HotoffthepressWhat’snewandpotentiallyrelevant

PetrPolasekMDFRCPCFACC

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HotOffthePress

• Diet,NutritionandCVRisk• CVtrialsinDiabetes• AFpatient+CAD/PCI• BloodLipid/InflammationManagement• Obesityepidemic• Hypertension• Lp(a)• HeartFailure

Diet,NutritionandCVRisk

• AHArecommended3eggs/weekin1968• 1egg=↑bloodCHLby0.26mmol/L• Consumelessthan300mgCHL/day• AHAdroppedtheeggrestrictionin2002• Media“tugofwar”.• SaturatedFattyAcidsnotallthesame.• Meat/eggs/dairy=mixedeffect.

Diet,NutritionandCVRisk

• BottomLine• 1.HighCarbohydrateDiet=bad• 2.HighintakeofFruit,Vegetables,Nuts,Seeds=Beneficial• 3.TransFatsbad=willbebannedin2018• 4.Baconandprocessedmeat=notgood

•EATLESS!

CVtrialsinDiabetes

• DMdoublesriskofCVD• MalewithDMwilllive6yearslessthanequalw/oDM• Insulinnobetterthanplaceboinreducingcvevents• FDAmandatesthanallnewDiabeticRxmusthavecvoutcomes

CVtrialsinDiabetes

• DPP4:safeforcvd,butno↓cvevents• Empa-Reg:↓mortality,slight↑CVA,m.i.onlylittle↓• CANVAS:similartoEmpa-Reg,but↑lowerextremityamputation• GLP1:Lixionetalide:safeforcvd• LEADERtrial:↓cvevents• Samoglutide:↓cveventsby25%• EXSCEL:nobenefit• SGLT2:↓HF,no↓m.i.orCVA(diuretic=offloadthe❤)• GLP1:↓atherogenesis:↓m.i./CVA,nochangeinHF

AFpatient+CAD/PCI

• AFtrials:OACbetterthanDAPT• PCI:DAPTbetterthanOAC• AF+PCI=“tripleRx”=riskofbleeding↑4fold

• PIONEER• Re-Dual

AFpatient+CAD/PCI

• PIONEER• Re-DUAL• AUGUSTUS,ENTRUST-AFPCI

• RIVA15mgod+antiplatelet• RIVA2.5mgbid+DAPT• RIVAWarfarin+DAPT

• RIVA– lessbleeding,noincreasestentthrombosis,notpoweredforCVA

• SMOKING↑↑riskofstentthrombosis!

BloodLipid/InflammationManagement

• Anatetracib: ↑HDL,modest↓LDL• ↑DM,sBP,KidneyFailure

• PCSK9inhibitors:nolevelbelowwhichthereisnobenefit• $8000/year

Conclusions

• Antiinflammatory therapy targeting the interleukin-1β innate immunity pathway with canakinumab at a dose of 150 mg every 3 months led to a significantly lower rate of recurrent cardiovascular events than placebo, independent of lipid-level lowering.

Obesityepidemic

• 20genesrelatedtoobesity• Adiposetissueisanorgan• Gutisahormonegenerator• 60%haveamentalhealthissues• Behavioralmodification: 1-5%weightreduction• Pharmaintervention: 5-15%• BariatricSurgery: 20-40%

Obesityepidemic

• Fashionablediets(allofthem),longterm:1-5%weightreduction.• Lowcarb/highfatdiets:betterforpre-DMpopulation• Intermittentfasting• INDIVIDUALIZE!

CADandanticoagulants/antiplateletagents

• COMPASSstudy:chronic,stableCAD,Riva2.5bid+100mgASAorRIVA5bidreducesCVdeath,stroke,micomparedtoASA100mg

• Riva+ASA:ischemicCVA↓by50%• Riva+ASA:↓mortalityby18%• Riva:↑GIbleeds(?pre-existingsource),most<1st year

• COMPASSPAD

Cumulative Incidence of the Primary Efficacy Outcome among Participants Receiving Rivaroxaban plus Aspirin, Rivaroxaban Alone, or Aspirin Alone.

Eikelboom JW et al. N Engl J Med 2017;377:1319-1330

Hypertension

• Doctors,STOPcheckingBPyourself!!!• SPRINTtrial: Frail+elderlynotrepresented

NottoomanypatientswithDIFFICULTBP

• StartwithlowerdoseCOMBOpills:fastertotarget,lesssideeffects,betteroutcomes

• IfusingHTZ:useb.i.d.orreplacewithChlorthalidone orIndapamide

Lp(a)

• Veryatherogenic• ↑in20%ofpopulation• >50mg/dL =strongpredictorofCAD,CVA,↑riskofAorticStenosis• Geneidentified• StatinsdonotlowerLp(a)• Ifmeasured:lowerLDL<2,considerASA,Niacin,lifestylechange• AntisenseRx:coming• ExerciseandLifestylechangeTRUMPSgeneticrisk(NEJM2017)

HeartFailure

• HFpEF (EF>40%)=50%ofallHF(restisHFrEF).• Difficulttodifferentiate• HFpEF:ARB,Spironolactone,BetaBlockers=nobenefit.• TOPCATre-analysis(excludeformerUSSR):Spironolactonebetter?• HFrEF:treatmentpyramid

HeartFailure

• PatientsareNOTbeingdosedproperly.• Sacubitrol/Valsartan=ENTRESTO• IfreplacingACE-I:needtostopACEx36hrs• IfreplacingARB:nowashout• WatchforGFR(mustbe>30)hypotension