Joint undertakings stand a better chance when they benefit both sides

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During one of the press conferences at the ACC conference, co-chair Edward J. McNulty, MD, of the University of California San Francisco and Kaiser Permanente in San Francisco, noted that many aspects of cardiovascular care are “just getting better,” including medical therapy, cardiac surgery and percutaneous interventions; therefore, it is becoming harder to show a statistically significant improvement for a single therapy – which ultimately is very good news for the cardiovascular patient.

As the Ancient Greek playwright Euripides suggests, when such a unique benefit is reached, it usually results from “joint undertakings,” which is now a major impetus within CV care – better relationships between interventionalists and surgeons, between cardiologists and PCPs and between physicians and their patients. The 60th American College of Cardiology annual conference demonstrated the benefits of these types of undertakings.

Case in point, the success of the of the potentially explosive new heart valve technique of transcatheter aortic valve implantations (TAVI) requires mutual decision making from surgeons and interventionalists – bridging a long-standing turf issue – to the benefit of inoperable or high risk patients with aortic stenosis.

At ACC.11, for the first time, researchers revealed that patient outcomes with TAVI when compared with the gold standard of aortic valve replacement are similar for high-risk patients, according to data from Cohort A of the PARTNER trial.

Also important, TAVI was found to be cost-effective for the inoperable patient cohort of PARTNER (Cohort B). With a projected life expectancy of approximately 1.9 years, TAVI patients compared with the non-surgical standard of care have an incremental cost-effectiveness ratio of about $50,200 for each additional year of life gained, or approximately $62,000 for each quality-adjusted life year gained.

Patients with left main disease have traditionally been considered too high risk for PCI. However, in the PRECOMBAT trial, PCI with a sirolimus-eluting stent was shown to be a viable option and demonstrated similar outcomes when compared with CABG for patients with unprotected left main coronary artery stenosis.

In surprising results, the RIVAL trial showed that radial access for PCI in patients with acute coronary syndromes (ACS) does not reduce death, heart attack, stroke or major bleeding compared with femoral access. While the radial access point showed benefits for STEMI patients and improvement in vascular complications, both arms showed very low rates of bleeding: 3.7 percent in the radial access group and 4 percent in the femoral access group—which is far below the U.S. average, despite only 3 percent of the patient population taking bivalirudin.
 
Also, the STICH trial showed that in heart failure patients with coronary artery disease, CABG can now be considered to reduce cardiovascular mortality and morbidity, as patients have similar outcomes to contemporary medical therapy. Prior to this trial, the role of CABG surgery in patients with coronary artery disease and heart failure had not been “clearly established,” said principal investigator Eric J. Velazquez, MD, director of the cardiac diagnostic unit and echocardiography laboratories at Duke University Medical Center in Durham, N.C.

Finally, drug-eluting stents continue to prove their worth, with improving safety outcomes. In fact, the new Resolute (Medtronic) stent achieved a low rate of clinical restenosis, while maintaining low rates of important safety events at 12 months in a U.S. patient population, even with a diabetic population of 34 percent, according to the RESOLUTE U.S. late-breaking clinical trial.

Of course, the quest for better therapies to treat patients suffering from a variety of cardiovascular disease states will never be completed, with such ardent participants. As Euripides recommended: Question everything. Learn something. Answer nothing.

On these topics, or any others, please feel free to contact me.

Justine Cadet
jcadet@cardiovascularbusiness.com
Executive Editor of Cardiovascular Business