or more atherosclerotic CVD risk factors, to reduce LDL to < 70 mg/dL. Additionally, their updated definition of hypertension now aligns with the current ACC/AHA definition, < 130/80 mm Hg. The ADA now recommends treatment with an SGLT2 inhibitor for people with type 2 diabetes and established HF with either reduced or preserved EF.
Several groups have stressed the importance of a multidisciplinary heart team. We have emphasized “team science” in clinical investigation for more than a decade; however, this idea is only now starting to penetrate the clinical practices where multiple disciplinary teams are helpful. It is a welcome change. Research shows that these teams — ideally, an exercise physiologist, pharmacist, dietitian and many of the disciplines in cardiology — are associated with improved outcomes for our patients.
A sobering report from the ACC together with the Global Burden of Cardiovascular Disease Collaboration, published in December, emphasized that CVD remains the leading cause of death and hypertension remains the leading modifiable risk factor for premature CV death worldwide. The most preventable form of CVD is ischemic CVD. We have seen a plethora of approaches to reducing hypertension burden, from combination drugs to triple therapy, and new data suggesting quadruple therapy, may improve BP control compared with angiotensin receptor blocker monotherapy. The idea behind such strategies is to capture a larger group with these lower doses of multiple drugs and lower BP earlier, rather than the traditional “wait and see” approach. We also see a movement toward greater reliance on out-of-office BP and home BP, and greater reliance on novel devices to monitor BP. We also saw novel strategies for enhancing BP control and compliance. Keith C. Ferdinand, MD, FACC, FAHA, FASPC, FNLA, professor of medicine at Tulane University School of Medicine, and his group demonstrated that an NIH-sponsored text messaging program for patients with hypertension was associated with increased medication adherence and reduced systolic BP.
From a cardiology standpoint, this has been a challenging year. The COVID-19 pandemic continues and we are left with the fallout. Cardiologists — many burned out, others retiring early — are leaving the workforce in greater numbers. Our overworked and underpaid nursing workforce has been decimated. We saw an early flu epidemic and the emergence of respiratory syncytial virus. This “tripledemic” has caused a critical shortage of available hospital beds across the country. At the same time, keeping up with the pace of new developments can be difficult; important information, often reduced to short video snippets, can actually discourage learning and affect the dissemination of information.
Moving into 2023, we must find creative ways to better support our cardiology community, which will only lead to better outcomes for our patients.
Pepine is Chief Medical Editor of Cardiology Today. He also holds the title of Eminent Scholar Emeritus and professor in the division of cardiovascular medicine at University of Florida , Gain e sville .
Michelle M. Kittleson, MD, PhD
The most important cardiology development of 2022 has to be, without a doubt, the STRONG-HF trial.
The STRONG-HF trial enrolled more than 1,000 patients hospitalized with HF, who were assigned a high-intensity regimen or the usual care on discharge. The high-intensity care involved uptitration of guideline-directed medical therapy (GDMT) to 100% of recommended doses within 2 weeks of discharge and four scheduled outpatient visits during the 2 months after discharge to monitor clinical status and laboratory values. No surprise, there was better achievement of optimal GDMT in the high-intensity care group: By 90 days, 55% vs. 2% were on full-dose ACE inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor and 49% vs. 4% were on full-dose beta-blockers. While that alone is impressive, it is the next part — translating the theory of max-dose GDMT benefit into practice — that really caught everyone's attention. By 180 days, HF readmission or all-cause death occurred in 15.2% of the high-intensity group and 23.3% of the usual care group.
Why is this amazing? STRONG-HF demonstrates not only the feasibility of aggressive GDMT titration, but also the benefit. An absolute 8% risk reduction is astounding and a larger effect size than most clinical trials achieve. This trial did not involve a fancy new device but tried-and-true close monitoring to provide the best evidence and guideline-based therapies we already have. It is always satisfying when theoretical benefits are borne out in practice, but even more satisfying when the benefits are this dramatic.
Kittleson is director of heart failure research, director of postgraduate education in heart failure and transplantation and professor of medicine at the Smidt Heart Institute at Cedars - Sinai.
Khadijah Breathett, MD, MS, FACC, FAHA, FHFSA
It has been a delight to see thought-provoking work focused on understanding and correcting racial and ethnic disparities that contribute to CVD. I would like to highlight three major studies of 2022 that are worth reviewing and implementing more broadly.
The first is a study by Anika L. Hines, PhD, MPH, who used photovoice to capture how Black patients with chronic kidney disease and hypertension experience structural racism while accessing healthy foods in Baltimore. Participants took photos of their food environments and in the course of several focus groups expressed how prevalence of food deserts limited their ability to achieve CV health, and that food deserts were forms of social injustice that were purposefully designed and should be intentionally corrected. Participants identified steps to address years of structural racism. The photographs are quite powerful.
A second study led by LaPrincess C. Brewer, MD, MPH, demonstrated how a mobile health intervention application (the FAITH! app) developed by and created for the Black community was able to achieve statistically significant improvement in the AHA’s Life’s Simple 7 Risk factors. This pilot study demonstrated success in adoption and implementation over a 6-month period.
A final study led by Eugenia C. South, MD, MSHP, demonstrated how neighborhood cleanup of abandoned homes and structures was associated with reduction in gun violence in low-income neighborhoods in the city of Philadelphia as a randomized, controlled cluster trial. This work is pivotal. Dr. South’s earlier work demonstrated an association between reduction in crime and receipt of Department of Housing and Urban Development grants to structurally repair homes for owners with low income. This more recent prospective randomized controlled trial clearly demonstrated that addressing impacts of structural racism through redlining have broader impact on communities. Given that housing is associated with CV health, perhaps future work can identify longitudinal impact on CV outcomes.
Breathett is a Cardiology Today Editorial Board Member and associate professor of medicine, tenured, in the division of cardiovascular medicine, advanced heart failure and transplant cardiology at Indiana University.
Milind Desai, MD, MBA, FACC, FAHA, FESC
In my opinion, the biggest overall story of 2022 has been the stunning success of SGLT2 inhibitors in multiple facets of CVD and type 2 diabetes, in terms of significant improvement in hard outcomes.
From a personal perspective, the biggest story has been the emergence of cardiac myosin inhibitors in obstructive hypertrophic cardiomyopathy. The demonstration of sustained long-term efficacy of mavacamten in EXPLORER-HCM and demonstration of significant reduction in need/eligibility of septal reduction therapy in the VALOR-HCM trial have essentially changed the management paradigm for these fairly complex patients. The very convincing scientific data resulted in the approval of mavacamten by the FDA in April, opening the door for many such scientific breakthroughs in the future.
Desai is director of the Hypertrophic Cardiomyopathy Center and director of clinical operations for the Cleveland Clinic Heart, Vascular and Thoracic Institute and professor of medicine at Cleveland Clinic Lerner College of Medicine.
Sharonne N. Hayes, MD, FACC, FAHA
Two developments come to mind this year, both of which directly affect my practice. One is the growing knowledge, refinement and expertise with minimally invasive valve procedures, whether it is transcatheter aortic valve replacement, transcatheter mitral valve repair or implantation of mitral and tricuspid valves. I have two subspecialized practices — a pericardial disease clinic and a women’s spontaneous coronary artery dissection clinic. The conversations I have with these patients now compared with a decade ago, when surgery was certainly in their future, have changed dramatically. Even for patients who are more functional, we have more options. These options are becoming mainstream.
The other is the paradigm-shifting evidence that came to the fore this year for SGLT2 inhibitors. Again, I reflect to when I was a resident when some of the first ACE inhibitor trials came out, and I remember faculty concerns about adverse effects. Now, ACE inhibitors are standard. HF is so prevalent, in my subspecialty and community practices, and I am watching not just cardiologists but family and internal medicine clinicians talking with their patients about SGLT2 inhibitors. Within a span of about 18 months, we have evidence that show cardiologists need to learn how to use them, and so do all of our colleagues in primary care. The question now is not “should I start them?” It is “how should I dose this?” or “When?”
Hayes is professor of cardiovascular medicine, former director of the Office of Diversity and Inclusion, and founder of the Women’s Heart Clinic at Mayo Clinic in Rochester, Minnesota.
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