Blog observations about this study:
Calcium supplementation may adversely affect cardiovascular health in older women.
New Zealand researchers randomized nearly 1500 postmenopausal women to either 1 g of calcium or placebo daily; they then measured cardiovascular events over the ensuing 5 years
Vascular events in healthy older women receiving calcium supplementation: randomised controlled trial
Mark J Bolland, research fellow1, P Alan Barber, senior lecturer1, Robert N Doughty, associate professor1, Barbara Mason, research officer1, Anne Horne, research fellow1, Ruth Ames, research officer1, Gregory D Gamble, research fellow1, Andrew Grey, associate professor1, Ian R Reid, professor1
Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand
Correspondence to: I R Reid i.reid@auckland.ac.nz
Abstract
Objective
To determine the effect of calcium supplementation on myocardial infarction, stroke, and sudden death in healthy postmenopausal women.
Design
Randomised, placebo controlled trial.
Setting
Academic medical centre in an urban setting in New Zealand.
Participants
1471 postmenopausal women (mean age 74): 732 were randomised to calcium supplementation and 739 to placebo.
Main outcome measures
Adverse cardiovascular events over five years: death, sudden death, myocardial infarction, angina, other chest pain, stroke, transient ischaemic attack, and a composite end point of myocardial infarction, stroke, or sudden death.
Results
Myocardial infarction was more commonly reported in the calcium group than in the placebo group (45 events in 31 women v 19 events in 14 women, P=0.01). The composite end point of myocardial infarction, stroke, or sudden death was also more common in the calcium group (101 events in 69 women v 54 events in 42 women, P=0.008). After adjudication myocardial infarction remained more common in the calcium group (24 events in 21 women v 10 events in 10 women, relative risk 2.12, 95% confidence interval 1.01 to 4.47). For the composite end point 61 events were verified in 51 women in the calcium group and 36 events in 35 women in the placebo group (relative risk 1.47, 0.97 to 2.23). When unreported events were added from the national database of hospital admissions in New Zealand the relative risk of myocardial infarction was 1.49 (0.86 to 2.57) and that of the composite end point was 1.21 (0.84 to 1.74). The respective rate ratios were 1.67 (95% confidence intervals 0.98 to 2.87) and 1.43 (1.01 to 2.04); event rates: placebo 16.3/1000 person years, calcium 23.3/1000 person years. For stroke (including unreported events) the relative risk was 1.37 (0.83 to 2.28) and the rate ratio was 1.45 (0.88 to 2.49).
Conclusion
Calcium supplementation in healthy postmenopausal women is associated with upward trends in cardiovascular event rates. This potentially detrimental effect should be balanced against the likely benefits of calcium on bone.
Showing posts with label Myocardial Infarction. Show all posts
Showing posts with label Myocardial Infarction. Show all posts
Wednesday, January 16, 2008
Monday, January 7, 2008
Anxiety Predicts Increased MI Risk
Anxiety Predicts Increased MI Risk
MedPage Today
LOS ANGELES, Jan. 7 -- Among older men with no history of coronary disease, anxiety predicts an increased risk of myocardial infarction, irrespective of cardiac risk factors, investigators here found.
The adjusted relative risk of MI associated with each standard deviation increase in anxiety was 1.43 (95% confidence interval: 1.17 to 1.75), Biing-Jiun Shen, Ph.D., of the University of Southern California, and colleagues reported in the Jan. 8 issue of the Journal of the American College of Cardiology.
In addition to overall anxiety, several specific manifestations of anxiety also independently predicted an increased risk of MI, the researchers said.
"The results suggest that moderately elevated anxiety is associated with a modest risk of MI and severe anxiety represents an MI risk that may warrant attention," the authors concluded.
"The findings indicate that anxiety not only represents an independent, prospective, and unique risk factor for MI, but may also explain the associations between MI and other psychosocial risk factors observed in earlier studies."
Several psychological conditions, including anxiety, have been associated with the onset of coronary artery disease, independent of conventional CAD risk factors, the authors noted.
However, previous studies left a variety of conceptual and methodologic issues unaddressed.
In an effort to explore some of them, the researchers evaluated 735 older men (mean age 60) enrolled in the prospective Normative Aging Study. The men had no history of coronary artery disease or diabetes at baseline.
The investigators assessed anxiety by means of four scales from the Minnesota Multiphasic Personality Inventory: psychasthenia, social introversion, phobia, and manifest anxiety. Overall anxiety was calculated from scores on the four scales.
After a mean follow-up of 12.4 years, anxiety traits independently predicted MI risk after controlling for age, education, marital status, fasting glucose, body mass index, HDL cholesterol, and systolic blood pressure.
The following adjusted relative risks emerged from the analysis:
Psychasthenia, 1.37 (95% CI: 1.12 to 1.68)
Social introversion, 1.31 (95% CI: 1.05 to 1.63)
Phobia, 1.36 (95% CI: 1.10 to 1.68)
Manifest anxiety, 1.42 (95% CI: 1.14 to 1.76)
Overall anxiety, 1.43 (95% CI: 1.17 to 1.75)
The relationships remained significant after further adjustment for health behaviors, use of medications for hypertension, hypercholesterolemia, and diabetes during follow-up, and additional psychological variables.
The authors suggested several potential explanations for the findings:
Associations between anxiety and repeated and chronic elevations of stress
Dysregulation of stress-related pathophysiologic pathways (such as hypothalamic-pituitary-adrenal axis and disturbed platelet activation)
Stimulation of systemic inflammation
Reduced vagal tone and heart-rate variability
The study was performed mainly in otherwise healthy Caucasian men, which limits extrapolation of findings to other groups.
Although anxiety was the strongest predictor of MI risk among psychological variables, the authors cautioned against dismissing other psychological factors, such as depression and hostility.
"Psychological factors are interrelated and may contribute to one another in a reciprocal fashion," they stated. "Recognizing multiple psychosocial risk components may better inform risk assessment and management for people at higher risk for MI."
MedPage Today
LOS ANGELES, Jan. 7 -- Among older men with no history of coronary disease, anxiety predicts an increased risk of myocardial infarction, irrespective of cardiac risk factors, investigators here found.
The adjusted relative risk of MI associated with each standard deviation increase in anxiety was 1.43 (95% confidence interval: 1.17 to 1.75), Biing-Jiun Shen, Ph.D., of the University of Southern California, and colleagues reported in the Jan. 8 issue of the Journal of the American College of Cardiology.
In addition to overall anxiety, several specific manifestations of anxiety also independently predicted an increased risk of MI, the researchers said.
"The results suggest that moderately elevated anxiety is associated with a modest risk of MI and severe anxiety represents an MI risk that may warrant attention," the authors concluded.
"The findings indicate that anxiety not only represents an independent, prospective, and unique risk factor for MI, but may also explain the associations between MI and other psychosocial risk factors observed in earlier studies."
Several psychological conditions, including anxiety, have been associated with the onset of coronary artery disease, independent of conventional CAD risk factors, the authors noted.
However, previous studies left a variety of conceptual and methodologic issues unaddressed.
In an effort to explore some of them, the researchers evaluated 735 older men (mean age 60) enrolled in the prospective Normative Aging Study. The men had no history of coronary artery disease or diabetes at baseline.
The investigators assessed anxiety by means of four scales from the Minnesota Multiphasic Personality Inventory: psychasthenia, social introversion, phobia, and manifest anxiety. Overall anxiety was calculated from scores on the four scales.
After a mean follow-up of 12.4 years, anxiety traits independently predicted MI risk after controlling for age, education, marital status, fasting glucose, body mass index, HDL cholesterol, and systolic blood pressure.
The following adjusted relative risks emerged from the analysis:
Psychasthenia, 1.37 (95% CI: 1.12 to 1.68)
Social introversion, 1.31 (95% CI: 1.05 to 1.63)
Phobia, 1.36 (95% CI: 1.10 to 1.68)
Manifest anxiety, 1.42 (95% CI: 1.14 to 1.76)
Overall anxiety, 1.43 (95% CI: 1.17 to 1.75)
The relationships remained significant after further adjustment for health behaviors, use of medications for hypertension, hypercholesterolemia, and diabetes during follow-up, and additional psychological variables.
The authors suggested several potential explanations for the findings:
Associations between anxiety and repeated and chronic elevations of stress
Dysregulation of stress-related pathophysiologic pathways (such as hypothalamic-pituitary-adrenal axis and disturbed platelet activation)
Stimulation of systemic inflammation
Reduced vagal tone and heart-rate variability
The study was performed mainly in otherwise healthy Caucasian men, which limits extrapolation of findings to other groups.
Although anxiety was the strongest predictor of MI risk among psychological variables, the authors cautioned against dismissing other psychological factors, such as depression and hostility.
"Psychological factors are interrelated and may contribute to one another in a reciprocal fashion," they stated. "Recognizing multiple psychosocial risk components may better inform risk assessment and management for people at higher risk for MI."
Friday, January 4, 2008
Recent respiratory infection and risk of cardiovascular disease: case-control study through a general practice database.
Recent respiratory infection and risk of cardiovascular disease: case-control study through a general practice database.
European Heart Journal
Volume 29, Number 1 : January 2008
Aims: Respiratory infection may be associated with an increased risk of major cardiovascular events. This case-control study describes associations with these events of respiratory infection.
Methods and results: The IMS Disease Analyzer Mediplus primary care database was used to identify all cases of first-time diagnosis of myocardial infarction (MI) or stroke and single matched controls. Details were extracted on visits for respiratory infection over the preceding year. A total of 11 155 MI cases and 9208 stroke cases were identified. For MI and stroke respectively, there were 326 and 260 respiratory infections during the month preceding the index date. There was strong evidence of an increased risk of both events in the 7 days following infection, for MI adjusted odds ratio (OR) 2.10 (95% confidence interval 1.38–3.21), for stroke OR 1.92 (95% confidence interval 1.24–2.97). The strength of these associations fell over time. The associations for MI occurred at all levels of initial underlying cardiovascular risk.
Conclusions: There are strong associations between recent respiratory infection and major cardiovascular events, for MI at all levels of underlying risk. The benefits of reducing respiratory infection either through immunization or treating or preventing infection may be substantial.
European Heart Journal
Volume 29, Number 1 : January 2008
Aims: Respiratory infection may be associated with an increased risk of major cardiovascular events. This case-control study describes associations with these events of respiratory infection.
Methods and results: The IMS Disease Analyzer Mediplus primary care database was used to identify all cases of first-time diagnosis of myocardial infarction (MI) or stroke and single matched controls. Details were extracted on visits for respiratory infection over the preceding year. A total of 11 155 MI cases and 9208 stroke cases were identified. For MI and stroke respectively, there were 326 and 260 respiratory infections during the month preceding the index date. There was strong evidence of an increased risk of both events in the 7 days following infection, for MI adjusted odds ratio (OR) 2.10 (95% confidence interval 1.38–3.21), for stroke OR 1.92 (95% confidence interval 1.24–2.97). The strength of these associations fell over time. The associations for MI occurred at all levels of initial underlying cardiovascular risk.
Conclusions: There are strong associations between recent respiratory infection and major cardiovascular events, for MI at all levels of underlying risk. The benefits of reducing respiratory infection either through immunization or treating or preventing infection may be substantial.
Friday, November 23, 2007
Venous thromboembolism and subsequent hospitalisation due to acute arterial cardiovascular events: a 20-year cohort study
Venous thromboembolism and subsequent hospitalisation due to acute arterial cardiovascular events: a 20-year cohort study
The Lancet, Current Issue, Volume 370, Number 9601, 24 November 2007
Henrik Toft Sørensen, Erzsebet Horvath-Puho, Lars Pedersen, John A Baron, Paolo Prandoni
Summary
Background
In some studies, venous thromboembolism has been associated with atherosclerosis and with the risk of arterial cardiovascular events such as myocardial infarction and stroke. Other studies, however, do not show this association. To help clarify these discrepant findings, we aimed to investigate the risk of arterial cardiovascular events in patients who were diagnosed with venous thromboembolism.
Methods
We undertook a 20-year population-based cohort study using data from nationwide Danish medical databases. After excluding those with known cardiovascular disease, we assessed the risk of myocardial infarction and stroke in 25 199 patients with deep venous thrombosis, 16 925 patients with pulmonary embolism, and 163 566 population controls.
Findings
For patients with deep venous thrombosis, the relative risks varied from 1·60 for myocardial infarction (95% CI 1·35–1·91) to 2·19 (1·85–2·60) for stroke in the first year after the thrombotic event. For patients with pulmonary embolism, the relative risks in that year were 2·60 (2·14–3·14) for myocardial infarction and 2·93 (2·34–3·66) for stroke. The relative risks were also raised, though less markedly, during the subsequent 20 years of follow-up, with 20–40% increases in risk for arterial cardiovascular events. Relative risks were similar for those with provoked and unprovoked deep venous thrombosis and pulmonary embolism.
Interpretation
Patients with venous thromboembolism have a substantially increased long-term risk of subsequent arterial cardiovascular events.
The Lancet, Current Issue, Volume 370, Number 9601, 24 November 2007
Henrik Toft Sørensen, Erzsebet Horvath-Puho, Lars Pedersen, John A Baron, Paolo Prandoni
Summary
Background
In some studies, venous thromboembolism has been associated with atherosclerosis and with the risk of arterial cardiovascular events such as myocardial infarction and stroke. Other studies, however, do not show this association. To help clarify these discrepant findings, we aimed to investigate the risk of arterial cardiovascular events in patients who were diagnosed with venous thromboembolism.
Methods
We undertook a 20-year population-based cohort study using data from nationwide Danish medical databases. After excluding those with known cardiovascular disease, we assessed the risk of myocardial infarction and stroke in 25 199 patients with deep venous thrombosis, 16 925 patients with pulmonary embolism, and 163 566 population controls.
Findings
For patients with deep venous thrombosis, the relative risks varied from 1·60 for myocardial infarction (95% CI 1·35–1·91) to 2·19 (1·85–2·60) for stroke in the first year after the thrombotic event. For patients with pulmonary embolism, the relative risks in that year were 2·60 (2·14–3·14) for myocardial infarction and 2·93 (2·34–3·66) for stroke. The relative risks were also raised, though less markedly, during the subsequent 20 years of follow-up, with 20–40% increases in risk for arterial cardiovascular events. Relative risks were similar for those with provoked and unprovoked deep venous thrombosis and pulmonary embolism.
Interpretation
Patients with venous thromboembolism have a substantially increased long-term risk of subsequent arterial cardiovascular events.
Sunday, November 11, 2007
AHA - 2007: More Evidence of Cardiovascular Safety of Second-Generation Sulfonylureas
AHA: More Evidence of Cardiovascular Safety of Second-Generation Sulfonylureas
By Peggy Peck, Executive Editor, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor University of Pennsylvania School of Medicine.
November 09, 2007
Primary source: American Heart Association
Source reference:
Patch RK, et al "Treatment of diabetes and outcome after myocardial infarction: a community study" AHA Meeting 2007; Abstract 3588.
ORLANDO, Nov. 9 -- Diabetes patients who used second- generation sulfonylureas had no excess one-year mortality after a myocardial infarction, researchers said here.
A community study of patients treated for MI found that the 12-month survival for diabetes patients using second-generation sulfonylureas was about 95%, versus a one-year survival of 90% for non-diabetic MI patients (P0.001), Richard K. Patch, III, M.D., of the Mayo Clinic in Rochester, Minn., and colleagues, reported at the American Heart Association meeting.
Moreover, diabetes patients treated with second-generation sulfonylureas also had significantly better one-year survival than diabetes patients using diet alone or insulin (P0.001).
After adjusting for age, sex, reperfusion, and duration of diabetes, only use of insulin was associated with excess mortality and the risk was greatest among patients with the longest history of diabetes, he said. "There was no association between sulfonylurea use and excess mortality," he said.
The concern about increased cardiovascular mortality with sulfonylureas emerged in the early 1970s, when first-generation drugs in this class began to be widely used. The likely mechanism for increased mortality was the drug's ability to bind to adenosine triphospate-sensitive potassium channels in pancreatic beta cells -- ironically the same mechanism that made the drug effective in treating diabetes.
In pancreatic cells, binding ATP keeps the potassium channels closed, which triggers an influx of calcium ions into the cell, promoting increased release of insulin via exocytosis of insulin-containing granules.
The downside to the first-generation sulfonylurea drugs was that they were not specific to ATP-sensitive potassium channels in the pancreas, but also binded to ATP-sensitive potassium channels in heart cells and vascular smooth-muscle cells. In the heart and the vasculature, this binding action impairs coronary blood flow, which limits control of ischemic damage during myocardial infarction.
But studies of second-generation sulfonylureas have reported that the drugs may reduce the risk of MI.
Against that background, Dr. Patch and colleagues studied the question of the impact of second-generation sulfonylurea on survival following MI.
They analyzed outcomes data from 2,732 MIs that occurred in Olmsted County, Minn., from 1979 through 2002. The average age of patients was 70, and women made up 56% of the cohort.
Four hundred and eighty-six of the MI patients had diabetes and 24% of them used second-generation sulfonylureas, 47% used insulin, while 22% relied on diet alone for management of diabetes.
Five hundred and eight MI patients died within a year of the incident MI.
Compared with non-diabetic MI patients, patients with diabetes were more likely to be overweight or obese, hyperlipidemic, and to have received urgent reperfusion therapy during hospitalization for treatment of the incident MI.
By Peggy Peck, Executive Editor, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor University of Pennsylvania School of Medicine.
November 09, 2007
Primary source: American Heart Association
Source reference:
Patch RK, et al "Treatment of diabetes and outcome after myocardial infarction: a community study" AHA Meeting 2007; Abstract 3588.
ORLANDO, Nov. 9 -- Diabetes patients who used second- generation sulfonylureas had no excess one-year mortality after a myocardial infarction, researchers said here.
A community study of patients treated for MI found that the 12-month survival for diabetes patients using second-generation sulfonylureas was about 95%, versus a one-year survival of 90% for non-diabetic MI patients (P0.001), Richard K. Patch, III, M.D., of the Mayo Clinic in Rochester, Minn., and colleagues, reported at the American Heart Association meeting.
Moreover, diabetes patients treated with second-generation sulfonylureas also had significantly better one-year survival than diabetes patients using diet alone or insulin (P0.001).
After adjusting for age, sex, reperfusion, and duration of diabetes, only use of insulin was associated with excess mortality and the risk was greatest among patients with the longest history of diabetes, he said. "There was no association between sulfonylurea use and excess mortality," he said.
The concern about increased cardiovascular mortality with sulfonylureas emerged in the early 1970s, when first-generation drugs in this class began to be widely used. The likely mechanism for increased mortality was the drug's ability to bind to adenosine triphospate-sensitive potassium channels in pancreatic beta cells -- ironically the same mechanism that made the drug effective in treating diabetes.
In pancreatic cells, binding ATP keeps the potassium channels closed, which triggers an influx of calcium ions into the cell, promoting increased release of insulin via exocytosis of insulin-containing granules.
The downside to the first-generation sulfonylurea drugs was that they were not specific to ATP-sensitive potassium channels in the pancreas, but also binded to ATP-sensitive potassium channels in heart cells and vascular smooth-muscle cells. In the heart and the vasculature, this binding action impairs coronary blood flow, which limits control of ischemic damage during myocardial infarction.
But studies of second-generation sulfonylureas have reported that the drugs may reduce the risk of MI.
Against that background, Dr. Patch and colleagues studied the question of the impact of second-generation sulfonylurea on survival following MI.
They analyzed outcomes data from 2,732 MIs that occurred in Olmsted County, Minn., from 1979 through 2002. The average age of patients was 70, and women made up 56% of the cohort.
Four hundred and eighty-six of the MI patients had diabetes and 24% of them used second-generation sulfonylureas, 47% used insulin, while 22% relied on diet alone for management of diabetes.
Five hundred and eight MI patients died within a year of the incident MI.
Compared with non-diabetic MI patients, patients with diabetes were more likely to be overweight or obese, hyperlipidemic, and to have received urgent reperfusion therapy during hospitalization for treatment of the incident MI.
Monday, November 5, 2007
AHA - 2007: Study compares cost, health outcomes in clearing coronary blockages
Study compares cost, health outcomes in clearing coronary blockages
Late-Breaking Clinical Trials News Release 12
ORLANDO, Nov. 5 – In a follow-up analysis of a major clinical study presented last year, researchers found that percutaneous coronary intervention (PCI) with stenting at 3-28 days after a heart attack was not an economically efficient way to improve health outcomes in people with coronary blockage, according to late-breaking clinical trial results announced at the American Heart Association’s Scientific Sessions 2007.
The Occluded Artery Trial (OAT) was an NHLBI-funded prospective, randomized, multicenter trial comparing late PCI (at 3 to 28 days) with medical therapy alone in 2,166 heart attack patients with a totally blocked major heart artery. Patients were eligible for OAT if they had not received effective therapy (early PCI or clot-buster medicine) to open the blocked artery within the first 12 hours after symptom onset.
“The overall goal of this study was to compare cost and quality of life outcomes in patients randomized to the two arms of OAT,” said Daniel Mark, M.D., substudy lead author and professor of medicine and director of outcomes research at Duke Clinical Research Institute in Durham, N.C.
Patients received either state-of-the art medical therapy alone (which included daily aspirin, beta-blockers, ACE inhibitors and cholesterol-lowering drugs) or medical therapy plus PCI with stenting. Patients’ median age was 59 years, 83 percent were Caucasian, and 78 percent were male. All patients were considered high-risk but stable and without evidence of severe ischemia.
Researchers obtained quality of life data from 951 OAT patients at the start of the study, then again during follow-up interviews at four months, one year and two years after enrollment. They also collected medical resource-use data (all OAT patients) and detailed healthcare costs data (U.S. patients only) out to two years. All comparisons were done according to the principal of intention-to-treat., so patients assigned to medical treatment were analyzed as belonging to that group, even if they later crossed over and had a PCI.
Two principal quality of life outcomes were compared: PCI was associated with a clinically significant benefit in physical functioning (what patients are able to do) at four months, but this benefit was not sustained at one year or beyond. There were no significant effects on psychological well being. Of the secondary quality of life outcomes, PCI was associated with a modestly lower level of heart pains (angina) at four months and one year but these benefits also diminished over time.
In the 469 U.S. OAT patients, 30-day costs (hospital + physician) were about $10,000 higher in the PCI arm than the medical arm. At the end of two years, the cost difference had narrowed somewhat to $7,000. In cost effectiveness analysis, PCI had higher costs and worse health outcomes than medicine.
“This analysis showed that in OAT eligible patients, a strategy of routine late (3-28 day) PCI was substantially more expensive than optimal medical therapy alone when the results were examined over a two year period and the small symptom benefits provided were insufficient to make PCI an economically attractive strategy,” Mark said.
Support for this substudy was provided by Boston Scientific (Argentina), Cordis, Eli Lilly and Guidant.
Statements and conclusions of study authors that are presented at American Heart Association scientific meetings are solely those of the study authors and do not necessarily reflect association policy or position. The American Heart Association makes no representation or warranty as to their accuracy or reliability.
Late-Breaking Clinical Trials News Release 12
ORLANDO, Nov. 5 – In a follow-up analysis of a major clinical study presented last year, researchers found that percutaneous coronary intervention (PCI) with stenting at 3-28 days after a heart attack was not an economically efficient way to improve health outcomes in people with coronary blockage, according to late-breaking clinical trial results announced at the American Heart Association’s Scientific Sessions 2007.
The Occluded Artery Trial (OAT) was an NHLBI-funded prospective, randomized, multicenter trial comparing late PCI (at 3 to 28 days) with medical therapy alone in 2,166 heart attack patients with a totally blocked major heart artery. Patients were eligible for OAT if they had not received effective therapy (early PCI or clot-buster medicine) to open the blocked artery within the first 12 hours after symptom onset.
“The overall goal of this study was to compare cost and quality of life outcomes in patients randomized to the two arms of OAT,” said Daniel Mark, M.D., substudy lead author and professor of medicine and director of outcomes research at Duke Clinical Research Institute in Durham, N.C.
Patients received either state-of-the art medical therapy alone (which included daily aspirin, beta-blockers, ACE inhibitors and cholesterol-lowering drugs) or medical therapy plus PCI with stenting. Patients’ median age was 59 years, 83 percent were Caucasian, and 78 percent were male. All patients were considered high-risk but stable and without evidence of severe ischemia.
Researchers obtained quality of life data from 951 OAT patients at the start of the study, then again during follow-up interviews at four months, one year and two years after enrollment. They also collected medical resource-use data (all OAT patients) and detailed healthcare costs data (U.S. patients only) out to two years. All comparisons were done according to the principal of intention-to-treat., so patients assigned to medical treatment were analyzed as belonging to that group, even if they later crossed over and had a PCI.
Two principal quality of life outcomes were compared: PCI was associated with a clinically significant benefit in physical functioning (what patients are able to do) at four months, but this benefit was not sustained at one year or beyond. There were no significant effects on psychological well being. Of the secondary quality of life outcomes, PCI was associated with a modestly lower level of heart pains (angina) at four months and one year but these benefits also diminished over time.
In the 469 U.S. OAT patients, 30-day costs (hospital + physician) were about $10,000 higher in the PCI arm than the medical arm. At the end of two years, the cost difference had narrowed somewhat to $7,000. In cost effectiveness analysis, PCI had higher costs and worse health outcomes than medicine.
“This analysis showed that in OAT eligible patients, a strategy of routine late (3-28 day) PCI was substantially more expensive than optimal medical therapy alone when the results were examined over a two year period and the small symptom benefits provided were insufficient to make PCI an economically attractive strategy,” Mark said.
Support for this substudy was provided by Boston Scientific (Argentina), Cordis, Eli Lilly and Guidant.
Statements and conclusions of study authors that are presented at American Heart Association scientific meetings are solely those of the study authors and do not necessarily reflect association policy or position. The American Heart Association makes no representation or warranty as to their accuracy or reliability.
Electrocardiographic Signs of Remote Myocardial Infarction.
Electrocardiographic Signs of Remote Myocardial Infarction.
Prog Cardiovasc Dis. 2007 November - December;50(3):198-208.
Michael MA, El Masry H, Khan BR, Das MK.
Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN.
Twelve-lead electrocardiogram is an integral part of the evaluation of an acute and a remote myocardial infarction (MI).
Electrocardiographic signs of an acute ST-elevation MI are more precise than those of an acute non-ST-elevation MI.
Recognition of a remote MI is more difficult because once the repolarization abnormalities (ST-segment and T-wave changes) stabilize after an acute MI resolves, then the Q wave remains as the only universally recognized sign of MI.
In addition, there is no specific sign of a non-Q-wave MI or a non-ST-elevation MI, or in fact of an ST-elevation MI that did not result in Q waves.
The fragmented QRS (fQRS) is another recently described sign of a remote MI.
It is defined by the presence of an additional R wave (R') or notching in the nadir of the S wave, or the presence of >1 R' (fragmentation) in 2 contiguous leads corresponding to a major coronary artery territory.
The specificity of fQRS is inferior to that of a Q wave for an MI scar (89% vs 99%). However, fQRS has a superior sensitivity and a negative predictive value compared with a Q wave. In addition, there is an incremental gain in the sensitivity up to 91.4% when these 2 signs (fQRS and Q wave) are combined.
The repolarization abnormalities of MI may also persist indefinitely as a sign of a remote MI in few patients. These abnormalities include persistent ST elevation, ST depression, nonspecific ST-T wave changes, and T-wave inversion.
Prog Cardiovasc Dis. 2007 November - December;50(3):198-208.
Michael MA, El Masry H, Khan BR, Das MK.
Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, IN.
Twelve-lead electrocardiogram is an integral part of the evaluation of an acute and a remote myocardial infarction (MI).
Electrocardiographic signs of an acute ST-elevation MI are more precise than those of an acute non-ST-elevation MI.
Recognition of a remote MI is more difficult because once the repolarization abnormalities (ST-segment and T-wave changes) stabilize after an acute MI resolves, then the Q wave remains as the only universally recognized sign of MI.
In addition, there is no specific sign of a non-Q-wave MI or a non-ST-elevation MI, or in fact of an ST-elevation MI that did not result in Q waves.
The fragmented QRS (fQRS) is another recently described sign of a remote MI.
It is defined by the presence of an additional R wave (R') or notching in the nadir of the S wave, or the presence of >1 R' (fragmentation) in 2 contiguous leads corresponding to a major coronary artery territory.
The specificity of fQRS is inferior to that of a Q wave for an MI scar (89% vs 99%). However, fQRS has a superior sensitivity and a negative predictive value compared with a Q wave. In addition, there is an incremental gain in the sensitivity up to 91.4% when these 2 signs (fQRS and Q wave) are combined.
The repolarization abnormalities of MI may also persist indefinitely as a sign of a remote MI in few patients. These abnormalities include persistent ST elevation, ST depression, nonspecific ST-T wave changes, and T-wave inversion.
Monday, October 22, 2007
Universal Definition of Myocardial Infarction
Title: Universal Definition of Myocardial Infarction
Author(s): Thygesen K, Alpert JS, White HD, et al., on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction.Citation: Eur Heart J. 2007;28:2525-2538.
Date Posted: 10/22/2007
Perspective: The following are 12 points to remember about this expert consensus document:
1. Clinically, one can classify myocardial infarction (MI) into different types.
2. Type 1 is spontaneous MI related to ischemia due to a primary coronary event such as plaque erosion and/or rupture, fissuring, or dissection.
3. Type 2 is MI secondary to ischemia due to either increased oxygen demand or decreased supply (e.g., coronary artery spasm, coronary embolism, anemia, arrhythmias, hypertension, or hypotension).
4. Type 3 is sudden unexpected cardiac death, including cardiac arrest, often with symptoms suggestive of myocardial ischemia, accompanied by presumably new ST elevation, or new left bundle branch block, or evidence of fresh thrombus in a coronary artery by angiography and/or at autopsy, but death occurring before blood samples could be obtained, or at a time before the appearance of cardiac biomarkers in the blood.
5. Type 4a is MI associated with percutaneous coronary intervention.
6. Type 4b is MI associated with stent thrombosis, as documented by angiography or at autopsy.
7. Type 5 is MI associated with coronary artery bypass grafting.
8. Myocardial cell death can be recognized by the appearance in the blood of different proteins released into the circulation from the damaged myocytes: myoglobin, cardiac troponin T and I, creatine kinase, lactate dehydrogenase, as well as many others.
9. The preferred biomarker for myocardial necrosis is cardiac troponin (I or T), which has nearly absolute myocardial tissue specificity as well as high clinical sensitivity, thereby reflecting even microscopic zones of myocardial necrosis.
10. An increased value for cardiac troponin is defined as a measurement exceeding the 99th percentile of a normal reference population (one-quarter upper reference limit). Detection of a rise and/or fall of the measurements is essential to the diagnosis of acute MI.
11. New ST elevation at the J-point in two contiguous leads with the cut-off points: ≥0.2 mV in men or ≥0.15 mV in women in leads V2–V3 and/or ≥0.1 mV in other leads suggests acute myocardial ischemia.
12. The change in the definition of MI based on elevated biomarker measurement exceeding the 99th percentile of a normal reference population will have a substantial impact on the identification, prevention, and treatment of cardiovascular disease throughout the world.
Debabrata Mukherjee, M.D., F.A.C.C.
Author(s): Thygesen K, Alpert JS, White HD, et al., on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction.Citation: Eur Heart J. 2007;28:2525-2538.
Date Posted: 10/22/2007
Perspective: The following are 12 points to remember about this expert consensus document:
1. Clinically, one can classify myocardial infarction (MI) into different types.
2. Type 1 is spontaneous MI related to ischemia due to a primary coronary event such as plaque erosion and/or rupture, fissuring, or dissection.
3. Type 2 is MI secondary to ischemia due to either increased oxygen demand or decreased supply (e.g., coronary artery spasm, coronary embolism, anemia, arrhythmias, hypertension, or hypotension).
4. Type 3 is sudden unexpected cardiac death, including cardiac arrest, often with symptoms suggestive of myocardial ischemia, accompanied by presumably new ST elevation, or new left bundle branch block, or evidence of fresh thrombus in a coronary artery by angiography and/or at autopsy, but death occurring before blood samples could be obtained, or at a time before the appearance of cardiac biomarkers in the blood.
5. Type 4a is MI associated with percutaneous coronary intervention.
6. Type 4b is MI associated with stent thrombosis, as documented by angiography or at autopsy.
7. Type 5 is MI associated with coronary artery bypass grafting.
8. Myocardial cell death can be recognized by the appearance in the blood of different proteins released into the circulation from the damaged myocytes: myoglobin, cardiac troponin T and I, creatine kinase, lactate dehydrogenase, as well as many others.
9. The preferred biomarker for myocardial necrosis is cardiac troponin (I or T), which has nearly absolute myocardial tissue specificity as well as high clinical sensitivity, thereby reflecting even microscopic zones of myocardial necrosis.
10. An increased value for cardiac troponin is defined as a measurement exceeding the 99th percentile of a normal reference population (one-quarter upper reference limit). Detection of a rise and/or fall of the measurements is essential to the diagnosis of acute MI.
11. New ST elevation at the J-point in two contiguous leads with the cut-off points: ≥0.2 mV in men or ≥0.15 mV in women in leads V2–V3 and/or ≥0.1 mV in other leads suggests acute myocardial ischemia.
12. The change in the definition of MI based on elevated biomarker measurement exceeding the 99th percentile of a normal reference population will have a substantial impact on the identification, prevention, and treatment of cardiovascular disease throughout the world.
Debabrata Mukherjee, M.D., F.A.C.C.
Friday, October 19, 2007
MI redefined; troponin remains gold standard
MI redefined; troponin remains gold standard
by Judith Rusk
Cardiology Today
by Judith Rusk
Cardiology Today
October 2007
VIENNA, Austria – Just as not every patient with an elevated liver function test has hepatitis B, not every patient with elevated troponin levels has had myocardial infarction.
Using this analogy, a group of experts unveiled the new definition of MI at the European Society of Cardiology Congress 2007 last month. Joseph S. Alpert, MD, special assistant to the dean and a professor of medicine in the department of medicine at University Medical Center, Tucson, Ariz., and co-chair of the universal MI definition committee, said that despite the confusion and consternation troponin measurement can cause, it is still the gold standard to define MI.
“However, the advance of science has created a number of nuances that are reflected in the new document,” said Alpert, also a member of the Coronary Heart Disease section of the Cardiology Today Editorial Board.
First update since 2000
The new definition, which will be simultaneously published this month in the European Heart Journal, Circulation and the Journal of the American College of Cardiology is divided into five types (see chart).
According to the ESC’s pocket guideline on the universal definition, “The term myocardial infarction should be used when there is evidence of myocardial necrosis in a clinical setting consistent with myocardial ischemia.”
Alpert said type 4 is the most controversial addition to the redefinition. It was added in light of data from meta-analysis trials presented at last year’s Congress. Those trials, presented in hotline sessions, demonstrated more late stent thrombosis with drug-eluting stents.
Imaging will help demonstrate whether a patient has prior MI, Alpert said. If the patient has new Q waves or pathological healings, imaging evidence of a region of loss of viable myocardium that is thinned or fails to contract in the absence of a nonischemic cause will help.
Implications
Despite the changes, Alpert said the committee does not expect the reported numbers of MI to change much.
“There were 10% and 30% increases (in MI) following first definition,” he said.
Allan Jaffe, MD, professor of medicine at the Mayo Clinic, said defining reinfarction remains a challenge. “We used CK-MB for so long,” said Jaffe, also a member of the Coronary Heart Disease section of the Cardiology Today Editorial Board. Despite one paper published in 2005 that had a small population, trials validating the criteria for recurrent MI have not been done since 1988.
Another challenge is universal definition of MI in clinical trials. Maarten Simoons, MD, Rotterdam, said researchers should complete a small chart – that will be included in the guidelines – that asks pointed questions in defining MI.
When it comes down to it, Jaffe said, clinicians have to rely on their gut when identifying MI.
“There is still a need for good bedside clinical judgment,” he said.
For more information:
Alpert JS, Jaffe A, Underwood SR, Wallentin LC, Simoons ML. Universal definition of myocardial infarction. Symposium #2466-2470. Presented at: European Society of Cardiology Congress 2007; Sept. 1-5, 2007; Vienna, Austria.
Thursday, October 18, 2007
The influence of gender on the effects of aspirin in preventing myocardial infarction
The influence of gender on the effects of aspirin in preventing myocardial infarction
Todd Yerman, Wen Q Gan and Don D Sin
BMC Medicine 2007, 5:29doi:10.1186/1741-7015-5-29
Background
There is considerable variation in the effect of aspirin therapy reducing the risk of myocardial infarction (MI). Gender could be a potential explanatory factor for the variability. We conducted a systematic review and meta-analysis to determine whether gender mix might play a role in explaining the large variation of aspirin efficacy across primary and secondary MI prevention trials.
Methods
Randomized placebo-controlled clinical trials that examined the efficacy of aspirin therapy on MI were identified by using the PUBMED database (1966 to October 2006). Weighted linear regression technique was used to determine the relationship between log-transformed relative risk (RR) of MI and the percentage of male participants in each trial. The reciprocal of the standard error of the RR in each trial (1/SE) was used as the weight.
Results
A total of 23 trials (n = 113 494 participants) were identified. Overall, compared with placebo, aspirin reduced the risk of non-fatal MI (RR = 0.72, 95% confidence interval (CI) 0.64-0.81, p < 0.001) but not of fatal MI (RR = 0.88, 95% CI 0.75-1.03, p = 0.120). A total of 27% of the variation in the non-fatal MI results could be accounted for by considering the gender mix of the trials (p = 0.017). Trials that recruited predominantly men demonstrated the largest risk reduction in non-fatal MI (RR = 0.62, 95% CI 0.54-0.71), while trials that contained predominately women failed to demonstrate a significant risk reduction in non-fatal MI (RR = 0.87, 95% CI 0.71-1.06).
Conclusions
Gender accounts for a substantial proportion of the variability in the efficacy of aspirin in reducing MI rates across these trials, and supports the notion that women might be less responsive to aspirin than men.
Todd Yerman, Wen Q Gan and Don D Sin
BMC Medicine 2007, 5:29doi:10.1186/1741-7015-5-29
Background
There is considerable variation in the effect of aspirin therapy reducing the risk of myocardial infarction (MI). Gender could be a potential explanatory factor for the variability. We conducted a systematic review and meta-analysis to determine whether gender mix might play a role in explaining the large variation of aspirin efficacy across primary and secondary MI prevention trials.
Methods
Randomized placebo-controlled clinical trials that examined the efficacy of aspirin therapy on MI were identified by using the PUBMED database (1966 to October 2006). Weighted linear regression technique was used to determine the relationship between log-transformed relative risk (RR) of MI and the percentage of male participants in each trial. The reciprocal of the standard error of the RR in each trial (1/SE) was used as the weight.
Results
A total of 23 trials (n = 113 494 participants) were identified. Overall, compared with placebo, aspirin reduced the risk of non-fatal MI (RR = 0.72, 95% confidence interval (CI) 0.64-0.81, p < 0.001) but not of fatal MI (RR = 0.88, 95% CI 0.75-1.03, p = 0.120). A total of 27% of the variation in the non-fatal MI results could be accounted for by considering the gender mix of the trials (p = 0.017). Trials that recruited predominantly men demonstrated the largest risk reduction in non-fatal MI (RR = 0.62, 95% CI 0.54-0.71), while trials that contained predominately women failed to demonstrate a significant risk reduction in non-fatal MI (RR = 0.87, 95% CI 0.71-1.06).
Conclusions
Gender accounts for a substantial proportion of the variability in the efficacy of aspirin in reducing MI rates across these trials, and supports the notion that women might be less responsive to aspirin than men.
Friday, September 14, 2007
GRACE - increased medical therapy use in AMI patients
GRACE shows 'encouraging' increased medical therapy use in AMI patients
By Caroline Price
14 September 2007
Arch Intern Med 2007; 167: 1766-1773
MedWire News: Use of both single and combination medical therapy in patients hospitalized with acute myocardial infarction (AMI) increased from 2000 through 2005, suggest results from the Global Registry of Acute Coronary Events (GRACE).
Robert Goldberg (Brown University, Providence, Rhode Island, USA) and colleagues explored use of four effective cardiac medications, namely aspirin, beta blockers, angiotensin converting enzyme (ACE) inhibitors, and lipid-lowering agents at discharge in 26,413 adult men and women without contraindications to any of the drugs.
Increases were seen in singular use of three out of the four therapies, particularly that of statins, which increased from 45% of patients in 2000 to 85% in 2005. ACE inhibitor use increased from 63% to 77%, and beta blocker use from 83% to 91%.
There was little or no increase in aspirin over time, since this therapy was already being used in most AMI hospital survivors (around 95%).
There were marked increases in the use of multiple medications, particularly in use of all four combined, which increased from 23% of patients in the first half of 2000 to 58% in the second half of 2005.
Virtually identical trends were seen in the use of single and combination therapy in ST-elevation myocardial infarction (STEMI) and non-STEMI patients.
Further analysis revealed that patients of advancing age (=65 years), women, and those with a history of heart failure or stroke, who were hospitalized in participating centers in Argentina and Brazil, or developed atrial fibrillation during hospitalization, were more likely to be discharged receiving one, two, or three instead of all four medications.
Similar factors were associated with underuse of all four medications when STEMI or non-STEMI patients were studied separately, and with use of relatively few compared with three medications, the authors say in the Archives of Internal Medicine.
However, they conclude: "Despite these encouraging trends, gaps in the use of combination medical therapies continue to exist. Closing this gap will require novel and concerted efforts."
They say increased understanding and minimization of drug interactions, increased use of combination tablets, and education about the differences between "polypharmacy" and effective combination therapy are needed to this end.
LINNK:
Free abstract
By Caroline Price
14 September 2007
Arch Intern Med 2007; 167: 1766-1773
MedWire News: Use of both single and combination medical therapy in patients hospitalized with acute myocardial infarction (AMI) increased from 2000 through 2005, suggest results from the Global Registry of Acute Coronary Events (GRACE).
Robert Goldberg (Brown University, Providence, Rhode Island, USA) and colleagues explored use of four effective cardiac medications, namely aspirin, beta blockers, angiotensin converting enzyme (ACE) inhibitors, and lipid-lowering agents at discharge in 26,413 adult men and women without contraindications to any of the drugs.
Increases were seen in singular use of three out of the four therapies, particularly that of statins, which increased from 45% of patients in 2000 to 85% in 2005. ACE inhibitor use increased from 63% to 77%, and beta blocker use from 83% to 91%.
There was little or no increase in aspirin over time, since this therapy was already being used in most AMI hospital survivors (around 95%).
There were marked increases in the use of multiple medications, particularly in use of all four combined, which increased from 23% of patients in the first half of 2000 to 58% in the second half of 2005.
Virtually identical trends were seen in the use of single and combination therapy in ST-elevation myocardial infarction (STEMI) and non-STEMI patients.
Further analysis revealed that patients of advancing age (=65 years), women, and those with a history of heart failure or stroke, who were hospitalized in participating centers in Argentina and Brazil, or developed atrial fibrillation during hospitalization, were more likely to be discharged receiving one, two, or three instead of all four medications.
Similar factors were associated with underuse of all four medications when STEMI or non-STEMI patients were studied separately, and with use of relatively few compared with three medications, the authors say in the Archives of Internal Medicine.
However, they conclude: "Despite these encouraging trends, gaps in the use of combination medical therapies continue to exist. Closing this gap will require novel and concerted efforts."
They say increased understanding and minimization of drug interactions, increased use of combination tablets, and education about the differences between "polypharmacy" and effective combination therapy are needed to this end.
LINNK:
Free abstract
Monday, September 3, 2007
ESC Congress News - Immediate emergency angioplasty can save the lives of those experiencing MI (CARESS)
ESC Daily Congress News
Immediate emergency angioplasty can save the lives of those experiencing MI
Authors:
Professor Carlo Di MarioUnited KingdomTel: +44 207 351 8616Fax+44 207 351 8629E-mail: c.dimario@rbht.nhs.uk
Hot Line II, CARESS in AMI Combined Abciximab RE-teplase Stent Study in Acute Myocardial Infarction, 707005
Vienna, Austria, 3 September 2007: We have demonstrated that patients who have an acute myocardial infarction and are admitted to a hospital which has no possibility to perform direct angioplasty, benefit from being transferred immediately after having received thrombolytics to a hospital where angioplasty (percutaneous coronary intervention, PCI, often including stent implantation) can be immediately performed.
Patients who are transferred and receive angioplasty immediately after thrombolytics are much more likely (4.1% vs. 11.1% at 30 days, p<0.001)> This advantage was present despite the fact that all the patients (36% of the entire conservative group) randomized to the group of more conservative treatment (no immediate transfer) were also promptly referred during the first hours post treatment if there was no evidence in their ECG/clinical status that the lytic drugs had open the occluded artery.
Clinical implications: When a patient cannot receive direct angioplasty, which unfortunately still includes the majority of the patients with acute myocardial infarction in most European countries, the current practice in most hospitals in Europe is to administer lytics and to wait, watching the effect of the drug on ECG and patient’s symptoms. It appears that this practice is wrong and all patients should be transferred immediately for angioplasty after thrombolysis is started. The reason why this does not happen, despite the fact that an ESC Guideline advises the practice, is because there was evidence from recent trials, namely ASSENT-4, reported in Lancet 2006; 367:569-68, that lytics immediately before PCI can be deleterious and increase the risk of adverse events, especially bleedings but also death and need for new emergency angioplasty.
We had an opposite result and we believe the reason is the type of lytic treatment used -- not just a thrombolytic drug, but a cocktail of a powerful intravenous anti-platelet agent called abciximab, and a reduced dose of a fibrin specific lytic drug called reteplase. This combination is very powerful and rapid in its action, with a synergistic effect demonstrated in previous trials and in in-vitro models, and achieved restoration of flow in the occluded artery in 85% of cases by the time patients reached the hospital where angioplasty was performed. Its main advantage is, however, the ability to inactivate platelets during the subsequent angioplasty, the opposite of the result observed when only lytics are given which tend to activate platelets instead.
IMPORTANT NOTE: This study will be presented immediately after a larger trial of almost 2,000 patients called FINESSE, with a PI from the Cleveland Clinic, Dr Stephen Ellis. The results of this second trial in AMI will be complementary to the CARESS results because FINESSE compares direct (primary) angioplasty with facilitated angioplasty using only abciximab or using the same combination of drugs we used in this trial. I expect the combined presentation of these 2 trials, with ours clearly positive and reaching unquestionable statistical significance with a favourable effects on all the endpoints (death, re-AMI and refractory ischaemia) will represent one of the highlights of this year’s ESC congress.
Immediate emergency angioplasty can save the lives of those experiencing MI
Authors:
Professor Carlo Di MarioUnited KingdomTel: +44 207 351 8616Fax+44 207 351 8629E-mail: c.dimario@rbht.nhs.uk
Hot Line II, CARESS in AMI Combined Abciximab RE-teplase Stent Study in Acute Myocardial Infarction, 707005
Vienna, Austria, 3 September 2007: We have demonstrated that patients who have an acute myocardial infarction and are admitted to a hospital which has no possibility to perform direct angioplasty, benefit from being transferred immediately after having received thrombolytics to a hospital where angioplasty (percutaneous coronary intervention, PCI, often including stent implantation) can be immediately performed.
Patients who are transferred and receive angioplasty immediately after thrombolytics are much more likely (4.1% vs. 11.1% at 30 days, p<0.001)> This advantage was present despite the fact that all the patients (36% of the entire conservative group) randomized to the group of more conservative treatment (no immediate transfer) were also promptly referred during the first hours post treatment if there was no evidence in their ECG/clinical status that the lytic drugs had open the occluded artery.
Clinical implications: When a patient cannot receive direct angioplasty, which unfortunately still includes the majority of the patients with acute myocardial infarction in most European countries, the current practice in most hospitals in Europe is to administer lytics and to wait, watching the effect of the drug on ECG and patient’s symptoms. It appears that this practice is wrong and all patients should be transferred immediately for angioplasty after thrombolysis is started. The reason why this does not happen, despite the fact that an ESC Guideline advises the practice, is because there was evidence from recent trials, namely ASSENT-4, reported in Lancet 2006; 367:569-68, that lytics immediately before PCI can be deleterious and increase the risk of adverse events, especially bleedings but also death and need for new emergency angioplasty.
We had an opposite result and we believe the reason is the type of lytic treatment used -- not just a thrombolytic drug, but a cocktail of a powerful intravenous anti-platelet agent called abciximab, and a reduced dose of a fibrin specific lytic drug called reteplase. This combination is very powerful and rapid in its action, with a synergistic effect demonstrated in previous trials and in in-vitro models, and achieved restoration of flow in the occluded artery in 85% of cases by the time patients reached the hospital where angioplasty was performed. Its main advantage is, however, the ability to inactivate platelets during the subsequent angioplasty, the opposite of the result observed when only lytics are given which tend to activate platelets instead.
IMPORTANT NOTE: This study will be presented immediately after a larger trial of almost 2,000 patients called FINESSE, with a PI from the Cleveland Clinic, Dr Stephen Ellis. The results of this second trial in AMI will be complementary to the CARESS results because FINESSE compares direct (primary) angioplasty with facilitated angioplasty using only abciximab or using the same combination of drugs we used in this trial. I expect the combined presentation of these 2 trials, with ours clearly positive and reaching unquestionable statistical significance with a favourable effects on all the endpoints (death, re-AMI and refractory ischaemia) will represent one of the highlights of this year’s ESC congress.
Thursday, August 16, 2007
Reversing Cocaine's Effects On The Cardiovascular System
Reversing Cocaine's Effects On The Cardiovascular System
16 Aug 2007
UT Southwestern Medical Center researchers have discovered a treatment that counteracts the effects of cocaine on the human cardiovascular system, including lowering the elevated heart rate and blood pressure often found in cocaine users.
"We have found that cocaine's effects on the cardiovascular system can be reversed by the use of a drug called dexmedetomidine, which is currently approved by the Food and Drug Administration for anesthetic purposes in operating rooms or intensive care units," said Dr. Wanpen Vongpatanasin, associate professor of internal medicine and senior author of a study appearing in the Aug. 14 issue of the Journal of the American College of Cardiology.
Researchers used dexmedetomidine to test whether cocaine's effect on the cardiovascular system could be muted.
They found that the drug was effective in reversing the actions of cocaine on heart rate, blood pressure and vascular resistance in the skin by interfering with the ability of cocaine to increase nerve activity.
"Typically, patients with cocaine overdoses in the emergency room are treated with nitroglycerin, sedatives such as Valium, and some blood-pressure medications such as calcium channel blockers and some beta blockers," Dr. Vongpatanasin said.
"However, the standard treatments don't alleviate all of the adverse effects of cocaine on the heart, blood pressure and central nervous system."
The study examined results from 22 healthy adults who reported to have never used cocaine.
The investigators administered a small, medically approved dose of cocaine nose drops to the study participants, which doubled their sympathetic nerve activity, part of the body's 'automatic' response system that becomes more active during times of stress.
Participants experienced increases in several cardiovascular parameters including heart rate, blood pressure and resistance to blood flow in the skin. Microelectrodes, similar to acupuncture needles, were used to record sympathetic nerve activity following doses of intranasal cocaine.
Research subjects who were treated with dexmedetomidine had a decrease in sympathetic nerve activity as well as in all three cardiovascular parameters, which returned to baseline levels measured before administration of cocaine.
Dexmedetomidine proved to be more effective than intravenous saline, which was used as a placebo in another group of study participants.
Cocaine abuse in the U.S. is widespread, with nearly 35 million Americans reporting having ever tried cocaine and an estimated 7.3 million users, including 15 percent of young adults ages 18 to 25, according to the National Institute on Drug Abuse.
Life-threatening emergencies related to cocaine use include sudden cardiac death, high blood pressure, stroke and acute myocardial infarctions.
"We also found that dexmedetomidine was equally effective in counteracting effects of cocaine in subjects with a rare genetic mutation thought to disrupt the effects of dexmedetomidine," said Dr. Ronald Victor, professor of internal medicine and co-author of the study.
"Because this particular mutation is more common in African-Americans than in Caucasians, our study results are applicable to a more diverse, multiethnic population."
Further research is needed, study authors said, to determine whether the treatment would be effective for acute cocaine overdose in the emergency room and to gauge whether it would be effective in reversing cocaine-induced constriction of the coronary vessels to the same degree it does in skin vessels.
Article adapted by Medical News Today from original press release.
16 Aug 2007
UT Southwestern Medical Center researchers have discovered a treatment that counteracts the effects of cocaine on the human cardiovascular system, including lowering the elevated heart rate and blood pressure often found in cocaine users.
"We have found that cocaine's effects on the cardiovascular system can be reversed by the use of a drug called dexmedetomidine, which is currently approved by the Food and Drug Administration for anesthetic purposes in operating rooms or intensive care units," said Dr. Wanpen Vongpatanasin, associate professor of internal medicine and senior author of a study appearing in the Aug. 14 issue of the Journal of the American College of Cardiology.
Researchers used dexmedetomidine to test whether cocaine's effect on the cardiovascular system could be muted.
They found that the drug was effective in reversing the actions of cocaine on heart rate, blood pressure and vascular resistance in the skin by interfering with the ability of cocaine to increase nerve activity.
"Typically, patients with cocaine overdoses in the emergency room are treated with nitroglycerin, sedatives such as Valium, and some blood-pressure medications such as calcium channel blockers and some beta blockers," Dr. Vongpatanasin said.
"However, the standard treatments don't alleviate all of the adverse effects of cocaine on the heart, blood pressure and central nervous system."
The study examined results from 22 healthy adults who reported to have never used cocaine.
The investigators administered a small, medically approved dose of cocaine nose drops to the study participants, which doubled their sympathetic nerve activity, part of the body's 'automatic' response system that becomes more active during times of stress.
Participants experienced increases in several cardiovascular parameters including heart rate, blood pressure and resistance to blood flow in the skin. Microelectrodes, similar to acupuncture needles, were used to record sympathetic nerve activity following doses of intranasal cocaine.
Research subjects who were treated with dexmedetomidine had a decrease in sympathetic nerve activity as well as in all three cardiovascular parameters, which returned to baseline levels measured before administration of cocaine.
Dexmedetomidine proved to be more effective than intravenous saline, which was used as a placebo in another group of study participants.
Cocaine abuse in the U.S. is widespread, with nearly 35 million Americans reporting having ever tried cocaine and an estimated 7.3 million users, including 15 percent of young adults ages 18 to 25, according to the National Institute on Drug Abuse.
Life-threatening emergencies related to cocaine use include sudden cardiac death, high blood pressure, stroke and acute myocardial infarctions.
"We also found that dexmedetomidine was equally effective in counteracting effects of cocaine in subjects with a rare genetic mutation thought to disrupt the effects of dexmedetomidine," said Dr. Ronald Victor, professor of internal medicine and co-author of the study.
"Because this particular mutation is more common in African-Americans than in Caucasians, our study results are applicable to a more diverse, multiethnic population."
Further research is needed, study authors said, to determine whether the treatment would be effective for acute cocaine overdose in the emergency room and to gauge whether it would be effective in reversing cocaine-induced constriction of the coronary vessels to the same degree it does in skin vessels.
Article adapted by Medical News Today from original press release.
Tuesday, August 7, 2007
ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction
Aug 6, 2007
ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction
LINK: http://www.cardiosource.com/guidelines/UA-NSTEMI.FullText.pdf
Aug 6, 2007
Highlights From the 2007 UA/NSTEMI Revision:
Text and summary table from Dr. Nanette Wenger, MD, MACP, FACC, FAHA
LINK: http://www.cardiosource.com/images/acs_gfc_chart.pdf
ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction
LINK: http://www.cardiosource.com/guidelines/UA-NSTEMI.FullText.pdf
Aug 6, 2007
Highlights From the 2007 UA/NSTEMI Revision:
Text and summary table from Dr. Nanette Wenger, MD, MACP, FACC, FAHA
LINK: http://www.cardiosource.com/images/acs_gfc_chart.pdf
Friday, July 20, 2007
ICTUS Trial
Three year follow-up from the ICTUS trial: Early intervention or selective-based treatment for coronary heart disease?
Christopher CannonTIMI Study Group, Boston, MA, USA19 June 2007
Globally, coronary artery disease (CAD) is the leading cause of mortality, with non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina (UA) being the most common manifestations of this condition.
There has been much debate over the past decade regarding the optimal management of patients with CAD.
Should we provide routine early invasive strategies, or do we need to adopt a more “conservative” approach based on selective intervention focused towards high-risk patients?
Cardiac catheterization and revascularization: The two main approaches
There are two general approaches to the use of cardiac catheterization and revascularization in UA/NSTEMI.
The “early invasive” strategy involves routine early cardiac catheterization and revascularization with percutaneous coronary intervention (PCI), or bypass surgery depending on the coronary anatomy.
The “conservative” strategy involves providing initial medical management, with catheterization and revascularization only for recurrent ischemia either at rest or on a non-invasive stress test.
The ACC/AHA guidelines were updated in 2002, and were based on the results of the FRagmin and Fast Revascularization during InStability in coronary artery disease (FRISC II) and Treat Angina with aggrastat and determine Cost of Therapy with Invasive or Conservative Strategy - Thrombolysis In Myocardial Infarction 18 (TACTICS-TIMI 18) trials, both of which compared early invasive strategies with the conservative approach.
The results of these trials suggested that patients who received early invasive therapy benefited more than those who underwent conservative treatment.
However, to date, 10 randomized trials have studied the relative merits of an invasive versus a conservative strategy. These include the FRISC-II, RITA-3, and TACTICS. These trials yielded varying results.
Of note, the other recent long-term follow-up data available from the RITA-3 trial demonstrated a benefit of a significantly lower cardiovascular mortality rate in the early invasive arm which was observed over five years. [1] A meta-analysis of the contemporary trial has confirmed an overall significant reduction in death, MI or rehospitalization during follow-up was observed. [2]
The most recent trial, Invasive Treatment Versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS), examined an invasive versus conservative approach in 1200 patients. All patients received aspirin, enoxaparin, abciximab for PCI and intensive statin therapy. At one, year there was no significant difference in the rate of the primary endpoint, death, MI, or rehospitalization for angina. [3]
During the index hospitalization, there was a higher rate of MI in the invasive arm, although this trial used a definition of MI that included any elevation of any biomarker following PCI, and thus had a much higher peri-procedural MI rate compared with prior trials.
Throughout the three year follow-up period, the higher overall rate of MI (again using their definition of MI) persisted, with rates of 18 versus 12 (p=0). No difference in mortality was seen. [4]
How do we incorporate this new information? Based on multiple randomized trials, an early invasive strategy remains the recommended approach to higher risk patients with UA/NSTEMI who have either ST-segment changes, positive troponin, or other other high-risk indicators, such as recurrent ischemia, evidence of congestive heart failure. [5]
References
de Winter RJ, Windhausen F, Cornel JH, et al. Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med 2005; 353:1095-104.
Bavry AA, Kumbhani DJ, Rassi AN, Bhatt DL, Askari AT. Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials. J Am Coll Cardiol 2006; 48:1319-25.
Hirsch A, Windhausen F, Tijssen JG, Verheugt FW, Cornel JH, de Winter RJ. Long-term outcome after an early invasive versus selective invasive treatment strategy in patients with non-ST-elevation acute coronary syndrome and elevated cardiac troponin T (the ICTUS trial): a follow-up study. Lancet 2007; 369:827-35.
Fox KAA, Poole-Wilson P, Clayton TC, et al. 5-year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomised trial. Lancet 2005; 366:914-920.
Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction-2002: Summary Article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). Circulation 2002; 106:1893-900.
Christopher CannonTIMI Study Group, Boston, MA, USA19 June 2007
Globally, coronary artery disease (CAD) is the leading cause of mortality, with non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina (UA) being the most common manifestations of this condition.
There has been much debate over the past decade regarding the optimal management of patients with CAD.
Should we provide routine early invasive strategies, or do we need to adopt a more “conservative” approach based on selective intervention focused towards high-risk patients?
Cardiac catheterization and revascularization: The two main approaches
There are two general approaches to the use of cardiac catheterization and revascularization in UA/NSTEMI.
The “early invasive” strategy involves routine early cardiac catheterization and revascularization with percutaneous coronary intervention (PCI), or bypass surgery depending on the coronary anatomy.
The “conservative” strategy involves providing initial medical management, with catheterization and revascularization only for recurrent ischemia either at rest or on a non-invasive stress test.
The ACC/AHA guidelines were updated in 2002, and were based on the results of the FRagmin and Fast Revascularization during InStability in coronary artery disease (FRISC II) and Treat Angina with aggrastat and determine Cost of Therapy with Invasive or Conservative Strategy - Thrombolysis In Myocardial Infarction 18 (TACTICS-TIMI 18) trials, both of which compared early invasive strategies with the conservative approach.
The results of these trials suggested that patients who received early invasive therapy benefited more than those who underwent conservative treatment.
However, to date, 10 randomized trials have studied the relative merits of an invasive versus a conservative strategy. These include the FRISC-II, RITA-3, and TACTICS. These trials yielded varying results.
Of note, the other recent long-term follow-up data available from the RITA-3 trial demonstrated a benefit of a significantly lower cardiovascular mortality rate in the early invasive arm which was observed over five years. [1] A meta-analysis of the contemporary trial has confirmed an overall significant reduction in death, MI or rehospitalization during follow-up was observed. [2]
The most recent trial, Invasive Treatment Versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS), examined an invasive versus conservative approach in 1200 patients. All patients received aspirin, enoxaparin, abciximab for PCI and intensive statin therapy. At one, year there was no significant difference in the rate of the primary endpoint, death, MI, or rehospitalization for angina. [3]
During the index hospitalization, there was a higher rate of MI in the invasive arm, although this trial used a definition of MI that included any elevation of any biomarker following PCI, and thus had a much higher peri-procedural MI rate compared with prior trials.
Throughout the three year follow-up period, the higher overall rate of MI (again using their definition of MI) persisted, with rates of 18 versus 12 (p=0). No difference in mortality was seen. [4]
How do we incorporate this new information? Based on multiple randomized trials, an early invasive strategy remains the recommended approach to higher risk patients with UA/NSTEMI who have either ST-segment changes, positive troponin, or other other high-risk indicators, such as recurrent ischemia, evidence of congestive heart failure. [5]
References
de Winter RJ, Windhausen F, Cornel JH, et al. Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med 2005; 353:1095-104.
Bavry AA, Kumbhani DJ, Rassi AN, Bhatt DL, Askari AT. Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials. J Am Coll Cardiol 2006; 48:1319-25.
Hirsch A, Windhausen F, Tijssen JG, Verheugt FW, Cornel JH, de Winter RJ. Long-term outcome after an early invasive versus selective invasive treatment strategy in patients with non-ST-elevation acute coronary syndrome and elevated cardiac troponin T (the ICTUS trial): a follow-up study. Lancet 2007; 369:827-35.
Fox KAA, Poole-Wilson P, Clayton TC, et al. 5-year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomised trial. Lancet 2005; 366:914-920.
Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction-2002: Summary Article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). Circulation 2002; 106:1893-900.
Thursday, July 19, 2007
Nonfasting Triglycerides and Risk of Myocardial Infarction, Ischemic Heart Disease, and Death in Men and Women
Børge G. Nordestgaard, MD, DMSc; Marianne Benn, MD, PhD; Peter Schnohr, MD; Anne Tybjærg-Hansen, MD, DMSc
JAMA. 2007;298:299-308.
Context Elevated nonfasting triglycerides indicate the presence of remnant lipoproteins, which may promote atherosclerosis.
Objective To test the hypothesis that very high levels of nonfasting triglycerides predict myocardial infarction (MI), ischemic heart disease (IHD), and death.
Design, Setting, and Participants A prospective cohort study of 7587 women and 6394 men from the general population of Copenhagen, Denmark, aged 20 to 93 years, followed up from baseline (1976-1978) until 2004.
Main Outcome Measures Hazard ratios (HRs) for incident MI, IHD, and total death according to baseline nonfasting triglyceride level categories of 1 to 1.99 mmol/L (88.5-176.1 mg/dL), 2 to 2.99 mmol/L (177.0-264.6 mg/dL), 3 to 3.99 mmol/L (265.5-353.0 mg/dL), 4 to 4.99 mmol/L (354.0-441.6 mg/dL), and 5 mmol/L or more (442.5 mg/dL) vs triglyceride levels of less than 1 mmol/L (<88.5 mg/dL).
Results With increasing levels of nonfasting triglycerides, levels of remnant lipoprotein cholesterol increased. During a mean follow-up of 26 years, 1793 participants (691 women and 1102 men) developed MI, 3479 (1567 women and 1912 men) developed IHD, and 7818 (3731 women and 4087 men) died. For MI, among women, the age-adjusted HRs and multifactorially adjusted HRs (aHRs) for each respective category per 1-mmol/L increase in nonfasting triglyceride levels were 2.2 (aHR, 1.7), 4.4 (aHR, 2.5), 3.9 (aHR, 2.1), 5.1 (aHR, 2.4), and 16.8 (aHR, 5.4); for both, P for trend < .001. For MI, among men, the values were 1.6 (aHR, 1.4), 2.3 (aHR, 1.6), 3.6 (aHR, 2.3), 3.3 (aHR, 1.9), and 4.6 (aHR, 2.4); for both, P for trend < .001. For IHD, among women, the values were 1.7 (aHR, 1.4), 2.8 (aHR, 1.8), 3.0 (aHR, 1.8), 2.1 (aHR, 1.2), and 5.9 (aHR, 2.6); for both, P for trend < .001. For IHD, among men, the values were 1.3 (aHR, 1.1), 1.7 (aHR, 1.3), 2.1 (aHR, 1.3), 2.0 (aHR, 1.2), and 2.9 (aHR, 1.5); P for trend < .001 for age-adjusted and P for trend = .03 for multifactorially adjusted. For total death, among women, the values were 1.3 (aHR, 1.3), 1.7 (aHR, 1.6), 2.2 (aHR, 2.2), 2.2 (aHR, 1.9), and 4.3 (aHR, 3.3); for both, P for trend < .001. For total death, among men, the values were 1.3 (aHR, 1.2), 1.4 (aHR, 1.4), 1.7 (aHR, 1.5), 1.8 (aHR, 1.6), and 2.0 (aHR, 1.8); for both, P for trend < .001.
Conclusion In this general population cohort, elevated nonfasting triglyceride levels were associated with increased risk of MI, IHD, and death in men and women.
Børge G. Nordestgaard, MD, DMSc; Marianne Benn, MD, PhD; Peter Schnohr, MD; Anne Tybjærg-Hansen, MD, DMSc
JAMA. 2007;298:299-308.
Context Elevated nonfasting triglycerides indicate the presence of remnant lipoproteins, which may promote atherosclerosis.
Objective To test the hypothesis that very high levels of nonfasting triglycerides predict myocardial infarction (MI), ischemic heart disease (IHD), and death.
Design, Setting, and Participants A prospective cohort study of 7587 women and 6394 men from the general population of Copenhagen, Denmark, aged 20 to 93 years, followed up from baseline (1976-1978) until 2004.
Main Outcome Measures Hazard ratios (HRs) for incident MI, IHD, and total death according to baseline nonfasting triglyceride level categories of 1 to 1.99 mmol/L (88.5-176.1 mg/dL), 2 to 2.99 mmol/L (177.0-264.6 mg/dL), 3 to 3.99 mmol/L (265.5-353.0 mg/dL), 4 to 4.99 mmol/L (354.0-441.6 mg/dL), and 5 mmol/L or more (442.5 mg/dL) vs triglyceride levels of less than 1 mmol/L (<88.5 mg/dL).
Results With increasing levels of nonfasting triglycerides, levels of remnant lipoprotein cholesterol increased. During a mean follow-up of 26 years, 1793 participants (691 women and 1102 men) developed MI, 3479 (1567 women and 1912 men) developed IHD, and 7818 (3731 women and 4087 men) died. For MI, among women, the age-adjusted HRs and multifactorially adjusted HRs (aHRs) for each respective category per 1-mmol/L increase in nonfasting triglyceride levels were 2.2 (aHR, 1.7), 4.4 (aHR, 2.5), 3.9 (aHR, 2.1), 5.1 (aHR, 2.4), and 16.8 (aHR, 5.4); for both, P for trend < .001. For MI, among men, the values were 1.6 (aHR, 1.4), 2.3 (aHR, 1.6), 3.6 (aHR, 2.3), 3.3 (aHR, 1.9), and 4.6 (aHR, 2.4); for both, P for trend < .001. For IHD, among women, the values were 1.7 (aHR, 1.4), 2.8 (aHR, 1.8), 3.0 (aHR, 1.8), 2.1 (aHR, 1.2), and 5.9 (aHR, 2.6); for both, P for trend < .001. For IHD, among men, the values were 1.3 (aHR, 1.1), 1.7 (aHR, 1.3), 2.1 (aHR, 1.3), 2.0 (aHR, 1.2), and 2.9 (aHR, 1.5); P for trend < .001 for age-adjusted and P for trend = .03 for multifactorially adjusted. For total death, among women, the values were 1.3 (aHR, 1.3), 1.7 (aHR, 1.6), 2.2 (aHR, 2.2), 2.2 (aHR, 1.9), and 4.3 (aHR, 3.3); for both, P for trend < .001. For total death, among men, the values were 1.3 (aHR, 1.2), 1.4 (aHR, 1.4), 1.7 (aHR, 1.5), 1.8 (aHR, 1.6), and 2.0 (aHR, 1.8); for both, P for trend < .001.
Conclusion In this general population cohort, elevated nonfasting triglyceride levels were associated with increased risk of MI, IHD, and death in men and women.
Monday, July 16, 2007
Women more depressed after heart attack
ACC - Cardiosource
CV News Digest – What Your Patients Are Reading
Women more depressed after heart attack
EDMONTON, Alberta, July 14 (UPI) -- Women are more likely than men to have lingering depression after suffering heart attacks, Canadian researchers said.
A study by the University of Alberta and McGill University found that 14.3 percent of women had worsening depression one year after their initial myocardial infarctions. Eleven percent of men studied had a similar experience.
Results of the study were published in the European Journal of Cardiovascular Nursing.
"The findings are of concern because depression impedes recovery and ultimately, the quality of life in patients following a heart event," said lead author Colleen Norris, an associate professor in the Faculty of Nursing at the University of Alberta in Edmonton, said Friday in a release.
Norris said women are less likely to be referred to or to attend cardiac rehabilitation, and therefore don't have access to the support and assistance to make necessary lifestyle changes
CV News Digest – What Your Patients Are Reading
Women more depressed after heart attack
EDMONTON, Alberta, July 14 (UPI) -- Women are more likely than men to have lingering depression after suffering heart attacks, Canadian researchers said.
A study by the University of Alberta and McGill University found that 14.3 percent of women had worsening depression one year after their initial myocardial infarctions. Eleven percent of men studied had a similar experience.
Results of the study were published in the European Journal of Cardiovascular Nursing.
"The findings are of concern because depression impedes recovery and ultimately, the quality of life in patients following a heart event," said lead author Colleen Norris, an associate professor in the Faculty of Nursing at the University of Alberta in Edmonton, said Friday in a release.
Norris said women are less likely to be referred to or to attend cardiac rehabilitation, and therefore don't have access to the support and assistance to make necessary lifestyle changes
Saturday, July 14, 2007
Impact of multivessel disease on reperfusion success and clinical outcomes in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction -- Sorajja et al. 28 (14): 1709 -- European Heart Journal
Impact of multivessel disease on reperfusion success and clinical outcomes in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction --
Sorajja et al. 28 (14): 1709 -- European Heart Journal
Aims: We sought to investigate the impact of multivessel coronary artery disease (CAD) on reperfusion success and prognosis following primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). The influence of multivessel disease on myocardial reperfusion and subsequent survival after primary PCI has not been studied.
Conclusion: Patients with extensive CAD in vessels remote from the infarct-related artery have reduced reperfusion success and an adverse prognosis following primary PCI in AMI. Future studies regarding the optimal treatment of patients with multivessel disease and AMI are warranted.
Sorajja et al. 28 (14): 1709 -- European Heart Journal
Aims: We sought to investigate the impact of multivessel coronary artery disease (CAD) on reperfusion success and prognosis following primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). The influence of multivessel disease on myocardial reperfusion and subsequent survival after primary PCI has not been studied.
Conclusion: Patients with extensive CAD in vessels remote from the infarct-related artery have reduced reperfusion success and an adverse prognosis following primary PCI in AMI. Future studies regarding the optimal treatment of patients with multivessel disease and AMI are warranted.
Wednesday, July 11, 2007
PCI benefits over fibrinolysis found in diabetic patients
MedWire News - Cardiology - PCI benefits over fibrinolysis found in diabetic patients
PCI benefits over fibrinolysis found in diabetic patients
11 July 2007
Arch Intern Med 2007; 167: 1353-1359
MedWire News: The beneficial effects of primary percutaneous coronary intervention (PCI) over reperfusion therapy in diabetic patients with ST-segment elevation myocardial infarction (STEMI) are consistent with those for non-diabetic patients, meta-analysis findings indicate.
Writing in the Archives of Internal Medicine, Jan Paul Ottervanger (Isala Klinieken, Zwolle, The Netherlands) and colleagues note that an increasing amount of evidence indicates that primary PCI improves outcomes of STEMI compared with fibrinolysis in the general population. But effects of both reperfusion and fibrinolysis may differ in diabetic patients, they say, and previous trials comparing the strategies in diabetic patients have produced conflicting data.
"In our analysis including a large number of patients, it was more clearly demonstrated that primary PCI is associated with improved survival after 30 days in both patients with and without diabetes," the team reports.
The researchers analyzed data from 19 trials that compared primary PCI with fibrinolysis for STEMI in a total of 6315 patients, 877 (14%) of whom had diabetes.
At 30 days, 401 (6.3%) patients had died. Mortality was significantly higher in patients with than without diabetes (9.4% vs 5.9%, p<0.001).
Primary PCI was associated with lower mortality than fibrinolysis in both non-diabetic patients (4.8% vs 6.9%, unadjusted odds ratio [OR]=0.69; p=0.001) and diabetic patients (6.6% vs 12.4%, OR=0.49; p=0.001).
Recurrent MI and stroke were also less common with PCI in patients with and without diabetes, with corresponding ORs of 0.33 and 0.60, and 0.58 and 0.40.
After adjusting for potential confounders, including age, gender, time to randomization, treatment delay, systolic blood pressure, anterior MI, previous MI, heart rate, and randomized treatment, primary PCI was independently associated with reduced 30-day survival (OR=0.64). This association held true in patients with diabetes (OR=0.50) and without diabetes (OR=0.68).
The authors note that these point estimates indicate a greater benefit of PCI in diabetic patients, in whom the absolute risk is higher than in non-diabetic patients.
"This observation may be the result of delay in initiation of therapy and longer ischemic time in diabetic patients, which may be related in part to atypical symptoms," they write. "In particular, thrombolytic therapy seems to be negatively influenced by longer time to initiation of therapy."
They add that impairment of microvascular flow after fibrinolysis in diabetic patients could also contribute to a more favorable effect with PCI.
"Wider application of timely primary PCI could be an important strategy to improve outcomes in the high-risk population of diabetic patients," Timmer and co-authors conclude.
Free abstract
PCI benefits over fibrinolysis found in diabetic patients
11 July 2007
Arch Intern Med 2007; 167: 1353-1359
MedWire News: The beneficial effects of primary percutaneous coronary intervention (PCI) over reperfusion therapy in diabetic patients with ST-segment elevation myocardial infarction (STEMI) are consistent with those for non-diabetic patients, meta-analysis findings indicate.
Writing in the Archives of Internal Medicine, Jan Paul Ottervanger (Isala Klinieken, Zwolle, The Netherlands) and colleagues note that an increasing amount of evidence indicates that primary PCI improves outcomes of STEMI compared with fibrinolysis in the general population. But effects of both reperfusion and fibrinolysis may differ in diabetic patients, they say, and previous trials comparing the strategies in diabetic patients have produced conflicting data.
"In our analysis including a large number of patients, it was more clearly demonstrated that primary PCI is associated with improved survival after 30 days in both patients with and without diabetes," the team reports.
The researchers analyzed data from 19 trials that compared primary PCI with fibrinolysis for STEMI in a total of 6315 patients, 877 (14%) of whom had diabetes.
At 30 days, 401 (6.3%) patients had died. Mortality was significantly higher in patients with than without diabetes (9.4% vs 5.9%, p<0.001).
Primary PCI was associated with lower mortality than fibrinolysis in both non-diabetic patients (4.8% vs 6.9%, unadjusted odds ratio [OR]=0.69; p=0.001) and diabetic patients (6.6% vs 12.4%, OR=0.49; p=0.001).
Recurrent MI and stroke were also less common with PCI in patients with and without diabetes, with corresponding ORs of 0.33 and 0.60, and 0.58 and 0.40.
After adjusting for potential confounders, including age, gender, time to randomization, treatment delay, systolic blood pressure, anterior MI, previous MI, heart rate, and randomized treatment, primary PCI was independently associated with reduced 30-day survival (OR=0.64). This association held true in patients with diabetes (OR=0.50) and without diabetes (OR=0.68).
The authors note that these point estimates indicate a greater benefit of PCI in diabetic patients, in whom the absolute risk is higher than in non-diabetic patients.
"This observation may be the result of delay in initiation of therapy and longer ischemic time in diabetic patients, which may be related in part to atypical symptoms," they write. "In particular, thrombolytic therapy seems to be negatively influenced by longer time to initiation of therapy."
They add that impairment of microvascular flow after fibrinolysis in diabetic patients could also contribute to a more favorable effect with PCI.
"Wider application of timely primary PCI could be an important strategy to improve outcomes in the high-risk population of diabetic patients," Timmer and co-authors conclude.
Free abstract
Friday, June 29, 2007
Cell Therapy in MI
Cardiologists express cautious optimism for cell therapy in MI
29 June 2007
Lancet 2007; 369: 2142-2143
MedWire News: Continued research will hopefully lead to stem cell transfer therapies that can improve outcomes for myocardial infarction (MI) patients, conclude experts in a Lancet comment article.
But Harald Arnesen (Ullevål University Hospital, Oslo, Norway) and co-authors challenge the proposal that studies should now be conducted in large populations based on methods used in the recent REPAIR-AMI study.
The researchers reviewed studies published to date of autologous bone marrow cell (BMC) transfer in patients with acute MI. They say results of a 2002 trial and other small uncontrolled trials using the same method "were encouraging," but that three randomized trials were negative for the primary endpoint of improvement in left ventricular ejection fraction (LVEF).
The larger REPAIR-AMI (Reinfusion of Enriched Progenitor Cells And Infarct Remodeling in Acute MI) study included 204 patients with acute MI who received either an intracoronary infusion of BMC or placebo into the infarct artery after successful revascularization by percutaneous coronary intervention.
Patients who received BMC experienced a "modest" improvement in LV function compared with the placebo group at 4 months, at a mean greater increase in LVEF of 2.5%, and a surprisingly significant reduction in events at 12 months, Arnesen and colleagues write.
But the authors say they are concerned at the REPAIR-AMI investigators' conclusion that large-scale trials based on the methods used are now warranted. They believe the benefits in LV function were based on suboptimal measurements of LVEF and volumes, and that the positive clinical effect seems to be driven by the poor outcome in the placebo group.
They suggest that the apparently worse outcomes in the REPAIR-AMI placebo group compared with control groups in other trials could be due to harmful effects of the cell culture medium used for the placebo infusion.
Although the same medium was used for the BMC infusion, they write, "a metabolizing process had been operating during the incubation period which could have attenuated the possible deleterious effects to the injured coronary vessel wall."
The authors conclude: "While results of ongoing adequately powered clinical trials with satisfactory methods for endpoint assessment are awaited, research should also move 'from bed to bench' and focus on unsolved problems, such as the selection of optimum cell type, dosing, timing, and mode of delivery, which will hopefully bring cell therapies close to clinical application."
Link: http://www.thelancet.com/home
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