ACC president, Edward T. A. Fry, MD, FACC, on the troubling trends and exciting breakthroughs happening within cardiology.

Cardiology

Cardiac Wire’s Top 8 Takeaways from ACC 2023

ACC 2023 is officially a wrap. We hope you had a blast if you made it, and had a great weekend if you stayed home. We also hope you enjoy our recap of cardiology’s biggest event in three years. Here’s Cardiac Wire’s top eight takeaways from ACC 2023:

• Crowds & Conversations – Helped by some NOLA mojo and post-COVID vibes, ACC’s attendance (estimated by some at 20k) and overall energy surpassed most expectations.

• Chronic Trends – Starting at the keynote and continuing throughout the conference, the rising prevalence of cardiovascular disease and major CVD risk factors dominated conversations.

• The Guidelines Gap – If you had “treat to guidelines” on your ACC bingo card you’d be in a good spot, because the exhibit hall and sessions were full of conversations about the challenges achieving guidelines adherence.

• The Diagnosis Gap – The same conversations often revealed massive estimates of how many more people would have qualified for those guidelines if they weren’t living undiagnosed.

• Treatment Expansion – The continued expansion of available preventative treatments (plus new indications added to existing treatments) remains a major theme, even if many of these treatments were the focus of the fiercest debates.

• Consumer Confidence – Healthcare insiders aren’t always quick to endorse technologies from outside of their domains, but ACC revealed a surprising acceptance of consumer products (e.g. the Apple Watch) and the overall benefits of home-based monitoring and care.

• AI at ACC – Artificial intelligence played a much greater role at this year’s ACC, with what seemed like far more AI studies and twice as many AI vendors and AI applications in the exhibit hall.

• Cardiologists in Demand – If you’re wondering about the state of cardiologist staffing levels, one look at all the health system and staffing company booths at ACC would have told you everything you need to know.

The Takeaway

Cardiology faces plenty of challenges, but it’s populated by some of the smartest and most passionate people in medicine who are working hard to solve those challenges (even if they don’t always agree on the solutions). Hats off to the ACC team for getting all those smart people together to push those solutions forward.

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Monebo’s AF ECG Algorithm

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The Wire

• Esperion’s CLEAR Outcomes: Esperion’s Nexletol (bempedoic acid) garnered major ACC buzz after its CLEAR Outcomes results showed that it reduces LDL-C and nonfatal events in statin-intolerant patients. In the large RCT (14k patients, 40mo), the oral treatment reduced LDL-C (-20% to 29.2 mg/dL), incidence of MACE (11.7% vs. 13.3% w/ placebo), and risk of MI and revascularization (-20% & -19%) without safety issues. Critics pointed out that Nexletol didn’t impact mortality, although they still saw “clear positives” in these results.

• Bioimpedance Pacemaker Interference: New research published in Heart Rhythm suggests that patients with a pacemaker might want to think twice before stepping on a smart scale. The bioimpedance technology that’s gaining popularity as a way to estimate body composition showed evidence of interference at pacing electrodes across all three devices studied – smart scales, smart watches, smart rings – leading the researchers to recommend that this patient population avoid all three.

• Cytokinetics’ Promising New Aficamten Data: Cytokinetics presented encouraging results from two trials that will help advance its hypertrophic cardiomyopathy drug, aficamten, toward pivotal Phase 3 clinical studies. Results from cohort 4 of REDWOOD-HCM found that aficamten was well-tolerated and led to significant improvements in heart failure symptoms and cardiac biomarkers over the 10 week treatment period. Additionally, long term results from FOREST-HCM showed that aficamten led to sustained effectiveness and tolerability out to 48 weeks.

• Missed Aortic Aneurysm Screenings: The vast majority of privately insured patients who qualify for abdominal aortic aneurysm screenings don’t receive their recommended exams. A new JVS study analyzed 2006-2017 data from 35k eligible patients (male ever-smokers, 65-75yrs), finding that just 38.7% underwent AAA screening. That’s well below the 74-79% adherence rates that have been reported by integrated health systems (e.g. the VA, Kaiser) and suggests that interventions are required to address this shortcoming.

• Amgen’s New Repatha & Olpasiran Data: Amgen presented two new studies on Repatha and olpasiran at ACC. The Repatha data (a combination of the Phase 3 FOURIER and FOURIER-OLE studies) showed that over a 2.2 year follow-up, patients with atherosclerotic CVD who were already receiving statin therapy had fewer adverse CV outcomes when Repatha was initiated earlier. Additionally, a new analysis of the Phase 2 OCEAN(a)-DOSE study showed olpasiran reduced Lp(a) concentration, even in patients whose baseline Lp(a) burden was very high.

• Echo-Based RV Intracardiac Flow: Purdue University researchers developed an echo-based method for measuring right ventricular intracardiac flow, which could serve as a more accessible alternative to Cardiac MRI-based 4D Flow. The team’s Doppler Velocity Reconstruction (DoVeR) technique measured RV intracardiac flow in 20 pediatric Repaired Tetralogy of Fallot patients (RTOF, who typically develop RV dysfunction), finding that DoVeR could indeed detect increased velocity and diastolic flow energy loss.

• Medtronic’s Three-Year TAVR Outcomes: JACC published a new study comparing clinical outcomes between TAVR (using Medtronic’s Evolut system) and traditional open-heart surgery. The study followed 1.4k patients for three years and found that TAVR was associated with a lower risk of death or disabling stroke (7.4% vs. 10.4%), and this difference between the two procedures was consistent over time. Patients who received TAVR also showed superior valve hemodynamics by the end of the study (mean gradient: 9.1mmHg vs. 12.1mmHg).

• RPM Adoption Up 1,294%: The adoption of remote patient monitoring skyrocketed 1,294% from January 2019 to November 2022, according to a recent report from Definitive Healthcare. Adoption unsurprisingly appears to be led by providers managing patients with chronic conditions such as heart disease and diabetes, with 29% of internal medicine physician procedure claims related to RPM, followed closely by cardiologists (21%) and family practice physicians (19%).

• Andexanet Alfa for Major Bleeding: In a multicenter, prospective study, authors tested a drug called andexanet alfa, which is designed to reverse the effects of blood thinning Factor Xa inhibitors. Analysis of 479 patients who were bleeding due to Factor Xa revealed that andexanet alfa reduced the activity of the blood thinner and was able to stop or control bleeding in 80% of patients. There were some side effects, including blood clots, but overall the drug appeared to be quite effective.

• Previous CTs for Presurgical Planning: NYU researchers found that surgeons might be able to use previous chest CTs to predict heart-related surgical risks, potentially avoiding the costs and radiation of presurgical scans. Four NYU physicians without CT interpretation experience were briefly trained to estimate coronary artery calcium plaque buildup and then assessed 2,650 patients using their previous chest CTs (0-9 total scores). The CAC estimates accurately predicted patients’ risks of major events (0-2 = <4%; 3-4 = 8%; 6-9 = 13%) and were consistent across each physician.

• January Hospital Margin Update: Kaufman Hall’s latest National Hospital Flash Report is in, and although hospitals entered 2023 on “more stable footing” than during last year’s omicron outbreak, median margins were still down from -0.7% in December to -1% in January. Lower volumes and ED visits combined with a 3% monthly rise in labor costs to drag down the margins, but Kaufman Hall expects that hospitals making purchases for the year in January contributed to the shaky performance. Last year’s numbers are scary to look at.

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