ESC Congress 2017 In Review – Focus on CAD&ACS - 17

ESC Congress 2017

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In Review

CAD & ACS

Pharmacotherapy After STEMI
Written by Brian Hoyle

Beta-blockers
Early trials indicated the value of intravenous or oral
ß-blocker therapy in reducing mortality associated with
acute myocardial infarction (AMI). This was quickly
updated by other trials in the ensuing decades leading to
the recommendation of only oral therapy. As such, oral
therapy is now considered the norm, while intravenous
ß-blockers can be considered for ischaemic patients with
no haemodynamic instability or heart failure. In the era
of percutaneous coronary intervention (PCI), the value of
ß-blockers was questioned because of the improved outcome resulting from revascularisation, explained Joseph
Alpert, MD, University of Arizona College of Medicine,
Tucson, Arizona, USA, at the Pharmacotherapy after
STEMI: Current Concepts session on 28 August 2017.
The issue remains contentious in the absence of randomised trials of long-term ß-blocker therapy in patients
treated with primary PCI. Still, for post-MI patients with
normal or near-normal left ventricular ejection fraction,
it seems reasonable to begin oral ß-blockers therapy and
continue the therapy for up to 3 years. The consensus is
that for most STEMI patients, ß-blockers probably reduce
short-term complications and improve long-term survival.
The general recommendation from various guidelines is
that for patients with no contraindications, oral ß-blocker
begun within 24 hours of diagnosis is acceptable.
There is much less evidence to support longer term
use of ß-blockers after STEMI however, for high-risk
patients, longer treatment may be better. Conversely,
ß-blocker therapy might be discontinued for lower risk
patients or in select scenarios (Table 1).
Table 1. Discontinuing ß-Blocker Therapy
Is it reasonable to discontinue ß-blocker therapy at some point?
YES
* Patients with unacceptable side effects
* Financial burden - rare
* Polypharmacy
* Absence of compelling indications such as systolic CHF (LVEF < 40%);
ventricular arrhythmias
CHF, chronic heart failure; LVEF, left ventricular ejection fraction.

Lipid-Lowering Agents
Lowering cholesterol levels is associated with significant clinical benefit after STEMI. The various strategies
were discussed by François Mach, MD, Geneva University
Hospital, Geneva, Switzerland.

LDL-C elevation that occurs in dyslipidaemia should be
lowered in patients with a very high cardiovascular (CV)
risk with a statin used at the highest recommended or tolerable dose [Catapano AL et al. Eur Heart J. 2016; Collins
R et al. Lancet. 2016]. In cases of statin intolerance, ezetimibe and/or bile acid sequestering agents can be used. If
the target LDL-C level is not reached, a statin in combination with a cholesterol absorption inhibitor can be used.
While target levels are provided in the guidelines,
the evidence from various analyses of over 170,000
patients [Cholesterol Treatment Trialists' Collaboration.
Lancet. 2010] and the IMPROVE-IT trial [Cannon CP et al.
N Engl J Med. 2015] indicate that lower levels of LDL-C
are associated with reductions in CV risk. However, the
reality is that relatively few patients achieve the target LDL-C goal. In the SPUM-ACS trial [Gencer B et al.
Atherosclerosis. 2015] the success rate was only 30%.
For these patients, treatment with an inhibitor of
proprotein convertase subtilisin/kexin type 9 (PCSK9)
may be warranted. The efficacy and safety of the human
monoclonal antibody to PCSK9 evolocumab, in plaque
regression [Nicholls SJ et al. JAMA. 2016] and risk reduction of CV events have been impressively demonstrated
[Giugliano RP et al. Lancet. 2017; Sabatine MS et al. N Engl
J Med. 2017], with no detriment of evolocumab on cognitive function [Giugliano RP et al. N Engl J Med. 2017].
Targeting PCSK9 may in addition have merit in the
treatment of acute coronary syndrome (ACS) [Navarese
EP et al. Ann Intern Med. 2016]. The EVOPACS trial comparing evolocumab plus rosuvastatin with placebo plus
rosuvastatin will hopefully clarify this issue.
The timing of the reduction of LDL-C is also clinically
relevant, with a more rapid reduction delaying the onset
of coronary heart disease [Nordestgaard BG et al. Eur
Heart J. 2013].
Dual Antiplatelet Therapy (DAPT)
The issue of extending dual antiplatelet therapy (DAPT)
beyond 1 year in acute coronary syndrome (ACS) patients
was discussed by Deepak Bhatt, MD, MPH, Brigham and
Women's Hospital and Harvard Medical School, Boston,
Massachusetts, USA. The benefits of DAPT with aspirin
along with clopidogrel or ticagrelor in ACS are clear
[Wallentin L et al. N Engl J Med. 2009; Bhatt DL et al.
J Am Coll Cardiol. 2007; Bhatt DL et al. N Engl J Med.
2006]. However, the duration of therapy remains uncertain. The longer-term protection from atherothrombotic
events might be counterbalanced by an increased risk
of major bleeding.

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