Обзор американских кардиологических журналов за неделю (ссылки)

[Chevychelov]

Hypertension rate could be as high as 20% in young adults

Nguyen Q. Epidemiology. 2011;22:532-541.

New findings have revealed that rates of hypertension among young adults may be close to 20%, nearly five times the rate found among participants of the National Health and Nutrition Examination Survey.

Senior study researcher Kathleen Mullan Harris, PhD, and colleagues examined 14,252 participants from the National Longitudinal Study of Adolescent Health (Add Health), Wave IV study, and compared them with participants from NHANES 2007-2008 (n=733). All of the participants were aged 24 to 32 years and had BP of at least 140 mm Hg/90 mm Hg.

Overall, rates of hypertension were much higher for Add Health study participants (19% vs. 4%), although self-reported history was only slightly higher (11% vs. 9%). Among participants with self-reported hypertension, approximately 50% of those in Add Health vs. 20% in NHANES actually had elevated BP by study measurement.

Adjustments for differences in participant characteristics, use of antihypertensive medications, examination time, as well as the consumption of food, caffeine and cigarettes before BP measurement had little influence on these estimates.

“The large and unexplained differences between Add Health and NHANES merit further investigation,” the researchers wrote. “US CHD mortality and policy models rely heavily on NHANES systolic BP distributions and, in some cases, on optimistic assumptions regarding relatively small decreases of 0–1 mm Hg per year in population mean systolic BP.”

Also meriting further scrutiny, they wrote, is the prevalence of hypertension found among Add Health Wave IV participants, indicating an unexpectedly high risk for CVD among young adults in the United States.
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FDA: No increased risk for cancer with angiotensin receptor blockers

Angiotensin II receptor blockers do not increase the risk for cancer, despite a study from last year reporting a small increased risk for cancer among those taking the drug, according to a news release issued by the FDA.

The FDA’s finding was based on a review performed by the agency that began in July 2010, shortly after the study was published. The review looked specifically at 31 randomized controlled trials that compared those taking with those not taking angiotensin II receptor blockers (ARBs) to determine the incidence of cancer.

“The FDA has completed its review of controlled trial data on more than 155,000 patients randomized to ARBs or other treatments — the largest evaluation of such data to date — and finds no evidence of an increased risk of cancer in patients who take an ARB,” Mary Ross Southworth, PharmD, deputy director for safety in the Division of Cardiovascular and Renal Drugs of the FDA’s Center for Drug Evaluation and Research, said in the release.

As a result of these findings, the FDA concluded in the release that any concern about a link between ARB use and development of cancer has been resolved, and that patients currently taking any antihypertensive medication should continue to unless advised by a health care professional.

[Chevychelov]

New antiplatelet agents face hurdles in clopidogrel-dominated market

For the treatment of patients with acute coronary syndrome or percutaneous coronary intervention, the antiplatelet therapy of choice has been consistent among physicians since it was first approved in 1997 — clopidogrel.

“[Clopidogrel (Plavix, Sanofi-Aventis)] was the first safe thienopyridine in the marketplace, so in a sense, it had a huge head start over a lot of other drugs in the field that are now available or about to be available,” David P. Faxon, MD, vice chair of medicine for strategic planning at the Brigham and Women’s Hospital, Boston, and Cardiology Today Editorial Board member, said in an interview. “So, for that reason, there hasn’t been much competition for it, and it has taken over the marketplace.”

The substantial, high-level evidence that supports the use of clopidogrel for reduction of morbidity and mortality in patients with ACS, MI and many other indications has helped the drug develop its formidable presence, said Rhonda M. Cooper-DeHoff, PharmD, MS, associate professor in the colleges of pharmacy and medicine at University of Florida, Gainesville, and a Cardiology Today Editorial Board member.

“Additionally, its relative ease of use, good tolerability and low incidence of adverse reactions have made it the antiplatelet agent of choice for reduction of atherosclerotic events in patients with MI or stroke since its approval,” she said.

Yet, despite its strengths, shortcomings with clopidogrel are still hindering its use in all patients in need of therapy. At the top of this list, according to Cooper-DeHoff, is clopidogrel resistance, which is the result of a patient’s genetic makeup, “whereby they are not able to adequately convert the prodrug to the active metabolite, resulting in inadequate protection, or they over-convert to the active metabolite, resulting in increased risk of bleeding,” she said.

Other shortcomings, according to Gilles Montalescot, MD, PhD, professor of cardiology at the Pitié-Salpêtrière Hospital in Paris, include poor predictability of the effect, slow onset of action, possible interactions with proton pump inhibitors, as well as recent negative studies on double doses of clopidogrel, including the CURRENT and GRAVITAS trials.

In response to these limitations, new agents have and are continuing to be developed that could potentially change the paradigm of the antiplatelet market by providing answers to several of these concerns.

Adoption of prasugrel inhibited by risks

After its approval in 2009, prasugrel (Effient, Daiichi Sankyo/Eli Lilly) became the only other available thienopyridine compound, which is still true today. Similar to clopidogrel, prasugrel is an indirect platelet inhibitor. However, platelet inhibition with prasugrel is observed after only 15 or 30 minutes and at a significantly lower loading dose compared with clopidogrel (60 mg vs. 300 mg), which occurs within 1 to 2 hours after a single-loading dose.

“While both compounds are prodrugs, clopidogrel requires a two-step enzymatic conversion to the active metabolite, while prasugrel only has to undergo a single conversion,” Cooper-DeHoff said. “However, prasugrel must be used with caution in the very elderly and/or lean population.”

This issue with the elderly, Faxon said, stems from the risk for bleeding with the drug, which he cited as the greatest obstacle currently inhibiting its widespread use. “They say patients have to be off [prasugrel] for 7 days, even longer for surgery. For people who are older, with stroke risk and prior transient ischemic attacks, you get higher risk of intracranial bleeding. This is serious because half the patients with [intracranial bleeding] die and the other half are severally disabled,” he said.

There is even some concern stemming from a study that found a link between prasugrel use and cancer, but Faxon said the study was not powered to look at the connection, and as a result, the finding has not made a huge effect on the drug’s usage.

“It needs to be evaluated, but the incidence was tiny,” he said. “If you’re going to do a study to determine whether prasugrel has any relation to cancer, you need a study of 22,000 patients. You can forget about that. … Personally, I think it was purely by chance because there is no plausible explanation.”

Upcoming trials for prasugrel that will help expound upon current knowledge of the drug, according to Montalescot, include the TRILOGY trial, which will be looking at a new regimen of the drug in ACS, as well as the ACCOAST trial, which will examine pretreatment with the drug in non-STEMI.

Need for data halts ticagrelor

With the FDA panel’s vote of 7-1 in July to recommend approval of the direct-acting P2Y12 inhibitor ticagrelor (Brilinta, AstraZeneca) for the reduction of thrombotic events in patients with ACS, it seemed an almost sure thing that clopidogrel would soon face one of its greatest challenges yet. However, less than 5 months later, the momentum of the drug was halted when the FDA issued a complete response letter to AstraZeneca declining the approval of the drug without additional analysis of the PLATO trial.

“There are a certain number of questions around the [PLATO] results that need to be answered. They are different from country to country,” Montalescot said. “Even if the results look impressive, this is not a home run. Heterogeneity in the results, same safety issues (bleeding) as prasugrel, side effects, reality of the death effect … all this needs to be answered.”

Yet, as many cardiologists agree, even these obstacles seem to be only a temporary setback to the drug’s ultimate approval.

“Ticagrelor is the only one in the group that has shown a reduction in mortality, and I always put a lot of weight into that. Saving lives is what you want to do,” Faxon said. “The bleeding rates are probably more significant than the papers would have you realize, but it seems to have a better profile than prasugrel. It has a relatively short half-life. So you can administer the drug and it works right away, and you can stop it and it goes away very quickly.”

Other promising agents

Although prasugrel and ticagrelor may currently have most of the spotlight in the category of newer antiplatelet therapies, others have emerged that are giving physicians a reason to take notice, including cangrelor, an IV-administered thienopyridine that is a direct and reversible P2Y12 inhibitor. This drug has the advantage of having an even more rapid onset and offset than ticagrelor due to IV administration.

However, the 2009 CHAMPION-PCI trial showed that cangrelor did not reduce the primary endpoint of a composite of death, MI or ischemia-driven revascularization at 48 hours after PCI compared with clopidogrel.

Still, these findings should not rule out possible use, Faxon said. “In some instances, a patient comes in with unstable coronary syndrome and has to go right to the cath lab, and you don’t know if they are going to be a surgical candidate or not. Here’s a drug that you could give them intravenously, cath them and if they don’t have the procedure, you can stop the drug. It wears right off, and you can take them to surgery,” he said. “So, it has a potential place, but if the next trial is negative, then it should be written off. But not quite yet.”

Also of interest to Faxon are protease-activated receptor-1 (PAR-1) drugs, which go to work on the platelet’s thrombin receptor.

“PAR-1 drugs are going to be interesting. There are some big studies with PAR-1 antagonist, including the TRACER study,” he said. “You might think it would only be good by itself, but since it works differently, it might be useful to combine it with clopidogrel or ticagrelor. This is true in general, as it might be good to combine different drugs that work in different ways for patients who want to have the most powerful effect.” – by Brian Ellis

For more information:
Bellemain-Appaix A. J Am Coll Cardiol. 2010;56:1542-1551.
Wallentin L. Eur Heart J. 2009;30:1964-1977.

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Widespread Increase in Myeloid Calcifying Cells Contributes to Ectopic Vascular Calcification in Type 2 Diabetes
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SHIFT data reveal key improvements with ivabradine

Patients with chronic HF who were treated with ivabradine had improved quality of life at 2 years and lowered heart rate at 8 months, according to results from two substudies of the SHIFT trial presented at the Heart Failure Congress 2011.

In the quality-of-life substudy, patients with chronic HF (n=1,944) were randomly assigned to either ivabradine (Procoralan, Servier; n=968) or placebo (n=976). The Kansas City Cardiomyopathy Questionnaire (KCCQ) score was determined at baseline and at 4, 12 and 24 months after randomization.

Researchers found that the difference in KCCQ overall summary score — which included clinical summary score and quality of life — for surviving patients from baseline to last assessment was nearly two times greater in the ivabradine arm (5.3 vs. 3; P<.001). Although both arms reported decreases in overall summary score when researchers included death, the least reduction was found in the ivabradine group (–2.8 vs. –6.4; P=.004).

Similar but less significant results were also reported when researchers looked at clinical summary score alone for both scores including (P=.012) or not including (P=.015) death.

“In patients with HF and systolic dysfunction who are in sinus rhythm with HR >70 bpm, heart rate reduction with ivabradine was associated with improved health-related quality of life,” Inger Ekman, PhD, study investigator and director, University of Gothenburg Centre for Person-Centred Care (GPCC), Gothenburg, Sweden, said in her presentation. “This … benefit was seen in addition to reduction in the primary endpoint of CV death or hospitalization for worsening HF.”

Also presented at the Heart Failure Congress was the SHIFT ECG-Holter substudy, which looked at 501 patients of SHIFT to better understand the heart rhythm safety profile of ivabradine. All patients were given optimized HF therapy and ivabradine (n=254) or placebo (n=247).

At 8 months, 24-hour heart rate was significantly reduced in the ivabradine arm compared with placebo (P<.0001), and higher rates of at least one episode of heart rate less than 40 bpm were also reported in the ivabradine group (P<.0001). However, rates of atrial fibrillation were slightly higher in the ivabradine group (2.4% vs. 2%), whereas rates of second- or high-degree atrioventricular block were higher with those taking placebo (3.6% vs. 1.6%).
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SHARP: Simvastatin plus ezetimibe linked with fewer atherosclerotic events

Baigent C. Lancet. 2011;doi:10.1016/S0140-6736(11)60822-2.

In patients with chronic kidney disease, a combination of simvastatin 20 mg plus ezetimibe 10 mg given daily was associated with a significant reduction in atherosclerotic events, results from the SHARP study indicated.

Researchers for the study enrolled 9,270 patients with chronic kidney disease and a known history of MI or coronary revascularization. Patients were randomly assigned to receive either simvastatin (Zocor, Merck) 20 mg daily plus ezetimibe (Zetia, Merck) 10 mg daily (n=4,650) or matching placebo (n=4,620). The primary endpoint was the first major atherosclerotic event (nonfatal MI or coronary death, non-hemorrhagic stroke or any revascularization).

According to the results, patients in the combined therapy group had an average LDL difference of 0.85 mmol/L during the median follow-up of 4.9 years, which produced a 17% proportional reduction in major atherosclerotic events (11.3%) vs. placebo (13.4%, P=.0021). Fewer patients receiving the combined therapy died from CHD (4.6% vs. 5.0%), and there were also reductions in non-hemorrhagic stroke (2.8% vs. 3.8%) and arterial revascularization procedures (6.1% vs. 7.6%) vs. placebo, but these reductions did not attain statistical significance.

“The SHARP randomized trial has now shown that lowering of LDL cholesterol with simvastatin plus ezetimibe safely reduces the risk of major atherosclerotic events in a wide range of patients with chronic kidney disease,” the researchers wrote in their interpretation of the results. “When the SHARP results are compared with those of previous statin trials in renal patients, it appears that the absence of significant reductions in earlier trials could have been due both to the much smaller number and the much smaller proportion of vascular events in the primary outcomes that were related to atherosclerosis and, hence, preventable by lowering of LDL cholesterol.”

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Epidemiology of hypertension in low-income countries: a cross-sectional population-based survey in rural Uganda
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The next decade in mechanical assist: advances that will help the patient and the doctor
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Success in Implementing a Hospital-wide Evidence-based Clinical Pathways System for the Management of Cardiac Patients: The ACAP Program Experience
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MI rate fell nearly 75% in London cohort during 20-year period

Hardoon S. Eur Heart J. 2011;doi:10.1093/eurheartj/ehr142.

From 1985 to 2004, the rate of MI among participants of a cohort in London decreased 74%, with declining non-HDL cholesterol levels and increased HDL cited as the main reasons for the decline. However, the study, appearing in the European Heart Journal, also found that rising BMI could potentially reverse the trend in the future.

The researchers performing the study looked at men (n=6,379) and women (n=3,074) from the Whitehall II cohort. All participants were from 20 civil service departments in London between 1985 and 1988, aged 35 to 55 years and had clinic visits every 5 years. Participants completed questionnaires and examinations on health and lifestyle during four periods: 1985 to 1988, 1991 to 1993, 1997 to 1999 and 2002 to 2004.

During the 20 years, 256 first MI events were reported, of which 81.3% occurred in men. The age-sex adjusted hazard for MI decreased by 74% (95% CI, 48-87) during this time, which corresponded to a mean decline of 6.5% (95% CI, 3.2-9.7) per year.

According to the researchers, 56% of this decline could be attributed to percent decreases in non-HDL levels (34%), systolic BP (13%) and cigarette smoking (6%), as well as increases in HDL levels (17%) and fruit and vegetable consumption (7%). Also noteworthy, rising BMI reduced the scale of the decline by 11%.

These findings, the researchers wrote, highlight what can be achieved and emphasize the value of measures to reduce exposure to risk factors in the population.

“Further research is needed to determine whether the residual unexplained portion of the decline in MI may be explained by early treatment, underestimated contributions of the major risk factors (reflecting imprecision in the analyses) or the influence of other risk factors,” they said, while adding that the rising BMI in the UK and other countries still needs urgent attention.
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SPARCL: Statin treatment did not affect outcomes in patients with type 2 diabetes, metabolic syndrome

Callahan A. Arch Neurol. 2011;doi:10.1001/archneurol.2011.146.

A cohort of patients with type 2 diabetes mellitus or metabolic syndrome did not benefit from statin treatment, according to recent results.

The secondary analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial aimed to determine whether treatment with atorvastatin (Lipitor, Pfizer) could reduce stroke in patients with type 2 diabetes or metabolic syndrome who had recently had a stroke or transient ischemic attack.

There were 794 patients with type 2 diabetes at enrollment; 642 patients retrospectively included in a metabolic syndrome cohort; and 3,295 patients in a reference group who belonged to neither category.

Compared with the reference group, those with type 2 diabetes were at an increased risk for stroke (HR=1.62; 95% CI, 1.33-1.98), major CV events (HR=1.66; 95% CI, 1.39-1.97) and revascularization procedures (HR=2.39; 95% CI, 1.78-3.19).

There was no increased risk for stroke (P=.78) or major CV events (P=.38) among patients with metabolic syndrome compared with those in the reference group. However, patients with metabolic syndrome were more likely to undergo revascularization procedures (HR=1.78; 95% CI, 1.26-2.5).

No significant treatment interactions were observed for the SPARCL primary endpoint (P=.47), according to the results.

The primary endpoint was combined risk for nonfatal and fatal stroke, and secondary endpoints included major coronary events, major CV events, any coronary disease event and any revascularization procedure. Regression analysis was conducted to determine whether the effect of treatment varied based on the presence of type 2 diabetes or metabolic syndrome.
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SIRTAX LATE: Comparable outcomes for sirolimus-, paclitaxel-eluting stents at 5 years

Räber L. Circulation. 2011;123:2819-2828. Su

New randomized trial data have indicated that patients treated with first generation sirolimus-eluting stents had no significant differences in clinical and angiographic outcomes at 5 years compared with patients receiving paclitaxel-eluting stents.

The Sirolimus-Eluting Versus Paclitaxel-Eluting Stents for Coronary Revascularization (SIRTAX LATE) trial involved 1,012 patients randomly assigned to receive either sirolimus-eluting stents (SES; Cypher, Cordis; n=503) or paclitaxel-eluting stents (PES; Taxus, Boston Scientific; n=509). In addition, all patients had at leastone lesion in a vessel with a reference diameter between 2.25 and 4.00 mm.

At 5 years, 97.6% of SES and 96.1% of PES patients had obtainable clinical follow-up. Major adverse cardiac events (a composite of cardiac death, MI and ischemia-driven target lesion revascularization) occurred in 19.7% of SES patients and 21.4% of PES patients (HR=0.89; 95% CI, 0.68-1.17). Individually, there were no statistically significant differences in the rates of cardiac death (SES, 5.8% vs. PES, 5.7%), MI (SES, 6.6% vs. PES, 6.9%) or target lesion revascularization (TLR; SES, 13.1% vs. PES, 15.1%).

Also reported, the annual rate of TLR between 1 and 5 years was 2.0% for the SES group and 1.4% for PES group, while delayed lumen loss for those undergoing paired angiography between 8 months and 5 years was 0.37 ± 0.73 mm for SES and 0.29 ± 0.59 mm for PES patients.

Among the clinical implications of the study, the researchers wrote, were the low risk of repeat revascularization with first-generation drug-eluting stents (DES) and the observation that very late stent thrombosis remains an important liSIRTAX LATE: Comparable outcomes for sirolimus-, paclitaxel-eluting stents at 5 years

Räber L. Circulation. 2011;123:2819-2828.

New randomized trial data have indicated that patients treated with first generation sirolimus-eluting stents had no significant differences in clinical and angiographic outcomes at 5 years compared with patients receiving paclitaxel-eluting stents.

The Sirolimus-Eluting Versus Paclitaxel-Eluting Stents for Coronary Revascularization (SIRTAX LATE) trial involved 1,012 patients randomly assigned to receive either sirolimus-eluting stents (SES; Cypher, Cordis; n=503) or paclitaxel-eluting stents (PES; Taxus, Boston Scientific; n=509). In addition, all patients had at leastone lesion in a vessel with a reference diameter between 2.25 and 4.00 mm.

At 5 years, 97.6% of SES and 96.1% of PES patients had obtainable clinical follow-up. Major adverse cardiac events (a composite of cardiac death, MI and ischemia-driven target lesion revascularization) occurred in 19.7% of SES patients and 21.4% of PES patients (HR=0.89; 95% CI, 0.68-1.17). Individually, there were no statistically significant differences in the rates of cardiac death (SES, 5.8% vs. PES, 5.7%), MI (SES, 6.6% vs. PES, 6.9%) or target lesion revascularization (TLR; SES, 13.1% vs. PES, 15.1%).

Also reported, the annual rate of TLR between 1 and 5 years was 2.0% for the SES group and 1.4% for PES group, while delayed lumen loss for those undergoing paired angiography between 8 months and 5 years was 0.37 ± 0.73 mm for SES and 0.29 ± 0.59 mm for PES patients.

Among the clinical implications of the study, the researchers wrote, were the low risk of repeat revascularization with first-generation drug-eluting stents (DES) and the observation that very late stent thrombosis remains an important liSIRTAX LATE: Comparable outcomes for sirolimus-, paclitaxel-eluting stents at 5 years

Räber L. Circulation. 2011;123:2819-2828. Submit a Comment Print Email


New randomized trial data have indicated that patients treated with first generation sirolimus-eluting stents had no significant differences in clinical and angiographic outcomes at 5 years compared with patients receiving paclitaxel-eluting stents.

The Sirolimus-Eluting Versus Paclitaxel-Eluting Stents for Coronary Revascularization (SIRTAX LATE) trial involved 1,012 patients randomly assigned to receive either sirolimus-eluting stents (SES; Cypher, Cordis; n=503) or paclitaxel-eluting stents (PES; Taxus, Boston Scientific; n=509). In addition, all patients had at leastone lesion in a vessel with a reference diameter between 2.25 and 4.00 mm.

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At 5 years, 97.6% of SES and 96.1% of PES patients had obtainable clinical follow-up. Major adverse cardiac events (a composite of cardiac death, MI and ischemia-driven target lesion revascularization) occurred in 19.7% of SES patients and 21.4% of PES patients (HR=0.89; 95% CI, 0.68-1.17). Individually, there were no statistically significant differences in the rates of cardiac death (SES, 5.8% vs. PES, 5.7%), MI (SES, 6.6% vs. PES, 6.9%) or target lesion revascularization (TLR; SES, 13.1% vs. PES, 15.1%).

Also reported, the annual rate of TLR between 1 and 5 years was 2.0% for the SES group and 1.4% for PES group, while delayed lumen loss for those undergoing paired angiography between 8 months and 5 years was 0.37 ± 0.73 mm for SES and 0.29 ± 0.59 mm for PES patients.

Among the clinical implications of the study, the researchers wrote, were the low risk of repeat revascularization with first-generation drug-eluting stents (DES) and the observation that very late stent thrombosis remains an important limitation of first-generation DES, accounting for more than half of all MIs between 1 and 5 years.

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Late postoperative atrial fibrillation after cardiac surgery: a national survey within the cardiac rehabilitation setting
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Evaluation of the hypertensive state in treated patients: selection of appropriate blood pressure measurements per visit to the community pharmacy
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Core Competencies for Cardiac Rehabilitation/Secondary Prevention Professionals: 2010 Update: Position Statement of the American Association of Cardiovascular and Pulmonary Rehabilitation
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VALOR II: Thoracic stent graft safe, efficacious in patients with descending TAA

The Valiant thoracic stent graft produced favorable results at 1 year among patients with descending thoracic aortic aneurysms of degenerative etiology and proved to be noninferior to a predicate device, according to presented data.

The nonrandomized, prospective, pivotal VALOR II trial followed 160 patients with descending thoracic aortic aneurysms (TAA) of degenerative etiology who were treated with a thoracic stent graft (Valiant, Medtronic) at 24 US centers. Outcomes were compared with those obtained in the VALOR pivotal trial, a study that examined a precursor thoracic stent graft (Talent, Medtronic) among 195 patients with the same inclusion criteria.

Overall, 96.3% of VALOR II patients had successful stent graft delivery and deployment. At 30 days, perioperative mortality was 3.1% with a major adverse event rate of 38.1%. At 1 year, among 94.4% of patients from the VALOR II trial who were available for follow-up, rates of aneurysm-related mortality was 3.3%, 2.9% for stent-graft migration and 13% for endoleak, with no cases of rupture, conversion to open surgery or loss of stent-graft patency.

In all, the Valiant stent graft proved to be statistically noninferior to the Talent stent graft in 12-month all-cause mortality (12.6% vs. 16.1%) and exceeded the primary effectiveness goal of 12-month successful aneurysm treatment (97.4% vs. 80%), which was defined as the absence of aneurysm growth of more than 5 mm and of secondary procedures for type I/III endoleak.
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Sustained effectiveness of paclitaxel-eluting stent observed in patients with diabetes

For treating superficial femoral artery lesions in diabetic patients, the paclitaxel-eluting stent was shown to have sustained effectiveness at 1 and 2 years compared with percutaneous transluminal angioplasty, according to results of a late-breaking clinical trial presented at the 65th Vascular Annual Meeting of the Society for Vascular Surgery.

“Most superficial femoral artery interventions have worse outcomes in diabetics,” Sean P. Lyden, MD, with the Cleveland Clinic Foundation and researcher of the prospective, randomized trial, told Cardiology Today. “Diabetics do as well as nondiabetics with the paclitaxel-eluting [Zilver PTX, Cook Medical] stent.”

The trial involved 479 patients with symptomatic de novo or restenotic superficial femoral artery lesions who were treated at 55 institutions in the United States, Japan and Germany. All of patients were randomly assigned to receive a paclitaxel-eluting stent (n=241) or percutaneous transluminal angioplasty (PTA; n=238). In the event of acute PTA failure, defined as at least 30% residual stenosis, patients underwent secondary randomization to either provisional bare metal stent (Zilver) or provisional paclitaxel-eluting stent (Zilver PTX).

Overall, 118 patients had acutely successful PTA, and 120 did not. Of those 120 patients, 61 had provisional paclitaxel-eluting stent implantation vs. 59 who had provisional bare metal stent implantation. Among the 302 patients who received primary or provisional paclitaxel-eluting stent treatment, 48.3% had diabetes.

For patients with and without diabetes, demographics and lesion characteristics were similar. Event-free survival was comparable between groups, but slightly favored the nondiabetes group at both 1 year (93.5% vs. 89.2%) and 2 years (88.7% vs. 84.4%). Also similar were paclitaxel-eluting stent patency rates, which were nonsignificantly higher in nondiabetes patients at 1 year (85.2% vs. 83.9%) and 2 years (77.5% vs. 74.1%).

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ADDITION-Europe: Diabetes screening, early intensive intervention improved CV outcomes

SAN DIEGO — In patients who had their type 2 diabetes detected by screening in general practice, intensive multifactorial treatment led to small but significant improvements in risk factors when compared with usual care, including small reductions in mortality and cardiovascular events, researchers found in a new study.

Patients with longstanding diabetes will likely draw CV benefits from intensive multifactorial therapy, although how such treatment affects patients with diabetes found through screening is unclear. To answer this question, researchers conducted the multicenter Anglo-Danish-Dutch Study of Intensive Treatment In People with Screen Detected Diabetes in Primary Care (ADDITION-Europe).

Routine vs. intensive multifactorial therapy

Between 2001 and 2006, patients were screened for type 2 diabetes at 343 general practices in Denmark, the Netherlands and the United States. The researchers then randomly assigned the centers to provide routine care or intensive multifactorial therapy to the 3,057 patients (mean age, 60 years) who were diagnosed with diabetes via screening.

“Practices in routine care were asked to follow national guidelines, whereas family physicians assigned to provide intensive care were urged to give intensive lifestyle advice, such as changing diet or physical activity level, and drug treatments for blood glucose, lipids and blood pressure,” Torsten Lauritzen, MD, chairman of the ADDITION-Europe steering committee and professor at the University of Arhus in Denmark, said at a press conference said.

After a mean follow-up of 5 years, the intensive therapy group had CV outcomes that were only slightly better than the routine care group, results showed. The incidence of first CV event was 7.2% in the intensive therapy arm and 8.5% in the routine care arm. The incidence of all-cause mortality was 6.2% in the intensive treatment group and 6.7% in the routine care group. The slight discrepancies between the two treatment groups linked the intensive therapy to a nonsignificant 17% reduction in incidence of CV events.

Likewise, improvements in CV risk factors were comparable. The decline in BP, from 150 mm Hg at baseline to 138 mm Hg at follow-up, in the routine care arm was on par with the decrease observed in the intensive therapy arm (149 mm Hg to 135 mm Hg). Similarly, cholesterol levels dropped from 5.6 mmol/L to 4.4 mmol/L in the routine care group and from 5.5 mmol/L to 4.2 mmol/L in the intensive treatment group.

“Family physicians in the routine care group did a much better job than we expected,” Lauritzen said in a press release. “Even in that group, there was a clinically significant reduction in BP and cholesterol levels, and small reductions in blood glucose levels and weight were maintained over 5 years.”

Lauritzen explained that the study results provide a basis for offering routine screening for type 2 diabetes. “This study adds to the evidence that early detection and treatment is beneficial and may be useful in terms of encouraging high risk screening in the general population,” he said.

In an accompanying editorial, David Preiss, MRCP, of the British Heart Foundation, and Naveed Sattar, MBChB, MRCP, of the University of Glasgow, remained cautious.

While they noted that the data indicate the benefits of early diagnosis and treatment of diabetes, they said this study cannot answer “whether screen detection of diabetes is clinically beneficial against the background of current clinical diagnosis and practice.

“The key questions now are whether a sizeable reduction in the lead time between diabetes onset and clinical diagnosis can be achieved by implementation of simpler diagnostic criteria and, if so, to what extent this development might further reduce CV and mortality risks in patients with diabetes,” Preiss and Sattar wrote in The Lancet editorial. – by Melissa Foster

For more information:
Lauritzen T. Joint ADA/The Lancet Symposium. Presented at: American Diabetes Association’s 71st Scientific Sessions; June 24-28, 2011; San Diego, Calif.
Griffin SJ. Lancet. 2011;doi:10.1016/S0140-6736(11)60698-3.
Preiss D. Lancet. 2011;doi:10.1016/S0140-6736(11)60819-2.

Disclosure: ADDITION-Europe received funding from several institutions, public health councils as well as Novo Nordisk, Astra, Pfizer, GlaxoSmithKline, Servier, HemoCue and Merck. Drs. Preiss and Sattar report no relevant financial disclosures.

You might look at this trial and say that it is a little disappointing that the researchers did not see a significant difference between the intensive care and the routine care groups, but there are a couple of things to consider. First, only 5 years of follow-up were done. I do not know that you would really expect to see a very significant difference in the sort of hard CV outcomes with only 5 years, especially when treating people with very early diabetes. It will be interesting to see how the long-term follow-up works out. Second, the kind-of-surprising thing is how well the routine care patients were treated. It is almost like there were not huge differences between the care. Overall, [the study] does suggest that screening, finding people early and treating them early does seem to have some benefits.

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Smoking during pregnancy could adversely affect children’s HDL levels

Ayer J. Eur Heart J. 2011;doi:10.1093/eurheartj/ehr174.

Data from a community-based longitudinal study have indicated that 8-year-old children whose mothers smoked during pregnancy had lower HDL levels while also having higher triglycerides and systolic BP.

“The prevalence of maternal smoking during pregnancy remains high, [about] 15% in many Western countries,” the researchers wrote. “The documented associations between smoking in pregnancy and childhood behavioral problems, neurocognitive deficits and sudden infant death syndrome highlight the potential for smoking to result in adverse fetal programming. The independent effect of prenatal exposure to cigarette smoke on the risk of future CVD, however, remains uncertain.”

Researchers performed a prospective analysis, culling data from questionnaires that were completed by face-to-face interviews of mothers soon after giving birth, which assessed their smoking status during the first, second and third trimesters. At the beginning of the study, 616 newborn infants were included in the analysis, and data on 405 of these children who reached 8 years of age were available.

Overall, women who smoked in pregnancy tended to have lower levels of education and shorter breast-feeding duration. At 8 years of age, children whose mothers smoked during pregnancy had lower levels of HDL (1.32 mmol/L vs. 1.50 mmol/L; P=.0005], as well as higher systolic BP (102.1 mm Hg vs. 99.9 mm Hg; P=.006) and triglycerides (1.36 mm Hg vs. 1.20 mmol/L; P=.04). However, no significant difference regarding carotid intima-media thickness was observed.

After multivariable adjustment, smoking during pregnancy remained predictive of lower HDL levels in children (P=.003), although not higher systolic BP (P=.07).

These data, the researchers concluded, “may be important for informing population-based prevention of atherosclerosis, as smoking in pregnancy remains common and HDL cholesterol has important atheroprotective functionality.”

This is a novel study of importance that extends our knowledge about long-term adverse effects on offspring of smoking during pregnancy. Lower levels of HDL that persist in childhood is clear evidence of formative pre-natal conditioning that has long-term consequences and while the mechanistic pathway(s) are not understood, the implications are clear - smoking during pregnancy sets the child up for CVD. Renewed efforts must address the smoking epidemic among younger women today.
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Intensive statin therapy may increase risk for new-onset diabetes

Preiss D. JAMA. 2011;305:2556-2564.

An analysis of data from previously published studies revealed an increased risk for new-onset diabetes with intensive-dose statin therapy as compared with moderate-dose therapy.

Pooled results from five statin trials indicated that, of 32,752 participants without diabetes, 8.4% developed diabetes during a mean follow-up of about 5 years. Diabetes developed in 1,449 of those assigned to intensive-dose statin therapy and 1,300 assigned to moderate-dose therapy.

The researchers calculated an OR of 1.12 (95% CI, 1.04-1.22) for new-onset diabetes in patients who received intensive statin therapy vs. moderate therapy. Data also showed that two more cases of incident diabetes occurred per 1,000 patient-years among those who received intensive treatment (18.9) compared with those who received moderate therapy (16.9). Consequently, the researchers found that the number needed to harm was 498 per year for intensive therapy as compared with moderate therapy.

In contrast, intensive therapy conferred cardiovascular benefits. In those who received intensive therapy, 3,134 patients experienced CV events compared with 3,550 who received moderate therapy. Compared with moderate therapy, the researchers calculated an OR of 0.84 (95% CI, 0.75-0.94) for CV events in patients who received intensive therapy. Further, 6.5 fewer first major CV events occurred per 1,000 patient-years in the intensive-dose group (44.5) vs. the moderate-dose group (51). These results suggested that the number needed to treat to prevent one CV event per year was 155.

According to other results, the risk for incident diabetes was similar among patients who received an 80-mg dose of simvastatin (Zocor, Merck) and those who received an 80-mg dose of atorvastatin (Lipitor, Pfizer), although high-dose atorvastatin was associated with greater reductions in risk for CV events.

“Our findings suggest that clinicians should be vigilant for the development of diabetes in patients receiving intensive statin therapy,” the researchers concluded.

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Multiple readings may be necessary for accurate BP measurement

Appel L. Ann Intern Med. 2011;154:838-839.
Powers B. Ann Intern Med. 2011;154:781-788.

The averaging of several BP measurements could have a substantial effect on reducing the variability in measurements witnessed among hypertensive patients, with the greatest benefit observed with five to six measurements, according to a new study.

In the study, 444 veterans (mean age, 64 years; 92% men) with hypertension from the Durham Veterans Affairs Medical Center, Durham, N.C., were followed for 18 months. Investigators obtained BP through three methods — clinic BP measurements obtained during outpatient visits; standardized research BP measurements every 6 months; and home BP measurements with a monitor transmitting measurements electronically. Controlled systolic BP was defined as a mean measurement of less than 140 mm Hg for clinic or research measurement and less than 135 mm Hg for home measurement.

During follow-up, a substantial variability in BP measurements was found among patients. Specifically, 28% of patients were designated as in control by clinic measurement, 47% by home measurement and 68% by research measurement. Variability was particularly apparent during the short-term for all methods, culminating with a mean within-patient coefficient of variation of 10%.

Overall, a single clinic systolic BP measurement from 120 mm Hg to 157 mm Hg was unable to classify patients as having BP in or out of control with 80% certainty. However, variability could be substantially reduced by averaging several measurements, the researchers said, with the most benefit detected at five to six measurements.

“Current treatment of patients with hypertension relies heavily on clinic measurement of BP, and the quality of this care is evaluated solely in this setting,” the researchers wrote. “For patients who visit their physician to receive personalized health recommendations, high-quality care should reflect good clinical decision-making based on adequate information. In hypertension, simple changes in the setting and number of BP measurements used for decision-making could greatly enhance the personalization of care.”

In an accompanying editorial, Lawrence J. Appel, MD, Edgar R. Miller III, MD, PhD, and Jeanne Charleston, BSN, RN,with Johns Hopkins University, wrote that previously, the importance of accurate and precise BP measurement had been largely ignored and that this study highlights the benefits of recording and averaging high-quality BP measurements across several visits.

“Given persistent problems in obtaining such measurements, a regulatory approach should be considered in which the Joint Commission, the National Committee for Quality Assurance and other organizations set standards and monitor compliance,” they said. “It is time to get serious about BP measurement.”

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Rivaroxaban Wins FDA Approval for DVT Prevention
By Peggy Peck, Executive Editor, MedPage Today
Published: July 01, 2011

WASHINGTON -- The FDA has approved rivaroxaban (Xarelto), an oral, once-daily, factor Xa inhibitor, for prevention of deep vein thrombosis in patients undergoing knee or hip replacement surgery, according to an announcement by Janssen Pharmaceuticals.

The drug is approved for use at a 10 mg dose, once a day for 35 days following hip replacement and for 12 days following knee replacement.

Rivaroxaban, which is also being developed for prevention of recurrent DVT and for prevention of stroke in patients with atrial fibrillation, is the second oral anticoagulant approved by the FDA within the last nine months.

Dabigatran (Pradaxa), a direct thrombin inhibitor, won FDA approval last October for prevention of stroke in patients with atrial fibrillation. It is not approved for DVT prophylaxis.

A third novel oral anticoagulant, apixaban (Eliquis), has also posted promising results in clinical trials and it is widely expected that an NDA for it will be submitted by year end.

Janssen said the FDA based its decision on data from the rivaroxaban phase III clinical development program in which the drug demonstrated greater efficacy than enoxaparin while demonstrating a similar safety profile "including low rates of major bleeding."

When compared with enoxaparin in EINSTEIN DVT, a study of more than 3,400 older adults with symptomatic DVT, rivaroxaban-treated patients had a significantly lower rate of recurrent DVT than warfarin-treated patients.

Likewise, in ROCKET-AF rivaroxaban was as effective as warfarin for preventing stroke in patients with Afib and boasted a slightly better safety profile.

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Low vitamin D increased risk for arterial stiffness, endothelial dysfunction
Mheid AL. J Am Coll Cardiol. 2011;58:186–192.

In a study of over 500 patients, low levels of the vitamin D marker 25-hydroxyvitamin D significantly increased the likelihood of arterial stiffness and endothelial dysfunction in the conductance and resistance blood vessels.

“Our findings … provide mechanistic explanation of how depressed vitamin D status, by precipitating vascular dysfunction, might predispose individuals to a higher risk for the development of CVD and adverse events,” the researchers wrote.

In the study, a group of researchers from Georgia and the United Kingdom measured 25-hydroxyvitamin D (25-OH D) in 554 subjects between the ages of 20 and 79. They then determined arterial stiffness as well as endothelial and microvascular function.

Overall, mean 25-OH D among the population was 31.8 ± 14 ng/ml. Following adjustment for several variables, including age, sex, race, BMI, medication use, total cholesterol, LDL, triglycerides and CRP, 25-OH D was associated with reactive hyperemia index (P<.001), subendocardial viability ratio (P=.001), flow-mediated vasodilation (P=.03), augmentation index (P=.03) and pulse wave velocity (P=.04).

Among those with vitamin D deficiency (n=42), 25-OH D normalization by 6 months resulted in increases in both reactive hyperemia index (P=.009) and subendocardial viability ratio (P=.04), and a decrease in mean arterial pressure (P=.02).

As a result of these findings, the researchers called for larger trials to assess the effect of vitamin D therapy on prevention of CVD in individuals with vitamin D insufficiency.
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Drug-, device-induced effects on HF markers did not predict mortality benefit
Wessler BS. Circ Heart Fail.2011;doi: 10.1161/circheartfailure.111.961573.

In an analysis of trial level data from different eras, the average drug- and device-induced effects on peak oxygen consumption, 6 minute walk distance and two biomarkers among patients with HF and reduced ejection fraction was not predictive of long-term therapeutic effects on mortality.

The study featured a total 20,820 patients from 109 trials that were published between January 1966 to September 2009. All trials determined the role of the functional markers peak oxygen consumption (VO2) and 6 minute walk distance, and natriuretic peptide biomarkers (BNP and NT-proBNP) in predicting mortality in patients with HF and left ventricular dysfunction. As a requisite, the trials were randomized controlled trials, and determined mortality in at least 500 patients over a period of at least 6 months.

Overall, there was no significant association between mortality and therapy-induced placebo-corrected change in peak VO2 or in natriuretic peptides. Researchers did observe a modest correlation between drug or device induced average change in 6 minute walk distance and an increased odds ratio for mortality (P= 0.036). However, with regards to the latter finding, James E. Udelson, MD, with Tufts Medical Center, Boston, and study investigator, told Cardiology Today that because the correlation was so weak, “it is clear that you could never really use change in 6 minute walk distance as a predictor of mortality in any clinical sense.”

As a result, Udelson and colleagues concluded in the study that while these markers may objectively reflect functional capacity and represent pathophysiologic changes that are seen in HF, “our findings do not provide support for their use as surrogates for an intervention’s effect on long-term mortality. Continued work is needed to validate potential markers and find novel surrogates for research trials of therapies in HF.” – by Brian Ellis

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Diastolic dysfunction predicted mortality in patients with normal systolic function

Halley CM. Arch Intern Med. 2011;171:1082-1087.
Piña IL. Arch Intern Med. 2011;171:1088-1089.

Diastolic dysfunction in the presence of impaired systolic dysfunction is associated with mortality, but a new study has found that diastolic dysfunction in patients with normal systolic function is also predictive of mortality.

In the study, researchers from the Cleveland Clinic found that both moderate and severe diastolic dysfunction as assessed by echocardiography among patients with normal systolic function was linked with mortality. However, mild diastolic dysfunction was not.

“This finding has important clinical implications, especially given the high prevalence of mild diastolic dysfunction in the population studied,” they wrote.

The study population included 36,261 patients (mean age, 58.3 years; 54.4% female) with normal ejection fraction (>55%) between January 1996 and December 2005. Researchers determined diastolic function on the basis of four echocardiographic Doppler variables: normal (n=12,603), mild dysfunction (grade 1; n=21,758), moderate dysfunction (grade 2; n=1,773) and severe dysfunction (grade 3; n=127).

Overall, patients who were male, obese (BMI >30) and older than 65 years were more likely to have diastolic dysfunction.

During a mean follow-up of 6.2 years, 5,789 deaths were reported. According to unadjusted analysis, survival was worse depending on the presence and degree of diastolic dysfunction (P<.001). The researchers then performed propensity matching and found that moderate (HR=1.58) and severe (HR=1.84; P<.001) diastolic dysfunction were significantly associated with an increased risk for mortality.

For Ileana L. Piña, MD, with Case Western Reserve University, Cleveland, and author of the accompanying editorial, these findings lend credence to the complexity of HF with preserved ejection fraction beyond only diastolic dysfunction and of the ways patients ultimately progress to frank HF.

“Halley et al provide an important piece of the puzzle (ie, that diastolic dysfunction is common and that physicians need to be aware of the prognostic value of moderate and severe diastolic dysfunction),” she wrote. “The missing link between diastolic dysfunction diagnosed via echocardiographic testing and the acute presentation of older women with HF with preserved ejection fraction is yet to be elucidated. Further work will help solve this puzzle.”
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Atherosclerotic plaque characteristics differ between black, white patients

Nance JW. Radiology. 2011;doi:10.1148/radiol.11110158.

Using coronary CTA, researchers were able to detect differences in atherosclerotic plaque burden and composition between black and white patients, which highlighted the presence of more non-calcified disease in blacks and more calcified disease in whites.

“For a long time, physicians have searched for explanations as to why African Americans have higher rates of heart disease and higher cardiac death rates, but less coronary artery calcium than Caucasians,” U. Joseph Schoepf, MD, director of CV imaging at Medical University of South Carolina, Charleston, and study investigator, said in a press release. “We show that one possible explanation for the discrepancy may be found in the higher rate of less stable, non-calcified plaque in the heart vessels of African Americans.”

All patients (n=301; 50.2% white, 49.8% black) in the analysis had acute chest pain and underwent coronary CT angiographic examination that included the evaluation of each coronary artery segment for the presence of atherosclerotic plaque, plaque composition and stenosis.

According to results, with the exception of diabetes, which was higher in blacks (P=.003), no other difference in a CV risk factor reached statistical significance between white and black patients. Overall, the presence of any plaque and stenosis did not significantly differ between white and black patients. However, other characteristics did, including higher rates in blacks of prevalence (64% vs. 41%; P<.001) and volume (2.2 mL vs. 1.4 mL; P<.001) of non-calcified plaque independent of CV risk factors, as well as a lower prevalence of calcified plaque (26% vs. 45%; P=.001).

“For African-American patients, coronary CTA may be a more appropriate screening tool for CV risk,” Schoepf said.

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Salt reduction initiatives around the world
[Ссылки доступны только зарегистрированным пользователям ]

Depression and Cardiac Disease: A Review
[Ссылки доступны только зарегистрированным пользователям ]

Impact of smoking on acute phase outcomes of myocardial infarction
[Ссылки доступны только зарегистрированным пользователям ]

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Varenicline linked to increased chance for serious CV events
Singh S. CMAJ. 2011;doi:10.1503/cmaj.110218.

The use of varenicline, a medication used for smoking cessation, was associated with an increased risk for serious adverse CV events, results from a meta-analysis suggested.

The researchers analyzed data from 14 double blind, randomized controlled trials that included 8,216 participants. The studies included smokers or users of smokeless tobacco who had reported CV events such as ischemia, arrhythmia, congestive HF, sudden death or CV-related death as serious adverse events linked with the use of the drug. The trials ranged in duration from 7 weeks to 1 year.

According to the results, the use of varenicline (Chantix, Pfizer) was associated with an increased risk for serious adverse CV events (52 of 4,908 patients) vs. placebo (27 of 3,308 patients; 1.06% vs. 0.82%; Peto OR=1.72; 95% CI, 1.09-2.71). The researchers said there were not enough patients in the analysis to allow meaningful comparisons of mortality.

“Our meta-analysis raises safety concerns about the potential for an increased risk of serious adverse CV events associated with the use of varenicline among tobacco users,” the researchers concluded. “Despite the limitations of our analysis, our findings have potential regulatory and clinical implications.”

In an addendum, the researchers said the FDA had announced the addition of a warning to the product label of varenicline regarding “the small increased risk of certain adverse CV events associated with the use of varenicline among smokers with CVD.”
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Recurrent stroke, vascular event rate on decline during past 50 years

Hong K. Circulation. 2011;123:2111-2119.

During a 50-year span, the annual event rate of strokes and major vascular events declined by roughly 1% per decade each, according to an analysis of nearly 60 secondary prevention trials.

The systematic review included only randomized controlled trials (n=59) published from 1960 to 2009 with a more than 6-month follow-up. Other inclusion factors were that most qualifying events were ischemic stroke or transient ischemic attack and intervention was a medical treatment. A total of 66,157 patients comprised the study population.

During the 50 years, annual event rates for recurrent stroke declined by 0.996% per decade (P=.001), with similar reductions also found for fatal stroke (0.282% decline per decade; P=.003). However, the greatest percent deduction was found with major vascular events, which declined by 1.331% per decade (P=.001).

The researchers then performed multiple regression analysis to determine the underlying causes of the decline in stroke and found that increasing use of antithrombotic agents and lowering systolic/diastolic BPs were the major contributors.

In the clinical perspective of the study, the researchers wrote on the influence of drug therapy, commenting that the introduction into practice of successive waves of therapies with proven efficacy in stroke prevention “has been notably successful, resulting in a substantial decline in the rate of recurrent vascular events in the control arms of secondary stroke prevention trials. Consequently, trials of new therapies are more arduous, requiring ever larger sample sizes to confirm treatment efficacy, and clinical investigators must cope with the paradox of progress.”

Other study data of interest showed that compared with the 3 decades before 1990, the past 20 years saw rises in hypertension, diabetes and hyperlipidemia, whereas smoking and transient ischemic attacks declined (P<.05 for all). – by Brian Ellis
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Therapeutic hypothermia yielded positive neurological outcomes among certain cardiac arrest patients

Mooney MR. Circulation. 2011;doi:10.1161/circulationaha.110.986257.

More than 90% of patients who had received therapeutic cooling as treatment for an out-of-hospital cardiac arrest survived with positive neurological outcomes, according to trial results.

There were 140 out-of-hospital cardiac arrest patients who participated in the trial between February 2006 and August 2009. Eligible patients had remained unresponsive after a return of spontaneous circulation. These patients were cooled and re-warmed with an automated, non-invasive cooling device.

Three-quarters of the patients (n=107) — including those with non-ventricular fibrillation arrest or cardiogenic shock — were transferred to a therapeutic hypothermia-capable hospital via referral from other hospitals within the participating network. Sixty-eight patients with concurrent STEMI received cardiac intervention and cooling simultaneously.

The overall survival to discharge rate was 56%. Ninety-two percent of survivors had a positive neurological outcome at discharge.

No differences in survival rates were observed between transferred and non-transferred patients. Non-ventricular fibrillation arrest and presence of cardiogenic shock were strongly linked to death. However, survivors with non-ventricular fibrillation arrest had a 100% positive neurological recovery rate, and survivors with cardiogenic shock present had an 89% positive neurological recovery rate.

For each hour of delay in initiating cooling, mortality risk increased 20% (95% CI, 4-39).

The endpoint of positive neurological outcome was defined as cerebral performance category 1 or 2 at discharge.

The researchers said therapeutic hypothermia is an underused treatment strategy despite showing signs that it improves survival and confers neuroprotection on patients who have a cardiac arrest outside of the hospital, and regional systems of care for these patients are necessary. A comprehensive protocol may result in further dispersion of this “essential therapy for [out-of-hospital cardiac arrest].”
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CAD affecting atrial branches predictive of AF development after MI
Alasady M. Heart Rhythm. 2011;8:955-960.

In a population of patients with acute MI, coronary artery disease was shown to be an independent determinant of atrial fibrillation after MI.

After examining patients (n=2,460) admitted to a cardiac care unit for MI between 2004 and 2009 and excluding patients with prior AF, pericarditis, severe valvular heart disease, left ventricular hypertrophy, LV dysfunction and recent CABG, the researchers ended up with a study population of 42 AF cases and 42 MI but no AF cases (control).

Overall, AF patients had a higher likelihood of presenting with an inferior MI (P=.002), but a lower likelihood of presenting with STEMI (P=.03) and undergoing early revascularization with primary angioplasty within 6 hours (P=.004).

Researchers also found the following variables associated with AF: indexed left atrial volume (P<.001), right atrial branch disease (P<.001), sinoatrial branch disease (P<.001), LV filling pressure (P=.001), time from onset of symptoms to coronary intervention (P=.002), left atrial branch disease (P=.009) and left main stem disease (P=.02). After multivariable analysis, they determined that both right and left coronary artery arterial branch disease predicted AF after MI (P=.02).

“With the angiographic data and echocardiographic findings, our results provide novel insight into the mechanisms underlying the development of AF in patients after they experience a heart attack,” study researcher Prashanthan Sanders, MBBS, PhD, of the Royal Adelaide Hospital, Australia, said in a press release. “The findings shed new light on how coronary disease affects the atrial branches after the trauma of a heart attack regardless of measurable effects such as a patient’s gender or age.”