EDITOR’S CORNER
Alfred A. Bove, MD, PhD
Editor-in-Chief, CardioSource WorldNews
Great Debates
T
his month’s cover story focuses on great debates that present common challenges to our
treatment of patients with cardiovascular
disease. Like all debates, there is no single answer,
but the debates point out some of the areas where
more data are needed and where clinical judgement
must take a role in clinical decision making.
SPRINT: what is the BP goal?
What do we tell patients about their target blood
pressure (BP)? A standard part of cardiology practice is the common conversation about BP targets,
the need for good blood pressure control and the
value of therapies including medication, dietary
changes, weight reduction, exercise, and salt restriction. But what should be the recommended targets?
In trying to do what’s best for our patients,
we relied on a number of clinical trials, such as
ACCORD and HYVET, got excited about renal
denervation, and tried various combinations of
medications to reach a BP target. Most of the studies prior to the publication of the Systolic Pressure
Interventional Trial (SPRINT) told us that a target
BP of 140/90 was a reasonable goal, and some
studies indicated that going too low actually caused
harm. Then we saw the data from SPRINT that
suggested our target should be <120/80. The data
disrupted much of our current behavior with strong
recommendations to aim for this lower normal.
But SPRINT selected a narrow cohort of patients
to show improved mortality. Other trials, however, in
a wider spectrum of patients, do not show such improvement in outcomes and indicate BP targets should
remain at the 140/90 limit rather than a lower one.
Factors that weigh on our decision are ones we all
encounter in our daily practice of cardiology: age above
80 years, multiple co-morbidities, diabetes, obesity, and
a sedentary life style. All of these factors contribute to
risk as do concerns relating to too low a blood pressure that have emerged from several clinical trials.
So, where do we go with BP targets? Like most
aspects of medicine, clinical judgement is necessary. The elderly patient may not tolerate a systolic
BP of 120. Orthostasis and falls were increased in
SPRINT for this reason. As in all clinical situations,
clinical judgement, individual patient characteristics, patient preference, and data from clinical trials
all should enter into our decision making when
advising patients about BP targets.
ACC.org/CSWN
Stable CAD: invasive first?
I recently encountered a patient who had a PCI and
drug-eluting stent placed in his proximal right coronary artery 3 years ago. He is diabetic, with multivessel coronary disease who returned to excellent
functionality after the PCI, including returning to
work full time; nevertheless, he still had multivessel
coronary disease that was asymptomatic.
A stress test done 2 years after the procedure continued to show ischemia at moderate levels of exercise,
but in the absence of symptoms and with good functionality, he opted to continue with optimal medical
therapy rather than consider further revascularization.
Recent studies have questioned the wisdom of this
“watch and wait” approach, opting instead for aggressive interventional or surgical therapy to minimize
ischemia. Yet, data from the COURAGE trial indicated
that long-term survival was not changed by an aggressive revascularization strategy, and follow-up of
COURAGE patients also showed that within a few
years, symptoms were the same in the conservative
and aggressive therapy arms. Based on the COURAGE data and the patient’s current clinical status, we
continue with a conservative strategy to his follow-up
care. But what is the correct approach if he demonstrates a reduction in exercise tolerance and increasing
angina, but not enough to be labelled as unstable?
In COURAGE patients who became more symptomatic or unstable were revascularized; in other
studies, too, the data supported a shift to a more
aggressive approach when the patient became more
symptomatic. A shift to true unstable angina is a
clear indication for moving to an invasive strategy.
Data from a large registry in England and Wales
indicated that an early invasive strategy for both acute
coronary syndrome and non-ST-elevation myocardial
infarction (NSTEMI) reduced 180-day mortality. Looking at the many co-morbidities that we find in these
patients, it is important to use the best of guidelinedirected care for all patients with coronary disease,
including an early invasive strategy for patients with
ST-elevation myocardial infarction or NSTEMI, which
offered a small advantage in 6-month survival.
The large registries are pointing to a similar
early invasive strategy for patients with coronary
disease, but the choice of therapy needs to be made
in the context of each patient’s clinical status,
co-morbidities, and patient preference. While
there may or may not be long term gain in clini-
cal outcome with an early invasive strategy, given
the relatively low complication rate and safety of
coronary cathetization, concern of harm from the
diagnostic procedure is greatly diminished. The real
challenge will be to avoid revascularization of noncritical lesions when the decisions we make based
on invasive data are all in the eye of the beholder.
Thromboembolic prevention after TAVR:
antiplatelets or anticoagulants?
Transcatheter aortic valve replacement (TAVR) has
now become part of our therapeutic armamentarium for treating critical aortic stenosis. We evolved
from first targeting just the high-risk cases to considering this approach for moderate-risk cases, too,
and found TAVR to be a valuable tool for therapy of
the elderly with aortic stenosis.
However, there is one devastating complication:
stroke. The patient trades the clinical aspects of critical
aortic stenosis with the long-term need for supportive
care following a disabling stroke. Success needs to be
defined by the functional outcome and not just the fact
that the aortic