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Lipid lowering drugs and risk of vascular events in older patients

7 Jul, 15 | by Alistair Lindsay

Although elderly patients are at higher risk of cardiovascular events, the majority cardiovascular trials exclude these patients.  Accordingly, little is known about the use of lipid lowering medications for prevention of cardiovascular events in elderly populations. This prospective cohort study evaluated the association between use of statins or fibrates for prevention of vascular events among a random sample of 7484 patients aged 65 years of older without prior vascular disease living in three French cities recruited from 1999-2000.  Patients were followed for a median of 9.1 years, with 732 vascular events (440 coronary events, 292 strokes) occurring during the study period.  The study found that 27.4% (n=2084) of patients reported baseline lipid lowering medication use (13.5% statins, 13.9% fibrates).   more…

Improved Atrial Fibrillation Outcomes Despite Rising Arrhythmia Prevalence

7 Jul, 15 | by Alistair Lindsay

Little is known about temporal trends in atrial fibrillation (AF) incidence, prevalence, and outcomes. Using the Framingham Heart Study, Schnabel and colleagues assessed AF incidence, prevalence, and outcomes over 50 years (202,417 person-years). Researchers drew on a cohort of 9,511 participants enrolled between 1958 and 2007 in which 1,544 incident AF cases (47% women) were identified. Over the study period, age-adjusted incidence increased threefold (3.7 to 13.4 new cases per 1000 person-years in men and from 2.5 to 8.6 new cases per 1000 person-years in women) and age-adjusted prevalence increased fourfold (20.4 to 96.2 cases per 1000 person-years in men and from 13.7 to 49.4 cases per 1000 person-years in women). more…

Investigating chest pain: anatomy or function?

22 May, 15 | by Alistair Lindsay

Among patients with chest pain, it is unclear if anatomic assessment of coronary obstruction or functional assessment with stress testing leads to better patient outcomes. In this randomized controlled trial of 10,003 symptomatic patients, individuals were randomly assigned in a 1:1 fashion to either anatomical testing with coronary CT angiography (CTA) or to functional testing by one of several different modalities (exercise ECG (10%), nuclear stress testing (67%) or stress echo (23%)).  Instead of diagnostic accuracy, as is seen with most such studies, the trial was powered for clinical outcomes with a primary composite endpoint of death, myocardial infarction, hospitalization for unstable angina, or major procedural complication.  more…

Antiplatelet therapy in long-term risk reduction after myocardial infarction

22 May, 15 | by Alistair Lindsay

The activated platelet is central to development of ischemic cardiovascular events. Guidelines recommend treatment with a P2Y12 receptor antagonist for 1-year after myocardial infarction (MI) to reduce the risk of recurrent events.  The PEGASUS trial sought to determine the impact of using the P2Y12 antagonist ticagrelor as part of long-term therapy after MI.  In this trial, a total of 21,162 clinically stable patients with a MI in the prior 1 to 3 years (median 18 months) were randomized in a 1:1:1 fashion to either placebo, ticagrelor 90mg twice daily, or ticagrelor 60mg twice daily.  All patients remained on aspirin and standard secondary prevention as tolerated.  Follow up was for a median of 33 months with the primary outcome being a composite of cardiovascular death, myocardial infarction, or stroke and the primary safety end-point of bleeding.  more…

Precision Medicine to Reduce Bleeding with PCI   

5 May, 15 | by Alistair Lindsay

 

Periprocedural bleeding remains one of the most common adverse events after percutaneous coronary intervention (PCI) and is associated with increased mortality.  Although strategies to minimize PCI bleeding have been identified, these strategies are infrequently applied to patients at highest bleeding risk.  Using a pre-post study design, Spertus et al. evaluated the impact of assessing individual patient bleeding risk from validated models and providing this bleeding risk estimate in personalized informed consent documents for PCI.  The intent of the intervention was to increase the procedural team’s awareness of patients at low, moderate, and risk for PCI related bleeding and thereby influence the use of bleeding avoidance strategies (i.e. bivalirudin, radial access, and vascular closure devices) and reduce periprocedural bleeding events.  more…

Relationship Between Physical Activity and Mortality     

5 May, 15 | by Alistair Lindsay

 

The 2008 Physical Activity Guidelines for Americans recommended 150 to 300 minutes of moderate-intensity or 75 to 150 minutes of vigorous-intensity aerobic activity weekly for optimal health. However, these guidelines acknowledged uncertainty on the upper threshold of benefit or potential harms of high activity levels.  Using data from 6 pooled cohorts from the National Cancer Institute Cohort Consortium (baseline 1992-2003) with self-reports of leisure-time physical activity (LTPA), Arem and colleagues aimed to address this question. The total cohort consisted of 661,137 men and women with a median age of 62 years and a median follow-up of 14.2 years in which 116,686 deaths were accrued. more…

Long-Term Outcomes of Transcatheter Aortic Valve Replacement 

5 May, 15 | by Alistair Lindsay

The Placement of Aortic Transcatheter Valves (PARTNER) trial demonstrated that transcatheter aortic valve replacement (TAVR) for high-risk patients with aortic stenosis resulted in similar outcomes at 1, 2 and 3 years compared with surgical aortic valve replacement (SAVR). The present study reports the 5-year outcomes of this trial. The study enrolled 699 patients who were randomized to SAVR or TAVR (via a transfemoral or transapical approach). Overall, mean age was 84.1 years, 94% were NYHA Class 3 or 4, and the mean Society of Thoracic Surgeons Predicted Risk of Mortality at 30 days was 11.8%. At 5 years, there were no significant differences in mortality between groups (67.8% in the TAVR group versus 62.4% in the SAVR group; hazard ratio 1.04, 95% CI 0.86–1.24; p=0.76). more…

Clinical Outcomes at 1 Year Following Transcatheter Aortic Valve Replacement  

16 Apr, 15 | by Alistair Lindsay

To date, long-term outcome data following transcatheter aortic valve replacement (TAVR) has only been available from clinical trial data.  Evaluating long-term outcomes of TAVR in real-world use is important to ensure the anticipated benefits are observed in routine clinical practice.  Using data from the Society of Thoracic Surgeons/American College of Cardiology (STS/ACC) Transcatheter Valve therapies registry merged with Centers for Medicare & Medicaid Services administrative claims data, this study evaluated 1-year outcomes of mortality, stroke, and rehospitalization among 12,182 patients who underwent TAVR between November 2011 and June 2013.  In this cohort, the 1-year mortality rate 23.7%, the stroke rate was 4.1%, the rate of heart failure was 14.3%, and 1.4% had aortic valve reintervention.  A total of 53.2% were readmitted to the hospital within 1-year.    more…

Second-generation stents fail to BEST CABG

16 Apr, 15 | by Alistair Lindsay

The technology of drug eluting stents for percutaneous coronary intervention (PCI) has improved over time with resultant improvements in patient outcomes.  Although prior studies have demonstrated the benefit of surgical coronary artery bypass grafting (CABG) over transcatheter PCI among patients with multivessel coronary artery disease (CAD), these studies did not incorporate newer generation drug-eluting stents.  The multicenter BEST trial randomized 880 patients with multivessel CAD to PCI with an everolimus-eluting stent or to CABG. The primary end point for this non-inferiority study was a composite of death, myocardial infarction, or target-vessel revascularization at 2 years.  The results of the study non-significantly favored CABG at 2 years of follow-up with the primary end-point occurring in 7.9% of the CABG group and 11% of the PCI group.  more…

Aspiration thrombectomy fails to demonstrate benefit in primary PCI  

16 Apr, 15 | by Alistair Lindsay

Although primary percutaneous coronary intervention (PPCI) restores epicardial coronary flow in the majority of patients with ST-segment myocardial infarction, this approach can lead to microvascular obstruction resulting from distal embolization of thrombus.  Manual thrombectomy (i.e. aspiration thrombectomy) prior to PPCI has been proposed as a method to reduce thrombus burden and resultant distal embolization with PPCI.  Although results from early studies of aspiration thrombectomy suggested improvements in patient outcomes, subsequent trials have failed to demonstrate a clinical benefit of aspiration thrombectomy prior to PPCI.  more…

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