Key opinion leaders discuss top news from 2019

More discussion on the implications of major developments in cardiology in 2019.

Joseph S. Alpert, MD, University of Arizona Sarver Heart Center

Joseph S. Alpert, MD
Joseph S. Alpert

Approximately 50% of high school students are vaping. The major product in these devices is nicotine, one of the most addicting substances known. As editor-in-chief of The American Journal of Medicine, I have already accepted several articles pointing out serious pulmonary complications related to vaping. This new product is well on its way to becoming a major public health problem.

Disclosure: Alpert reports no relevant financial disclosures.

Vera Bittner, MD, University of Alabama at Birmingham

Vera Bittner, MD
Vera Bittner

Diabetes treatment has undergone a transformation from sugar control to CV event prevention and now potential use of glucose-lowering agents in the absence of diabetes. Cardiologists need to become “diabetes pharmacologists” and learn to really understand these drugs inside out to optimize their patients’ prognosis. The ISCHEMIA trial will have a huge impact on how we treat chronic stable coronary disease. As practicing cardiologists, we need to understand all the strengths and limitations of this study in detail.

Disclosure: Bittner reports she received institutional research grants from Amgen, AstraZeneca, DalCor, Sanofi and The Medicines Company.

Javed Butler, MD, MPH, MBA, University of Mississippi Medical Center

Javed Butler, MD, MPH, MBA
Javed Butler

After several decades of year-over-year reduction in mortality from CVD, the current reversal of trend at the population level is of incredible concern. We have all gotten accustomed to the fact and tacitly and inadvertently assumed that it will continue to improve. What we are learning is that research, clinical and population health measures need to continue to be implemented and assessed on an ongoing basis. CVD remains the leading cause of death globally and the worsening population-based risk factor profile needs to be dealt with aggressively.

Disclosure: Butler reports he has financial ties with Abbott, Actelion, Adrenomed, Amgen, Applied Therapeutics, Arca Biopharma, Arena, Array, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, CVRx, G3 Pharma, Gilead, Innolife, Janssen, LivaNova, Luitpold, Medtronic, Merck, Nestle, Novartis, Novo Nordisk, Relypsa, Roche, Sanofi, V-Wave Ltd. and Vifor.

JoAnn Lindenfeld, MD, Vanderbilt University Medical Center

JoAnn Lindenfeld, MD
JoAnn Lindenfeld

The DAPA-HF trial demonstrates a reduction in CV mortality and HF hospitalizations for patients with type 2 diabetes and without diabetes, making the SGLT2 inhibitors appropriate drugs for most patients with HF and reduced left ventricular ejection fraction. I am looking forward to data on SGLT2 inhibitors in patients with HF with preserved EF.

Disclosure: Lindenfeld reports she consults for Abbott, Boston Scientific, Edwards Lifesciences, ResMed and V-Wave Ltd. and received research grants from AstraZeneca and Novartis.

Seth J. Baum, MD, Florida Atlantic University and Boca Raton Regional Hospital

Seth J. Baum, MD
Seth J. Baum

Drug pricing and cost-effectiveness analyses have become top of mind since the approval of PCSK9 inhibitors in 2015. Initial barriers to prescribing these safe and effective medications severely limited patient access. Drug companies lowered their prices 60%, and yet only a fraction of appropriate patients have been prescribed the drugs. This scenario will play out with all new drugs unless we quickly get a handle on it. The future of drug development and our patients’ lives depend on our success. Let’s win this battle in 2020.

Disclosure: Baum reports he was principal investigator in a trial sponsored by Akcea.

Jonathan Piccini, MD, MHS, Duke University Medical Center

Jonathan Piccini, MD, MHS
Jonathan Piccini

2019 was a year in which there were a lot of important developments in heart rhythm medicine. Most notable among these were the publication of the CABANA trial results, the results from the Apple Heart Study, and the updated guidelines for the treatment and management of atrial fibrillation. Going forward, a trend to watch is the incorporation of wearables into clinical trials.

Disclosure: Piccini reports he is a consultant for Abbott, Boston Scientific, Medtronic and Philips and received research funding from Abbott, the American Heart Association, Boston Scientific, Johnson & Johnson and the NHLBI.

Steven E. Nissen, MD, MACC, Cleveland Clinic

Steven E. Nissen, MD, MACC
Steven E. Nissen

The ISCHEMIA trial raised new questions about the appropriateness of many coronary interventional procedures and reemphasized the importance of offering patients medical treatment as the first choice in stable angina. Trends to watch in 2020 include the emergence of triglycerides as a risk factor, more evidence for the CV benefits of bariatric surgery and the use of inclisiran (The Medicines Company) as a new therapy for elevated LDL.

Disclosure: Nissen reports no relevant financial disclosures.

Nathaniel Reichek, MD, St. Francis Hospital, Roslyn, New York

Nathaniel Reichek, MD
Nathaniel Reichek

The results of ISCHEMIA provide a basis for effective treatment without massive overutilization of stress testing, invasive angiography, PCI and CABG. In 2020, I expect to see more stringent preapproval requirements for all but emergent CV procedures; more evidence of the value of intracoronary imaging, especially OCT, in optimizing PCI results; and further evidence supporting the impact of more systematic treatment of diabetes and hypertension.

Disclosure: Reichek reports no relevant financial disclosures.

Allan S. Jaffe, MD, Mayo Clinic

Allan S. Jaffe, MD
Allan S. Jaffe

In 2019, we saw the results of a long-awaited important trial on the proper management of stable ischemic heart disease. It is reassuring that a strategy of optimal medical therapy is perfectly appropriate and at least initially may be better than an invasive approach. This will allow clinicians much greater leeway in determining with their patients the best treatment course.

Disclosure: Jaffe reports he consults for all companies that make troponin assays.

Deepak L. Bhatt, MD, MPH, Brigham and Women’s Hospital and Harvard Medical School

Deepak L. Bhatt, MD, MPH
Deepak L. Bhatt

Targeting residual CV risk will increasingly become a major part of cardiology practice. In high-risk patients already on intensive lifestyle modification and on maximally tolerated doses of statins, targeting persistent elevation in LDL and triglycerides will be the next major step in driving down rates of ischemic events. The list of available, evidence-based, cost-effective options will grow.

Disclosure: Bhatt reports he has financial ties with numerous pharmaceutical and device companies.

Bradford C. Berk, MD, PhD, University of Rochester Medical Center

Bradford C. Berk, MD, PhD
Bradford C. Berk

The lack of benefit, and probable harm, associated with aspirin for primary prevention of CVD will have an enormous impact on a very large number of people. It is the most impactful story in terms of change in practice guidelines and number of people affected by the change.

Disclosure: Berk reports no relevant financial disclosures.

Joseph S. Alpert, MD, University of Arizona Sarver Heart Center

Joseph S. Alpert, MD
Joseph S. Alpert

Approximately 50% of high school students are vaping. The major product in these devices is nicotine, one of the most addicting substances known. As editor-in-chief of The American Journal of Medicine, I have already accepted several articles pointing out serious pulmonary complications related to vaping. This new product is well on its way to becoming a major public health problem.

Disclosure: Alpert reports no relevant financial disclosures.

Vera Bittner, MD, University of Alabama at Birmingham

Vera Bittner, MD
Vera Bittner

Diabetes treatment has undergone a transformation from sugar control to CV event prevention and now potential use of glucose-lowering agents in the absence of diabetes. Cardiologists need to become “diabetes pharmacologists” and learn to really understand these drugs inside out to optimize their patients’ prognosis. The ISCHEMIA trial will have a huge impact on how we treat chronic stable coronary disease. As practicing cardiologists, we need to understand all the strengths and limitations of this study in detail.

Disclosure: Bittner reports she received institutional research grants from Amgen, AstraZeneca, DalCor, Sanofi and The Medicines Company.

Javed Butler, MD, MPH, MBA, University of Mississippi Medical Center

Javed Butler, MD, MPH, MBA
Javed Butler

After several decades of year-over-year reduction in mortality from CVD, the current reversal of trend at the population level is of incredible concern. We have all gotten accustomed to the fact and tacitly and inadvertently assumed that it will continue to improve. What we are learning is that research, clinical and population health measures need to continue to be implemented and assessed on an ongoing basis. CVD remains the leading cause of death globally and the worsening population-based risk factor profile needs to be dealt with aggressively.

Disclosure: Butler reports he has financial ties with Abbott, Actelion, Adrenomed, Amgen, Applied Therapeutics, Arca Biopharma, Arena, Array, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, CVRx, G3 Pharma, Gilead, Innolife, Janssen, LivaNova, Luitpold, Medtronic, Merck, Nestle, Novartis, Novo Nordisk, Relypsa, Roche, Sanofi, V-Wave Ltd. and Vifor.

JoAnn Lindenfeld, MD, Vanderbilt University Medical Center

JoAnn Lindenfeld, MD
JoAnn Lindenfeld

The DAPA-HF trial demonstrates a reduction in CV mortality and HF hospitalizations for patients with type 2 diabetes and without diabetes, making the SGLT2 inhibitors appropriate drugs for most patients with HF and reduced left ventricular ejection fraction. I am looking forward to data on SGLT2 inhibitors in patients with HF with preserved EF.

Disclosure: Lindenfeld reports she consults for Abbott, Boston Scientific, Edwards Lifesciences, ResMed and V-Wave Ltd. and received research grants from AstraZeneca and Novartis.

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Seth J. Baum, MD, Florida Atlantic University and Boca Raton Regional Hospital

Seth J. Baum, MD
Seth J. Baum

Drug pricing and cost-effectiveness analyses have become top of mind since the approval of PCSK9 inhibitors in 2015. Initial barriers to prescribing these safe and effective medications severely limited patient access. Drug companies lowered their prices 60%, and yet only a fraction of appropriate patients have been prescribed the drugs. This scenario will play out with all new drugs unless we quickly get a handle on it. The future of drug development and our patients’ lives depend on our success. Let’s win this battle in 2020.

Disclosure: Baum reports he was principal investigator in a trial sponsored by Akcea.

Jonathan Piccini, MD, MHS, Duke University Medical Center

Jonathan Piccini, MD, MHS
Jonathan Piccini

2019 was a year in which there were a lot of important developments in heart rhythm medicine. Most notable among these were the publication of the CABANA trial results, the results from the Apple Heart Study, and the updated guidelines for the treatment and management of atrial fibrillation. Going forward, a trend to watch is the incorporation of wearables into clinical trials.

Disclosure: Piccini reports he is a consultant for Abbott, Boston Scientific, Medtronic and Philips and received research funding from Abbott, the American Heart Association, Boston Scientific, Johnson & Johnson and the NHLBI.

Steven E. Nissen, MD, MACC, Cleveland Clinic

Steven E. Nissen, MD, MACC
Steven E. Nissen

The ISCHEMIA trial raised new questions about the appropriateness of many coronary interventional procedures and reemphasized the importance of offering patients medical treatment as the first choice in stable angina. Trends to watch in 2020 include the emergence of triglycerides as a risk factor, more evidence for the CV benefits of bariatric surgery and the use of inclisiran (The Medicines Company) as a new therapy for elevated LDL.

Disclosure: Nissen reports no relevant financial disclosures.

Nathaniel Reichek, MD, St. Francis Hospital, Roslyn, New York

Nathaniel Reichek, MD
Nathaniel Reichek

The results of ISCHEMIA provide a basis for effective treatment without massive overutilization of stress testing, invasive angiography, PCI and CABG. In 2020, I expect to see more stringent preapproval requirements for all but emergent CV procedures; more evidence of the value of intracoronary imaging, especially OCT, in optimizing PCI results; and further evidence supporting the impact of more systematic treatment of diabetes and hypertension.

Disclosure: Reichek reports no relevant financial disclosures.

PAGE BREAK

Allan S. Jaffe, MD, Mayo Clinic

Allan S. Jaffe, MD
Allan S. Jaffe

In 2019, we saw the results of a long-awaited important trial on the proper management of stable ischemic heart disease. It is reassuring that a strategy of optimal medical therapy is perfectly appropriate and at least initially may be better than an invasive approach. This will allow clinicians much greater leeway in determining with their patients the best treatment course.

Disclosure: Jaffe reports he consults for all companies that make troponin assays.

Deepak L. Bhatt, MD, MPH, Brigham and Women’s Hospital and Harvard Medical School

Deepak L. Bhatt, MD, MPH
Deepak L. Bhatt

Targeting residual CV risk will increasingly become a major part of cardiology practice. In high-risk patients already on intensive lifestyle modification and on maximally tolerated doses of statins, targeting persistent elevation in LDL and triglycerides will be the next major step in driving down rates of ischemic events. The list of available, evidence-based, cost-effective options will grow.

Disclosure: Bhatt reports he has financial ties with numerous pharmaceutical and device companies.

Bradford C. Berk, MD, PhD, University of Rochester Medical Center

Bradford C. Berk, MD, PhD
Bradford C. Berk

The lack of benefit, and probable harm, associated with aspirin for primary prevention of CVD will have an enormous impact on a very large number of people. It is the most impactful story in terms of change in practice guidelines and number of people affected by the change.

Disclosure: Berk reports no relevant financial disclosures.