NEJM Journal Watch Cardiology Top Stories of 2019

A perspective on the most important research in the field from the past year

Dear Readers,

In 2019, we had another great year of cardiovascular research progress.

Leading the way was the ISCHEMIA trial, a much-anticipated study whose researchers announced its topline results at the American Heart Association (AHA) Scientific Sessions in November. Even as we await the ISCHEMIA publications, its finding that an invasive strategy for patients with stable ischemic heart disease does not improve survival or reduce the risk for myocardial infarction (MI) should be practice changing. We are bound to learn more about the trial in 2020.

Also related to interventions for coronary disease, our editor noted a study that he thought should change guidelines. These researchers found that staged complete revascularization for patients with ST-segment elevation MI reduced the risk for death or MI.

On the structural heart disease front, transcatheter aortic-valve replacement (TAVR) is growing in use. One of our top stories reported on two studies showing that the procedure is a reasonable alternative even in low-risk patients with severe aortic stenosis.

Some prevention stories also made it into our top group. In a study of almost 20,000 people, proprotein convertase subtilisin-kexin type 9 (PCSK-9) inhibitors improved outcomes (major cardiovascular events) in statin-treated patients with persistently high LDL levels, with a number needed to treat of 49 patients on the composite endpoint over 4 years. The use of colchicine after MI yielded a pleasant and, perhaps, unexpected benefit. Colchicine at 0.5 mg/day reduced the risk for the composite primary endpoint (major cardiovascular events) by 23%.

Prevention with sodium-glucose cotransporter 2 (SGLT-2) inhibitor drugs also received a boost. In the DAPA-HF trial, which studied patients who had heart failure with and without diabetes, dapagliflozin reduced the risk for the composite primary endpoint (worsening heart failure or death) by 26% — and the benefit extended to deaths and symptoms. An observational study of SGLT-2 inhibitors in patients with diabetes also reported a reduction in risk for heart failure.

Amid these treatment successes, there remains plenty of concern about the use of aspirin for primary prevention. A useful meta-analysis showed that aspirin in this setting did not reduce the risks for death, cardiovascular death, or fatal MI, while the benefits in risks for nonfatal MI and stroke seemed to be offset by bleeding risks. The AUGUSTUS trial addressed how to proceed with patients who have atrial fibrillation and who take dual antiplatelet treatment This study found that apixaban was better than a vitamin K antagonist — and that the addition of aspirin to an anticoagulant plus a P2Y₁₂ inhibitor (typically clopidogrel) increased bleeding risk without providing an offsetting benefit.

Finally, an important study reminded us that our evidence in cardiology, despite our progress, remains too thin. Investigators found that fewer than 10% of the American College of Cardiology/AHA guideline recommendations are supported by strong evidence. This is a call to action for more and better research in the future.

Thanks to the NEJM Journal Watch Cardiology team for another wonderful year — and thank you to our readers for your continued support of our publication and for sharing our goal of improving the quality of care of our cardiology patients.

The NEJM Journal Watch Cardiology top stories for 2019 are:

Author

Harlan M. Krumholz, MD, SM

Disclosures

Consultant/Advisory BoardUnited Healthcare; Element Science; Eyedentifeye, F-Prime

EquityHugo Health; Refactor Health; Element Science