Archive for July, 2014

Prinzmetal’s original paper

Dr. Parsonage has kindly provided Prinzmetal’s original paper as part of the discussion from Education Seesion 29/7/2014. The paper is here.

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Revascularization in Stable Coronary Artery Disease

The interesting meta-analysis of revascularization for stable coronary artery disease versus medical therapy in the BMJ is available here.
The revascularization strategies: coronary artery bypass grafting, PCI: POBA, bare metal stents, old generation DES (paclitaxel, sirolimus) and new generation (zotarolimus, everolimus).

Model for Prediction Sudden Cardiac Death in Hypertrophic Cardiomyopathy

Professor Atherton’s journal club will be posted in due course. In due course: ” O’Mahony et al. A novel clinical risk prediction model for sudden \
cardiac death in hypertrophic cardiomyopahty (HCM Rsk-SCD). European \
Heart Journal doi:10.1093/eurheartj/eht439″. The following animated gif is based on the model. It demonstrates some of the effects of the model:





An interactive CDF is available here. This requires downloading free CDF player.

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Journal Club 16 July 2014


Clinical Classifications of Atrial Fibrillation Poorly Reflect Its Temporal Persistence Insights From 1,195 Patients Continuously Monitored With Implantable Devices





This study aimed to identify how accurately the current clinical atrial fibrillation (AF) classifications reflect its
temporal persistence.


Clinical classification of AF is employed to communicate its persistence, to select appropriate therapies, and as
inclusion criterion for clinical trials.
Methods Cardiac rhythm histories of 1,195 patients (age 73.0  10.1 years, follow-up: 349  40 days) with implantable
devices were reconstructed and analyzed. Patients were classified as having paroxysmal or persistent AF by
physicians at baseline in accordance with current guidelines. AF burden, measured as the proportion of time spent in
AF, was obtained from the device. Additionally we evaluated the agreement between clinical and device-derived AF


Patients within the same clinical class were highly heterogeneous with regards to AF temporal persistence.
Agreement between the clinical AF classification and the objective device-derived assessments of AF temporal
persistence was poor (Cohen’s kappa: 0.12 [95% CI: 0.05 to 0.18]). Patient characteristics influenced the clinical
decision to classify AF as paroxysmal or persistent. Higher ejection fraction (odds ratio: 0.97/per unit [95% CI: 0.95
to 0.98/per unit]; p < 0.0001) and presence of coronary artery disease (odds ratio: 0.53 [95% CI: 0.32 to 0.88];
p ¼ 0.01) were independently associated with a lower probability of being classified as persistent AF for the same
AF burden level.


The currently used clinical AF classifications poorly reflect AF temporal persistence. Patient characteristics
significantly influence the physician’s classification of AF. Patients classified in identical clinical categories may
be inherently heterogeneous with regard to AF temporal persistence. Further study is required to determine if
patient selection on the basis of objective criteria derived from rigorous AF monitoring can improve reported
outcomes and better identify responders and non-responders to treatments.

Related Material

Classifying AF

Journal Club 8 July 2014


Unfractionated heparin versus bivalirudin in primary percutaneous coronary intervention (HEAT-PPCI): an open-label, single centre, randomised controlled trial





Bivalirudin, with selective use of glycoprotein (GP) IIb/IIIa inhibitor agents, is an accepted standard of
care in primary percutaneous coronary intervention (PPCI). We aimed to compare antithrombotic therapy with
bivalirudin or unfractionated heparin during this procedure.


In our open-label, randomised controlled trial, we enrolled consecutive adults scheduled for angiography in
the context of a PPCI presentation at Liverpool Heart and Chest Hospital (Liverpool, UK) with a strategy of delayed
consent. Before angiography, we randomly allocated patients (1:1; stratifi ed by age [<75 years vs ≥75 years] and
presence of cardiogenic shock [yes vs no]) to heparin (70 U/kg) or bivalirudin (bolus 0·75 mg/kg; infusion
1·75 mg/kg per h). Patients were followed up for 28 days. The primary effi cacy outcome was a composite of all-cause
mortality, cerebrovascular accident, reinfarction, or unplanned target lesion revascularisation. The primary safety
outcome was incidence of major bleeding (type 3–5 as per Bleeding Academic Research Consortium defi nitions).
This study is registered with, number NCT01519518.


Between Feb 7, 2012, and Nov 20, 2013, 1829 of 1917 patients undergoing emergency angiography at our
centre (representing 97% of trial-naive presentations) were randomly allocated treatment, with 1812 included in the
final analyses. 751 (83%) of 905 patients in the bivalirudin group and 740 (82%) of 907 patients in the heparin group
had a percutaneous coronary intervention. The rate of GP IIb/IIIa inhibitor use was much the same between groups
(122 patients [13%] in the bivalirudin group and 140 patients [15%] in the heparin group). The primary effi cacy
outcome occurred in 79 (8·7%) of 905 patients in the bivalirudin group and 52 (5·7%) of 907 patients in the heparin
group (absolute risk diff erence 3·0%; relative risk [RR] 1·52, 95% CI 1·09–2·13, p=0·01). The primary safety outcome
occurred in 32 (3·5%) of 905 patients in the bivalirudin group and 28 (3·1%) of 907 patients in the heparin group
(0·4%; 1·15, 0·70–1·89, p=0·59).


Compared with bivalirudin, heparin reduces the incidence of major adverse ischaemic events in the
setting of PPCI, with no increase in bleeding complications. Systematic use of heparin rather than bivalirudin would
reduce drug costs substantially.

Supplementary Material

Commentary 1
Commentary 2

Journal Club 1 July 2014


Will be loaded in due course



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