Commentary by Rob Donnino MD, NYU Division of Cardiology
The annual meeting of the ACC was held last month in Chicago. A good number of NYU faculty and fellows either presented at or attended the meetings. The cardiology fellows exhibited an impressive balance between exploring the Chicago nightlife and diligent attendance at the meetings. Several of the cardiology fellows presented some of the highlights of the ACC meeting at a recent journal club conference for the Cardiology Division. They are being summarized in a 3 part weekly series. Part 1 was posted last week. Part 2 follows below:
Dr. Amit Pursnani presented the results from the REVERSE study which was the first large (n=610) randomized, controlled, double-blinded study to look at resynchronization therapy in NYHAA Class I and Class II patients (previous larger trials have focused on NYHAA Class III and IV patients). All patients had a QRS > 120 ms on ECG, and a dilated left ventricle (> 5.5 cm). The primary endpoint was a composite of heart failure symptoms/admissions and overall mortality. There was no significant difference between the 2 groups (those with the biventricular device turned on and those with the device turned off) over the course of 1 year. There were several important secondary endpoints, however, that did favor resynchronization therapy including: improved left ventricular (LV) size (both end systolic and diastolic), improved LV EF (approx. 4 points), and time to first hospital admission for heart failure.
This was a “mixed” trial, and some debate exists over whether the demonstrated benefit is clinically important enough to outweigh the possible risks of this treatment. The implantation success rate was 97%, however lead complications were present in 9.5% of these patients. In addition, as Dr. W. Slater pointed out at journal club, the average LV diastolic diameter was 7 cm, which is quite large for a group with minimal or no symptoms, and the observed improvements may not be applicable to patients with smaller ventricles. It seems unlikely that current guidelines or clinical practice will change significantly based on this single, mixed results trial given the possible complications and large expense of this therapy. Nonetheless, some, including the lead author of the study, argue that the benefits shown in this study do outweigh the risks of this treatment. Perhaps future studies with clinically relevant endpoints over longer-term follow-up can shed more light on this group of patients.
Dr. Emily Rose reviewed the results of the ACCOMPLISH trial which compared treatment combinations for patients with hypertension in a large (n=11,290) randomized controlled trial. The combination of an ACE-inhibitor and diuretic (benazepril/HCTZ) was compared to the combination of an ACE-inhibitor and a calcium channel blocker (CCB) (benazepril/amlodipine). Slightly more patients reached blood pressure goals in the ACE-inhibitor/CCB group (81.7% vs. 78.5%, p <0.001) at 30 month follow-up. More importantly, the primary endpoint of cardiovascular morbidity and mortality was significantly reduced in the ACE-inhibitor/CCB group compared to the ACE-inhibitor/HCTZ group (20% risk reduction at p = 0.0002).
While treatment for hypertension must be carefully individualized for each patient, the ACCOMPLISH trial, with its impressive size and scope, provides strong evidence for the initial treatment of hypertension using a combination of an ACE-inhibitor and CCB combination when appropriate. The current National Heart, Lung, and Blood Institute guidelines (JNC7) advocate for the initial treatment of hypertension with a diuretic. As the guidelines are revisited this year, the results from ACCOMPLISH will undoubtedly be looked at closely by the committee and may lead to a revision of the current guidelines. Of one final note, the patient population in this study included both U.S. (70%) and Scandinavian patients with many characteristics similar to what we see in our NYU population, including diabetics (60%), obesity (50%), women (40%), black (12%), all with mean age of 68.