Angiotensin receptor blockers - advantages of the new sartans

Advantages of the new angiotensin receptor blockers (ARBs) include once daily dosing, an absence of significant adverse reactions, well tolerated side effect profile and cost effectiveness. A growing realization is their beneficial pleotropic effects. Antihypertensive agents are widely used to reduce the risk of cardiovascular events partly beyond that of blood pressure-lowering. The RAAS, and its primary mediator Ang II, also have a direct influence on the progression of the atherosclerotic process via effects on endothelial function, inflammation, fibrinolytic balance, and plaque stability. For patients at high cardiovascular risk based on the results of the ONTARGET and TRANSCEND studies, telmisartan is indicated for cardiovascular prevention. Studies have shown that olmesartan medoxomil treatment may slow the progression of atherosclerosis and postpone albuminuria thereby potentially improving CV outcomes.

Two-year outcomes after deployment of XIENCE V everolimus-eluting stents in patients undergoing percutaneous coronary intervention of bifurcation lesions: a report from the SPIRIT V single arm study

The aim of this analysis was to analyze outcomes of patients undergoing Xience V EES treatment of bifurcation lesions, a subset in which treatment is particularly challenging. The SPIRIT V Study provided an evaluation of the Xience V everolimus eluting stent (EES) performance in complex patient and lesion population. The SPIRIT V Single Arm Study enrolled 2700 patients with de novo coronary artery lesions suitable to be optimally treated with a maximum of four planned Xience V EES. Lesion evaluation was by visual assessment. The outcomes of the 492 patients undergoing Xience V EES stenting of ≥1 bifurcation lesion were compared to those with no bifurcation lesion treated. Compared to those without bifurcation treatment, patients with bifurcation treatment were more likely to have multi-vessel disease (49% vs 40%), left main treatment (3.1% vs 0.9%), more lesions treated (1.5 vs 1.3), calcification (36.4% vs 27.5%), and ostial (17.1% vs 8.2%) and angulated lesions (29.3% vs 21.1%), all P < 0.001. The 30-day composite rate of death, myocardial infarction (MI), target vessel revascularization (TVR) was 4.3% in patients with bifurcation PCI and 2.2% in those with non-bifurcation PCI (P = 0.017). At 2 years, this composite event rate was 11.3% and 10.0% in these two groups, respectively (P = 0.403). Rates of cardiac death, MI, target lesion revascularization (TLR), TVR, and ARC defined definite or probable stent thrombosis (0.4% vs 0.9%, P = 0.402) were not significantly different between the two groups. Despite greater patient and lesion complexity, treatment of patients with bifurcation lesions using the Xience V EES in the SPIRIT V prospective Single Arm Study was safe and effective, with low overall event rates that were similar to those without bifurcation lesion treatment. © 2013 Wiley Periodicals, Inc.

Fractional flow reserve: intracoronary versus intravenous adenosine induced maximal coronary hyperemia

BACKGROUND

Fractional Flow Reserve (FFR), a measure of coronary stenosis severity is based on the achievement of maximal hyperemia of coronary microcirculation. The most widely used pharmacological agent is adenosine which is administered either by intra coronary or intra venous routes. IV route is time consuming, has more side effects and expensive. This study is undertaken to compare the two routes of administration.

METHODS

FFR was assessed in 50 patients with 56 intermediate focal lesions using both IV and intracoronary (IC) adenosine. FFR was calculated as the ratio of the distal coronary pressure to the aortic pressure at maximal hyperemia.

RESULTS

A total of 25 left anterior descending, 8 right, 21 circumflex, and 2 left main coronary arteries were evaluated. The mean percent stenosis was 63.91 ± 13.13 SD and, the mean FFR was 0.831 ± 0.0738 SD for IV and 0.832 ± 0.0707 SD for IC adenosine. There was a strong and linear correlation between 2 sets of observations with IV dose and IC adenosine dose (R = 0.964, y = 0.065 + 0.923x; p < 0.001) (y = IV dose, x = IC dose). The agreement between the two sets of measurements was also high, with a mean difference of: 0.001 ± 0.0197. The changes in heart rate and blood pressure were significantly higher in IV adenosine group. Different incremental doses were well tolerated, with fewer systemic adverse events with IC adenosine. Transient AV blocks were observed with both IV and IC adenosine.

CONCLUSIONS

This study suggests that IC adenosine is equivalent to IV infusion for the determination of FFR. The administration of IC adenosine is easy to use, cost effective, safe and associated with fewer systemic events.

Post-marketing study of clinical experience of atorvastatin 80 mg vs 40 mg in Indian patients with acute coronary syndrome- a randomized, multi-centre study (CURE-ACS)

OBJECTIVE

To generate comparative clinical data in Indian patients with acute coronary syndrome (ACS) in terms of safety and efficacy of atorvastatin 80 mg vis-à-vis atorvastatin 40 mg

MATERIALS AND METHODS

A total of 236 patients with diagnosed ACS (with TIMI Risk score > or = 3) within preceding 10 days were randomized to receive either atorvastatin 80 mg or atorvastatin 40 mg once daily for 12 weeks. Out of 236 patients, data for 173 was analyzed who had both baseline and post-baseline lipid assessment. The primary end point of the trial was percentage change in LDL-C at the end of treatment from baseline. Other end points were change in high sensitivity C reactive protein, incidence of increase in liver enzymes > or = 3 times upper limit of normal and incidence of myotoxicity (with or without elevation of creatinine phosphokinase) at the end of treatment.

RESULTS

A dose-dependent response was observed with greater reduction of LDL -C in atorvastatin 80 mg (27.5% vs 19.04%) than that of atorvastatin 40 mg group. Both the treatment groups had a significant reduction (p < 0.001) in LDL-C at the end of 6 and 12 weeks in comparison to baseline. hs-CRP was also significantly reduced (p < 0.001) in both the treatment groups i.e. atorvastatin 80 mg (76.15%) and atorvastatin 40 mg (84.4%) from baseline at the end of 12 weeks. Both doses of atorvastatin were well tolerated. No patient had elevation of (> or = 3 times of upper limit of normal) liver enzymes or creatinine phosphokinase. One patient on atorvastatin 80 mg complained of myalgia. There were no dose-related differences in incidence of adverse events between two treatment groups.

CONCLUSION

The CURE-ACS trial indicated that atorvastatin 80 mg was more effective than atorvastatin 40 mg in terms of reduction in LDL cholesterol and was as safe and well tolerated as 40 mg dose in Indian patients with ACS.

Evolving coronary stent designs. Journey from substance to sublime

Coronary artery disease continues to remain a global health care burden. Paradoxical changes in global economies have redefined future development and consumption markets. Within the next decade the need for high quality, low cost coronary stents may reach up to 10 million units. Parallel changes in technological trends further necessitate ingenuity in coronary stent development. Developing nations, armed with novel technologies, supported with low development costs and access to high end manufacturing are poised to serve the global demands of future coronary stent requirements. New concepts in DES engineering employing novel stent designs, drug delivery technologies and affordable DES systems will effectively bridge the need gap between metal backed DES and its ultimate nemesis the bioresorbable scaffold.

The SPIRIT V diabetic study: a randomized clinical evaluation of the XIENCE V everolimus-eluting stent vs the TAXUS Liberté paclitaxel-eluting stent in diabetic patients with de novo coronary artery lesions

BACKGROUND

Diabetic patients respond less favorably to revascularization and have poorer long-term outcomes. Our main aim was to evaluate the angiographic efficacy of XIENCE V (everolimus-eluting stent, or EES) in diabetic patients compared with TAXUS Liberté (paclitaxel-eluting stent, or PES).

METHODS

The SPIRIT V Diabetic Study was a prospective, single-blind, randomized study that enrolled 324 diabetic (insulin and non-insulin dependent) patients at 28 sites in Europe and Asia Pacific. Randomization was 2:1 between EES (n = 218) and PES (n = 106). The primary end point was sequential noninferiority and superiority of EES for in-stent late loss at 9 months. Secondary clinical end points included stent thrombosis, death, myocardial infarction, and revascularization rates up to 1 year.

RESULTS

Everolimus-eluting stent was superior to PES for in-stent late loss at 9 months (0.19 mm vs 0.39 mm, respectively; P(superiority) = .0001). The composite rate of death, myocardial infarction, and target vessel revascularization was the same in the 2 groups at 1 year (16.3% vs 16.4%). No stent thromboses (Academic Research Consortium definite and probable) were seen through 1 year with EES compared with 2 of 104 (2%) with PES (P = .11).

CONCLUSION

In this prospective, randomized trial in a high-risk group of diabetic patients, implantation of EES compared with PES resulted in significantly better inhibition of intimal hyperplasia with a comparable safety outcome.

Platelet adenosine diphosphate receptor antagonists: ticlopidine to ticagrelor-a long continuing journey

Platelet aggregation plays a central role in the pathogenesis of atherothrombosis. Platelet adenosine diphosphate (ADP) receptor antagonists (ticlopidine, clopidogrel, prasugrel, and ticagrelor) are a major advance in the treatment of atherothrombotic diseases, especially acute coronary syndromes (ACS). Ticlopidine was the first thienopyridine introduced into clinical practice, but its potentially serious haematological side-effects limited its use and it was quickly eclipsed by clopidogrel. Clinical trials established aspirin plus clopidogrel as the standard dual anti-platelet therapy in patients with ACS and patients undergoing percutaneous coronary intervention (PCI) with stenting. Clopidogrel was found to have pharmacokinetic and pharmacodynamic limitations. Prasugrel is the next approved thienopyridine that has shown superior efficacy in ACS patients undergoing PCI in comparison to clopidogrel, although at the cost of a higher bleeding risk. Ticagrelor is the latest non-thienopyridine ADP receptor blocker that is potent, effective, reversible, and relatively safer as compared to clopidogrel. Both prasugrel and ticagrelor are more potent than clopidogrel. The data so far suggests that ticagrelor has a wider applicability in usage in patients with ACS as compared to prasugrel. Prasugrel however seems to be better tolerated. Search is on for newer more potent but safer anti-platelet agents.

Prevalence of diagnosed and undiagnosed diabetes and hypertension in India--results from the Screening India's Twin Epidemic (SITE) study

OBJECTIVE

Despite the rising number of patients with diabetes and hypertension in India, there is a dearth of nationwide, comprehensive prevalence data on these diseases. Our study aimed at collecting data on the prevalence of diabetes and hypertension and the underlying risk factors in various outpatient facilities throughout India.

METHODS

This cross-sectional study was planned to be conducted in 10 Indian states, one state at a time. It was targeted to enroll about 2,000 patients from 100 centers in each state. Each center enrolled the first 10 patients (≥18 years of age, not pregnant, signed consent) per day on two consecutive days. "Diabetes" and "hypertension" were defined by the 2008 American Diabetes Association and the Joint National Committee's 7(th) Report guidelines, respectively. Patient data (demographics, lifestyle factors, medical history, and laboratory diagnostic results) were collected and analyzed.

RESULTS

During 2009-2010, in total, 15,662 eligible patients (54.8% males; mean age, 48.9±13.9 years) from eight states were enrolled. Diabetes was prevalent in 5,427 (34.7%) patients, and 7,212 (46.0%) patients had hypertension. Diabetes and hypertension were coexistent in 3,227 (20.6%) patients. Among those whose disease status was not known at enrollment, 7.2% (793 of 11,028) and 22.2% (2,408 of 10,858) patients were newly diagnosed with diabetes and hypertension, respectively; additionally, 18.4% (2,031 of 11,028) were classified as having prediabetes and 60.1% (6,521 of 10,858) as having prehypertension. A positive association (P<0.05) was observed between diabetes/hypertension and age, familial history of either, a medical history of cardiovascular disorders, alcohol consumption, and diet.

CONCLUSIONS

Our study demonstrates that the substantial burden of diabetes and hypertension is on the rise in India. Patient awareness and timely diagnosis and intervention hold the key to limiting this twin epidemic.

Approach to STEMI and NSTEMI

Acute coronary syndrome (ACS) refers to any constellation of clinical symptoms that are compatible with acute myocardial ischemia. ACS is divided into ST- elevated myocardial infarction (STEMI), non-ST elevated myocardial infarction (NSTEMI), and unstable angina (UA). STEMI results from complete and prolonged occlusion of an epicardial coronary blood vessel and is defined based on ECG criteria..NSTEMI usually results from severe coronary artery narrowing, transient occlusion, or microembolization of thrombus and/or atheromatous material. NSTEMI is defined by an elevation of cardiac biomarkers in the absence of ST elevation. The syndrome is termed UA in the absence of elevated cardiac enzymes. History, physical examination, ECG, biochemical markers, ECHO all remain important tools to make an appropriate diagnosis The management of ACS should focus on rapid diagnosis, risk stratification, and institution of therapies that restore coronary blood flow and reduce myocardial ischemia.

Evaluation of the XIENCE V everolimus eluting coronary stent system in the Asian population of the SPIRIT V single arm study. 2-year clinical follow-up data

BACKGROUND

Asian patients have a uniquely high risk for heart disease compared to other ethnicities. Past drug eluting stent trials have examined mainly populations of European heritage. As a significant proportion of the real world population in the SPIRIT V single arm study is Asian, the study provides insight into how this population responds to stenting with the XIENCE V Everolimus Eluting Coronary Stent (EES).

METHODS AND RESULTS

2,700 patients were enrolled at 93 sites in Europe, Asia Pacific and Canada between November 2006 and November 2007. 698 (26%) patients were recruited from Asian sites in India, China, Hong Kong, Malaysia, Singapore and Thailand. De novo coronary artery lesions of all patients were to be treated with up to 4 planned EES. Up to 2 year follow-up, major adverse cardiac events, myocardial infarction and target lesion revascularization rates were lower in the Asian subgroup than in the non-Asian subgroup. These results were mainly driven by better clinical outcomes in the Indian population. All populations showed similar low stent thrombosis rates.

CONCLUSION

These findings demonstrate the safety and efficacy of the EES when used in a real-world Asian population, known to be at higher risk for heart disease.

Type IV Dual Left Anterior Descending Coronary Artery:A Rare Anomaly

Type IV dual left anterior descending (LAD) coronary artery is a rare anomaly and was detected incidentally during a routine coronary angiogram. The article discusses the types of dual LAD and their clinical implications.

The SPIRIT V study: a clinical evaluation of the XIENCE V everolimus-eluting coronary stent system in the treatment of patients with de novo coronary artery lesions

OBJECTIVES

The SPIRIT V (A Clinical Evaluation of the XIENCE V Everolimus-Eluting Coronary Stent System in the Treatment of Patients With De Novo Coronary Artery Lesions) study is a post-market surveillance experience of the XIENCE V (Abbott Vascular, Santa Clara, California) everolimus-eluting stent (EES) in patients with higher-risk coronary anatomy.

BACKGROUND

Previous pre-approval studies have shown the safety and efficacy of EES in highly selected groups of patients.

METHODS

The SPIRIT V trial is a prospective, open label, single arm, multicenter study. Two thousand seven hundred patients with multiple de novo coronary artery lesions suitable for treatment with a planned maximum of 4 EES were enrolled at 93 centers in Europe, Asia Pacific, Canada, and South Africa. Lesions had a reference vessel diameter between 2.25 and 4.0 mm and a length of ≤ 28 mm by visual estimation. An independent clinical events committee adjudicated all end point-related events. The primary end point was the composite rate of all death, myocardial infarction (MI), and target vessel revascularization at 30 days. Secondary end points included stent thrombosis and acute success (clinical device and procedure success).

RESULTS

At 30 days, the primary composite end point of all death, MI, and target vessel revascularization was 2.7%. At 1 year, rates of cardiac death, overall MI, and target lesion revascularization were 1.1%, 3.5%, and 1.8%, respectively. The cumulative rate of definite and probable stent thrombosis was low at 0.66% at 1 year.

CONCLUSIONS

Use of EES in patients with multiple, complex de novo lesions yielded 1-year major adverse cardiac events, stent thrombosis, and target lesion revascularization rates that are comparable to those of the more controlled SPIRIT II and SPIRIT III trials-which included patients with restricted inclusion/exclusion criteria-and other all-comer population, physician-initiated studies like the X-SEARCH (Xience Stent Evaluated At Rotterdam Cardiology Hospital) and COMPARE (A Randomized Controlled Trial of Everolimus-eluting Stents and Paclitaxel-eluting Stents for Coronary Revascularization in Daily Practice) trials.

Percutaneous coronary intervention in small coronary vessels: from balloon angioplasty to drug eluting stent era

Small vessel (< 3 mm) coronary artery disease is common and has been identified as independent predictor of restenosis after percutaneous coronary intervention. It remains controversial whether bare metal stent (BMS) implantation in small vessels has an advantage over balloon angioplasty in terms of angiographic and clinical outcomes. Introduction of drug-eluting stent (DES) has resulted in significant reduction in restenosis and the need for repeat revascularisation. Several DESs have been introduced resulting in varying reduction in outcomes as compared to BMS. However, their impact on outcomes in small vessels is not clearly known. It is expected that DES could substantially reduce restenosis in smaller vessels. Large, randomised studies are warranted to assess the impact of different DES on outcomes in patients with small coronary arteries.

Perspective on coronary interventions & cardiac surgeries in India

Cardiovascular disease has become the leading cause of morbidity and mortality in India during the last 3 decades. The genetic predisposition and acquisition of traditional risk factors at a rapid rate as a result of urbanization seems to be the major cause. While efforts are being made to contain this epidemic by educating public and applying preventive measures, the ever increasing burden of patients with symptomatic and life threatening manifestations of the disease is posing a major challenge. This requires a concerted effort to develop modern facilities to treat these patients. The healthcare facilities to manage these high risk patients by contemporary methods like percutaneous coronary revascularization and surgical methods have shown a very promising trend during the last decade. The facilities of modern diagnostic methods and new proven techniques to offer symptomatic relief and improve their prognosis are available in most parts of the country. The lack of social security and health insurance for the large majority of the population, however, is a serious limitation. Unregulated availability of some of the newer devices for these techniques had become a very concerning issue. However, in the last few years serious efforts have been made to streamline these procedures. Indigenous research and scientific data acquisition in relation to the modern technology for achieving coronary revascularization has also started on a promising note.

Measurement and modeling of bentazone in the river Main (Germany) originating from point and non-point sources

A Water Framework Directive pilot project combines measured data and model approaches to calculate fluxes and mass balance of the pesticide bentazone in an 81 km section of the river Main (Germany). During the study period (six weeks in spring 2004) the observed bentazone inflow and outflow in the river section amounted to 52.8 and 53.1 kg, respectively; the maximum concentrations reached 220 and 290 ng l(-1). Based on sampling of seven sewage treatment plants a specific loss of 0.87 g bentazone per farm was calculated. Extrapolation to the entire sub-basin results in 2.6 kg bentazone in total as point source contribution from farms. Diffuse input into the surface water network occurred after an intensive rainfall event on May 7th. Total bentazone load was simulated with the pesticide emission model DRIPS to be 23.2 kg. One third of this load was estimated to be degraded by photolysis before reaching the main waterway, the river Main. The ATV water quality model was applied to predict the concentration profile of bentazone in river Main between Schweinfurt and Würzburg with reasonable results. The difference between total measured and modeled fluxes amounted to 1.5 kg corresponding to 2% of the overall input. The combined approach of monitoring and modeling appears to be a valuable strategy to quantify the relevance of point and non-point sources and to focus effective mitigation measures to the most relevant origins within a river basin.