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The 2011 results of the American Heart Association (AHA) and American Stroke Association (ASA) annual assessments of the top 10 advances in their respective fields are rich in findings affecting interventional cardiology. Following are 6 areas in which research reports released last year have the potential to impact practice, from extending transcatheter aortic valve replacement (TAVR) to high-risk operable patients to helping clarify the roles of stenting vs. medical therapy in a variety of patient settings.

Transcatheter Valve Therapy Makes Steady Gains

This past year saw publication of new data from the randomized PARTNER trial that justify offering TAVR to patients with severe aortic stenosis who are operable but at high surgical risk. The finding adds to the earlier indication for TAVR for inoperable patients. Results from PARTNER Cohort A showed no mortality difference between TAVR and surgery at 1 year and similar symptomatic improvement. However, there was a trend toward more major strokes and a higher risk of major vascular complications with TAVR.

In another percutaneous approach to valve dysfunction, data from the EVEREST II trial showed that mitral valve repair with a catheter-delivered clip resulted in similar 1-year efficacy (freedom from death, mitral valve surgery, or grade 3+ or 4+ mitral regurgitation) compared with surgery, but a threefold lower rate of major adverse events at 30 days.

Coronary CTA Shows its Diagnostic, Prognostic Mettle

The CT-STAT trial confirmed that low-risk patients who present to the emergency department with chest pain can be evaluated for CAD more rapidly and at lower cost using coronary CTA rather than stress myocardial perfusion imaging, with no sacrifice in safety or accuracy. Meanwhile, data from the large CONFIRM registry demonstrated that CTA assessment of the severity of CAD adds incremental prognostic value to standard predictors like reduced ventricular function and conventional clinical risk factors.

Reduction Seen in Primary PCI Delays—But Room for Improvement

A study of nationwide CMS data from 2005 to 2010 highlighted progress in providing timely treatment of STEMI patients. Now over 90% receive primary PCI within the recommended window of 90 minutes. Over the 6-year period, median door-to-balloon time declined by 32 minutes, from 96 minutes in 2005 to 64 minutes in 2010. Improvements were seen across the country and across different types of hospitals, with the greatest reductions achieved in older patients, women, and African-Americans. Several national quality initiatives were credited for the positive changes, including the CMS D2B reporting system Hospital Compare, the ACC D2B Alliance, and the AHA Mission: Lifeline program.

However, transfer times from a referring hospital to a PCI-capable hospital have lagged behind, jeopardizing STEMI outcomes. A review of data on STEMI receiving centers in the ACTION Registry—Get With the Guidelines between January 2007 and March 2010 found a median door-in/door-out time of 68 minutes, with only 11% of patients transferred within the recommended 30 minutes. Those who took longer were less likely to achieve an overall D2B time of 90 minutes and after primary PCI had higher in-hospital mortality. Factors associated with prolonged door-in/door-out time included older age, female sex, off-hours presentation, and non-emergency services transport.

Revealing Data on Appropriateness

A nationwide sample of 1,091 hospitals in the NCDR CathPCI Registry found that in almost all instances, acute PCI procedures were justified. But 38% of nonacute cases were deemed ‘uncertain’ and about 12% ‘inappropriate,’ with substantial variation across hospitals. Reasons for the latter assessment included absence of angina (53.8%), low-risk ischemia on noninvasive stress testing (71.6%), and suboptimal antianginal therapy (95.8%). The authors called for decision tools that can provide physicians performing diagnostic angiography real-time guidance on whether to proceed to PCI.

Another appropriateness study drawing on the NCDR-ICD Registry showed that 22.5% of patients who received an ICD did not meet evidence-based criteria for implantation of the device. These patients had a higher risk of postprocedural complications including death than counterparts whose ICDs were in line with guidelines. Moreover, nonelectrophysiology specialists were more likely to implant ICDs inappropriately. The wide variability among hospitals in the proportion of non-evidence-based implantations suggests an opportunity for quality benchmarking, the authors concluded.

Guidance on When Carotid Stenting Does—and Does Not—Help

Most patients with asymptomatic carotid stenosis fare better with medical therapy, but identifying those at high stroke risk who would benefit from revascularization has been difficult. A Canadian study evaluated asymptomatic patients with transcranial Doppler ultrasound to detect emboli and 3-D ultrasound to detect ulcers. Over 3 years, the 4% of patients who had 3 or more ulcers were far more likely to die or have a stroke than those with fewer ulcers (18% vs. 2%; P = 0.03). The presence of microemboli increased risk similarly (20% vs. 2% for no emboli; P = 0.003).

In another effort to improve risk-stratification of asymptomatic carotid stenosis patients, the ACES study evaluated a visual rating scale based on echolucent plaque morphology and Doppler-detected embolic signals. The presence of these 2 traits at baseline identified a high-risk group with an annual stroke risk of 8% and a low-risk group with a risk of less than 1% per year.

Intracranial Stenting Dangerous

In a related development, the randomized SAMMPRIS trial showed that stenting of severe symptomatic intracranial stenosis more than doubles the risk of early stroke and death compared with aggressive medical management alone. And at midterm follow-up, dual antiplatelet therapy plus intensive medical treatment of all risk factors provided similar protection against recurrent stroke.

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• TAVI, Carotid Stenting Prominent on AHA-ASA Lists of ‘Top 10’ Advances of 2010
• TCTMD’s Top 10 Most Popular News Stories From 2011