Top Coronary Artery Disease News of 2022

Top coronary news stories in 2022 ran the gamut from interventional strategies to pharmacologic studies, as well as improvements in vascular access and STEMI care.

The best approach to treating left main CAD continues to be debated: In April, a viewpoint in the European Heart Journal made the case that PCI (26 Down) and CABG (60 Across) should be viewed as “complementary” rather than “competitively” when it comes to left main CAD.

In a blow to interventionalists who hoped STICH results might also apply to PCI, the REVIVED (51 Down)-BCIS2 trial showed no advantage of percutaneous revascularization over guideline-directed medical therapy for patients with severely impaired LV function and extensive CAD.  Extended follow-up from the ISCHEMIA trial (ISCHEMIAEXTEND; 11 Down), presented at the American Heart Association (AHA) 2022 Scientific Sessions, also made waves. There was no survival benefit for an initial invasive strategy over a conservative approach for patients with chronic coronary disease and moderate-to-severe ischemia over a median follow-up of 5.7 years. The twist? Patients randomized to an invasive strategy had a lower rate of CV death, but a higher rate of noncardiovascular death.

In 2022, more US hospitals are adopting high-sensitivity cardiac troponin assays (HSCTN; 23 Across) to diagnose acute MI. According to another AHA presentation, only one in three US hospitals have made the switch, although this rate seems to be increasing.

This was also a year for more data, including new numbers from Michigan, confirming the COVID-19-era patterns of “missing” acute MIs (AMI; 59 Across) during the 2020 lockdowns.

For those who do survive an MI, a polypill containing aspirin, an ACE inhibitor, and a statin has the potential to drastically improve 6-month rates of major cardiovascular events in a population of elderly patients, according to data from SECURE (47 Down) presented at the European Society of Cardiology (ESC) Congress 2022. Also in the pharmacologic space, a set of three trials presented at ESC 2022 showed the potential for a new class of drugs, FACTORXIA (66 Across) inhibitors, to be safer alternatives for anticoagulation following MI or stroke.

Extracorporeal membrane oxygenation (ECMO; 6 Across) got a close look in another study from AHA 2022, which demonstrated that it does not improve outcomes over an initially conservative strategy, with bailout ECMO as needed, in patients with rapidly deteriorating or severe cardiogenic shock.

Lastly, the RIVARAD trial, presented at TCT 2022, offered some welcome good news for rivaroxaban, showing that 1 week of this agent (Xarelto; 1 Down) after transradial coronary procedures reduces the risk of radial artery occlusion by half without a statistical trade-off in bleeding events.

What Else?

Did we miss anything important regarding coronary news in our Crossword Challenge? Looking at the more “bread-and-butter” aspects of coronary interventions, Arnold Seto, MD (University of California, Irvine, and VA Long Beach Healthcare System), told TCMTD several other trials stood out for their immediate impact on day-to-day practice.

First, the BRIGHT-4 trial, presented at AHA, which showed small mortality and bleeding benefits with bivalirudin over heparin in STEMI, “was a landmark trial to settle the decades-long controversy,” Seto said. He argued that the study was scientifically sound, and said he was surprised by the resistance seen in the community to reconsider a role for bivalirudin in practice.

While many physicians have already transitioned back to using heparin in this context, Seto said “it's very feasible for them to change back, especially now that bivalirudin is generic.” And this is likely to happen, he added, because “it is actually more convenient to me as the operator because I don't have to worry about the ACT not being therapeutic, and that was still one of the major logistical benefits of using bivalirudin.”

Video Interview

Beyond the Data: Top Cardiology Trials of 2022

December 12, 2022

Lastly, Seto pointed to the ARCH trial, presented at EuroPCR 2022, as one that will change his practice. The large study showed that using the StatSeal potassium ferrate patch (Biolife), which Seto had tested in a previous study, could lead to consistent, adequate hemostasis within 1 hour following radial PCI. “In terms of an inexpensive, simple thing that we can use to help reduce discharge times and hemostasis times together, I was very excited to hear that this trial basically validated our results quickly and with a much larger population,” he said.

Calling vascular access a “daily hassle,” Seto continued, “I think we just killed the idea that radial artery occlusion is a major problem for transradial access. And maybe that is overstating the case, but I think radial artery occlusion is not something that we need to worry about anymore, and perhaps do not need to do any very complex interventions for, such as ulnar compression or high-dose heparin.”