From the New York Cardiovascular Symposium
Major Topics in Cardiology Today: Meeting Highlights

NEW YORK CITY—The American College of Cardiology Annual New York Cardiovascular Symposium, “Major Topics in Cardiology Today,” was a potpourri of “hot” topics in cardiology, as well as of experts and attendees from 42 countries. Valentin Fuster, MD, PhD, director of the Cardiovascular Institute of the Mount Sinai School of Medicine in New York City, once again directed the event, challenging us with the big picture by his question: “What must we do as a society to prevent heart disease?” His answer was to focus on children, whose behavior we can still modulate much more than the behavior of adults.

Acute Coronary Syndrome
It does not matter how good our interventions for acute coronary syndrome (ACS) are if we cannot get our patients to them. David P. Faxton, MD, of Brigham and Women’s Hospital, Boston, spoke on the challenge of getting patients with ACS to percutaneous coronary intervention (PCI) quickly. Current guidelines suggest that this “door-to-balloon time” should be 90 minutes or less.

“Ischemic time matters, and we are far from goal,” Dr Faxton said. In fact, the average time to intervention noted in the Global Registry of Acute Coronary Events is 174 minutes, and only 5% of patients receive PCI within 90 minutes. One possible solution is facilitated PCI, whereby thrombolytics is given until PCI is done (known as “drip and ship”), but this has not been shown to be superior to primary PCI. Dr Faxton also emphasized that primary PCI was superior to thrombolysis in many patients, so the question “is not whether we should do it [PCI] but how we should do it.”

Many new biomarkers are emerging, and experts continue to debate which ones best predict outcome in ACS. Eugene Braunwald, MD, also of Brigham and Women’s Hospital, proposed using a “multimarker” approach that characterizes risk along the 5 following pathophysiologic axes, which, taken together, would give a better prediction:
• Troponin I: myocyte necrosis
• Brain-natriuretic peptide: hemodynamic stress
• C-reactive protein (CRP): inflammation
• Microalbuminuria: vascular damage
• Hemoglobin A1c: accelerated atherosclerosis.

The TIMI (Thrombosis in Myocardial Infarction) group recently evaluated a number of novel biomarkers that may, in the near future, play an important role. One was neopterin, a marker of monocyte activation that appears to provide information about vascular inflammation above and beyond that provided by CRP (Johnston DT, et al. Coron Artery Dis. 2006; 17: 511-516).

The State of Biomedical Research
In a very thought-provoking talk about the state of biomedical research entitled, “Recent Trials in Hypertension: Compelling Science or Commercial Speech?” Curt D. Furberg, MD, PhD, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, said, “Industry’s interest in increasing the market share commonly trumps the need for important science.”

Among other reasons, he cited selective funding of clinical trials with likely “winners,” publication bias, discontinuation of negatively trending trials, unfair and inadequate comparisons (by design), and a biased spin of analyses and/or publications. Dr Furberg warned the audience to “be careful accepting findings from comparative drug trials.” The solution, he said, was more safeguards, such as guidelines for comparative trials, more critical investigators and institutional review boards, stricter reviews by journals and regulatory agencies, and mandatory trial registration.

Devices
The indications for implanting pacemakers and automatic implantable cardioverter-defibrillators, as well as for cardiac resynchronization therapy (CRT), are expanding. And “we’re headed for more devices” in the future was the word from Eric Prystowsky, MD, of The Care Group at the Heart Center of Indiana, Indianapolis. “CRT beats medical therapy. It saves lives, remodels the heart, and increases the quality of life.” 

Cardiac Surgery
There has been so much attention to catheter-based interventions that one might almost forget about the advances in surgical approaches to heart disease, that is, until you hear Dr Young and his colleagues.

James B. Young, Jr, MD, FACC, chairman, Division of Medicine, Cleveland Clinic Foundation, spoke about surgical remodeling for left ventricular dysfunction. Dr Young emphatically stated that “surgery is not a debate; it is mainline.” He described procedures such as the partial left ventriculectomy and the Dor procedure (left ventricular reconstructive surgery), saying surgery “solves the problems of polypharmacy in heart failure treatment, and there is no problem with compliance and adherence.”

Surgery for valve disease was promoted by several speakers. Jeffrey S. Borer, MD, of Weill Medical College of Cornell University, New York City, said that “the clock for valve surgery should be advanced.” In the past, it was reasonable to question whether “prophylactic” surgery should be performed for asymptomatic people with hemodynamically important valve disease. Improvements in valve surgery have resulted in reduced morbidity and mortality and greatly altered the risk-to-benefit ratios. For patients without particular descriptors of high risk (ie, serum creatinine >2.0 mg/dL, diabetes, and no more than mild chronic obstructive pulmonary disease), it is reasonable and appropriate to operate if there is hemodynamically significant valve disease. “What is the risk of surgery versus the risk of waiting?” he asked. “There is a risk associated with avoiding surgery and an opportunity cost. We need to be more aggressive.”

David H. Adams, MD, chairman of the Department of Cardiothoracic Surgery at Mount Sinai Medical Center, gave reasons for choosing mitral valve repair over replacement. Of the many advantages, valve repair generally does not require anticoagulation. “The problem is, we don’t do enough [repairs instead of replacements], and the patients lose.” He cited New York City as an example, saying that even in a city with great hospitals, more mitral valve replacements were being done than repairs. The cardiologist and the surgeon must realistically assess the surgeon’s experience and ability to perform mitral valve repair.  

Cardiomyopathy
Barry J. Maron, MD, of the Minneapolis Heart Institute Foundation, an expert in the area of cardiomyopathy, asked the crowd, “Why talk about the classification of cardiomyopathies to cardiologists?” The old ones, he said, are obsolete and do not add much to our understanding of the diagnostic criteria, management strategies, and recognition of “new” diseases. He stressed that cardiomyopathy was a heterogeneous disease and that diversity exists even within the subcategories. For example, hypertrophic cardiomyopathy may be caused by any of hundreds of mutations, both sarcomeric and nonsarcomeric.

Focus on AF in Young Patients
The main news about atrial fibrillation (AF) is that it is a large and growing problem, and we must also address issues specific to younger patients who will live with AF for many years.

Dr Prystowsky noted that in the debate over rate versus rhythm control, the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial should be viewed in a new perspective. “You must look at who got into this trial. It was 70-year-olds, and most in the trial were on amiodarone [Cordarone, Pacerone],” which, he said, is effective but not safe. “What are the consequences of keeping a young person on amiodarone for many years?”

One option many now choose is to perform ablation for younger patients. “We do not have enough data on ablation versus drug therapy for rhythm control. Therefore, guidelines do not consider it to be first-line therapy. However, in some patients we are using it as first line.”

Although rate control and anticoagulation are often selected and may be easier to manage, he thinks we need to consider rhythm control (with ablation or medication) in the following patient populations:
• Younger patients with AF
• Patients with significant symptoms even with good rate control
• Those with hemodynamic compromise even during good rate control.

 If we do choose rate control, he says, we need to assess how. Not every method is ideal:
• Resting electrocardiogram: useless. What patient is at rest 24/7?
• Treadmill stress test: older people not doing this in real life
• 6-min walk test: Who has the time?
• 24-h Holter monitor: best.

Use of the Holter monitor allows evaluation of rate control in the “natural environment” and during routine activity. It can also identify tachybrady syndrome and the effect of atrio-ventricular node blocking agents. Dr Prystowsky agrees it is harder to treat young patients who may be very active. Most of all, he advises that we must “reduce the burden of atrial fibrillation in our patients.”