Practice Update: Cardiology

AMERICAN HEART ASSOCIATION ANNUAL SCIENTIFIC SESSIONS 22

Dr Joerg Herrmann on the FUTURE, EUCLID, ART, PRECISION and PIONEER AF-PCI trials

AHA 2016 12–16 NOVEMBER • NEW ORLEANS, USA This year’s American Heart Association Scientific Sessions saw the presentation of key studies such as the GLAGOV, EUCLID, FUTURE, ART and PRECISION trials. PracticeUpdate Cardiology Editorial Board members Dr Joerg Herrmann and Dr Peter Libby share their insights on these trials.

Joerg Herrmann MD is Associate Professor of Medicine at Mayo Graduate School of Medicine, Rochester, Minnesota and Associate Editor of PracticeUpdate Cardiology . The FUTURE trial The FUTURE trial set out to randomise over 1700 patients with multivessel CAD that had to include the LAD to either FFR or angiography alone in order to test if FFR helps guide treatment strategy and thereby improves outcome. The study was powered to detect a 30% relative reduction in the risk of MACE. However, at just over 900 patients, the data safety monitoring and steering committee advised to stop the trial in view of a >2-fold increase in overall mortality in the FFR group. One-year outcome data available for nearly 800 patients does not show a significant difference in overall MACE and only a trend towards higher overall and CV mortality in the FFR group. In summary, this trial may cast some uncertainty on the future of the use of FFR in clinical practice. Further data are needed on the impact on decision making and how this could be linked to adverse outcomes. By itself the FFR procedure does not increase the risk and nothing else is evident and intuitive.

However, the trial is a good reminder that one of the greatest benefit in all previous FFR trials was the reduction of stent implantations when haemodynamically not required, and thereby a reduction of costs and related risks. The EUCLID trial Encouraged by the results of the PLATO trial of superior outcomes of ticagrelor compared with clopidogrel in ACS patients and the PEGASUS trial on the benefits of ticagrelor over aspirin in patients with PAD, the EUCLID trial was pursued. This was a trial assessing the incidence of cardiovascular death, MI, and stroke in nearly 14,000 patients with symptomatic PAD randomised to ticagrelor or clopidogrel. No difference in the primary composite endpoint was found, even though there was a significant, 20% lower rate of ischaemic stroke in the ticagrelor group. There was no difference in bleeding events. Even though contrary to the study hypothesis, one important point is that poor metabolisers of clopidogrel were excluded from this trial. Thus, in essence this trial then shows that clopidogrel is as effective as ticagrelor in this population when effectively metabolised. The observation of the difference of a lower rate of strokes with ticagrelor needs further exploration. These findings are opposite to the PLATO trial results. The ART trial The ART trial randomised >3000 patients scheduled for coronary artery bypass grafting (CABG) to either left or bilateral internal mammary (IMA) bypass grafting (of note,

There is more to be explored, or, speaking in terms of the investigators, to be pioneered. Clinicians, however, are provided now for some first-time andmuch needed data on the use of NOACs for the large and challenging population of atrial fibrillation patients undergoing PCI.

© AHA/Edmund D. Fountain 2016

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