Platelet glycoprotein IIb/IIIa inhibitors reduce mortality in diabetic patients with non-ST-segment-elevation acute coronary syndromes

BACKGROUND

Diabetes mellitus is a major risk factor for adverse outcomes after acute coronary syndromes (ACS). Because this disease may be associated with increased platelet aggregation, we investigated whether diabetic patients with ACS derive particular benefit from platelet glycoprotein (GP) IIb/IIIa receptor inhibition.

METHODS AND RESULTS

We performed a meta-analysis of the diabetic populations enrolled in the 6 large-scale platelet GP IIb/IIIa inhibitor ACS trials: PRISM, PRISM-PLUS, PARAGON A, PARAGON B, PURSUIT, and GUSTO IV. Among 6458 diabetic patients, platelet GP IIb/IIIa inhibition was associated with a significant mortality reduction at 30 days, from 6.2% to 4.6% (OR 0.74; 95% CI 0.59 to 0.92; P=0.007). Conversely, 23 072 nondiabetic patients had no survival benefit (3.0% versus 3.0%). The interaction between platelet GP IIb/IIIa inhibition and diabetic status was statistically significant (P=0.036). Among 1279 diabetic patients undergoing percutaneous coronary intervention (PCI) during index hospitalization, the use of these agents was associated with a mortality reduction at 30 days from 4.0% to 1.2% (OR 0.30; 95% CI 0.14 to 0.69; P=0.002).

CONCLUSIONS

This meta-analysis, including the entire large-scale trial experience of intravenous platelet GP IIb/IIIa inhibitors for the medical management of non-ST-segment-elevation ACS, shows that these agents may significantly reduce mortality at 30 days in diabetic patients. Although not based on a randomized assessment, the survival benefit appears to be of greater magnitude in patients undergoing PCI. Therefore, the use of platelet GP IIb/IIIa inhibitors should be strongly considered in diabetic patients with ACS.

Dual antiplatelet therapy with clopidogrel and aspirin after carotid artery stenting

BACKGROUND

Carotid artery stenting is being used as an alternative to carotid endarterectomy, both within the context of clinical trials and in non-surgical candidates. Though stenting is known to activate platelets, the role of antithrombotic therapy in carotid stenting has not been fully characterized.

METHODS AND RESULTS

Consecutive patients (n = 162) were followed in a single-center carotid stent registry. The cumulative rate of 30-day death, stroke, transient ischemic attack and myocardial infarction in those patients receiving a thienopyridine was determined, as were rates of stent thrombosis and intracranial hemorrhage. The mean age of the patients was 70.3 years and there was an extremely high prevalence of cardiovascular comorbidities, including 40% with unstable angina. The carotid lesion was symptomatic in 59% of patients. The average pre-treatment stenosis was 83%. The cumulative 30-day rate of death, stroke, transient ischemic attack and myocardial infarction was 5.6%. Specifically, in the patients who received ticlopidine (n = 23), the rate was 13%, versus 4.3% in the patients who received clopidogrel (n = 139) (p = 0.01). In this series, there were no cases of stent thrombosis and 1 intracranial hemorrhage.

CONCLUSION

Dual antiplatelet therapy with clopidogrel plus aspirin in patients receiving carotid artery stents is associated with a low rate of ischemic events. Furthermore, clopidogrel appears superior to ticlopidine. Thus, our findings lend support to the dual antiplatelet strategy of clopidogrel plus aspirin for patients undergoing carotid artery stenting.

Self-expanding stents for carotid interventions: comparison of nitinol versus stainless-steel stents

BACKGROUND

Angioplasty and stenting are becoming increasingly accepted techniques for the treatment of carotid stenosis. However, the optimal stent for carotid intervention is not known.

METHODS

We compared the short- and intermediate-term results of carotid stenting using either nitinol or stainless-steel self-expanding stents in 178 high surgical risk patients undergoing carotid stenting at our institution. Of these 178 patients, eighty-nine received stainless-steel stents and 89 received nitinol stents. The groups were similar with respect to age, gender, diabetes, hypertension, left ventricular function, and symptom status. There were more patients with contralateral carotid occlusion in the nitinol stent group. Independent neurological evaluation was performed in all patients pre- and post-carotid stenting.

RESULTS

At 6 months, there was a similar incidence of stroke (3.3% versus 2.2%) in the stainless-steel group and nitinol stent group, respectively. There was higher 6-month mortality noted in the stainless-steel stent group, but there were no neurological deaths in either group.

CONCLUSIONS

In a single-center patient cohort with similar baseline characteristics, patients receiving nitinol stents and stainless-steel stents had similar neurological outcomes.

Risk of cardiovascular events associated with selective COX-2 inhibitors

Atherosclerosis is a process with inflammatory features and selective cyclooxygenase 2 (COX-2) inhibitors may potentially have antiatherogenic effects by virtue of inhibiting inflammation. However, by decreasing vasodilatory and antiaggregatory prostacyclin production, COX-2 antagonists may lead to increased prothrombotic activity. To define the cardiovascular effects of COX-2 inhibitors when used for arthritis and musculoskeletal pain in patients without coronary artery disease, we performed a MEDLINE search to identify all English-language articles on use of COX-2 inhibitors published between 1998 and February 2001. We also reviewed relevant submissions to the US Food and Drug Administration by pharmaceutical companies. Our search yielded 2 major randomized trials, the Vioxx Gastrointestinal Outcomes Research Study (VIGOR; 8076 patients) and the Celecoxib Long-term Arthritis Safety Study (CLASS; 8059 patients), as well as 2 smaller trials with approximately 1000 patients each. The results from VIGOR showed that the relative risk of developing a confirmed adjudicated thrombotic cardiovascular event (myocardial infarction, unstable angina, cardiac thrombus, resuscitated cardiac arrest, sudden or unexplained death, ischemic stroke, and transient ischemic attacks) with rofecoxib treatment compared with naproxen was 2.38 (95% confidence interval, 1.39-4.00; P =.002). There was no significant difference in cardiovascular event (myocardial infarction, stroke, and death) rates between celecoxib and nonsteroidal anti-inflammatory agents in CLASS. The annualized myocardial infarction rates for COX-2 inhibitors in both VIGOR and CLASS were significantly higher than that in the placebo group of a recent meta-analysis of 23 407 patients in primary prevention trials (0.52%): 0.74% with rofecoxib (P =.04 compared with the placebo group of the meta-analysis) and 0.80% with celecoxib (P =.02 compared with the placebo group of the meta-analysis). The available data raise a cautionary flag about the risk of cardiovascular events with COX-2 inhibitors. Further prospective trial evaluation may characterize and determine the magnitude of the risk.

Update on peripheral vascular diseases: from smoking cessation to stenting

Newer pharmacologic agents including gene therapy hold promise for the treatment of atherosclerotic peripheral vascular disease (PVD), as do advances in endovascular revascularization techniques. Nonetheless, the two most important treatments remain the same: stopping smoking and starting a walking program.

Clinical outcome of a cohort of patients eligible for therapeutic angiogenesis or transmyocardial revascularization

BACKGROUND

Newer methods of coronary revascularization are being investigated in patients who are not candidates for coronary artery bypass grafting or percutaneous intervention. Our objective was to determine the proportion of patients eligible for newer methods of revascularization and determine their 1-year clinical outcome.

METHODS

Five hundred consecutive charts and angiograms from patients undergoing diagnostic angiography for coronary artery disease from January to May of 1998 were reviewed to assess the suitability for revascularization. Patients ineligible for conventional revascularization were followed up for 1 year.

RESULTS

Fifty-nine patients of the 500 studied were identified who had refractory ischemia but were not candidates for traditional revascularization. The 59 patients ineligible for traditional methods of revascularization had a rehospitalization rate of 128% (76 total hospitalizations), a 25.5% rate of myocardial infarction (15 of 59), and a mortality rate of 16.9% (10 of 59).

CONCLUSIONS

The prognosis of many patients eligible for newer methods of revascularization on maximal medical therapy is poor.

Long-term exposures to higher environmental temperature and body temperature: effect of chlorpromazine in relation to hypothalamic GABA

Treatment with a single dose of chlorpromazine (CPZ; 1 mg/kg, ip) at room temperature (28 degrees +/-0.5 degrees C) significantly reduced body temperature by its anticholinergic action. Long-term exposures to higher environmental temperature (40 degrees +/-0.5 degrees C, 2 h/day, for 30 consecutive days) increased body temperature significantly by reduction of hypothalamic GABAergic activity, but this increase in body temperature was attenuated from that observed with a single exposure to higher environmental temperature (40 degrees C for 2 h). Treatment with a single dose of CPZ on the last day of 30 consecutive days of exposures to higher environmental temperature increased body temperature of rats more than that observed with long-term exposures to higher environmental temperature possibly due to (i) reduction of hypothalamic GABAergic activity, (ii) heat dissipation and (iii) reverse-anticholinergic action of CPZ at higher environmental temperature.

Fas-induced apoptosis in mouse hepatocytes is dependent on C/EBPbeta

Apoptotic cell death in the liver in response to activation of the Fas pathway has been implicated in human disease states as well as liver remodeling and tissue repair. C/EBPbeta, a member of the CCAAT enhancer binding protein family of bZIP transcription factors has been linked to both growth response and apoptotic targets in the liver, and, therefore, is a likely candidate for the regulation of apoptotic liver injury. We investigated differences in apoptotic cell death in the livers of C/EBPbeta-null mice using the Jo-2 agonistic anti-Fas antibody. Apoptotic injury was dramatically reduced in C/EBPbeta -/- livers as shown by a nearly 20-fold reduction in apoptotic hepatocytes 6 hours post-Jo-2 treatment in C/EBPbeta -/- hepatocytes compared with controls (P < .04) and reduced activation of caspase 3. Bid cleavage occurred in Jo-2 treated C/EBPbeta -/- livers indicating a block of Fas-induced injury distal to the death-inducing signaling complex. The level of the antiapoptotic protein bcl-x(L) was increased greater than tenfold in the mutant animals (P < .04), which can, at least in part, account for the protection from Fas-mediated apoptosis. In contrast, bcl-x(L) mRNA levels were unchanged. These observations link C/EBPbeta to Fas-induced hepatocyte apoptosis through a mechanism that likely involves translational or posttranslational regulation of bcl-x(L).

Percutaneous intervention for symptomatic vertebral artery stenosis using coronary stents

BACKGROUND

There is very limited experience with percutaneous treatment of symptomatic vertebral artery disease. Angioplasty and stenting for vertebral artery stenosis are still evolving and have generally been performed for asymptomatic disease. We performed vertebral artery stenting in 12 patients with vertebrobasilar transient ischemic attacks and present our short- and intermediate-term results.

METHODS

A total of 12 lesions affecting the vertebral artery were treated by coronary stent placement. The mean age was 72 +/- 8 years and 83% were males (10 males, 2 females). Baseline characteristics included hypertension (11/12); hypercholesterolemia (8/12); coronary artery disease (8/12); and diabetes (5/12). Mean lesion length was 8.6 +/- 2.7 mm, mean calipered stenosis was 78 +/- 8%, and mean arterial diameter was 4.1 +/- 0.3 mm. All patients were symptomatic, fulfilling our criteria for vertebral artery angioplasty. All patients were followed for at least 6 months after treatment.

RESULTS

All 12 lesions were successfully stented, with a mean residual stenosis of 11 +/- 6%. Clinical follow-up showed resolution or improvement of symptoms in all patients. One patient had symptomatic restenosis seven months after the initial procedure requiring repeat angioplasty.

CONCLUSIONS

Stent placement for symptomatic stenosis involving the vertebral artery is safe and effective for alleviating symptoms of vertebrobasilar ischemia. Coronary stents appear to be well suited to treat atherosclerotic lesions of the vertebral artery.

Effectiveness of training on infant feeding practices among community influencers in a rural area of west Bengal

Total 34 Influencers were trained in a subcentre area of South 24-parganas district of West Bengal. Knowledge was imparted to community influencers on infant feeding practices through lecture, group discussion, question-answer session and hand-on-training by trained health workers. Pre-assessment was done before initiation of training. Repeat training was conducted at frequent intervals within a period of 3 months. Mean score of knowledge of influencers during pre-training assessment was 13.3 and improved thereafter-following training to 20.8 (1st assessment), 20.6 (2nd assessment), 23.7 (3rd assessment) and 25.2 (final-assessment). Repeat training had also desired impact.

Clinical application of procedural platelet monitoring during percutaneous coronary intervention among patients at increased bleeding risk

The goal of platelet function testing in the catheterization laboratory is to provide information about the platelet contributions to the risk of thrombotic or hemorrhagic events and optimization of anti-platelet therapy for percutaneous interventions. We present several illustrative cases in which platelet monitoring with the Rapid Platelet Function Assay (RPFA, Accumetrics) was used to guide dosing of a glycoprotein (GP) IIb/IIIa inhibitor for coronary and peripheral intervention among patients at increased bleeding risk.

Extra-anatomic arterial reconstruction with ligation of common iliac arteries and embolization of the aneurysm for the treatment of abdominal aortic aneurysms in high-risk patients

PURPOSE

The mortality of an unrepaired abdominal aortic aneurysm (AAA) generally exceeds the mortality associated with surgical repair. However, as our longevity increases, more frequently we see patients whose risk of surgical repair approximates the risk of rupture. We present an extra-anatomic bypass graft with complete aneurysm exclusion by iliac ligation and coil embolization of the aneurysm as an alternative for these high-risk patients.

METHODS

An extra-anatomic bypass graft, followed by bilateral iliac artery ligation (retroperitoneal approach) and complete coil embolization of the AAA, was performed in eight patients (mean age, 77 years) found to be at prohibitive operative risk because of multiple comorbidities (American Society of Anesthesiologists class IV). Most patients (5 of 8) were symptomatic on presentation with a mean AAA diameter of 7 cm (range, 6.7-9.5 cm). We repair approximately 30 infrarenal aneurysms per year electively at our institution.

RESULTS

All patients tolerated the surgical procedures. The average hospital stay was 8 days. All but two aneurysms demonstrated complete thrombosis by 48 hours. After 48 months there was no incidence of graft thrombosis, peripheral ischemia, visceral ischemia or thrombus infection. There was one perioperative death from aspiration pneumonia. Seventy-five percent (6 of 8) of patients have survived at least 1 year without surgical complications. No patient has had a ruptured aneurysm.

CONCLUSION

Combining an extra-anatomic bypass graft and complete exclusion of the AAA by ligation of the common iliac arteries and a coil embolization is an effective, less invasive treatment option for patients with AAA and prohibitive operative risk. We emphasize the need for complete embolization documented by decreased aneurysm size.

Hearing aids versus ventilation tubes in persistent otitis media with effusion: a survey of clinical practice

A postal survey was carried out to determine the current clinical practice amongst consultant otolaryngologists in the UK, regarding re-insertion of ventilation tubes or recommendation of hearing aids in cases of recurrence of otitis media with effusion (OME) after ventilation tube extrusion. Amongst the 319 respondents, 15 (4.70 per cent) routinely, 146 (45.77 per cent) sometimes, and 158 (49.53 per cent) either never, or very rarely, recommend hearing aids. Hearing aids and ventilation tubes were both suggested to be equally good options by some consultants but they preferred surgery for a number of reasons. There were inconsistencies in practice and some of the reasons for re-inserting ventilation tubes are not evidence-based. A hearing aid is a non-invasive option and this survey shows a need for a randomized control trial of hearing aids and ventilation tubes in the management of persistent and recurrent OME.

Hepatopulmonary syndrome: prevalence and clinical profile

BACKGROUND

The hepatopulmonary syndrome (HPS) is defined as a triad of liver dysfunction, intrapulmonary vascular dilatations (IPVD) and arterial hypoxemia. There is paucity of Indian studies regarding the prevalence of IPVD and arterial hypoxemia particularly amongst patients with non-cirrhotic portal fibrosis (NCPF) and extrahepatic portal vein obstruction (EHPVO), where liver dysfunction is not a feature.

METHODS

All patients with portal hypertension and esophageal varices seen at a tertiary care hospital during 1995-98 were studied. Ultrasonography of abdomen, contrast-enhanced echocardiography (CEE), arterial blood gas analysis and assessment of alveolar-arterial oxygen gradient were done.

RESULTS

Of 138 patients with portal hypertension seen during the study period, 88 fulfilled the inclusion and exclusion criteria. These included 63 with cirrhosis, 15 with NCPF and 10 with EHPVO. CEE showed IPVD in 17 (27%) patients with cirrhosis, of which 11 (17.5%) fulfilled the criteria for HPS. IPVD were also noted in 4 (26.6%) cases of NCPF and 3 (30%) of EHPVO, though only 2 (13.3%) and 1 (10%) respectively had elevated alveolar-arterial gradient and liver dysfunction in addition. Age and sex distribution and duration of symptoms were not different in patients with HPS. Patients with HPS had higher incidence of dyspnea, platypnea, clubbing and spider nevi.

CONCLUSIONS

Hepatopulmonary syndrome is present in 17.5% of cirrhotics, 13.3% of patients with NCPF and 10% with EHPVO. Patients with HPS had significantly higher incidence of dyspnea, platypnea, clubbing and spider nevi.

Monitoring antiplatelet therapy: What is the best method?

Platelet function tests measure different aspects of platelet function, which include adherence, activation, aggregation and secretion. Clinically, the goal of platelet function testing is to provide information about the platelet contribution to the risk of thrombotic or haemorrhagic events and the optimisation of antiplatelet therapy. The important clinical questions are whether an antiplatelet agent is having the desired effect on platelet inhibition (effectiveness) and whether the patient has sufficient residual platelet function to avoid bleeding (safety). The role of aspirin (acetylsalicylic acid) and thienopyridines is well established in the management of patients with coronary artery disease and in the setting of coronary interventions. The last several years have demonstrated the unequivocal effectiveness of intravenously administered platelet glycoprotein (GP) IIb/IIIa antagonists in the management of acute coronary syndromes and in the setting of percutaneous coronary interventions. With the increasing use of these GPIIb/IIIa antagonists, it is becoming more important clinically to measure platelet inhibition with these agents. This paper reviews major techniques and instrumentation for platelet monitoring and discusses the goals of the best method.