Hot off the press. What s new and potentially relevant. Petr Polasek MD FRCPC FACC

Transcription

1 Hot off the press What s new and potentially relevant Petr Polasek MD FRCPC FACC

2 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.

3 Hot Off the Press Diet, Nutrition and CV Risk CV trials in Diabetes AF patient + CAD/PCI Blood Lipid/Inflammation Management Obesity epidemic Hypertension Lp(a) Heart Failure

4 Diet, Nutrition and CV Risk AHA recommended 3 eggs/week in egg = blood CHL by 0.26 mmol/l Consume less than 300 mg CHL/day AHA dropped the egg restriction in 2002 Media tug of war. Saturated Fatty Acids not all the same. Meat/eggs/dairy = mixed effect.

5 Diet, Nutrition and CV Risk Bottom Line 1. High Carbohydrate Diet = bad 2. High intake of Fruit, Vegetables, Nuts, Seeds = Beneficial 3. Trans Fats bad = will be banned in Bacon and processed meat = not good EAT LESS!

6 CV trials in Diabetes DM doubles risk of CVD Male with DM will live 6 years less than equal w/o DM Insulin no better than placebo in reducing cv events FDA mandates than all new Diabetic Rx must have cv outcomes

7 CV trials in Diabetes DPP 4: safe for cvd, but no cv events Empa-Reg: mortality, slight CVA, m.i. only little CANVAS: similar to Empa-Reg, but lower extremity amputation GLP1: Lixionetalide: safe for cvd LEADER trial: cv events Samoglutide: cv events by 25% EXSCEL: no benefit SGLT2: HF, no m.i. or CVA (diuretic = off load the ) GLP1: atherogenesis: m.i./cva, no change in HF

8 AF patient + CAD/PCI AF trials: OAC better than DAPT PCI: DAPT better than OAC AF + PCI = triple Rx = risk of bleeding 4 fold PIONEER Re-Dual

9 AF patient + CAD/PCI PIONEER Re-DUAL AUGUSTUS, ENTRUST-AF PCI RIVA 15 mg od + antiplatelet RIVA 2.5 mg bid + DAPT RIVA Warfarin + DAPT RIVA less bleeding, no increase stent thrombosis, not powered for CVA SMOKING risk of stent thrombosis!

10 Blood Lipid/Inflammation Management Anatetracib: HDL, modest LDL DM, sbp, Kidney Failure PCSK 9 inhibitors: no level below which there is no benefit $ 8000/year

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12 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.

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14 Obesity epidemic 20 genes related to obesity Adipose tissue is an organ Gut is a hormone generator 60% have a mental health issues Behavioral modification: 1-5% weight reduction Pharma intervention: 5-15% Bariatric Surgery: 20-40%

15 Obesity epidemic Fashionable diets (all of them), long term: 1-5% weight reduction. Low carb/high fat diets: better for pre-dm population Intermittent fasting INDIVIDUALIZE!

16 CAD and anticoagulants/antiplatelet agents COMPASS study: chronic, stable CAD, Riva 2.5 bid mg ASA or RIVA 5 bid reduces CV death, stroke, mi compared to ASA 100 mg Riva + ASA: ischemic CVA by 50% Riva + ASA: mortality by 18% Riva: GI bleeds (?pre-existing source), most < 1 st year COMPASS PAD

17 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:

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20 Hypertension Doctors, STOP checking BP yourself!!! SPRINT trial: Frail + elderly not represented Not too many patients with DIFFICULT BP Start with lower dose COMBO pills: faster to target, less side effects, better outcomes If using HTZ: use b.i.d. or replace with Chlorthalidone or Indapamide

21 Lp(a) Very atherogenic in 20% of population >50 mg/dl = strong predictor of CAD, CVA, risk of Aortic Stenosis Gene identified Statins do not lower Lp(a) If measured: lower LDL < 2, consider ASA, Niacin, lifestyle change Antisense Rx: coming Exercise and Lifestyle change TRUMPS genetic risk (NEJM 2017)

22 Heart Failure HFpEF (EF>40%) = 50% of all HF (rest is HFrEF). Difficult to differentiate HFpEF: ARB, Spironolactone, Beta Blockers = no benefit. TOPCAT re-analysis (exclude former USSR): Spironolactone better? HFrEF: treatment pyramid

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24 Heart Failure Patients are NOT being dosed properly. Sacubitrol/Valsartan = ENTRESTO If replacing ACE-I: need to stop ACE x 36 hrs If replacing ARB: no wash out Watch for GFR (must be >30) hypotension