(dramatic music)
- Welcome, we're here to discuss some
of the late breaking clinical science
that was presented today at the
American Heart Association's
scientific sessions.
I'm Kristin Newby, a cardiologist
from Durham North Carolina.
- Hi, I'm Eldrin Lewis a cardiologist
specializing in heart failure
at Brigham and Women's Hospital in Boston.
- Hi, I'm Jose Joglar I'm a cardiology
specializing in arrhythmias for
UT Southwestern Medical
Center, in Dallas, Texas.
- So, an interesting day in the
late breaking clinical science.
I really thought that the heart failure
session was fascinating, Eldrin,
maybe you can start us off by saying
a little bit about Pioneer-HF.
- Absolutely, I was really
impressed by Pioneer.
We know from Paradigm-HF
that these patients
who have chronic heart
failure with predominately
class two and three heart failure
have a significant benefit with the ARNI,
but one of the residual
concerns and questions was,
you know there was a run in period.
So what happens if they're sicker
and if they're in the hospital?
And is it safe to actually start it?
So, in Pioneer, they actually look at
about 800 patients where the patients
were acutely decompensated,
they were stabilized,
and then randomized to an ARNI,
which is a Sacubitril/Valsartan
versus Enalapril, and followed.
And in fact, the primary outcome
was just looking at N-terminal pro-BNP.
And there was a significant decline
in N-terminal pro-BNP compared to
the Enalapril, even though both declined
However, the secondary outcome
measures were met as well.
You know, including the combination
of MACE and cardiovascular death.
- So, it sounds like,
you know, a huge advance
potential, for us in practice,
Jose what do you think?
- Yeah, that's right, one thing is
this drug, the ARNI,
has been only approved
by my institution to be used
as an outpatient, for example.
Nobody considered to be
giving it as an inpatient,
and also the possibility in the future,
it will replace, as a first alternative,
it will replace the ACE inhibitor,
or the IRB potentially, it's
a possibility, in the future.
What do you think about that?
- I agree.
- And save us all the problem of
having to think about conversion
in the outpatient setting.
- [Eldrin] That's right, exactly.
- So we're more likely to use it,
and actually reap the benefits of it.
- [Eldrin] Yes.
- So on the flip side,
another interesting trial
in that session was what to do with
people who have recovered
left ventricular function,
and do they need to stay on their
medications the entire time?
Jose, tell us about-
- Exactly.
- Tred-HF
- Right, exactly, and
the issue, like you said,
we never know what happens in the
patients who recover, the heart is better,
that we stop these
medication, we call them
guideline-directed medical
therapy for heart failure,
including Beta blockers, ACE inhibitors,
do we, are we able to stop them,
if we are, when that is, and heart failure
tells us that we should
not be doing that because
it's potentially dangerous
and harmful to the patient.
- Right, and I agree.
It's amazing how many people recover
and we define recovery as kind of
New York Heart Association class one,
with an ejection fraction that
has gone above 50 percent,
and patients always say,
can I stop taking these meds?
And now, based upon
Tred-HF, I have to say no.
You know, it was actually a small study,
but powerful in that 40 percent
of the patients actually had declinations.
They failed the wean, and they define
failure as a drop in
your ejection fraction
by 10 percent, and a
variety of other parameters.
It was well done.
But the scary thing is,
three of those 20 patients
who actually had a drop in
their ejection fraction,
didn't recover by the end of the trial
by re-instituting the therapy.
And this is consistent
with the epidemiology.
So I think based upon Tred-HF,
I think we have to tread very lightly
when we have to consider weaning,
and I think in the majority of patients,
we say that you're in
remission, but you're not cured.
- So two trials, very
impactful, to how we practice.
So, let's turn to another one,
and that's the intersection between
diabetes and cardiovascular disease.
And we've seen a couple of studies
this session, one today
Empa-Heart failure.
Looking at the SGLT2 inhibitors,
in this case, more of a mechanistic study,
and what did we learn
from Empa-Heart failure?
- I think Empa-Heart,
you know there's been
so much excitement with SGLT2 inhibitors
because of the three trials
that preceded this trial.
And Empa-Heart, we saw a heart failure
signal, in all three trials, and the
question is what is the mechanism?
So Empa-Heart actually looked at LV mass
as the surrogate outcome measure.
And in fact, patients
who were randomized to
empagliflozin in comparison to placebo,
all with patients who were enriched
to cardiovascular disease, had a
significant reduction in LV mass.
And it was not trivial, and it
was in a very short time period.
So the interesting this
is if this is a link,
you know historically, if we see
a reduction in LV mass,
it usually translates
into a reduction in heart failure events,
and subsequent mortality
in hypertension trials.
And if you look at the regression,
of LV mass and compare it to what you
see with hypertension, it is actually
much greater than you see
with typical hypertension.
The one thing that was
interesting, though,
is there was a difference
in systolic blood pressure
of about seven milometers of mercury.
So, one of the interesting things
that I'd look forward to seeing
is whether or not you adjust for
reduction in blood
pressure, and see if you
have an independent affect on LV mass.
Independent of the reduction
in systolic blood pressure.
- Interesting, so Jose, how do we get
cardiologist and
diabetologists on the same page
about these new drugs and how we use them?
- That's right, and that's an important
consideration now that
these SGLT2 inhibitors
are showing improvements
in cardiovascular outcomes,
they're becoming sort of
a diabetes drug to be used
by the cardiologists in general.
To improve the outcome of our patients,
second study today showed improvements
in heart failure hospitalizations
from one of these agents.
So really, that's a debate
we have in our institution
and elsewhere, who is
going to be owning the
prescription of these agents, because
again, these are diabetic drugs,
but they improve cardiovascular outcomes.
- And you know, Kristin and I,
remember there was also a very
interesting study called
the neuro protect study,
remind me, what was that about?
- Yes, the neuro protect
study was interesting
and it's trying to get into this space of
how do we do a better job with
neurologic recovery after cardiac arrest.
And in this case what they were looking at
was management of blood pressure,
in the post arrest period,
and not targeting kind of,
the typical map of 65, but let's move the
blood pressure up into the 85 to 100
mean arterial pressure,
using pressors, inotropes,
whatever we have to do to do that.
And what they saw was that doing that
using transcranial doppler
improved blood flow,
oxygen saturations stayed higher,
they avoided kind of this reflex dip,
in oxygen saturation
that occurs after arrest.
What they couldn't clearly show
was long term neurologic improvement,
meaning at six months,
using the CPC score.
At 30 days there was a
trend towards improvement.
So I think what it tells us is
mechanistically there are things
we can do to improve cerebral profusion,
to improve oxygen delivery to the brain,
what we still don't know yet is
does it improve neurologic recovery?
And that's probably going to mean
another large scale
trial, to determine that.
So, Jose, anything that kind of caught
your eye that you want to throw out?
- Well, I'm glad to report that today
we presented the 2018 new guidelines
for the management of bradycardia,
and conduction system disease,
and I'm proud to say that compared to
the prior guidelines, these new guidelines
are more patient centric, meaning that
instead of being a guideline about
devices, or about therapies, these
are guidelines about patients.
Where we make recommendations through
the entire patient experience,
from diagnosis to interventions.
And there is a great focus on shared
decision making, for example.
And making sure that the patient
is the center of care,
not the intervention.
- Yeah, wonderful.
And then there was this
interesting trial called REGROUP,
looking at endovascular vein harvest for
bypass surgery versus open vein harvest.
Triggered by an observational report
by another study that showed actually
worse outcomes with endovascular harvest.
- That's right, and that's why it's
important that we do randomized trial,
because sometimes observational studies,
can give you pitfalls, right?
So in these, this is a trial
done, via medical center,
multi-center study,
randomized perspective,
which is very important,
and showed actually,
no difference in outcomes,
whether the vein was harvested
as a percutaneous approach,
or an open approach.
And very important that the difference,
was not there, there was no harm,
because the patients prefer
the percutaneous approach.
It's better for patient satisfaction and
comfort and post-operative care.
- Perfect, kind of tying together
our patient centered, our
patient centered focus.
So we hope this has been a helpful recap
of the hot science from today at the AHA.
On behalf of my colleagues, thank you
all for your attention.
- Thank you
- Thank you
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