December 23rd, 2010

John Mandrola: Looking Back at 2010 and Ahead to 2011

To celebrate the holiday season, CardioExchange asked several of our contributors to choose the 3 most important cardiology-related events of the past year and to make 3 predictions for 2011.

Looking back at 2010:

1. By far, the number one heart story of 2010 was the release of the novel blood-thinning drug, dabigatran (Pradaxa), for the prevention of stroke in atrial fibrillation (AF). Until this October, the only way to reduce stroke risk in AF was warfarin — the active ingredient of rat poison. Assuming that there aren’t any post-market surprises, Pradaxa figures to be a true blockbuster. Doctors and patients have waited a long time to say goodbye to warfarin.

2. The Mark Midei stent story: Whether Dr. Midei is guilty or innocent of implanting hundreds of unnecessary stents isn’t really the big story. The real impact of this well-chronicled saga is the attention that it brings to the therapeutic misconceptions of coronary stenting. The problem with squishing and stenting is that although they improve the physics (of blood flow), they do not change the biology of arterial disease — a hard concept to grasp when staring at a picture of a partial blockage. The vast press coverage of Dr Midei’s alleged transgressions has served to educate many about this nation’s number-one killer, heart disease.

3. The percutaneous (non-surgical) therapy of valvular heart disease. Presently, the only effective means of treating valvular heart disease is open-heart surgery — the most invasive of invasive. Percutaneous approaches to both the mitral valve and the aortic valve made news in 2010. Of the two, transcatheter aortic valve implantation (TAVI) is farther along. The PARTNER Trial showed that patients with severe aortic stenosis who were not suitable for surgery fared better with TAVI than with medical therapy. That the PARTNER Trial was non-negative means that further investigations into percutaneous approaches to valvular heart disease will continue in earnest. Here’s a real-life vignette to illustrate why non-surgical treatment of valvular heart disease is exciting:

He is an “old” 82; thin, grey-haired, and he keeps coming in for breathlessness and chest pain related to severe aortic stenosis. That dang valve just will not open. He lives alone, but barely; he has a walker, and a scooter for the grocery. His mind is sharp and his disposition good. “I can’t handle surgery…I know that, but I am happy…Can you help me?” he asks. Perhaps in the future, we can fix his aortic valve without a saw.

Predictions for 2011:

1. A pill or surgery will never effectively treat obesity. Take that one to the bank!

2. Coronary stents will surpass ICDs in regulatory oversight. And on a more general note, due to our utilization of expensive imaging studies and costly implantable devices, cardiologists will be increasingly burdened by the take-the-fun-out-of-medicine regulators.

3. The therapy of AF will stay on the front page of heart news. Expect another (perhaps two) dabigatran-like warfarin substitute(s) for stroke prevention in AF. Also, especially from me, expect more good news on catheter ablation of AF.

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