Duke Heart Pulse — November 19, 2023 – The Pulse

Highlights of the week:

Happy Thanksgiving!

In advance of the Thanksgiving holiday, we hope each of you – whether you’re staying close to home or traveling to see loved ones — has a safe and wonderful holiday! Thank you for all you do each day to care for our patients and to advance our collective understanding of cardiovascular disease and treatments. We all contribute in myriad ways to the success of Duke Heart and to the relationships we have with our patients and our community. We are truly blessed to have a terrific team. Enjoy the holiday!

AHA Scientific Sessions Recap

The American Heart Association’s Annual Scientific Sessions held in Philadelphia last weekend saw terrific representation by Duke faculty and fellows! We had two Late-Breaking sessions, 21 presentations, 19 moderated sessions, and more than 38 poster presentations by Duke team members. Impressive!

Our Duke team included the following authors, presenters, and moderators/discussants:

Kevin Thomas, Larry Jackson, Emily Obrien, Svati Shah, Jason Katz, Joseph Lerman, Brittany Zwischenberger, Nishant Shah, Schuyler Jones, Stephen Greene, Jennifer Rymer, Vishal Rao, Christopher Granger, Marat Fudim, William Kraus, Dennis Narcisse, Fawaz Alenezi, Leanna Ross, Melissa Daubert, Bradi Granger, Josephine Harrington, Andrew Landstrom, Jonathan Piccini, Manesh Patel, Sana Al-Khatib, Renato Lopes, Sudarshan Rajagopal, Camille Frazier-Mills, Sean Pokorney, Sarah Snow, Zak Loring, Robert Mentz, Jessica Duran, Dan Friedman, Balim Senman, and Alina Nicoara.

Highlights from across the weekend included:

Jason Katz, participated in the Contemporary Debates in STEMI. This education session was planned by the Committee on Scientific Sessions Program and was moderated by Chris Granger. The pro/con debates addressed controversial areas of management in ACS. Particularly, this debate addresses an important issue in ICU care. Katz reviewed a few case studies that suggest implementing a risk-based triage strategy could be a better alternative to the current strategy where patients with STEMI are typically admitted to the CICU.

In summary, the CICU admission decision for STEMI patients will continue to be based on individual judgment and traditional protocols rather than robust and evidence-based risk prediction models.

As part of a Saturday morning session examining controversies in high-risk PCI procedures focusing on calcium modification and bifurcation lesions, Jennifer Rymer participated in a debate on a one-stent vs. two-stent strategy for Bifurcation Disease, detailing scenarios in which a one-stent approach would be appropriate.

Rymer emphasized that her position in favor of a provisional, one-stent strategy should be the default for many, but not all bifurcation lesions.

Pointing first to a meta-analysis of nine randomized controlled trials co-authored by her debate opponent Margaret McEntegart, Rymer noted that the one-stent strategy showed reduced mortality compared to a two-stent strategy over a longer-term follow-up.

Rymer reviewed further evidence from the Nordic bifurcation study, EBC Two, and EBC main trials, among others, showing that the provisional single-stent strategy was more favorable than a two-stent strategy. Still, Rymer acknowledged that the one-stent strategy is not the definitive answer in every case.

“There’s significant evidence that a provisional stent strategy with often one stent can be a viable strategy for many bifurcation lesions,” Rymer said. “However, it’s key to assess and examine the anatomy and features of the bifurcation lesions, particularly within the left-main bifurcation. There isn’t always a one-size-fits-all approach in any aspect of medicine and certainly in these lesions there’s not.”

In rebuttal, McEntegart largely agreed that a one-stent strategy is best when treating simple bifurcations, while highlighting the exceptions — when treating more complex bifurcations — in which a two-stent strategy is a better approach.

As a discussant for the late-breaking science session “Heart Failure – VADS, Kids, and Money,” Stephen Greene shared details of recent heart failure trials and reflected on how patient outcomes can be improved by treating heart failure with a greater sense of urgency, more efficient trial enrollment, and a focus on implementation.

He shared examples of innovative trial designs such as the CHIEF-HF study and TRANSFORM-HF trial that reduced the burden on patients and sites and then emphasized a focus on implementation as the missing link in heart failure outcomes.

“Even when we know what is quote-unquote best for patients — we know the answer, what makes them live longer, stay out of the hospital, feel better, spend more time at home with their families — history has told us that we do not routinely act on this information,” Greene said. “And, as a result, the grim reality is that every day in this country, many patients with heart failure are dying and being hospitalized without ever having the opportunity to receive medicines definitively proven to prevent these events, despite the patient being eligible for them.”

Greene cited “persistent and pervasive” gaps in the use of guideline-directed medical therapy, including less than one in 10 eligible patients being discharged on quadruple medical therapy, and less than one in three eligible patients going home on triple therapy.

“While of course quadruple therapy should be our goal for HFrEF patients, just think how much better off it would be for the heart failure community if we did complete, equitable, and timely initiation of even just three generic heart failure medications,” Greene said.

“Traditional scientific investment in heart failure is largely focused on discovery science, and thankfully we’ve gotten enormous therapeutic advancements, but with these advancements comes the responsibility to get these therapies to our patients. … Regardless of any specific implementation strategy, there’s an overarching need to change the culture of care from therapeutic hesitancy to one of therapeutic urgency.”

Marat Fudim shared predictions for the future of treatment for patients with heart failure with preserved ejection fraction (HFpEF) during an afternoon session packed with attendees eager to better understand what’s next. A more tailored approach with endo- and phenotyping, he said, is what will advance treatment for these patients, and machine learning may be able to help.

First outlining the need for more specialized research in HFpEF, Fudim noted that the subgroup makes up more than half the heart failure population and continues to grow. Yet the most helpful research for this subgroup has largely come by happenstance.

“In the past, we have applied therapeutic successes from the HFrEF space, which is much easier to diagnose and conceptualize, and applied that to the heart failure preserved ejection fraction space,” Fudim said. “We’ve really seen no positive trials over the two decades that we’ve been testing it until we started getting lucky with therapies which are actually primarily not cardio-centric — cardiometabolic drugs such as SGLT2s, GLP1RAs.”

But that approach will not be sustainable moving forward, he said.

“The future of HFpEF, I believe, will be looking as follows — we will have to do phenotyping,” Fudim said. “You can call it endotyping or phenotyping, and it will have to involve some form of superficial or deep phenotyping looking at clinical variables as well as biopsies or blood work that might tell us a little bit more about the patient, and then apply specific mechanisms of treatment to the diagnostically identified mechanism of pathology.”

Fudim provided the example of a case where spironolactone was found to be more therapeutically beneficial when matched to the proper phenotypical group.

“Certain groups will simply benefit more from certain interventions, even possible interventions found not to be significantly beneficial,” he said.

Machine learning is already applied with screening echocardiograms, Fudim noted, and could also be useful in identifying specific disease processes and matching with specific drugs, as well as identifying patients for future clinical trials where specific endotypes or phenotypes could be matched to a specific drug.

During an early morning Sunday session highlighting the pros and cons of controversial therapies for arrhythmia management in special and vulnerable patient populations, Sana Al-Khatib, shared evidence against catheter ablation for supraventricular tachycardia (SVT) in pregnant patients.

Following Kamala Tamirisa who took the “pro” position in favor of catheter ablation for SVT to avoid drug therapy, Al-Khatib argued that ablation should be avoided in these patients. Despite the presentation title, Al-Khatib cited guidelines and an expert consensus statement recommending that medications can and should be used to safely manage these patients. Al-Khatib went on to recommend that ablation could be considered either before or after pregnancy.

“Of course, I completely agree with my friend Dr. Tamirisa that we have to optimize safety, we have to make sure that we know about the properties of these medications that we use, when we can use them, when we cannot use them, dose them appropriately, see if we can get away with lower doses,” Al-Khatib said. “In fact, many of us have been able to manage pregnant women with lower doses of these medications.”

A lot has changed since the 2002 AFFIRM study showed a rhythm-control strategy offered no survival advantage over a rate-control strategy, according to Jonathan Piccini. On the contrary, data from more recent observational and randomized trials demonstrate that early initiation of rhythm control in patients with atrial fibrillation (AFib) can improve outcomes, Piccini said.

Presenting as part of a learning studio session on treating patients with AFib, Piccini reviewed recent evidence on early rhythm control such as the EAST-AFNET 4 trial, and discussed the applications of early rhythm control among different types of patients.

Which patients benefit most from early rhythm control?

“Some of the greatest benefit may be in patients who have more comorbidities,” Piccini said.

“I’d argue that we have good data that early rhythm control improves outcomes in persons with Afib and there appears to be a pretty durable 20% relative risk reduction in cardiovascular events. Persons with heart failure, left ventricular dysfunction, high degrees of comorbidity, and who have AFib progression or who are at risk for developing AFib progression are particularly important candidates for early rhythm control.”

Renato Lopes detailed how randomized controlled trials (RCTs) and real-world evidence can help inform clinical practice and shared examples of successful RCTs for atrial fibrillation.

“We always ask this question, what is the best type of study?” Lopes said. “Is it randomized trials, or is it the real-world type of study? …The right answer should be another question, ‘What is the question that I will answer?’ Because depending on the answer that I want to have from a clinical perspective, I might have different types of studies that might be the best.”

Randomized controlled trials are the gold standard for determining treatment effect, he added. “I really need randomization to be able to define cause and effect relationships.”

However, for determining real-world application and understanding patterns of care — such as what dose people are using of a particular drug — real-world evidence studies are a better approach. So, a combination of the two types of studies is helpful to support clinical decisions, he continued.

Lopes summarized two pivotal trials on atrial fibrillation with Apixaban — ARISTOTLE and AVERROES. Both RCTs, ARISTOTLE compared Apixaban to Warfarin, and AVERROES compared Apixaban against Aspirin. ARISTOTLE was able to show that Apixaban was not only non-inferior to Warfarin, but superior to it in terms of reducing stroke, risk of bleeding, and all-cause mortality.

“We couldn’t believe when we saw that we were able to meet every single endpoint of the trial. That’s what we call a home run,” Lopes said. “To hit every single endpoint, preserving your alpha was a really unique moment.”

During a session on heart failure guidelines and implementation of therapies, Stephen Greene advocated for rapid titration of quadruple therapy for every eligible heart failure patient. Greene outlined the extreme risk associated with heart failure and emphasized the need for a more urgent therapeutic response. The status quo approach of introducing medications slowly using a one-move-at-a-time, serial, and selective approach, he said, has substantial risks associated as it can take 28 to 58 weeks before guideline-directed medical therapy (GDMT) is fully implemented at the targeted doses.

Simultaneous or rapid-sequence initiation of GDMT, on the other hand, treats heart failure with the urgency that it deserves, he said, and the clinical benefits become noticeable within days to weeks.

“If you delay therapy, even a couple of weeks in an eligible patient, you’re exposing them to excess clinical risk,” Greene said. “And when you remember that the benefits of all four of these drugs are completely additive to each other, and when you further remember that we’re talking about an extreme risk condition that needs all the help it can get, we need to fully take advantage of these medicines ASAP.”

In rebuttal, University of Kentucky Healthcare’s Craig Beavers presenting on behalf of Alanna Morris, argued that while the rapid titration approach is ideal, it wasn’t rooted in real-world thinking. Beavers outlined barriers to quadruple guideline-directed medical therapy for heart failure, including lack of provider knowledge, side effects, administrative burden, Medicare prescription drug coverage, high out-of-pocket costs, and clinical inertia. He also outlined barriers to rapid titration therapy, including polypharmacy, side effects, financial toxicity, and patients failing to understand the rationale for changes.

Beavers concluded that while he agrees that an approach of rapid titration of quadruple therapy is needed for eligible heart failure patients, the current system is not set up to achieve it.

Presenting as part of an afternoon session on arrhythmia treatment, electrophysiologist Jonathan Piccini acknowledged that catheter ablation will not be needed by every patient. Most patients, though, will benefit from catheter ablation — “Absolutely yes, beyond a shadow of a doubt,” he said.

Piccini went on to outline reasons to ablate — it can suppress atrial fibrillation, improve quality of life, and reduce symptoms in patients.

“It’s not a cure, but it’s a highly effective form of suppressing active episodes of AFib,” Piccini said. “This forms the foundational pathophysiology and rationale on which catheter ablation is built.”

The EAST trial showed a 20 percent risk reduction in cardiovascular mortality, stroke, and hospitalization for both heart failure and coronary syndrome over five years, Piccini shared. In CABANA, the procedure showed similar risk reduction in deaths and cardiovascular hospitalization.

Like any procedure or drug prescribed in patients or intervention, applying it to the appropriate patients is critically linked to effectiveness and safety, he noted.

“Does every (AFib patient) need an ablation? No. But most people will probably benefit from ablation because at some point they will have symptoms. Or at some point they are going to benefit from rhythm control,” Piccini said. “EAST shows us that’s probably the beginning of their journey. … If we diagnosed it upfront and implemented early rhythm control, there is a very large role for catheter ablation in their health.”

In additional AHA news, Lesley Curtis, chief of the Department of Population Health Sciences at Duke was selected to receive the QCOR Outstanding Lifetime Achievement Award by the American Heart Association’s Council on Quality of Care and Outcomes Research (QCOR). Congratulations, Lesley!

Jay Lusk, a resident physician at Duke, was named a finalist in the American Heart Association’s Lp(a) Data Challenge. His project, titled “A Random Survival Forest Model for Cardiovascular Risk Prediction from Electronic Health Record Data” was presented Nov. 12. Way to go, Jay!

Congratulations to all!

Duke Heart Faculty Among World’s Most Influential

Congratulations to Chris Granger, Renato Lopes, and Adrian Hernandez! They, along with 27 other Duke faculty members, made Clarivate‘s Most Highly Cited Scientists list of most cited researchers for 2023. Nearly 7,000 were named to this year’s list. Hernandez has been named to the list for each of the last five years, while Granger has been included each year since 2014. This year marks Lopes’ first appearance on the list.

Data used to evaluate and select the honorees are procured from Clarivate’s Web of Science citation index and analysis by bibliometric experts and data scientists at the Clarivate’s Institute for Scientific Information.

Nicely done!

ICYMI: Editorials in JAMA

Adrian Hernandez and Christopher Lindsell as well as Mike Felker and Joe Rogers have editorials in the November 11, 2023 online issue of JAMA. Hernandez, director of the DCRI and Lindsell, professor of Biostatistics & Bioinformatics are coauthors of The Future of Clinical Trials: Artificial to Augmented to Applied Intelligence, while Felker, professor of medicine in Cardiology and head of cardiovascular research at DCRI, and Rogers, president and CEO of the Texas Heart Institute are coauthors of Addition by Subtraction in Mechanical Cardiac Support. Both are worth checking out!

Duke Heart Grows by One!

We are thrilled to share Duke Heart’s latest addition with you. Miguel Yaport, one of our cardiac anesthesia fellows, and Allie Levin, a cardiology fellow, welcomed their daughter, Noa Yaport, on August 15th. Miguel and Allie ask for your forgiveness for this delayed announcement, and hope to make up for it with cute photos!

Despite only being three months old, Noa can calculate EROAs like a pro (thanks to dad’s nightly TEE textbook reading with her, as depicted below). When she is not learning about valve pathologies, she loves tummy time, strolls in the neighborhood, and brunch with her co-fellow Willard.

Welcome, Noa! Congratulations, Allie & Miguel!!!

Duke Heart Celebrates Nurse Practitioners

This past week, we celebrated National Nurse Practitioner Week (Nov. 12-18), in recognition of the NP profession and the many contributions NPs make to Duke Heart and Duke Health. There are more than 355,000 certified NPs in the U.S. caring for patients of all ages. We are deeply grateful for the efforts and contributions these vital Duke Heart team members make each and every day.

As highly skilled team members and healthcare leaders, NPs provide exceptional patient care in virtually all healthcare specialties and settings. NPs are pivotal in the health care delivery of Duke Heart and Duke Health, serving in critical roles throughout clinical care, education, health administration, leadership, and research.

A very special thank you to all NPs in Duke Heart and throughout Duke Health. We hope all of you had a great week!

5th Annual Invented at Duke Celebration

Duke’s Office for Translation & Commercialization (OTC) will hold its 2023 ‘Invented at Duke’ celebration next week on Tuesday, November 28, 2023, from 4:30-7 p.m. at Duke’s Penn Pavilion. Their annual showcase of Duke inventors and inventions will include remarks from Vincent Price, president of Duke University, Robin Rasor, head of OTC, and Jungsang Kim, the Schiciano Family Distinguished Professor of Electrical and Computer Engineering, and co-founder of IonQ.

Whether you’re already part of the Duke entrepreneurial and innovation ecosystem or you’re just starting to explore how to bring your research out to the public – or perhaps you’re a member of the wider Triangle technology commercialization ecosystem – there will be something to learn and celebrate.

The event is free, but registration is required. You’ll receive an e-ticket to present at the door. Attire is business casual. Parking can be found at the Bryan Center Parking Garage – follow event signs and tell the attendant at the entrance and exit that you’re there for Invented at Duke and you will receive free parking.

Upcoming Events & Opportunities

November is Native American Heritage Month; Men’s Health month, and Lung Cancer Awareness month.
Masking is strongly recommended throughout all clinical areas during respiratory virus season, from now through early March.

Cardiology Grand Rounds

Nov. 21: There will be no CGR this week.

All 2023 Duke Cardiology Grand Rounds recordings are uploaded to Warpwire. Recordings can be accessed via this link: https://duke.is/DukeCGR; NET ID and password required. Our newest recording is of Dr. Holger Thiele of the Heart Center Leipzig at University of Leipzig, Germany, who presented Cardiogenic shock treatment: Between clinical practice and current evidence on Nov. 14.

CD Fellows Core Curriculum Conference

Nov. 22: Journal Club with Ivan Nenadic Wood. DMP 2W96.

Nov. 24: No CD Fellows Core Curriculum Conference today.

Call for Abstracts: Duke’s Annual Quality & Safety Conference

Save the date for Duke’s Annual Quality and Safety Conference scheduled for April 11 in the Trent Semans Center. Click here to view Abstract Guidelines. Abstracts are due by 5 p.m. on Dec. 31, 2023. Late submissions will not be accepted. Contact cynthia.gordon@duke.edu or kyle.rehder@duke.edu with any questions.

A&H Winterfest 2023

The dates for Winterfest Marketplace 2023, the annual holiday art show and sale hosted by Arts & Health at Duke, will take place across six Thursdays in November and December, local North Carolina-based artisans will display and sell their work to Duke Health employees, visitors and patients in the main concourse of Duke Hospital.

The event begins on November 2 and runs until December 14. During Winterfest, art will be available for purchase on Thursdays from 11 a.m. to 2 p.m. Featured artisans will include Beth Ann Taylor, Chapel Hill Woodturners, Bonnie Toney, and Justin Leitner.

A portion of the proceeds from Winterfest will go back to Arts & Health at Duke, which provides support to patients through music, visual art activities, and journaling. This is a great opportunity to support local artists, and the Arts & Health programming at Duke Health, and to score some beautiful holiday gifts for loved ones!

Have news to share?

If you have news to share with the Pulse readership, please contact Tracey Koepke, director of communications for Duke Heart at tracey.koepke@duke.edu. We would love to hear about your latest accomplishments, professional news, cool happenings, and any events or opportunities that may be of interest to our Duke Heart family. Please call with any questions: 919-681-2868. Feedback on Pulse is welcome and encouraged. Submissions by Noon, on Wednesdays, to be considered for weekend inclusion.

Duke Heart in the News:

November 10 — Michael Pencina and Nicoleta Economou (Duke AI Health)

Healthcare IT News

Vanderbilt and Duke awarded $1.25M to study HCO AI maturity

November 11 — G. Michael Felker

Medpage Today

No Aspirin Needed After LVAD, ARIES-HM3 Trial Says

November 12 — Manesh Patel

Medpage Today

DOAC Cuts Stroke Risk From Subclinical Afib

November 12 — Manesh Patel and Jonathan Piccini

tctMD