Practice Update: Cardiology

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The year’s top research, all in one issue
Welcome to our special issue, PracticeUpdate Cardiology: Best of 2016 – bringing
you a collection of the best research of 2016 from the world’s top cardiology
congresses. You’ll find the best in here plus key clinical commentary on why these
studies are practice-changing.
Our PracticeUpdate Cardiology advisory and editorial board members share their
views on the best cardiology story of the year (see left) as well as commenting on
the studies to make an impact from the American College of Cardiology, European
Society of Cardiology and the American Heart Association.
The Elsevier Australia editorial team has specially selected these highlights of 2016
including DAPT, PARTNER-2, EMPA-REG OUTCOME, DANISH, FUTURE, EUCLID
and PRECISION. To discover more please visit
On behalf of the Elsevier Australia PracticeUpdate Cardiology team, I thank you
for your continued support and readership. We’ve had some big changes this year
with a new name and improved content which we hope helps you in your clinical
practice providing the best patient outcomes.
I wish you well for 2017 – and to the breakthroughs next year will bring.
Happy summer reading!
Anne Neilson
Managing editor, PracticeUpdate Cardiology (Australian Edition)
Optimal duration
of DAPT
By Joerg Herrmann MD
Dr Herrmann is Associate
Professor of Medicine at
Mayo Graduate School
of Medicine, Rochester,
Minnesota.
A pproximately 1 million percutaneous cor-
onary interventions (PCIs) are performed
annually in the United States. Accordingly,
any recommendation that pertains to the care of
these patients is of great magnitude and so is then
the “2016 ACC/AHA Guideline Focused Update
on Duration of Dual Antiplatelet Therapy in Pa-
tients With Coronary Artery Disease” (J Am Coll
Cardiol 2016;68:1082–1115). This update comes
5 years after the last ACC/AHA guidelines on
myocardial revascularisation and 2 years after the
corresponding ESC guidelines. Most importantly,
the recommendations for the minimum duration of
DAPT are now in sync across these major societies:
a minimum of 1 month after bare-metal stenting
and 6 months after newer-generation drug-eluting
stenting in patients with stable coronary artery
disease and 12 months after an acute coronary
syndrome regardless of revascularisation strategy.
Interestingly, to extend DAPT beyond the recom-
mended minimum timeframe is given a class IIb
rating in the ACC/AHA guideline. Accordingly,
there is a universal mandate for DAPT early af-
ter stenting, but long-term DAPT is an individual
decision. Even though patient groups at increased
ischemic/stent thrombosis risk on the one hand and
at higher bleeding risk on the other hand can be
listed, this does not provide much-needed concrete
guidance for daily practice.
This gap was addressed by the development of a pre-
diction rule relative to which patient would derive
a net benefit from prolonged DAPT based on the
DAPT trial data and subsequent validation using
the PROTECT trial data (JAMA 2016;315:1735–
1749). Despite the fact that the “DAPT score” may
not be applicable to all comers outside the DAPT
trial criteria, and, in fact, performed only modestly
in the validation cohort, it is still the best tool avail-
able currently and a major advance.
Thus, significant steps were taken in 2016 to pro-
vide more concrete guidance on the optimal dura-
tion of DAPT, which is one of the most common
inquiries in daily practice. For this reason, these
two articles should be remembered as top stories
for the year 2016.
The study carries important implications for
both guidelines and regulatory policy, because it
provides strong evidence that muscle-related statin
intolerance is a real and reproducible phenomenon.
Steven Nissen MD, MACC, Cleveland Clinic, on the challenging clinical
problem of muscle symptoms in statin-treated patients at ACC 2016.
While it is disappointing not to find a reduction in
cardiovascular events with CPAP, our results showed
that treatment of obstructive sleep apnoea in patients
with cardiovascular disease is nevertheless worthwhile.
They weremuch less sleepy and depressed, and their
productivity and quality of life was enhanced.
Doug McEvoy MD, Flinders University, on results of the SAVE study
at ESC 2016.
While ticagrelor was nomore effective in reducing
risk than clopidogrel, we learned valuable information
about this population, specifically, that patients with a
history of lower extremity revascularisation are at higher
risk of acute limb events and cardiovascular events.
Schuyler Jones MD, Duke University School of Medicine, while
presenting results of the EUCLID trial at AHA 2016.
DECEMBER 2016
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