The year in Cardiology 2014 — a top-10 list

When the editors at Medscape asked me to put together an essay on the Top 10 stories in cardiology in 2014, I thought it would be an easy project. I was wrong. It turns out there was a lot to say about the happenings in cardiology this year.  In the end, the final essay had 37 references–a bunch for a blogger.

The link to the piece is at the end of this post. What follows is a regular-language breakdown of the ten topics. The first five deal with specifics; the second five touch on trends.

Here we go:

1. Renal denervation is the medical name given to a procedure in which a doctor uses a catheter to ablate (burn) nerves in the kidneys. I realize that sounds dubious, nerves are there for a reason, but the procedure had promised to cure high blood pressure. (Grin.)

But then reality struck. A properly done clinical trial showed the procedure did not work. Drinking beetroot juice looked better. This was a big story not just because it surprised experts, but also because it exposed the danger of basing medical therapy on flawed science. (See points 8 and 10.)

2. Congestive heart failure is the name we use when the heart fails to pump enough nutrients to the body. One of the many causes of CHF is a weak heart muscle–which we call systolic dysfunction. There hasn’t been a new drug released for systolic heart failure in more than two decades.

This year, the PARADIGM-HF study showed that CHF patients treated with a new class of drugs, called angiotensin-neprilysin inhibitors (ARNI), fared better than those treated with standard ACE-inhibitors. The absolute differences in outcomes were small but the large numbers of patients enrolled in the study resulted in statistical significance. Novartis has yet to give the drug (LCZ696) a real name. The FDA has yet to hear the details. This story will continue into 2015.

3. Cardiac monitoring can be useful. But like everything in medicine, overuse can lead to a loathsome outcome: the creation of fear, which can transform a well person into a diseased one. Perhaps it is the concerning trends in electrophysiology that lead to my (negative) bias about monitoring of the human body.

Bias aside, cardiac monitoring had a good year. Two clinical trials showed the utility of prolonged rhythm monitoring after stroke. The idea here is to pick up non-symptomatic atrial fibrillation–a treatable cause of a second stroke.

Another group of studies suggested promise for remote wireless monitoring of patients with cardiac devices. These observational trials revealed a strong association between lower mortality and the presence of wireless monitoring.

4. Aspirin therapy is losing its mystique. The old drug is one I often deprescribe. Two studies released this year strengthened the message that aspirin used in combination with anti-coagulant drugs is rarely useful. I’m not sure why so many patients get continued on the combination of these two classes of drugs. I’ve called the combination a dangerous cocktail.

That was not the only bad news for aspirin. Another group of studies questioned the use of aspirin for the prevention of a first cardiac event–which we call primary prevention. The thinking on aspirin for prevention is similar to statins: benefit turns on baseline risk. Low risk patients get little benefit. High risk patients get more benefit. Both groups are exposed to the bleeding risk.

5. Cardioversion of atrial fibrillation is usually a safe procedure. The caveat here is that patients have had adequate anticoagulation (blood thinning) in the month before and after the shock. A dogmatic rule passed down over decades of doctors holds that cardioversion can be done without anticoagulation if the AF is less than 48 hours in onset.

In 2014, findings of a Finnish study questioned the safety of the 48-hour “rule.” The researchers found a small but not insignificant risk of stroke in patients shocked without the protection of anticoagulation. Risk was higher later in the 48-hour window. I wrote about hitting the pause button on cardioversion in August.

5a. Using new oral anticoagulant drugs (NOACs) before and after cardioversion is common. Although these drugs compared favorably to warfarin in clinical trials, doctors wonder whether they provide adequate protection for cardioversion. The concern stems from the fact that, unlike warfarin, NOAC effect cannot be measured. The good news was that two studies released this year reassured doctors that NOACs look to be safe for cardioversion.

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This is a break point. The next five topics indicate changes in thinking, culture or approaches to care.

6. “Board-certified” was once a term people used without thinking about whom the board was and what certified meant. That changed in 2014. The board is actually the American Board of Internal Medicine, a well-endowed non-profit organization, and being certified now requires complying with onerous and expensive new procedures. I covered the near universal resistance to the new mandates in a previous post. This is a big topic because everyone wants doctors to be well-informed and qualified. How that is accomplished in the future may change.

7. Less-is-more is an old way of thinking about medical care. Numerous studies in 2014 bolstered the idea that less is indeed more when it comes to treating people. Survival in cardiac arrest was better when basic not advanced care was applied. Doing extra testing at the time of ICD implant made no difference in outcomes. Burning in the atria less, rather than more, proved the better strategy in the treatment of advanced AF. Simpler surgery (or no surgery) of the mitral valve also came out ahead.

I can’t stress this concept enough. If I could blog about only one topic, it would be the widespread over-testing and over-treatment of the American public.

8. Expert guideline statements have steadily grown in prominence and influence in the practice of medicine. Documents that were designed to help physicians treat patients in the most evidence-based way have now become shackles of a sort. The irony is that adherence to guidelines, enforced now with a stick rather than a carrot, can actually impair patient-centered decisions. Eg: You will take that (needed) anticoagulant or statin, otherwise, I will be deemed a poor quality doctor.

In 2014, guideline statements lost some of their luster and power. First, numerous researchers made compelling cases that the statistical evidence upon which guidelines are based is less than definitive. Second, a major scandal involving scientific misconduct further exposed the tenuous nature of the evidence. Finally, two studies that delved into the nitty-gritty of guidelines found reasons to suspect the quality and durability of said decrees.

I thought this was a big story because expert guideline statements, and the protocols and quality measures they induce, are running amok. It was a delight to see skepticism reenter mainstream thinking. Don’t you think medical decisions would improve if more patients and doctors were familiar with Dr. John Ioannidis’ 2005 paper in PLoS Medicine, Why Most Published Research Findings Are False?

9. End-of-life treatment in the US remains a national disgrace. I noticed the inhumanity when I started this job in 1996, and I don’t think we have made any progress. Death denial is our default: Death occurs because of a deficit in science or therapy, not because it is the normal end to all life, goes the disordered thinking.

This year, however, three events injected some hope that enlightenment about death is possible. There was Brittany Maynard, who taught us that how we die was a personal choice. There were two literary works from physician writers. Dr. Atul Gawande and Dr. Ezekiel Emanuel both wrote thought-provoking words that stand the chance of jump-starting the conversation.

Oncologists and cardiologists are in the thick of this crisis. And it’s about time we stepped up and provided some needed leadership. Here is a start: If your emaciated patient with metastatic cancer is still on a statin, you fail!

10. Lifestyle choices are health. This equation should be obvious. Yet our situation is stunning. We routinely use expensive and often futile means for treating unnecessary disease. We look right past the value of nutrition, exercise and sleep hygiene, to pills, stents and even surgery.

The good news was that major studies published in 2014 showed us that heart attacks, heart failure and atrial fibrillation are, in great measure, preventable. Eating a healthy diet most of the time, using our bodies on a regular basis, not smoking, drinking alcohol moderately (or not at all), and controlling abdominal girth was the secret sauce.

It’s critical that all doctors start seeing this. For if we don’t; we will be the first generation of caregivers to witness a decline in both the quality and quantity of life of our patients. While we perseverate over statins, or statins-with-ezitimibe, or stents, or AF ablation, our patients are growing fatter, less mobile and more chronically ill. Shame on us.

It’s true that a lot of the obesity mess is out of our hands, but not all of it is. When it comes to health and healthcare, we are the professionals. It’s our job to take the lead.

The link and title to the essay is here:

Cardiology’s Top 10 Stories of 2014: Back-to-Basics Promises Big Advancements

JMM