PIONEER AF-PCI: Impressions From Duane Pinto, MD, MPH From AHA 2016 Scientific Sessions, New Orleans, LA
The American Heart Association (AHA) Annual Scientific Sessions 2016 in New Orleans showcased novel, cutting-edge science that will impact patient care and move the field of scientific discovery and innovation forward. For the clinical cardiologists, interventionalists and electrophysiologists that take care of patients with atrial fibrillation who undergo percutaneous coronary interventions, this year’s Scientific Sessions in The Big Easy featured what will go down in the history, in my opinion, as one of the pivotal trials ever done in cardiovascular medicine — the PIONEER AF-PCI trial orchestrated by my former attending and faculty member at Beth Israel Deaconess Medical Center, Harvard Medical School, Dr. C. Michael Gibson.
I met with my mentor, Dr. Duane S. Pinto (Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA), who has co-authored another simultaneous publication with Dr. Gibson from the PIONEER AF-PCI data to discuss the results of this pivotal trial, and his impressions from this important work.
Dr. Pinto: I think Dr. Gibson and the PERFUSE study group should be commended for taking an important clinical question from a concept to its completion. Its a clinical question that we deal with frequently, i.e. how to manage patients with atrial fibrillation with antiplatelet/anticoagulant therapy after a stent implantation. The PIONEER AF-PCI investigators had the exemplary courage to reduce medications in a randomized controlled trial, and the rewards were so high. The trial results are a beacon for efficiency of care in reducing rehospitalization by avoiding bleeding complications, thereby helping patients after their (stent) procedures. The results from this pivotal trial help us in managing patients and inform us about what we should not be doing (triple therapy), and move the field ahead to know what we should be doing (antiplatelet/anticoagulant therapy combination).
Ankur: The NEJM paper has been widely accessed and read; however, there is another simultaneous Circulation paper describing the PIONEER AF-PCI data that discusses all-cause mortality and rehospitalization.
Dr. Pinto: We have reached a stage in cardiology where finding best practices and improving efficiency and quality of care is almost as important as the clinical outcomes. Our patients (obviously) suffer from bleeding events, but our system suffers as well, when we don’t provide optimal care. Often, the decisions we make at the time of an event (unstable angina or non-ST-segment-elevation myocardial infarction) may reap adverse consequences with regard to rehospitalization and cost. This was the context of the (Circulation) paper. When one sees that clinical (bleeding) events are reduced with baby dose of rivaroxaban plus dual-antiplatelet therapy, and with avoidance of triple therapy, then that translates into something tangible for patients, i.e. rehospitalization. This is something that I think is important in our current health care system and environment, where resources are constrained.
Ankur: Dr. Deepak L. Bhatt (Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School) wrote a terrific editorial on it that I encourage everyone to read. Its titled, “The beginning of the end of full dose triple therapy with warfarin?” I think, looking 5 years from now, this will go down in history as one of the pivotal trials in cardiology.
Dr. Pinto: My mentor, Mike (Dr. C Michael) Gibson, has done admirable work over decades. Much of what he’s done has been impactful for cardiology. But I think that this trial is one of the highlights of his very storied career. We are going to look back and say that this was a game changer.
Ankur Kalra, MD
Advanced Interventional and Structural Cardiology, Houston Methodist
DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX
Weill Cornell Medical College, New York, NY
Safety, Quality, Informatics and Leadership, Harvard Medical School, Boston, MA
Ankur is an advanced interventional and structural cardiology fellow at Houston Methodist Hospital, Weill Cornell Medical College. He served as a clinical and research fellow in interventional cardiology at Beth Israel Deaconess Medical Center, Harvard Medical School in 2015-16. His research is focused on cardiovascular care quality improvement in low- and middle-income countries, and works in collaboration with the American College of Cardiology (Washington, DC) for the PINNACLE (Practice Innovation and Clinical Excellence) India Quality Improvement Program (PIQIP). Follow him on Twitter @AnkurKalraMD