1. Update from the AHA 2010 Jonathan Silberberg February 2011

5. Part 1. Trials Rocket-AF Closure I Emphasis-HF SMART Fish oil and AF Symplicity-HTN 2

6. Rocket-AF Trial of rivaroxiban in AF oral Factor Xa inhibitor Half life 5-12 hours, given once daily Dose reduction in renal failure

7. Rocket-AF High CHAD-2 score ~3.5 ave 90% >3, cf. previous trials ~2.0 55% prior stroke 63% heart failure, 40% diabetes N=14,171

8. Rocket-AF warfarin-treated target INR 2-3 Median time in range 58% Over range12% Under range 20% Up to 40 months followup

9. Rocket-AF RivaroxabanWarfarin N70817090 Intracranial/cerebral bleed8455 Stroke or embolism269306 ‘Primary endpoint’2.12%2.42% ‘noninferiority’1.71%2.16% Patients were already stable on warfarin before randomisation

10. conclusions Warfarin monitoring is suboptimal even in well-funded trials Under-anticoagulation protects against bleeding; more consistent treatment brings higher bleeding rates Absolute stroke rates may be overestimated Benefits of treatment are small

11. StarFlex Closure I N=909 Age 18 to 60 Cryptogenic stroke and PFO Open label ASA or WarfarinvsStarFlex with ASA/clopidogrel

12. StarFlex Closure I DeviceMedical stroke/TIA/ neuro death Within 2 years 5.5%7.7% Stroke in 2 years3.1%3.4% Recurrent stroke2329 Alternative cause2022 PFO is usually incidental to stroke

13. Emphasis-1 Eplerenone in mild heart failure N=2737, average 5 years CHF EF <35%; NYHA class II 65% coronary disease median 21 mo followup

14. Emphasis-1

16. Absolute 15.5% vs 12.5% NNT 33 for 3 years

17. EMPHASIS-1

18. SMART A-V delay in CRT (biventricular pacing) N=980, CHF with mean EF 24% Empirical 120 msecvs H’dynamic max dP/dtvs Supine echo algorithm

19. Fish oil and AF N=542 paroxysmal AF N=121 persistent AF 4g omega-3 vs placebo 24 weeks

21. Fish oil and AF Participants were at least 18 years old and had a confirmed diagnosis of either symptomatic paroxysmal AF that had never been treated by long-term pharmacological or electrical therapy to terminate an AF episode or had a diagnosis of symptomatic persistent AF, defined as AF that had been previously successfully treated with pharmacological or electrical cardioversion at least 1 time and were currently in normal sinus rhythm.

22. Fish oil and AF Inclusion required at least 1 suspected or documented episode of symptomatic AF within 3 months of screening and at least 1 electrocardiographically documented episode of symptomatic AF within 12 months of screening.

25. Symplicity-HTN 2 Ardian device renal denervation SBP >160 despite 3 drugs Omron automatic oscillometry home and office BP 84/190 fell <160 during run-in

27. Next week...part 2 Cardiac hypertrophy Decompensated heart failure Brown & Goldstein PHT in heart failure LDL cholesterol Thoracic aorta