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Archive for May, 2012

Mortality Morbidity Meeting 30 May 2012

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Categories: Mortality Morbidity

Churg Strauss and Hypereosinophilia selected references

Journal Club 23 May 2012

Professor Alistair Hall (Professor of Clinical Cardiology, University of Leeds) presented a systematic review comparing angiotensin converting enzyme inhibitors and angiotensin receptor blockers looking at historical, pharmacological and clinical trial evidence.

The presentation is posted here.

Journal Club 16 May 2012

Article

Eplerenone and Atrial Fibrillation in Mild Systolic Heart Failure. Results From the EMPHASIS-HF (Eplerenone in Mild
Patients Hospitalization And SurvIval Study in Heart Failure) Study

Presenter

CJ

PICO

Population

Patients in New York Heart Association functional class II and with ejection fraction 35%

Intervention

Eplerenone at a dose of 25 mg once daily (or 25 mg alternate days if eGFR was 30 to 49 ml/min/1.73 m2)
and increased after 4 weeks to 50 mg once daily (25 mg daily if eGFR was 30 to 49 ml/min/1.73 m2), provided the serum
potassium was no more than 5.0 mmol/l.

Control

Placebo

Outcome

This study examined the incidence of new atrial fibrillation/flutter in this randomized clinical trial

 

Findings

New onset AFF was significantly reduced by eplerenone: 25 of 911 (2.7%) versus 40 of 883 (4.5%) in the placebo
group (hazard ratio [HR]: 0.58, 95% confidence interval [CI]: 0.35 to 0.96; p  0.034). The reduction in the
primary endpoint with eplerenone was similar among patients with and without AFF at baseline (HR: 0.60, 95%
CI: 0.46 to 0.79 vs. HR: 0.70, 95% CI: 0.57 to 0.85, respectively; p for interaction  0.41). The risk of cardiovascular
(CV) death or hospital admission for worsening heart failure, the primary endpoint, was not significantly
different in subjects with and without AFF at baseline (both study groups combined: HR: 1.23, 95% CI: 0.81 to
1.86; p  0.33).

In patients with systolic heart failure and mild symptoms, eplerenone reduced the incidence of new onset AFF. The
effects of eplerenone on the reduction of major CV events were similar in patients with and without AFF at
baseline

Journal Club 9 May 2012

Article

Morphometric Assessment of Coronary Stenosis Relevance With Optical Coherence Tomography
A Comparison With Fractional Flow Reserve and Intravascular Ultrasound

Presenter

MD

PICO

This paper compared optical coherence tomography and intravascular ultrasound anatomical measurements correlation with functional significance of intermediate coronary stenosis as assessed using fractional flow reserve

Population

Patients scheduled for coronary angiography in whom 1 or more coronary stenoses with intermediate angiographic severity (40% to 70% diameter stenosis by quantitative coronary angiography [QCA])

Exclusions: Stenoses located in culprit vessels of acute coronary syndromes, serial stenoses, or diffuse coronary narrowings were excluded. Vessels providing circulation to previously infarct regions were also excluded. Other exclusion criteria were left main stenosis,
graft stenosis, contraindications to adenosine administration, hemodynamic instability, renal insufficiency, and anatomical
characteristics such as vessel tortuosity and severe calcification that do not allow the advancement of OCT and IVUS catheters.

Intervention

Optical coherence tomography: minimal luminal area, minimal luminal diameter, area stenosis

Comparator

Intravascular ultrasound: minimal luminal area, minimal luminal diameter, area stenosis

Outcome

Correlation between the measures and FFR were determined.  Receiver operator characteristic curves were created and limits of agreement of the anatomical measures between IVUS and OCT were determined.

Findings

Angiographic stenosis severity was 50.9  8% diameter stenosis with 1.28  0.3 mm minimal lumen diameter.
FFR was 0.80 in 28 (45.9%) stenoses. An overall moderate diagnostic efficiency of OCT was found (area under
the curve [AUC]: 0.74; 95% confidence interval [CI]: 0.61 to 0.84), with sensitivity/specificity of 82%/63% associated
with an optimal cutoff value of 1.95 mm2. Comparison of the results in patients with simultaneous IVUS
and OCT imaging revealed no significant differences in the diagnostic efficiency of OCT (AUC: 0.70; 95% CI: 0.55
to 0.83) and IVUS (AUC. 0.63; 95% CI: 0.47 to 0.77; p  0.19). Sensitivity/specificity for IVUS was 67%/65% for
an optimal cutoff value of 2.36 mm2. In the subgroup of small vessels (reference diameter 3 mm) OCT
showed a significantly better diagnostic efficiency (AUC: 0.77; 95% CI: 0.60 to 0.89) than IVUS (AUC: 0.63; 95%
CI: 0.46 to 0.78) to identify functionally significant stenoses (p  0.04).

See also this post for further material.

Journal Club 2 May 2012

Article

Comparative Effectiveness of Revascularization Strategies

Presenter

LOC

PICO

This was an observational study combining data from  two registries ( ACCF National Cardiovascular Data Registry and the STS Adult Cardiac Surgery Database)  was linked to claims data from the Centers for Medicare and Medicaid Services for the years 2004 through 2008

Population

patients 65 years of age or older who had two-vessel or three-vessel coronary artery disease without acute myocardial infarction

Intervention

The aim of the study was to compare CABG and PCI. Statistical modelling was used to control for confounders between CABG and PCI patients

Comparator

See above

Outcome

Mortality

Findings

Results

Among patients 65 years of age or older who had two-vessel or three-vessel coronary
artery disease without acute myocardial infarction, 86,244 underwent CABG and
103,549 underwent PCI. The median follow-up period was 2.67 years. At 1 year,
there was no significant difference in adjusted mortality between the groups (6.24% in
the CABG group as compared with 6.55% in the PCI group; risk ratio, 0.95; 95% confidence
interval [CI], 0.90 to 1.00). At 4 years, there was lower mortality with CABG
than with PCI (16.4% vs. 20.8%; risk ratio, 0.79; 95% CI, 0.76 to 0.82). Similar results
were noted in multiple subgroups and with the use of several different analytic
methods. Residual confounding was assessed by means of a sensitivity analysis.

Conclusions

In this observational study, we found that, among older patients with multivessel coronary disease that did not require emergency treatment, there was a long-term survival advantage among patients who underwent CABG as compared with patients who underwent PCI.

Discussion Summary

  • The limitations of registry data, particularly the capacity to use statistical modelling to correct for selection bias was uniformly expressed. Specific concerns were raised regarding differences in definitions, accuracy and compliance between surgical and PCI databases; the specific context in which the procedures were performed (United States: surgical report carding, prevalence of low volume PCI operators). The consensus view was that such as analyses are hypotheses generating rather definitive and directive.
  • The statistical methodology was very complex. Propensity score with inverse probability weighting was used to correct for confounders (selection bias). After adjustment the lower mortality of the CABG group persisted. It was noted that there was an early hazard with CABG then a divergence of survival curves in favour of CABG thereafter.  The authors assessed the possibility 0f hidden confounders and provided bounds for prevalence and hazard ratios to account for the observed difference.  Possible unmeasured confounders, such as  measures of frailty were discussed.

The editorial is available here. The supplementary data is available here.