Archive

Archive for the ‘General Cardiology’ Category

Medically treated NSTEMI

Feldman et al (European Heart Journal: Acute Cardiovascular Care
2017, Vol. 6(3) 262–271) report on the characteristics and outcomes of patients presenting with a non ST elevation acute coronary syndrome.

Abstract

Background:

Medically managed individuals represent a high-risk group among patients with non–ST-elevation acute myocardial infarction (NSTE-AMI). We hypothesized that prognosis in this group is heterogeneous, depending on whether medical management was decided with or without coronary angiography (CAG).

Methods:

Using data from the French Registry of Acute ST-Elevation or Non–ST-Elevation Myocardial Infarction (FASTMI), we analysed data from 798 patients with NSTE-AMI who were medically managed (i.e. without revascularization during the index hospitalization). Patients were categorized according to the performance of CAG and, if performed, to the extent of coronary artery disease (CAD).

Results:

There were marked differences in baseline demographics, according to whether CAG was performed and to the extent of CAD. While the overall mortality rate at five years was high (56.2%), it differed greatly between groups,
with patients who did not undergo CAG having a higher mortality rate (77.4%) than patients who underwent CAG (36.7%, p<0.001), and a higher mortality rate even than patients with multivessel CAD (54.2%, p<0.001). By multivariable
analysis, non-performance of CAG was an independent predictor of all-cause mortality among medically managed NSTEAMI patients (adjusted hazard ratios (95% confidence intervals) 3.19 (1.79–5.67) at 30 days, 2.28 (1.60–3.26) at one year,
and 1.63 (1.28–2.07) at five years; all p<0.001).

Conclusion:

Medically managed patients with NSTE-AMI are a heterogeneous group in terms of baseline characteristics and outcomes. The highest risk patients are those who do not undergo CAG. Non-performance of CAG is a strong predictor of death.

 

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AF Screening

Freedman et al present a white paper from the AF-SCREEN International Collaborative. This important paper collates evidence for AF screening and provides insights into the risk of asymptomatic atrial fibrillation and the temporal relationship between AF and ischemic stroke.

 

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DAPT Duration in Acute Coronary Syndrome

Wilson et al summarize the evidence for duration of dual antiplatelet therapy in patients with acute coronary syndrome.  The DAPT score use is also highlighted.

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Area: Height Ratio in Patients With Proximal Ascending Aortic Dilation and Trileaflet Aortic Valve

Masri et al report an observational longitudinal study of patients with proximal dilation of the ascending aorta and trileaflet aortic valves. The authors report the relationship between ascending aortic area to height ration (as assessed by CT or MRI) and clinical outcome.

Abstract

BACKGROUND:

In patients with a dilated proximal ascending aorta
and trileaflet aortic valve, we aimed to assess (1) factors independently
associated with increased long-term mortality and (2) the incremental
prognostic utility of indexing aortic root to patient height.

METHODS:

We studied consecutive patients with a dilated aortic root (≥4
cm) that underwent echocardiography and gated contrast-enhanced thoracic
aortic computed tomography or magnetic resonance angiography between
2003 and 2007. A ratio of aortic root area over height was calculated
(cm2/m) on tomography, and a cutoff of 10 cm2/m was chosen as abnormal,
on the basis of previous reports. All-cause death was recorded.

RESULTS:

The cohort comprised 771 patients (63 years [interquartile range,
53–71], 87% men, 85% hypertension, 51% hyperlipidemia, 56% smokers).
Inherited aortopathies, moderate to severe aortic regurgitation, and severe
aortic stenosis were seen in 7%, 18%, and 2%, whereas 91% and 54% were
on β-blockers and angiotensin-converting enzyme inhibitors, respectively.
Aortic root area/height ratio was ≥10 cm2/m in 24%. The Society of
Thoracic Surgeons score and right ventricular systolic pressure were 3.3±3
and 31±7 mm Hg, respectively. At 7.8 years (interquartile range, 6.6–8.9),
280 (36%) patients underwent aortic surgery (76% within 1 year) and 130
(17%) died (1% in-hospital postoperative mortality). A lower proportion of
patients in the surgical (versus nonsurgical) group died (13% versus 19%,
P<0.01). On multivariable Cox proportional hazard analysis, aortic root area/
height ratio (hazard ratio, 4.04; 95% confidence interval [CI], 2.69–6.231)
was associated with death, whereas aortic surgery (hazard ratio, 0.47;
95% CI, 0.27–0.81) was associated with improved survival (both P<0.01).
For longer-term mortality, the addition of aortic root area/height ratio ≥10
cm2/m to a clinical model (Society of Thoracic Surgeons score, inherited
aortopathies, hypertension, hyperlipidemia, medications, aortic regurgitation,
and right ventricular systolic pressure), increased the c-statistic from 0.57
(95% CI, 0.35–0.77) to 0.65 (95% CI, 0.52–0.73) and net reclassification
index from 0.17 (95% CI, 0.02–0.31) to 0.23 (95% CI, 0.04–0.34), both
P<0.01. Of the 327 patients with aortic root diameter between 4.5 and 5.5
cm, 44% had an abnormal aortic root area/height ratio, of which 78% died.

CONCLUSIONs:

In patients with dilated aortic root and trileaflet aortic
valve, a ratio of aortic root area to height provides independent and
improved stratification for prediction of death.

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AHA 2016: Initial Look

Review of Statin Safety and Efficacy

The Lancet has published an excellent review of statin efficacy and safety.

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Update

The following very instructive comments form <a href="https://twitter.com/erictopol/status/774647016525737984?refsrc=email&s=11&quot; E. Topol tweet.

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Meta-analysis of Peri-operative Beta-Blocker Secure Randomised Trials

Bouri et al present a very important meta-analysis of secure randomised clinical trials of peri-operative beta-blocker therapy. The authors urge retraction from guidelines (see following image) and note the 27% statistically significant increase in mortality observed in secure trials.

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Summary

Background

Current European and American guidelines recommend the perioperative initiation of a course of β-blockers in those at risk of cardiac events undergoing high- or intermediate-risk surgery or vascular surgery. The Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) family of trials, the bedrock of evidence for this, are no
longer secure. We therefore conducted a meta-analysis of randomised controlled trials of β-blockade on perioperative mortality, non-fatal myocardial infarction, stroke and hypotension in non-cardiac surgery using the secure data.

Methods

The randomised controlled trials of initiation of β-blockers before non-cardiac surgery were examined. Primary outcome was all-cause mortality at 30 days or at discharge. The DECREASE trials were separately analysed.

Results

Nine secure trials totalling 10 529 patients, 291 of whom died, met the criteria. Initiation of a course of β-blockers before surgery caused a 27% risk increase in 30-day all-cause mortality ( p=0.04). The DECREASE family of studies substantially contradict the meta-analysis of the secure trials on the effect of mortality (p=0.05 for divergence). In the secure trials,β-blockade reduced non-fatal myocardial infarction (RR 0.73, p=0.001) but increased stroke (RR 1.73, p=0.05)
and hypotension (RR 1.51, p<0.00001). These results were dominated by one large trial.

Conclusions

Guideline bodies should retract their recommendations based on fictitious data without further delay. This should not be blocked by dispute over allocation of blame. The well-conducted trials indicate a statistically significant 27% increase in mortality from the initiation of perioperative β-blockade that guidelines currently recommend. Any remaining enthusiasts might best channel their energy into a further randomised trial which should be designed carefully and conducted honestly.

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