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