American Heart Association Scientific Sessions 2017 Upload

The Journal of Thrombosis and Thrombolysis is proud to present the commencement article in a new section entitled "National and International Coming together Highlights". Each article in this series will review some of the major studies or guideline updates presented at international conferences. The conferences covered in this series will include the American Heart Association Almanac Scientific Sessions, American Society of Hematology Annual Meeting, American College of Cardiology Annual Scientific Session, International Society of Thrombosis and Haemostasis Biennial Congress, and European Society of Cardiology Annual Congress. Although all the exciting presentations at each briefing cannot be covered in these articles, we promise this series provides readers with a taste of the ones that may shape guidelines and practise.

New insights from CANTOS

The primary results of the Canakinumab Antiinflammatory Thrombosis Outcomes Study (CANTOS) were showtime presented at the 2017 ESC Congress [one]. This basis-breaking trial tested the "pure" anti-inflammatory drug (i.e. no bear on on lipids), canakinumab, a monoclonal antibody targeting interleukin-1β, in the reduction of recurrent major adverse cardiovascular events (MACE). The investigators found a xv% relative risk reduction with canakinumab in MACE, providing validation of the "inflammatory hypothesis", targeting of inflammation in atherosclerotic cardiovascular disease (ASCVD) reduction, and spurring excitement for further investment in understanding anti-inflammatory mechanisms and related drug discovery.

At the AHA, Dr. Ridker presented subanalyses of CANTOS that demonstrated that the benefit of canakinumab did not differ in subgroups of varying baseline clinical characteristics, including the LDL-C [2]. In addition, analyses likewise demonstrated that on-handling loftier-sensitivity C-reactive protein (hsCRP), a biomarker of inflammation, could place responders to canakinumab (Table 1). These data demonstrated that the benefits of canakinumab were direct related to the magnitude of hsCRP reduction and that this biomarker can serve as a valuable target to assess treatment response.

Table ane Adjusted hazard ratios for prespecified endpoints according to on-treatment hsCRP

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PRESERVE trial primary results

The employ of contrast material in cardiovascular angiography carries with it the well-known hazard of astute kidney injury and long term renal complications. Investigators have long hypothesized that the risk of renal complications might be reduced by sodium bicarbonate infusion or oral acetylcysteine, even so previous studies have yielded inconclusive results. The Prevention of Serious Adverse Events Following Angiography (PRESERVE) trial, a 2 × 2 factorial design trial, randomized subjects to sodium bicarbonate infusion versus sodium chloride infusion and acetylcysteine versus placebo [three]. The primary endpoint was expiry, need for dialysis, or a persistent increment of at least fifty% from baseline in serum creatinine at ninety–104 days after angiography. The report which intended to enroll 7680 patients was stopped later on 5177 patients were randomized (4993 included in the primary assay group) afterwards a preplanned interim analysis demonstrated no between-group differences. The results of the report provided convincing testify that at that place is neither incremental do good of sodium bicarbonate versus sodium chloride infusion nor of acetylcysteine administration.

TRISC III primary results

Strategies of liberal versus restrictive thresholds for packed red blood cell (PRBC) transfusion have undergone evaluation beyond a variety of atmospheric condition. The unknown balance of risks of anemia-induced tissue hypoxia versus risks due to transfusions, led the investigators of the Transfusion Requirements in Cardiac Surgery (TRISC) III trial to evaluate these strategies in adult patients undergoing cardiac surgery with cardiopulmonary bypass [4]. Using a noninferiority blueprint, patients with a EuroSCORE I of 6 or higher (higher scores indicating college take a chance of death subsequently cardiac surgery) were randomized ane:ane to a transfusion threshold of: (ane) 7.v 1000/dL intraoperatively and postoperatively, versus (2) 9.5 g/dL intraoperatively and in the ICU and then viii.5 g/dL in the not-ICU ward. The primary endpoint was a composite of death, nonfatal myocardial infarction, stroke, or new-onset renal failure.

At baseline, hateful hemoglobin concentration was thirteen.1 yard/dL. During the post-operative menstruum, the hemoglobin concentration between the groups differed by approximately 1 g/dL. In the restrictive-threshold group 52.3% received a transfusion versus 72.6% the liberal-threshold group. The main endpoint occurred in eleven.4 versus 12.5% in the restrictive versus liberal-threshold groups (Tabular array two). These data demonstrate that a more restrictive arroyo to transfusion is noninferior to a more liberal approach for patients undergoing cardiac surgery with cardiopulmonary bypass.

Table ii Outcomes in the per-protocol population

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New Insights from RE-DUAL PCI

The chief results of the Randomized Evaluation of Dual Antithrombotic Therapy with Dabigatran versus Triple Therapy with Warfarin in patients with Nonvalvular Atrial Fibrillation Undergoing Percutaneous Coronary Intervention (REDUAL-PCI) study were first presented at the 2017 ESC Congress [five]. This noninferiority trial randomized patients with nonvalvular atrial fibrillation undergoing PCI to either dabigatran 110 mg BID plus a P2Y12 inhibitor, dabigatran 150 mg BID plus a P2Y12 inhibitor, or warfarin plus both a P2Y12 inhibitor and aspirin. Every bit expected, the primary safety end point of commencement major or clinically relevant nonmajor ISTH-defined haemorrhage was substantially reduced in the 110 mg dabigatran arm compared to the warfarin triple-therapy comparator group, xv.4 versus 26.9%, respectively, and in the 150 mg dabigatran arm compared to its warfarin triple-therapy comparator group, xx.ii versus 25.seven%, respectively. Of note, the composite efficacy endpoint of thromboembolic events, death, and unplanned revascularization did not differ between the combined dabigatran arms versus the warfarin triple-therapy arm, xiii.vii versus thirteen.4%.

At the AHA, Dr. Oldgren presented subgroup analyses for fundamental baseline clinical subgroups, including stenting for ACS versus non-ACS indication, drug-eluting versus bare-metallic stent use, and P2Y12 option of clopidogrel versus ticagrelor. The investigators plant no signification interactions past subgroups and ended that the main report results were consistent amidst them. These findings support use of non-warfarin based strategies in these patients also equally the safety of ticagrelor if desired in those at college thrombotic risk.

Release of 2017 hypertension guidelines

Finally, the new ACC/AHA hypertension guidelines were released [six]. Although this article doesn't allow coverage of this long and comprehensive document, some fundamental points are worth mentioning:

1. (ane)

   The definitions of systolic and diastolic claret pressure (SBP and DBP) categories have been modified. Normal BP is < 120/<lxxx mm Hg; elevated BP is 120–129/<80; hypertension stage 1 is 130–139 or 80–89; and hypertension stage 2 is ≥ 140 or ≥ 90.

2. (2)

   BP should be estimated using ≥ 2 readings on ≥ 2 occasions. Out-of-office and self-monitoring are recommended to ostend the diagnosis and titrate therapy.

3. (iii)

   Use of BP-lowering medication is recommended in patients with cardiovascular disease with an average SBP ≥ 130 or DBP ≥ eighty. Medication is also recommended in primary prevention for those with a 10-yearr ASCVD risk ≥ 10% with the same BP measurements. In primary prevention, those with a 10-year adventure < 10% and SBP ≥ 140 or DBP ≥ 90 should also exist treated.

4. (4)

   First-line therapy for stage ane hypertension includes thiazide diuretics, calcium aqueduct blockers, and angiotensin-converting-enzyme inhibitors or angiotensin Two receptor blockers. Two first-line drugs of unlike classes are recommended for stage ii hypertension. Notation that for specific conditions (e.grand. eye failure with reduced ejection fraction, thoracic aortic disease), BP medication recommendations will vary (e.yard. beta-blockers).

References

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3. Weisbord SD, Gallagher Grand, Jneid H et al (2017) Outcomes subsequently angiography with sodium bicarbonate and acetylcysteine. NEJM. https://doi.org/10.1056/NEJMoa1710933

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4. Mazer CD, Whitlock RP, Fergusson DA et al (2017) Restrictive or liberal red-cell transfusion for cardiac surgery. NEJM xxx(22):2133–2144 377)

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5. Cannon CP, Bhatt DL, Oldgren J et al (2017) Dual antithrombotic therapy with dabigatran afterwards PCI in atrial fibrillation. NEJM 19(sixteen):1513–1524 377)

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6. Whelton PK, Carey RM, Aronow WS et al (2017) 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/AphA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high claret pressure level in adults: a report of the American College of Cardiology/American Heart Clan Task Force on Clinical Practice Guidelines. JACC. https://doi.org/x.1016/j.jacc.2017.xi.006

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1. Cincinnati, USA

   Dylan Fifty. Steen

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Correspondence to Dylan 50. Steen.

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Steen, D.Fifty. Highlights from the 2017 American Center Association Scientific Sessions in Anaheim, California. J Thromb Thrombolysis 45, 466–468 (2018). https://doi.org/10.1007/s11239-018-1632-3

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• Published: 07 March 2018

• Event Appointment: April 2018

• DOI : https://doi.org/x.1007/s11239-018-1632-3

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