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Professor TomMarwick discusses the
DANISH, REM-HF, MORECARE, CE-MARC 2,
CONSERVE andNACIAMtrials
Tom Marwick, MBBS, PhD, MPH, Director and Chief Executive of BakerIDI Heart and
Diabetes Institute.
1. DANISH: ICDs in nonischaemic heart failure
For me, this was the top trial presented at this year’s meet-
ing. The DANISH study looked at primary prevention with
ICDs for patients with nonischaemic heart failure. Most
cardiologists have, at some stage, had some disquiet about
the impact of primary prevention ICDs, especially in the
elderly. Many ICDs are implanted and never discharge.
This Danish group, in a pragmatic clinical trial, looked
at whether there was a benefit of implanting an ICD in
nonischaemic HF with an impaired ejection fraction.
The investigators reported no difference in all-cause mor-
tality with ICD versus medical care in nonischaemic HF.
This is despite the fact that ICDs reduce sudden cardiac
death. The results point to the role of multi-morbidity –
HF patients are very likely to have multiple diseases. The
message from this study is that ICDs do not benefit older
patients – the study did a subgroup analysis of patients older
than 68 years – whereas it might benefit younger patients.
This is contrary to current guidelines and an incredibly
important observation.
2. REM-HF and MORE CARE: remote
telemonitoring in heart failure
The REM-HF and MORE CARE were two studies of
remote telemonitoring in HF presented at the ESC. The
conclusions were pretty much the same: telemonitoring did
not change HF outcomes. We know that telemonitoring
is inexpensive, and some private insurers in the US are
considering it as a means of controlling costs. Clearly, the
long-term care of patients with HF requires more than
monitoring – we can get huge amounts of data but there
needs to be some kind of interventional strategy that arises
from the interpretation of the data. These results are a
reality check on what telemonitoring has to offer – I don’t
think they signal the end of telemonitoring but it needs to
be thought through more carefully.
3. CE-MARC 2 and CONSERVE: diagnostic
trials on imaging technologies for
recognition of coronary disease
Both of these were diagnostic trials on the use of new im-
aging technologies for the recognition of coronary disease,
comparing combinations of functional testing with CT and
invasive angiography. In CE-MARC-2, the authors looked
at MRI or SPECT imaging for perfusion versus the current
NICE guidelines (which use a probability-based approach
for test selection). They found that the use of a functional
test reduced the need for angiography and reduced inter-
ventions. In fact, in the group that had the functional test,
8% of the subsequent angiography was unnecessary com-
pared with 28% in the group that was guided by the NICE
guidelines. So that one was a win for doing stress testing.
The CONSERVE trial was a comparison between coronary
CT angiography versus invasive angiography in symptomatic
patients to reduce the number of negative angiograms. The
study showed that if CT angiogram was performed before
catheterisation, there was an 85% reduction of invasive
angiography, with similar outcomes. That one was a win
for CT angiography.
I think it’s an interesting juxtaposition that one study says
“do a non-invasive CT test before an angiogram so that you
can avoid doing angiography” while the other says “do a
non-invasive stress test instead of using current guidelines”
because, again, you can save a bunch of angiograms.
It also demonstrates how we’re still really uncertain about
how to use non-invasive testing in people with chest pain.
There is still a lot of work to be done in this area and I
think the emphasis here is that MRI perfusion imaging is
an interesting strategy that we should probably think more
about in Australia.
4. NACIAM: N-acetylcysteine with glyceryl
trinitrate on infarct size
This is an important Australian trial investigating the free
radical scavenger N-acetylcysteine. The hypothesis was
that, in people having myocardial infarction, some of the
damage from the infarct is related to free radicals. And so if
you could scavenge the free radicals, either that would be of
direct benefit or it would enable nitrates to be effective. The
investigators found a 38% reduction in infarct size with the
use of the N-acetylcysteine with glyceryl trinitrate versus
glyceryl trinitrate alone.
What we’ve been doing with MI has really been focused on
early revascularisation for a long time, but not so much on
other things we can do to try to salvage tissue. This is a nice
example of such a strategy. Second, this group in Adelaide
has been really imaginative about selecting agents for that
purpose. It’s nice to see one of these come in with a really
impactful result.
DECEMBER 2016
ESC 2016
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