DANISH

Prophylactic implantable cardioverter defibrillator (ICD) implantation in patients with symptomatic systolic heart failure (HF) not caused by coronary artery disease did not “significantly lower long-term rate of death from any cause” as compared to usual care, according to results from the DANISH Trial. The trial, led by Lars Kober, MD, DMSc, et al., randomly assigned 1,116 patients to receive an ICD vs. usual care. The authors explain that they saw an “important interaction with age that suggested that younger patients may have a survival benefit in association with an ICD implantation.”

In a related editorial, John J.V. McMurray, MD, FACC, explains that the results “probably represent the most optimistic estimate of the benefit of ICD therapy in patients with nonischemic HF who receive evidence-based treatment.” He adds that “these considerations highlight the need to target ICDs to the patients most likely to benefit … those that remain at high absolute risk for sudden cardiac death despite receiving the best available pharmacologic and device therapy.”

CLARIFY

Findings from the CLARIFY Trial suggest caution in the use of blood pressure (BP)-lowering treatment in patients with coronary artery disease. Researchers analyzed data from 22,672 patients from 45 countries (excluding the U.S.) with stable coronary artery disease who were enrolled in the CLARIFY registry and treated for hypertension from November 2009 to June 2010. After a median follow-up of five years, increased systolic BP (SBP) of 140 mm Hg or more and diastolic BP (DBP) of 80 mm Hg or more were each associated with increased risk of cardiovascular events. SBP of less than 120 mm Hg was also associated with increased risk for the primary outcome, as well as increased risk for all secondary outcomes except stroke. Similarly, DBP of less than 70 mm Hg was associated with an increase in the primary outcome and in all secondary outcomes except stroke.

Study authors said their findings support the existence of a J-curve phenomenon. They also point out that the broad international cohort of patients who were treated in real-life conditions is a “particular strength” of the study and might have greater external validity than randomized trials. “There is a concern that low BP goals from randomized trials, when translated into routine practice, might be associated with higher adverse effects or worse outcomes, especially in older patients,” they said.

They caution that results from the study “should not slow down the constant effort that is still needed to improve patient care, because even with the conventional pressure goal of less than 140/90 mm Hg, only about half of the population with hypertension is controlled.”

Deepak L. Bhatt, MD, MPH, FACC, echoed this sentiment in a commentary published in the Journal of the American College of Cardiology (JACC). “A key cautionary note about appropriate BP targets is that the majority of patients with hypertension are not optimally treated, even using thresholds higher than those that are currently being debated,” he writes. “From a population health perspective, more would be gained from maintaining traditional BP targets for the entire population (perhaps adjusted for age) while sorting out the nuances of who might benefit from tighter BP control.”

CE-MARC 2

In patients with suspected coronary heart disease (CHD), cardiovascular magnetic resonance (CMR)-guided care was shown to significantly reduce unnecessary angiography as compared to care using the UK NICE guidelines, but showed no difference from myocardial perfusion scintigraphy (MPS)-guided care, according to results from the CE-MARC 2 Trial. The study, led by John P. Greenwood, PhD, et al., looked at 1,202 symptomatic patients with suspected CHD from six UK hospitals. “[Our] results show that a broader use of functional imaging (CMR or MPS), in low, intermediate and high risk patient groups, could reduce the rates of invasive angiography that ultimately show no obstructive coronary disease,” said Greenwood. “In addition, CE-MARC and CE-MARC 2 further support the role of CMR as an alternative to MPS for the diagnosis and management of patients with suspected CHD.”

DOCTORS

In patients with non–ST-segment elevation acute coronary syndromes (NSTEACS), optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) may be associated with higher post-procedure fractional flow reserve than PCI guided by angiography alone, according to findings from the DOCTORS Trial. The multicenter, randomized study involving 240 patients with NSTEACS compared OCT-guided PCI to fluoroscopy-guided PCI. “[Our] results suggest that there may be a role for OCT as a complement to fluoroscopy for the guidance of PCI procedures in NSTEACS,” said the study authors. They suggest additional prospective studies with clinical endpoints before OCT guidance is incorporate as a standard option for treating patients with NSTEACS.