Archive

Archive for the ‘Uncategorized’ Category

PCI in the Elderly with NSTEMI

Gnanenthiran et al (http:// dx. doi. org/ 10. 1136/heartjnl- 2017- 311233). report a meta-analysis of randomized clinical trials of percutaneous coronary intervention in the elderly presenting with non ST elevation myocardial infarction.  Reduction in myocardial infarction, repeat revascularization and a trend to reduction in mortality was noted. Bleeding was increased (compared with medical therapy) but appeared to decrease across time.

Abstract

Objective

Whether revascularisation is superior to medical therapy in older populations presenting with non-ST-elevation acute coronary syndromes (NSTEACS) remains contentious, with inconclusive evidence from randomised trials. We aimed to compare routine invasive therapy with initial medical management in the elderly
presenting with NSTEACS.

Methods

MEDLINE, EMBASE and Cochrane Controlled Trial Register were searched for studies comparing routine invasive therapy with initial medical management
in patients ≥75 years old presenting with NSTEACS. Endpoints included long-term mortality, myocardial infarction (MI), revascularisation, rehospitalisation, stroke and major bleeding reported as ORs.

Results

Four randomised trials and three observational studies met inclusion criteria, enrolling a total of 20 540 patients followed up from 6 months to 5 years. Routine invasive therapy reduced mortality (OR 0.67, CI 0.61 to 0.74), MI (OR 0.56, CI 0.45 to 0.70) and stroke (OR 0.53, CI 0.30 to 0.95). Analyses restricted to randomised controlled trials (RCTs) confirmed a reduction in MI (OR 0.51, CI 0.40 to 0.66), revascularisation (OR 0.27, CI 0.13 to 0.56) and a trend to reduced mortality (OR 0.84, CI 0.66 to 1.06) at the expense of major bleeding (OR 2.19, CI 1.12 to 4.28). Differences in major bleeding were unapparent in more recent studies.

Conclusion

Routine invasive therapy reduces MI and repeat revascularisation and may reduce mortality at the expense of major bleeding in elderly patients with NSTEACS. Our findings highlight the need for further RCTs to better determine the effect on mortality and contemporary bleeding risk.

pcie01pcie02pcie03pcie04pcie05

Bioresorbable Vascular Scaffold Thrombosis

Wykrzykowska et al (N Engl J Med 2017;376:2319-28. DOI: 10.1056/NEJMoa1614954) report on a randomized clinical trial of bioresorbable vascular scaffold versus metallic drug eluting stent. The rates of target vessel failure were similar. However, scaffold thrombosis was significantly higher than stent thrombosis. There is an instructive accompanying editorial (DOI: 10.1056/NEJMe1703202).

ABSTRACT

BACKGROUND

Bioresorbable vascular scaffolds were developed to overcome the shortcomings of drugeluting stents in percutaneous coronary intervention (PCI). We performed an investigatorinitiated,randomized trial to compare an everolimus-eluting bioresorbable scaffold with an everolimus-eluting metallic stent in the context of routine clinical practice.

METHODS

We randomly assigned 1845 patients undergoing PCI to receive either a bioresorbable vascular scaffold (924 patients) or a metallic stent (921 patients). The primary end point was target-vessel failure (a composite of cardiac death, target-vessel myocardial infarction, or target-vessel revascularization). The data and safety monitoring board recommended early reporting of the study results because of safety concerns. This report provides descriptive information on end-point events.

RESULTS

The median follow-up was 707 days. Target-vessel failure occurred in 105 patients in the scaffold group and in 94 patients in the stent group (2-year cumulative event rates, 11.7% and 10.7%, respectively; hazard ratio, 1.12; 95% confidence interval [CI], 0.85 to 1.48; P = 0.43); event rates were based on Kaplan–Meier estimates in time-to-event analyses. Cardiac death occurred in 18 patients in the scaffold group and in 23 patients in the stent group (2-year cumulative event rates, 2.0% and 2.7%, respectively), target-vessel myocardial
infarction occurred in 48 patients in the scaffold group and in 30 patients in the stent group (2-year cumulative event rates, 5.5% and 3.2%), and target-vessel revascularization occurred in 76 patients in the scaffold group and in 65 patients in the stent group (2-year cumulative event rates, 8.7% and 7.5%). Definite or probable device thrombosis occurred in 31 patients in the scaffold group as compared with 8 patients in the stent group (2-year cumulative event rates, 3.5% vs. 0.9%; hazard ratio, 3.87; 95% CI, 1.78 to 8.42; P<0.001).

CONCLUSIONS

In this preliminary report of a trial involving patients undergoing PCI, there was no significant difference in the rate of target-vessel failure between the patients who received a bioresorbable scaffold and the patients who received a metallic stent. The bioresorbable scaffold was associated with a higher incidence of device thrombosis than the metallic stent through 2 years of follow-up.

scaff02scaff01

Aortic Stenosis and Non-cardiac Surgery

A useful reference on assessment and management of aortic stenosis in the context of non-cardiac surgery is available here.

Categories: Uncategorized

Late Gadolinium Enhancement in Dilated Cardiomyopathy

Halliday et al (Circulation. 2017;135:2106–2115. DOI: 10.1161/CIRCULATIONAHA.116.026910) report on the relationship between late gadolinium enhancement on cardiac MRI and sudden cardiac death in patients with dilated cardiomyopathy. They identify a subgroup with LVEF \ge 40% at increased risk of sudden cardiac death.

Abstract

BACKGROUND

Current guidelines only recommend the use of an implantable
cardioverter defibrillator in patients with dilated cardiomyopathy for the primary prevention of sudden cardiac death (SCD) in those with a left ventricular ejection fraction (LVEF) 35%. Patients with an LVEF >35% also have low competing risks of death from nonsudden causes. Therefore, those at high risk of SCD may gain longevity from successful implantable cardioverter defibrillator therapy. We investigated whether late gadolinium enhancement (LGE) cardiovascular magnetic resonance identified patients with dilated cardiomyopathy without severe LV systolic dysfunction at high risk of SCD.

METHODS

We prospectively investigated the association between midwall LGE and the prespecified primary composite outcome of SCD or aborted SCD among consecutive referrals with dilated cardiomyopathy and an LVEF ≥40% to our center between January 2000 and December 2011 who did not have a preexisting indication for implantable cardioverter defibrillator implantation.

RESULTS

Of 399 patients (145 women, median age 50 years, median LVEF 50%, 25.3% with LGE) followed for a median of 4.6 years, 18 of 101 (17.8%) patients with LGE reached the prespecified end point, compared with 7 of 298 (2.3%) without (hazard ratio [HR], 9.2; 95% confidence interval [CI], 3.9–21.8; P<0.0001). Nine patients (8.9%) with LGE compared with 6 (2.0%) without (HR,4.9; 95% CI, 1.8–13.5; P=0.002) died suddenly, whereas 10 patients (9.9%) with LGE compared with 1 patient (0.3%) without (HR, 34.8; 95% CI, 4.6–266.6; P<0.001) had aborted SCD. After adjustment, LGE predicted the composite end point (HR, 9.3; 95% CI, 3.9–22.3; P<0.0001), SCD (HR, 4.8; 95% CI, 1.7–13.8; P=0.003), and aborted SCD (HR, 35.9; 95% CI, 4.8–271.4; P5% compared with those without LGE were 10.6 (95% CI, 3.9–29.4), 4.9 (95% CI, 1.3–18.9), and 11.8 (95% CI, 4.3–32.3), respectively.

CONCLUSIONS

Midwall LGE identifies a group of patients with dilated cardiomyopathy and an LVEF ≥40% at increased risk of SCD and low risk of nonsudden death who may benefit from implantable cardioverter defibrillator implantation.

dcmmri01dcmmri02dcmmri03

Chocolate Consumption and Apparent Atrial Fibrillation

Mostofsky et al (Heart Online First, published on May 23, 2017 as 10.1136/heartjnl-2016-310357) report a large population cohort study and assess the relationship between chocolate consumption and risk of apparent atrial fibrillation.

ABSTRACT

Objective

To evaluate the association between chocolate intake and incident clinically apparent atrial fibrillation or flutter (AF).

Methods

The Danish Diet, Cancer, and Health Study is a large population-based prospective cohort study. The present study is based on 55 502 participants (26 400 en and 29 102 women) aged 50–64 years who had provided information on chocolate intake at baseline.
Incident cases of AF were ascertained by linkage with nationwide registries.

Results

During a median of 13.5 years there were 3346 cases of AF. Compared with chocolate intake less than once per month, the rate of AF was lower for people consuming 1–3 servings/month (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.82 to 0.98), 1
serving/week (HR 0.83, 95% CI 0.74 to 0.92), 2–6 servings/week (HR 0.80, 95% CI 0.71 to 0.91) and ≥1 servings/day (HR 0.84, 95% CI 0.65 to 1.09; p-linear trend <0.0001), with similar results for men and women.

Conclusions

Accumulating evidence indicates that moderate chocolate intake may be inversely associated with AF risk, although residual confounding cannot be ruled out.

 

chocaf.png

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.

 

macs01

IFR v FFR

Another useful video from the EuroPCR

 

Related papers: here and here.

Categories: Uncategorized