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. The third and final installment of this 3 part series follows below. (see also Part 1 and Part 2)
Dr. Josh Stern reviewed another trial on hypertension, the HYVET trial, which focused on hypertension in the elderly. While a very large body of literature supports blood pressure control in adults, the treatment of hypertension in the elderly is much more controversial. The HYVET trial was a randomized, controlled trial comparing blood pressure treatment with indapamide (a thiazide-like diuretic) +/- perindopril to placebo to in 3,845 patients over age 80 (mean age 84 years old). The trial was stopped early by the steering committee due to the significant improvements seen in the treatment group including a 21% reduction in total mortality, a 39% reduction in fatal strokes, a 64% reduction in heart failure, and a 34% reduction in cardiovascular events over the nearly 2-year follow up.
This trial enrolled patients from many non-U.S. countries (from Europe, China, Australasia, and North Africa). Because most clinicians treat elderly patients with systolic blood pressures over 160, this trial is unlikely to change current practice significantly, but it will give the physician more confidence that treatment is beneficial. The goal blood pressure was 150/80 which is a bit higher than current guidelines recommend. More investigation would be needed to determine whether this is a more appropriate goal in the elderly, or whether a lower goal is even more beneficial.
Dr. Lou Miller presented results of the Home Automated External Defibrillator Trial (HAT) which explored the possible benefit of keeping an automated external defibrillator in the home of patients at moderate risk of sudden cardiac death following a myocardial infarction (MI). Unfortunately, in this randomized trial of 7,001 patients, there was no mortality benefit for the patients with the home defibrillator on 37-month follow-up.
The investigators surmised that the reason for the lack of benefit was a lower-than-expected event rate (6.5% overall mortality), along with a high number of unwitnessed cardiac arrests (50% of all arrests). Nonetheless this trial provides good evidence that the widespread recommendation/distribution of automated external defibrillators to this moderate-risk group is not warranted. Of note, all families in both groups were educated on performing cardiopulmonary resuscitation.
Another important trial presented at the ACC meeting was the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET). This large trial randomized 25,620 patients with vascular disease or diabetes with end-organ damage (but not with heart failure) to three separate arms: telmisartan (Micardis, an angiotensin receptor blocker), ramipril (Altace, an ACE inhibitor), or a combination of the two drugs. All patients were already receiving standard care, including statins, anti-platelet therapy, and other antihypertensives. At follow-up (mean of 56 months) both the telmisartan and ramipril groups had similar cardiovascular event rates. The combination group did not show any improvement over the monotherapy group, but did have more complications (syncope, hypotension, and renal dysfunction).
This enormous and well-designed trial provides the strongest evidence to date against the routine use of combined ACE-I and ARB in patients with vascular disease or diabetes. It also provides more evidence that the use of an ARB in this population is just as effective as an ACE-I, and many will now view ARB’s as possible initial treatment instead of reserving them for those that don’t tolerate ACE-I’s. Some may even prefer the initiation of treatment with ARB’s over ACE-I’s for these patients, as the ARB’s were somewhat better tolerated (less cough, angioedema, and hypotension). It is important to keep in mind that heart failure patients were not included in this trial, and no conclusions can be drawn from this trial with regard to that population.