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My Top Four Practice-Changers From ACC: Alcohol To Aspirin

The American College of Cardiology meeting in New Orleans has wrapped up and I must stop letting the good times roll.

In the areas I paid attention to, I found these four presentations the most important:

1. PARTNER 3 and Evolut trials: After these historic back-to-back presentations, it is clear that transcatheter aortic valve replacement (TAVR) should be the preferred approach to most patients with severe symptomatic aortic stenosis.

Both TAVR valves (the balloon-expanded Edwards and the self-expanding Medtronic) proved superior to surgical AVR in terms of 1-year clinical outcomes.

2. Alcohol-AF Trial: It is well known that binge alcohol consumption (holiday heart) can trigger atrial fibrillation (AF) and that observational studies show a higher incident of AF with higher amounts of alcohol consumption.

This trial was the first ever randomized controlled trial of alcohol abstinence in moderate drinkers with paroxysmal AF (minimum of two episodes in the last 6 months) or persistent AF requiring cardioversion.

Participants consuming at least 10 standard drinks per week at baseline were randomized to abstinence or usual consumption. They underwent comprehensive rhythm monitoring with implantable loop recorders or existing pacemakers and twice daily AliveCor monitoring for 6 months.

Abstinence prolonged AF-free survival by 37% (118 vs 86 days) and lowered the AF burden from 8.2% to 5.6%

AF-related hospitalizations occurred in 9% of abstinent patients versus 20% of controls. Those in the abstinence arm also experienced improved symptom severity, weight loss, and BP control.

This trial gives me precise numbers to present to my AF patients to show them how important eliminating alcohol consumption is if they want to have fewer AF episodes.

It further emphasizes the point that lifestyle changes (including weight loss, exercise, and stress-reduction) can dramatically reduce the incidence of atrial fibrillation.

3. AUGUSTUS: This trial looked at two hugely important questions in patients who have both AF and recent acute coronary syndrome, PCI, or stenting. The trial was simultaneously published in the New England Journal of Medicine. The questions were:

Apixaban (Eliquis, one of the four newer oral anticoagulants [NOAC]) versus warfarin for patients with AF: Which is safer for prevention of stroke related to AF?

Triple therapy with low-dose aspirin and clopidogrel (Plavix) plus warfarin or NOAC versus dual therapy with clopidogrel plus warfarin or NOAC: Which is safer in preventing stent thrombosis without causing excess bleeding in patients with AF and recent stent?

Briefly, they found: Apixaban had a 31% reduction in bleeding and hospitalization compared to warfarin, without a difference in ischemic events. Adding aspirin increased bleeding by 89%. There was no difference in ischemic events.

Major or clinically-relevant nonmajor bleeding was noted in 10.5% of the patients receiving apixaban, as compared with 14.7% of those receiving a vitamin K antagonist (HR 0.69; 95% CI 0.58 to 0.81; P<0.001 for both noninferiority and superiority). It occurred in 16.1% of the patients receiving aspirin, as compared with 9.0% of those receiving placebo (HR 1.89; 95% CI 1.59 to 2.24; P<0.001).

This means that the dreaded “triple therapy” after PCI in patients with AF with its huge bleeding risks no longer is needed.

It also further emphasizes that NOACs should be preferred over warfarin in most patients with AF.

The combination of choice now should be a NOAC, like apixaban, plus clopidogrel.

4. REDUCE-IT provided further evidence that icosapent ethyl (Vascepa) significantly reduces major cardiovascular events in patients with established CV disease on maximally-tolerated statin therapy.

The results of the primary endpoint from the REDUCE-IT were presented at the American Heart Association meeting last year and they were very persuasive. At the ACC, Deepak Bhatt presented data on reduction of total ischemic events from the study and they were equally impressive. Adding the pharmaceutical-grade esterified form of EPA at 2 grams BID reduced first, second, third, and fourth ischemic events in this high-risk population.

The benefit was noted on all terciles of baseline triglyceride levels. Thus, the lowest tercile of 81 to 190 mg/dL benefitted as well as the highest tercile (250 to 1401 mg/dL).

Although I dread the costs, it’s time to start discussing adding Vascepa to statin therapy in high risk atherosclerotic cardiovascular disease patients who have triglycerides >100 mg/dL.

I didn’t learn anything from the much ballyhooed and highly anticipated Apple Heart Study, as I wrote here. It’s entirely possible more participants were harmed than helped by this study.

Anthony Pearson, MD, is a private practice noninvasive cardiologist and medical director of echocardiography at St. Luke’s Hospital in St. Louis. He blogs on nutrition, cardiac testing, quackery, and other things worthy of skepticism at The Skeptical Cardiologist, where a version of this post first appeared.