ACC.15: Do less testing & DAPT’s OK among trial takeaways

SAN DIEGO—Jeffrey Cavendish, MD, of Kaiser Permanente in San Diego, shared his impressions of the first day of the American College of Cardiology’s (ACC) scientific session with Cardiovascular Business. His highlights touch on three Ps: prevention, PROMISE and PEGASUS.

The interview has been edited for brevity.

CVB: What stood out for you today?

JC: The overall theme has been to promote great quality care, and cardiologists lead the way. Prevention is a key component in cardiology that sometimes gets a little overshadowed by the big trials and flashy technologies and imaging modalities. There is a definite theme of preventive cardiology.

Dr. O’Gara [Patrick O’Gara, MD, president of the ACC] has been a huge proponent of high-quality education and has been pushing the envelope so that education is meaningful and we will take the education back to our practices. We see changes in how lectures are given, trying to be more interactive.

CVB: What did you think about the late-breakers?

JC: For the PROMISE trial, with over 10,000 patients, the primary endpoint occurred in only 3 percent of patients. Either arm was fairly equal in terms of those endpoints occurring. There was a very low incidence of a significant outcome; three out of 100 patients in that population had an event.

For me, it begs the question: What are we doing with all this testing? Do we really need to do a CT scan or a stress test at all? In the practice I have seen over the years and in our practice as well, we do a lot of stress testing and I think it is over-utilized. We over-utilize it, and I know it is over-utilized in the country, whether it is defensive medicine or fear of making a firm decision based on talking to the patient and doing an exam.

This study validates that these patients might not need any [testing] done. We could do a better job at fine-tuning stress tests and CT ordering in the patients who we see.

CVB: What did you think of PEGASUS?

JC: PEGASUS was very interesting. In these prior MI patients, the likelihood of them having another heart attack is very high; inhibiting the platelets is important. The DAPT study showed that prolonged dual antiplatelet therapy was not harmful overall and could provide a benefit. The PEGASUS study continued that theme: that in this higher-risk population of patients, prolonging dual antiplatelet therapy can protect patients from heart attacks and strokes—but with some risk.

The risk of bleeding was not inconsequential. And the side effects, the dyspnea that patients might get with ticagrelor, can be bothersome for them. Not a lot of [trial] patients stopped ticagrelor because of side effects but in a real-world setting, patients will be very bothered by feeling that dyspnea.

It validates that we can continue to do dual antiplatelet therapy but also safely tailor the therapy to individual patients.

CVB: Did either of these trials change how you will practice?

JC: No on PEGASUS. I would continue what I have been doing; it just validates what I feel is good care of individual patients. If I thought someone needed prolonged dual antiplatelet therapy because he or she was higher risk, I would continue that. If the patient wanted to stop the dual antiplatelet therapy, I would have a conversation with him or her.

PROMISE will make me further push our organization to decrease the stress testing we are doing. When we see this population of patients, we don’t need to be ordering all these tests. I think this will be a huge savings.