Editorial In New England Journal Of Medicine Written By Nationally Known VCU Cardiologist
Medical News Today
09 Feb 2008
George W. Vetrovec, M.D., chair of cardiology at the Virginia Commonwealth University Medical Center, known nationally for his study and treatment of coronary artery disease, says a new technique for treating blocked coronary arteries shows promise, but is best performed by experienced physicians.
The editorial review, Improving Reperfusion in Patients with Myocardial Infarction, appears in the current issue of the New England Journal of Medicine.
A study - also published in the current issue - investigates a technique for treating patients suffering a myocardial infarction, or heart attack.
The procedure, called a thrombectomy, uses a special aspiration catheter placed at the site of an arterial blockage, or clot, causing the heart attack. Doctors then suction out the thrombus, or blockage, and place a stent to prevent the area from becoming occluded again.
According to Vetrovec, the technique reduces the chance that pieces of the blockage could travel downstream and cause another obstruction - a potential consequence with traditional balloon angioplasty.
Importantly, he adds, beyond the improvement of perfusion, or blood flow restoration, is the fact that clinical outcomes were improved and the improvements correlated with the improved markers of perfusion. Vetrovec is world-renowned for his studies on coronary artery disease.
Article adapted by Medical News Today from original press release.
Showing posts with label Angioplasty. Show all posts
Showing posts with label Angioplasty. Show all posts
Saturday, February 9, 2008
Monday, January 28, 2008
Similar outcome after thrombolysis or primary angioplasty in STEMI
Comparison of Left Ventricular Ejection Fraction and Inducible Ventricular Tachycardia in ST-Elevation Myocardial Infarction Treated by Primary Angioplasty Versus Thrombolysis
American Journal of Cardiology
Volume 101, Issue 2, Pages 153-157 (15 January 2008)
James J.H. Chong, MDa, Anand N. Ganesan, MD, PhD, Vicki Eippera, Pramesh Kovoor, MD, PhD
Electrophysiologic studies predict the risk for sudden death after myocardial infarction (MI). Although primary angioplasty has become the preferred method of treatment for ST-elevation MI, intravenous thrombolysis remains the first-line treatment in 30% to 70% of cases worldwide. Rates of ventricular tachyarrhythmias may vary according to type of reperfusion treatment. This study was undertaken to examine the hypothesis that the left ventricular ejection fraction (LVEF) and rates of inducible ventricular tachycardia may be more favorable in treatment with primary angioplasty rather than thrombolysis. Consecutive patients receiving primary angioplasty (n = 225) or thrombolysis (n = 195) for ST-elevation MI were included. The mean LVEF was 48 ± 12% for the primary angioplasty group and 46 ± 13% for the thrombolysis group (p = 0.30). The proportion of patients with LVEFs <40% was 30% in the primary angioplasty group and 30% in the thrombolysis group (p = 0.98). Patients with LVEFs <40% underwent electrophysiologic studies. Ventricular tachycardia was inducible in 23 of 66 primary angioplasty patients (34.8%) compared with 21 of 55 (38.1%) thrombolysis patients (p = 0.69). Implantable cardiac defibrillators were inserted in 30 patients, of whom 8 (27%) had appropriate device activations. The mean time from MI to first spontaneous activation was 387 ± 458 days.
In conclusion, patients treated with thrombolysis or primary angioplasty for ST-elevation MIs had similar resultant LVEFs and rates of inducible ventricular tachycardia. There was a surprisingly high rate of spontaneous defibrillator activations, often occurring late after MI.
American Journal of Cardiology
Volume 101, Issue 2, Pages 153-157 (15 January 2008)
James J.H. Chong, MDa, Anand N. Ganesan, MD, PhD, Vicki Eippera, Pramesh Kovoor, MD, PhD
Electrophysiologic studies predict the risk for sudden death after myocardial infarction (MI). Although primary angioplasty has become the preferred method of treatment for ST-elevation MI, intravenous thrombolysis remains the first-line treatment in 30% to 70% of cases worldwide. Rates of ventricular tachyarrhythmias may vary according to type of reperfusion treatment. This study was undertaken to examine the hypothesis that the left ventricular ejection fraction (LVEF) and rates of inducible ventricular tachycardia may be more favorable in treatment with primary angioplasty rather than thrombolysis. Consecutive patients receiving primary angioplasty (n = 225) or thrombolysis (n = 195) for ST-elevation MI were included. The mean LVEF was 48 ± 12% for the primary angioplasty group and 46 ± 13% for the thrombolysis group (p = 0.30). The proportion of patients with LVEFs <40% was 30% in the primary angioplasty group and 30% in the thrombolysis group (p = 0.98). Patients with LVEFs <40% underwent electrophysiologic studies. Ventricular tachycardia was inducible in 23 of 66 primary angioplasty patients (34.8%) compared with 21 of 55 (38.1%) thrombolysis patients (p = 0.69). Implantable cardiac defibrillators were inserted in 30 patients, of whom 8 (27%) had appropriate device activations. The mean time from MI to first spontaneous activation was 387 ± 458 days.
In conclusion, patients treated with thrombolysis or primary angioplasty for ST-elevation MIs had similar resultant LVEFs and rates of inducible ventricular tachycardia. There was a surprisingly high rate of spontaneous defibrillator activations, often occurring late after MI.
Friday, January 4, 2008
Single-lead ST-segment deviation after primary angioplasty
Single-lead ST-segment deviation after primary angioplasty
By Caroline Price
04 January 2008
Heart 2008; 94: 44-47
MedWire News: Residual ST-segment deviation in a single lead 3 hours after primary angioplasty in ST-elevation myocardial infarction (STEMI) patients is an “easy and accurate” predictor of 1-year mortality, cardiologists report.
Electrocardiography (ECG) is a simple way to measure reperfusion outcomes, with ST-segment deviation providing better prognostic accuracy than ST-segment resolution, explain A van’t Hof (Hospital De Weezenlanden, Zwolle, The Netherlands) and team.
To evaluate the prognostic role of postprocedural single-lead ST-segment deviation (STD) in primary angioplasty, relative to single-lead ST-segment resolution and elevation, and 12-lead ST-segment deviation, the researchers prospectively studied 1660 STEMI patients undergoing the procedure between 1997 and 2002.
Successful reperfusion was defined as postprocedural thrombolysis in myocardial infarction (TIMI) 3 flow, residual stenosis <50%, and myocardial blush grade (MBG) 2-3. ECGs were recorded at 3 hours after the procedure.
As reported in the journal Heart, maximal residual STD correlated well with postprocedural MBG 3, distal embolization, enzymatic infarct size, and predischarge left ventricular ejection fraction.
At 1 year of follow-up, 63 (3.8%) patients had died. In multivariate analysis, after correction for baseline characteristics, maximal residual single-lead STD was the strongest predictor of mortality of all postprocedural ECG measures, at a hazard ratio of 1.87 (p<0.001).
Using receiver operating characteristic curves, the researchers identified ≥2 mm as the optimal threshold for maximal single-lead STD.
“The simple evaluation of maximal residual STD in a single lead 3 hours after the procedure is the best electrocardiographic measure for the evaluation of myocardial perfusion and prognostic stratification of patients with STEMI treated with primary angioplasty,” the authors write.
Link: http://heart.bmj.com/cgi/content/abstract/94/1/44
By Caroline Price
04 January 2008
Heart 2008; 94: 44-47
MedWire News: Residual ST-segment deviation in a single lead 3 hours after primary angioplasty in ST-elevation myocardial infarction (STEMI) patients is an “easy and accurate” predictor of 1-year mortality, cardiologists report.
Electrocardiography (ECG) is a simple way to measure reperfusion outcomes, with ST-segment deviation providing better prognostic accuracy than ST-segment resolution, explain A van’t Hof (Hospital De Weezenlanden, Zwolle, The Netherlands) and team.
To evaluate the prognostic role of postprocedural single-lead ST-segment deviation (STD) in primary angioplasty, relative to single-lead ST-segment resolution and elevation, and 12-lead ST-segment deviation, the researchers prospectively studied 1660 STEMI patients undergoing the procedure between 1997 and 2002.
Successful reperfusion was defined as postprocedural thrombolysis in myocardial infarction (TIMI) 3 flow, residual stenosis <50%, and myocardial blush grade (MBG) 2-3. ECGs were recorded at 3 hours after the procedure.
As reported in the journal Heart, maximal residual STD correlated well with postprocedural MBG 3, distal embolization, enzymatic infarct size, and predischarge left ventricular ejection fraction.
At 1 year of follow-up, 63 (3.8%) patients had died. In multivariate analysis, after correction for baseline characteristics, maximal residual single-lead STD was the strongest predictor of mortality of all postprocedural ECG measures, at a hazard ratio of 1.87 (p<0.001).
Using receiver operating characteristic curves, the researchers identified ≥2 mm as the optimal threshold for maximal single-lead STD.
“The simple evaluation of maximal residual STD in a single lead 3 hours after the procedure is the best electrocardiographic measure for the evaluation of myocardial perfusion and prognostic stratification of patients with STEMI treated with primary angioplasty,” the authors write.
Link: http://heart.bmj.com/cgi/content/abstract/94/1/44
Friday, November 16, 2007
Angioplasty vs. Bypass Surgery
Surgery for Heart Disease: Angioplasty vs. Bypass Surgery
Johns Hopkins Health Alerts: Heart Health
Johns Hopkins experts discuss these two life-saving procedures and reviews the advantages and risks of each.
The pain of angina, usually experienced in the chest, is caused by a shortage of blood and oxygen to the heart muscle due to partial blockage of a coronary artery. The two goals in treating angina symptoms are to decrease the heart’s demand for oxygen and to increase its blood supply.
Several types of drugs can often help control angina pain. But when medication is not successful, revascularization—bypass surgery or angioplasty—may be necessary.
Since neither bypass surgery or angioplasty is a cure for atherosclerosis, it is essential to continue dietary and other preventive lifestyle measures and, in many cases, to take lipid-lowering drugs, blood pressure-lowering drugs, and aspirin after undergoing one of these procedures.
Angioplasty and Bypass Surgery -- Two Techniques to Improve Blood FlowEach year more than 300,000 people in the United States undergo coronary artery bypass graft surgery (often called CABG or, simply, bypass surgery). During bypass surgery, a blood vessel from elsewhere in the body is used to reroute blood around a segment of a coronary artery narrowed by atherosclerosis. When needed, five or more bypass grafts can be performed during a single bypass surgery.
About 90%of people who undergo bypass surgery experience relief of angina symptoms after the procedure. Bypass surgery is extremely successful, even for people with extensive heart disease or who are elderly. But bypass surgery is arduous for patients, requiring general anesthesia and four to six days of hospitalization. And bypass surgery is usually performed with the help of a heart-lung machine that maintains blood circulation while the heart is stopped.
About 640,000 Americans a year undergo percutaneous transluminal coronary angioplasty (often called PTCA or, simply, angioplasty). Angioplasty involves inserting a balloon-tipped catheter into an artery; the balloon is guided to the diseased section of the coronary artery and inflated to break up and compress artery-clogging plaque.
Conventional angioplasty does not remove atherosclerotic plaque from the coronary arteries but instead widens the channel (lumen) through which blood flows by squeezing the plaque against the artery wall, cracking the hard part of the plaque, and/or stretching the artery.
About 90% of people notice an immediate improvement in symptoms when the artery lumen is at least 50% open after angioplasty. In about 85% of cases, a small, scaffold-like device called a stent is permanently placed in the artery during angioplasty to help keep the artery open. This helps reduce the rate of restenosis (further narrowing of the artery) to 10% to 20% (compared to 20% to 40% without a stent).
Angioplasty is performed in a cardiac catheterization laboratory and generally takes about one to two hours. Angioplasty does not require general anesthesia and usually involves no more than a night’s stay in the hospital. The risks associated with angioplasty are low.
Factors To Weigh in Choosing Angioplasty or Bypass SurgeryAngioplasty has several advantages over bypass surgery. Angioplasty is a relatively simple procedure, there is no need for general anesthesia, and the rigors of open heart surgery are avoided.
A major disadvantage of angioplasty is restenosis in the first six months after the procedure. People who undergo angioplasty must accept the risk that a repeat angioplasty or, ultimately, bypass surgery may become necessary.
Recurring angina is another consideration. These risks are considerably decreased with the implantation of a stent. Another disadvantage to angioplasty is that many people with coronary heart disease are not suitable candidates for angioplasty.
Bypass surgery may keep arteries open longer and improve blood flow through the coronary arteries more than angioplasty. Bypass surgery generally provides good relief of angina for at least five years.
In addition, bypass surgery is generally favored over angioplasty in people with one or more of the following:
· Disease in the left main coronary artery. This vessel is the main artery supplying blood to the heart, and even a brief period of blockage could damage heart muscle or be fatal.
· Diffuse coronary heart disease. Angioplasty is not effective for the treatment of multiple blockages in several vessels.
· Blockages at an arterial branch. If the blockage is at a point where one artery meets another, angioplasty may move the plaque into the adjacent artery, causing a new blockage.
· Diabetes. In the Bypass Angioplasty Revascularization Investigation (BARI) study, seven-year survival for people with diabetes was significantly better in those who underwent bypass surgery (76%) than angioplasty (56%). However, this study was conducted before traditional and drug-coated stents were available, and if the study were repeated today the results may be different.
Other factors. Other factors that make bypass surgery a better choice than angioplasty include severe disease of the three major coronary arteries (especially in people with reduced left ventricular function) and a history of heart failure.
Two drawbacks to bypass surgery are longer hospital stays and rehabilitation time than with angioplasty. In addition, a recent study of 261 bypass surgery patients found that about 40% of them had a decline in cognitive function that persisted five years after surgery. It is possible, however, that this decline was caused by underlying vascular disease in these patients and not the bypass surgery itself.
Johns Hopkins Health Alerts: Heart Health
Johns Hopkins experts discuss these two life-saving procedures and reviews the advantages and risks of each.
The pain of angina, usually experienced in the chest, is caused by a shortage of blood and oxygen to the heart muscle due to partial blockage of a coronary artery. The two goals in treating angina symptoms are to decrease the heart’s demand for oxygen and to increase its blood supply.
Several types of drugs can often help control angina pain. But when medication is not successful, revascularization—bypass surgery or angioplasty—may be necessary.
Since neither bypass surgery or angioplasty is a cure for atherosclerosis, it is essential to continue dietary and other preventive lifestyle measures and, in many cases, to take lipid-lowering drugs, blood pressure-lowering drugs, and aspirin after undergoing one of these procedures.
Angioplasty and Bypass Surgery -- Two Techniques to Improve Blood FlowEach year more than 300,000 people in the United States undergo coronary artery bypass graft surgery (often called CABG or, simply, bypass surgery). During bypass surgery, a blood vessel from elsewhere in the body is used to reroute blood around a segment of a coronary artery narrowed by atherosclerosis. When needed, five or more bypass grafts can be performed during a single bypass surgery.
About 90%of people who undergo bypass surgery experience relief of angina symptoms after the procedure. Bypass surgery is extremely successful, even for people with extensive heart disease or who are elderly. But bypass surgery is arduous for patients, requiring general anesthesia and four to six days of hospitalization. And bypass surgery is usually performed with the help of a heart-lung machine that maintains blood circulation while the heart is stopped.
About 640,000 Americans a year undergo percutaneous transluminal coronary angioplasty (often called PTCA or, simply, angioplasty). Angioplasty involves inserting a balloon-tipped catheter into an artery; the balloon is guided to the diseased section of the coronary artery and inflated to break up and compress artery-clogging plaque.
Conventional angioplasty does not remove atherosclerotic plaque from the coronary arteries but instead widens the channel (lumen) through which blood flows by squeezing the plaque against the artery wall, cracking the hard part of the plaque, and/or stretching the artery.
About 90% of people notice an immediate improvement in symptoms when the artery lumen is at least 50% open after angioplasty. In about 85% of cases, a small, scaffold-like device called a stent is permanently placed in the artery during angioplasty to help keep the artery open. This helps reduce the rate of restenosis (further narrowing of the artery) to 10% to 20% (compared to 20% to 40% without a stent).
Angioplasty is performed in a cardiac catheterization laboratory and generally takes about one to two hours. Angioplasty does not require general anesthesia and usually involves no more than a night’s stay in the hospital. The risks associated with angioplasty are low.
Factors To Weigh in Choosing Angioplasty or Bypass SurgeryAngioplasty has several advantages over bypass surgery. Angioplasty is a relatively simple procedure, there is no need for general anesthesia, and the rigors of open heart surgery are avoided.
A major disadvantage of angioplasty is restenosis in the first six months after the procedure. People who undergo angioplasty must accept the risk that a repeat angioplasty or, ultimately, bypass surgery may become necessary.
Recurring angina is another consideration. These risks are considerably decreased with the implantation of a stent. Another disadvantage to angioplasty is that many people with coronary heart disease are not suitable candidates for angioplasty.
Bypass surgery may keep arteries open longer and improve blood flow through the coronary arteries more than angioplasty. Bypass surgery generally provides good relief of angina for at least five years.
In addition, bypass surgery is generally favored over angioplasty in people with one or more of the following:
· Disease in the left main coronary artery. This vessel is the main artery supplying blood to the heart, and even a brief period of blockage could damage heart muscle or be fatal.
· Diffuse coronary heart disease. Angioplasty is not effective for the treatment of multiple blockages in several vessels.
· Blockages at an arterial branch. If the blockage is at a point where one artery meets another, angioplasty may move the plaque into the adjacent artery, causing a new blockage.
· Diabetes. In the Bypass Angioplasty Revascularization Investigation (BARI) study, seven-year survival for people with diabetes was significantly better in those who underwent bypass surgery (76%) than angioplasty (56%). However, this study was conducted before traditional and drug-coated stents were available, and if the study were repeated today the results may be different.
Other factors. Other factors that make bypass surgery a better choice than angioplasty include severe disease of the three major coronary arteries (especially in people with reduced left ventricular function) and a history of heart failure.
Two drawbacks to bypass surgery are longer hospital stays and rehabilitation time than with angioplasty. In addition, a recent study of 261 bypass surgery patients found that about 40% of them had a decline in cognitive function that persisted five years after surgery. It is possible, however, that this decline was caused by underlying vascular disease in these patients and not the bypass surgery itself.
Sunday, October 7, 2007
Coronary artery bypass graft vs. percutaneous coronary angioplasty: CABG on the rebound?.
Coronary artery bypass graft vs. percutaneous coronary angioplasty: CABG on the rebound?.
Department of Cardiac Surgery, John Radcliffe Hospital, Oxford, UK
Current Opinion in Cardiology. 22(6):517-523, November 2007.
Taggart, David P
Purpose of review: To examine the benefits of coronary artery bypass grafting (CABG) against percutaneous coronary intervention (PCI) and particularly the use of drug-eluting stents (DES) in situations where CABG has traditionally been considered the most effective therapy on clinical and economic grounds.
Recent findings: Current studies reconfirm that CABG is still the best therapy in terms of improved survival and freedom from reintervention for most patients with proximal left anterior descending, multivessel and left main-stem coronary artery disease (CAD) and that these benefits are even greater in diabetic patients. Health economic analyses also confirm the cost-effectiveness of medical therapy and CABG but not PCI. Furthermore, several meta-analyses have shown that DES do not improve survival or freedom from myocardial infarction compared with bare metal stents, but increase the risk of stent thrombosis, with associated medical and financial implications for prolonged dual antiplatelet medication.
Summary: In view of the evidence in favour of CABG, this article questions the justifiability of some trials of PCI vs. CABG, especially in diabetic patients and those with left main-stem CAD, and exhorts the need for a multidisciplinary team approach to the management of CAD as a minimum standard of care.
Department of Cardiac Surgery, John Radcliffe Hospital, Oxford, UK
Current Opinion in Cardiology. 22(6):517-523, November 2007.
Taggart, David P
Purpose of review: To examine the benefits of coronary artery bypass grafting (CABG) against percutaneous coronary intervention (PCI) and particularly the use of drug-eluting stents (DES) in situations where CABG has traditionally been considered the most effective therapy on clinical and economic grounds.
Recent findings: Current studies reconfirm that CABG is still the best therapy in terms of improved survival and freedom from reintervention for most patients with proximal left anterior descending, multivessel and left main-stem coronary artery disease (CAD) and that these benefits are even greater in diabetic patients. Health economic analyses also confirm the cost-effectiveness of medical therapy and CABG but not PCI. Furthermore, several meta-analyses have shown that DES do not improve survival or freedom from myocardial infarction compared with bare metal stents, but increase the risk of stent thrombosis, with associated medical and financial implications for prolonged dual antiplatelet medication.
Summary: In view of the evidence in favour of CABG, this article questions the justifiability of some trials of PCI vs. CABG, especially in diabetic patients and those with left main-stem CAD, and exhorts the need for a multidisciplinary team approach to the management of CAD as a minimum standard of care.
Monday, September 24, 2007
Primary Angioplasty compared with Thrombolysis - Acute Myocardial Infarction
Assessing the effectiveness of primary angioplasty compared with thrombolysis and its relationship to time delay: a Bayesian evidence synthesis
Heart 2007;93:1244-1250
Christian Asseburg, Yolanda Bravo Vergel, Stephen Palmer, Elisabeth Fenwick, Mark de Belder, Keith R Abrams, Mark Sculpher
ABSTRACT
Background: Meta-analyses of trials have shown greater benefits from angioplasty than thrombolysis after an acute myocardial infarction, but the time delay in initiating angioplasty needs to be considered.
Objective: To extend earlier meta-analyses by considering 1- and 6-month outcome data for both forms of reperfusion. To use Bayesian statistical methods to quantify the uncertainty associated with the estimated relationships.
Methods: A systematic review and meta-analysis published in 2003 was updated. Data on key clinical outcomes and the difference between time-to-balloon and time-to-needle were independently extracted by two researchers. Bayesian statistical methods were used to synthesise evidence despite differences between reported follow-up times and outcomes. Outcomes are presented as absolute probabilities of specific events and odds ratios (ORs; with 95% credible intervals (CrI)) as a function of the additional time delay associated with angioplasty.
Results: 22 studies were included in the meta-analysis, with 3760 and 3758 patients randomised to primary angioplasty and thrombolysis, respectively. The mean (SE) angioplasty-related time delay (over and above time to thrombolysis) was 54.3 (2.2) minutes. For this delay, mean event probabilities were lower for primary angioplasty for all outcomes. Mortality within 1 month was 4.5% after angioplasty and 6.4% after thrombolysis (OR = 0.68 (95% CrI 0.46 to 1.01)). For non-fatal reinfarction, OR = 0.32 (95% CrI 0.20 to 0.51); for non-fatal stroke OR = 0.24 (95% CrI 0.11 to 0.50). For all outcomes, the benefit of angioplasty decreased with longer delay from initiation.
Conclusions: The benefit of primary angioplasty, over thrombolysis, depends on the former’s additional time delay. For delays of 30–90 minutes, angioplasty is superior for 1-month fatal and non-fatal outcomes. For delays of around 90 minutes thrombolysis may be the preferred option as assessed by 6-month mortality; there is considerable uncertainty for longer time delays.
Heart 2007;93:1244-1250
Christian Asseburg, Yolanda Bravo Vergel, Stephen Palmer, Elisabeth Fenwick, Mark de Belder, Keith R Abrams, Mark Sculpher
ABSTRACT
Background: Meta-analyses of trials have shown greater benefits from angioplasty than thrombolysis after an acute myocardial infarction, but the time delay in initiating angioplasty needs to be considered.
Objective: To extend earlier meta-analyses by considering 1- and 6-month outcome data for both forms of reperfusion. To use Bayesian statistical methods to quantify the uncertainty associated with the estimated relationships.
Methods: A systematic review and meta-analysis published in 2003 was updated. Data on key clinical outcomes and the difference between time-to-balloon and time-to-needle were independently extracted by two researchers. Bayesian statistical methods were used to synthesise evidence despite differences between reported follow-up times and outcomes. Outcomes are presented as absolute probabilities of specific events and odds ratios (ORs; with 95% credible intervals (CrI)) as a function of the additional time delay associated with angioplasty.
Results: 22 studies were included in the meta-analysis, with 3760 and 3758 patients randomised to primary angioplasty and thrombolysis, respectively. The mean (SE) angioplasty-related time delay (over and above time to thrombolysis) was 54.3 (2.2) minutes. For this delay, mean event probabilities were lower for primary angioplasty for all outcomes. Mortality within 1 month was 4.5% after angioplasty and 6.4% after thrombolysis (OR = 0.68 (95% CrI 0.46 to 1.01)). For non-fatal reinfarction, OR = 0.32 (95% CrI 0.20 to 0.51); for non-fatal stroke OR = 0.24 (95% CrI 0.11 to 0.50). For all outcomes, the benefit of angioplasty decreased with longer delay from initiation.
Conclusions: The benefit of primary angioplasty, over thrombolysis, depends on the former’s additional time delay. For delays of 30–90 minutes, angioplasty is superior for 1-month fatal and non-fatal outcomes. For delays of around 90 minutes thrombolysis may be the preferred option as assessed by 6-month mortality; there is considerable uncertainty for longer time delays.
Monday, September 3, 2007
ESC Congress - News - the DANAMI-2 trial - fibrinolytic therapy versus primary angioplasty in acute myocardial infarction
ESC Congress - News
The Danish multicenter randomised study of fibrinolytic therapy versus primary angioplasty in acute myocardial infarction (the DANAMI-2 trial). Outcome after three years follow-up.
Presenter report:
Nielsen, Torsten Toftegaard (Denmark)
Long-term randomized results on transfer for primary angioplasty (pPCI) versus on-site fibrinolysis for treatment of STEMI patients are sparse.The DANAMI-2 trial randomized 1572 STEMI patients to primary angioplasty (pPCI) or fibrinolysis (alteplase); 1129 of the patients were enrolled at 24 local hospitals without PCI facilities. Ninety-six percent of inter-hospital transfers for pPCI were completed within two hours. At 30 days, inter-hospital transfer for pPCI compared with fibrinolysis halved the primary composite endpoint of death, clinical reinfarction, or disabling stroke. The present study reports the long term (3 year) outcome. No patients were lost to follow-up.
The initial benefit of transfer for primary angioplasty based on the composite endpoint was sustained after three years (20.1 vs 26.7%, p=0.0007). Death occurred in 13.6 vs 16.4% (p=0.18), clinical reinfarction in 8.9% vs 12.3% (p=0.05), and disabling stroke in 3.2 vs 4.7% (p=0.23). Independent predictors of death were: clinical reinfarction, HR: 5.23 (3.63-7.54), anterior STEMI, HR.1.68 (1.26-2.23) and age, HR 1.08 (1.07-1.10).
We conclude that when inter-hospital transfer can be completed within two hours, primary angioplasty should be preferred over on-site fibrinolysis.
The Danish multicenter randomised study of fibrinolytic therapy versus primary angioplasty in acute myocardial infarction (the DANAMI-2 trial). Outcome after three years follow-up.
Presenter report:
Nielsen, Torsten Toftegaard (Denmark)
Long-term randomized results on transfer for primary angioplasty (pPCI) versus on-site fibrinolysis for treatment of STEMI patients are sparse.The DANAMI-2 trial randomized 1572 STEMI patients to primary angioplasty (pPCI) or fibrinolysis (alteplase); 1129 of the patients were enrolled at 24 local hospitals without PCI facilities. Ninety-six percent of inter-hospital transfers for pPCI were completed within two hours. At 30 days, inter-hospital transfer for pPCI compared with fibrinolysis halved the primary composite endpoint of death, clinical reinfarction, or disabling stroke. The present study reports the long term (3 year) outcome. No patients were lost to follow-up.
The initial benefit of transfer for primary angioplasty based on the composite endpoint was sustained after three years (20.1 vs 26.7%, p=0.0007). Death occurred in 13.6 vs 16.4% (p=0.18), clinical reinfarction in 8.9% vs 12.3% (p=0.05), and disabling stroke in 3.2 vs 4.7% (p=0.23). Independent predictors of death were: clinical reinfarction, HR: 5.23 (3.63-7.54), anterior STEMI, HR.1.68 (1.26-2.23) and age, HR 1.08 (1.07-1.10).
We conclude that when inter-hospital transfer can be completed within two hours, primary angioplasty should be preferred over on-site fibrinolysis.
ESC Congress - News - Long term mortality after drug eluting stents in Sweden - one additional year of follow-up
Hotlines and Clinical Trial Updates - Long term mortality after drug eluting stents in Sweden - one additional year of follow-up
Conclusion:
With inclusion of one additional year, thereby doubling the number of DES treated patients and outcome events, the previously reported increase in mortality with drug eluting stents can no longer be observed. Still there remains a slightly raised risk of late stent thrombosis and reinfarction after 6 months, which is however compensated by a lower event rate during the first 6 months. The reduction of clinically relevant restenosis is lower than in randomized trials with mandated angiography at follow-up and amounts only to 4%.
Conclusion:
With inclusion of one additional year, thereby doubling the number of DES treated patients and outcome events, the previously reported increase in mortality with drug eluting stents can no longer be observed. Still there remains a slightly raised risk of late stent thrombosis and reinfarction after 6 months, which is however compensated by a lower event rate during the first 6 months. The reduction of clinically relevant restenosis is lower than in randomized trials with mandated angiography at follow-up and amounts only to 4%.
Friday, August 31, 2007
Angioplasties Increasing, Bypass Surgeries Decreasing
Angioplasties Increasing, Bypass Surgeries Decreasing
31 Aug 2007
Use of transluminal coronary angioplasty, or PTCA, a procedure for opening blocked arteries in patients with coronary artery disease, is now used nearly three times more often than the older and more invasive coronary artery bypass graft surgery (CABG), according to the latest News and Numbers from the Agency for Healthcare Research and Quality.
AHRQ found that:
The number of angioplasties nearly doubled from 1993 to 2005, rising steadily from 418,000 to 800,000 a year.
In contrast, heart bypass surgeries rose slowly from 344,000 to 426,000 a year between 1993 and 1997, and then declined steadily to 278,000 a year by 2005.
Although hospital stays in 2005 for angioplasty are much shorter than they were in 1993 (on average 2.7 days instead of 4.6 days), hospital charges have increased by more than 50 percent during the period, rising from $31,300 to $48,000 (adjusted for inflation).
With 1.1 million hospital stays in 2005, coronary artery disease was the third most common reason for hospitalization after childbirth and pneumonia.
It was the second leading reason for men, and the seventh for women.
http://www.ahrq,gov
31 Aug 2007
Use of transluminal coronary angioplasty, or PTCA, a procedure for opening blocked arteries in patients with coronary artery disease, is now used nearly three times more often than the older and more invasive coronary artery bypass graft surgery (CABG), according to the latest News and Numbers from the Agency for Healthcare Research and Quality.
AHRQ found that:
The number of angioplasties nearly doubled from 1993 to 2005, rising steadily from 418,000 to 800,000 a year.
In contrast, heart bypass surgeries rose slowly from 344,000 to 426,000 a year between 1993 and 1997, and then declined steadily to 278,000 a year by 2005.
Although hospital stays in 2005 for angioplasty are much shorter than they were in 1993 (on average 2.7 days instead of 4.6 days), hospital charges have increased by more than 50 percent during the period, rising from $31,300 to $48,000 (adjusted for inflation).
With 1.1 million hospital stays in 2005, coronary artery disease was the third most common reason for hospitalization after childbirth and pneumonia.
It was the second leading reason for men, and the seventh for women.
http://www.ahrq,gov
Tuesday, July 31, 2007
The EVASTENT Matched-Cohort Registry
Risk Factors for Stent Thrombosis After Implantation of Sirolimus-Eluting Stents in Diabetic and Nondiabetic Patients
The EVASTENT Matched-Cohort Registry
Objectives: We sought to assess the frequency and causes of stent thrombosis in diabetic and nondiabetic patients after implantation of sirolimus-eluting stents.
Background: Safety concerns about late stent thrombosis have been raised, particularly when drug-eluting stents are used in less highly selected patients than in randomized trials.
Methods: The EVASTENT study is a matched multicenter cohort registry of 1,731 patients undergoing revascularization exclusively with sirolimus stents; for each diabetic patient included (stratified as single- or multiple-vessel disease), a nondiabetic patient was subsequently included. Patients were treated with aspirin + clopidogrel for at least 3 months and were followed for 465 (range 0 to 1,062) days (1-year follow-up in 98.5%). The primary end point was a composite of stent thrombosis (according to Academic Research Consortium definitions), cardiovascular death, and nonfatal myocardial infarction (major adverse cardiac events [MACE]).
Results: During follow-up, MACE occurred in 78 patients (4.5%), cardiac death in 35 (2.1%), and stent thrombosis in 45 (2.6%): 30 definite, 23 subacute, and 22 late, including 9 at >6 months. In univariate analysis, the 1-year stent thrombosis rate was 1.8 times higher in diabetic than in nondiabetic patients (3.2% vs. 1.7%; log rank p = 0.03), with diabetic patients with multiple-vessel disease experiencing the highest rate and nondiabetic single-vessel disease patients the lowest (4.3% vs. 0.8%; p < 0.001). In multivariate analysis, in addition to the interruption of antithrombotic treatment, independent stent thrombosis predictors were previous stroke, renal failure, lower ejection fraction, calcified lesion, length stented, and insulin-requiring diabetes.
Conclusions: The risk of sirolimus stent thrombosis is higher for multiple-vessel disease diabetic patients.
Wednesday, July 25, 2007
Specific Gene Suppressor Described As A 'Dictator With A Conscience'
Specific Gene Suppressor Described As A 'Dictator With A Conscience'
25 Jul 2007 University of New South Wales (UNSW) researchers have uncovered an important naturally occurring mechanism in the body where "bad" cells that cause blockages in our blood vessels are kept under strict growth control, while "good" cells that keep our blood vessels free of clots and growths are left unaffected.
The discovery is expected to benefit those who will need heart coronary bypass surgery, an angioplasty -- the mechanical widening of a narrowed or totally blocked blood vessel -- or will undergo haemodialysis.
Professor Levon Khachigian, from UNSW's Centre for Vascular Research, who previously pioneered "molecular assassin" drug technology, describes this novel mechanism he discovered as "a molecular dictatorship with a conscience".
"The dictator is a specific gene suppressor called YY1, which has the therapeutically appealing capacity to differentiate between certain cell types when it goes about its activity," says Professor Khachigian.
This key finding has just been published in the world's premier cardiovascular research journal, Circulation Research.
Professor Khachigian's research provides new hope in tackling the global problems of coronary bypass graft failure, and restenosis -- the closing or narrowing of an artery that was previously opened by a procedure such as angioplasty.
"While the most effective way to head off restenosis is a drug-coated stent, the drugs that sit on these stents inhibit the growth of good cells as well as the bad.
"If you had to have catheter intervention to re-open an occluded artery, for sustained symptom-free benefit you would be hoping for suppressed smooth muscle cell growth, without affecting endothelial cell growth," says Professor Khachigian.
"And that's exactly what happens when we simply top up blood vessels with the body's natural reserves of YY1."
Article adapted by Medical News Today from original press release.
25 Jul 2007 University of New South Wales (UNSW) researchers have uncovered an important naturally occurring mechanism in the body where "bad" cells that cause blockages in our blood vessels are kept under strict growth control, while "good" cells that keep our blood vessels free of clots and growths are left unaffected.
The discovery is expected to benefit those who will need heart coronary bypass surgery, an angioplasty -- the mechanical widening of a narrowed or totally blocked blood vessel -- or will undergo haemodialysis.
Professor Levon Khachigian, from UNSW's Centre for Vascular Research, who previously pioneered "molecular assassin" drug technology, describes this novel mechanism he discovered as "a molecular dictatorship with a conscience".
"The dictator is a specific gene suppressor called YY1, which has the therapeutically appealing capacity to differentiate between certain cell types when it goes about its activity," says Professor Khachigian.
This key finding has just been published in the world's premier cardiovascular research journal, Circulation Research.
Professor Khachigian's research provides new hope in tackling the global problems of coronary bypass graft failure, and restenosis -- the closing or narrowing of an artery that was previously opened by a procedure such as angioplasty.
"While the most effective way to head off restenosis is a drug-coated stent, the drugs that sit on these stents inhibit the growth of good cells as well as the bad.
"If you had to have catheter intervention to re-open an occluded artery, for sustained symptom-free benefit you would be hoping for suppressed smooth muscle cell growth, without affecting endothelial cell growth," says Professor Khachigian.
"And that's exactly what happens when we simply top up blood vessels with the body's natural reserves of YY1."
Article adapted by Medical News Today from original press release.
Saturday, July 21, 2007
Fewer Stents Implanted
Wall Street Journal
July 20, 2007
Fewer Stents Implanted in June,Signaling Impact of New Studies
By KEITH J. WINSTEINJuly 20, 2007; Page B2
U.S. doctors implanted fewer coronary stents in June than any other month in the last year, according to a market researcher, indicating that medical studies critical of the devices appear to be having a sustained impact.
Stents are tiny scaffolds that prop open clogged arteries. Doctors flocked to them until late last year because they quickly relieve the chest pains and shortness of breath caused by a blocked artery. Last year, Americans spent more than $14 billion on stent procedures, with doctors implanting about 130,000 stents a month, according to various estimates.
But data from Goodroe Healthcare Solutions LLC, of Norcross, Ga., which surveys 75 U.S. hospitals with catheterization facilities for stenting, indicated that rate has significantly slowed.
According to Goodroe, doctors in June performed fewer artery-inflating angioplasties -- 11% below January levels. Fewer of those procedures involve a stent -- 92%, down from 94% in January. And doctors in June used about 1.48 stents per procedure, down 4% from January.
Those numbers indicate stent usage, in total, fell about 16%. (See more data from Goodroe1.)
Goodroe didn't provide usage numbers in units of stents. In the past, its numbers have largely agreed with figures released by manufacturers and market researchers.
In late March, the New England Journal of Medicine published a study indicating that patients with mild chest pains could safely delay stenting in favor of treatment with drugs. Some of those patients may return for stenting later in the year if their pain persists.
Stent use has also been hurt by studies linking the most popular and expensive kind -- those coated with drugs to prevent reclogging -- with blood clots more than a year after implantation. In response, doctors have shifted back to older, bare-metal stents.
That has been good news for Abbott Laboratories, whose U.S. sales of bare-metal stents were up 179% in the last year. But the makers of drug-coated stents -- Johnson & Johnson, whose U.S. stent sales fell 41%, and Boston Scientific Corp., which reports its quarterly results today -- have been hit hard. Boston Scientific and Abbott said they predicted an eventual recovery in the market. J&J declined to comment.
July 20, 2007
Fewer Stents Implanted in June,Signaling Impact of New Studies
By KEITH J. WINSTEINJuly 20, 2007; Page B2
U.S. doctors implanted fewer coronary stents in June than any other month in the last year, according to a market researcher, indicating that medical studies critical of the devices appear to be having a sustained impact.
Stents are tiny scaffolds that prop open clogged arteries. Doctors flocked to them until late last year because they quickly relieve the chest pains and shortness of breath caused by a blocked artery. Last year, Americans spent more than $14 billion on stent procedures, with doctors implanting about 130,000 stents a month, according to various estimates.
But data from Goodroe Healthcare Solutions LLC, of Norcross, Ga., which surveys 75 U.S. hospitals with catheterization facilities for stenting, indicated that rate has significantly slowed.
According to Goodroe, doctors in June performed fewer artery-inflating angioplasties -- 11% below January levels. Fewer of those procedures involve a stent -- 92%, down from 94% in January. And doctors in June used about 1.48 stents per procedure, down 4% from January.
Those numbers indicate stent usage, in total, fell about 16%. (See more data from Goodroe1.)
Goodroe didn't provide usage numbers in units of stents. In the past, its numbers have largely agreed with figures released by manufacturers and market researchers.
In late March, the New England Journal of Medicine published a study indicating that patients with mild chest pains could safely delay stenting in favor of treatment with drugs. Some of those patients may return for stenting later in the year if their pain persists.
Stent use has also been hurt by studies linking the most popular and expensive kind -- those coated with drugs to prevent reclogging -- with blood clots more than a year after implantation. In response, doctors have shifted back to older, bare-metal stents.
That has been good news for Abbott Laboratories, whose U.S. sales of bare-metal stents were up 179% in the last year. But the makers of drug-coated stents -- Johnson & Johnson, whose U.S. stent sales fell 41%, and Boston Scientific Corp., which reports its quarterly results today -- have been hit hard. Boston Scientific and Abbott said they predicted an eventual recovery in the market. J&J declined to comment.
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