AHA 2023
Self-monitoring and physician-optimized antihypertensive titration post-partum decreases BP during the first 9 months
Key Points:
- Up to 1 in 10 women experience a hypertensive disorder of pregnancy, which is associated with long-term cardiovascular disease. However there are no established interventions to reduce risk post-partum.
- The POP-HT study examined the impact of a targeted physician-optimized postnatal BP control regimen on long-term BP control and cardiac remodeling.
- Physician-Optimized post-partum BP control resulted in a significant reduction in both systolic and diastolic BP at 9 months, in addition to BP-related postnatal admissions and evidence of adverse cardiac remodeling on both cardiac MRI and echocardiogram.
Novel RNA interference therapeutic Zilebesiran results in dose-dependent sustained BP reduction
Key Points:
- Uncontrolled hypertension is a major public health concern, and this condition is often primarily driven by the renin-angiotensin (RAAS) pathway.
- A new RNA interference therapy, Zilebesiran, was developed to target to most upstream precursor of the RAAS pathway (angiotensinogen). This study was a Phase 2 study examining the safety and efficacy of zilebesiran.
- A single dose of subcutaneous zilebesiran resulted in sustained BP reduction with low rates of adverse events over 6 months.
VERVE-101, a novel DNA-base editing medication, results in dose-dependent reductions in blood PCSK9 and LDL-C
Key Points:
- Despite the advent of PCSK9 inhibitors, the majority of patients with familial hypercholesterolemia do not meet their LDL-C targets with standard therapies.
- VERVE-1 is a novel CRISPR base editing medication which was designed to inactivate hepatic PCKS9 with a single DNA base pair change, thus reducing LDL-C.
- In this study, the highest dose of VERVE-101 treatment resulted in a sustained >55% LDL-C reduction at 180 days. VERVE-101 was generally well tolerated, with mild infusion reactions at high doses and two observed severe adverse CV events which were attributed to underlying severe ASCVD.
A multi-level hypertension program improved hypertension control in Nigeria
Key Points:
- The global burden of hypertension is high and increasing, with high rates of underdiagnosis and undertreatment.
- This study implemented a multi-pronged implementation package of HTN treatment within the capital of Nigeria.
- Results showed significant improvement in BP control and successful uptake of the implementation package, specifically anti-HTN medication prescription.
- The investigators hope to scale up this intervention to all the major geopolitical regions within Nigeria.
IMPACTS: A multifaceted implementation significantly improved BP control among low-income patients
Key Points
- This cluster-randomized trial found that a multifaceted implementation strategy to target an SBP <120 among low-income patients cared for at FQHCs lead to a significant reduction in mean blood pressure and a significant increase in the proportion of patients who achieved an SBP <120 compared to usual care.
- This strategy could be applied widely to other practices caring for low-income patients experiencing health disparities.
SPEECH: Novel speech analysis technology may be useful for early recognition of worsening heart failure events
Key Points
- Novel speech processing technology has the potential to detect heart failure exacerbations before they happen, and may be better than the conventional weight monitoring approach.
- Additional studies are needed to explore the generalizability, practicality, efficacy, and effectiveness of the HearO model.
SUPER-LIPID: Non-visit based automated orders sent to central pharmacy increased appropriate statin prescriptions
Key Points
- In two simultaneous pragmatic trials, an asynchronous, non-visit based, automated order for statins placed to a centralized pharmacy significantly increased both overall statin and appropriate dose statin prescriptions, while an interruptive visit based EHR notification strategy had an overall smaller effect.
Recaticimab Effective as Add-On Therapy in Non-Familial Hypercholesterolaemia and Mixed Hyperlipidemia: REMAIN-2 Trial
Key Points
- Recaticimab effectiveness demonstrated dosage-dependent response indicating versatility in treatment options.
- Sustained reduction in LDL-C levels throughout the 48-week study period as well as favorable outcomes observed in additional lipid variables.
Dual Cardioversion More Effective than Single in Obese Patients with AF
Key Points:
- The prevalence of obesity, and AF is increasing substantially and are inextricably linked.
- Patients with obesity show less response to single-DCCV due to chest wall impedance
- This trial compared dual-DCCV to single-DCCV among patients with BMI ≥ 35 in ability to attain sinus rhythm in a patient refractory to initial DCCV
- Dual-DCCV showed significantly lower rates of failure compared to single-DCCV, suggesting its utility for AF refractory to DCCV in obese patients
AI -ECG Results in Faster and More Accurate Identification of STEMI
Key Points:
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- The use of an artificial intelligence electrocardiogram (AI-ECG) support tool in the evaluation of patient ECGs was associated with a reduction in the door to coronary angiography time (43.3 minutes vs. 52.3 minutes) in patients who presented with an ECG concerning for ST-elevation myocardial infarction (STEMI).
- The AI-ECG support tool has a high positive predictive value of 88.0 (81.8-94.1) and high negative predictive value of 99.9 (99.9-100.0).
- AI technology helped to reduce the treatment waiting time for patients with STEMI from about 52 minutes to 43 minutes.
Abelacimab, a novel Factor XI/XIa Inhibitor, reduced bleeding vs Rivaroxaban in AF
Key Points:
- Previous studies have investigated the use of direct oral anticoagulants (DOACs) instead of warfarin for reduction of stroke risk in AF, but the risk of clinically significant bleeding remains.
- Abelacimab is a novel Factor XI inhibitor that may be useful in reducing thromboembolic events while also being less likely to cause major bleeding.
- Patients were assigned to rivaroxaban 20 mg/ day or two different doses of abelacimab, 150mg SC monthly and 90mg SC monthly. The primary endpoint was major or clinically relevant non-major bleeding.
- The trial was stopped premature due to significant reduction in bleeding with 74% reduction in major bleeding and 93% reduction in GI bleeding on abelacimab 150mg SC versus rivaroxaban.
Coronary Inflammation on CCTA as Predictor of Cardiac Events: the ORFAN Study
Key Points:
- Out of all patients who undergo a CCTA, the highest number of cardiac events occurs in patients without obstructive CAD.
- In patients with non-obstructive CAD on CCTA, the use of a novel AI tool to quantify coronary inflammation results in accurate predictions of patients’ ten-year risk of cardiac mortality and MACE.
- In this study, patients with non-obstructive CAD on CCTA who have an inflammation score that is above the 75th percentile have an ~ 20 times higher risk of dying from a cardiac event over the next ten years.
- The AI risk model used in this study results in the reclassification of the risk profile of ~ 40% of patients and was found to lead to changes in clinical management in roughly half the patients.
ESPIRIT: Intensive blood pressure control lowers MACE vs Standard Treatment
Key Points
- This randomized trial of 11255 patients in China with established CVD or at least 2 CVD risk factors but without a significantly reduced ejection fraction or advanced kidney disease (mean age ~65 years, 100% Asian, baseline SBP 147, 39% with diabetes, 27 % with stroke) found that a blood pressure target of <120 led to a 12% reduction in major vascular events, 39% reduction in cardiovascular mortality, and 21% reduction in all-cause mortality compared to a blood pressure target of <140.
- This was the first major randomized trial to show benefit of aggressive blood pressure in those with prior stroke, diabetes, or Asian ancestry.
REPRIEVE Substudy: Pitavastatin reduces non-calcified coronary plaque in people with HIV
Key Points
- The REPRIEVE trial recently demonstrated that pitavastatin reduced major adverse cardiovascular events by 35% among individuals with HIV at low-moderate risk predicted risk for cardiovascular disease. However, little is known regarding the mechanism of benefit.
- The mechanistic sub-study of REPRIEVE enrolled 804 participants from the overall trial from 31 U.S. sites and randomized them to daily pitavastatin at a dose of 4mg or placebo.
- At 2 years follow-up, pitavastatin reduced non-calcified plaque volume by 7% relative to placebo and reduced the risk of plaque progression by 33%.
NOAH-AFNET 6: AHRE>24 hours associated with low stroke risk but more likely to develop AF later
Key Points
- This pre-specific subanalysis of NOAH-AFNET 6 found that those with long lasting atrial high rate episodes >24 hours were more likely to develop atrial fibrillation (AF); there was no significant interaction found between the duration of the longest AHRE and the efficacy and safety of oral anticoagulation.
ARTESIA: Apixaban reduces the risk of stroke in subclinical AF, with an increase in major non-fatal bleeding
Key Points
- This randomized trial of 4012 patients (median age ~77, mean CHA2DS2VASC ~4, ~65% male) with an implanted pacemaker, defibrillator, or cardiac monitor with subclinical atrial fibrillation (SCAF) found that apixaban significant reduced stroke and systemic embolism compared with aspirin.
- Major bleeding was higher in the anticoagulation group in both on treatment and intention to treat analyses, but rates of fatal bleeding and symptomatic intracranial hemorrhage were similar and numerically fewer in the apixaban arm.
Novel siRNA targeting therapy lepodisiran results in a dose-dependent and sustained reduction in Lipoprotein(a)
Key Points:
- There are currently no approved targeted therapies for the reduction of Lp(a).
- In this Phase I study, a novel siRNA therapy (lepodisiran) was tested in escalating doses and compared to placebo in 48 patients. Lp(a) concentrations and safety events were examined for 48 weeks.
- Single-dose lepodisiran administration resulted in up to 94% reduction in Lp(a) at 48 weeks and was generally well-tolerated, supporting further development of this therapy.
ARIES-HM3: Aspirin avoidance Is safe and reduces bleeding events in patients with HM3 LVAD on VKA
Key Points:
- Since the advent of novel HeartMate 3 LVAD technology with lower thrombotic risk, the clinical utility of continuing to add aspirin to the antithrombotic strategy has not been established.
- In the ARIES-HM3 study, an aspirin exclusion strategy (ie, Vitamin K antagonist [VKA] + placebo) was compared with the typical dual VKA/ASA therapy in patients with a HeartMate 3 LVAD. The primary endpoint was survival free of any non-surgical major hemocompatibility related adverse event one year post implant.
- Aspirin avoidance resulted in fewer bleeding events and hospitalizations for bleeding complications without any concurrent increase in thrombosis or mortality.
POCKET-COST-HF: Comprehensive Cost Disclosure improves cost-informed decision making
Key Points:
- Out-of-pocket costs for GDMT in HFrEF have risen substantially with the advent of novel effective therapies. However, there is limited information regarding the utility of comprehensive cost disclosure in informing patient and clinician decision-making regarding prescribing GDMT.
- The POCKET-COST-HF study was a stepped-wedge cluster randomized trial examining the utility of a tailored, comprehensive cost disclosure intervention on a primary endpoint of cost-informed decision-making, ascertained by transcription of audio recordings of a clinic visit for HF.
- Comprehensive cost disclosure resulted in a higher proportion of encounters in which cost of medication was discussed, with further studies needed to inform the potential impact on medication prescribing and implementation strategies.
Dietary sodium reduction significantly lowered BP in middle-aged to elderly adults
Key Points:
- Daily sodium intake remains high (on average ~3,500 mg/day), despite recommendations from the AHA and WHO to limit sodium intake to around 2,000 mg/day.
- Salt-sensitivity to BP (SSBP) is an emerging concept supporting the notion that both normotensive and hypertensive individuals can have BP responses to their dietary sodium concentration.
- The CARDIA-SSBP trial was a prospective, multicenter, randomized cross-over study that enrolled 228 participants to 1 week of either a high sodium diet (with up to 2,200 mg of sodium added/day) or a low sodium diet (with standardized meals containing 500 mg of sodium added/day), followed by another week crossing over to the other diet. At baseline and at the end of each week of diet, 24-hr ABPM and 24-hr urine collections were performed.
- The low-sodium diet resulted in a significant reduction in median SBP of 6 mm Hg, which was similar to the average effect that would be observed with 12.5 mg of hydrochlorothiazide. On the other hand, further increases in daily sodium intake did not result in any significant increase in BP in this cohort – most likely as the baseline diets were already saturated in sodium.
- In conclusion, these data support that clinically meaningful lowering of BP through dietary sodium reduction can be achieved safely and rapidly within 1 week, with a magnitude comparable with that of a common first-line antihypertensive medication.
