Davide Capodanno, MD, PhD on the deluge of positive interventional trials at ACC24.

Cardiology

Cardiac Wire’s Top 8 Takeaways from ACC 2024

The ACC 2024 meeting is now complete, after over 17,000 cardiology professionals converged in Atlanta to witness cardiovascular medicine evolve in front of their eyes. Among dozens of highlights, here are the Cardiac Wire’s eight biggest trends emerging from ACC24.

• Interventional Innovations – Interventional cardiology was the clear winner at ACC24, with numerous trials supporting an expanded role for interventional procedures across a wider range of conditions than we ever could have imagined five years ago.

• Neutral Pharma – Conversely, the pharma late breakers featured an outsized share of neutral trials, that might be hypothesis-generating, but won’t be changing cardiovascular medicine in the short term.

• Cutting Polypharmacy – ACC 2024 gave cardiologists a good reason to trim their patients’ medications, after late-breakers showed that beta blockers might not help post-MI and suggested that ACS patients might be able to stick with ticagrelor monotherapy one month after PCI (while dropping DAPT and aspirin).

• GLP-1s Are So Hot Right Now – In the year since ACC 2023, GLP-1s went from a weight loss and diabetes drug that “might” have cardiovascular benefits to becoming a promising (and Medicare-covered) option for CV event reduction. GLP-1s’ list of cardiovascular indications might continue to grow from here, noting that we just learned at ACC24 that semaglutide also reduces HF symptoms.

• Diagnostic Barriers – Many conversations drifted towards the elusive goal of treating heart disease more like cancer, including more comprehensive screening and much earlier treatments. ACC24 featured some impressive AI-based technologies that could significantly widen cardiology’s patient-detection pipeline, but we saw little evidence of screening policies/practices keeping pace with screening technologies.

• Drug Barriers – Most cardiovascular drugs work quite well, but getting them approved, covered, guideline-recommended, and physician-adopted remains a major challenge… and even once those challenges are overcome, achieving patient adherence still arguably remains the greatest barrier of all.

• Always-On Treatments – Perhaps in light of the aforementioned patient adherence barrier, ACC24 showed the continued surge in long-lasting treatments, ranging from long-term LDL-C and antihypertensive injections to emerging interventions like renal denervation.

• ACC is Back – This week’s 17k attendance number puts the ACC24 on par with the last pre-pandemic ACC in Spring 2019, and you could feel the difference across the packed sessions, exhibit hall, and evening events.

The Takeaway

Between the innovations in the exhibit hall and the practice-changing results revealed in the various late-breakers, it’s clear that cardiology is changing fast, and despite a long list of challenges, most ACC24 attendees would agree that it’s headed in the right direction.

Making the Leap to Outsource Post-Processing

Interested in how to outsource cardiac image post-processing, but not sure where to start? PIA walks you through how to assess and compare vendors, understand pricing models and payment options, and outline your requirements to identify vendors who meet your clinical needs. 

Where to Go for Cardio AI?

TeraRecon’s Cardio Suite is a collection of hand-selected, vendor-neutral Cardiology AI algorithms that aid in the analysis and interpretation of echocardiograms and chest CTs. Learn about TeraRecon’s AI offering and how they improve efficiency and accuracy here.

The Wire

• Evolut TAVR’s SAA Evidence: The SMART trial raised eyebrows at ACC, showing that Medtronic’s Evolut self-expanding TAVR has solid 1-year advantages over Edwards’ SAPIEN 3 balloon-expandable TAVR in patients with small aortic annuli (≤430 mm2). Among 716 randomized global patients (87% women!), the two devices had similar rates of death, disabling stroke, or HF hospitalization (9.4% vs. 10.6%), but Evolut had much lower bioprosthetic-valve dysfunction (9.4% vs. 41.6%), hemodynamic structural valve dysfunction (3.5% vs. 32.8%), and aortic-valve mean gradient (7.7 vs. 15.7 mm Hg).

• More Post-MI Beta-Blocker Doubt: The REDUCE-AMI trial added more evidence that beta-blockers might not benefit post-MI patients over the long-term. The study randomized 5,020 Swedish patients with acute myocardial infarction who underwent early coronary angiography and had normal LVEF (≥50%), finding that the beta-blocker group actually had similar rates of the composite primary endpoint (death or a new MI) over a 3.5-year average follow up (7.9% vs. 8.3%). Beta-blockers also didn’t seem to reduce the risk of any of the secondary endpoints.

• J&J Adds Shockwave: Johnson & Johnson officially acquired Shockwave for a massive $13.1B, giving J&J access to Shockwave’s standout intravascular lithotripsy system and deep R&D pipeline. The acquisition continues J&J’s push into interventional cardiology, following its acquisitions of heart pump maker Abiomed ($16.6B) and LAA closure startup Laminar ($1B) over the last 18 months. When combined with its Biosense Webster electrophysiology business (plus future potential M&A moves), J&J seems to be on pace to create a top tier cardiology medtech business.

• Wegovy for Heart Failure: We might be able to add heart failure to the growing list of diseases that GLP-1s can help, after the STEP-HFpEF trial showed that semaglutide (Novo Nordisk’s Wegovy) improved HFpEF quality-of-life symptoms in patients who also had obesity and type 2 diabetes. The researchers randomized 616 patients to take semaglutide or a placebo for one year, finding that the semaglutide group had greater improvements to KCCQ-CSS (13.7 vs. 6.4) and 6-minute walk distance (14.3m difference), despite more modest weight loss differences (−9.8% vs. −3.4%).

• Impella’s STEMI Shock Benefits: It’s been a tough run for Abiomed’s Impella pump, but things are looking brighter after the DanGer Shock trial provided the best evidence yet of its benefits. Among 355 randomized STEMI patients with cardiogenic shock, the Impella group had a significantly lower mortality rate than standard-care patients (45.8% vs. 58.5%). However, these mortality improvements “did not come without a cost,” as the Impella group had far more safety events (24% vs. 6.2%) and more renal-replacement therapy (41.9% vs. 26.7%). Subgroup analysis also revealed that it might be far less effective with women.

• Cardiology Board Advances: Six months after the major cardiovascular societies announced plans to create a new board to replace the ABIM, board leaders revealed that they have submitted their application and the new board could launch by early 2025. The ACC24 briefing reiterated many of the same testing goals as previous statements (more logical, economical, cardiology-centric, less focused on memorization), while revealing that it has already appointed 10 of its 15 transitional board members, its application will soon enter a 90-day public comment period, and a decision should come within the next 6 to 8 months.

• Acoramidis’ CMRI Improvements: BridgeBio Pharma added new cardiac MRI evidence that its acoramidis ATTR-CM treatment drives cardiac structural and functional improvements (and potentially cardiac amyloid regression), eight months after acoramidis’ Phase 3 trial showed improvements to mortality, morbidity, and quality-of-life. The substudy performed CMRI on 35 participants at baseline and throughout their treatments, finding that the acoramidis group showed greater stability/improvements across a range of structural and functional measurements.

• Adding Zilebesiran Cuts BP: Results from the KARDIA-2 trial showed that Alnylam’s twice-yearly injectable zilebesiran effectively reduces blood pressure when added to standard of care among patients with uncontrolled hypertension. The researchers randomized 672 patients to receive zilebesiran and one of three antihypertensives, finding that zilebesiran reduced 24-hour SBP by 12.1 mmHg after three months versus a placebo (the primary endpoint). Zilebesiran also drove significant office SBP reductions across each of the three antihypertensives at three months, and reductions were sustained through six months.

• Preventative PCIs: Perhaps no ACC study stirred more debate than the PREVENT trial, which showed that patients with vulnerable plaques achieve significant long-term benefits from preventative PCIs. The trial randomized 1,606 patients with vulnerable plaques (that weren’t flow-limiting) to either receive PCI and optimal medical therapy, or only receive optimal medical therapy. After two years, the PCI group had an 89% lower risk of the primary outcome (0.4% vs. 3.4% = cardiac death, target-vessel MI, target vessel revascularization, or angina hospitalization), and PCI also maintained its primary outcome advantage over 7 years (6.5% vs. 9.4%).

• Inclisiran-First for ASCVD Patients: For CVD patients unable to reach their LDL goals despite maximal statin therapy, an “inclisiran-first” strategy may offer a solution. The VICTORION-INITIATE trial added inclisiran (Novartis’ Leqvio siRNA PCSK9i) to typical lipid management, slashing LDL levels by an average of 60% compared to a 7% reduction with usual care alone. Even more impressive, over 80% of patients achieved LDL goals with inclisiran (vs. just 22% with usual care) without increasing statin discontinuation rates.

• International AFib Standards: New standards for treating AFib have been established by international experts, with a particular focus on catheter ablation. The consensus statement advises ablating patients with: concurrent AFib and heart failure, treatment resistant recurrent or persistent AFib, and symptomatic patients with recurrent paroxysmal AFib. The guidelines also delve into classifications, anatomical considerations, and mapping and ablation tools and strategies for AFib management.

Leveraging a Proven Echo AI Platform

Us2.ai has developed a promising new pathway for bringing custom echo AI applications into widespread clinical and commercial use – historically a challenge for algorithms produced by health systems and academic institutions. Find out how it worked in a Ugandan RHD program here.

Can AI Prevent Heart Disease Progression?

Tune in to Cleerly’s on-demand webinar where study leaders will discuss how the landmark TRANSFORM randomized controlled trial will test whether an AI-personalized care strategy can outperform traditional risk factor management and prevent cardiovascular events.

The Resource Wire

• Monebo’s AF ECG Algorithm: Atrial fibrillation is often difficult to characterize with an automated algorithm due to the changing waveform morphology, system, or muscle noise. This is especially true given the size constraints of ambulatory devices to detect AFib. See how Monebo’s Kinetic AF ECG Algorithm overcomes these size limitations without sacrificing accuracy.

• Experience the future of learning: Medtronic Academy 2.0 is here! Ulock your ultimate destination for structural heart medical education with the newly redesigned Medtronic Academy 2.0. Gain access to expert-led courses, webinars, and a wealth of resources to stay ahead in cardiovascular care. Visit now!

• Merge Cardiology is Best in KLAS: Merge Cardio and Merge Hemo continued their KLAS hot streak, ranking Best in KLAS 2024 for Cardiology and Hemodynamics for the 9th and 12th years. The Merge by Merative cardiology solutions further expanded their KLAS score leads this year, with Merge Cardio scoring 82.8 (up from 82.7 last year) and Merge Hemo surging to 91.5 (from 85.7 in 2023).

• Advancing CAD Risk Assessments: When HeartFlow used its Plaque Analysis solution to analyze more than 11,000 CCTAs in the DECODE Study, the solution achieved 95% agreement with IVUS and led to changes in two out of every three patients’ treatment plans. See how HeartFlow Plaque Analysis can help you accurately assess your patients’ CAD risks and personalize their treatment.

• Incidental CAC Predicts Long-Term Risks: What if you could identify which of your asymptomatic patients have high risks of future cardiac events? Stanford-led researchers used Bunkerhill Health’s Incidental CAC algorithm to do just that, finding that patients with ≥100 incidental CAC scores had a 24% 10-year risk of developing ASCVD and far higher risks of major adverse events.