Title: Choice of Prosthetic Heart Valve in Adults: An Update
Topic: Cardiovascular Surgery
Date Posted: 5/24/2010 5:00:00 PM
Author(s): Rahimtoola SH.
Citation: J Am Coll Cardiol 2010;55:2413-2426.
Clinical Trial: No
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JACC Article: Choice of Prosthetic Heart Valve in Adults: An Update
Perspective: The following are 10 points to remember about choice of prosthetic heart valve (PHV) in adults.
1. Patient survival after PHV has increased markedly and it is essential to consider the patient’s point of view regarding the ideal PHV.
2. At present, the choice of PHV in most clinical situations is between a mechanical PHV and a stented bioprosthesis. An important determining factor in the choice between these two PHVs is which of the two complications—anticoagulation therapy or structural valve deterioration (SVD)—one wants to avoid.
3. Mechanical PHVs that are approved by the Food and Drug Administration and have good and comparable outcomes at ≥15-20 years of follow-up will likely have good outcomes on very long-term follow-up.
4. Currently for the overwhelming majority of adult patients ages >60-65 years, the choice of a biological PHV is a stented bioprosthesis. However, there are exceptions; for example, for active infective endocarditis with an associated abscess or uncontrolled infection, a homograft valve may be chosen.
5. Anticoagulants are essential with the use of mechanical valves, and can be instituted and maintained in many patients with low risk. The disadvantages include lifetime needs of therapy and tests, difficulties in initiating and maintaining an adequate international normalized ratio in many patients, and major risks of bleeding.
6. The risks of bleeding are increased for patients ≥65 years old, greatly so for those ≥75 years old, and for those with CHADS2 score ≥3.
7. All biological valves are at risk for SVD. The age of the patient at the time of PHV implantation is the most important determinant of SVD.
8. Typically, in ‘young’ people, use of a biological valve will result in reoperation, probably in multiple reoperations.
9. There is no significant difference in valve areas at 6 months between a bileaflet mechanical valve and porcine bioprosthesis for valves with the same valve size.
10. The physicians involved in the decision-making process should be very knowledgeable about the patient outcomes with the use of the various PHV, and they should be completely discussed with the patient. The final choice of PHV should be a joint decision by the patient, cardiologist, and cardiac surgeon. Debabrata Mukherjee, M.D., F.A.C.C.
Title: Impact of the ALLHAT/JNC7 Dissemination Project on Thiazide-Type Diuretic Use
Topic: Prevention/Vascular
Date Posted: 5/24/2010 4:00:00 PM
Author(s): Stafford RS, Bartholomew LK, Cushman WC, et al., on behalf of the ALLHAT Collaborative Research Group.
Citation: Arch Intern Med 2010;170:851-858.
Clinical Trial: No
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Trial: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)
Study Question: What was the impact of Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) results on physician practice patterns?
Methods: To improve discrimination and adoption of changes in practice management resulting from landmark trials and changes in guidelines, specific strategies are considered. Academic detailing incorporates several approaches used in pharmaceutical marketing including use of investigator-educators as opinion leaders, and communication of antihypertensive management through individualized small groups. Two national databases were used to evaluate this academic detailing model. The National Disease and Therapeutic Index is a physician-based survey, which surveys approximately 4,800 physicians every 3 months; data collection included prescribing information on antihypertensives. Data from this survey overlapped with academic detailing efforts in 176 counties from 38 states. The IMS Health Xponent database is a national computerized sample of approximately 36,000 retail pharmacies. Practice patterns prior to 2004 and in 2007 were compared. In addition, national trends in use of thiazide type diuretics were examined for an 8-year time period (2000-2008).
Results: The ALLHAT findings were published in 2002. The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) was published in 2003. Survey data showed that thiazide-type diuretic use increased in most in US counties where academic detailing activity was the greatest (an increase from 37.9% to 46.5%, p < 0.05) compared to counties where activity was moderate or low. Pharmacy dispensing data showed that thiazide-type diuretic prescriptions increased by 8.7% in counties with dissemination project activities compared to 3.9% in counties without such activities (p < 0.001). On a national level, thiazide-type diuretic use did not increase between 2004 and 2008.
Conclusions: The investigators suggest the ALLHAT/JNC7 dissemination project was associated with a small effect on thiazide-type diuretic use, demonstrating that academic detailing may increase physician implementation of clinical trials.
Perspective: These findings suggest a modest adoption of thiazide diuretics, as recommended by the ALLHAT findings and JNC7. However, this project was initiated 2 years after the publication of ALLHAT; thus, antihypertensive management may have already undergone significant changes. Further research would be needed to understand specific factors related to the adoption of recommendations for control of blood pressure. Elizabeth A. Jackson, M.D., F.A.C.C.
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