Latest / Morning Medical with Dr. Chow / TAVR Advances, Medication Safety, and Diabetes Prevention Insights

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TAVR Advances, Medication Safety, and Diabetes Prevention Insights · Morning Medical with Dr. Chow

• 0:00
  Good morning, everyone, and welcome to another episode of Morning Medical with Dr.
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  Chow.
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  I'm your host, Dr.
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  Chi-Ming Chow, and today we're diving into an intriguing topic in the world of cardiology
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  that has caught the attention of the medical community.
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  We're going to discuss the long-term outcomes of transcatheter aortic valve replacement, or
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  TAVR, focusing on the balloon-expandable Sapien XT device, which has been a subject of study in
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  the PARTNER 2A trial.
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  Let's explore what the 10-year follow-up has revealed.
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  The PARTNER 2A trial was a significant study that compared the outcomes of the
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  second-generation balloon-expandable Sapien XT TAVR with surgical aortic valve replacement, or
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  SAVR, among patients with severe, symptomatic aortic stenosis at intermediate surgical risk.
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  What the researchers found at the 10-year mark was quite revealing.
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  The all-cause mortality rate for those who underwent TAVR reached 86.1%, which was notably
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  higher than the 82.8% observed in patients who received surgery.
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  This statistic is accompanied by a higher incidence of aortic valve reinterventions in
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  the TAVR group, at 6.3%, compared to just 1.6% in the SAVR group.
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  One of the challenges highlighted by the study was the rate of moderate or greater
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  paravalvular regurgitation, which was 10.5% in the TAVR group, compared to none in the SAVR
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  group.
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  According to the researchers, these outcomes underscore some limitations of the Sapien XT
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  device and the procedural methods used at the time.
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  It's important to note that the field has evolved significantly since then, with advances
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  in device design and procedural planning, including the adoption of systematic computed
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  tomography-based sizing, which were not routine during the initial study period.
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  Interestingly, when looking at the third-generation Sapien 3 device, the results
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  were more reassuring.
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  In an observational analysis comparing Sapien 3 TAVR and SAVR, there were no significant
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  differences in survival or aortic valve reinterventions at the 10-year follow-up for
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  those at intermediate surgical risk.
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  This suggests that advancements in technology and procedural strategies have indeed made a
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  positive impact.
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  These findings highlight the evolution of TAVR technology and the importance of procedural
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  advancements over the years.
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  As Dr.
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  Aakriti Gupta from Cedars-Sinai Medical Center noted, there is no single 10-year TAVR result.
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  Instead, long-term outcomes are shaped by various factors, including the generation of
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  the valve used, access strategy, and preprocedural planning.
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  Looking ahead, the field of TAVR continues to progress with newer devices like the Sapien 3
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  Ultra and Ultra Resilia that promise even better outcomes.
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  However, as Dr.
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  Michael Borger from the Leipzig Heart Center cautioned, there may be inherent limits to how
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  far TAVR can be pushed, especially in lower-risk patient populations.
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  The long-term performance of TAVR will likely continue to be a topic of interest as more data
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  becomes available.
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  Managing medications has come a long way from the days of thick paper charts and handwritten
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  prescriptions.
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  Many of us remember the challenges of deciphering messy scripts and the
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  time-consuming process of manually filling out prescription pads.
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  But now, with the advent of electronic medical records, or EMRs, the landscape of prescription
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  management has transformed significantly.
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  These systems have brought about a more streamlined and efficient process, allowing
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  healthcare providers to quickly type in medication names, select dosages, and send
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  prescriptions directly to pharmacies with just a few clicks.
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  Despite these advancements, managing medication refills remains a complex task.
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  In the modern medical practice, EMR in-baskets are flooded with refill requests daily.
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  These requests come from various sources—current patients, patients we have
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  supervised, and sometimes even patients we have never met.
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  The requests can be chaotic, often bundled with other patient messages or unrelated medical
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  complaints, creating a potential for error.
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  The Swiss cheese model of medical error is especially relevant here, as there are multiple
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  opportunities for mistakes in the medication management process.
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  Sometimes, medications are prescribed that should not be, or refills are requested for
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  patients who have not been seen in years.
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  There are cases where mental health medications are refilled without any accompanying mental
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  health care, highlighting the need for careful oversight in prescription practices.
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  Every provider seems to have their own set of rules when it comes to refilling medications.
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  Some may only provide a 90-day supply without a follow-up visit, while others might be more
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  liberal for chronic conditions, offering a year's worth of refills.
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  The key is to balance safety and convenience, ensuring that medications are prescribed and
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  monitored appropriately.
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  High-risk medications, such as anticoagulants and steroids, require particular caution, as
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  their improper use can lead to serious health issues.
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  To address these challenges, practices need to implement standards and policies that can help
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  streamline the refill process.
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  For instance, setting alerts in the EMR system that notify providers when a patient requires a
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  check-up before further refills can be authorized.
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  Additionally, assigning medications to specific providers or practices can help ensure that the
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  right specialists are managing specific drug therapies, minimizing the risk of errors.
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  As the field of medication management continues to evolve, it's crucial that we remain vigilant
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  in refining our systems to reduce errors and improve patient care.
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  By doing so, we can ensure that our patients receive the medications they need safely and
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  efficiently, without unnecessary delays or complications.
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  Now let's delve into the realm of preventive care and discuss a significant study that has
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  spanned over two decades.
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  The Diabetes Prevention Program, or DPP, trial has provided us with long-term data on the
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  impact of lifestyle interventions in individuals with prediabetes.
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  This landmark study followed participants for an impressive twenty-one years and has
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  uncovered some fascinating insights into the risk of developing multiple chronic conditions,
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  or multimorbidity.
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  The study revealed that lifestyle changes were associated with a reduced risk of
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  multimorbidity among adults with prediabetes.
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  However, the same benefit was not observed with the use of metformin.
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  Over eighty percent of all participants, regardless of their treatment group, eventually
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  developed at least two chronic conditions over time.
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  This highlights the persistent challenge of multimorbidity in this population.
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  Participants who progressed to diabetes had a thirty-three percent higher risk of developing
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  multiple chronic conditions, independent of their treatment group.
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  Those who were randomized to lifestyle interventions had a significantly lower risk of
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  developing multiple chronic conditions compared to those who received a placebo.
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  This benefit was not seen among those assigned to metformin, according to the long-term data
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  from the DPP trial.
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  At the twenty-one-year mark, the risk of multimorbidity was twenty-one percent lower
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  among individuals who received lifestyle interventions compared to those who received a
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  placebo.
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  Interestingly, there was no significant difference in the risk of multimorbidity
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  between participants who received metformin and those who were randomized to placebo.
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  Dr.
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  Griffin Rodgers from the National Institute of Diabetes and Digestive and Kidney Diseases
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  emphasized that these findings reinforce the value of lifestyle programs focused on diet and
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  exercise.
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  Such programs may persistently lower the risk of developing multiple chronic conditions
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  beyond just diabetes.
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  Moreover, because lifestyle modifications can be safe and cost-effective, maintaining these
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  healthy behaviors among people at risk of diabetes may help reduce not only the
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  individual health burden but also broader healthcare spending.
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  By the end of the follow-up, the study showed that eighty-two percent of the lifestyle group,
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  eighty-five percent of the metformin group, and eighty-seven percent of the placebo group
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  developed at least two chronic conditions.
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  These conditions included hypertension, heart failure, coronary artery disease, stroke, and
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  many others.
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  The apparent benefits of lifestyle interventions are logical as they can improve
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  inflammation, metabolic regulation, and cellular aging.
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  This is supported by Dr.
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  Hermes Florez from the Medical University of South Carolina, who noted in an accompanying
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  editorial that the latest American Diabetes Association guidelines still recommend
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  pharmacotherapy for weight management and cardiovascular risk reduction, supporting
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  person-centered goals through more intensive preventive strategies.
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  While data on diabetes risk reduction with certain medications remain limited, attention
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  is shifting towards the long-term health effects of these drugs.
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  The potential to reduce the multimorbidity burden in individuals with or at risk for
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  diabetes is an active area of research.
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  The original findings of the DPP trial showed that lifestyle interventions reduced diabetes
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  incidence by fifty-eight percent and metformin by thirty-one percent in the first three years
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  compared with placebo.
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  However, this risk reduction fell to twenty-four percent and seventeen percent
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  respectively after twenty-one years.
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  Despite the success of these interventions in preventing or delaying diabetes, the DPP trial
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  sought to determine whether they could prevent or delay multimorbidity in addition to diabetes
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  alone.
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  Although DPP interventions have not shown significant long-term associations with
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  microvascular or cardiovascular disease, cancer, or mortality, the odds of frailty were
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  found to be thirty-seven percent lower for lifestyle compared with metformin and placebo
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  twelve to fourteen years after randomization.
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  This study enrolled over three thousand participants at high risk for diabetes across
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  twenty-seven sites in the United States.
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  Those randomized to lifestyle interventions were offered individual sessions followed by
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  monthly sessions with a goal of at least a seven percent weight loss.
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  Participants on metformin received eight hundred fifty milligrams twice daily.
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  By the twenty-one-year follow-up, the lifestyle group had a lower risk of having high-cost
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  multimorbidity dyad conditions compared with the placebo group.
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  Participants who progressed to diabetes had a thirty-three percent higher risk of
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  multimorbidity, reinforcing how chronic conditions tend to cluster around the disease.
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  It's important to note that the participants of the DPP trial may not fully reflect the general
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  prediabetes population, as this cohort had less baseline hypertension but a higher body mass
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  index compared with national data.
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  Adherence to metformin also waned throughout the study.
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  And that wraps up today's episode of Morning Medical with Dr.
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  Chow.
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  We've explored the long-term outcomes of transcatheter aortic valve replacement, the
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  modern management of medication refills, and the impact of lifestyle changes in prediabetes.
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  Thank you for joining me, Dr.
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  Chi-Ming Chow, and I look forward to bringing you more insights into the world of medicine in
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  our next episode.
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  Have a wonderful day!