Commentary

2018: A year of enhanced understanding about risk, personalized treatment

This was, once again, an exciting year in cardiology. The Top 10 Stories of the Year in cardiology, selected by the Cardiology Today Editorial Board, reflect new knowledge across many different subspecialties. A trend over the past year, and also reflected in the Top 10 Stories of the Year, is considerable interest in better ways of addressing risk and residual risk, and a move toward more personalized risk assessment and treatment.

One of the highlights for me this year was the release of data from the REDUCE-IT trial, which analyzed icosapent ethyl (Vascepa, Amarin Pharmaceuticals), a prescription-grade omega-3 fatty acid, in patients with elevated triglycerides at high CV risk despite LDL controlled by statin therapy. As presented at the American Heart Association Scientific Sessions, icosapent ethyl was superior to placebo for reducing risk for ischemic events. For me, the anticipated results of REDUCE-IT help to straighten out the omega-3 field, which has yielded inconsistent CV findings over the years.

Carl J. Pepine

Aspirin for primary prevention was another highlight in the cardiology, as well as the general medicine community, in 2018. As seen in the ARRIVE, ASCEND and ASPREE trials, aspirin reduced vascular events compared with placebo in some populations but not others, and increased risk for bleeding, particularly gastrointestinal bleeding. I do not believe the last word on aspirin for primary prevention is in. Principally, I believe some very important signals emerged in the three aforementioned trials. I do not believe that we should abandon aspirin for primary prevention just because an intention-to-treat analysis did not show a statistically significant reduction in outcome. I base my notion on the fact that a lot of patients do not tolerate aspirin and, in my view, perhaps the on-treatment data may be more important.

Also highlighted on the Top 10 list is the promise of wearable technologies for prevention of CV events. Rapid advances in “wearables” have enabled patients to be monitored by their physicians as never before. These gains have ranged from enabling physicians to receive information about their patients’ heart rates and rhythms and activity levels from wrist devices (eg, Fitbit and Apple Watch) and smartphone apps, allowing HF specialists to remotely monitor patients’ pulmonary artery pressures, and so on. The assumption is that such information will result in improved outcomes and reduce health resource utilization by detecting emerging problems before they require hospitalization. This is an area of rapid development.

Other highlights, for me, that did not make our Top 10 list are increased focus on BP, which is the most prevalent modifiable risk factor in the United States; revived interest in renal artery ablation for management of resistant hypertension as well as more garden-variety hypertension; how the field is getting closer to a purely genetic risk profile for CVD and CAD; and CorMicA, the first randomized trial evidence supporting the benefit of invasive coronary diagnostic testing for patients with angina without obstructive epicardial CAD.

All of these topics, and others selected by the Cardiology Today Editorial Board, spawned discussions about many issues that should continue well into 2019 and beyond.

Disclosure: Pepine reports no relevant financial disclosures.

This was, once again, an exciting year in cardiology. The Top 10 Stories of the Year in cardiology, selected by the Cardiology Today Editorial Board, reflect new knowledge across many different subspecialties. A trend over the past year, and also reflected in the Top 10 Stories of the Year, is considerable interest in better ways of addressing risk and residual risk, and a move toward more personalized risk assessment and treatment.

One of the highlights for me this year was the release of data from the REDUCE-IT trial, which analyzed icosapent ethyl (Vascepa, Amarin Pharmaceuticals), a prescription-grade omega-3 fatty acid, in patients with elevated triglycerides at high CV risk despite LDL controlled by statin therapy. As presented at the American Heart Association Scientific Sessions, icosapent ethyl was superior to placebo for reducing risk for ischemic events. For me, the anticipated results of REDUCE-IT help to straighten out the omega-3 field, which has yielded inconsistent CV findings over the years.

Carl J. Pepine

Aspirin for primary prevention was another highlight in the cardiology, as well as the general medicine community, in 2018. As seen in the ARRIVE, ASCEND and ASPREE trials, aspirin reduced vascular events compared with placebo in some populations but not others, and increased risk for bleeding, particularly gastrointestinal bleeding. I do not believe the last word on aspirin for primary prevention is in. Principally, I believe some very important signals emerged in the three aforementioned trials. I do not believe that we should abandon aspirin for primary prevention just because an intention-to-treat analysis did not show a statistically significant reduction in outcome. I base my notion on the fact that a lot of patients do not tolerate aspirin and, in my view, perhaps the on-treatment data may be more important.

Also highlighted on the Top 10 list is the promise of wearable technologies for prevention of CV events. Rapid advances in “wearables” have enabled patients to be monitored by their physicians as never before. These gains have ranged from enabling physicians to receive information about their patients’ heart rates and rhythms and activity levels from wrist devices (eg, Fitbit and Apple Watch) and smartphone apps, allowing HF specialists to remotely monitor patients’ pulmonary artery pressures, and so on. The assumption is that such information will result in improved outcomes and reduce health resource utilization by detecting emerging problems before they require hospitalization. This is an area of rapid development.

Other highlights, for me, that did not make our Top 10 list are increased focus on BP, which is the most prevalent modifiable risk factor in the United States; revived interest in renal artery ablation for management of resistant hypertension as well as more garden-variety hypertension; how the field is getting closer to a purely genetic risk profile for CVD and CAD; and CorMicA, the first randomized trial evidence supporting the benefit of invasive coronary diagnostic testing for patients with angina without obstructive epicardial CAD.

All of these topics, and others selected by the Cardiology Today Editorial Board, spawned discussions about many issues that should continue well into 2019 and beyond.

Disclosure: Pepine reports no relevant financial disclosures.