AHA Names Top Heart Disease and Stroke Advances for 2021

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While the ongoing pandemic continued to dominate public health headlines in 2021, research progressed on a variety of heart disease and stroke fronts, according to the American Heart Association’s (AHA) annual recap of “pivotal” developments.

Some of the most important research of the past year addressed topics such as obesity, hypertension, diabetes, heart failure (HF), kidney failure, and stroke. The year also saw strides made in the practice of precision medicine.

Weight Loss, Diabetes

Topping the AHA’s list of key developments in cardiovascular disease (CVD) for 2021 is the US approval of semaglutide for chronic weight management.

Developed for type 2 diabetes, a series of studies in 2021 showed weight loss benefits with the glucagon-like peptide-1 (GLP-1) receptor agonist even in people without diabetes.

In three trials of individuals with overweight and obesity, those taking semaglutide achieved 15% to 18% weight loss over 68 weeks. Semaglutide has been called a breakthrough and “game-changer” in weight management.

The AHA list of pivotal developments in 2021 also includes sodium-glucose cotransporter 2 (SGLT2) inhibitors, which have continued to extend their potential beyond the initial approved use to treat type 2 diabetes, with several studies showing that SGLT2 inhibitors have CV benefits.

The SCORED trial of patients with type 2 diabetes and chronic kidney disease showed a lower risk of hospitalization/urgent care for HF or death from CVD in patients receiving the SGLT2 inhibitor sotagliflozin, compared with placebo.

Findings from another placebo-controlled trial (SOLOIST-WHF) showed sotagliflozin could lower those same risks in people with diabetes and a recent worsening of HF.

And in EMPEROR-Preserved, the SGLT2 inhibitor empagliflozin cut the incidence of CV death or hospitalization in patients with HF, with or without diabetes, and preserved ejection fraction (HFpEF), a condition with few available treatments.

Two drugs that address common complications of type 2 diabetes also made the AHA’s annual list of pivotal developments.

Finerenone, a first-in-class nonsteroidal, selective mineralocorticoid receptor antagonist, showed significant benefit in slowing progression of diabetic kidney disease and reducing risk of CV death or complications, compared with placebo, in the FIGARO-DKD trial.

Results of the trial led to the drug’s approval in July for slowing chronic kidney disease in type 2 diabetes.

Efpeglenatide, an exendin-based GLP-1 receptor agonist, reduced the risk of worsening renal and CV outcomes in patients with type 2 diabetes at high CV risk in the AMPLITUDE-O phase 3 trial.

Precision Medicine, BP Control

Advances in precision CV medicine also made the AHA’s 2021 list of pivotal developments.

“Using precise gene editing, investigators may have opened new therapeutic doors for two life-threatening diseases, transthyretin amyloidosis and Duchenne muscular dystrophy,” the AHA said in a news release. 

The advances stem from advanced gene-editing technology known as CRISPR-Cas9, which was recently recognized with a Nobel Prize.

Also making the AHA list of noteworthy advances in 2021 in what the association calls “simple successes in blood pressure, from kitchen table to clinic.”

The landmark Salt Substitute and Stroke Study from China showed that switching from regular salt to a low-sodium salt substitute had major public health benefits, including a reduction in stroke, CV events, and death.

The massive study involved 600 rural villages and nearly 21,000 people with a history of stroke or high blood pressure. With an average follow-up of nearly 5 years, rates of stroke were 14% lower in villages assigned to use the salt mixture containing 25% potassium chloride, compared with those where regular (all-sodium-chloride) salt use continued.

Another large trial from China, dubbed STEP, which focused on people ages 60 to 80 with hypertension, supports the benefits of intensive blood pressure control.

Intensive treatment with a systolic blood pressure target of 110 to < 130 mmHg produced a lower incidence of CV events than standard treatment with a target of 130 to < 150 mmHg.

The intensive group showed a 26% reduction in CV events, a 33% reduction in stroke, a 33% reduction in acute coronary syndrome, and a 73% reduction in acute HF.

The findings support current AHA and American College of Cardiology guidelines for managing high blood pressure, which set a systolic goal of < 130 mmHg for most patients.

Impact of COVID-19 on the Heart

The impact of COVID-19 on young people’s heart health also made headlines in 2021 and the AHA’s list of pivotal happenings.

Several publications reported on emerging COVID-19-related conditions including multisystem inflammatory syndrome in children (MIS-C) causing inflammation in the heart, lungs, kidneys, brain, skin, eyes, and other organs.

In a study involving 286 young patients with MIS-C from across Europe, the syndrome’s most common cardiac complications were arrhythmias, shock, reduced ejection fraction, dilated coronary arteries, and fluid build-up in the pericardial sac around the heart. Most of the children had elevated inflammatory markers and nearly two thirds had evidence of previous SARS-CoV-2 infection.

Myocarditis following administration of one of the mRNA COVID-19 vaccines was another emerging concern in 2021. However, as the year went on, it became clear that myocarditis after vaccination was extremely rare and most cases were mild or moderate and eventually resolved.

The AHA continues to recommend COVID-19 vaccination in adults and eligible children, citing ongoing research that clearly shows a far greater risk of heart complications, stroke, and blood clotting problems after infection than after vaccination.

The importance of influenza vaccination to protect against CV and other risks also made the AHA list of key developments. 

A large study showed that vaccinating people against influenza within 72 hours of myocardial infarction (MI) or revascularization decreased the risk of death, nonfatal MI, or stent thrombosis by 28% over the following year. Their all-cause mortality dropped 41%, as did their CV mortality.

Time Is Brain

Advances in stroke care in 2021 continue to support the old adage, “time is brain.”

The AHA cites two key studies that examined efforts to shave minutes off the time from stroke onset to initiation of therapy. Both reported better patient outcomes.

In the BEST-MSU observational study of patients with acute ischemic stroke, treatment in a mobile stroke unit was associated with better functional outcomes than treatment by emergency medical services.

In the ANGIOCAT study, patients with suspected large-vessel occlusion stroke who were taken directly to the angiography suite, bypassing the emergency department, received endovascular treatment faster and had better 90-day functional outcomes.

Key findings on CVD during pregnancy also made the AHA’s top 2021 list of pivotal developments.

CVD is the number one cause of maternal death in the United States and the AHA cites a large study that showed pre-pregnancy heart health is getting worse.

Other research indicates that poor maternal heart health can echo far beyond pregnancy and the postpartum months — and into adolescence.

The study showed children born to mothers in poor CV health during pregnancy had an almost eight times higher risk for landing in the poorest CV health category in early adolescence than children born to mothers who had ideal CV health during pregnancy.

Less Is More

Two studies that took “new looks at old habits related to the use of antiplatelet medicines” also made the AHA list.

MASTER DAPT found that shortening the duration of antiplatelet therapy (DAPT) after percutaneous coronary intervention is safe and effective

Research from Michigan suggested that concurrent use of a direct oral anticoagulant (DOAC) and aspirin increases bleeding with no difference in thrombosis rates, compared with a DOAC alone, in patients with atrial fibrillation and/or venous thromboembolism.  

Finally, the AHA top picks list highlights the potential for a single pill to treat both high cholesterol and blood pressure.

“In the challenge of preventing cardiovascular disease, a one-pill-fits-all approach could have a broad public health impact,” the AHA notes.

A large international study, called TIPS-3, found that such a polypill, taken with aspirin, was associated with a 31% lower risk of CV death or events including MI, stroke, cardiac arrest, and HF, compared with placebo. The polypill contained four drugs: simvastatin, hydrochlorothiazide, atenolol, and ramipril.

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