– Hello, I’m Elliot Antman, President of the American
Heart association. We’re here in sunny San Diego at the 64th annual scientific sessions of the American College of Cardiology. This is the end of the meeting, so I’m so pleased to be joined by Dr. Eric Peterson, Dr. Clyde Yancy, and we’re going to talk about what we learned at this
very interesting meeting. So let’s start where the
whole meeting began, Eric, which was a comparative
effectiveness research trial, that was the PROMISE study. Could you put that in context for us? What was the purpose of the
study and what did they find? – I think this was great. It was run by the NHLBI, 10,000 patients looking at
two different strategies on diagnosing coronary disease, and their evaluation. I think it looked at it from
both the outcome’s perspective, but also the patient’s perspective, their exposure to radiation and then ultimately the economic sense. Overall, the trial showed that depending on which strategy you took, it came into sort of neutral differences in terms of outcomes, and truly some of the economic factors will in part help drive
these decisions downstream. – And no big difference in the cost of either strategy that I heard. Clyde, is this going to affect
the way you manage patients? – I think the beauty of
PROMISE is that it says, “whatever you do well in your shop, “continue to do this.” You don’t have to feel as if you’ve got to create a new
technology or get a new skillset. If you do it well, then you can continue to diagnose coronary disease
just as you’ve already done. – One of the things that we wrote into the guidelines way back when we didn’t have the kind of
information like PROMISE provides was whatever’s really
best at your institution, that’s the one you can rely on, because that’s the information that’s going to help you the most for caring for your individual patient. – The other thing I think we
haven’t yet seen from PROMISE, it’s still early, the results just came in before the meetings, but there’ll be interesting
subgroup analyses. I think, depending on
the pretest likelihood for disease, for example, there may be variant strategies that will end up turning out
to be superior or inferior. – I would really like to see more cold, hard data from PROMISE, understanding issues about
sex, gender, race, ethnicity, that would be very good. – 50% women enrollment? – Isn’t that great? – [Eric] That’s great, yeah.
– That’s good. Now Clyde, there were
lots of reports about ways that we might be managing patients with chronic ischemic heart disease, perhaps differently in the future. Long term dual antiplatelet therapy, and some novel ways to actually dramatically lower cholesterol. What did you hear that excited you? – So part of what I heard
that really got me going was a validation of what I think are the most provocative
results from the DAP study. The fact that about half of
the vents that were prevented were essentially de novo coronary lesions that had nothing to do with previously intervened-upon targets, and so the idea that we saw this again with dual antiplatelet therapy and chronic ischemic heart disease tells me that you know what? It’s reasonable as a practitioner to keep patients protected for as long as it’s safe and feasible so that was a really good
take-home message from that– – So long-term dual antiplatelet therapy– – Makes sense to me now
– [Elliot] Made sense to you, now how about PCSK9 inhibition, dramatic lowerings of cholesterol, where do you see that at this point? – This is one of those things where you really have to
temper your enthusiasm. All of us have been in
the business long enough that we recognize the necessity to wait, and to wait and to wait, but there’s a part of us that says, “Is this the dawn of a new
generation of interventions?” The drop in LDO, so profound, 60% drop, LDLs down in the 40s, even down to 25, and what really got to me is that if you looked at
OSLA one and OSLA two, and then read the ODYSSEY
long-term results, put everything together that
dealt on cardiovascular events, none of these trails were a
priority sign to look at events but the Delta was about
a 50% or more reduction. – That’s pretty dramatic, and Eric, a lot of this also involves
some regression techniques to look at reduction in LDL and projection to what we think the reduction in events is likely to be. Very dramatically reduced ranges. – I think you’re absolutely right. These PCSK9 inhibitors are exciting, predominantly just because of how much they can lower cholesterol, but to see if that will
translate into patient outcomes, getting those first hints
was remarkably positive. I think you’re absolutely
getting at the right point. It’s going to create a
need for the guidelines to reconsider the idea, is it better to go progressively lower? As we get more and more choices and agents to do that, some of them being confirmed
in large outcome studies, that’s going to be exciting times for management of patients. – So we began our discussion about comparison of imaging, and then we talked
about some therapeutics, but we’ve got devices to talk about here. That’s some interesting
information there as well. Of course we heard some long
term follow-up about Taver, not actually reported at this meeting but mentioned from the FDA was their approval of the Watchman device for atrial fibrillation, and then there was the information about the mitral clip registry, so let me ask you what you heard of the mitral clip registry. What did you learn there? – So, as someone who’s
been reasonably circumspect about intervening up on
the mitral valve disease, because particularly for functional MR, I’ve always thought that’s
a ventricular disease, but it looks like one,
it can be done safely, only about a 7% real adverse event rate, that’s not trivial but in
an older patient population, that’s really important. Same day discharge, again in an older patient population, that’s pretty important as well. At least from an imaging standpoint, there was a reduction
in mitral regurgitation. How that translates into clinical
outcomes, I’m not certain, but at least it looks
like in skilled hands, and that was the other thing we learned, and experience sensors. This can be done, we need to be careful about patient selection, and
be diligent about followup, but as a heart filler person, I’m reasonably optimistic, maybe that’s too strong of a word, I’m reasonably curious about the next development of these things. – So actually, I’d agree with that. I think that the exciting
thing is we’re getting trials, actually testing these
things out first-hand, which is really good. The evidence is coming out
around the device itself and more importantly as we look into both short and long term outcomes following these out to
make sure it’s durable. Then the final part, which
is probably most important, which you get at the
difference between centers, is it really appears that being able to track these in registries will allow us to know whether or not specialized centers get better results, whether this is being able to translate into community practice in
a safe and effective manner. – So think about writing
guidelines in the future. We can actually be very specific about how this should be done. – I think you must feel very proud because you’ve been such a leader about the important of
introducing registries and our evidence base and this is just a dramatic example of the benefit of actually doing it right so this has been a very
interesting meeting, lots of information and you can find them AHA science news. This is Elliot Antman with Clyde Yance and Eric Peterson from sunny San Diego, 64th annual scientific sessions of the American College of Cardiology. Thank you for listening.