News and Views from ACC 2015

News and Views from ACC 2015

The American College of Cardiology (ACC) meeting was in San Diego from March 14 to March 16, 2015. Our journalists and contributors blogged live from the conference floor, providing top-line results of the major studies and tidbits from the conference sessions.

Scroll through the blog below to see how the meeting unfolded. Full coverage of the meeting found on our ACC conference page.
    Antonio Columbo - update on bifurcation tips and tricks
    1. If side branch disease is more than 5 mm beyond the ostium don't treat it as bifurcation - put in 2 stents
    2. For sidebranch rewiring avoid hydrophillic wire for recrossing
    3. DK-crush is preferred to culotte because yoou dont have to give up the parent wire
    4. Almost always do post dilation and finish with IVUS with goal of > 7 mm2 final CSA
    5. When crossing to 2 stent strategy from provisional approach use TAP: T and protrusion
    6. In planned 2 stent technique use DK Crush or culotte
    7. Ostial diagonal lesions are particularly challenging - use medical therapy until the patient matures the LAD lesion. The hazard of ostial diagonal lesion treatment alone is significant for LAD compromise. Less is more.
    Dr. Jung-Min Ahn from South Korea presented the 5-year follow up results from the Pre-COMBAT study. These were Unprotected left main patients comparing PCI to standard surgery. At 1 year, PCI was non-inferior. After two years, ischemic TVR rates were higher in the PCI group at 9% vs. 4.2%. 5-year follow up data demonstrated that only 70% of PCI patients were still on standard anti- platelet therapy. Though the rate of MACCE as well as the rate of death, MI or stroke was not significantly different between patients assigned to PCI with a CYPHER stent compared to those who underwent CABG, there was an increased incidence of ischemia driven TVR of 17% in those with Left Main and 3v vessel disease who underwent a PCI vs. 4% in those who underwent CABG. An audience question: Would newer stent platforms have preformed better? My question: Especially in CYPHER patients if more than 70% had remained on standard anti-platelet therapy, would that have significantly impacted outcomes?
    Commenting on the GARY Registry, the LARGE high-risk all-comer population of German cohorts of 15,964 TAVR patients Dr. Thomas Walther presented outcomes of a severe vital complication rate plus cross-over rates remaining at 4%, stable sternotomy requirements of 1.2% and decreasing complication rates over the years. At the conclusion of his presentation, he was asked, “Do you plan to go on recording every single procedure?” He replied, “We can’t go on forever capturing every single procedure. It costs some money”. He later added, “We need some more time for valve durability studies”, so I guess that really is a “yes”.
    Tips for crossing uncrosable lesions by Emmanouil Brilakis
    1.  Make sure wire is in distal main vessel before starting 
    2.  Modify the lesion with 1.25 mm balloon - inflate it until the balloon ruptures =  "grenadoplasty" - this can modify the lesion and permit crossing
    3.  Use a Tornus catheter or Corsair or Fine Cross or Turnpike or Threader to cross
    4.  Use the wire cutting technique (basically inflating with a buddy wire)
    5.  Improve guide support: better guide, e.g. AL1, and upsize to 8 F.  Consider support with Guideliner, Guideliner Navigator  or Guidezilla.  Can also use sidebranch anchor or a distal anchor inflated balloon that will allow the guide to support delivery
    6.  modify the lesion with laser or atherectomy (orbital or rotatonal)
    7.  Use shorter stents or balloons
    The DAPT data was described today by a commenter as “An amazing study not likely to be duplicated”. This study randomized 11K ACS and non-ACS patients post PCI remaining on thienopyridine therapy for 12 months to now 18 months. While ACS patients had greater risks for ischemic events, the treatment benefit of continuing thienopyridine therapy was beneficial for both and bleeding risks were similar. When Dr. Robert Yeh, the presenter of the DAPT data was asked ‘what is the future?’, he replied, “We have an NIH grant to develop clinical tools to identify a population of patients in whom it’s exceedingly necessary to continue therapy. He also pointed out that the majority who developed adverse events were due to repeat revascularization, oddly enough, not bleeding. There was a numerical imbalance as well with cancer rates that was explained by a cancer diagnosis at the time of randomization.
    BEST trial of teh ABbot Xience DES vs CABG in multivessel CAD, showed that MACE was higher with PCI 17% vs. 12% CABG at 5 yrs, mostly driven by revascuaization with no signifiant digffenece in death (but trends against PCI.

    >CABG still "best" for MVD esp daibetes
    Additional commentary from Dr. Rajeev Pathak from the LEGACY trial, "Sustained weight loss is associated with a 'dose-dependent' reduction in AFib and maintenance of sinus rhythm". Interesting that we feel compelled to couch the impact of life style changes on outcomes with pharmaceutical vernacular in order to make practitioners better relate to the results. Gets the point across though!
    Just heard a wonderful quote about the LEGACY trial: "Next time I see my fat AF patients I'm putting them on a weight-loss program."
    This morning I'm covering a 2x2 trial: MATRIX. The first is looking at radial vs femoral access PCI in patients with ACS. The other half of that trial will be examining different antithrombotic regimens used during PCI. I have to say, I love covering radial vs femoral access trials. Last year, Dr. Sanjit Jolly took me down to his cath lab at Hamilton General Hospital and I got to see him do a few radial PCIs. It was very cool. Dr. Jolly is a big proponent of the benefits of radial-access PCI, particularly improved mobility and reduced bleeding.
    MATRIX: Transradial Versus Transfemoral Access In Patients With Acute Coronary Syndromes Undergoing Invasive Management
    MATRIX: Bivalirudin Infusion Compared To Unfractionated Heparin In Patients With Acute Coronary Syndromes Undergoing Invasive Management
    We can't stop quoting quotes that Dr. Pathak used to describe his Legacy Data: "It's never too late to be what you should have been before" , on the impact of obesity on atrial fibrillation and the impact of weight loss and weight gain on recurrence.

    ulnar sketch

    @DrSethdb with Dr R K Gokhroo

    One of the only indispensable reasons for going to meetings is having a chance to discuss best practices and procedures with thought leaders. (Can't get that from remote access or web based learning)  I missed a presentation on ulnar artery catheterization and PCI but because Mellissa Walton-Shirley reported on it here I was moved to reach out to the author of the paper on ulnar access Dr R K Gokhroo (made possible through he ACC.2015 app) who graciously agreed to meet with me.
    I have been a radial first operator for 7 years but have had little experience with ulnar approach

    his tips:
    1. hyperextension of the wrist straightens the ulnar
    2. stick the ulnar more distally than we normally stick the  between 2 creases that are transverse across the distal wrist
    3. palpation alone is adequate - no ultrasound needed
    4. as you move more proximally along the palpable ulnar artery the tendon may need to be laterally reflected or displaced to access the ulnar which is significantly deeper
    5.  More proximally the vessel is difficult to compress and has higher issues with gaining hemostasis
    6.  Infiltrate with 1 -2 ml of lidocaine - important to give it on the radial side of the ulnar artery to avoid infiltration near the ulnar nerve
    6.  wire access and sheath placement require the same caution and approach as the radial sheath
    7.  Less spasm with ulnar - he use Diltiazem 2.5 mg, Nitroglycerin 50 mcg and Lidocaine 2% 2 ml (without preservative) as his cocktail.  The total of 4 cc diluted with 4 cc of saline and then given rapidly through sheath.
    8.  Ulnar loops are less frequent (he has seen 2 cases of 1500) and they can be often managed by palpation and physically straightening of the loop in the antecubitum
    9.  Ulnar occlusion rates are similar to radial occlusion are around 3%
    10. He does not use a compressive band - he uses a tightly bound rolled gauze - he does this in part because of cost.  It is then supported by a  dynaplast dressing.  He uses  3 overlapping 1 inch bands placed by the assisted while he maintains hemostasis manually. - he does not incrementally reduce pressure - he does not have any experience with TR band.

    K M of stroke in thrombectomy patients

    MACE of thrombectomy treated patients

    TOTAL trial of routine thrombectomy conclusions

    TOTAL 
    routine thrombectomy is not beneficial and increases stroke when patients with STEMI are treated with primary PCI
    one of the many things in CV medicine that make excellent sense but FAILS!!
    Add this to FIsh Oil, hormone replacement therapy, glucose - insulins - potassium and PVC suppression to the list of great ideas that were casualties of good RCT that demonstrated limited or no benefit and increased hazard that was not anticipated
    we should stop

    DANAMI 3 results

    DANAMI3 PRIMULTI trial
    This trial continued the effort to clarify an uncertain but very important question
    Should we fix stenoses other than the culprit lesion when the patient has a primary PCI
    The difference here is that the patient had guidance with FFR for deciding about proceeding non culprit PCI.  This is an objective criteria not done in the prior studies.
    With complete revascularization (rather than culprit only) PCI there was a significant benefit with MACE = 22% v 13% ARR = 9  NNT = 11.  In patients who had culprit only revascularization 40% of the revascularizations were urgent.
    The ABIM Choosing Wisely initiative has recently dropped there prohibition against non culprit PCI which is good.  It seems like the ABIM is making allot of mistakes in the last year but as least they are not intransigent

    Here is my fast and short summary of the most important trial to come out of ACC-- LEGACY
    1 Sustained weight lost associated with a dose-dependent reduction in AF burden.
    2 Patients with long-term weight loss were six-times more likely to be free of AF.
    3. Nearly half (46%) of overweight patients who lost 10% of their body weight were AF-free without drugs or ablation.
    4 Weight loss also benefited patients who were treated with medications and/or ablation.
    5. Patients with linear (gradual and steady) weight loss did better than those whose weight fluctuated, which offset some of the gains.
    6 Participation in a separate goal-directed, physician-led weight loss clinic increased the odds of durable weight loss and decreased the likelihood of weight fluctuation.
    7 Weight loss induced favorable structural remodeling. LA volume and CRP levels were lower in the >10% weight loss group.
    8. Durable weight also resulted in marked improvement in blood pressure—with less medication.
    9 Weight loss lowered the number of patients with HbA1c>7, decreased insulin levels, and lowered LDL..
    One word: Wow.
    Dr Steven Wiviott @swiviott of @BrighamWomens Use and abuse of stress tests at #ACC15
    take homes
    1. Bayes Theorem of preprocedure likelihood is critical to thinking about stress testing
    2. Once a stress test is done if low risk but equivocal more hazard results are then challenging going forward: reassurance? , planning additional testing? hazards of additional testing?
    3. AUC in 2013 - outlined that many low risk patients are rarely appropriate - many patients get cath and PCI but only the appropriate cases have an impact on reducing MACE
    4. Utilization is increasing despite the AUC and Choosing Wisely initiative efforts which has a huge cost and radiation exposure risk

    Appropriate Use Stress Testing 1

    Appropriate Use 2

    AUC stress test 3



    I have been on Twitter for years and have never had a Tweet retweeted as much as the above picture. As of this note, it had been RTed 151 times.

    I said it was heresy at a cardiology meeting to…stop statins, stop anticoagulants, reduce blood pressure meds and ignore guidelines.  It’s not, really.

    Here is the story of that picture.

    The slide belongs to Staci Mandrola. She showed it during her talk on palliative care for the cardiologist.

    Her point on reducing pill burden is important. Staci told the audience that medicines that once conferred benefit can become a burden. That’s because things change over time—mostly, things get worse with age. (Humans are not like wine.)

    Guidelines may have directed us to use these drugs when patients were younger and healthier. But guidelines are drawn from RCTs that did not include older patients with multiple morbidities. 

    If we do as Dr. Staci and Dr. Verghese suggest—see the person in front of us as a whole person, not a series of organ systems--we would have no trouble with the act of deprescribing. It would be normal to remove burdensome treatments. It is, in fact, our duty to do no harm.

    The Cardiology Show ACC 2015 Participants

    We will be liveblogging from the ACC in San Diego, providing top-line results of the major studies, tidbits from the conference sessions, and more. Full coverage of the congress can be found on our ACC collection page
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