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No differences in on-pump versus off-pump bypass grafting at 5 years.

18 Apr, 17 | by flee

Coronary artery bypass grafting (CABG) may significantly improve quality of life and longevity.  As with all therapies, however, these benefits must be weighed against potential risks. Some hypothesize that aortic cross clamping and cardiopulmonary bypass, historically utilized during CABG, increase the potential for certain complications and can be successfully avoided with newer “off-pump” CABG techniques.  Various studies have examined the benefits of off-pump vs. on-pump CABG with the largest to date being the international, multi-center, randomized CABG Off or On Pump Revascularization Study (CORONARY)  study, involving 4,752 patients.  The previously reported 30 day and 1 year data from this study demonstrated no difference between techniques, but here the 5-year data are published.   Using a composite outcome of death, stroke, myocardial infarction, renal failure, or repeat coronary revascularization, there was no difference between the two surgical techniques (23.1% vs. 23.6%, P=0.72) or indeed, in any of the individuals components of the outcome.  There were also no significant between-group differences in quality-of-life measures.  A secondary analysis of economic cost also found no significant difference between the two modalities (US$15,107 vs. US$14,992).


Genetic analysis of sudden cardiac death in the young

20 Sep, 16 | by flee

Sudden cardiac death (SCD) is a rare but devastating event among children and young adults. SCD in which no obvious cause is apparent despite comprehensive toxicological and histological autopsy analysis is particularly vexing.  The role of genetic testing in unexplained SCD is studied in this prospective analysis of  Australians and New Zealanders 1 to 35 years old.  Between 2010 and 2012 a total of 490 SCDs were identified across the population of 26.7 million (1.3 per 100,000). Seventy-two percent were boys or men. The highest overall incidence was in persons aged 31-35, in whom coronary artery disease was the commonest cause, and the lowest incidence was in children aged 6-10.  Inherited cardiomyopathies were found in 16% of all cases.  Most deaths (65%) occurred either at rest or during sleep, whereas sudden death during or after exercise was relatively uncommon (15%). Following post-mortem, 40% of cases were classified as unexplained. Female sex, younger age and death at night particularly common in this sub-group.  Subsequent genetic analysis was performed in these individuals using commercial panels of 59 cardiac genes including genes for long QT and catecholamine polymorphic ventricular tachycardia. As an alternative, 72 epilepsy genes were also investigated. Among analyzed individuals, 27% were found to have a clinically relevant cardiac gene disorder considered the probable cause of death (only 6% were found to carry an epilepsy gene).


Repair versus replacement for ischemic mitral regurgitation

8 Jan, 16 | by flee

Whether repair or replacement is the preferred approach to surgical correction of ischemic mitral regurgitation is debated.  The Cardiothoracic Surgical Trials Network previously reported 1-year results of a randomized study of these two approached and found no differences echocardiographic or clinical outcomes. This paper reports the 2-year echocardiographic and clinical outcome results from this randomized trial of 251 patients with severe ischemic mitral regurgitation.  At 2 years follow-up, there were no significant differences in mortality (19% after repair versus 23% after replacement; P=0.39). Compared with replacement, the rate of recurrence of moderate or severe mitral regurgitation was significantly higher following repair (58.8% versus 3.8%; P<0.001).  Although the rate of major adverse cardiovascular events did not differ between the groups (42.1% in the repair group versus 42.4% in the replacement group), there were more serious heart failure events following repair (24.0 per 100 patient-years vs. 15.2 per 100 patient-years, P=0.05) and no significant difference in the rate of bleeding events between the two groups (3.5% in the repair group versus 5.3% in the replacement group; P=0.41).


In this study of mitral valve replacement versus repair for ischemic mitral regurgitation, no differences were observed in left ventricular remodeling or mortality at two years of follow-up.  However, there are significant differences in durability with much higher rates of severe mitral regurgitation following repair. The issue of durability as it relates to clinical outcomes will be important to monitor in continued follow-up of this study population.

Summarized by Hussain Contractor and Steven M. Bradley

Goldstein D, Moskowitz AJ, Gelijns AC, Ailawadi G, Parides MK, Perrault LP, Hung JW, Voisine P, Dagenais F, Gillinov AM, Thourani V, Argenziano M, Gammie JS, Mack M, Demers P, Atluri P, Rose EA, O’Sullivan K, Williams DL, Bagiella E, Michler RE, Weisel RD, Miller MA, Geller NL, Taddei-Peters WC, Smith PK, Moquete E, Overbey JR, Kron IL, O’Gara PT, and Acker MA. Two-Year Outcomes of Surgical Treatment of Severe Ischemic Mitral Regurgitation. N Engl J Med. 2015 Nov 9. [Epub ahead of print]

Increased radiation exposure with transradial access for coronary procedures

8 Dec, 15 | by flee

Compared with the transfemoral approach, coronary angiography and percutaneous coronary intervention (PCI) performed via transradial access reduces rates of bleeding and vascular complications.  However, the potential for increased radiation exposure to patients and operators may be a barrier to the adoption of the transradial approach.  In this systematic review and meta-analysis of 24 published studies comparing transradial and transfemoral access for coronary angiography and PCI, the authors compared the differences in radiation exposure between access approaches as measured by fluoroscopy time (min) and kerma-area product (KAP, Gy cm2).  After a rigorous search to identify studies of coronary procedural access that reported radiation exposure, the authors found 24 published randomized controlled trials from 1996-2014 with 19,328 patients for analysis.  Comparing radiation exposure by access site strategy, the authors found a statistically significant increase in fluoroscopy time for diagnostic coronary angiography (DCA) (weighted mean difference [WMD]: 1.04 min [95% CI 0.84-1.24]) and PCI (WMD fluoroscopy time 1.15 min [95% CI 0.96–1.33]), while only a statistically significant increase in KAP for PCI (0.55 Gy cm2 [95% CI 0.08–1.02] but not DCA (1.72 Gy cm2 [95% CI −0.10 – 3.55]. In meta-regression analysis comparing differences in radiation exposure by year of study, differences in fluoroscopy time between transradial and transfemoral approaches decreased over time.  The analysis was limited by significant heterogeneity in the pooled studies (I2 > 75%).


Conclusion: This systematic review and meta-analysis suggests transradial access for coronary procedures is associated with a small increase in radiation exposure.  However, this gap in radiation exposure between transradial and transfemoral access has closed over time, presumably reflecting increased operator experience with transradial access.  Further, the clinical significance of the observed difference in radiation exposure is unclear. Given the benefits of transradial access for reducing rates of periprocedural complications, these findings should not discourage use of transradial access.  Instead, these findings emphasize the importance of continued attention to radiation safety as operators adopt a transradial approach.


Summarized by Javier A. Valle and Steven M. Bradley


Plourde G, Pancholy SB, Nolan J, Jolly S, Rao SV, et al. Radiation exposure in relation to the arterial access site used for diagnostic coronary angiography and percutaneous coronary intervention: a systematic review and meta-analysis

Lancet 2015; 386: 2192–203

Lipid Lowering Therapy and Risk of Acute Memory Impairment

25 Sep, 15 | by flee

Prior data on the use of statin drugs and risk of acute memory impairment has been inconsistent.  In this study, Strom and colleagues sought to investigate use of statins in association with acute memory impairment and compare results to non-users and users of non-statin lipid lowering drugs (LLDs).  The authors performed a retrospective cohort study through The Health Improvement Network database (composed of primary medical records from general practitioners in the United Kingdom) identifying 482,543 patients with newly prescribed statin drugs without underlying cognitive dysfunction or dementia.  Propensity-matched control groups included 482,543 non-users of any LLDs and 26,484 users of non-statin LLDs.  The primary outcome of the analysis was the onset of acute, reversible memory impairment as determined by review of diagnosis codes. Exposure to statins was strongly associated with incident acute memory loss within 30 days of first use compared to matched non-users of LLDs (OR 4.40, CI 3.01-6.41).  The relationship persisted for users of non-statin LLDs compared to non-users (OR 3.60, CI 1.34-9.70) but was not reproduced in comparing statins with non-statin LLDs (OR 1.03, CI 0.63-1.66). more…

Testosterone Therapy: No Impact on Atherosclerosis…and No Improvements in Health

25 Sep, 15 | by flee

For men with age-related decline in testosterone levels, there is significant controversy over the risks and benefits of testosterone supplementation.  Despite a paucity of data, testosterone sales have increased markedly in the past decade.  The Testosterone’s Effects on Atherosclerosis Progression in Aging Men (TEAAM) Trial evaluated the impact of increasing testosterone concentrations on progression of atherosclerosis as determined by common carotid artery intima-media thickness and coronary artery calcium.  In addition, the investigators evaluated the effect of testosterone therapy on patient reported sexual function and health-related quality of life (SF-36). This randomized, double-blind, placebo-controlled trial enrolled 308 men >60 years old with low or low-normal testosterone (100-400ng/dL) levels and compared testosterone supplementation to levels between 500-900 ng/dL to placebo. For the measures of atherosclerosis progression, there was no difference between the treatment and placebo group.  Additionally, measures of sexual function and health-related quality of life did not differ between the treatment groups. more…

Coronary Computed Tomography Angiography Versus Radionuclide Myocardial Perfusion Imaging in Clinical Evaluation of Chest Pain Admissions

25 Sep, 15 | by flee

Chest pain concerning for a coronary syndrome leads to millions of hospital admissions each year that is often evaluated with diagnostic testing.  As a noninvasive diagnostic study, coronary computed tomography angiography (CCTA) has been shown to have excellent diagnostic capabilities.  However, concerns over CCTA remain, including radiation exposure, false-positives, and trials of the diagnostic modality that were mostly limited to low-risk patients with underrepresentation of minorities and women.  In this single-center randomized, controlled comparative effectiveness trial, 400 intermediate-risk patients (63% women, 54% Hispanic, 37% African-American) admitted to a telemetry floor were randomized to either CCTA or myocardial perfusion imaging (MPI) and followed for 40 months.  Patients with baseline renal dysfunction were excluded.  At 1 year, there were no significant differences in the primary outcome of coronary angiography that did not lead to revascularization (hazard ratio [HR], 0.77; 95% confidence interval [CI] 0.40-1.49; P = 0.44) or secondary outcomes that included length of stay, resource utilization, and patient experience.  All-cause radiation exposure was lower in the CCTA group (24 vs 29 millisieverts, P <0.0001) and more CCTA patients graded their experience favorably (P = 0.001).  Ten of 200 patients in the coronary CTA group were found to have non-cardiac diagnoses leading to chest pain (3 surgical), whereas no non-cardiac causes were found in the MPI group.   more…

Azithromycin and cardiac death

4 Jun, 12 | by Alistair Lindsay

 Macrolide antibiotics are associated with prolongation of the QT interval in susceptible individuals and increase the risk of serious ventricular arrhythmias and sudden cardiac death.  Azithromycin has become one of the most widely used macrolides worldwide due to its broad spectrum, excellent tissue penetrance, and long half-life, and has been reported to be minimally cardiotoxic.  However, several case reports have been published associating azithromycin with polymorphic ventricular tachycardia suggesting this may not be the case.  In this large retrospective cohort study Ray et al utilised data from a Medicaid cohort collating information on patients who took azithromycin (347,795 prescriptions), propensity-score-matched persons who took no antibiotics (1,391,180 control periods), and patients who took amoxicillin (1,348,672 prescriptions), ciprofloxacin (264,626 prescriptions), or levofloxacin (193,906 prescriptions).  more…

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