Обзор американских кардиологических журналов за неделю (ссылки)

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5-Year Outcomes Following Percutaneous Coronary Intervention With Drug-Eluting Stent Implantation Versus Coronary Artery Bypass Graft for Unprotected Left Main Coronary Artery Lesions: The Milan Experience
Chieffo A, Magni V, Latib A, et al.
J Am Coll Cardiol Intv 2010;3:595-601.
Study Question: What are the comparative outcomes with drug-eluting stent (DES) versus coronary artery bypass graft (CABG) in unprotected left main coronary artery (ULMCA) lesions at 5 years?

Long-Term Clinical Results Following Stenting of the Left Main Stem: Insights From RESEARCH (Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital) and T-SEARCH (Taxus-Stent Evaluated at Rotterdam Cardiology Hospital) Registries
Onuma Y, Girasis C, Piazza N, et al.
J Am Coll Cardiol Intv 2010;3:584-594.
Study Question: What are the long-term clinical outcomes and independent predictors of major cardiac events in unprotected left main coronary artery disease (ULMCA) patients treated by percutaneous coronary intervention with drug-eluting stent (DES)?

Transcatheter Aortic Valve Implantation for High-Risk Patients With Severe Aortic Stenosis: A Systematic Review
Yan TD, Cao C, Martens-Nielsen J, et al.
J Thorac Cardiovasc Surg 2010;139:1519-1528.
Study Question: What is the safety and clinical effectiveness of transcatheter aortic valve implantation for patients at high surgical risk with severe aortic stenosis?


Once Weekly Exenatide Compared With Insulin Glargine Titrated to Target in Patients With Type 2 Diabetes (DURATION-3): An Open-Label Randomised Trial
Diamant M, Van Gaal L, Stranks S, et al.
Lancet 2010;375:2234-2243.
Study Question: What is the effect of once weekly exenatide on improvement in glycated hemoglobin (HbA1c), as compared to insulin glargine titrated to glucose targets?
ACCF/AHA Clopidogrel Clinical Alert: Approaches to the FDA “Boxed Warning”: A Report of the American College of Cardiology
Holmes DR, Dehmer G, Kaul S, et al.
J Am Coll Cardiol 2010;Jun 28:[Epub ahead of print].
Perspective: The following are 10 points to remember about this American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Expert Consensus Document.

Beta-Blockers May Reduce Mortality and Risk of Exacerbations in Patients With Chronic Obstructive Pulmonary Disease
Rutten FH, Zuithoff NP, Hak E, Grobbee DE, Hoes AW.
Arch Intern Med 2010;170:880-887.
Study Question: What is the long-term effect of beta-blocker use on survival and chronic obstructive pulmonary disease (COPD) exacerbations in subjects with COPD?

Circulating Endothelial Progenitor Cell Levels and Function in Patients Who Experienced Late Coronary Stent thrombosis
Lev EI, Leshem-Lev D, Mager A, et al.
Eur Heart J 2010;Jun 11:[Epub ahead of print].
Study Question: Do patients who experience late stent thrombosis have defective or reduced circulating endothelial progenitor cells?


Diabetes Mellitus, Fasting Blood Glucose Concentration, and Risk of Vascular Disease: A Collaborative Meta-Analysis of 102 Prospective Studies
The Emerging Risk Factors Collaboration.
Lancet 2010;375:2215-2222.
Study Question: What are the risks associated with diabetes and blood glucose concentrations associated with vascular disease?

Effects of Homocysteine-Lowering With Folic Acid Plus Vitamin B12 vs. Placebo on Mortality and Major Morbidity in Myocardial Infarction Survivors: A Randomized Trial
Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH) Collaborative Group.
JAMA 2010;303:2486-2494.
Study Question: Does supplementation with folic acid and vitamin B12 reduce homocysteine levels and improve mortality and morbidity among patients after myocardial infarction (MI)?
Effects of Fibrates on Cardiovascular Outcomes: A Systematic Review and Meta-Analysis
Jun M, Foote C, Lv J, et al.
Lancet 2010;375:1875-1884.
Study Question: What is the effect of fibrates on major cardiovascular outcomes?

Association Between Coronary Artery Calcification Progression and Microalbuminuria: The MESA Study
DeFilippis AP, Kramer HJ, Katz R, et al.
J Am Coll Cardiol Img 2010;3:595-604.
Study Question: What is the relationship between microalbuminuria (MA) and the development and progression of atherosclerosis, as assessed by incident and progression of coronary artery calcification (CAC)?
Long-Term Response to Calcium-Channel Blockers in Non-Idiopathic Pulmonary Arterial Hypertension
Montani D, Savale L, Natali D, et al.
Eur Heart J 2010;Jun 11:[Epub ahead of print].
Study Question: Does the acute vasodilator response predict long-term response to calcium-channel blockers (CCBs) in pulmonary arterial hypertension (PAH) with associated conditions (e.g., non-idiopathic PAH)?

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New ACCF/AHA Clinical Alert Addresses Clopidogrel Warning
by Ralph Brindis
June 29, 2010 04:12

The ACC Foundation and the American Heart Association yesterday released a joint clinical alert on clopidogrel (Plavix). The alert is intended to help CV professionals make sense of a recent FDA black box warning for the drug saying that some patients’ genetic makeup can affect their response and put them at risk for serious adverse events.

Two to 14 percent of patients are “poor metabolizers” of clopidogrel and do not benefit fully from it, according to FDA analysis. Information about the specific genetic variation that might affect clopidogrel metabolism – and thus, lead to suboptimal clinical responses – is increasing, but there still isn’t sufficient evidence available to develop specific recommendations related to genetic testing in patients. Many questions remain about how and when to use genetic tests for clopidogrel candidates, which tests to use, as well as whether tests will be reimbursed.

The new ACCF/AHA report reviews the backdrop for the black box warning, including the multiple unknown factors that can influence individual patient outcomes. Its recommendations for practice are as follows:
Adherence to existing evidence-based guidelines from ACC, AHA or other professional societies for using antiplatelet therapies should remain the foundation of care. If clopidogrel is prescribed, health care providers should help ensure that patients take it as prescribed.

Clinicians must be aware that in certain patients with either acute or chronic coronary artery disease, genetic variability in response to clopidogrel can affect its inhibition of platelet function.

Careful clinical judgment, including weighing the risks and benefits, is needed in considering all therapies. The new boxed warning points out that for clopidogrel, if there is a lack of efficacy, the consequences can potentially result in fatal outcomes.

Results from ongoing clinical trials in large groups of patients will provide more information about the predictive value of genetic testing and better inform the role genotyping might play in personalizing medicine and optimizing outcomes.

Genetic testing to determine if a patient is a “poor metabolizer” may be considered before starting clopidogrel therapy in patients believed to be at moderate or high risk for poor outcomes (e.g., patients undergoing elective high-risk PCI procedures).

Using alternative antiplatelet therapies or altering the dosing of clopidogrel may be reasonable options in patients who experience an adverse event while taking clopidogrel and have been taking the drug as prescribed.

These recommendations are intended to help guide health care providers in devising the best treatment plan for each patient. That said, care providers of course should continue to use careful clinical judgment in each patient.

Relationships With Industry

An interesting side note to this document is that it was the first major clinical document to be produced under a new set of ACC principles for relationships with industry for the development of clinical documents. Of the many things discussed in the document, one principle outlined is that the chair of the writing committee and greater than 50% of its members must have no relevant relationships with industry.

For the clopidogrel document, only two out of the five authors have relevant relationships with industry that needed to be disclosed. ACC Vice President and writing committee Chair David Holmes, M.D., F.A.C.C., did not. Being 2/3 of the way free of relationship represents a vast improvement over both our previous clinical documents and our new RWI guidelines. It’s important to the ACC that it be able to offer unbiased clinical documents. It’s not that we think that cardiologists who accept money from drug companies are biased (we believe that the RWI can provide value when such relationships are ethically structured) , it’s just that we feel strongly in the importance of transparency and maintaining rigorous levels of relationship-free writing committee members helps us to do this.

I’ll be talking more about relationships with industry in the coming weeks, but I’m interested to hear what you think now. Should clinical document writing committees exclude physicians because they accept industry funding or is there an acceptable level of relationships within a writing committee?

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Title: Risk of Acute Myocardial Infarction, Stroke, Heart Failure, and Death in Elderly Medicare Patients Treated With Rosiglitazone or Pioglitazone
Date Posted: June 29, 2010
Authors: Graham DJ, Ouellet-Hellstrom R, MaCurdy TE, et al.
Citation: JAMA 2010;304:E1-E8.

Print
Study Question:
Is the risk of cardiovascular events increased with use of rosiglitazone compared with pioglitazone?
Methods:
Patients who were Medicare beneficiaries ages 65 years or older, who initiated treatment with rosiglitazone or pioglitazone through a Medicare Part D prescription drug plan from July 2006-June 2009, were included in this observational, retrospective cohort. Patients were excluded if they had less than 3 years of follow-up after thiazolidinedione initiation. Primary endpoints included acute myocardial infarction (AMI), stroke, heart failure, and all-cause mortality (death), and composite endpoint of AMI, stroke, heart failure, or death.
Results:
A total of 227,572 Medicare beneficiaries were included (mean age, 74.4 years). During the study period, 8,667 events occurred. Compared with pioglitazone, rosiglitazone had a nonsignificant risk for AMI (hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.96-1.18). However, with other cardiovascular disease endpoints, rosiglitazone was associated with increased risk: HR, 1.27 (95% CI, 1.12-1.45) for stroke; HR, 1.25 (95% CI, 1.16-1.34) for heart failure; and HR 1.14 (95% CI, 1.05-1.24) for death. Rosiglitazone was also associated with increased risk for the combined cardiovascular disease endpoint (HR, 1.18; 95% CI, 1.12-1.23) compared to pioglitazone. The attributable risk for the combined endpoint was 1.68 (95% CI, 1.27-2.08) excess events per 100 person-years of treatment with rosiglitazone compared with pioglitazone. The corresponding number needed to harm was 60 (95% CI, 48-79) treated for 1 year.
Conclusions:
The authors concluded that rosiglitazone was associated with increased risk of stroke, heart failure, and all-cause mortality and an increased risk of the composite of AMI, stroke, heart failure, or all-cause mortality in patients 65 years or older compared to pioglitazone.
Perspective:
These data suggest that use of pioglitazone is associated with less adverse events compared to rosiglitazone. However, as the authors suggest, several limitations exist, including the observational retrospective study design and the use of prescription data. These data suggest the need for further studies, preferably large randomized clinical trials.
Author(s):
Elizabeth A. Jackson, M.D., F.A.C.C.
Topic(s):
General Cardiology, Prevention/Vascular, Heart Failure/Transplant

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Title: A Randomized, Controlled Trial of Early Versus Late Initiation of Dialysis
Date Posted: June 28, 2010
Authors: Cooper BA, Branley P, Bulfone L, et al., on behalf of the IDEAL Study Investigators.
Citation: N Engl J Med 2010;Jun 27:[Epub ahead of print].
Study Question:
What is the influence of the timing of the initiation of maintenance dialysis on survival among patients with chronic kidney disease?
Methods:
The Initiating Dialysis Early and Late (IDEAL) study investigators randomly assigned patients 18 years of age or older with progressive chronic kidney disease and an estimated glomerular filtration rate (eGFR) between 10.0-15.0 ml/min/1.73 m2 of body-surface area (calculated with the use of the Cockcroft–Gault equation) to planned initiation of dialysis when the eGFR was 10.0-14.0 ml/min (early start) or when the eGFR was 5.0-7.0 ml/min (late start). The primary outcome was death from any cause.
Results:
Between July 2000 and November 2008, a total of 828 adults (mean age, 60.4 years; 542 men and 286 women; 355 with diabetes) underwent randomization, with a median time to the initiation of dialysis of 1.80 months (95% confidence interval [CI], 1.60-2.23) in the early-start group and 7.40 months (95% CI, 6.23-8.27) in the late-start group. A total of 75.9% of the patients in the late-start group initiated dialysis when the eGFR was above the target of 7.0 ml/min, owing to the development of symptoms. During a median follow-up period of 3.59 years, 152 of 404 patients in the early-start group (37.6%) and 155 of 424 in the late-start group (36.6%) died (hazard ratio with early initiation, 1.04; 95% CI, 0.83-1.30; p = 0.75). There was no significant difference between the groups in the frequency of adverse events (cardiovascular events, infections, or complications of dialysis).
Conclusions:
The authors concluded that planned early initiation of dialysis in patients with stage V chronic kidney disease was not associated with an improvement in survival or clinical outcomes.
Perspective:
In this study involving patients with chronic kidney disease, early initiation of dialysis had no significant effect on the rate of death from any cause or on cardiovascular events, infectious events, or complications of dialysis. The results suggest that with careful clinical management of chronic kidney disease, dialysis can be delayed for some patients until the GFR drops below 7.0 ml/min or until more traditional clinical indicators for the initiation of dialysis are present. It should be noted that the majority of the patients assigned to the late-start group did not commence dialysis at the level of GFR defined in the protocol, and the mean difference in eGFR was only 2.2 ml/min. However, there was a difference of 6 months between the groups in the start time for dialysis, reflecting the critical importance of close clinical follow-up if dialysis is to be delayed.
Author(s): Debabrata Mukherjee, M.D., F.A.C.C.


Title: Acquired von Willebrand Syndrome After Continuous-Flow Mechanical Device Support Contributes to a High Prevalence of Bleeding During Long-Term Support and at the Time of Transplantation
Date Posted: June 30, 2010
Authors: Uriel N, Pak SW, Jorde UP, et al.
Citation: J Am Coll Cardiol 2010;Jun 30.
Study Question:
What is the prevalence and mechanism of bleeding events in patients receiving left ventricular assist device (LVAD) support?
Methods:
This was a retrospective study of 79 HeartMate II (HM II) patients who underwent implantation between 2004 and 2009. Bleeding was defined as the need for transfusion >7 days after device insertion. Transfusion at heart transplantation was compared with that in Heart-Mate XVE patients.
Results:
Some 44.3% of HM II patients had bleeding episodes at 112 ± 183 days after LVAD implantation, with 50% experiencing an event within 2 months. Gastrointestinal bleeding was the most frequent event. At the index event, the INR averaged 1.67 ± 0.53, and the platelet count was 237 ± 119 x 109/L. Comparison of the transfusion requirements at heart transplantation of 35 HM II patients with 62 HeartMate XVE patients demonstrated twice the transfusion requirements in HM II patients (packed red blood cells, 6.3 ± 0.8 U vs. 3.8 ± 0.5 U; platelets, 12.5 ± 5.4 U vs. 8.6 ± 6.4 U; fresh frozen plasma, 9.6 ± 4.9 U vs. 4.9 ± 3.6 U; and cryoprecipitate, 4.3 ± 3.6 U vs. 2.2 ± 3.5 U; p < 0.05 for all). High molecular weight von Willebrand factor (VWF) multimers were measured in 31 HM II patients and were reduced in all patients; 18 of these 31 (58%) patients had bleeding.
Conclusions:
Patients with the HM II had a high incidence of bleeding events during device support and at heart transplantation. HM II patients had reduced high molecular weight VWF multimers.
Perspective:
Bleeding complications are high in patients receiving LVAD support, especially in continuous-flow devices that require anticoagulation. This study supports previous observations that an acquired hemostatic defect involving reduced VWF multimers may contribute to bleeding events in patients with HM II devices. This is presumably related to enhanced proteolysis of hemostatic VWF multimers triggered by shear stress, a hypothesis previously proposed to explain increased bleeding in patients with severe aortic stenosis. If these findings are confirmed in larger trials, measurement of VWF multimers may prove useful in guiding anticoagulant and antiplatelet therapy in patients receiving LVAD support, to reduce bleeding complications.
Author(s): Daniel T. Eitzman, M.D., F.A.C.C.

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Title: Effectiveness of Sensor-Augmented Insulin-Pump Therapy in Type 1 Diabetes
Date Posted: June 29, 2010
Authors: Bergenstal RM, Tamborlane WV, Ahmann A, et al.
Citation: N Engl J Med 2010;Jun 29:[Epub ahead of print].
Study Question:
What is the relative value of a sensor-augmented pump therapy (pump therapy), as compared to a regimen of multiple daily insulin injections (injection therapy) in patients with type 1 diabetes?
Methods:
A 1-year, multicenter, randomized, controlled trial was conducted in 485 patients (329 adults and 156 children) with inadequately controlled type 1 diabetes. Patients received recombinant insulin analogues and were supervised by expert clinical teams. The primary endpoint was the change from the baseline glycated hemoglobin level.
Results:
Mean age of adults was about 41 years and for children it was 12 years old, and 57% were male. At 1 year, the baseline mean glycated hemoglobin level (8.3% in the two study groups) had decreased to 7.5% in the pump-therapy group, as compared with 8.1% in the injection-therapy group (p < 0.001). Pump therapy was associated with a 0.6 percentage point greater reduction in glycated hemoglobin in adults (p < 0.001) and 0.5 percentage point greater in children. The proportion of patients who reached the glycated hemoglobin target (<7%) was greater in the pump-therapy group than in the injection-therapy group. The rate of severe hypoglycemia in the pump-therapy group (13.31 cases per 100 person-years) did not differ significantly from that in the injection-therapy group (13.48 per 100 person-years, p = 0.58). There was no significant weight gain in either group.
Conclusions:
In both adults and children with inadequately controlled type 1 diabetes, sensor-augmented pump therapy resulted in significant improvement in glycated hemoglobin levels, as compared with injection therapy. A significantly greater proportion of both adults and children in the pump-therapy group than in the injection-therapy group reached the target glycated hemoglobin level.
Perspective:
Although the design was randomized, the glucose and glycated hemoglobin values were disclosed to investigators, caregivers, and patients, which maximized outcome in each group and minimized the risk of hypoglycemia. The added value of sensor-pump therapy compared to standard injection therapy was greater with greater sensor sampling, which did not increase in hypoglycemic episodes.
Author(s): Melvyn Rubenfire, M.D., F.A.C.C.

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Compliance high among patients with wearable cardioverter defibrillator
By
In addition to showing high rates of patient compliance, new study data suggested that survival and mortality rates were similar among patients with a wearable cardioverter defibrillator and those with an implantable cardioverter defibrillator.
Data from 3,569 patients who wore a wearable defibrillator for at least one day from August 2002 through December 2006 were collected from the device manufacturer’s database. Baseline data were available for 2,731 patients. The researchers compared survival among these patients with a cohort who had an ICD implanted at the Cleveland Clinic. Primary outcomes included patient compliance and efficacy of the wearable defibrillator as treatment for arrhythmia.
Median daily use was 21.7 hours (91% of time available) and mean duration of use was 52.6 ± 69.9 days (range 1 to 1,590 days). Daily use was >90% in 52% of patients and >80% in 71%, and more days of use correlated with higher daily use (P<.001). Discomfort or adverse reactions — mainly the weight and size of the device — resulted in discontinued use among 14.2% of patients.
Eighty sustained ventricular tachycardia/ventricular fibrillation (VT/VF) events occurred in 59 patients during wearable defibrillator use; 8 deaths occurred after conversion of unconscious VT/VF. During wearable defibrillator use, overall acute survival was 99.2% (3,541 of 3,569 patients) with 0.78% mortality due to sudden death over mean usage of 53 days, according to the researchers. Survival was 90% for VT events and 73.6% for all events, including non-VT/VF events.
Sudden death mortality occurred in patients not wearing the device, who had bystander interference electrocardiogram signal disruption or unipolar pacing artifacts, according to the researchers. In addition, 24.5% of sudden cardiac arrest events with high mortality rates were caused by asystole or pulseless electrical activity.
“Patient instruction regarding proper usage of and compliance with the wearable defibrillator is vital to ensuring the efficacy of the wearable defibrillator in preventing sudden cardiac death,” the researchers wrote.
In an accompanying editorial, Ralph J. Verdino, MD, of the Hospital of the University of Pennsylvania noted that the study contained some flaws, including missing information regarding patient demographics and treatment indications, but also acknowledged the observed efficacy of the device.
“It has a high degree of success in treating ventricular tachyarrhythmia and does not appear to be very cumbersome for patient use. Not prescribing this lifesaving attire to your high-risk patient awaiting ICD implantation or reimplantation is the real faux pas.”
Chung M. J Am Col Cardiol. 2010;56:194-203.

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Drug-eluting stents produced favorable PCI outcomes
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The use of drug-eluting stents was associated with favorable results in percutaneous coronary intervention for unprotected left main coronary artery stenosis when compared with bare metal stents, according to study data.
Researchers utilized PubMed, clinicaltrials.gov and BioMed Central databases, finding 44 studies (n=10,343) from January 2000 to September 2009 that met the inclusion criteria, which involved unprotected left main disease, bare metal stents or drug-eluting stents, and at least20 patients in the overall study cohort. The primary endpoints were MI, target vessel/lesion revascularization (TVR/TLR), major adverse cardiac events and mortality.
Researchers determined event rates for drug-eluting stents and bare metal stents at 6 to 12 months, 2 years and 3 years. Crude event rates at 3 years for drug-eluting stents vs. bare metal stents were 8.8% vs. 12.7% for mortality, 4% vs. 3.4% for MI, 8% vs. 16.4% for TVR/TLR and 21.4% vs. 31.6% for major adverse cardiac events. The researchers also included nine studies (n=5,081) in a comparative analysis. At 6 to 12 months, the adjusted OR for drug-eluting stents vs. bare metal stents was 0.94 for mortality (95% CI, 0.06-15.48), 0.64 for MI (95% CI, 0.19-2.17), 0.1 for TVR/TLR (95% CI, 0.01-0.84) and 0.34 for major adverse cardiac events (95% CI, 0.15 to 0.78). The OR for drug-eluting stents vs. bare metal stents at 3 years was 0.7 for mortality (95% CI, 0.53-0.92), 0.49 for MI (95% CI, 0.26-0.92), 0.46 for TVR/TLR (95% CI, 0.30-0.69) and 0.78 for major adverse cardiac events (95% CI, 0.57-1.07).
“Our meta-analysis suggests that drug-eluting stents are associated with favorable outcomes for mortality, MI, TVR/TLR and major adverse cardiac events as compared to bare metal stents in PCI for unprotected left main coronary artery stenosis,” the researchers reported. “The improved outcomes observed when drug-eluting stents are compared with bare metal stents support a continued re-evaluation of the role of PCI for the treatment of unprotected left main coronary artery stenosis.”
Pandya S. J Am Coll Cardiol Intv. 2010;3:602-611.

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Pre-existing conditions covered by new high-risk insurance pools
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Beginning today, individuals with pre-existing health conditions are eligible to enroll in a temporary high-risk insurance pool, courtesy of the health care reform law. The new Pre-Existing Condition Insurance Plan is a provision of the Patient-Protection and Affordable Care Act.
The new plan — administered by either a state or the Department of Health and Human Services — will provide health coverage options for individuals who have been uninsured for at least 6 months, have been denied coverage due to a pre-existing condition and are a U.S. citizen or legal resident. The program will be in effect until 2014 when insurers will no longer be able to deny coverage based on pre-existing medical conditions.
As of today, HHS will run the Pre-Existing Condition Insurance Plan in 21 states. The remaining 29 states and the District of Columbia will begin enrolling residents in their own insurance pools by the end of the summer, according to a press release from HHS.
From July 1, 2010, through Jan. 1, 2014, the law will provide $5 billion to fund the new plan in each state. Money will be allocated based on the population and costs of each state.
The plan, which is not based on income, will likely be an option for individuals with money to spend on insurance, but who have been denied coverage in the past due to a pre-existing medical condition such as cancer or diabetes. Although some states already have high-risk pools, by law, the new pools cannot charge higher premiums than the standard premiums in an individual’s given state.
Modeled after the Children’s Health Insurance Program (CHIP), the Pre-Existing Condition Plan allows for flexibility by state as long as basic requirements are met. State programs may vary on cost, benefits and determination of pre-existing conditions. In addition, any unspent funding will be reallocated by the states. Unlike CHIP, however, there is no state matching requirement and the entire cost of the new plan will be covered by the federal government.
For more information on the federal high-risk pools, visit [Ссылки доступны только зарегистрированным пользователям ].

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Adherence to SCIP measures showed little improvement on infection probability
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There was no significant improvement on infection probability when physicians adhered to the Surgical Care Improvement Project, despite the project’s aim to lower surgical care infectious complication rates, study findings suggested.
The retrospective cohort study consisted of 405,720 patients from 398 hospitals in the United States that had their Surgical Care Improvement Project (SCIP) performance recorded and submitted for public report on the Hospital Compare website. The Cleveland-based researchers joined three original infection-prevention measures and all six infection-prevention measures into two separate all-or-none composite scores.
There were 3,996 reported postoperative infections. The six infection-prevention measures’ composite process-of-care measure predicted a decrease in postoperative infection rates from 14.2 to 6.8 per 1,000 discharges (adjusted OR=0.85; 95% CI, 0.76-0.95). The three original infection-prevention measures’ composite process-of-care measure also correlated with a decrease in postoperative infection rates from 11.5 to 5.3 per 1,000 discharges (adjusted OR=0.86; 95% CI, 0.74-1.01), which researchers determined was not a statistically significantly lower probability of infection.
“Our study demonstrated that although publicly reported adherence rates to SCIP process-of-care measures were associated with improved patient outcomes in our aggregated measures, the individual item relationships are weak and lack clinical significance,” the researchers concluded. “Improved individual process-of-care measures and use of aggregation techniques in addition to improved data collection methods may be necessary to truly drive improvements in patient outcomes.”
Stulberg J. JAMA. 2010; 303:2479-2485.

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“SOURCE” of Enthusiasm for Transcatheter Aortic Valve Implantation
Tuzcu EM, Kapadia SR, Svensson LG, et al.
Circulation 2010;122:8-10.
Perspective: Transcatheter aortic valve implantation (TAVI) is one of the most exciting recent advances in interventional cardiology and has been a well coordinated collaborative effort by both physicians and surgeons.

Repair of the Bicuspid Aortic Valve: A Viable Alternative to Replacement With a Bioprosthesis
Ashikhmina E, Sundt TM III, Dearani JA, Connolly HM, Li Z, Schaff HV.
J Thorac Cardiovasc Surg 2010;139:1395-1401.
Study Question: What is the relative safety and durability of bicuspid aortic valve repair compared to bioprosthetic aortic valve replacement?


Center Variation and Outcomes Associated With Delayed Sternal Closure After Stage 1 Palliation for Hypoplastic Left Heart Syndrome
Johnson JN, Jaggers J, Li S, et al.
J Thorac Cardiovasc Surg 2010;139:1205-1210.
Study Question: What are the differences in outcomes between a primary or delayed chest closure strategy in infants undergoing stage 1 palliation for hypoplastic left heart syndrome (HLHS)?

Total Anomalous Pulmonary Venous Connection: Results of Surgical Repair of 100 Patients at a Single Institution
Kelle AM, Backer CL, Gossett JG, Kaushal S, Mavroudis C.
J Thorac Cardiovasc Surg 2010;139:1387-1394.
Study Question: What are the outcomes of patients undergoing surgical repair of total anomalous pulmonary venous connection (TAPVC)?

Screening Asymptomatic Subjects for Subclinical Atherosclerosis: Can We, Does It Matter, and Should We?
Shah PK.
J Am Coll Cardiol 2010;56:98-105.
Conclusions: The following are 10 points to remember about this viewpoint and commentary.

Effectiveness of Sensor-Augmented Insulin-Pump Therapy in Type 1 Diabetes
Bergenstal RM, Tamborlane WV, Ahmann A, et al.
N Engl J Med 2010;Jun 29:[Epub ahead of print].
Study Question: What is the relative value of a sensor-augmented pump therapy (pump therapy), as compared to a regimen of multiple daily insulin injections (injection therapy) in patients with type 1 diabetes?

Prandial Inhaled Insulin Plus Basal Insulin Glargine Versus Twice Daily Biaspart Insulin for Type 2 Diabetes: A Multicentre Randomised Trial
Rosenstock J, Lorber DL, Gnudi L, et al.
Lancet 2010;375:2244-2253.
Study Question: Insulin therapy is often a delayed strategy in patients with type 2 diabetes mellitus because it is associated with weight gain, hypoglycemia, and the need for subcutaneous injections. What is the efficacy and safety of prandial Technosphere inhaled insulin compared with twice daily biaspart insulin?

Acquired von Willebrand Syndrome After Continuous-Flow Mechanical Device Support Contributes to a High Prevalence of Bleeding During Long-Term Support and at the Time of Transplantation
Uriel N, Pak SW, Jorde UP, et al.
J Am Coll Cardiol 2010;Jun 30:[Epub ahead of print].
Study Question: What is the prevalence and mechanism of bleeding events in patients receiving left ventricular assist device (LVAD) support?

Long-Term Outcome of a Routine Versus Selective Invasive Strategy in Patients With Non–ST-Segment Elevation Acute Coronary Syndrome: A Meta-Analysis of Individual Patient Data
Fox KA, Clayton TC, Damman P, et al., on behalf of the FIR Collaboration.
J Am Coll Cardiol 2010;55:2435-2445.
Study Question: What is the effect of routine invasive (RI) strategy on the long-term frequency of cardiovascular (CV) death or nonfatal myocardial infarction (MI)?

Statins and All-Cause Mortality in High-Risk Primary Prevention: A Meta-Analysis of 11 Randomized Controlled Trials Involving 65,229 Participants
Ray KK, Kondapally Seshasai SR, Erqou S, et al.
Arch Intern Med 2010;170:1024-1031.
Study Question: Does statin use for primary prevention reduce risk of all-cause mortality?

Effects of Medical Therapies on Retinopathy Progression in Type 2 Diabetes
The ACCORD Study Group and ACCORD Eye Study Group.
N Engl J Med 2010;Jun 29:[Epub ahead of print].
Study Question: Do intensive glycemic control, combination therapy for dyslipidemia, and intensive blood pressure control limit the progression of diabetic retinopathy in persons with type 2 diabetes?

Clinical Predictors of Plaque Progression Despite Very Low Levels of Low-Density Lipoprotein Cholesterol
Bayturan O, Kapadia S, Nicholls SJ, et al.
J Am Coll Cardiol 2010;55:2736-2742.
Study Question: What risk factors are associated with coronary plaque growth in patients who have already achieved very low low-density lipoprotein cholesterol (LDL-C) levels?

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CASES-PMS: With formalized training, physicians with varied experience achieved similar results to those highly experienced in carotid stenting
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The varied experience level of physicians in the CASES-PMS trial did not prevent them from attaining similar stenting results as the highly experienced physicians from the SAPPHIRE trial, new study data suggested.
Carotid Artery Stenting With Emboli Protection Surveillance – Post-Marketing Study (CASES-PMS) researchers included patients in their study who were older than 18 years and had de novo atherosclerotic or post-endarterectomy restenotic obstructive lesions in native carotid arteries with either ≥50% carotid stenosis if symptomatic or≥80% carotid stenosis if asymptomatic; and patients with at least one anatomic or physiologic risk factor placing them at high risk for surgery. The primary endpoint was a composite of 30-day major adverse events, which included death, any stroke or MI. The patients (n=1,492) were enrolled at 73 sites from August 2003 to October 2005.
The rate of the primary endpoint was 5%, which met criteria for noninferiority to the prespecified objective performance criteria set by the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial. The 1-year cumulative percentage of major adverse events was 12.5%, and all strokes to 30 days plus ipsilateral stroke between 31 and 360 days were similar in the CASES-PMS trial (5.4%) vs. the SAPPHIRE cohort (4.9%).
“With the formalized training program utilized in this study, physicians with varied experience in carotid stenting can achieve short- and longer-term results similar to the highly experienced SAPPHIRE investigators,” the researchers concluded. “One-year outcomes with CASES-PMS showed little additional neurological morbidity and mortality beyond an acceptable 30-day outcome previously reported, and largely reflects the natural history of a large cohort of patients with a high prevalence of advanced cardiovascular disease at baseline.”
Schreiber TL. J Am Coll Cardiol. 2010;56:49-57.

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SEARCH: Homocysteine reductions with folic acid and vitamin B12 did not benefit vascular outcomes
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Substantial long-term reductions in blood homocysteine levels with folic acid and vitamin B12 supplementation had no beneficial effects on vascular outcomes, according to study findings.
The Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH) was a double blind, randomized, controlled trial, in which 12,064 survivors of MI in secondary care hospitals in the United Kingdom between 1998 and 2008 were given 2 mg folic acid plus 1 mg vitamin B12 daily vs. matching placebo. The main outcome measure was the first major vascular event, defined as a major coronary event (coronary death, MI or coronary revascularization), fatal or nonfatal stroke, or noncoronary revascularization.
Supplementation of the vitamins reduced homocysteine by a mean of 3.8 mcmol/L (28%). During the 6.7-years of follow-up, major vascular events occurred in 1,537 participants of the supplementation group (n=6,033) vs. 1,493 of participants allocated placebo (n=6,031; RR=1.04; 95% CI, 0.97-1.12). Researchers reported no apparent effects on major coronary events (vitamins, 1,229 vs. placebo, 1,185; RR=1.05; 95% CI, 0.97-1.13), stroke (vitamins, 269, vs. placebo, 265; RR=1.02; 95% CI, 0.86-1.21) or noncoronary revascularizations (vitamins, 178 vs. placebo, 152; RR=1.18; 95% CI, 0.95-1.46). There was also no significant difference in the number of deaths attributed to vascular causes (vitamins, 578 vs. placebo, 559) or nonvascular causes (vitamins, 405 vs. placebo, 392).
“These results highlight the importance of focusing on drug treatments (eg, aspirin, statins and antihypertensive therapy) and lifestyle changes (in particular, stopping smoking and avoiding excessive weight gain) that are of proven benefit, rather than lowering homocysteine with folic acid–based vitamin supplements for the prevention of CV disease,” the researchers concluded.
Armitage JM. JAMA. 2010;303:2486-2494.

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Trial Summary PROMISS
Title: Prospective Randomized Comparison of Off-Pump and On-Pump Multi-vessel Coronary Artery Bypass Surgery
Trial Sponsor: Merck Foundation, and Sociedade de Gestão Hospitalar Cruz Vermelha Portuguesa SA
Year Published: 2010
Topic(s): Cardiovascular Surgery
Summary Posted: 07/6/2010
Writer: Anthony A. Bavry, M.D., M.P.H., F.A.C.C.
Author Disclosure: NOTHING TO DISCLOSE
Reviewer: Deepak L. Bhatt, M.D., M.P.H., F.A.C.C.
Reviewer Disclosure: RESEARCH/RESEARCH GRANTS: The Medicines Company, Bristol Myers Squibb, Heartscape, Ethicon, Eisai, Astra Zeneca, Sanofi Aventis PLx Pharma, Takeda, Cogentus
Description:
The goal of the trial was to evaluate coronary artery bypass grafting (CABG) with the off-pump compared with the on-pump technique.
Hypothesis:
Off-pump CABG would result in similar graft patency.
Drugs/Procedures Used:
Patients undergoing CABG were randomized to off-pump (n = 75) versus on-pump (n = 75) surgery.
Concomitant Medications:
Patients in the off-pump group received heparin 200 U/kg to achieve an activated clotting time >250 seconds, whereas patients in the on-pump group received heparin 300 U/kg to achieve an activated clotting time >400 seconds.
At the conclusion of surgery, patients in both groups were reversed with 1.3 mg/100 U protamine.
Principal Findings:
There was no difference in baseline characteristics between the groups. Among off-pump patients, the mean age was 66 years, 18% were women, 18% had a body mass index ≥30 kg/m2, 36% had diabetes, 49% had previous myocardial infarction, and 67% had an acute coronary syndrome.
One patient crossed over from off-pump to on-pump, whereas two patients crossed over from on-pump to off-pump due to porcelain aorta. The mean dose of heparin was 15,000 U in the off-pump group and 23,000 U in the on-pump group (p < 0.001). The mean number of grafts performed per patient was 3.5 in both groups. All patients received a left internal mammary artery graft and 37% versus 41%, respectively, received bilateral mammary artery grafts.
The primary outcome, graft patency (by computed tomography angiography) at 5 weeks was 90% in the off-pump group versus 95% in the on-pump group (p = 0.03). There was no significant interaction based on type of graft or the grafted vessel. After controlling for dose of intraoperative heparin, the difference was no longer significant (p = 0.83).
At 30 days, there were no deaths or strokes in either group. Transient ischemic attacks occurred in zero versus two patients, for the off-pump versus on-pump groups. At a mean of 498 days, there were one versus three deaths, respectively.
Interpretation:
Among patients with multi-vessel coronary artery disease undergoing CABG, the use of the off-pump technique resulted in lower graft patency at 5 weeks. Both groups received the same number of grafts per patient, although the off-pump group received less total intraoperative heparin. When the dose of heparin was accounted for, there was no longer a difference in graft patency between the groups. Short- and long-term clinical outcomes appeared to be similar between the groups.
An accumulating body of evidence is revealing that while off-pump CABG is feasible, graft patency appears to be slightly compromised with this technique. In addition to inferior graft patency, the much larger ROOBY trial also revealed worse clinical outcomes including cardiac death with off-pump CABG. This surgical technique might be a reasonable option for patients with a severely calcified aorta, and it remains understudied in women.
Conditions:
Coronary heart disease
Coronary heart disease / Angina pectoris
Coronary heart disease / Angina pectoris / Stable
Coronary heart disease / Acute MI / Non-Q-Wave
Prevention
Therapies:
CABG
Study Design:
Randomized. Blinded. Parallel.
Primary Endpoints:
Coronary artery bypass graft patency at 5 weeks
Secondary Endpoints:
Clinical outcomes at 30 days and 1 year
Patient Population:
Screened applicants: 196
Enrollees: 150
Duration of follow-up: mean 498 days
Age range: mean 66 years
Percentage female: 18%
Ejection fraction: 93% with LVEF ≥50%
Patients between the ages of 30 and 90 years with multi-vessel coronary artery disease undergoing CABG with at least three distal coronary anastomoses
Exclusions:
Patients requiring inotropes
Use of intra-aortic balloon pump
Intubation
Serum creatinine >1.5 x the upper limit of normal
Atrial fibrillation
Allergy to contrast dye
Premenopausal women
Inability to provide informed consent
References:
Uva MS, Cavaco S, Oliveira AG, et al. Early graft patency after off-pump and on-pump coronary bypass surgery: a prospective randomized study. Eur Heart J 2010;Jul 1:

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Title: Low-Dose Combination Therapy With Rosiglitazone and Metformin to Prevent Type 2 Diabetes Mellitus (CANOE trial): A Double-Blind Randomized Controlled Study
Date Posted: July 8, 2010
Authors: Zinman B, Harris SB, Neuman J, et al.
Citation: Lancet 2010;Jun 2:[Epub ahead of print].

Study Question:
What is the effect of low-dose combination therapy with rosiglitazone and metformin on development of type 2 diabetes?
Methods:
In this double-blind, randomized, controlled trial undertaken in clinics in Canadian centers, 207 patients with impaired glucose tolerance were randomly assigned to receive combination rosiglitazone (2 mg) and metformin (500 mg) twice daily or matching placebo for a median of 3.9 years (interquartile range [IQR], 3.0-4.6). Randomization was computer-generated in blocks of four, with both participants and investigators masked to treatment allocation. The primary outcome was time to development of diabetes, measured by an oral glucose tolerance test or two fasting plasma glucose values of 7.0 mmol/L or greater.
Results:
A total of 103 participants were assigned to rosiglitazone and metformin, and 104 to placebo; all were analyzed. Vital status was obtained in 198 (96%) participants, and medication compliance (taking at least 80% of assigned medication) was 78% (n = 77) in the metformin and rosiglitazone group, and 81% (n = 80) in the placebo group. Incident diabetes occurred in significantly fewer individuals in the active treatment group (n = 14 [14%]) than in the placebo group (n = 41 [39%]; p < 0.0001). The relative risk reduction was 66% (95% confidence interval, 41-80) and the absolute risk reduction was 26% (14-37), yielding a number needed to treat of 4 (2.70-7.14). Seventy (80%) patients in the treatment group regressed to normal glucose tolerance compared with 52 (53%) in the placebo group (p = 0.0002). Insulin sensitivity decreased by study end in the placebo group (median −1.24; IQR −2.38 to −0.08) and remained unchanged with rosiglitazone and metformin treatment (−0.39; −1.30 to 0.84; p = 0.0006 between groups). The change in β-cell function, as measured by the insulin secretion-sensitivity index-2, did not differ between groups (placebo −252.3, −382.2 to −58.0 vs. rosiglitazone and metformin −221.8, −330.4 to −87.8; p = 0.28). The investigators recorded an increase in diarrhea in participants in the active treatment group compared with the placebo group (16 [16%] vs. 6 [6%]; p = 0.0253).
Conclusions:
The authors concluded that low-dose combination therapy with rosiglitazone and metformin was highly effective in prevention of type 2 diabetes in patients with impaired glucose tolerance.
Perspective:
This study suggests that the combination of rosiglitazone with metformin at half the maximum dose was very effective in prevention of diabetes and in normalization of glucose tolerance in individuals with impaired glucose tolerance, with little evidence of adverse events of these two drugs. These results lend support to the use of low-dose combination therapies as an effective means to manage complex metabolic disorders. A comprehensive approach to the global epidemic of type 2 diabetes should include lifestyle intervention, focusing on obesity and physical activity, with the option of pharmacological intervention for the primary prevention of diabetes as needed.
Author(s):
Debabrata Mukherjee, M.D., F.A.C.C.

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Title: Predicting Survival in Pulmonary Arterial Hypertension. Insights From the Registry to Evaluate Early and Long-Term Pulmonary Arterial Hypertension Disease Management (REVEAL)
Date Posted: July 8, 2010
Authors: Benza RL, Miller DP, Gomberg-Maitland M, et al.
Citation: Circulation 2010;122:164-172.

Study Question:
Factors that determine survival in pulmonary arterial hypertension (PAH) drive clinical management. Can an effective quantitative survival prediction tool be established for research and clinical use?
Methods:
Data from 2,716 patients with PAH enrolled consecutively in the US Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL) were analyzed to assess predictors of 1-year survival. Independent prognosticators of survival were used to derive a multivariable, weighted risk formula for clinical use.
Results:
Mean (standard deviation) age was 50.4 (16.8) years; 79% were women; 13.5% were newly diagnosed and the remainder previously diagnosed; 49.4% had idiopathic or familial PAH; the remainder had associated PH including 23.9% connective tissue disease (CTD), 11.8% congenital heart disease, 5.1% portal hypertension, 4.9% drugs/toxins, and other 5%. The modified New York Heart Association/World Health Organization functional class (FC) distribution: I = 8.5%, II = 37.8%, III = 48%, and IV = 5.5%. PAH therapies included prostacyclin analogs in 1,092 (41.6%), endothelin receptor antagonists in 1,231 (46.9%), and phosphodiesterase-5 inhibitors in 1,301 (49.6%) patients. A total of 1,087 (40.0%) and 687 (26.2%) patients received combination PAH therapies or an intravenous prostacyclin analog, respectively. One-year survival from the date of enrollment was 91.0% (95% confidence interval [CI], 89.9-92.1). In a multivariable analysis with Cox proportional hazards, variables independently associated with increased mortality included pulmonary vascular resistance >32 Wood units (hazard ratio [HR], 4.1; 95% CI, 2.0-8.3), PAH associated with portal hypertension (HR, 3.6; 95% CI, 2.4-5.4), FC IV (HR, 3.1; 95% CI, 2.2-4.4), men >60 years of age (HR, 2.2; 95% CI, 1.6-3.0), and family history of PAH (HR, 2.2; 95% CI, 1.2-4.0). Renal insufficiency, PAH associated with CTD, FC III, mean right atrial pressure, resting systolic blood pressure and heart rate, 6-minute walk distance, brain natriuretic peptide, percent predicted carbon monoxide diffusing capacity, and pericardial effusion on echocardiogram all predicted mortality. Based on these multivariable analyses, a prognostic equation was derived and validated by bootstrapping technique.
Conclusions:
Key predictors of survival based on a PAH patient’s most recent evaluation were used to develop a contemporary prognostic equation. Use of this tool may allow the individualization and optimization of therapeutic strategies. Serial follow-up and reassessment are warranted.
Perspective:
The strength of the REVEAL registry is the size of the cohort and that 54 geographically diverse community and university PAH specialty care facilities in the United States participated. I would like to see an analysis of how or whether the number of patients referred per site influences the predictive value of each variable and the predictive formula. It is particularly interesting that the equation may be used at the time of diagnosis or at any time during a patient’s first year course. I suspect there will be a considerable modification of the formula for predicting longer-term follow-up. As the authors suggest, by obtaining an evidence-based global assessment of the patient, clinicians may be better able to individualize and optimize therapeutic strategies to improve survival.
Author(s):
Melvyn Rubenfire, M.D., F.A.C.C.

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Title: ACCF/AHA Clopidogrel Clinical Alert: Approaches to the FDA “Boxed Warning”: A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the American Heart Association
Date Posted: June 28, 2010
Authors: Holmes DR, Dehmer G, Kaul S, et al.
Citation: J Am Coll Cardiol 2010;Jun 28:[Epub ahead of print].

Print
Perspective:
The following are 10 points to remember about this American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Expert Consensus Document.

1. On March 12, 2010, the Food and Drug Administration (FDA) approved a new label for clopidogrel with a “boxed warning” about the diminished effectiveness of the drug in patients with impaired ability to convert the drug into its active form.

2. Patients with decreased CYP2C19 function because of genetic polymorphisms metabolize clopidogrel poorly and have higher rates of cardiovascular events after acute coronary syndrome and percutaneous coronary interventions than patients with normal CYP2C19 function.

3. The clopidogrel boxed warning leaves the issue of whether to perform CYP2C19 testing up to the individual physician. It serves to make clinicians aware of the imperfect, but significant knowledge that we have about genetic variations in response to clopidogrel, and to emphasize that clinicians should use this knowledge to make decisions about how to treat individual patients.

4. Although genetic variability plays an important role in adenosine diphosphate (ADP)-stimulated platelet aggregation in response to clopidogrel, known genetic and nongenetic factors explain only a portion of the majority of variation.

5. The number of reduced function alleles is important: individuals with one variant allele (intermediate metabolizers) had 26-31% lower exposure to the active metabolite of clopidogrel, and those with two genetic polymorphisms (poor metabolizers) had 46-55% lower exposure compared with those with no CYP2C19 polymorphisms. Other genetic variations (ABCB1, P2Y12 receptor, and the CYP3A4 and CYP3A5 enzymes) may also affect the pharmacokinetics, pharmacodynamics, and clinical efficacy of clopidogrel.

6. Platelet function assays can measure the effect of ADP or P2Y12 activation on platelet aggregation, receptor expression, or the level of intracellular molecules (e.g., vasodilator-stimulated phosphoprotein phosphorylation), thereby directly or indirectly measuring the platelet inhibitory effect of clopidogrel.

7. Adherence to existing ACCF/AHA guidelines for the use of antiplatelet therapy should remain the foundation for therapy. Careful clinical judgment is required to assess the importance of the variability in response to clopidogrel for an individual patient and its associated risk to the patient.

8. The evidence base is insufficient to recommend either routine genetic or platelet function testing at the present time.

9. Higher loading doses (LDs) (600 mg vs. 300 mg), double-dose loading (600 mg twice over 2 hours), and higher maintenance doses (MDs) of clopidogrel (150 mg daily) have been found to improve platelet inhibition and might be considered alternatives for high-risk patients who respond poorly to standard loading and MDs of clopidogrel, although there is uncertainty of the long-term safety and efficacy of this approach. New antiplatelet drugs such as prasugrel and ticagrelor, if FDA approved, are additional alternatives.

10. The risk-benefit ratio, in terms of safety and efficacy of each of these alternative strategies, remains to be determined by adequately powered clinical trials.
Author(s):
Debabrata Mukherjee, M.D., F.A.C.C.

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Early PCI After Fibrinolysis Safely Reduces Reinfarction, Recurrent Ischemia
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Syntax Score Validated in All-Comers LEADERS Trial
July 12 - On the heels of several studies that showed the benefit of alternative models in predicting safety in patients undergoing percutaneous coronary intervention...
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Better MI Care, Safer PCI Among Trends Identified in National Registries
July 12 - The past few years have seen incremental improvement in treatment and outcomes for patients with acute myocardial infarction (AMI). Meanwhile, use...
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Cardiac Imaging Leads to Substantial Radiation Exposure
July 9 - While the association between radiation exposure from medical tests and increased risk of cancer is debatable, data from a study published online July...
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Subclavian Access Feasible, Safe with Transcatheter CoreValve Device
July 9 - In patients undergoing transcatheter aortic valve implantation (TAVI), subclavian access may be feasible for those with anatomical or disease characteristics...
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SES Superior to BMS for Chronic Total Occlusions
July 7 - In chronic total occlusions (CTOs), treatment with sirolimus eluting stents (SES) results in less restenosis at 8 months compared with bare metal stents...
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Light physical activity associated with reduced arterial stiffness
Gando Y. Hypertension. 2010;doi:10.1161/hypertensionaha.110.156331.
By
Longer time spent in light physical activity was linked with attenuation of arterial stiffening, particularly in unfit, older people, study data indicated.
The cross-sectional study included 538 healthy men and women divided into three age categories: <40 years (young), 40 to 59 years (middle-aged), and >60 years (older). Participants in each category were divided into either high-light or low-light physical activity groups determined by daily time spent in light physical activity. Researchers measured arterial stiffness by carotid-femoral pulse wave velocity.
Two-way analysis of variance revealed an interaction between age and time spent in light physical activity in determining carotid-femoral pulse wave velocity (P<.05). For the older group, carotid-femoral pulse wave velocity was higher in the low-light physical activity level group (945 ±19 cm/s) than in the high-light physical activity level group (882±16 cm/s). The difference remained after normalizing carotid-femoral pulse wave velocity for amounts of moderate and vigorous physical activity. Furthermore, the researchers correlated the carotid-femoral pulse wave velocity (r=–0.47) with daily time spent in light physical activity in older, unfit people, but observed no such relationship in older, fit people.
The study findings “suggested that replacing inactivity with light physical activity, such as household tasks and other unstructured activities, may be an effective means of preventing age-related arterial stiffening. The underlying mechanisms and practical implications of these findings warrant further investigation,” the researchers wrote.

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Increased fructose intake linked to higher blood pressure
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Fructose intake in the form of added sugar may be independently associated with elevated blood pressure levels in adults without a history of hypertension, according to new data.
“The US population ingests large amounts of fructose from added sugar nowadays, and this large intake may be associated with an increased risk of high BP in the general population,” Diana Jalal, MD, study author and assistant professor at the University of Texas Medical school at Houston told Cardiology Today.
The cross-sectional analysis of 4,528 adults with no history of hypertension generated data through the National Health and Nutrition Examination Survey (NHANES).
Median fructose intake of participants was roughly 2.5 sugary soft drinks (74 g) daily.
Researchers reported that increased fructose intake (>74 g daily) was associated with higher odds of elevated BP levels. This intake led to a 26% (>135/85 mmHg), 30% (>140/90 mmHg), and 77% (>160/100 mmHg) higher risk for blood pressure cutoffs of >135/85.
“Although the mechanism by which fructose may lead to high BP couldn’t be addressed in our study (by virtue of the design being cross sectional epidemiological study), it is important to educate our patients not only about salt but also about the potential risks of high intake of fructose from added sugars, and that making relevant changes to our diet may reduce the risk of high BP in our population,” Jalal said.

Jalal DI. J Am Soc Nephrol. 2010;164:doi:10.1001.