The 15th Century Dutch theologian Desiderius Erasmus references the Greek mythological figure, Sisyphus, who was condemned by the gods to spend eternity rolling a boulder up a mountain, at which point it would roll back down, and he would have to start again at the beginning of each day. While treating certain patient conditions may seem comparable to this type of insurmountable task, the fervor with which cardiologists are attempting to seek new treatments reveals a continuous dedication toward improved patient care and no brokenness of spirit to which Sisyphus is so oft tied. These efforts were on display this week at the American Heart Association (AHA) Scientific Sessions in Chicago through a multitude of well-designed clinical trials.
Patients with chronic heart failure (HF) are one such population, for which improved treatments are not readily presenting themselves. While the embattled nesiritide (Natrecor) was proven to be a safe therapy in patients with acute decompensated HF, the AHA late-breaking ASCEND-HF trial showed that nesiritide had little effect on dyspnea and no significant effect on hospital readmission or death rates for these patients.
Dr. Marriell Jessup, a heart failure specialist from the University of Pennsylvania, told Cardiovascular Business News that once the symptoms are recognized, practitioners immediately need to begin prescribing ACE inhibitors, beta-blockers and aldosterone antagonists. “However, for the management of chronic HF patients in the hospital, we really haven’t learned anything more. This is particularly depressing.”
However, data results proved more beneficial for patients with moderate or mild HF. In fact, the RAFT trial may result in an expansion of the indications for ICD plus CRT from just those patients with class III or IV HF to those patients with a lesser degree of HF. In the trial, adding CRT to an ICD reduced rates of death and hospitalization by 25 percent for patients with class II or III heart failure, a wide QRS complex and left ventricular systolic dysfunction.
However, for the 30 percent of patients who are non-responders to CRT, the SMART-AV trial did not show a better response in any of the three arms: fixed empiric atrioventricular (AV) delay, echocardiographic optimization of AV delay or AV delay optimization based on the SmartDelay algorithm (Boston Scientific). Principal investigator Dr. Kenneth A. Ellenbogen called the results “disappointing” because no clear path has been revealed on how to treat these patients.
Speaking of non-responders, the GRAVITAS trial failed to show benefit from a high-dose clopidogrel (Plavix) approach to treating post-PCI patients who do not respond to the drug due to high residual platelet reactivity. While the trial does not advocate for higher clopidogrel, former AHA president Dr. Raymond J. Gibbons told Cardiovascular Business News that the trial also will not spawn greater adoption of platelet reactivity testing in real-life clinical practice.
Despite these more challenging cases, incoming AHA President Dr. Ralph Sacco set forth a lofty goal in his presidential address: “It’s our 10-year goal to improve the cardiovascular health of all Americans by 20 percent by the year 2020, while reducing cardiovascular and stroke deaths by 20 percent.”
However, Erasmus wouldn't shy away from such lofty goals, as he describes the unique nature of those individuals striving for such feats: There are some people who live in a dream world, and there are some who face reality; and then there are those who turn one into the other.”
Please review our additional coverage from the 2010 AHA Scientific Sessions.
On these topics, and any others, please feel free to contact me.