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DANAMI-2 16 year follow up
Thrane et al report on the 16 year follow up from the DANAMI-2 trial.
Abstract
Aims
The DANish Acute Myocardial Infarction 2 (DANAMI-2) trial found that interhospital transport to primary percutaneous coronary intervention (pPCI) was superior to fibrinolysis at the local hospital in patients with ST-segment
elevation myocardial infarction (STEMI) at 30 days. The present study investigates the 16-year cardiovascular
outcomes.
Methods and results
We randomized 1572 STEMI patients to pPCI or fibrinolysis at 24 referral hospitals and 5 invasive centres in Denmark. Patients randomized to pPCI at referral hospitals were immediately transported to the nearest invasive
centre. The main endpoint of the current study was a composite of death or rehospitalization for myocardial infarction (MI). Outcome information beyond 3 years was obtained through Danish health registries. After 16 years,
pPCI-treated patients had a sustained lower rate of composite endpoint compared to patients treated with fibrinolysis in the overall cohort [58.7% vs. 62.3%; hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.76–0.98],
and among patients transported for pPCI (58.7% vs. 64.1%; HR 0.82, 95% CI 0.71–0.96). No difference in all-cause mortality was found, but cardiac mortality was reduced by an absolute of 4.4% in favour of pPCI (18.3% vs. 22.7%;
HR 0.78, 95% CI 0.63–0.98). pPCI postponed a main event with 12.3 months in average compared to fibrinolysis(95% CI 5.0–19.5).
Conclusion
The benefit of pPCI over fibrinolysis was maintained at 16-year follow-up. pPCI reduced the composite endpoint of death or rehospitalization for MI, reduced cardiac mortality, and delayed average time to a main event by approximately 1 year.
Transradial versus Transfemoral Coronary Angiography
Kalkailah et al report a meta-analysis of coronary access: transradial versus transfemoral in Cochrane’s corner. Please note the limitations the author’s express.
Low Flow Low Gradient Aortic Stenosis Algorithm
Annabi et al provide a useful algorithm for low flow low gradient aortic stenosis.
Off pump versus On pump Bypass Surgery for Left Main: Insights from EXCEL
Bennedeto et al report the results of posthoc analysis of EXCEL trial re: outcomes of off pump and on-pump bypass surgery for left main disease.
The study is summarized here.
Low dose Colchine after Myocardial Infarction
Tardif et al reports the results of the COLCOT trial of low dose colchicine after myocardial infarction.
Abstract
BACKGROUND
Experimental and clinical evidence supports the role of inflammation in atherosclerosis and its complications. Colchicine is an orally administered, potent antiinflammatory medication that is indicated for the treatment of gout and pericarditis.
METHODS
We performed a randomized, double-blind trial involving patients recruited within 30 days after a myocardial infarction. The patients were randomly assigned to receive either low-dose colchicine (0.5 mg once daily) or placebo. The primary efficacy end point was a composite of death from cardiovascular causes, resuscitated cardiac arrest, myocardial infarction, stroke, or urgent hospitalization for angina leading to coronary revascularization. The components of the primary end point and safety were also assessed.
RESULTS
A total of 4745 patients were enrolled; 2366 patients were assigned to the colchicine group, and 2379 to the placebo group. Patients were followed for a median of 22.6 months. The primary end point occurred in 5.5% of the patients in the colchicine group, as compared with 7.1% of those in the placebo group (hazard ratio, 0.77; 95% confidence interval [CI], 0.61 to 0.96; P=0.02). The hazard ratios were 0.84 (95% CI, 0.46 to 1.52) for death from cardiovascular causes, 0.83 (95% CI, 0.25 to 2.73) for resuscitated cardiac arrest, 0.91 (95% CI, 0.68 to 1.21) for myocardial infarction, 0.26 (95% CI, 0.10 to 0.70) for stroke, and 0.50 (95% CI, 0.31 to 0.81) for urgent hospitalization for angina leading to coronary revascularization. Diarrhea was reported in
9.7% of the patients in the colchicine group and in 8.9% of those in the placebo
group (P=0.35). Pneumonia was reported as a serious adverse event in 0.9% of the
patients in the colchicine group and in 0.4% of those in the placebo group (P=0.03).
CONCLUSIONS
Among patients with a recent myocardial infarction, colchicine at a dose of 0.5 mg daily led to a significantly lower risk of ischemic cardiovascular events than placebo.
Psoriasis, Perivascular Fat Index, Coronary Artery Disease
Elnabawi et al report on the use of CT perivascular fat index to assess response of biologic therapy in patients with coronary artery disease and psoriasis.
Abstract
Importance
Psoriasis is a chronic inflammatory skin disease associated with increased coronary plaque burden and cardiovascular events. Biologic therapy for psoriasis has been found to be favorably associated with luminal coronary plaque, but it is unclear whether these associations are attributable to direct anti-inflammatory effects on the coronary arteries.
Objective
To investigate the association of biologic therapy with coronary inflammation in patients with psoriasis using the perivascular fat attenuation index (FAI), a novel imaging biomarker that assesses coronary inflammation by mapping spatial changes of perivascular fat composition via coronary computed tomography angiography (CCTA).
Design, Setting, and Participants
This prospective cohort study performed from January 1, 2013, through March 31, 2019, analyzed changes in FAI in patients with moderate to severe psoriasis who underwent CCTA at baseline and at 1 year and were not receiving biologic psoriasis therapy at baseline.
Exposures
Biologic therapy for psoriasis.
Main Outcomes and Measures
Perivascular FAI mapping was performed based on an established method by a reader blinded to patient demographics, visit, and treatment status.
Results
Of the 134 patients (mean [SD] age, 51.1 [12.1] years; 84 [62.5%] male), most had low cardiovascular risk by traditional risk scores (median 10-year Framingham Risk Score, 3% [interquartile range, 1%-7%]) and moderate to severe skin disease. Of these patients, 82 received biologic psoriasis therapy (anti–tumor necrosis factor α, anti–interleukin [IL] 12/23, or anti–IL-17) for 1 year, and 52 did not receive any biologic therapy and were given topical or light therapy (control group). At baseline, 46 patients (27 in the treated group and 19 in the untreated group) had a focal coronary atherosclerotic plaque. Biologic therapy was associated with a significant decrease in FAI at 1 year (median FAI −71.22 HU [interquartile range (IQR), −75.85 to −68.11 HU] at baseline vs −76.09 HU [IQR, −80.08 to −70.37 HU] at 1 year; P < .001) concurrent with skin disease improvement (median PASI, 7.7 [IQR, 3.2-12.5] at baseline vs 3.2 [IQR, 1.8-5.7] at 1 year; P < .001), whereas no change in FAI was noted in those not receiving biologic therapy (median FAI, −71.98 [IQR, −77.36 to −65.64] at baseline vs −72.66 [IQR, −78.21 to −67.44] at 1 year; P = .39). The associations with FAI were independent of the presence of coronary plaque and were consistent among patients receiving different biologic agents, including anti–tumor necrosis factor α (median FAI, −71.25 [IQR, −75.86 to −66.89] at baseline vs −75.49 [IQR, −79.12 to −68.58] at 1 year; P < .001) and anti–IL-12/23 or anti–IL-17 therapy (median FAI, −71.18 [IQR, −75.85 to −68.80] at baseline vs −76.92 [IQR, −81.16 to −71.67] at 1 year; P < .001).
Conclusions and Relevance
In this study, biologic therapy for moderate to severe psoriasis was associated with reduced coronary inflammation assessed by perivascular FAI. This finding suggests that perivascular FAI measured by CCTA may be used to track response to interventions for coronary artery disease.<h2
Hemodynamic Effects of Weight Loss
Reddy et al report on the hemodynamic effects of weight loss.
Statin Discontinuation At 75 Years
Giral et al report the outcome of discontinuation of statins at 75 years.
Abstract
Aims
The role of statin therapy in primary prevention of cardiovascular disease in persons older than 75 years remains a
subject of debate with little evidence to support or exclude the benefit of this treatment. We assessed the effect of statin discontinuation on cardiovascular outcomes in previously adherent 75-year-olds treated for primary
prevention.
Methods and results
A population-based cohort study using French national healthcare databases was performed, studying all subjects
who turned 75 in 2012–14, with no history of cardiovascular disease and with a statin medication possession ratio
>_80% in each of the previous 2 years. Statin discontinuation was defined as three consecutive months without exposure. The outcome was hospital admission for cardiovascular event. The hazard ratio comparing statin discon-tinuation with continuation was estimated using a marginal structural model adjusting for both baseline and time-varying covariates (cardiovascular drug use, comorbidities, and frailty indicators). A total of 120 173 subjects were
followed for an average of 2.4 years, of whom 17 204 (14.3%) discontinued statins and 5396 (4.5%) were admitted
for a cardiovascular event. The adjusted hazard ratios for statin discontinuation were 1.33 [95% confidence interval
(CI) 1.18–1.50] (any cardiovascular event), 1.46 (95% CI 1.21–1.75) (coronary event), 1.26 (95% CI 1.05–1.51)
(cerebrovascular event), and 1.02 (95% CI 0.74–1.40) (other vascular event).
Conclusion
Statin discontinuation was associated with a 33% increased risk of admission for cardiovascular event in 75-year-
old primary prevention patients. Future studies, including randomized studies, are needed to confirm these findings and support updating and clarification of guidelines on the use of statins for primary prevention in the elderly.
EXCEL Trial: Periprocedural Myocardial Infarction
Yehuda et al report on the impact of periprocedural myocardial infarction (PCI or CABG) observed in the EXCEL trial.
Transthyretin Amyloid Cardiomyopathy
Ruberg et al provide a review on transthyretin amyloid cardiomyopathy.
Phoenix Cardiology 