More questions than answers

The recently held American College of Cardiology (ACC) scientific session was flush with insights on cardiovascular disease, treatments, practice management and professional development. Several topics showed we still have many gaps in knowledge and understanding, though.

Two areas in particular stood out: renal denervation and cholesterol control. The late-breaking clinical trials included results from SYMPLICITY HTN-3, whose sponsor already announced had failed to meet its efficacy endpoint. Questions still swirl, but trial design can probably now be ruled out. It was a rigorous randomized sham-controlled trial.

Numerous observers made a point that the field lacks a reliable method to ascertain that denervation occurred. Some suggested operator inexperience could be a factor, although the interventionalists in the trial were among the best operators in the U.S. and the procedures were proctored. Previous trials have reported significant decreases in blood pressure readings in patients with uncontrolled hypertension treated with renal denervation; procedural differences may account for some of the discrepancy.

Results from a global registry, also presented at ACC.14, favored renal denervation. Lead investigator Michael Böhm, MD, PhD, University of Saarland in Homburg, Germany, suggested subpopulation differences may be worth exploring. Medtronic, sponsor of both studies, indicated it would fund another trial based on positive signals in its own subgroup analyses.

Deepak L. Bhatt, MD, MPH, SYMPLICITY HTN-3 lead investigator and an interventional cardiologist at Brigham and Women’s Hospital Heart and Vascular Center in Boston, told Cardiovascular Business that both presentations offered top-line findings. More analyses will follow.

Preventive guidelines published in 2013 by the American Heart Association and the ACC to reduce the risk of atherosclerotic disease in the U.S. remain a hot-button topic. A session titled “Statins in the Real World” was so packed that conference staff turned attendees away at the door. Does the risk calculator overestimate risk? Some studies say yes. Others support its use.

Physicians expressed their ambivalence and confusion about the guidelines at an evening educational session on lipid management. Neil Stone, MD, of Northwestern University Feinberg School of Medicine in Chicago and chair of the guideline committee, prefaced a summary of the guidelines by saying, “I have a tough task. I have to persuade you that what we said is a valuable place to start in your assessment and treatment of patients to reduce atherosclerotic cardiovascular risk.”

An attendee at a session on end-of-life issues raised what may have been the most poignant question. Physicians were discussing when, who and how to inform families that a patient was near the end of life. The attendee said the biggest question was why this talk was so sparsely attended. Admittedly, it was Monday, but nonetheless the continuum of care should include the end of life and physicians should be engaged in the process.

The panelists and the handful of nurses and physicians in the audience agreed that this issue needs to be moved to the forefront and given more prominence at the conference. Scheduling an evidence-based session at the beginning of the conference would be a start.  

Candace Stuart

Cardiovascular Business, editor