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Archive for May, 2015

RBWH Cardiology Showcase 2015

This is an announcement for forthcoming RBWH Catdiology Showcase. The details are available here. All are welcome.

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Journal Club 27 May 2015

Paper

Trial of Everolimus-Eluting Stents or Bypass Surgery for Coronary Disease

Presenter

Summary

BACKGROUND

Most trials comparing percutaneous coronary intervention (PCI) with coronaryartery
bypass grafting (CABG) have not made use of second-generation drug-eluting
stents.

METHODS

We conducted a randomized noninferiority trial at 27 centers in East Asia. We
planned to randomly assign 1776 patients with multivessel coronary artery disease
to PCI with everolimus-eluting stents or to CABG. The primary end point was a
composite of death, myocardial infarction, or target-vessel revascularization at
2 years after randomization. Event rates during longer-term follow-up were also
compared between groups.

RESULTS

After the enrollment of 880 patients (438 patients randomly assigned to the PCI
group and 442 randomly assigned to the CABG group), the study was terminated
early owing to slow enrollment. At 2 years, the primary end point had occurred in
11.0% of the patients in the PCI group and in 7.9% of those in the CABG group
(absolute risk difference, 3.1 percentage points; 95% confidence interval [CI], −0.8
to 6.9; P = 0.32 for noninferiority). At longer-term follow-up (median, 4.6 years), the
primary end point had occurred in 15.3% of the patients in the PCI group and in
10.6% of those in the CABG group (hazard ratio, 1.47; 95% CI, 1.01 to 2.13; P = 0.04).
No significant differences were seen between the two groups in the occurrence of
a composite safety end point of death, myocardial infarction, or stroke. However,
the rates of any repeat revascularization and spontaneous myocardial infarction
were significantly higher after PCI than after CABG.

CONCLUSIONS

Among patients with multivessel coronary artery disease, the rate of major adverse
cardiovascular events was higher among those who had undergone PCI with the use
of everolimus-eluting stents than among those who had undergone CABG.

Journal Club 20 May 2015

Paper


Screening for dysglycaemia in patients with coronary artery disease as reflected by fasting glucose, oral glucose tolerance test, and HbA1c: a report fromEUROASPIRE IV—a survey from the European Society of Cardiology

Presenter

Summary

Aims

Three methods are used to identify dysglycaemia: fasting plasma glucose (FPG), 2-h post-load plasma glucose (2hPG)
from the oral glucose tolerance test (OGTT), and glycated haemoglobin A1c (HbA1c). The aim was to describe the
yield and concordance of FPG, HbA1c, and 2hPG alone, or in combination, to identify dysglycaemia in patients with
coronary artery disease.

Methods and results

In EUROASPIRE IV, a cross-sectional survey of patients aged 18–80 years with coronary artery disease in 24 European
countries, 4004 patients with no reported history of diabetes had FPG, 2hPG, and HbA1c measured. All participants
were divided into different glycaemic categories according to the ADA and WHO criteria for dysglycaemia. Using all
screening tests together, 1158 (29%) had undetected diabetes. Out of them, the proportion identified by FPG was
75%, by 2hPG 40%, by HbA1c 17%, by FPG + HbA1c 81%, and byOGTT(¼FPG + 2hPG) 96%. Only 7% were detected
by all three methods FPG, 2hPG, and HbA1c. The ADA criteria (FPG + HbA1c) identified 90% of the population as
having dysglycaemia compared with 73% with the WHO criteria (OGTT ¼ FPG + 2hPG). Screening according to the
ADA criteria for FPG + HbA1c identified 2643 (66%) as having a ‘high risk for diabetes’, while the WHO criteria for
FPG + 2hPG identified 1829 patients (46%).

Conclusion

In patients with established coronary artery disease, the OGTT identifies the largest number of patients with previously
undiagnosed diabetes and should be the preferred test when assessing the glycaemic state of such patients.

Supplementary material

Editorial of the paper
Editorial on diagnosis of diabetes mellitus

Categories: Journal Club Tags:

Journal Club 13 May 2015

Paper

Abnormal Left Ventricular Contractile Response to
Exercise in the Absence of Obstructive Coronary Artery Disease Is Associated with Resting Left Ventricular Long-Axis Dysfunction

Presenter

SP

Summary

Background

The etiology of reduced left ventricular (LV) ejection fraction after exercise, without obstructive
coronary artery disease or other established causes, is unclear. The aims of this study were to determine
whether patients undergoing treadmill stress echocardiography with this abnormal LV contractile response
to exercise (LVCRE) without established causes have resting LV long-axis dysfunction or microvascular
dysfunction and to determine associations with this abnormal LVCRE.

Methods

Of 5,275 consecutive patients undergoing treadmill stress echocardiography, 1,134 underwent cardiac
computed tomography angiography or invasive angiography. Having excluded patientswith obstructive coronary
artery disease, hypertensive response, submaximal heart rate response, resting LV ejection fraction < 50%, and
valvular disease, 110 with ‘‘abnormal LVCRE’’ and 212 with ‘‘normal LVCRE’’ were analyzed. Resting mitral
annular velocities were measured to assess LV long-axis function. Myocardial blush grade and corrected Thrombolysis
InMyocardial Infarction frame count were determined angiographically to assess microvascular function.

Results

Comparing normal LVCRE with abnormal LVCRE, age (mean, 59.7 6 11.1 vs 61.4 6 10.0 years),
hypertension (53% vs 55%), diabetes (16% vs 20%), and body mass index (mean, 29.1 6 5.4 vs
29.5 6 6.4 kg/m2) were similar (P > .05). Abnormal LVCRE had reduced resting LV long-axis function with lower
septal (mean, 6.1 6 1.9 vs 7.7 6 2.2 cm/sec) and lateral (mean, 8.1 6 2.9 vs 10.4 6 3.0 cm/sec) e0 velocities
(P < .001) and larger resting left atrial volumes (mean, 37.3 6 10.1 vs 31.1 6 7.2 mL/m2, P < .001). On
multivariate analysis, femalegender (oddsratio[OR],1.21;95%confidence interval [CI],1.15–1.99;P<.001), exaggerated
chronotropic response (OR,1.49;95%CI, 1.09–2.05;P<.001), resting left atrial volume(OR, 2.38;95%CI,
1.63–3.47; P < .001), and resting lateral e0 velocity (OR, 1.70; 95%CI, 1.22–2.49; P = .003) were associated with
abnormal LVCRE, but notmyocardial blush grade or corrected Thrombolysis InMyocardial Infarction frame count.

Conclusions

An abnormal LVCRE in the absence of established causes is associated with resting LV long-axis
dysfunction and is usually seen in women.

Categories: Journal Club

Journal Club 6 May 2015

Paper

Prognostic capabilities of coronary computed tomographic
angiography before non-cardiac surgery: prospective cohort study

Presenter

KK

Summary

Objectives

To determine if coronary computed tomographic
angiography enhances prediction of perioperative risk
in patients before non-cardiac surgery and to assess
the preoperative coronary anatomy in patients who
experience a myocardial infarction after non-cardiac
surgery.

Design

Prospective cohort study.
Setting
12 centers in eight countries.
Participants
955 patients with, or at risk of, atherosclerotic disease
who underwent non-cardiac surgery.

Interventions

Coronary computed tomographic angiography was
performed preoperatively; clinicians were blinded to
the results unless left main disease was suspected.
Results were classified as normal, non-obstructive
(<50% stenosis), obstructive (one or two vessels with
≥50% stenosis), or extensive obstructive (≥50%
stenosis in two vessels including the proximal left
anterior descending artery, three vessels, or left main).

Main outcome measure

Composite of cardiovascular death and non-fatal
myocardial infarction within 30 days after surgery
(primary outcome). This was the dependent variable in
Cox regression. The independent variables were scores
on the revised cardiac risk index and findings on
coronary computed tomographic angiography.

Results

The primary outcome occurred in 74 patients (8%). The
model that included both scores on the revised cardiac
risk index and findings on coronary computed
tomographic angiography showed that coronary
computed tomographic angiography provided
independent prognostic information (P=0.014;
C index=0.66). The adjusted hazard ratios were 1.51 (95%
confidence interval 0.45 to 5.10) for non-obstructive
disease; 2.05 (0.62 to 6.74) for obstructive disease; and
3.76 (1.12 to 12.62) for extensive obstructive disease. For
the model with coronary computed tomographic
angiography compared with the model based on the
revised cardiac risk index alone, with 30 day risk
categories of 15% for the primary
outcome, the results of risk reclassification indicate that
in a sample of 1000 patients that coronary computed
tomographic angiography would have resulted
appropriately in 17 net patients receiving a higher risk
estimation among the 77 patients who would have
experienced the primary outcome (P<0.001). Coronary
computed tomographic angiography, however, would
have resulted inappropriately in 98 net patients
receiving a higher risk estimation, among the 923
patients who would not have experienced the primary
outcome (P<0.001). Among patients who had a
perioperative myocardial infarction, preoperative
coronary anatomy showed extensive obstructive disease
in 31% (22/71), obstructive disease in 41% (29/71),
non-obstructive disease in 24% (17/71), and normal
findings in 4% (3/71).

Conclusions

Though findings on coronary computed tomographic
angiography can improve estimation of risk for
patients who will experience perioperative
cardiovascular death or myocardial infarction, findings
are more than five times as likely to lead to an
inappropriate overestimation of risk among patients
who will not experience these outcomes. Perioperative
myocardial infarction occurs across the spectrum of
coronary artery disease, suggesting that there could be
several pathophysiologic mechanisms.

Journal Club 29 April 2015

Paper

Long-Term Use of Ticagrelor in Patients with Prior Myocardial Infarction

Presenter

AL

Summary

BACKGROUND

The potential benefit of dual antiplatelet therapy beyond 1 year after a myocardial infarction has not been established. We investigated the efficacy and safety of ticagrelor, a P2Y12 receptor antagonist with established efficacy after an acute coronary syndrome, in this context.

METHODS

We randomly assigned, in a double-blind 1:1:1 fashion, 21,162 patients who had had a myocardial infarction 1 to 3 years earlier to ticagrelor at a dose of 90 mg twice daily, ticagrelor at a dose of 60 mg twice daily, or placebo. All the patients were to receive low-dose aspirin and were followed for a median of 33 months. The primary efficacy end point was the composite of cardiovascular death, myocardial infarction, or stroke. The primary safety end point was Thrombolysis in Myocardial Infarction (TIMI) major bleeding.

RESULTS

The two ticagrelor doses each reduced, as compared with placebo, the rate of the primary efficacy end point, with Kaplan–Meier rates at 3 years of 7.85% in the group that received 90 mg of ticagrelor twice daily, 7.77% in the group that received 60 mg of ticagrelor twice daily, and 9.04% in the placebo group (hazard ratio for 90 mg of ticagrelor vs. placebo, 0.85; 95% confidence interval [CI], 0.75 to 0.96; P=0.008; hazard ratio for 60 mg of ticagrelor vs. placebo, 0.84; 95% CI, 0.74 to 0.95; P=0.004). Rates of TIMI major bleeding were higher with ticagrelor (2.60% with 90 mg and 2.30% with 60 mg) than with placebo (1.06%) (P<0.001 for each dose vs. placebo); the rates of intracranial hemorrhage or fatal bleeding in the three groups were 0.63%, 0.71%, and 0.60%, respectively.

CONCLUSIONS

In patients with a myocardial infarction more than 1 year previously, treatment with ticagrelor significantly reduced the risk of cardiovascular death, myocardial infarction, or stroke and increased the risk of major bleeding.

Supplementary Material

A useful presentation is available here.