ACC Updates Part 2

Volume 3, Issue 4

Last week’s edition of Talking Therapeutics highlighted several new and exciting studies related to heart failure drug therapies. This week we tackle three more pivotal trials from this year’s exciting conference.

Point 1: Use Low-Dose Aspirin for Secondary Prevention

Few topics irk pharmacists more than the overuse of full-dose aspirin for prevention of recurrent cardiovascular events. The ADAPTABLE trial, which was recently presented at the ACC meeting and simultaneously published in the New England Journal of Medicine, found that low-dose (81-mg) aspirin appears to be as effective as the 325-mg dose in patients with established atherosclerotic cardiovascular disease. Over 15,000 patients were followed for 26 months, and the rate of the primary composite outcome—all-cause mortality and hospitalization for myocardial infarction or stroke—was similar between groups. The rate of hospitalization for major bleeding, the primary safety outcome, was also similar (0.63% and 0.60%).

Of note, 42% of patients randomized to 325 mg switched to the lower dose during the study, and 7% of those randomized to 81 mg switched to the higher dose. Some argue that this high rate of switching may weaken the overall trial finding; however, I think that this should be the final nail in the coffin for the 325 mg aspirin dose for secondary prevention.  

Point 2: Entresto Not “Besto” for Acute Myocardial Infarction and Heart Failure

The PARADISE-MI trial showed sacubitril/valsartan did not reduce the rate of cardiovascular death or adverse heart failure-related events in a contemporary enriched acute myocardial infarction population compared with ramipril. The trial enrolled 5,669 patients from 495 sites in 41 countries who had experienced an acute MI less than a week before enrolling in the study and had an LVEF of ≤40% and/or pulmonary congestion, plus one of eight additional risk-enhancing factors like atrial fibrillation, prior MI, diabetes, etc. None of the patients had prior heart failure and most were already taking antiplatelet therapy as well as antihypertensive and cholesterol lowering medications. While there was only a minimal signal for efficacy, the authors report that the trial’s findings offer further reassurance that sacubitril/valsartan is safe to use for patients with heart failure.

Point 3: Use DOACs When Indicated Post-TAVR

The ATLANTIS trial showed full-dose apixaban is not superior to standard of care among patients undergoing TAVR despite a reduction in valve leaflet thrombosis. The aim of this trial was to assess the efficacy and safety of apixaban 5 mg BID compared with standard of care (antiplatelet therapy for those without or warfarin for those with afib). With the non-superior findings, this trial shows that TAVR patients without indications for anticoagulation should continue to receive antiplatelet therapy, while those with such indications should receive a DOAC in favor of warfarin.

Dr Jennings is currently an Associate Professor of Pharmacy at Long Island University and the clinical pharmacist for the Heart Transplant and LVAD teams at New York- Presbyterian Hospital Columbia University Irving Medical Center.  He is an active researcher in his field, and he has published over 120 peer-reviewed abstracts and manuscripts, primarily focusing on the pharmacotherapy of patients under mechanical circulatory support. As a recognized expert in this area, he has been invited to speak at numerous national and international venues, including meetings in France, Saudia Arabia, and India. Finally, Dr Jennings has been active in professional organizations throughout his career. He is a fellow of the American College of Clinical Pharmacy, the American College of Cardiology, the Heart Failure Society of America, and the American Heart Association.  

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