Key clinical takeaways from ACC.26
The late-breaking clinical trials presented at ACC.26 in New Orleans highlighted advances that will likely impact patient care for years to come. Key topics included pulmonary embolism (PE), lipid management and noninvasive coronary assessment.
Hadley Wilson, MD, executive vice chair of Atrium Health's Sanger Heart and Vascular Institute and a former ACC president, shared his thoughts about the busy weekend in an exclusive interview with Cardiovascular Business.
One key study from ACC.26 was a randomized trial evaluating ultrasound-assisted, low-dose thrombolysis in intermediate-risk PE patients. The study demonstrated improved outcomes without increased bleeding compared to anticoagulation alone. This provides some of the first strong evidence in many years about the treatment of “gray zone” population.
In atrial fibrillation, the CHAMPION-AF trial showed that left atrial appendage occlusion (LAAO) using the Watchman FLX device in patients who do not have adverse bleeds from oral anticoagulants was noninferior to direct oral anticoagulants. Some experts interpreted this study as good news for clinicians considering LAAO in patients who do not want to take anticoagulant drugs. Other cardiology experts interpreted this as a negative trial, however, because LAAO did not show superiority over anticoagulation and is still associated with possible complications.
Wilson noted that several trials at ACC.26 focused on prevention and lipid management. For example, using the PCSK9 inhibitor evolocumab in patients who do not have any significant coronary atherosclerosis reduced cardiovascular events over time, possibly opening the door for using this drug for primary prevention in low-risk patients. Another important trial identified benefits to more aggressive LDL cholesterol level targets.
Advances in coronary imaging also drew attention, with two studies showing how angiography-derived fractional flow reserve (FFR) evaluations can match traditional wire-based measurements, potentially enabling faster, less invasive procedures in the future.
"If you want to say where is the future going, we probably will not have to be using these wires in the future. We now have coronary CT and we have the angiographic-derived models, so in several years, I would not be surprised if we no longer need a physiologic wire not determine our FFRs," Wilson explained.
One trial that was widely expected to be a possible paradigm shift in interventional cardiology was the STEMI DTU (door-to-unload) study, which fell short of gaining statistical significance. It looked at the novel concept of using an Impella heart pump to increase blood flow for 30 minutes before PCI. The trial did not demonstrate significant outcome improvements, but did show a signal in the data for smaller infarct size. It also showed Impella support can be given before PCI and time can be gained without increased damage to the heart.
"There were no difference in outcomes, there was not a reduction in heart infarct size. On the other hand, the fact that they were about to delay opening the arteries for more than 30 minutes and it did not impact infarct size suggests there might be a signal there for an advantage for unloading the heart. But further trials will be needed," Wilson explained.
The ORBITA-CTO trial confirmed that opening chronic total occlusions (CTOs) improves symptoms, but the study did not show it improved survival.
Also, intravascular ultrasound (IVUS) was not found to be helpful in two interventional trials, which showed angiography along led to better patient outcomes. Wilson said those findings were very unexpected.
One emerging therapy that shows promise is the drug sotatercept, which was found to improve outcomes in pulmonary hypertension patients.
Watch the video interview for more details about these trials.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]