Packed ballrooms and poster tube canisters — the nuisances of medical conferences that were once taken for granted — returned with a fervent welcome at this weekend’s American College of Cardiology (ACC) conference. Held in Washington D.C., from April 2-4, it was the first major cardiology conference held in person since the onset of the COVID-19 pandemic three years ago.
Participants walked up to microphones to ask presenters about their research. Colleagues across the world networked over dinner. The irony of looking into the future of cardiovascular care while at the same time feeling nostalgic for these quotidian activities of pre-COVID-19 times was lost on no one.
COVID-19 still shaped the discussion at the conference. Dr. Dipti Itchhaporia, president of the ACC, addressed COVID-19 directly in her opening remarks. She said, “The COVID-19 pandemic has underscored many existing realities of our health care system, including how much health matters, how health and the economy are inextricably linked, and the importance of achieving health equity to realize good health for everyone.”
Health equity will be one of the focuses of the ACC going forward, Dr. Itchhaporia remarked.
One particular aspect of health equity that began gaining traction within the ACC before COVID-19 was women’s cardiovascular health. Data consistently have shown that women receive evidence-based therapies less frequently than their male counterparts, including treatment for myocardial infarction and referrals to cardiac rehabilitation. Through focused sessions on cardio-obstetrics and various research presentations, women’s cardiovascular health again rose to the fore of discussion at the ACC conference.
Nowhere did women’s cardiovascular health receive more prominent consideration than at the presentation of the Chronic Hypertension and Pregnancy (CHAP) trial. Among pregnant women with mild hypertension, using antihypertensives to target normotension was found to have better pregnancy outcomes than remaining permissive of slightly elevated blood pressures. The findings of this trial were simultaneously published in the NEJM and presented as a late-breaking clinical trial by the study’s first author, Dr. Alan Tita, an ob/gyn at the University of Alabama at Birmingham.
The findings from the CHAP trial will be practice-changing. They provide clear support for aggressively treating blood pressure, despite the potential harms of doing so during pregnancy.
The American College of Obstetricians and Gynecologists (ACOG) and ACC/American Heart Association guidelines clearly delineate the need for treating severe hypertension, defined as a systolic pressure of at least 160 mmHg or a diastolic pressure of least 110 mmHg. Uncontrolled hypertension in this range increases the risk of stroke, heart failure, acute kidney injury, as well as maternal and fetal complications, such as perinatal death and preeclampsia.
In contrast, what to do with blood pressures over 140/90 mmHg remains murky. A theoretical concern exists that lower blood pressures can drop placental perfusion pressures and result in fetal demise. While the findings of a previously published study found that tighter blood pressure control in mild hypertension was not linked with pregnancy loss or high-level neonatal care, the study did not evaluate other pregnancy outcomes, and guidelines still do not provide clear recommendations on the management of mild hypertension in pregnancy.
The CHAP trial enrolled 2,408 pregnant women across the U.S. with systolic blood pressure between 140 and 160 mmHg and diastolic pressure between 90 and 105 mmHg. The women had to have a singleton pregnancy and be less than 23 weeks pregnant. They were randomized to receive antihypertensives to target a blood pressure less than 140/90 mmHg or receive no therapies at all until their blood pressure rose into the severe hypertension range. The majority of enrolled women had previously been diagnosed with hypertension and were non-white.
Dr. Tita and his colleagues determined that the composite outcome of pre-eclampsia with severe features, preterm birth, placental abruption, or fetal or neonatal death occurred less frequently in the women treated for their mild hypertension (30.2% vs. 37.0%). No differences in fetal growth retardation were found. Aggressive treatment with antihypertensives was associated with an 18% reduction in the likelihood of these events occurring, mostly driven by a reduction in rates of pre-eclampsia.
The imperative to treat mild hypertension through pregnancy has now been made clear, as the CHAP trial demonstrated that antihypertensives improve pregnancy outcomes without causing harm.
Another noteworthy trial presented at the ACC conference was the VALOR-HCM trial, which demonstrated that among patients with symptomatic obstructive hypertrophic cardiomyopathy (HCM), mavacamten improved symptoms and reduced the need for septal alcohol ablation or surgical myectomy. Mavacamten is a myosin inhibitor that was up-titrated in the study according to echocardiographic parameters. The drug decreases the number of myosin-actin cross-bridges to mitigate the excessive contractility that is pathognomonic for HCM. The novel drug is being actively considered for approval by the FDA later this month.
Also notable was the publication of new heart failure guidelines, which override those from 2013 that underwent a focused update in 2017. The latest guidelines stress the importance of using sodium-glucose co-transporter 2 (SGLT2) inhibitors in heart failure, a recommendation that was absent in the prior guidelines. Additionally, while angiotensin receptor-neprilysin inhibitors (ARNIs) were previously recommended in heart failure with ejection fraction under 40%, the current guidelines — in light of studies like PARAGON-HF — extend their utility to all classifications of heart failure, independent of the ejection fraction.
The ACC conference this year was marked by an outpouring of energy not just for the original research that was presented but also for the chance to connect with old colleagues and new. The event will forever be remembered within the field as a triumphant return to in-person formatting, one that hopefully is here to remain.
Dr. Haghighat is employed by the University of California, San Francisco. There are no conflicts of interest to report.
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