research, some of the most promising forms of cardiovascular care involve new technologies and wearables that are being introduced to patients and doctors around the world.

Dr. Seth Martin, MD, leader of The Mobile Technologies to Achieve Equity in Cardiovascular Health at Johns Hopkins Medicine, spoke with HCPLive about some of the advancements being made in the world of cardiovascular technology, a subject he will be speaking intensively on at this year’s American Society For Preventive Cardiology (ASPC) Virtual Summit.

In an interview with HCPLive, Martin spoke of the importance of ambition in the cardiovascular field, and how health care professionals should be ambitious and efficient in caring for patients with cardiovascular diseases.

“I think we have to think big,” Martin said. “We need to be thinking bigger about accelerating q version of the healthcare system in the future where patients truly are at the center and empowered and can achieve better outcomes. I think our pace of adoption of new evidence and guidelines is just too slow, and we really need to leverage technology to do that.”

Martin spoke of human centered design methodology, a practice used often in the technology industry, to create technology that is centered around the health and concerns of the patients, both mentally and physically.

For Martin, the process of creating effective technology for patients with cardiovascular diseases is dependent on patient satisfaction as well as the acknowledgment a myriad of health care professionals, all of whom make up an important collection of stakeholders.

“We need to make sure we're engaging the input of our nursing colleagues of our pharmacy, colleagues of our social work colleagues from a cardiac rehab standpoint, our exercise physiology colleagues, the list goes on,” Martin said. “We need to really be bringing in this diverse stakeholder input earlier in the process, and I think that will increase the probability of success.”

According to Martin, several advancements have been made from a diagnostic perspective.

His colleagues who work within the neurology space have developed diagnostic tools that can diagnose a stroke in patients based on their eye movements, and he feels as though there’s been momentum in arrythmia detection technology in the world of cardiology.

Martin also referenced studies that are being conducted based on patients’ blood pressure, resulting in Bluetooth connected blood pressure technology that is currently in development.

However, the development of these new technologies was not Martin’s sole concern. Accessibility of these new technologies and coaching for patients who are not accustomed to them was also vitally important.

Martin believed low-cost internet and technology coaching services could provide a path forward in terms of progressive cardiology research.

“In the future, I envision a robust kind of network (and) that we find ways to get patients access to technologies, if they can't otherwise afford it, just like we have programs to get patients access to medications, if they can't otherwise afford it,” Martin said.

Videos

Advancements in technology and the availability of resources for patients and doctors alike could mean a bright future for cardiology research.

Seth Martin, MD: Cardiologists Should “Think Big” About New Technologies

, particularly wearables and access to telemedicine, grew in importance during the COVID-19 pandemic and perhaps even the environment that has followed.

As part of this larger conversation, Ty Gluckman, MD, Medical Director, Center for Cardiovascular Analytics, Research, and Data Science at Providence St. Joseph Health, moderated “Practical Strategies in Practice” at the American Society for Preventive Cardiology’s 2021 Virtual Summit on CVD Prevention.

, Gluckman spoke on the importance and recognition of clinicians that as they shift into population health, the ability to collect information from patients to inform care delivery might have particular importance.

“The pandemic hit and many of us had to morph, having never done a telehealth virtual visit into that world, and remote patient monitoring and virtual care delivery became that much more important,” Gluckman said. “In light of the pandemic, and the landscape that has followed, the devices that we rely upon historically, will only grow in their importance and increasingly mobile health, virtual care delivery, telemedicine will become a key driver for us in the years to come.”

However, he noted the limits of advances in medicine technology, observing that the technological advances have outstripped understanding of what they can do with the information, noting a study done on the Apple Watch in accurately identifying atrial fibrillation.

“The ability to have technology that is moving faster than we know what to do with it, the trials, and the data that comes out allows us to understand how it should be operationalized,” Gluckman said. "I think that's a cycle that will persist. But having that information done in a more rigorous fashion, will allow us for boots on the ground clinicians to understand how to utilize the technology.”

Ty Gluckman, MD speaks on the use of medical technology, including wearables and and telemedicine, and the growing importance of mobile health. 

Ty Gluckman, MD: Utilizing Advances in Technology for Cardiovascular Care  

 Sid, I think you know that we’ve covered this next query quite well. But is there anything you wish to add that you’re interested in? This was in other novel therapies in clinical trials. That piqued your interest. I think we’ve heard a bunch and I think you’ve alluded to some. Anything that you want to add at this time?

No. I think you mentioned this, and I think this is going to be resurrected. I was disappointed at the NAEPP [The National Asthma Education and Prevention Program]/ NHLBI [National Heart, Lung, and Blood Institute] statement on thermoplastic-bronchial thermoplasty. If you look at the latest GINA [The Genetic Information Nondiscrimination Act] guidelines, they kind of pushed it aside. I think there is a group of patients, the non-T2 [type 2 asthma] patient—a patient who has severe persistent disease—and I think bronchial thermoplasty is an effective treatment. I know I’ve heard you speak about some of the fascinating things happening in smooth muscle when the thermal injury occurs, but I think that’s something that is going to probably emerge a little stronger in years to come, despite what the 2 groups have said. I think it was more of a caution rather than saying, “Don’t do it.”

Geoff, you acquired a lot of the primary data for bronchial thermoplasty. You’ve been a proponent. Do you see it going away, resurrecting, or maybe having a more focused use?

 Well, I think that what we’re looking at here is how it’s going to be used in the toolbox, in addition to biologics. Now that we are starting to attack the low T2 disease more effectively with biologic drugs, the subgroup of individuals who are more specifically candidates for bronchial thermoplasty alone is going to shrink. I think that. We also know from data that patients on biologics or receiving bronchial thermoplasty often do well when they receive both. So those people who get partial response to a biologic may also benefit from bronchial thermoplasty. As you know, Mario Castro, MD, director of the Clinical and Translational Science Institute at the University of Kansas School of Medicine in Lawrence, Kansas, has been looking at a more targeted approach to bronchial thermoplasty for airways that are showing poor ventilation by XeNA on gated MRIs. He has some good results suggesting that a more targeted approach, with 1 setting, may be more effective in people who have asthma in certain regions of the lung—more physiologically important—even though the whole lung may be inflamed. I definitely think that, hopefully, we will continue to have a role for this therapy. I agree completely with Sid that, and I wrote this in an editorial with Mario, that the NAEPP may have went a little too far or too restrictive in their guidance. I think we’re going to be seeing some interesting things in the alarming space. Analogous to what happened in the IL-5 [interleukin-5] space, we know the next target coming down the pipeline is probably in the IL-33 pathway with a receptor blocker, as opposed to a soluble cytokine blocker. We know that these alarms don’t have the same biologic effects. It’s going to be interesting to see how these drugs compare as they move through the clinical trial process. We also targeted the CRTH2 [chemokine receptor homologous molecule expressed on Th2 lymphocytes] receptor. These trials, unfortunately, failed in phase 3. Possibly because of the weaker effects of this target on biologically controlling disease, or the phenotype of the patient wasn’t correctly identified because there wasn’t a specific biomarker or endotypic biomarker that could be targeted.

Yeah. That, and if we go back in time, like mepolizumab [Nucala] when it first was trialed. Mepolizumab failed because the participants that were enrolled in the study were far too mild for the disease and were too diffuse. When it was more focused, it became 1 of the first IL-5, anti-IL-5 that could be used in the United States. So a very good point.

. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your inbox. It comes to you wherever you’re at: on your phone, in your office, or in your home. I want to thank everyone and our sponsors for this wonderful opportunity. Have a wonderful day and be safe. Thank you.

Sidney Braman, MD, and Geoffrey Chupp, MD, discuss other novel agents currently in clinical trials for the treatment of severe asthma.  

Novel Agents in Clinical Trials 

Geoff, how about you tell us a little bit about NAVIGATOR, the 2 patents of pathway trial, and some of the pivotal trial data that it’s reading out? It’s an exciting time, and these are ringing out in our international conferences very shortly. Could you punctuate some of those, Geoff?

Yeah. I think that the PATHWAY and NAVIGATOR trials were part of the anti-TSLP [thymic stromal lymphopoietin] pivotal trial program. Both were published in the New England Journal of Medicine as recently as 2 days ago for the NAVIGATOR study. Phase 2 of the PATHWAY study looked at patients with severe uncontrolled asthma. But as the criteria that we’ve discussed—regardless of their biomarker, phenotyping, as T2 [type 2 asthma] high or low T2—data shows really robust reductions in exacerbation rates over the course of the trial. What was very exciting about this trial, which has held up in NAVIATOR for the first time for a biologic, is that patients with both high T2 and low T2, by biomarker status, have very strong responses in terms of exacerbation reduction. So there’s less of a stratification by both blood eosinophil levels and FeNO [exhaled nitric oxide] in the patient’s response to the drug in terms of exacerbation reduction. I think it makes sense, from a mechanistic standpoint, because of the broader effects that TSLP has on both T2 and non-T2 inflammatory responses, to expect this response in the clinic. It holds up very nicely in both PATHWAY as well as NAVIGATOR. The other nice thing, as you discussed with blood eosinophil levels, is that we see biomarkers decrease with treatment of the drugs. For example, FeNO levels drop very nicely after treatment.

 One of the fascinating stories is when you’re on teze [tezepelumab], IgE levels drop. If you don’t use it, you can’t use IgE as a biomarker—pharmacodynamic biomarker, of course—with the use of reslizumab [Cinqair]. But you can see a decrease with teze and the filament. What we’re seeing now is this effect on the allergic phenotype, which is quite interesting, I think, and certainly valuable. Nic, were you excited by the New England Journal of Medicine paper?

 Absolutely. I think this type of target may open new doors for patients who we have in our clinic at Baylor College of Medicine in Houston, Texas, with borderline or 92-type inflammation. Even in those patients who are already on biologics that are targeted to inflammation are not doing well or not responding. And then some are naive. I see that there are 3 patient populations that, such as tezepelumab, may work. Obviously, we need to start doing it because real-life studies, as you know, are much more informative than clinical trials. I believe that there’s good, robust data on efficacy and safety in that type of patient population by just looking at the data from clinical trials. It’s a broader biologic than the ones we have right now. Obviously, there’s still room for all of these biologics to be used. The big question, the big elephant in the room, is: Who do we start first? Which one? Going back to our previous discussion, do we need to phenotype if this drug works in both using affiliate monies and affiliate allergic, non-allergic? Or why bother? I don’t know if we’re still there or if we’re there yet. But I think it’s a very interesting advancement to what we have right now.

 I think surprisingly, in their trial, when you look at the oral corticosteroid ability of teze, there were arithmetic directions to outcomes that made sense. But they didn’t quite hit the 0.05 significance. That appeared to be because the placebo responded to treatment. These are tricky studies. Aren’t they, Sid?

 Yeah. I think so. I talked to the company a couple of weeks ago, and they expressed the same frustration. But I thought that in future studies, they may be larger numbers. It may come out. But I don’t think that’s going to be a big negative. I don’t think we’re not going to use a drug because of a trial that didn’t show the immediate response that they’d hoped for. 

 Yeah. I’ll go back to what Nic had said. The real-world evidence where you’re going to take the drug and put it into other patients that aren’t homogeneous regarding their attributes, really tells the tale that the stewards vary. That may not get onto the label unless they do it vs placebo. On the other hand, from real-world experience, I know for a fact that with the use of omalizumab [Xolair], I was able to spare people of corticosteroid burden. Now it’s not in the label.

The other issue, Rey, is the medication’s efficacy on comorbidities. Obviously, we want to see more data on atopic dermatitis, nasal polyps, and chronic rhinosinusitis. As I mentioned earlier, 1 of the decision-making factors in my mind is to look at the whole picture—not just the asthma. Most asthmatics with severe disease have other teaching comorbidities that I would like to target. I think it would be nice to see what happens to patients with those comorbidities targeting TSLP.

Geoffrey Chupp, MD, and Nicola Hanania, MD, MS, review the phase 2 PATHWAY trial and the phase 3 NAVIGATOR trial details for tezepelumab in patients with severe, oral corticosteroid-dependent asthma. 

PATHWAY/NAVIGATOR Trials for Tezepelumab 

In an interview with HCPLive, Harold Bays, MD, Medical Director and President of the Louisville Metabolic and Atherosclerosis Research Center, discussed the considerations of GLP-1 RA as either a staple of care or agent use that is still being defined in the 

Bays led a discussion on GLP-1 receptor agonists at the 2021 American Society for Preventive Cardiology Virtual Summit on CVD Prevention. 

"I think they clearly recognize that any hierarchy abuse, you're going to first implement appropriate nutrition, physical activity, then I think most people would implement Metformin therapy," Bays said. "There's a lot of reasons for that being that first line choice, but then after that, I think the the two anti-diabetes drugs that are most recommended would be the SGLT2 inhibitors and the GLP-1 RA and both of them have a little bit differences in their pharmacodynamics."

He noted this choice between the 2 agents ultimately comes down to treating the comorbid conditions of the patients, including obesity or heart failure, but no agents are available to treat both. 

"For clarity, you would be using it to treat the diabetes mellitus, but the fact that there could be clinically meaningful weight loss amongst your patients with T2D, I think that that that could train you towards the decision of going in the direction of GLP-1 RA," Bays said. 

Lastly, he spoke on the recent FDA decision of semaglutide in the treatment of chronic weight management, noting its development has been a remarkable step forward in diabetes treatment. 

"Now, hopefully, we're gonna see similar types of technology where we could maybe convert other peptides, from injectable only into oral agents," Bays said. "From a conceptual standpoint, the development with the oral semaglutide is just remarkable. But, for semaglutide itself, the type of weight loss that we're seeing is also quite remarkable."

Harold Bays, MD discussed the effectiveness of GLP-1 RA in treatment, as well as the development of oral semaglutide.  

Harold Bays, MD: Exploring Benefits and Outcomes of GLP-1 RA Treatment 

This week, The American Society For Preventative Cardiology (ASPC) 2021 Virtual Summit welcomed a diverse group of doctors, health care professionals, and public speakers to introduce new ideas and strategies into the world of preventive cardiology.

In an interview with HCPLive, Dr. Pam Taub, MD, FACC, FASPC, Professor of Medicine

Director of Step Family Cardiovascular Rehabilitation and Wellness Center explained how diet and socioeconomic challenges affect 

 “Physical Disabilities- Focus on Risk Assessment, Diet, Accessibility – How To Overcome Unique Challenges”.

Taub noted how there are often misconceptions that patients have regarding what a healthy diet is, and how dietary recommendations are impacted by those misconceptions.

“I think that there's very little evidence-based study data to really drive what our recommendations are,” Taub said. “But this is also an area where the popular media gets involved. And there's a lot of fad diets, the keto diet, the Paleo diet, and everybody has their own twist on what the right diet should be, and so patients get confused.”

With the evidence that is available, Taub recommends dietary options based on 4 broad themes: calories, content, food intake, and how patients eat food.

With these 4 themes, Taub and fellow doctors can determine what patients are consuming, what they should be consuming, how often throughout the day patients are eating food, and the overall methods involved in their diet.

Typically, the plant-based Mediterranean diet is at the core of most healthy diet options and has significant data associated with it. Additionally, Taub urges patients to participate in metabolic rest, a process that involves eating at appropriate times throughout the day and keeps patients from late-night snacking and over/under eating.

Of course, each patient has specific dietary needs that can be related to their lifestyle, comorbidities, and overall health.

Additionally, Taub noted that accessibility plays a large role in cardiovascular health, and how it is often impacted by the socioeconomic status of a patient.

“Accessibility definitely depends on socioeconomic status, and race,” Taub said. “I mean, we know that people from low socioeconomic backgrounds and certain minority groups, like Hispanics, and African Americans have poor access to a lot of these resources. Also women. These 3 groups tend to be low utilizers of cardiac rehabilitation and other resources. It is a major problem in the healthcare system, and there are no easy answers about how we improve access.”

Access is a prominent concern for Taub and fellow doctors in the cardiology field, especially given the advancements in technology and communication within the medical community.

New strategies such as telemedicine, remote cardiac rehabilitation and video-based content delivery have become increasingly popular, especially since the world has been grappling with the COVID-19 pandemic.

While some in-person methods such as visits to community-based organizations such as local churches, community centers, or barber shops have proved useful in communicating with patients from low-income communities, Taub believed that all communities should have access to the advanced virtual care that has become more prominent in recent years.

“If this is a strategy that as a nation we're going to be deploying, then we need to make the accessibility of the Internet a basic, fundamental aspect of any program just like we guarantee water to everyone,” Taub said. “We need to guarantee free internet and some kind of device for connecting with their health care provider to everyone. If we focus on really the low-income communities, we will, I think really make a difference.”

Dr. Taub speaks on the technology-based advancements in cardiovascular care and socioeconomic status can affect a patient’s diet and access to care.

Pam Taub, MD: The Implication of Diet and Socioeconomic Status in CVD Management

Peter Toth, MD, Director of Preventive Cardiology, CGH Medical Center, discussed the use of new agents for 

 and whether they will become primary or secondary agents in the treatment.

"I think for the most part, virtually all of them can be used in combination with statins, or ezetimibe, or probably even the PCSK9 monoclonals," Toth said. "But let's say a patient is statin intolerant, then it gives you a whole new mechanistic approach by which to try and impact risk and lower atherogenic lipoprotein burden in serum."

He noted that clinicians can now take advantage of alternative pathways for reducing LDL-C and serum pathways that were once not possible. 

Further, Toth spoke on the effects of the COVID-19 pandemic on cholesterol levels in patients who were currently being treated for various comorbid conditions.

He noted people stopped their medication and did not visit the hospital during a cardiovascular event for fear of becoming infected with COVID-19. 

"We lost an average of one and a half years of life expectancy in the US due to the COVID pandemic," Toth said. "I'm absolutely certain that not only was the trend for rising cardiovascular mortality extended, but I'm sure it's spiked. We have a lot to learn, we're certainly going to have to think of novel ways to protect our patients from future pandemics."

Lastly, Toth observed the complications of statin adherence, as more patients believe themselves to be statin intolerant. 

"In the last 10 years, there has been a continuous rise in cardiovascular mortality among both men and women," Toth said. "Despite the fact that for the previous 30 years, it was a clear downward trend. So we have these miracle drugs, they're being inadequately used, and often for false pretenses being stopped."

Watch the first part of the interview with Peter Toth, MD 

Peter Toth, MD discusses the combination treatment aspects of lipid management agents, as well as the effect of the COVID-19 pandemic on cardiovascular care. 

Peter Toth, MD: Facing Complications in Lipid Management

The complications of cardiovascular disease are varied and require proper management by patients and doctors alike, and there are often misconceptions on what appropriate and health-centric cardiovascular care can be.

The American Society For Preventative Cardiology (ASPC) 2021 Virtual Summit assembled a diverse array of doctors, health care professionals, and public speakers to create a dialogue on progressive strategies and advancements made in the world of cardiology.

In an interview with HCPLive, Dr. Pam Taub, MD, FACC, FASPC, Professor of Medicine Director of Step Family Cardiovascular Rehabilitation and Wellness Center, spoke of the themes associated with her ASPC presentation “Physical Disabilities- Focus on Risk Assessment, Diet, Accessibility – How To Overcome Unique Challenges”.

Taub urged health care professionals and patients alike to consider the lifestyle approaches that are associated with cardiovascular disease. In many cases, the best strategies involve a combination of medication and physical exertion.

While conversations surrounding multi-layered management might be difficult, they are necessary.

“In addition to pharmacologic approaches, it's always easier to tell a patient to take a drug and to add drugs as to adjust parameters such as lipids, blood pressure,” Taub said. “However, it's much harder to talk to a patient about lifestyle strategies. For instance, exercise, what is the right types of things to be adding to their diet, those kinds of strategies.”

While pharmacologic therapies are often warranted, Taub found that patients received the most benefits when it was coupled with healthy lifestyle modifications.

Taub considered cardiac rehabilitation to be an important but “very underused” lifestyle-based program in the United States and the world at large. Traditionally, these types of programs are recommended to patients after they’ve had a cardiac event.

If a patient were to have a myocardial infraction or bypass surgery, an acceptable form of cardiac rehabilitation could be a valve replacement, resulting in improved exercise capacity and a reduction in rehospitalizations and overall mortality.

“In patients with physical disabilities are frail and elderly patients, they're often dismissed as not being able to benefit from cardiac rehabilitation, because there's this conventional view that in order to benefit from cardiac rehabilitation, you have to get on a treadmill and you have to be able to exercise,” Taub said. “But there's a lot of things that we can do with these patients that don't involve getting on a treadmill.”

Physical activities such as aerobic exercise can be implemented in the daily routines of older patients to build skeletal muscle and improve their quality of life.

Taub clarified that the health care community should not dismiss people with physical disabilities, as they can benefit from a myriad of lifestyle intervention programs like cardiac rehab. 

However, the hesitation surrounding these programs is also patient driven. Often, patients will consider themselves beyond help or lack the knowledge on programs and lifestyles that can truly benefit them.

Addition, Taub mentioned that providers are often data driven, and since the medical community is lacking in data on frail and elderly populations, additional effort must be taken to properly inform and enroll patients in quality, life-enhancing programs.

Taub has had countless successes with cardiovascular programs with her patients.

In the interview, she spoke of 1 former patient with bilateral below-the-knee amputations who was skeptical of the benefits of cardiac rehabilitation. Taub convinced the patient to enroll in a strength training program, and in time both she and the patient recorded physical improvements.

“He did a lot of things that really improved his overall quality of life, there's a lot of strength training that he did, there was a lot of resistance work that he did with bands, and by the end of the program, his skeletal muscle mass had increased his visceral fat had decreased his energy level and exercise performance had increased,” Taub said. “So, sometimes just educating patients that there are a lot of things we can offer.”

Dr. Pam Taub speaks on the misconceptions of cardiac rehabilitation and other lifestyle approaches recommended for patients with cardiovascular diseases. 

Pam Taub, MD: Healthy Lifestyle Programs for Patients with CVD

In an interview with HCPLive, Peter Toth, MD,  Director of Preventive Cardiology, CGH Medical Center, spoke on the trends in 

 and what he considers priorities in research. 

Toth presented "Emerging Therapies in Lipid Management" at the 2021 American Society for Preventive Cardiology Virtual Summit on CVD Prevention.   

"I'll be talking about innovative approaches to pharmacologically modulating serum levels of atherogenic level protein," Toth said. "My talk focuses in on reducing LDL, reducing remnants as well as lipoprotein little (a)."

He noted trends in finding ways to both safely and effectively reduce LDL cholesterol (LDL-C). 

"I think you're gonna see a progressive movement toward finding specific means by which to also reduce serum concentrations of remnant lipoproteins," Toth said. "And I think, third, there's definitely considerable movement toward finding ways to effectively and safely reduce lipoprotein, and then fourth, research on HDL is definitely not dead."

He mentioned the agents discussed included bempedoic acid, PCSK9 inhibitors, natural alternatives to PCSK9is, evinacumab, and others. 

"We find that a drug like bempedoic acid can actually reduce LDL somewhere between 18 and 25%, which is pretty darn good," Toth said. "And you can use it in combination with ezetimibe or statin. So it's very versatile and it gives you additive LDL reduction with other drugs." 

Peter Toth, MD, discusses the movement towards new agents in treatment of lipid management.

Peter Toth, MD: Innovative Approaches to Lipid Management 

There is a gap in treatment for patients with

That is the main takeaway of TARGET-NASH, an ongoing study looking at treatment and care for patients with 

 (NAFLD) or non-alcoholic steatohepatitis (NASH),for Mary Thomson, MD, MSC, Assistant Professor of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota Medical School.

Thomson, a lead author on TARGET-NASH, recently told 

that statin use is underutilized in this patient population, largely due to the risks associated with the treatment for additional liver damage.

TARGET-NASH is an observational study of participants with NAFLD and/or NASH in usual clinical practice and is part of a series of Target studies targeted several diseases, including inflammatory bowel disease and asthma.

All of the patients have been diagnosed with NASH, either by their physician or by a biopsy.

Thomson said the COVID-19 pandemic may have slightly impacted how the study is reported, but for the most part the ongoing analysis will transform care for this patient population.

Thomson also spoke about how individual decisions during the COVID-19 pandemic could play a role in liver care moving forward, including increases in alcohol and drug use, as well as an increase in poor dietary decisions.

A recent study has found statins are underutilized for NASH and NAFLD patients. 