The 2014 American Heart Association meeting included a number
of clinically important presentations, including several failing
to find support for some standard practices. So many negative
trials have gathered attention recently that new rules are being
considered that would require more such data be available freely
to the public. (See the sidebar on Positive News on Negative Trials.)
Here’s a collection of some of the most interesting items
from this meeting.
DAPT Beyond 1 Year Wins in Large Study
The optimal duration of dual antiplatelet therapy
(DAPT) has been the subject of considerable debate
in the last couple years. Supporters of longer-term
use got a big shot in the arm from the results of the
DAPT Study.
Study participants (about 10,000 total from 11
countries) who took aspirin plus a thienopyridine
(clopidogrel or prasugrel) for 30 rather than 12
months after stenting
• were half as likely to develop in-stent thrombosis than patients who received DAPT for 12
months, followed by aspirin plus placebo for 18
months (placebo group) (FIGURE), and
• had about half the risk of a new myocardial
infarction (MI) compared to the placebo group.
Kirk Garratt, MD, Lenox Hill Heart and Vascular
Institute, New York City, said in a press conference,
“Thirty months of treatment with prasugrel plus
aspirin was associated with important reductions in
major adverse cardiovascular and cerebrovascular
events and stent thrombosis compared to 12 months
of treatment, with no signal of truly dangerous
bleeds being increased with longer therapy.”
He added, “Withdrawal of prasugrel at 12 months
was associated with an important increase in the
risk of ischemic events early after drug discontinuation, the principal risk being myocardial infarction,
and the impact of drug withdrawal was evident
within 90 days of drug cessation.”
The study’s principal investigator and lead author,
Laura Mauri, MD, said DAPT “was the first and
only study comparing durations of treatment with
antiplatelet therapy that was adequately powered
to detect a benefit on stent-related heart attacks.”
The study enrolled “a broadly inclusive population
treated with coronary stents.” Dr. Mauri, who is an
interventional cardiologist at Brigham and Women’s
DAPT: Primary Endpoint – Stent
Thrombosis
FIGURE
CardioSource.org/CSWN
Hospital and chief scientific adviser at the Harvard
Clinical Research Institute in Boston, Massachusetts,
added, “Overall the benefits of longer therapy were
very consistent throughout the types of patients we
studied, and outweighed the risks.”
According to Dominick J. Angiolillo, MD, PhD,
director of Cardiovascular Research at the University of Florida College of Medicine, “…the guideline
recommendation of one year of dual antiplatelet
therapy remains steadfast.” He did add, “We cannot
ignore other trials presented this week or earlier
trials suggesting shorter durations of dual antiplatelet therapy for some patients. We will continue to
follow guideline-based care, while evaluating the
findings of DAPT and the forthcoming PEGASUS
trial and how best to implement the implications
of those results in clinical practice for the benefit of
each individual patient.”
IMPROVE IT: Ezetimibe/Statin Combination Better After ACS than Statin Alone
It has been a decade since Christopher Cannon,
MD, Brigham and Women’s Hospital, Boston, Massachusetts, presented the game-changing PROVE
IT – TIMI 22 results at ACC.04 comparing intensive
versus moderate lipid lowering with statins after
acute coronary syndrome (ACS). Now, he is the
lead author of IMPROVE-IT.
“This is the first trial to demonstrate an incremental clinical benefit when adding a non-statin
cholesterol-lowering agent to a statin,” he said, “and
we found that even lower was even better, reaffirming the LDL hypothesis that reducing LDL