Overview of the Cardiology PRN
Cardiology Practice and Research Network (PRN) members include students, residents, fellows, clinical pharmacists, faculty, researchers, and other practitioners with an interest in cardiovascular management. The PRN has 973 members, including 175 students, 40 residents, and 5 cardiology fellows. The PRN seeks to advance the pharmacotherapy of cardiovascular disorders through the promotion of excellence in education, research, and clinical practice by enhancing the knowledge, skills, and productivity of its members. The PRN’s objectives are to provide a means for communication and networking among members; provide quality educational programming at national meetings; facilitate access to information, expertise, and professional opportunities available through the PRN; and provide opportunities for collaborative research.
Regardless of whether you are a student, resident, fellow, or clinical specialist, a wide range of opportunities are available for those interested in participating. The PRN’s seven committees are Membership, Budget & Finance, Research & Scholarship, Student & Trainee, Programming, Nominations, and Communications & Social Media. Each year, committee charges are reviewed and updated, providing multiple opportunities to collaborate and engage. The Cardiology PRN’s Student & Trainee Committee seeks to expand student, resident, and fellow involvement.
The Cardiology PRN is one of the most active PRNs on social media. Clinical updates and controversies are routinely discussed on X (formerly Twitter) @acccardprn. These are excellent ways to stay up-to-date and engaged, but the Cardiology PRN’s community also provides a more traditional avenue for communicating through posting threads. Together, there are many options for communication and networking.
Opportunities and Resources
The Cardiology PRN has many programs that all members, especially trainees, can benefit from attending (or presenting). Perhaps the most popular initiatives are the monthly (sometimes bimonthly) online educational offerings. These include PGY2 cardiology resident–led journal clubs and case conferences. One or two professional development webinars for trainees (students, residents, and/or fellows) are also offered annually. Last year, the PRN provided a webinar of panel speakers, “Career Paths May Change: Demystifying Transitions from Clinical Practice,” and the 2024 professional development initiative will focus on further exposure to the different roles and career possibilities within cardiology pharmacy. Trainees may also participate in writing articles in the Annual Student & Trainee Committee Newsletter.
The Cardiology PRN is also dedicated to financially helping trainees attend the ACCP Annual Meetings. Two travel awards of $750 each are offered to selected students, residents, and fellows. Winners can attend the PRN business meeting to network with other pharmacists with cardiology interests.
Current Issue: Balancing Bleeding and Thrombosis in LVAD Management
By: Lily Hiott, Pharm.D., and Ariana Campos, Pharm.D. Candidate
Patients with advanced heart failure have few treatment options to reduce morbidity and mortality. Heart transplantation and the use of left ventricular assist devices (LVADs) are both potential treatments for stage D heart failure. Over the years, several LVADs have been designed to improve survival in these patients. The HeartMate II (HM2) axial-flow LVAD was previously the most widely implanted device, followed by the centrifugal-flow devices, which were designed to be more hemocompatible. The HeartMate III (HM3) centrifugal-flow device is the most recent form of LVAD technology and is currently the most widely used device.
Despite advances in technology, all LVADs are associated with thrombosis, stroke, and bleeding.1,2 Gastrointestinal bleeding is the most common bleeding complication in patients with LVADs, which is the result of shear stress caused by the LVAD pump leading to acquired von Willebrand disease and arteriovenous malformations.3 The risk of bleeding complications is increased by the need for antiplatelet and anticoagulation therapy, used to prevent thromboembolic complications. Traditional antiplatelet and anticoagulant therapy for the HM3 device consists of aspirin 81 mg daily and warfarin with an INR goal of 2–3. Despite the findings of the MOMENTUM 3 trial, which found the HM3 to be associated with significantly fewer bleeding complications than the HM2, almost 50% of the patients receiving the HM3 experienced a bleeding event.1 However, there was significantly less pump thrombosis and stroke in the HM3 group than in the HM2 group.1 The reduction in thrombotic events with the HM3 has prompted clinicians to question whether traditional antiplatelet and anticoagulation therapy is required for those with the HM3 device and whether a reduction in antiplatelet and anticoagulation therapy could reduce bleeding events without increasing thrombotic complications.
The Antiplatelet Removal and Hemocompatibility Events with the HeartMate 3 Pump (ARIES-HM3), published December 2023, was designed to assess the need for aspirin in patients with the HM3 LVAD.3 ARIES-HM3 was a multicenter, randomized, double-blind, placebo-controlled trial comparing aspirin and placebo in addition to vitamin K antagonist therapy in patients with HM3 LVADs. Six hundred twenty-eight patient were randomized to aspirin or placebo between post-implant days 2 and 7.3 The composite primary end point of survival free of nonsurgical major hemocompatibility-related adverse events (stroke, pump thrombosis, major nonsurgical bleeding, and arterial peripheral thromboembolism) at 12 months occurred in 74.2% of patients in the placebo group compared with 68.1% of patients in the aspirin group (p<0.001). This benefit persisted through month 24 of follow-up.3 Of note, no patients in either arm experienced pump thrombosis or arterial peripheral thromboembolism.3
The difference in the primary outcome was primarily driven by higher bleeding rates in the aspirin arm, with significantly more patients in this group experiencing a bleeding event compared with placebo (40.7% vs. 26.2%; RR 0.64 [0.50–0.83]).3 Of the bleeding events, there were significantly higher rates of nonsurgical moderate, severe, and GI bleeding in the aspirin group.3 More patients in the aspirin group experienced a hemorrhagic stroke; however, the difference was not significant (0.9% vs. 0.3%; RR 0.32 [95% CI, 0.03–3.08]). The use of aspirin was not found to significantly reduce the risk of thrombotic complications (2.8% in the aspirin group vs. 1.6% in the placebo group; RR 0.58 [95% CI, 0.21–1.58]). In addition, there was no difference in rates of ischemic stroke between groups.3
Those in the placebo group were hospitalized 47% less days for bleeding than those in the aspirin group.3 Despite differences in hospitalizations, no significant difference in quality of life was observed. Nonetheless, patients in the placebo group had lower rates of hospitalization because of nonsurgical bleeding, resulting in a cost savings of $380,092 in the placebo group compared with the aspirin group.3
In summary, the ARIES-HM3 trial showed that in patients with an HM3 taking warfarin with an INR goal of 2–3, withdrawal of aspirin was noninferior to continuation of aspirin regarding thrombotic events and was associated with a decreased risk of bleeding events.3 Of importance, the benefit of aspirin avoidance was seen regardless of history of vascular disease, percutaneous coronary revascularization, and diabetes. This trial provides long-awaited evidence supporting the option (together with clinical judgment) to remove aspirin from the traditional anticoagulation/antiplatelet regimen in patients with the HM3 LVAD in order to decrease the risk of bleeding without risking an increased incidence of pump thrombosis and ischemic stroke.
References
- Mehra MR, Uriel N, Naka Y, et al. A fully magnetically levitated left ventricular assist device – final report. N Engl J Med 2019;380:1618-27.
- Rogers JG, Pagani FD, Tatooles AJ, et al. Intrapericardial left ventricular assist device for advanced heart failure. N Engl J Med 2017;376:451-60.
- Mehra MR, Netuka I, Uriel N, et al. Aspirin and hemocompatibility events with a left ventricular assist device in advanced heart failure: the ARIES-HM3 randomized clinical trial. JAMA 2023;330:2171-81.
Submitted by:
A Closer Look at the Cardiology PRN and Opportunities and Resources
Jenna Foster Cox, Pharm.D., BCPS, BCCCP
Clinical Pharmacist Specialist – CPICU, Prisma Health Richland Hospital
Sabrina Dunham, Pharm.D., BCCP, BCPS
Clinical Pharmacist Specialist – CVICU, University of Michigan Health
Current Issue: Balancing Bleeding and Thrombosis in LVAD Management
Lily Hiott, Pharm.D.
PGY2 Cardiology Pharmacy Resident, Northwestern Memorial Hospital
Ariana Campos, Pharm.D. Candidate
University of Maryland School of Pharmacy