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Science News May 2013

// May 9 2013

Low Gradient Severe Aortic Stenosis despite Preserved Ejection Fraction
Although the pathophysiology, clinical features, and natural course of severe aortic stenosis have been extensively described, management recommendations are...


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Archivo Año 2006 -2012

  • To discontinue clopidogrel after a year of infarction can be risky


  • Renal failure in acute myocardial infarction
  • Hyperglycemia on admission, an excess risk for infarction
  • Polypill: Closer's "tailored suit"
  • Unstable angina - AMI without ST elevation: New ACC/AHA guidelines.
  • Validation of the Bleeding Academic Research Consortium Definition of Bleeding in Patients With Coronary Artery Disease Undergoing Percutaneous Coronary Intervention
  • Percutaneous closure of the appendage: results, evidence, team training.
  • Aspirines...what about statins?
  • In patients with stroke history, Ticagrelor is superior to Clopidogrel
  • ASCERT: CABG vs. PCI in elderly patients with multiple vessel coronary disease.
  • Three Rules to Identify STEMI in the Emergency Room
    Prioritization Rule for Obtaining an Immediate Electrocardiogram: Validation of an Algorithm
    // More
  • Ticagrelor vs. Clopidogrel in ST elevation MI: Pros and cons
    Platelet Inhibition in the PLATO study: insights from the ECG substudy.
    // More
  • 29-11-2011
    Off-Pump CABG Reduces Postoperative Stroke vs. Standard Surgery

    Patients who undergo off-pump coronary artery bypass grafting (CABG) surgery experience nearly one-third fewer postoperative strokes than those who receive standard surgery using cardiopulmonary bypass. However, the 2 procedures yield similar rates of early mortality and myocardial infarction, according to an updated meta-analysis published online October 10, 2011, ahead of print in the European Heart Journal.
    Jonathan Afilalo, MD, and colleagues at McGill University (Montreal, Canada) performed a meta-analysis of 59 randomized trials pulled from the medical literature and multiple databases through January 2011 that reported in-hospital or 30-day clinical outcomes. The pooled data comprised 8,961 patients randomized to off-pump (n = 4,461) or on-pump (n = 4,500) CABG.
    Reference: Afilalo J, Rasti M, Ohayon SM, et al. Off-pump vs. on-pump coronary artery bypass surgery: An updated meta-analysis and meta-regression of randomized trials. Eur Heart J 2011; Epub ahead of print.
  • 29-11-2011
    Incomplete Revascularization Linked With Mortality in Multivessel Disease Patients

    Complete revascularization was defined as a reduction of stenosis to less than 50% in all diseased (≥ 70% stenosis) lesions in major epicardial coronary vessels at the initial hospitalization or within 30 days after discharge before having a new MI.
    Complete and incomplete revascularization were obtained in 29.2% (n = 3,803) and 70.8% (n = 9,213) of patients, respectively. Those with incomplete revascularization were older and more likely to be Hispanic or black, have lower ejection fraction values, and have 3-vessel disease total occlusion. They also showed higher rates of comorbidities such as MI, cerebrovascular disease, PAD, and CHF.
    To compensate for these differences, the researchers performed a propensity analysis that matched the complete revascularization cohort to an equal number of patients with incomplete revascularization who had similar baseline risk. Among the 3,803 pair-matched subjects, 8-year survival rates were higher among those with complete vs. incomplete revascularization (80.8% vs. 78.5%; P = 0.04). The likelihood of mortality grew higher when more than one vessel was incompletely treated, although the difference did not reach statistical significance Despite the ongoing debate for or against complete revascularization, Dr. Hannan noted that this "study continues to show that there is a danger of incomplete revascularization and so certainly that is something that needs to be considered when doing this procedure." Future research should include stress tests and fractional flow reserve, he said, but acknowledged that this can be difficult to do since these tests are not performed on all patients.
    Reference: Wu C, Dyer AM, King SB, et al. Impact of incomplete revascularization on long-term mortality after coronary stenting. Circ Cardiovasc Interv 2011; 4: 413-21.

  • 29-11-2011
    Six Months Sufficient for Dual Antiplatelet Therapy

     

    Patients treated with zotarolimus-eluting stents (ZES) suffer no excess late ischemic events if they take dual antiplatelet therapy for 6 months instead of 12 months or longer, according to a study in the October 2011 issue of JACC: Cardiovascular Interventions.
    Researchers led by David E. Kandzari, MD, of the Piedmont Heart Institute (Atlanta, GA), looked at 2,032 patients undergoing PCI with ZES in 5 registration trials from Medtronic's (Santa Rosa, CA) Endeavor program. Of these, 1,414 were identified as event-free and on dual antiplatelet therapy at 6 months. Outcomes were compared in patients based on antiplatelet therapy duration at 6, 12, and 24 months.
    Dual antiplatelet therapy compliance was 100% at 6 months, 47.9% at 12 months, 38.5% at 24 months, and 28.8% at 3 years. "In this analysis limited to clinically stable patients undergoing elective percutaneous revascularization with ZES and censored for early (< 6 months) adverse events, late (3 years) safety outcomes were independent of dual antiplatelet therapy treatment durations ranging from 6 months to greater than 2 years," the researchers conclude.
    Reference: Kandzari DE, Barker CS, Leon MB, et al. Dual antiplatelet therapy duration and clinical outcomes following treatment with zotarolimus-eluting stents. JACC Cardiovasc Interv 2011; 4: 1119-28.

  • 07-10-2011
    Coronary CTA Use in Emergency Department saves time and money

     

    Using coronary computed tomographic angiography (CTA) as a screening tool for low-risk patients with chest pain in the emergency department achieves lower costs and faster diagnoses compared with myocardial perfusion imaging but does not sacrifice safety or accuracy, according to results of a randomized trial appearing in the September 27, 2011, issue of the Journal of the American College of Cardiology.
    For the trial, researchers led by Gilbert L. Raff, MD, of William Beaumont Hospital (Royal Oak, MI), randomized 699 patients with low-risk acute chest pain (TIMI risk score ≤ 4; normal initial ECG and cardiac enzymes) to standard nuclear stress imaging or coronary CTA as an initial screen at 16 different emergency departments between June 2007 and November 2008.
    Both groups had substantial portions of patients ruled out from having significant CAD (82.2% with CTA, 89.9% with nuclear stress imaging). In addition, 24 patients (6.7%) were referred for invasive coronary angiography after CTA, with 13 (3.6%) receiving subsequent revascularization (4 CABG, 9 PCI). After nuclear stress imaging, 21 patients (6.2%) went on to coronary angiography (P = 0.8 compared with CTA), with 8 (2.4%) subsequently receiving revascularization (8 PCI, 0 CABG; P = 0.34 compared with CTA with regard to total revascularizations). There were no CABG procedures in the stress imaging arm.
    Reference: Goldstein JA, Chinnaiyan KM, Abidov A, et al. The CT-STAT (coronary computed tomographic angiography for systemic triage of acute chest pain patients to treatment) trial. J Am Coll Cardiol 2011; 58: 1414-22.

  • 07-10-2011
    System Delays for STEMI patients linked to subsequent heart failure care

     

    In patients with ST-segment myocardial infarction (STEMI), delays in obtaining primary percutaneous coronary intervention (PCI) are associated with an increased need for subsequent care, both inpatient and outpatient, related to chronic heart failure (CHF). According to a paper published in the September 20, 2011, issue of Annals of Internal Medicine, the findings add to a large body of evidence that system delays, which are modifiable, can make a tremendous difference in patient outcome.
    On multivariable analysis, treatment delay as a whole independently predicted readmissions or outpatient visits for CHF treatment (adjusted HR 1.04 per hour increase; 95% CI 1.008-1.06; P = 0.012). However, separating treatment delay into its 2 components—patient delay and system delay—showed that only system delay was associated with CHF-related readmission or outpatient contact. According to the study authors, the findings make sense because delayed reperfusion is associated with more extensive myocardial necrosis and reduced LVEF. They say that health care system delay is the ideal performance measure in triaging patients with STEMI for primary PCI.
    Reference: Terkelsen CJ, Jensen LO, Tilsted H-H, et al. Health care system delay and heart failure in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention: Follow-up of population-based medical registry data. Ann Intern Med 2011; 155: 361-7.

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