Bonnie Ky, MD, on ESC’s new cardio-oncology guidelines.

Guidelines

Heart Disease Care in an Aging Population

The American Heart Association released a 31-page scientific statement offering expert insight into heart disease treatment for an aging US population. 

Considering Age-Related Changes – Cardiovascular changes that occur with normal aging make diagnosing and treating heart disease more complex: large arteries become stiffer, the heart muscle pumps less effectively, and blood vessels are less flexible and less able to respond to changes in the heart’s oxygen needs.

Here are some considerations AHA highlights: 

• ACS is more likely to occur without chest pain in older adults, presenting with symptoms such as shortness of breath, fainting, or sudden confusion.
  
• Measuring levels of circulating troponin is standard to diagnose heart attacks in younger people, but troponin levels may already be higher in older people. Evaluating the rise and fall patterns of troponin may be more appropriate. 

• Although many clinicians avoid cardiac rehab for frail patients, these are the patients who often benefit the most.
  
• Older adults are vulnerable to complications when transferred to outpatient centers; ensuring medications and other therapies are continued among these patients is particularly important. 

Quality of Life Emphasis – The authors note that the goals of care for older people with ACS should extend beyond clinical outcomes like bleeding, stroke, or another heart attack. Goals focused on quality of life may be more important to the patient, placing emphasis on concrete metrics such as pain relief and days spent at home.

The Takeaway

With the US facing an aging population, the AHA’s latest scientific statement provides timely information on the diagnosis and management of ACS in adults over 75. The organization emphasizes clinical considerations for age-related changes and the importance of prioritizing quality of life.

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The Wire

• Hello Heart’s Hypertension Findings: Digital therapeutic Hello Heart announced results from a 6k-person study on how minor lifestyle and behavioral changes can improve heart health. An average increase of only 34 minutes of walking/week (an extra five-minute walk/day) was associated with a clinically significant 8.7 mmHg decrease in systolic BP over a 6 month period. Hello Heart leverages AI to help people draw connections between their lifestyle choices and their heart health. 

• Precision CAD Care: An article in The American Journal of Medicine proposes a new treatment approach for coronary artery disease that prioritizes the direct quantification and characterization of atherosclerosis rather than indirect CAD markers like cholesterol. Combining coronary CT angiography with traditional CV risk factors and existing clinical guidelines may improve risk stratification, therapeutic decision-making, and longitudinal disease tracking. Not coincidentally, the last several years have brought an emergence of startups directly focused on AI-based plaque assessments that support this document’s proposed approach.

• Boston Scientific Moves in on Acotec: Boston Scientific will make a bid for a majority stake of up to 65%–about $523M–in the Chinese medtech company Acotec Scientific. Acotec maintains a portfolio of drug-coated balloons, percutaneous transluminal angioplasty devices, and radiofrequency ablation catheters. The acquisition, which is expected to close in the first half of 2023, is Boston Scientific’s second nine-figure deal in the last several weeks. 

• Oversized LAAO Devices: New research in Circulation found that most Watchman 2.5 devices implanted during left atrial appendage occlusion (LAAO) procedures are oversized, and that seems to be okay. Among 68.4k patients, 64% received an oversized device. Oversizing was tied to lower odds of leak and device embolization (odds ratio: 0.7), and did not increase adverse events. The number of oversized devices implanted increased from 2016 to 2020 (60% to 66%), likely due to a desire to decrease the risk of periprocedural leaks. 

• FDA Restricts Impella RP Heart Pump Label: The FDA updated the label for Abiomed’s Impella RP Heart Pump (approved in 2017) after a post-approval study revealed an 18.6% survival rate among patients who were not a part of the premarket study. In the initial studies, the heart pump was tied to 73.3% survival. The updated label specifies that the pump should only be used less than 48 hours after patients develop right heart failure, and should not be used in patients experiencing shock, end organ failure or acute neurologic injury. 

• Amgen’s $27.8B Horizon Therapeutics Buyout: In one of the biggest healthcare deals announced in 2022, Amgen is acquiring Horizon Therapeutics, a Dublin-based pharmaceutical company, for $27.8B. The acquisition brings together Amgen––which is focused on cardiovascular disease, oncology, bone health, neuroscience, nephrology and inflammation––and Horizon, which develops medicines for autoimmune and severe inflammatory diseases. 

• Redesigning Wearables: Researchers at the University of Missouri are designing an ultra-soft, breathable material with antimicrobial properties to use with their wearable heart monitor. The wearable device continuously tracks heart health via ECG and SCG (heart vibration) signals, and shares the data with the wearer’s healthcare provider to help identify heart disease warning signs. 

• Extreme Temperature Mortality: According to a multinational analysis of more than 32 million cardiovascular deaths over 40 years, mortality was highest on days when temperatures were at their highest or lowest. The authors estimate that for every 100 CV deaths, at least one additional death is attributed to extreme cold or hot days. Researchers suggest targeted warning systems and advice for vulnerable people may be needed to prevent cardiovascular deaths during temperature extremes.

• Esperion’s Positive CLEAR Outcomes: Esperion released positive results from its phase 3 CLEAR Outcomes trial, demonstrating that its bempedoic acid drug NEXLETOL significantly reduced CVD risk compared to placebo. Many providers expressed concern when the FDA first approved Esperion’s NEXLETOL in 2020 due to lack of outcomes data. Esperion answered this concern with CLEAR Outcomes, an event-driven, randomized, double-blind, placebo-controlled trial among over 14k high-risk, statin-intolerant patients across 32 countries. The company plans to present results in early 2023. 

• Digital Intervention to Control Hypertension: PCPs guided by a web-based platform helped patients achieve better blood pressure control over a 12-month period than PCPs without the web-based guide. In the Chinese study, over 4k patients with hypertension received either usual care or a “multicomponent intervention” – delivered on a web-based platform consisting of health education, lifestyle modification, and follow-up management plan. The intervention group had a much greater improvement in the proportion of patients with controlled BP at 12 months than the control group (24.6 percentage points vs. 7.7 percentage points). 

• Cardiosense Scores $15M: Cardiosense scored $15M in Series A funding to validate its CardioTag multi-sensor wearable that enables early detection of heart disease. Cardiosense plans to use the 500 participant clinical study to pursue the FDA approval of its CardioTag device while also improving its heart failure detection algorithm. 

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