Practice Update: Cardiology

ESC 2016 15

Professor TomMarwick discusses the DANISH, REM-HF, MORECARE, CE-MARC 2, CONSERVE andNACIAMtrials

Tom Marwick, MBBS, PhD, MPH, Director and Chief Executive of BakerIDI Heart and Diabetes Institute.

1. DANISH: ICDs in nonischaemic heart failure For me, this was the top trial presented at this year’s meet- ing. The DANISH study looked at primary prevention with ICDs for patients with nonischaemic heart failure. Most cardiologists have, at some stage, had some disquiet about the impact of primary prevention ICDs, especially in the elderly. Many ICDs are implanted and never discharge. This Danish group, in a pragmatic clinical trial, looked at whether there was a benefit of implanting an ICD in nonischaemic HF with an impaired ejection fraction. The investigators reported no difference in all-cause mor- tality with ICD versus medical care in nonischaemic HF. This is despite the fact that ICDs reduce sudden cardiac death. The results point to the role of multi-morbidity – HF patients are very likely to have multiple diseases. The message from this study is that ICDs do not benefit older patients – the study did a subgroup analysis of patients older than 68 years – whereas it might benefit younger patients. This is contrary to current guidelines and an incredibly important observation. 2. REM-HF and MORE CARE: remote telemonitoring in heart failure The REM-HF and MORE CARE were two studies of remote telemonitoring in HF presented at the ESC. The conclusions were pretty much the same: telemonitoring did not change HF outcomes. We know that telemonitoring is inexpensive, and some private insurers in the US are considering it as a means of controlling costs. Clearly, the long-term care of patients with HF requires more than monitoring – we can get huge amounts of data but there needs to be some kind of interventional strategy that arises from the interpretation of the data. These results are a reality check on what telemonitoring has to offer – I don’t think they signal the end of telemonitoring but it needs to be thought through more carefully. 3. CE-MARC 2 and CONSERVE: diagnostic

at MRI or SPECT imaging for perfusion versus the current NICE guidelines (which use a probability-based approach for test selection). They found that the use of a functional test reduced the need for angiography and reduced inter- ventions. In fact, in the group that had the functional test, 8% of the subsequent angiography was unnecessary com- pared with 28% in the group that was guided by the NICE guidelines. So that one was a win for doing stress testing. The CONSERVE trial was a comparison between coronary CT angiography versus invasive angiography in symptomatic patients to reduce the number of negative angiograms. The study showed that if CT angiogram was performed before catheterisation, there was an 85% reduction of invasive angiography, with similar outcomes. That one was a win for CT angiography. I think it’s an interesting juxtaposition that one study says “do a non-invasive CT test before an angiogram so that you can avoid doing angiography” while the other says “do a non-invasive stress test instead of using current guidelines” because, again, you can save a bunch of angiograms. It also demonstrates how we’re still really uncertain about how to use non-invasive testing in people with chest pain. There is still a lot of work to be done in this area and I think the emphasis here is that MRI perfusion imaging is an interesting strategy that we should probably think more about in Australia. 4. NACIAM: N-acetylcysteine with glyceryl trinitrate on infarct size This is an important Australian trial investigating the free radical scavenger N-acetylcysteine. The hypothesis was that, in people having myocardial infarction, some of the damage from the infarct is related to free radicals. And so if you could scavenge the free radicals, either that would be of direct benefit or it would enable nitrates to be effective. The investigators found a 38% reduction in infarct size with the use of the N-acetylcysteine with glyceryl trinitrate versus glyceryl trinitrate alone. What we’ve been doing with MI has really been focused on early revascularisation for a long time, but not so much on other things we can do to try to salvage tissue. This is a nice example of such a strategy. Second, this group in Adelaide has been really imaginative about selecting agents for that purpose. It’s nice to see one of these come in with a really impactful result.

trials on imaging technologies for recognition of coronary disease

Both of these were diagnostic trials on the use of new im- aging technologies for the recognition of coronary disease, comparing combinations of functional testing with CT and invasive angiography. In CE-MARC-2, the authors looked

DECEMBER 2016