Editorial

 

Roberto Ferrari & Kim Fox

 

It is hard to believe that a year has already passed since we announced the new format for Dialogues in Cardiovascular Medicine. We are pleased that it has been such a success so far, having received letters of appreciation, especially for the sections dedicated to “Snapshots in Cardiology” and the “Hot Topics.” The website (www.dialogues-cvm.org) is also proving to be popular with over 200 visits
per month. We are continuing to evolve and the format will change again slightly in 2018, adding the option to store the issues in an online library. We remain ambitious and hope to continue providing a good record of what has happened over the past year by reporting from the most prestigious cardiovascular congresses and journals.

The year 2017 was particularly full of important news, with preventive cardiology and coronary artery disease being at the forefront. We learned about several large trials that delivered new and unexpected results. Could we ever imagine that a medical trial could involve 135 000 individuals from 667 urban and rural communities in 18 countries and conclude that dietary fats are protective and carbohydrates are harmful? The PURE trial (Prospective Urban Rural Epidemiology) certainly gave us surprising results. Results are of course important, but their interpretation is even more important and challenging. Salim Yusuf and his team have certainly made us rethink and challenge the current guideline recommendations when an increased consumption of saturated fats decreases overall mortality. Medicine is a continuous evolution and we keep this innovative momentum.

Equally, the scientific community learned about the extraordinary reduction in low-density lipoprotein achieved by inhibiting PCSK-9. PCSK-9 inhibition gave good results on outcomes and showed an effective reduction in atheroma volume, as demonstrated by plaque regression, without any changes in plaque composition.

This result is indeed another challenge: a positive result that deserves further explanation. Perhaps the most unexpected result is related to cardiovascular disease and inflammation. What is not totally unexpected is that canakinumab, an inhibitor of interleukin 6 and therefore of inflammation, reduced the cardiovascular end point in the CANTOS trial. What was totally unexpected, however, was the benefit on cancer mortality, particularly lung cancer. Of course, a single study is not enough to draw a firm conclusion, but Paul Ridker and his team have pointed us in another direction regarding inflammation and coronary artery disease, even if the costs are currently prohibitive.

On the subject of cost, we should consider the recent anticancer drugs that have been approved with an equally prohibitive cost, with the understanding that their mechanism of action, aimed at a specific target, confirmed significant benefits. However, an analysis of drugs approved by European Medicines Agency between 2019 and 2013 shows that 49% of the 68 approved drugs do not show any survival benefit. Out of the 35 drugs that did show a survival benefit, a clinically meaningful benefit was only found with 11 of them. All 68 approved drugs are reimbursed throughout Europe, each at an annual cost higher than that of the full treatment of nearly 50 patients with coronary artery disease and heart failure, which tells us that we are missing adequate advocacy mastered by patient groups at national and European Union levels to support anticancer drugs. The mortality rate for cancer and cardiovascular disease is similar, but cardiology has managed to prolong life by nearly 7 years and, yet, when there is innovation, such as with canakinumab, we consider the cost prohibitive. We are certainly victims of our own success.

Still on the subject of costs, something quite interesting came about related to the guidelines for the symptomatic treatment of chronic ischemic heart disease. As you know, the guidelines recommend first- and second-line treatments with dated drugs: ie, β-blockers, calcium channel blockers, and short-acting nitrates being first-line recommendations and the others, such as ivabradine, ranolazine, and trimetazidine, being only second-line recommendations. They all have similar, if not identical, antianginal efficacy; unfortunately, none have improve outcomes. They are becoming generic, meaning that there is no longer a cost issue. Yet, habit is labeling them as either first- or second-line treatments, which is another example of how authorities and cardiologists are stifling instead of supporting innovation.

Interestingly, a newly proposed strategy, the “Diamond Approach,” suggests putting all antianginal drugs at the same level and providing a more personalized pharmacological approach to angina based on patient characteristics, pathophysiology, and comorbidities.

Of course, there have been many other interesting and challenging results presented in 2017, which have been highlighted and discussed by experts in this issue of Dialogues in Cardiovascular Medicine. We hope that you enjoy this user-friendly format that gives you up-to-date information.