Commentary

2019: To close out a decade of progress, new ways of thinking about cardiology emerge

This has been a most interesting year in cardiology and was a fitting conclusion to an exciting decade. The Top 10 Stories of the Year in cardiology, selected by the Cardiology Today Editorial Board, represent well the changing landscape in our field. These issues present new ways of thinking about a variety of topics.

We are still trying to digest the implications of ISCHEMIA, which is of major importance for the very large number of patients with stable ischemic heart disease. Those results support the position that there is likely to be no advantage for an invasive management strategy over optimal medical therapy. We are just beginning to understand that symptoms and signs of ischemia derived from noninvasive tests do not necessarily help to determine who is likely to benefit from an invasive strategy even with revascularization that includes DES and arterial grafts. That is why we should better emphasize invasive coronary physiologic or functional testing as suggested by the CorMicA investigators earlier this year.

Carl J. Pepine, MD, MACC
Carl J. Pepine

The hazards of vaping emerged as a major concern in 2019. My understanding so far is that most of the known hazards are pulmonary-related, and we do not yet know the true hazards from the CV standpoint. But cardiologists and all medical professionals are alarmed at the increasing adoption of vaping devices by the younger generations. Vaping has to become part of the conversation that doctors have with their patients.

This year, great strides were made in understanding the CV benefits of diabetes medications such as SGLT2 inhibitors and GLP-1 receptor agonists. Particularly with SGLT2 inhibitors, evidence is emerging that they are beneficial for HF with preserved ejection fraction and for HF even in patients without diabetes. With the exception of icosapent ethyl (Vascepa, Amarin), the pharma industry had turned away from small-molecule development for CVD, but these compounds developed for diabetes are becoming exciting small molecule therapies for our CV disorders. And from what we can see, they are relatively safe.

Top Trends from 2019 Offer Preview of 2020

The primary prevention guideline downplaying the role of aspirin in that population was a major development. The recent meta-analysis suggests that the number needed to treat for benefit is about the same as the number to harm. However, there is a stroke or MI every 40 seconds in the United States, and aspirin prevents strokes and MIs. Yes, aspirin confers increased risk for gastrointestinal and also some central nervous system bleeding. But in my view, the damage from a stroke or MI is irreversible due to permanent tissue loss, whereas GI bleeding is now easily treatable by nonsurgical interventions, as are many cases of central nervous system bleeding, without permeant tissue loss, so these adverse events do not equate. Unfortunately, these primary prevention guidelines are leading patients requiring secondary prevention, for which aspirin is proven, to ask their doctors if they can stop aspirin. But, in this era of “deprescribing” many such secondary prevention patients are not even asking their physicians before stopping aspirin. I do not believe that we have done anyone a favor with the interpretation of the ARRIVE, ASCEND and ASPREE trials.

Throughout the decade, we have continued to make a lot of progress in cardiology. It may seem like the 2010s did not bring as much change as the 1990s and early 2000s, but when one examines the advances of the past 10 years, I am not sure that is true.

The 2010s brought tremendous advances in interventional cardiology for structural heart diseases. Transcatheter aortic valve replacement became a routine procedure in the U.S., culminating in the successful trials of TAVR in patients at low surgical risk presented this year, which are paving the way for wider adoption of the procedure. The percutaneous approaches to mitral valve repair have also continued to advance.

The field sharpened its focus on prevention, especially in light of the abatement of the decline in CVD rates, thanks in part to the diabetes and obesity epidemics. Our cholesterol, hypertension and primary prevention guidelines have evolved to offer strong, proven strategies for reducing premature fatal and nonfatal CVD events. Going forward, it is up to all cardiologists to carry them out effectively.

Advances in technology over the past decade have made cardiologists’ jobs very different from what they once were. Wearable devices are demonstrating potential to help us diagnose CV conditions before symptoms emerge, and we can expect more progress in this area after the success of the Apple Heart Study. Also, of note, artificial intelligence platforms are helping us sift through large amounts of data to better diagnose CV conditions and deliver individualized (personalized) treatment approaches. Lastly, “participatory medicine” has penetrated into CVD, as patients appear to be much more interested in taking responsibility for their own health.

I hope you found this past year and this past decade as exhilarating as I did.

Disclosure: Pepine reports no relevant financial disclosures.

This has been a most interesting year in cardiology and was a fitting conclusion to an exciting decade. The Top 10 Stories of the Year in cardiology, selected by the Cardiology Today Editorial Board, represent well the changing landscape in our field. These issues present new ways of thinking about a variety of topics.

We are still trying to digest the implications of ISCHEMIA, which is of major importance for the very large number of patients with stable ischemic heart disease. Those results support the position that there is likely to be no advantage for an invasive management strategy over optimal medical therapy. We are just beginning to understand that symptoms and signs of ischemia derived from noninvasive tests do not necessarily help to determine who is likely to benefit from an invasive strategy even with revascularization that includes DES and arterial grafts. That is why we should better emphasize invasive coronary physiologic or functional testing as suggested by the CorMicA investigators earlier this year.

Carl J. Pepine, MD, MACC
Carl J. Pepine

The hazards of vaping emerged as a major concern in 2019. My understanding so far is that most of the known hazards are pulmonary-related, and we do not yet know the true hazards from the CV standpoint. But cardiologists and all medical professionals are alarmed at the increasing adoption of vaping devices by the younger generations. Vaping has to become part of the conversation that doctors have with their patients.

This year, great strides were made in understanding the CV benefits of diabetes medications such as SGLT2 inhibitors and GLP-1 receptor agonists. Particularly with SGLT2 inhibitors, evidence is emerging that they are beneficial for HF with preserved ejection fraction and for HF even in patients without diabetes. With the exception of icosapent ethyl (Vascepa, Amarin), the pharma industry had turned away from small-molecule development for CVD, but these compounds developed for diabetes are becoming exciting small molecule therapies for our CV disorders. And from what we can see, they are relatively safe.

Top Trends from 2019 Offer Preview of 2020

The primary prevention guideline downplaying the role of aspirin in that population was a major development. The recent meta-analysis suggests that the number needed to treat for benefit is about the same as the number to harm. However, there is a stroke or MI every 40 seconds in the United States, and aspirin prevents strokes and MIs. Yes, aspirin confers increased risk for gastrointestinal and also some central nervous system bleeding. But in my view, the damage from a stroke or MI is irreversible due to permanent tissue loss, whereas GI bleeding is now easily treatable by nonsurgical interventions, as are many cases of central nervous system bleeding, without permeant tissue loss, so these adverse events do not equate. Unfortunately, these primary prevention guidelines are leading patients requiring secondary prevention, for which aspirin is proven, to ask their doctors if they can stop aspirin. But, in this era of “deprescribing” many such secondary prevention patients are not even asking their physicians before stopping aspirin. I do not believe that we have done anyone a favor with the interpretation of the ARRIVE, ASCEND and ASPREE trials.

Throughout the decade, we have continued to make a lot of progress in cardiology. It may seem like the 2010s did not bring as much change as the 1990s and early 2000s, but when one examines the advances of the past 10 years, I am not sure that is true.

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The 2010s brought tremendous advances in interventional cardiology for structural heart diseases. Transcatheter aortic valve replacement became a routine procedure in the U.S., culminating in the successful trials of TAVR in patients at low surgical risk presented this year, which are paving the way for wider adoption of the procedure. The percutaneous approaches to mitral valve repair have also continued to advance.

The field sharpened its focus on prevention, especially in light of the abatement of the decline in CVD rates, thanks in part to the diabetes and obesity epidemics. Our cholesterol, hypertension and primary prevention guidelines have evolved to offer strong, proven strategies for reducing premature fatal and nonfatal CVD events. Going forward, it is up to all cardiologists to carry them out effectively.

Advances in technology over the past decade have made cardiologists’ jobs very different from what they once were. Wearable devices are demonstrating potential to help us diagnose CV conditions before symptoms emerge, and we can expect more progress in this area after the success of the Apple Heart Study. Also, of note, artificial intelligence platforms are helping us sift through large amounts of data to better diagnose CV conditions and deliver individualized (personalized) treatment approaches. Lastly, “participatory medicine” has penetrated into CVD, as patients appear to be much more interested in taking responsibility for their own health.

I hope you found this past year and this past decade as exhilarating as I did.

Disclosure: Pepine reports no relevant financial disclosures.