Tracking major trends and clinical research in acute coronary syndrome care

Bhatt cited a randomized trial and a meta-analysis he co-authored, which found no increase in adverse events for non-fasting patients—and significantly improved patient satisfaction. Fasting has been used for years because of concerns about aspiration of food if the patient needs to be intubated. But Bhatt points out that STEMI patients are treated all the time who have not fasted without complications, so it may not make sense to continue the practice with elective, less acute patients.

"I think the benefits outweigh the risk. And I don't mean just the benefits in terms of patient satisfaction ... Beyond that, I think of some of what we're doing with the fasting in diabetic patients. Does that mean now we should hold their insulin or cut it in half? What about their other diabetes drugs? It creates all these other things that happen that I think just create more chaos than is necessary," Bhatt explained.

New understanding of antithrombotic therapy stacking

Bhatt also touched on the evolving understanding of antithrombotic therapy. In patients with atrial fibrillation and stable coronary artery disease, he highlighted data showing no ischemic benefit, but increased bleeding, when aspirin was added to oral anticoagulants.

"There are trials that have shown when you do this, you increase bleeding predictably, but you don't seem to reduce ischemic for thromboembolic events by stacking therapy, Bhatt explained. "The U.S. still often stacks antithrombotics, but the evidence is telling us to reconsider that approach."

Shortening antiplatelet therapy duration post-PCI

Similarly, Bhatt reviewed several trials on the duration of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI). He reviewed data from ALT-DAPT ACS study and a new meta-analysis. While shorter durations, some as brief as one month, appear safe for some patients, especially those at high-bleeding risk, he emphasized the need for individualized treatment plans.

"There doesn't ever seem to be resolution on this topic," Bhatt said. "But probably you can get away with a month, though three months of DAPT looked maybe a little bit better."

A new late-breaking short DAPT trial was presented at ACC.25, HOST-BR RCT, which showed three months is the "sweet spot" in terms of duration of DAPT, Bhatt said. But, he added, the evidence seems to be a moving target.

"Every meeting, there's another trial on this topic that comes out. So I stick with my typical answer that you've got to individualize therapy," Bhatt explained.

Mixed results in ACS mechanical support trials

Mechanical circulatory support was another area of focus. Bhatt noted mixed findings in recent trials. While extracorporeal membrane oxygenation (ECMO) showed no benefit in a randomized trial, the DanGer Shock trial suggested potential mortality benefit with axial mechanical support devices like Impella, albeit with increased bleeding and vascular complications.

Inflammation drug does not se benefit in ACS patients

Inflammation in ACS remains a hot area of research, and Bhatt served as chair of the Data and Safety Monitoring Board for the CLEAR-SYNERGY trial, the largest colchicine trial to date. When presented at the Transcatheter Cardiovascular Therapeutics (TCT) 2024 meeting last fall, it surprised many when colchicine showed no cardiovascular benefit post-PCI, despite reducing inflammation markers.

"That was a bit of a shock to some people because other trials had shown a benefit for colchicine. But in this well-done largest of the colchicine trials, there was no benefit despite there being a reduction in C-reactive protein (CRP). So it was a little bit counterintuitive. I don't know how to correlate that with all the other colchicine data, but for sure in the acute ACS patient undergoing primary PCI, there is no role of colchicine," Bhatt explained.

He pointed to the ongoing ARTEMIS trial, which is investigating IL-6 inhibition in ACS patients, as one to watch.

SGLT Inhibitors & ACS

Although SGLT2 inhibitors have transformed treatment for heart failure and diabetes, Bhatt was cautious about their utility in ACS without other indications. Data from the DAPA-MI and EMPACT-MI trials showed no myocardial infarction (MI) reduction. However, he highlighted sotagliflozin, an SGLT1/2 inhibitor, which demonstrated reduced rates of MI and stroke in non-ACS populations.

"Unlike the other SGLT2 inhibitors, there was a clear reduction in MI, and definitely unlike the other SGLT2 inhibitors, a reduction in stroke that was significant. So maybe it could have a role in ACS, but that trial would have to be conducted," Bhatt said.

Managing the ACS patient from acute to chronic care

Finally, Bhatt emphasized the importance of transitioning ACS patients into long-term management. He praised European guidelines for chronic coronary syndrome and pointed to the SECURE trial, where a cardiovascular polypill improved medication adherence and outcomes post-MI.

"It is so important to think about long-term therapy, lifestyle therapy, lifestyle modification, diet and exercise, weight control, emphasizing with patients the education for that, keeping that at our forefront and adherence to medical therapy," Bhatt said. He added that a polypill with multiple medications could greatly simplify medication management and patient adherence.