Highlights of the American College of Cardiology Annual Scientific Sessions 2017
Recently, the 66th Annual American College of Cardiology (ACC) Scientific Sessions convened in Washington, DC, building on the theme of “more learning, less lecturing”. Despite the challenge of winter storm Stella, the meeting went off without a hitch, bringing together more than 18 500 attendees from across the world. Clinical science was at the forefront of the meeting, with 23 late-breaking clinical trials and 17 featured clinical research presentations. In addition, ACC.17 (2017 American College of Cardiology Annual Scientific Sessions) offered an updated core curriculum program, half-day intensive sessions focusing on palliative care, healthcare equity, and faculty development, live case demonstrations, and a personalized skills center, featuring hands-on simulation and test question review. Audience participation and response were featured throughout the meeting. New this year, physician attendees received simultaneous credit for continuing medical education and American Board of Internal Medicine Maintenance of Certification (ABIM-MOC) for the majority of the educational sessions; European physicians received external continuing medical education credit; and pharmacists and nurses received continuing education credits.
The opening session featured Richard Chazal, MACC, ACC President, and this year’s Simon Dack Lecturer, David Skorton, FACC, Secretary of the Smithsonian Institute. Dr Chazal remarked on the ever-changing landscape of cardiovascular medicine, while Dr Skorton emphasized the importance and richness of the arts and humanities in our profession and our lives. Thereafter, 3 late-breaking clinical trials were presented, setting the stage for an exciting display of practice-changing science. The FOURIER trial (Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk), the first PCSK-9 (proprotein convertase subtilisin/kexin type 9) outcomes trial, demonstrated that the addition of evolocumab to statin therapy in patients with elevated cardiovascular risk resulted in a significant reduction in low density lipoprotein (LDL) cholesterol and in the primary, composite outcome of cardiovascular death, myocardial infarction, stroke, hospitalization for unstable angina, or coronary revascularization. A marked reduction in cardiovascular death, myocardial infarction, and stroke (secondary end point) was also noted. One day later, a subset of patients from the FOURIER trial who underwent advanced cognitive testing was presented in the EBBINGHAUS study (Evaluating PCSK9 Binding Antibody Influence on Cognitive Health in High Cardiovascular Risk Subjects), a trial sharing the name of the German psychologist who studied memory. No adverse cognitive deficits were seen among patients receiving evolocumab on top of statin therapy, despite the marked reduction in LDL cholesterol levels. The second PCSK-9 trial, SPIRE 1 and 2 (Studies of PCSK9 Inhibition and the Reduction of Vascular Events), focused on the humanized PCSK9 inhibitor bococizumab. Part of the SPIRE Program, which had been stopped prematurely due to the development of antidrug antibodies with an associated attenuation effect on LDL cholesterol reduction, this study found no difference between patients with a baseline LDL cholesterol >70 mg/dL receiving placebo versus bococizumab in the primary end point of nonfatal myocardial infarction, nonfatal stroke, hospitalization for unstable angina requiring revascularization, or cardiovascular death; however, for patients with an LDL cholesterol >100 mg/dL, there was a significant reduction in the primary end point between the 2 groups. The final presentation in the opening session, the SURTAVI trial (Surgical Replacement and Transcatheter Aortic Valve Implantation), randomized intermediate risk patients with severe, symptomatic aortic valve stenosis to either a transcatheter (predominantly first generation self-expanding CoreValve Classic) or surgical (biological) approach. The transcatheter approach was found to be noninferior to surgery for the primary end point of mortality and disabling stroke.
The ground-breaking science did not end after the opening session. The EINSTEIN CHOICE Study (Reduced-Dosed Rivaroxaban in the Long-Term Prevention of Recurrent Symptomatic Venous Thromboembolism) showed that extending anticoagulation treatment by 1 year with rivaroxaban was superior to aspirin therapy for patients with venous thromboembolism. The risk of bleeding between the groups was not statistically different. GEMINI-ACS-1 (The Safety of Rivaroxaban Versus Acetylsalicylic Acid in Addition to Either Clopidogrel or Tricagrelor Therapy in Participants with Acute Coronary Syndrome), a phase 2 trial, showed that low-dose rivaroxaban, when compared with aspirin, did not provoke higher bleeding rates in patients already on concomitant P2Y12 inhibitors. The ORION-1 study (A Placebo-controlled, Double-blind, Randomized Trial to Compare the Effect of Different Doses of ALN-PCSSC Given as Single or Multiple Subcutaneous Injections in Subjects With High Cardiovascular Risk and Elevated LDL-C), focusing on LDL cholesterol reduction following infrequent injections of inclisiran, a novel siRNA compound, randomized patients with elevated cardiovascular risk to various doses of this therapy. At 180 days, marked reduction in LDL cholesterol levels were noted, with the greatest reduction in the 300 mg double dose group. Clinical outcomes were not measured in this study; adverse events were similar between placebo and treatment groups.
Three studies focusing on coronary flow measurements for indeterminant coronary artery stenosis comparing instantaneous wave-free ratio and fractional flow reserve were featured as part of an interventional-based late-breaking clinical trial session. The iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndromes) and the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularization) studies showed that coronary artery revascularization guided by instantaneous wave-free ratio was equivalent to fractional flow reserve for guiding therapy to reduce the risk of major cardiovascular events at 1 year. Procedural side effects, such as chest pain, were less common with instantaneous wave-free ratio than with fractional flow reserve. The COMPARE-ACUTE trial (Comparison Between FFR Guided Revascularization Versus Conventional Strategy in Acute STEMI Patients With Multivessel Disease) found a reduction in cardiovascular outcomes in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease undergoing primary percutaneous coronary intervention with fractional flow reserve-assisted revascularization of noninfarct related vessel(s), compared with treatment of infarct-related arteries only.
More science followed, including the results of the LEVO-CTS trial (Levosimendan in LV Systolic Dysfunction Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass), which found no improvement in the coprimary end points of death or dialysis through day 30, myocardial infarction or the use of a mechanical assist device through day 5 in high-risk patients undergoing cardiac surgery receiving the calcium-sensitizing inotrope levosimendan, despite an increased cardiac output in those receiving the drug. In the CVD-REAL study (Comparative Effectiveness of Cardiovascular Outcomes in New Users of SGLT-2 Inhibitors), a large, real-world study across 6 countries, nonparsimonious propensity scores for a sodium glucose cotransporter-2 inhibitor (SGLT-2i) initiation were used to match groups in which a broad population of patients with type 2 diabetes mellitus received either SGLT-2i or other-glucose-lowering-drugs treatment. In this study, treatment with SGLT-2i was associated with a marked reduction in hospitalization for heart failure when compared with treatment with other-glucose-lowering-drugs.
The excitement at ACC.17 extended well beyond the late-breaking clinical trial and featured clinical research sessions. More than 2400 abstracts, including young investigator competitions, were presented in oral, moderated, and flat board poster formats, allowing for key interaction between the presenters and the audience. In addition, key featured speakers anchored the meeting, including: Mariel Jessup, MD, FACC (Chatterjee Lecture, Heart Failure); Janet Wright, MD, FACC (Bishop Lecture, Healthcare Policy); Steven Bradley, MD (Zipes Young Scientist Award Lecture); Huon Gray, MD, FACC (Maseri-Florio, International Lecture); Gail Pearson, MD, ScD, FACC (McNamara Lecture, Congenital Heart Disease); and Jeffrey Drazen, MD (Braunwald Lecture, Future Directions in Cardiovascular Medicine).
In summary, this year’s ACC Scientific Sessions provided a buzz across the worldwide cardiovascular research and clinical communities. The energy, rhythm, and excitement were palpable, and importantly, the education that was delivered will allow clinicians to provide better cardiovascular care. Look for continued education innovation at upcoming ACC annual sessions.
Circulation is available at http://circ.ahajournals.org.
- © 2017 American Heart Association, Inc.