CardioSource WorldNews December 2014 - Page 28

CLINICAL NEWS JACC in a FLASH Featured topics in the current and recent issues of the JACC family of journals 2013 ACC/AHA Updated Guidelines “JNC-8” BP Goals Likely to Bring Significant Changes Will Require Close Monitoring of to LDL Management Compliance with the updated 2013 American College of Cardiology/ American Heart Association (ACC/ AHA) cholesterol guidelines for adults could result in some major shifts in statin use and cholesterol testing, according to the results of a study from the NCDR PINNACLE database published rec ently in JACC. “Achieving concordance with the new cholesterol guidelines would result in significant increases in statin use.” —Maddox, et al. Application of the new guidelines to a cohort of patients from 2008 to 2012 revealed that more than 30% of patients eligible for statins, according to the new guidelines, were not receiving them, and more than 20% of patients were receiving nonstatin lipid-lowering therapies. “Achieving concordance with the new cholesterol guidelines would result in significant increases in statin use and 26 CardioSource WorldNews might also lead to significant reductions in nonstatin therapies and laboratory testing,” wrote researchers led my Thomas M. Maddox, MD, of VA Eastern Colorado Health Care System. The researchers used the PINNACLE data from 2008 to 2012 to assess the practice patterns as a function of the 2013 guidelines among 1,174,545 patients. Data revealed that 96.1% of patients in the cohort were considered statin eligible, but 32.4% of these patients were not receiving any statin therapy. In addition, 22.6% of patients in the group were receiving a nonstatin therapy. The authors also examined the frequency of LDL cholesterol assessments and found that 20.8% of patients had undergone two or more assessments; 7% of patients had more than four assessments. In an editorial that accompanied the article, Nanette K. Wenger, MD, of Emory University School of Medicine, pointed out that the majority of patients examined were being treated for secondary prevention, ignoring primary prevention, a major focus of the controversy surrounding the new guidelines. However, given the large number of statin-eligible patients not being treated and the large number on nonstatin therapies, Wenger wrote that “others will likely examine the overall net cost effect of the new guideline related to increase cost of statin use, reduced cost for nonstatin therapies, reduced use of statin and nonstatin therapies among patients without indications, and reduced costs of LDLC testing, as well as potential savings from reduced cardiovascular event occurrences.” Maddox TM, Borden WB, Tang F, et al. J Am Coll Cardiol. 2014;64:2183-2192. Untreated Patients Still at High Risk Patients who meet the new, more relaxed 2014 expert panel—what was originally supposed to be the NHLBI Joint National Committee (JNC)-8— blood pressure (BP) goals may be at significantly greater cardiovascular risk than those who meet the 2003 JNC-7 BP goals, according to a data review using the NCDR PINNACLE database. In fact, researchers, led by William B. Borden, MD, of George Washington University, found that one in seven patients who did not meet JNC-7 BP goals would now meet the 2014 treatment goals. The 2003 JNC-7 goals require BP less than 140/90 mm Hg for the general population and less than 130/80 mm Hg for patients with diabetes or chronic kidney disease. In contrast, the 2014 panel goals increased blood pressure targets to 150/90 mm Hg for patients 60 years and older, and 140/90 mm Hg for patients with diabetes or chronic kidney disease. Borden and colleagues examined data from 1,185,253 patients in the PINNACLE database. They found that 59.6% achieved the 2003 JNC-7 BP goals, but that 74.3% of patients met the 2014 expert panel goals. That translated into 14.6% of patients for whom goal achievement changes based on the recommendations used. Of that 14.6%, the average Framingham risk score was 8.5 and the 10-year ASCVD risk score was 28; 23.2% had a prior stroke or transient ischemic attack, and 64.6% had coronary artery disease. In their discussion of the results, Borden and colleagues wrote, “using these data about patients age 60 years and older, treatment of the more than 80,000 older patients in our study population affected by the change in targets to a systolic blood pressure goal of 140mm Hg could potentially avert approximately 8,000 cardiovascular events over 10 years.” In an editorial published with the article, Clive Rosendorff, MD, PhD, of James J. Peters VA Medical Center wrote that although the 2014 expert panel recommendations included a thorough and useful review of currently available data on BP, there may be unintended consequences of the recommendations, including the fact that nearly 13.5 million patients with hypertension previously eligible for treatment may no longer be treated under these new recommendations. Borden WB, Maddox TM, Tang F, et al. J Am Coll Cardiol.2014;64:2196-2203. Outlook Positive Post-30 Days after PCI for STEMI Patients who survive the first 30 days after undergoing percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) have an excellent prognosis. Results of a study published recently in JACC, found that those who survive had less than a 1.5% annual risk for cardiac death. Frants Pedersen, MD, PhD, of the department of cardiology at the University of Copenhagen, and colleagues wrote that these results indicate that “patients who survive the acute phase of an STEMI treated with primary PCI have an excellent late cardiac prognosis and that late cardiac mortality in unselected all-comers is similar to that of selected participants of previous trials.” Pedersen and colleagues looked at the cause of death of 2,804 consecutive patients with STEMI who were treated with primary PCI. Patients December 2014