Dabigatran added to guidelines for management of patients with AF
Wann LS. J Am Coll Cardiol. 2011;doi:10.1016/j.jacc.2011.01.010.
The 2011 Focused Update on the Management of Patients with Atrial Fibrillation has incorporated dabigatran into its recommendations for the treatment of atrial fibrillation.
The focused update was a collaborative effort of the American College of Cardiology Foundation, American Heart Association and the Heart Rhythm Society. The recommendations come after dabigatran (Pradaxa, Boehringer-Ingelheim), an oral direct thrombin inhibitor, was recently approved by the FDA for stroke prevention in patients with nonvalvular AF.
According to the new recommendation, “Dabigatran is useful as an alternative to warfarin (Coumadin, Bristol-Myers Squibb) for the prevention of stroke and systemic thromboembolism in patients with paroxysmal to permanent AF and risk factors for stroke or systemic embolization who do not have a prosthetic heart valve or hemodynamically significant valve disease, severe renal failure (creatinine clearance <15 mL/minute) or advanced liver disease (impaired baseline clotting function).” The level of evidence for the recommendation was categorized as B, which indicates in this instance that the data were derived from a single randomized trial (RE-LY).
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Carotid stenting comparable to carotid endarterectomy for long-term stroke prevention
De Rango P. J Am Coll Cardiol. 2011;57:664-671.
For stroke prevention, carotid artery stenting can have similar 5-year outcomes to carotid endarterectomy, provided the physician uses sound judgment in choosing which technique to perform, according to a recent study.
Researchers prospectively tracked 1,118 patients who were treated by carotid endarterectomy (CEA) and 1,084 patients who underwent carotid artery stenting (CAS). Overall, 71% were men, and the mean age was 71.3 years. All of the patients were either more than 60% symptomatic or more than 70% asymptomatic for carotid stenosis. The choice of revascularization method was left to the treating physician. Typically, patients with known allergies to aspirin, clopidogrel, or contrast media and renal insufficiency were excluded from CAS, as were those patients with aortic arch anatomy, severe peripheral vascular disease precluding femoral access or extremely tortuous carotid anatomy. Patients with high-neck carotid bifurcation and long carotid lesions, as well as obese patients or those taking ongoing dual antiplatelet therapy, were generally excluded from CEA, according to the study.
Overall, 30-day stroke/death rates were 2.8% in the CAS group and 2% in the CEA group — a statistical similarity (P=.27). The risk of 30-day stroke or death was higher in symptomatic (3.5%) vs. asymptomatic (2%) patients (P=.04) but was statistically similar. At 5 years, survival rates were statistically similar between the two groups: 82% in CAS and 87.7% in CEA (P=.05). There were no sex- or age-related significant outcome differences, according to the study.
Per Kaplan-Meier estimates, the composite of any periprocedural stroke or death and ipsilateral stroke at 5 years after the procedure were similar in all patients (4.7% vs. 3.7%; P=.4). Kaplan-Meier estimates were similar for the subgroups of symptomatic (8.7% vs. 4.9%; P=.7) in CEA and asymptomatic (2.5% vs. 3.3%; P=.2) in CAS.
“When physicians use their clinical judgment to select the appropriate technique for carotid revascularization, CAS can offer efficacy and durability comparable to CEA with benefits persisting at 5 years,” the researchers concluded.
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