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Journal Club 26 September 2012

September 26, 2012 Leave a comment

Article

Outcome of Patients With Aortic Stenosis,
Small Valve Area, and Low-Flow, Low-Gradient Despite Preserved Left Ventricular Ejection Fraction

Presenter

SP on behalf of AC

Summary

Objectives

The aim of this case match study was to compare the outcome of patients with paradoxical low-flow (left ventricular
ejection fraction [LVEF] 50% but stroke volume index 35 ml/m2), low-gradient (mean gradient [MG]
40 mm Hg), a priori severe (aortic valve area [AVA] 1.0 cm2) aortic stenosis (AS) (PLG-SAS group) with that
of patients with a severe AS (AVA 1.0 cm2) and consistent high-gradient (MG 40 mm Hg) (HG-SAS group)
and with that of patients with a moderate AS (AVA 1.0 cm2 and MG 40 mm Hg) (MAS group).
Background In patients with preserved LVEF, a discordance between the AVA (in the severe range) and the gradient (in the
moderate range) raises uncertainty with regard to the actual severity of the stenosis and thus the therapeutic
management of the patient.

Methods

In a prospective cohort of AS patients with LVEF 50%, we identified 187 patients in the PLG-SAS group. These
patients were retrospectively matched: 1) according to the gradient, with 187 patients with MAS; and 2) according
to the AVA, with 187 patients with HG-SAS.

Results

Patients with PLG-SAS had reduced overall survival (1-year: 89  2%; 5-year: 64  4%) compared with patients
with HG-SAS (1-year: 96  1%; 5-year: 82  3%) or MAS (1-year: 96  1%; 5-year: 81  3%). After adjustment
for other risk factors, patients with PLG-SAS had a 1.71-fold increase in overall mortality and a 2.09-fold increase
in cardiovascular mortality compared with the 2 other groups. Aortic valve replacement was significantly
associated with improved survival in the HG-SAS group (hazard ratio: 0.18; p  0.001) and in the PLG-SAS group
(hazard ratio: 0.50; p  0.04) but not in the MAS group.

Conclusions

Prognosis of patients with paradoxical low-flow, low-gradient severe AS was definitely worse than those with
high-gradient severe AS or those with moderate AS. The finding of a low gradient cannot exclude the presence of
a severe stenosis in a patient with a small AVA and preserved LVEF and should mandatorily prompt further
investigation.

Journal Club 19 September 2012

September 19, 2012 Leave a comment

Journal Club 12 September 2012

September 11, 2012 Leave a comment

Paper

Fractional Flow Reserve–Guided PCI versus Medical Therapy in Stable Coronary Disease

Presenter

SC

Summary

Background

The preferred initial treatment for patients with stable coronary artery disease is the
best available medical therapy. We hypothesized that in patients with functionally
significant stenoses, as determined by measurement of fractional flow reserve (FFR),
percutaneous coronary intervention (PCI) plus the best available medical therapy
would be superior to the best available medical therapy alone.

Methods

In patients with stable coronary artery disease for whom PCI was being considered,
we assessed all stenoses by measuring FFR. Patients in whom at least one stenosis
was functionally significant (FFR, .0.80) were randomly assigned to FFR-guided
PCI plus the best available medical therapy (PCI group) or the best available medical
therapy alone (medical-therapy group). Patients in whom all stenoses had an FFR of
more than 0.80 were entered into a registry and received the best available medical
therapy. The primary end point was a composite of death, myocardial infarction, or
urgent revascularization.

Results

Recruitment was halted prematurely after enrollment of 1220 patients (888 who
underwent randomization and 332 enrolled in the registry) because of a significant
between-group difference in the percentage of patients who had a primary endpoint
event: 4.3% in the PCI group and 12.7% in the medical-therapy group (hazard
ratio with PCI, 0.32; 95% confidence interval [CI], 0.19 to 0.53; P<0.001). The difference
was driven by a lower rate of urgent revascularization in the PCI group than
in the medical-therapy group (1.6% vs. 11.1%; hazard ratio, 0.13; 95% CI, 0.06 to 0.30;
P<0.001); in particular, in the PCI group, fewer urgent revascularizations were triggered
by a myocardial infarction or evidence of ischemia on electrocardiography
(hazard ratio, 0.13; 95% CI, 0.04 to 0.43; P<0.001). Among patients in the registry,
3.0% had a primary end-point event.

Conclusions

In patients with stable coronary artery disease and functionally significant stenoses,
FFR-guided PCI plus the best available medical therapy, as compared with the best
available medical therapy alone, decreased the need for urgent revascularization. In
patients without ischemia, the outcome appeared to be favorable with the best
available medical therapy alone.

Third Universal Definition of Myocardial Infarction

September 10, 2012 1 comment

 

The 58 page full text is available here (or free online by searching).

Journal Club 5 September 2012

Paper

Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock

Presenter

AC

Summary

Background

In current international guidelines, intraaortic balloon counterpulsation is considered
to be a class I treatment for cardiogenic shock complicating acute myocardial
infarction. However, evidence is based mainly on registry data, and there is a paucity
of randomized clinical trials.

Methods

In this randomized, prospective, open-label, multicenter trial, we randomly assigned
600 patients with cardiogenic shock complicating acute myocardial infarction to
intraaortic balloon counterpulsation (IABP group, 301 patients) or no intraaortic
balloon counterpulsation (control group, 299 patients). All patients were expected
to undergo early revascularization (by means of percutaneous coronary intervention
or bypass surgery) and to receive the best available medical therapy. The primary
efficacy end point was 30-day all-cause mortality. Safety assessments included major
bleeding, peripheral ischemic complications, sepsis, and stroke.

Results

A total of 300 patients in the IABP group and 298 in the control group were included
in the analysis of the primary end point. At 30 days, 119 patients in the IABP group
(39.7%) and 123 patients in the control group (41.3%) had died (relative risk with
IABP, 0.96; 95% confidence interval, 0.79 to 1.17; P = 0.69). There were no significant
differences in secondary end points or in process-of-care measures, including the
time to hemodynamic stabilization, the length of stay in the intensive care unit,
serum lactate levels, the dose and duration of catecholamine therapy, and renal function.
The IABP group and the control group did not differ significantly with respect
to the rates of major bleeding (3.3% and 4.4%, respectively; P = 0.51), peripheral
ischemic complications (4.3% and 3.4%, P = 0.53), sepsis (15.7% and 20.5%, P = 0.15),
and stroke (0.7% and 1.7%, P = 0.28).

Conclusions

The use of intraaortic balloon counterpulsation did not significantly reduce 30-day
mortality in patients with cardiogenic shock complicating acute myocardial infarction
for whom an early revascularization strategy was planned.

PFO ASD Talk

Comprehensive presentation: PFO/ASD talk (also listed on Education Session page).

FFR Pharmacolgy and Echo Diastology in Myocardial Infarction

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