Interventional cardiology

What does 2018 hold for interventional cardiology?

In our series on the big issues for cardiology in 2018, this week we focus on the world of interventional cardiology, speaking to Professor Darren Walters, an interventional cardiologist and director of cardiology at The Prince Charles Hospital in Queensland.

Unnecessary stenting in stable coronary disease

Professor Darren Walters is director of cardiology at The Prince Charles Hospital in Queensland.

The ORBITA study shook things up last year, with the small trial triggering furious debate about the role of coronary stents in stable coronary disease. In the trial 200 patients with stable ischemic heart disease were randomized to PCI or a sham procedure, and the study authors concluded in patients with medically treated angina and severe coronary stenosis, PCI did not increase exercise time by more than the effect of a placebo procedure.

“The study was provocative and controversial, but can’t be ignored”, Professor Walters says.

“There were a lot of issues with that study, but it was really thought provoking and suggests that in stable coronary disease that we have to really select our patients well to determine those who are likely to benefit.”

The finding along with studies such as COURAGE, is likely to continue to influence decision-making on the future of Medicare-subsidised interventions, says Professor Walters.

“There has been a wide push to put more regulation around what patients then can have stents, the implication that maybe there are people out there who are getting unnecessary intervention. The Medicare Review Taskforce has proposed tightening the criteria for stenting (not yet finalised). Studies like the ORBITA will help shape those criteria.”

Reducing the duration of antiplatelet therapy

 Many studies are now emerging to support significantly reduced durations of dual antiplatelet therapy in patient who have undergone stenting with DES platforms, Professor Walters says.

“The research suggests with the current generation of stents we can really drop anti-platelet therapy to three months, or a month in people who are at high risk of bleeding, so that’s a big shift.

 This is good news for patients who have problems with bleeding especially the elderly, and those needing surgery.

 “We are much more confident about shortening antiplatelet therapy than we were five years ago.”

Great gains in structural heart disease management

There are many new developments in this area too , from the recent MBS listing of TAVI to the emergence of new interventions for heart failure, with the REDUCE LAP study of interatrial shunt therapy for heart failure and preserved ejection fraction is actively enrolling.

Meanwhile, the role of left atrial appendage and PFO closure in stroke has gained mounting evidence, and MSAC has supported left atrial appendage closure in a subset of patient who are at risk and cannot take anticoagulation.

There has never been a more exciting time in interventional cardiology,” he concludes.

“The world of medicine is going less and less invasive and more high-tech. We’re dealing with an older population which is more high risk so we really have to get smarter about how we do things and technology is really coming to the fore.”

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