Switching Dual Antiplatelet Therapy: TOPIC

Cuisset et al report the results of the TOPIC trial at EuroPCR 2017. This useful video:

The paper is available here.

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Bicuspid Aortic Valve Natural History; Rotational Atherectomy

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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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Scaffold Thrombosis in Routine PCI

Wykrzykowska et al report a randomized clinical trial of metallic stent v bioresorbable vascular scaffold in routine percutaneous coronary intervention. They found significantly higher risk of device thrombosis with BVS. The editorial is available here.

Summary

BACKGROUND

Bioresorbable vascular scaffolds were developed to overcome the shortcomings of drugeluting stents in percutaneous coronary intervention (PCI). We performed an investigator-initiated, 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.

 

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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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Moderate Alcohol Consumption and Cardiovascular Outcomes

Bell et al report a “big data” analysis of the relationship between alcohol consumption and cardiovascular outcomes. The editorial is available here.

Abstract

Objectives

To investigate the association between alcohol
consumption and cardiovascular disease at higher
resolution by examining the initial lifetime
presentation of 12 cardiac, cerebrovascular,
abdominal, or peripheral vascular diseases among five
categories of consumption.

Design

Population based cohort study of linked electronic
health records covering primary care, hospital
admissions, and mortality in 1997-2010 (median
follow-up six years).

Setting

CALIBER (ClinicAl research using LInked Bespoke
studies and Electronic health Records).
Participants
1 937 360 adults (51% women), aged ≥30 who were free
from cardiovascular disease at baseline.

Main outcome measures

12 common symptomatic manifestations of
cardiovascular disease, including chronic stable
angina, unstable angina, acute myocardial infarction,
unheralded coronary heart disease death, heart
failure, sudden coronary death/cardiac arrest,
transient ischaemic attack, ischaemic stroke,
intracerebral and subarachnoid haemorrhage,
peripheral arterial disease, and abdominal aortic
aneurysm.

Results

114 859 individuals received an incident cardiovascular
diagnosis during follow-up. Non-drinking was
associated with an increased risk of unstable angina
(hazard ratio 1.33, 95% confidence interval 1.21 to
1.45), myocardial infarction (1.32, 1.24 to1.41),
unheralded coronary death (1.56, 1.38 to 1.76), heart
failure (1.24, 1.11 to 1.38), ischaemic stroke (1.12, 1.01 to
1.24), peripheral arterial disease (1.22, 1.13 to 1.32),
and abdominal aortic aneurysm (1.32, 1.17 to 1.49)
compared with moderate drinking (consumption
within contemporaneous UK weekly/daily guidelines
of 21/3 and 14/2 units for men and women,
respectively). Heavy drinking (exceeding guidelines)
conferred an increased risk of presenting with
unheralded coronary death (1.21, 1.08 to 1.35), heart
failure (1.22, 1.08 to 1.37), cardiac arrest (1.50, 1.26 to
1.77), transient ischaemic attack (1.11, 1.02 to 1.37),
ischaemic stroke (1.33, 1.09 to 1.63), intracerebral
haemorrhage (1.37, 1.16 to 1.62), and peripheral arterial
disease (1.35; 1.23 to 1.48), but a lower risk of
myocardial infarction (0.88, 0.79 to 1.00) or stable
angina (0.93, 0.86 to 1.00).

Conclusions

Heterogeneous associations exist between level of
alcohol consumption and the initial presentation of
cardiovascular diseases. This has implications for
counselling patients, public health communication,
and clinical research, suggesting a more nuanced
approach to the role of alcohol in prevention of
cardiovascular disease is necessary.

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Physician Suicide

Physician suicide remains an important problem that requires ongoing attention. This perspective in the New England Journal of Medicine.