AHA 2021 Tackles AF Triggers, Watchful Waiting in AS, Data Overload, and More

Hot on the heels of TCT 2021 comes the American Heart Association (AHA) Scientific Sessions, which will be held November 13 to 15 as a fully virtual meeting.

Speaking with TCTMD, AHA program committee chair Manesh Patel, MD (Duke University School of Medicine, Durham, NC), noted that people are craving the chance to get together in person again, but on the other hand, the digital platform has allowed the sessions to have an even wider reach. For this year’s program, organizers have worked hard to bring what they hope is an even greater level of engagement, given the impossibility of fully replicating the interactivity of an in-person meeting, he said.

“Our mantra for thinking about what we're going to be doing at the AHA Scientific Sessions is giving people what I'll call an ‘I see’ experience,” he said. “But really, what people go to the meetings for is to get context for that, get expert opinion, and then be able to engage with information so they can bring it back to their practice. And if we do it right, then hopefully that information gets turned into clinical care.”

Late-Breaking Clinical Trials

This year’s meeting features seven late-breaking science (LBS) sessions, chosen from over 150 submissions, which have been organized thematically, Patel said, into the following groups: cardiothoracic surgery, global hypertension management, lipids, atrial arrhythmias, information and data, heart failure therapy, and new drugs/new indications.

“We think that’s a pretty broad spectrum of the things people with cardiovascular disease would care about now,” Patel said.

Highlights in LBS 1 include the AVATAR trial of aortic valve replacement versus watchful waiting in asymptomatic severe aortic stenosis (AS), as well as RAPID CABG addressing CABG timing among ACS patients pretreated with ticagrelor. The first, said Patel, is “a hot topic,” particularly since “it's hard to do a randomized trial where you tell people you have serious AS and we're going do watchful waiting versus taking you to surgery.”

This grouping also includes a study of concomitant tricuspid repair during mitral valve surgery—something that hasn’t been studied previously in a randomized trial. ”So, again, that's a big question with a lot of interest,” Patel said.

LBS 2 looks at controlling hypertension both on the macro and micro level. Similar to the massive SSaSS trial at ESC, the CRHCP study is a cluster-randomized trial of doctor-led interventions on blood pressure control conducted in 326 villages in China and reaching more than 33,000 people. Closer to home, a 10,000-patient study within the Partners Healthcare network evaluated the use of mobile technologies and nurse- and pharmacist-led interventions as a means of controlling cholesterol and blood pressure. A third study in this session looks at the impact of the COVID-19 pandemic on hypertension control across 24 US health systems.

LBS 3 is dedicated to atrial arrhythmias. This batch includes CRAVE, which “I’m sure you’re going to get asked about,” said Patel. CRAVE used continuous heart rhythm monitors and mobile technology to track the effects of caffeinated coffee on cardiac ectopy in real time, with subjects randomized to starting or stopping coffee intake. Also in this session are GIRAF, comparing the effects of dabigatran (Pradaxa; Boehringer Ingelheim) and warfarin on cognitive impairment in patients with nonvalvular atrial fibrillation (AF); PALACS, addressing pericardiotomy to reduce AF after cardiac surgery; and aMAZE, comparing adjunctive left atrial appendage ligation with the Lariat device to pulmonary vein isolation.

LBS 4 “is the one that's about information overload and digital health,” Patel said. The explosion of wearables and mobile tech offers a wealth of opportunity to keep a check on health parameters, he said, but it also portends enormous burden on healthcare professionals needing to wade through it. The first, REVeAL-HF, is “a randomized trial to examine whether knowledge about the prognosis of heart failure impacts decision-making and patient outcomes.” The 450,000-patient Fitbit Heart Study, like the Apple Watch study before it, delves into the specificity and sensitivity of information on abnormal heart rhythms picked up by the wearable device. Finally, I-STOP-AFib uses the AliveCor device and an app to look at whether common triggers for AF—like exercise, alcohol, and sleep deprivation—can be documented and avoided and if staying clear of those triggers can impact outcomes. “Can you control your own sort of triggers?” Patel asked. “This trial gets at that question.”

Heart failure is the focus of LBS 5 and includes three sodium-glucose cotransporter 2 (SGLT2) inhibitor analyses. There’s EMPULSE and EMPEROR-Preserved with empagliflozin (Jardiance; Boehringer Ingelheim/Eli Lilly)—the first addressing efficacy and safety in hospitalized patients and the latter a subanalysis focused on patients with ejection fractions of 50% or higher. Then there’s a look at quality of life and functional outcomes in CHIEF-HF with canagliflozin (Invokana; Janssen). Finally, DREAM-HF once again probes the possible effects of stem cells, this time in chronic heart failure.

LBS 6 is dubbed “fish oil, cocoa, and cholesterol: recipes for CVD prevention?” This set includes the results of PREPARE-IT 2, looking at icosapent ethyl (Vascepa; Amarin) for COVID-19 outpatients, and early safety, pharmacokinetics, and LDL cholesterol-lowering efficacy of the novel, oral PCSK9 inhibitor, MK-O616.

Finally, LBS 7 is a medicine cabinet unto itself with new and old drugs. There’s AXIOMATIC-TKR looking at the investigational agent, milvexian, an oral, direct, small molecule factor XIa inhibitor for preventing venous thromboembolic events, as well as REVERSE-IT with bentracimab, a ticagrelor-reversal agent, in patients requiring urgent surgery. The P2Y12 inhibitor results from the ACTIV-4a study in noncritically ill patients with COVID-19, as well an analysis of ASCEND addressing the effects of aspirin on dementia/cognitive impairment, round out the session. “I think the aspirin for cognitive effects from the ASCEND trial will be interesting to people,” Patel hinted, particularly given the recent US Preventive Services Task Force reminder not to routinely use aspirin in primary prevention.

Beyond the Late-Breakers

The theme of this year’s meeting is “one world together for science,” and a range of sessions look at that idea from different vantage points, Patel noted. “How do we democratize and get information out to as many people as possible?”

To that end, the opening session Saturday morning—entitled “Scientific Discovery as the Guiding Light: Moving Toward a Post-COVID World”—includes a talk by Gary Gibbons, MD, the director of the National Heart, Lung, and Blood Institute, about how to “galvanize” research to reach more-diverse populations while also getting research done faster.

A Sunday highlight is a health equity seminar moderated by Clyde Yancy, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), that confronts the “current realities” and then outlines the concrete steps physicians can take to improve equitable access and reduce bias in cardiology care.

Telehealth and digital interactions are increasingly on the minds of physicians, and there are several dedicated “main event” sessions looking at the impact of digital and mobile technologies on the delivery of care, data overload, and how “big tech” could help reduce disparities in cardiovascular care.

Patel also highlighted a special “fireside chat” on COVID-19 vaccine development that includes Pfizer’s chief scientific officer and Moderna’s chief executive officer. The aim here, said Patel, is thinking of ways to leverage lessons learned in the pandemic to improve the management of cardiovascular disease. “How did we get here and how are we thinking about the heart in this and what lessons can we learn from what we did for the COVID vaccine for exploding cardiovascular therapeutics and learning how to do it faster?”

Patel acknowledged that there are pros and cons to fully virtual meetings. On the one hand, physicians are increasingly burned out by the hours spent at the computer on top of the massive demands of delivering care during such a stressful time to work in health. On the other, what’s abundantly clear from the past year-and-a-half is that online sessions are reaching a far broader swath of physicians around the world, who could never have traveled to attend the AHA when it was initially planned for Boston.

“We’re never going back,” Patel predicted, referring to meetings that are only held in person. “I don't envision a time where we'll have meetings where there's not an opportunity to be able to virtually see parts of the meeting; I don't think anyone would favor that. But I think we would also want people who want to have the full immersive experience to be able to do that in a safe environment.”

The platform this year will include virtual networking opportunities, including a dedicated networking page and live studio commentary with questions answered in real time by in-studio faculty. International rebroadcasts are available for attendees on different time zones.