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Kapelios CJ, Benson L, Crespo-Leiro MG, Anker SD, Coats AJS, Chioncel O, Filippatos G, Lainscak M, McDonagh T, Mebazaa A, Metra M, Piepoli MF, Rosano GMC, Ruschitzka F, Savarese G, Seferovic PM, Volterrani M, Maggioni AP, Lund LH. Participation in a clinical trial is associated with lower mortality but not lower risk of HF hospitalization in patients with heart failure: observations from the ESC EORP Heart Failure Long-Term Registry. Eur Heart J 2023; 44:1526-1529. [PMID: 36879413 PMCID: PMC10149529 DOI: 10.1093/eurheartj/ehad109] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/07/2023] [Accepted: 02/15/2023] [Indexed: 03/08/2023] Open
Abstract
Abstract
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Affiliation(s)
- Chris J Kapelios
- Department of Cardiology, Laiko General Hospital, Athens, Greece
| | - Lina Benson
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, Solna, S1:02, 171 76 Stockholm, Sweden
| | - Maria G Crespo-Leiro
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Complexo Hospitalario Universitario A Coruna, CHUAC, INIBIC, UDC, CIBERCV, La Coruna, Spain
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), and German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | | | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine Carol Davila, Bucharest, Romania
| | - Gerasimos Filippatos
- Heart Failure Unit, Department of Cardiology, University Hospital Attikon, National and Kapodistrian University of Athens, Athens, Greece
| | - Mitja Lainscak
- Division of Cardiology, Murska Sobota, Murska Sobota and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Alexandre Mebazaa
- Department of Anesthesia-Burn-Critical Care, UMR 942 Inserm—MASCOT, University of Paris, APHP Saint Louis Lariboisière University Hospitals, Paris, France
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Massimo F Piepoli
- Department of Biomedical Science for Health, University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy, and Clinical Cardiology, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy
| | | | | | - Gianluigi Savarese
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, Solna, S1:02, 171 76 Stockholm, Sweden
| | | | - Maurizio Volterrani
- Department of Human Science and Promotion of Quality of Life, San Raffaele Open University of Rome, Rome, Italy
- Cardiopulmonary Department, IRCCS San Raffaele, Rome, Italy
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Lars H Lund
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, Solna, S1:02, 171 76 Stockholm, Sweden
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Mitra B, Roman C, Mercier E, Moloney J, Yip G, Khullar K, Walsh K, Smit DV, Cameron PA. Propofol for migraine in the emergency department: A pilot randomised controlled trial. Emerg Med Australas 2020; 32:542-547. [DOI: 10.1111/1742-6723.13542] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/20/2020] [Accepted: 04/29/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Biswadev Mitra
- Emergency and Trauma CentreThe Alfred Hospital Melbourne Victoria Australia
- Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
| | - Cristina Roman
- Emergency and Trauma CentreThe Alfred Hospital Melbourne Victoria Australia
- Department of PharmacyThe Alfred Hospital Melbourne Victoria Australia
| | - Eric Mercier
- CHU de Québec‐Université Laval Research CenterPopulation Health and Optimal Health Practices Axis, Université Laval Quebec Quebec Canada
- Département de Médecine Familiale et Médecine d'Urgence, Faculté de MédecineUniversité Laval Quebec Quebec Canada
- Centre de recherche sur les soins et les services de première ligne de l'Université Laval Quebec Quebec Canada
| | - John Moloney
- Department of Anaesthesiology and Perioperative MedicineThe Alfred Hospital Melbourne Victoria Australia
- Department of Community Emergency Health and Paramedic PracticeMonash University Melbourne Victoria Australia
| | - Gary Yip
- Department of NeurologyThe Alfred Hospital Melbourne Victoria Australia
| | - Keshav Khullar
- Emergency and Trauma CentreThe Alfred Hospital Melbourne Victoria Australia
| | - Kieran Walsh
- Emergency and Trauma CentreThe Alfred Hospital Melbourne Victoria Australia
| | - De Villiers Smit
- Emergency and Trauma CentreThe Alfred Hospital Melbourne Victoria Australia
- Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
| | - Peter A Cameron
- Emergency and Trauma CentreThe Alfred Hospital Melbourne Victoria Australia
- Department of Epidemiology and Preventive MedicineMonash University Melbourne Victoria Australia
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Cheng Y, Liu X, Zhao Y, Sun Y, Zhang D, Liu F, Ma Y, Zhou Y. Risk Factors for Postoperative Events in Patients on Antiplatelet Therapy Undergoing Off-Pump Coronary Artery Bypass Grafting Surgery. Angiology 2020; 71:704-712. [PMID: 32295386 DOI: 10.1177/0003319720919319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This retrospective study assessed the risk factors for adverse events following off-pump coronary artery bypass graft (CABG) surgery with dual antiplatelet therapy (DAPT). Records (between 2013 and 2017) were reviewed for patients who discontinued DAPT (clopidogrel 75 mg and aspirin 100 mg) ≤5 days before off-pump CABG. The primary outcome was the incidence of a Bleeding Academic Research Consortium (BARC) type 4 major event. Factors associated with bleeding events and perioperative myocardial ischemia were evaluated using multivariable logistic regression. The incidence of major bleeding events was 17.6% in 2012 patients. Adjusted multiple logistic regression analysis showed that the risk of postoperative bleeding increased when DAPT was discontinued <3 days before surgery (day 2: adjusted odds ratio [OR]: 1.70, 95% confidence interval [CI]: 1.09-2.64; day 1: adjusted OR: 2.37, 95% CI: 1.49-3.77; day 0: adjusted OR: 2.45, 95% CI: 1.53-3.92). The adjusted risk of mortality (OR: 13.14, 95% CI: 4.55-37.94) was increased with bleeding complications. In subgroup analysis, perioperative myocardial ischemia was related to increased blood loss (adjusted OR: 1.10, 95% CI: 1.02-1.18). Aspirin and clopidogrel should optimally be discontinued >3 days before CABG to reduce the risk of bleeding complications, myocardial ischemia, and death.
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Affiliation(s)
- Yujing Cheng
- Department of Cardiology, 12th ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Xiaoli Liu
- Department of Cardiology, 12th ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Yingxin Zhao
- Department of Cardiology, 12th ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Yan Sun
- Department of Cardiology, 12th ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Dai Zhang
- Department of Cardiology, 12th ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Fang Liu
- Department of Cardiology, 12th ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Yue Ma
- Department of Cardiology, 12th ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Yujie Zhou
- Department of Cardiology, 12th ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
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Affiliation(s)
- Sonali Kumar
- Division of Cardiology Department of Medicine Emory University Atlanta GA
| | - Michael McDaniel
- Division of Cardiology Department of Medicine Emory University Atlanta GA
| | - Habib Samady
- Division of Cardiology Department of Medicine Emory University Atlanta GA
| | - Farshad Forouzandeh
- Division of Cardiology Department of Medicine Emory University Atlanta GA.,Division of Cardiology Department of Medicine Case Western Reserve University Cleveland OH
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Ellis CJ, Gamble GD, Williams MJ, Matsis P, Elliott JM, Devlin G, Mann S, French JK, White HD. All-Cause Mortality Following an Acute Coronary Syndrome: 12-Year Follow-Up of the Comprehensive 2002 New Zealand Acute Coronary Syndrome Audit. Heart Lung Circ 2019; 28:245-256. [DOI: 10.1016/j.hlc.2017.10.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 09/04/2017] [Accepted: 10/18/2017] [Indexed: 12/22/2022]
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The risk-treatment paradox in non-ST-elevation myocardial infarction patients according to their estimated GRACE risk. Int J Cardiol 2018; 272:26-32. [DOI: 10.1016/j.ijcard.2018.08.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 08/06/2018] [Indexed: 12/22/2022]
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Atabegashvili MR, Gilyarov MY, Konstantinova EV, Kostina AN, Nesterov AP, Pakharkova TD, Udovichenko AE. Antithrombotic Therapy after Bleeding in Elderly Polimorbid Patient: Our Time Challenge. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2018. [DOI: 10.20996/1819-6446-2018-14-4-524-528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In recent years, there has been a clear trend towards an increase in the number of elderly patients suffering from several polymorbid diseases, which considerably complicates the forecast and tactics of management. A clinical case of an elderly patient, suffering for a long time from type 2 diabetes mellitus, receiving insulin and treated with programmed hemodialysis due to terminal chronic renal failure, and suffering from atrial fibrillation in permanent form, is presented. The patient was hospitalized in theCityClinicalHospital№1 named after N.I. Pirogov due to acute repeated myocardial infarction. An emergency percutaneous coronary intervention was performed, the infarct-dependent artery was stented with a drug-eluted stent. The postoperative period complicated by the development of acute blood loss associated with bleeding from the upper sections of the gastrointestinal tract, and severe anemia of the combined genesis (posthemorrhagic, renal). This situation required doctors to make non-standard decisions in the choice of antithrombotic therapy. This clinical case illustrates the difficulties in elderly polymorbid patient management in real clinical practice and the controversial issues arising in the prescribing the antithrombotic therapy, especially after bleeding had developed. The supporting guidelines cannot answer all the questions which the daily practice poses to the doctor. In each case, the resumption of antithrombotic therapy and its optimal choice for an elderly polymorbid patient with developed bleeding is the subject of discussion and presented a real challenge for the treating physician.
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Cavender MA, Bhatt DL, Stone GW, Steg PG, Gibson CM, Hamm CW, Price MJ, Prats J, Elkin S, Deliargyris EN, Mahaffey KW, White HD, Harrington RA. Cangrelor in Older Patients Undergoing Percutaneous Coronary Intervention: Findings From CHAMPION PHOENIX. Circ Cardiovasc Interv 2018; 10:CIRCINTERVENTIONS.117.005257. [PMID: 28801539 DOI: 10.1161/circinterventions.117.005257] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 07/14/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Older patients treated with percutaneous coronary intervention are at increased risk of periprocedural events. METHODS AND RESULTS CHAMPION (cangrelor versus standard therapy to achieve optimal management of platelet inhibition) PHOENIX randomized 11 145 patients to cangrelor or clopidogrel. We sought to determine the outcomes in the prespecified subgroup of patients ≥75 years old (n=2010; 18%). Cangrelor resulted in directionally consistent effects on the primary end point (death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis) in patients ≥75 years old (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.50-1.02) and in those <75 years old (OR, 0.81; 95% CI, 0.67-0.98; P [interaction]=0.55). Age ≥75 years was an independent predictor of GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) moderate/severe bleeding (1.0% versus 0.3%; adjusted OR, 2.94; 95% CI, 1.28-6.77; P=0.01) when compared with patients <75 years old. There was no significant difference in GUSTO moderate/severe bleeding with cangrelor versus clopidogrel (1.1% versus 1.0%; OR, 1.07; 95% CI 0.45-2.53) in patients ≥75 years old or in those <75 years old (0.4% versus 0.2%; OR, 2.24; 95% CI, 1.02-4.93; P [interaction]=0.21). For the net composite end point of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis plus GUSTO moderate/severe bleeding, the OR for cangrelor in those ≥75 years old was 0.75 (6.4% versus 8.3%; 95% CI, 0.54-1.05; P=0.09). The effects were similar in those <75 years old (4.9% versus 5.8%; OR, 0.85; 95% CI, 0.70-1.02; P=0.08; P [interaction]=0.53). CONCLUSIONS Patients ≥75 years old have an overall ≈3-fold increased odds of moderate/severe bleeding. Cangrelor, when compared with clopidogrel, provides similar efficacy and in patients ≥75 years old as in those <75 years old but does not increase the risk of major bleeding. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT01156571.
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Affiliation(s)
- Matthew A Cavender
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Deepak L Bhatt
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.).
| | - Gregg W Stone
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Ph Gabriel Steg
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - C Michael Gibson
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Christian W Hamm
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Matthew J Price
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Jayne Prats
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Steven Elkin
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Efthymios N Deliargyris
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Kenneth W Mahaffey
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Harvey D White
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Robert A Harrington
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
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Nanayakkara S, Marwick TH, Kaye DM. The ageing heart: the systemic and coronary circulation. Heart 2017; 104:370-376. [PMID: 29092917 DOI: 10.1136/heartjnl-2017-312114] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 09/27/2017] [Accepted: 09/28/2017] [Indexed: 12/22/2022] Open
Abstract
Most cardiovascular disease (CVD) occurs in patients over the age of 60. However, most evidence-based current cardiovascular guidelines lack evidence in an older population, due to the under-representation of older patients in randomised trials. Blood pressure rises with age due to increasing arterial stiffness, and stricter control results in improved outcomes. Myocardial ischaemia is also more common with increasing age, due to a combination of coronary artery disease and myocardial changes. However, despite higher rates of adverse outcomes, older patients are offered guideline-based therapy less frequently. Frailty is an independent predictor of mortality in adults over the age of 60, yet remains poorly assessed; slow gait speed is a key marker for the development of frailty and for adverse outcomes following intervention. Few trials have assessed frailty independent of age; however, there is evidence that non-frail older patients derive significant benefit from therapy, highlighting the urgent need to include frailty as a measure in clinical trials of treatment in CVD.In this review, the authors appraise the literature in regard to the cardiovascular changes with ageing, specifically in relation to the systemic and coronary circulation and with a particular emphasis on frailty and its implication in the evaluation and treatment of CVD.
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Affiliation(s)
- Shane Nanayakkara
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Thomas H Marwick
- Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - David M Kaye
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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Wei CC, Lee SH. Predictors of Mortality in Elderly Patients with Non-ST Elevation Acute Coronary Syndrome - Data from Taiwan Acute Coronary Syndrome Full Spectrum Registry. ACTA CARDIOLOGICA SINICA 2017; 33:377-383. [PMID: 29033508 PMCID: PMC5534417 DOI: 10.6515/acs20170126a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 01/26/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Some difficulties and variations remain associated with the care of elderly patients with non-ST elevation acute coronary syndrome (NSTE-ACS). METHODS We included 1470 patients from a Taiwan nationwide registry who fulfilled the criteria of NSTE-ACS, and stratified these patients by age and evaluated the treatment, complications and outcomes in different age groups. Furthermore, we analyzed risk factors and standards of care to determine the predictors of mortality. RESULTS Patients ≥ 75 years of age (n = 396) had significantly higher incidences of 90-day mortality [odd ratio (OR) = 4.5 (1.2-16.3), p = 0.023] and 1-year mortality [OR = 4.9 (2.0-12.3), p = 0.001] compared with those patients 45-64 years of age (n = 595). In the patients ≥ 75 years of age, previous myocardial infarction (MI) [OR = 3.3 (1.1-9.8), p = 0.035], statins [OR = 0.35 (0.1-0.9), p = 0.037], left ventricular ejection fraction (LVEF) < 35% [OR = 3.9 (1.5-10.4), p = 0.006] were associated with 90-day mortality. Furthermore, previous MI [OR = 4.0 (1.3-12.6), p = 0.019] was an independent predictor of 90-day mortality. Age [OR = 1.1 (1.03-1.2), p = 0.002], previous MI [OR = 2.2 (1.1-4.4), p = 0.034], angiotensin-converting enzyme inhibitor or angiotensin receptor blocker [OR = 0.5 (0.3-0.9), p = 0.028], and LVEF < 35% [OR = 4.3 (1.9-9.5), p < 0.001] were associated with 1-year mortality. Furthermore, previous MI [OR = 2.6 (1.1-6.5), p = 0.037], LVEF < 35% [OR = 4.7 (1.5-14.4), p = 0.007] and percutaneous coronary intervention(PCI) or not [OR = 0.3 (0.1-0.9), p = 0.021] were independent predictors of 1-year mortality. CONCLUSIONS Previous MI, LVEF < 35% and PCI or not could predict 1-year mortality in advanced elderly patients with NSTE-ACS. Despite their elevated morbidities and complications, PCI was still beneficial for these patients.
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Affiliation(s)
- Cheng-Chun Wei
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho Su Memorial Hospital, Taipei
| | - Shih-Huang Lee
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho Su Memorial Hospital, Taipei
- School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
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Kunadian V, Neely RDG, Sinclair H, Batty JA, Veerasamy M, Ford GA, Qiu W. Study to Improve Cardiovascular Outcomes in high-risk older patieNts (ICON1) with acute coronary syndrome: study design and protocol of a prospective observational study. BMJ Open 2016; 6:e012091. [PMID: 27554105 PMCID: PMC5013351 DOI: 10.1136/bmjopen-2016-012091] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION The ICON1 study (a study to Improve Cardiovascular Outcomes in high-risk older patieNts with acute coronary syndrome) is a prospective observational study of older patients (≥75 years old) with non-ST-elevation acute coronary syndrome managed by contemporary treatment (pharmacological and invasive). The aim of the study was to determine the predictors of poor cardiovascular outcomes in this age group and to generate a risk prediction tool. METHODS AND ANALYSIS Participants are recruited from 2 tertiary hospitals in the UK. Baseline evaluation includes frailty, comorbidity, cognition and quality-of-life measures, inflammatory status assessed by a biomarker panel, including microRNAs, senescence assessed by telomere length and telomerase activity, cardiovascular status assessed by arterial stiffness, endothelial function, carotid intima media thickness and left ventricular systolic and diastolic function, and coronary plaque assessed by virtual histology intravascular ultrasound and optical coherence tomography. The patients are followed-up at 30 days and at 1 year for primary outcome measures of death, myocardial infarction, stroke, unplanned revascularisation, bleeding and rehospitalisation. ETHICS AND DISSEMINATION The study has been approved by the regional ethics committee (REC 12/NE/016). Findings of the study will be presented in scientific sessions and will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT01933581: Pre-results.
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Affiliation(s)
- Vijay Kunadian
- Institute of Cellular Medicine, Newcastle University,Newcastle upon Tyne, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | - R Dermot G Neely
- Department of Biochemistry, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Hannah Sinclair
- Institute of Cellular Medicine, Newcastle University,Newcastle upon Tyne, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | - Jonathan A Batty
- Institute of Cellular Medicine, Newcastle University,Newcastle upon Tyne, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | - Murugapathy Veerasamy
- Institute of Cellular Medicine, Newcastle University,Newcastle upon Tyne, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | - Gary A Ford
- Institute for Ageing and Health, Newcastle University, Newcastle upon Tyne, UK
| | - Weiliang Qiu
- Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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12
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Safley DM, Venkitachalam L, Kennedy KF, Cohen DJ. Impact of Glycoprotein IIb/IIIa Inhibition in Contemporary Percutaneous Coronary Intervention for Acute Coronary Syndromes: Insights From the National Cardiovascular Data Registry. JACC Cardiovasc Interv 2016; 8:1574-82. [PMID: 26493250 DOI: 10.1016/j.jcin.2015.04.031] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/13/2015] [Accepted: 04/23/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study investigates the effects of glycoprotein IIb/IIIa inhibitors (GPIs) on outcomes after percutaneous coronary intervention (PCI). BACKGROUND Ischemic complications are reduced after PCI when a GPI is added to heparin. However, there are limited data on the safety and efficacy in contemporary PCI. METHODS We used the National Cardiovascular Data Registry CathPCI Registry data to assess the association between GPI use and PCI outcomes for acute coronary syndrome between July 2009 and September 2011. The primary outcome was all-cause in-hospital mortality. The secondary outcome was major bleeding. To adjust for potential bias, we used multivariable logistic regression, propensity-matched (PM) analysis, and instrumental variable analysis (IVA). RESULTS There were 970,865 patients included; 326,283 (33.6%) received a GPI. Unadjusted mortality and major bleeding were more common with a GPI (2.4% vs. 1.4% and 3.7% vs. 1.5%, respectively; p < 0.001 for both). In contrast, GPI use was associated with lower mortality on adjusted analyses; relative risks range from 0.72 (95% confidence interval [CI]: 0.50 to 0.97) with IVA to 0.90 (95% CI: 0.86 to 0.95) with PM. The association of GPI use with bleeding remained in adjusted analyses (multivariable relative risk: 1.93, 95% CI: 1.83 to 2.04; PM relative risk: 1.83, 95% CI: 1.74 to 1.92; and IVA relative risk: 1.53, 95% CI: 1.27 to 2.13). Subgroup analysis revealed enhanced risk reduction with ST-segment elevation myocardial infarction, high predicted mortality, and heparin-based anticoagulation. CONCLUSIONS In unselected acute coronary syndrome patients undergoing PCI, GPI use was associated with reduced in-hospital mortality and increased bleeding. In the modern era of PCI, there may still be a role for the judicious use of GPIs.
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Affiliation(s)
- David M Safley
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri.
| | - Lakshmi Venkitachalam
- Department of Biomedical & Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Kevin F Kennedy
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - David J Cohen
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
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Rutten GEHM, Tack CJ, Pieber TR, Comlekci A, Ørsted DD, Baeres FMM, Marso SP, Buse JB. LEADER 7: cardiovascular risk profiles of US and European participants in the LEADER diabetes trial differ. Diabetol Metab Syndr 2016; 8:37. [PMID: 27274772 PMCID: PMC4891842 DOI: 10.1186/s13098-016-0153-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 05/26/2016] [Indexed: 01/18/2023] Open
Abstract
AIMS To determine whether US and European participants in the Liraglutide Effect and Action in Diabetes: Evaluation of cardiovascular outcome Results (LEADER) trial differ regarding risk factors for cardiovascular mortality and morbidity. METHODS Baseline data, stratified for prior cardiovascular disease (CVD), were compared using multivariable logistic regression analysis to establish whether region is an independent determinant of achieved targets for glycated hemoglobin (HbA1c), blood pressure (BP), and low-density lipoprotein (LDL)-cholesterol. RESULTS Independent of CVD history, US participants were more often of non-White origin and had a longer history of type 2 diabetes, higher body weight, and higher baseline HbA1c. They had substantially lower systolic and diastolic BP, and a marginally lower LDL-cholesterol level. Fewer US participants were diagnosed with left ventricular dysfunction. In the largest group of patients, those with prior CVD and the highest cardiovascular risk, US participants were more often female, had a higher waist circumference, and had a decreased estimated glomerular filtration rate, but less frequently prior myocardial infarction or angina pectoris. CONCLUSIONS There were baseline differences between US and European participants. These differences may result from variation in regional targets for cardiovascular risk factor management, and should be considered in the analysis and reporting of the trial results. Clinical trial identifier: ClinicalTrials.gov, NCT01179048.
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Affiliation(s)
- Guy E. H. M. Rutten
- />Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, STR 6.131, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Cees J. Tack
- />Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Thomas R. Pieber
- />Division of Endocrinology and Metabolism, Medical University of Graz, Graz, Austria
| | - Abdurrahman Comlekci
- />Division of Endocrinology, Dokuz Eylul University Medical School, Inciralti, Izmir, Turkey
| | | | | | - Steven P. Marso
- />Department of Internal Medicine, UT Southwestern, Dallas, TX USA
| | - John B. Buse
- />Department of Medicine, The University of North Carolina School of Medicine, Chapel Hill, NC USA
| | - on behalf of the LEADER Investigators
- />Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, STR 6.131, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
- />Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- />Division of Endocrinology and Metabolism, Medical University of Graz, Graz, Austria
- />Division of Endocrinology, Dokuz Eylul University Medical School, Inciralti, Izmir, Turkey
- />Novo Nordisk, Søborg, Denmark
- />Department of Internal Medicine, UT Southwestern, Dallas, TX USA
- />Department of Medicine, The University of North Carolina School of Medicine, Chapel Hill, NC USA
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Fanning JP, Nyong J, Scott IA, Aroney CN, Walters DL. Routine invasive strategies versus selective invasive strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. Cochrane Database Syst Rev 2016; 2016:CD004815. [PMID: 27226069 PMCID: PMC8568369 DOI: 10.1002/14651858.cd004815.pub4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People with unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI) are managed with a combination of medical therapy, invasive angiography and revascularisation. Specifically, two approaches have evolved: either a 'routine invasive' strategy whereby all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularisation; or a 'selective invasive' (also referred to as 'conservative') strategy in which medical therapy alone is used initially, with a selection of patients for angiography based upon evidence of persistent myocardial ischaemia. Uncertainty exists as to which strategy provides the best outcomes for these patients. This Cochrane review is an update of a Cochrane review originally published in 2006, to provide a robust comparison of these two strategies in the early management of patients with UA/NSTEMI. OBJECTIVES To determine the benefits and harms associated with the following.1. A routine invasive versus a conservative or 'selective invasive' strategy for the management of UA/NSTEMI in the stent era.2. A routine invasive strategy with and without glycoprotein IIb/IIIa receptor antagonists versus a conservative strategy for the management of UA/NSTEMI in the stent era. SEARCH METHODS We searched the following databases and additional resources up to 25 August 2015: the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, MEDLINE and EMBASE, with no language restrictions. SELECTION CRITERIA We included prospective randomised controlled trials (RCTs) that compared invasive with conservative or 'selective invasive' strategies in participants with acute UA/NSTEMI. DATA COLLECTION AND ANALYSIS Two review authors screened the records and extracted data in duplicate. Using intention-to-treat analysis with random-effects models, we calculated summary estimates of the risk ratio (RR) with 95% confidence intervals (CIs) for the primary endpoints of all-cause death, fatal and non-fatal myocardial infarction (MI), combined all-cause death or non-fatal MI, refractory angina and re-hospitalisation. We performed further analysis of included studies based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. We assessed the heterogeneity of included trials using Pearson χ² (Chi² test) and variance (I² statistic) analysis. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, we assessed the quality of the evidence and the GRADE profiler (GRADEPRO) was used to import data from Review Manager 5.3 (Review Manager) to create Summary of findings (SoF) tables. MAIN RESULTS Eight RCTs with a total of 8915 participants (4545 invasive strategies, 4370 conservative strategies) were eligible for inclusion. We included three new studies and 1099 additional participants in this review update. In the all-study analysis, evidence did not show appreciable risk reductions in all-cause mortality (RR 0.87, 95% CI 0.64 to 1.18; eight studies, 8915 participants; low quality evidence) and death or non-fatal MI (RR 0.93, 95% CI 0.71 to 1.2; seven studies, 7715 participants; low quality evidence) with invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. There was appreciable risk reduction in MI (RR 0.79, 95% CI 0.63 to 1.00; eight studies, 8915 participants; moderate quality evidence), refractory angina (RR 0.64, 95% CI 0.52 to 0.79; five studies, 8287 participants; moderate quality evidence) and re-hospitalisation (RR 0.77, 95% CI 0.63 to 0.94; six studies, 6921 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies also at six to 12 months follow-up.Evidence also showed increased risks in bleeding (RR 1.73, 95% CI 1.30 to 2.31; six studies, 7584 participants; moderate quality evidence) and procedure-related MI (RR 1.87, 95% CI 1.47 to 2.37; five studies, 6380 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies.The low quality evidence were as a result of serious risk of bias and imprecision in the estimate of effect while moderate quality evidence was only due to serious risk of bias. AUTHORS' CONCLUSIONS In the all-study analysis, the evidence failed to show appreciable benefit with routine invasive strategies for unstable angina and non-ST elevation MI compared to conservative strategies in all-cause mortality and death or non-fatal MI at six to 12 months. There was evidence of risk reduction in MI, refractory angina and re-hospitalisation with routine invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. However, routine invasive strategies were associated with a relatively high risk (almost double the risk) of procedure-related MI, and increased risk of bleeding complications. This systematic analysis of published RCTs supports the conclusion that, in patients with UA/NSTEMI, a selectively invasive (conservative) strategy based on clinical risk for recurrent events is the preferred management strategy.
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Affiliation(s)
- Jonathon P Fanning
- The Prince Charles HospitalSchool of Medicine, The University of QueenslandRode RoadChermsideBrisbaneAustralia4032
| | - Jonathan Nyong
- FARR Institute UCLClinical Epidemiology222 Euston RoadLondonGreater LondonUKNW1 2DA
| | - Ian A Scott
- Princess Alexandra HospitalInternal Medicine Department and Clinical Services Evaluation UnitBrisbaneAustralia
| | - Constantine N Aroney
- The Prince Charles HospitalDepartment of CardiologyRode RdChermsideBrisbaneAustralia
| | - Darren L Walters
- The Prince Charles HospitalExecutive Chair Prince Charles Heart and Lung InstituteRoad RdBrisbaneQueenslandAustralia4032
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Cohen MG, Matthews R, Maini B, Dixon S, Vetrovec G, Wohns D, Palacios I, Popma J, Ohman EM, Schreiber T, O'Neill WW. Percutaneous left ventricular assist device for high-risk percutaneous coronary interventions: Real-world versus clinical trial experience. Am Heart J 2015; 170:872-9. [PMID: 26542494 DOI: 10.1016/j.ahj.2015.08.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 08/08/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND High-risk percutaneous coronary intervention (PCI) supported by percutaneous left ventricular assist devices offers a treatment option for patients with severe symptoms, complex and extensive coronary artery disease, and multiple comorbidities. The extrapolation from clinical trial to real-world practice has inherent uncertainties. We compared the characteristics, procedures, and outcomes of high-risk PCI supported by a microaxial pump (Impella 2.5) in a multicenter registry versus the randomized PROTECT II trial (NCT00562016). METHODS The USpella registry is an observational multicenter voluntary registry of Impella technology. A total of 637 patients treated between June 2007 and September 2013 were included. Of them, 339 patients would have met enrollment criteria for the PROTECT II trial. These were compared with 216 patients treated in the Impella arm of PROTECT II. RESULTS Compared to the clinical trial, registry patients were older (70 ± 11.5 vs 67.5 ± 11.0 years); more likely to have chronic kidney disease (30% vs 22.7%), prior myocardial infarction (69.3% vs 56.5%), or prior bypass surgery (39.4% vs. 30.2%); and had similar prevalence of diabetes, peripheral vascular disease, and prior stroke. Registry patients had more extensive coronary artery disease (2.2 vs 1.8 diseased vessels) and had a similar Society of Thoracic Surgeons predicted risk of mortality. At hospital discharge, registry patients experienced a similar reduction in New York Heart Association class III to IV symptoms compared to trial patients. Registry patients had a trend toward lower in-hospital mortality (2.7% vs 4.6, P = .27). CONCLUSIONS USpella provides a real-world and contemporary estimation of the type of procedures and outcomes of high-risk patients undergoing PCI supported by Impella 2.5. Despite the higher risk of registry patients, clinical outcomes appeared to be favorable and consistent compared with the randomized trial.
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Affiliation(s)
| | - Ray Matthews
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Simon Dixon
- William Beaumont University Hospital, Royal Oak, MI
| | - George Vetrovec
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | | | | | - Jeffrey Popma
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Abstract
Ischemic heart disease is the leading cause of mortality worldwide. Due to advances in medicine in the past few decades, life expectancy has increased resulting in an aging population in developed and developing countries. Acute coronary syndrome causes greater morbidity and mortality in this group of older patients, which appears to be due to age-related comorbidities. This review examines the incidence and prevalence of acute coronary syndrome among older patients, examines current treatment strategies, and evaluates the predictors of adverse outcomes. In particular, the impact of frailty on outcomes and the need for frailty assessment in developing future research and management strategies among older patients are discussed.
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17
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Endo A, Kohsaka S, Miyata H, Kawamura A, Noma S, Suzuki M, Koyama T, Ishikawa S, Momiyama Y, Nakagawa S, Sueyoshi K, Takagi S, Takahashi T, Sato Y, Ogawa S, Fukuda K. Disparity in the application of guideline-based medical therapy after percutaneous coronary intervention: analysis from the Japanese prospective multicenter registry. Am J Cardiovasc Drugs 2013; 13:103-12. [PMID: 23585142 DOI: 10.1007/s40256-013-0021-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Despite the known benefits of evidence-based medical care in patients with coronary artery disease, disparities exist in the application of guideline-based medical therapy (GBMT) after percutaneous coronary intervention (PCI), particularly in patients who have undergone revascularization procedures. Underestimation of risk, overestimation of side effects, and preference of the treating physician to prioritize invasive procedures may all affect the prescription pattern. OBJECTIVE We sought to describe how GBMT is prescribed after PCI in Japan. METHODS From September 2008 to 2010, 1,612 patients underwent PCI with stenting at 14 Japanese hospitals participating in the Japanese Cardiovascular Database Registry. GBMT was defined as treatment including dual antiplatelet therapy, beta-adrenoceptor antagonists (beta-blockers) and/or calcium channel blockers, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, and statins. RESULTS Overall, 749 patients (46.5%) were discharged on GBMT. Notably, the prescription rate of GBMT became lower with age (e.g. from 50.3% [age 50-59 years] to 35.9% [age over 80 years]). In addition, patients presenting with acute coronary syndrome (ACS) tended to receive GBMT more frequently (ST-segment elevation myocardial infarction [STEMI] 33.8 vs. 18.3%; p<0.001; non-ST-segment elevation myocardial infarction [NSTEMI] 8.5 vs. 5.9%; p=0.042), whereas patients presenting with cardiogenic shock (CS) had lower prescription rates of GBMT (2.1 vs. 4.1%; p=0.032). Overall age (odds ratio [OR] 0.647; p=0.020), as well as the acute and emergent presentation (OR 3.229; p<0.001 for STEMI; OR 2.122; p<0.001 for NSTEMI; OR 0.35; p=0.002 for CS) were also associated with prescription of GBMT. CONCLUSION Only about half of the post-PCI patients were discharged on ideal GBMT. Elderly patients and those presenting with non-ACS status or hemodynamic compromise tended not to receive GBMT, and required more attention for optimization of their care.
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18
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Biondi Zoccai G, Abbate A, D'Ascenzo F, Presutti D, Peruzzi M, Cavarretta E, Marullo AGM, Lotrionte M, Frati G. Percutaneous coronary intervention in nonagenarians: pros and cons. J Geriatr Cardiol 2013; 10:82-90. [PMID: 23610578 PMCID: PMC3627716 DOI: 10.3969/j.issn.1671-5411.2013.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 01/15/2013] [Accepted: 02/28/2013] [Indexed: 02/05/2023] Open
Abstract
Percutaneous coronary intervention is a mainstay in the management of symptomatic or high-risk coronary artery disease. The bulk of clinical evidence and experience underlying this fact relies, however, on relatively young patients. Indeed, few data of very limited quality are available which adequately define the risk-benefit and cost-benefit profile of coronary angioplasty and stenting in very old subjects, such as those of 90 years of age or older (i.e., nonagenarians). The aim of this review is to provide a concise, yet practical, synthesis of the available evidence on percutaneous coronary revascularization in the very elderly. The main arguments elaborated upon are to what extent we can extrapolate findings from studies including younger patients to nonagenarians, whether we should provide higher priority to prognosis or quality of life in such patients, and whether we can afford to allocate vast resources to care for such subjects in an era of financial constraints. Our review of 18 studies and 1082 patients suggest that percutaneous coronary intervention is feasible and associated with acceptable short- and long-term results in this population, which is nonetheless fraught with a high mortality risk irrespective of the revascularization procedure. Accordingly, the pros and cons of percutaneous coronary intervention should be carefully weighed when considering this treatment in nonagenarians.
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Affiliation(s)
- Giuseppe Biondi Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 04100 Latina, Italy
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Krzyzanowska MK, Kaplan R, Sullivan R. How may clinical research improve healthcare outcomes? Ann Oncol 2012; 22 Suppl 7:vii10-vii15. [PMID: 22039138 DOI: 10.1093/annonc/mdr420] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Healthcare outcomes such as overall survival or quality of life are the end results of a complex interaction between the patient, treatment and the healthcare system. Research may identify superior interventions but their dissemination and changing the behaviour of healthcare providers is challenging. Demonstrating and measuring the benefits of clinical research on healthcare outcomes is an important issue but there is remarkably little empiric work to date in this area. In this chapter we explore benefits that may arise in healthcare from contributing to clinical research, and consider the mechanisms which may be relevant. Improvements in infrastructure, the processes of care and workforces are important. Complex adaptive systems theory provides a framework for considering the many feedback loops that relate research, health outcomes and the behaviour of healthcare providers. Given the costs of research, additional studies to examine the impact of research on healthcare outcomes and to explore the mechanisms are justified and highly desirable.
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Affiliation(s)
- M K Krzyzanowska
- University of Toronto Princess Margaret Hospital, Toronto, Canada
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Abstract
Coronary disease is a major cause of death and disability. From 1975 to 2000, coronary mortality was reduced by half. Better treatments and reduction of risk factors are the main causes. This phenomenon is observed in most developed countries, but mortality from coronary heart disease continues to increase in developing countries. In-hospital mortality of ST elevation myocardial infarction (STEMI) is in the range of 7 to 10% in registries. In infarction without ST segment elevation (NSTEMI), in-hospital mortality is around 5%. More recent studies found a similar in-hospital mortality for STEMI and NSTEMI. Because of patient selection and monitoring, mortality in clinical trials is much lower. After adjustment for the extent of coronary disease, age, risk factors, history of myocardial infarction, the excess mortality observed in women is fading. Many clinical, biological and laboratory parameters are associated with mortality in myocardial infarction. They refer to the immediate risk of death (ventricular rhythm disturbances, shock…), the extent of infarction (number of leads with ST elevation on the ECG, release of biomarkers, ejection fraction…), the presence of heart failure, the failure of reperfusion and the patient's baseline risk (age, renal function…). Risk scores, and more specifically the GRACE risk score, synthesize these different markers to predict the risk of death in a given patient. However, their use for the treatment of myocardial only concerns NSTEMI. Only a limited number of mechanical or pharmacological interventions reduces mortality of heart attack. The main benefits are observed with reperfusion by thrombolysis or primary angioplasty in STEMI, aspirin, heparin, beta-blockers, angiotensin converting enzyme inhibitors. Some medications such as bivalirudin and fondaparinux reduce mortality by decreasing the incidence of hemorrhagic complications. The guidelines classify interventions according to their benefit and especially their ability to reduce mortality. Organized care systems that improve implementation of guidelines also reduce mortality. Finally, some new therapeutic approaches such as post-conditioning and new therapeutic classes offer encouraging prospects for further reducing the mortality of myocardial infarction.
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Affiliation(s)
- E Bonnefoy
- Soins intensifs et urgences cardiologiques, hôpital cardiovasculaire et pneumologique Louis-Pradel, BP Lyon-Montchat, France.
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Ranasinghe I, Alprandi-Costa B, Chow V, Elliott JM, Waites J, Counsell JT, Lopéz-Sendón J, Avezum Á, Goodman SG, Granger CB, Brieger D. Risk stratification in the setting of non-ST elevation acute coronary syndromes 1999-2007. Am J Cardiol 2011; 108:617-24. [PMID: 21714948 DOI: 10.1016/j.amjcard.2011.04.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Revised: 04/15/2011] [Accepted: 04/15/2011] [Indexed: 12/22/2022]
Abstract
It is unclear if clinician risk stratification has changed with time. The aim of this study was to assess the temporal change in the concordance between patient presenting risk and the intensity of evidence-based therapies received for non-ST-segment elevation acute coronary syndromes over a 9-year period. Data from 3,562 patients with non-ST-segment elevation acute coronary syndromes enrolled in the Australian and New Zealand population of the Global Registry of Acute Coronary Events (GRACE) from 1999 to 2007 were analyzed. Patients were stratified to risk groups on the basis of the GRACE risk score for in-hospital mortality. Main outcome measures included in-hospital use of widely accepted evidence-based medications, investigations, and procedures. Invasive management was consistently higher in low-risk patients than in intermediate- or high-risk patients (coronary angiography 66.7% vs 63.5% vs 35.3%, p <0.001; percutaneous coronary intervention 31.1% vs 22.0% vs 12.9%, p <0.001). Absolute rates of angiography and percutaneous coronary intervention in the high-risk group remained 24% and 15% lower compared to the low-risk group in the most recent time period (2005 to 2007). In-hospital use of thienopyridine, low-molecular weight heparin, and glycoprotein IIb/IIIa inhibitors showed a similar inverse relation with risk. Prescription of aspirin, β blockers, statins, and angiotensin receptor blockers was inversely related to risk before 2004, although this inverse relation was no longer present in the most recent time period (2005 to 2007). Only in-hospital use of unfractionated heparin showed use concordant with patient risk status. In conclusion, despite an overall increase in the uptake of evidence-based therapies, most investigations and treatments are not targeted on the basis of patient risk. Clinician risk stratification remains suboptimal compared to objective measures of patient risk.
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Villanueva-Benito I, Solla-Ruíz I, Paredes-Galán E, Díaz-Castro O, Calvo-Iglesias FE, Baz-Alonso JA, Iñiguez-Romo A. [Prognostic impact of interventional approach in non-ST segment elevation acute coronary syndrome in very elderly patients]. Rev Esp Cardiol 2011; 64:853-61. [PMID: 21784570 DOI: 10.1016/j.recesp.2011.04.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Accepted: 04/19/2011] [Indexed: 12/22/2022]
Abstract
INTRODUCTION AND OBJECTIVES In moderate or high risk non-ST segment elevation acute coronary syndrome, clinical practice guidelines recommend a coronary angiography with intent to revascularize. However, evidence to support this recommendation in very elderly patients is poor. METHODS All patients over 85 years old admitted to our hospital between 2004 and 2009 with a diagnosis of non-ST segment elevation acute coronary syndrome were retrospectively included. Using a propensity score, patients undergoing the interventional approach and those undergoing conservative management were matched and compared for survival and survival without ischemic events. RESULTS We included 228 consecutive patients with a mean age of 88 years (range: 85 to 101). Those in the interventional approach group (n=100) were younger, with a higher proportion of males and less comorbidity, less cognitive impairment and lower troponin I levels compared with patients in the conservative management group (n=128). We matched 63 patients from the interventional approach group and 63 from the conservative management group using propensity score. In the matched patients, the interventional approach group exhibited better survival (log rank 4.24; P=.039) and better survival free of ischemic events (log rank 8.63; P=.003) at the 3-year follow-up. In the whole population, adjusted for propensity score quintiles, the interventional approach group had lower mortality (hazard ratio 0.52; 95% confidence interval: 0.32-0.85) and a better survival free of ischemic events (hazard ratio 0.48; 95% confidence interval: 0.32-0.74). CONCLUSIONS Nearly all the very elderly patients admitted with non-ST segment elevation acute coronary syndrome were of moderate or high risk. In these patients, the interventional approach was associated with overall better survival and better survival free of ischemic events.
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Affiliation(s)
- Iñaki Villanueva-Benito
- Servicio de Cardiología, Complejo Hospitalario Universitario de Vigo, Hospital Meixoeiro, Vigo, Pontevedra, España.
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23
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Kontos MC, Diercks DB, Ho PM, Wang TY, Chen AY, Roe MT. Treatment and outcomes in patients with myocardial infarction treated with acute β-blocker therapy: results from the American College of Cardiology's NCDR(®). Am Heart J 2011; 161:864-70. [PMID: 21570515 DOI: 10.1016/j.ahj.2011.01.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Accepted: 01/16/2011] [Indexed: 01/14/2023]
Abstract
BACKGROUND Although β-blockers (BBs) reduce long-term mortality in patients after myocardial infarction (MI), data regarding acute usage are conflicting. METHODS We examined acute (≤24 hours) BB use in 34,661 patients with ST-elevation MI (STEMI) and non-ST-segment MI (NSTEMI) included in the NCDR(®) ACTION Registry(®)-GWTG™ (291 US hospitals) between January 2007 and June 2008. Patients with contraindications or did not receive BBs or with missing data were excluded. We analyzed the use and impact of BB stratified by variables associated with increased risk for shock specified in the recent guidelines: age >70 years, symptoms >12 hours (STEMI patients), systolic blood pressure <120 mm Hg, and heart rate >110 beat/min on presentation. RESULTS Among patients without contraindications, at least 1 high-risk variable was found in 45% of STEMI and 63% of NSTEMI patients. In-hospital complications including cardiogenic shock, mortality, and the composite outcome of shock or mortality were significantly increased with more shock risk factors in both STEMI and NSTEMI patients. Very early use in the emergency department was associated with a significantly increased risk of shock for both STEMI and NSTEMI patients compared to patients treated later but within 24 hours. CONCLUSIONS Risk factors for shock are common in STEMI and NSTEMI patients treated with early BBs. Increasing numbers of risk factors were associated with increased risk for shock or death in patients treated with BBs. These results are consistent with current recommendations for avoiding early BB treatment for patients with acute MI.
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Hutchinson-Jaffe AB, Goodman SG, Yan RT, Wald R, Elbarouni B, Rose B, Eagle KA, Lai CC, Baer C, Langer A, Yan AT. Comparison of baseline characteristics, management and outcome of patients with non-ST-segment elevation acute coronary syndrome in versus not in clinical trials. Am J Cardiol 2010; 106:1389-96. [PMID: 21059426 DOI: 10.1016/j.amjcard.2010.06.070] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Revised: 06/28/2010] [Accepted: 06/28/2010] [Indexed: 12/22/2022]
Abstract
Previous studies have questioned the external validity of randomized controlled trial results of acute coronary syndrome (ACS) because of potential selection bias toward healthier patients. We sought to evaluate differences in clinical characteristics and management of patients admitted with non-ST-elevation ACS according to participation in clinical trials over the previous decade. The Canadian ACS I (1999 to 2001), ACS II (2002-2003), GRACE (2004-2007), and CANRACE (2008) were prospective, multicenter registries of patients admitted to hospitals with ACS. We examined 13,556 patients with non-ST-elevation ACS, of whom 1,126 (8.3%) participated in clinical trials. Data were collected on baseline characteristics, medication use at admission and discharge, in-hospital procedures, and in-hospital adverse events. Patients enrolled in clinical trials were younger, more likely to be men, and had fewer co-morbidities. They were significantly more likely to be on several guideline-recommended medications and were significantly more likely to undergo invasive procedures, including coronary angiography, percutaneous coronary intervention, and coronary bypass surgery (all p values <0.001). Unadjusted in-hospital (2.1% vs 0.7%, p = 0.001) and 1-year (8.9% vs 6.3%, p = 0.037) mortality rates were higher in non-enrolled patients. In multivariable analysis, patients who were older, women, had a history of heart failure, and increased creatinine levels on presentation were less likely to be enrolled into clinical trials. In conclusion, significant differences persist in baseline characteristics, treatment, and outcomes between patients enrolled and those not enrolled in clinical trials. Consequently, generalization of ACS clinical trials over the previous decade to the "real-world" patient may remain in question.
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Vasaiwala S, Forman DE, Mauri L. Drug-eluting stents in the elderly. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2010; 12:76-83. [PMID: 20842483 DOI: 10.1007/s11936-009-0057-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OPINION STATEMENT The introduction of drug-eluting stents (DES) in 2003 has had a great impact on the management of coronary artery disease in the United States. The application of DES to older adults, the population with the highest prevalence of and worst prognosis for coronary artery disease, remains relatively more controversial. Dual-antiplatelet therapy, which is recommended for at least 12 months after DES placement, is particularly problematic for older patients because of greater age-related bleeding risks. Unfortunately, few current data are available to gauge the balance of risk and benefit in elderly community-dwelling DES patients. Although trial data show a benefit for DES among elderly patients, many older adults typically are excluded from randomized trials because of comorbidities, making generalizability of DES safety based on trial data less certain. New, more potent thienopyridines may place the elderly at a particularly elevated bleeding risk. There is a fine balance between efficacy and safety for older DES patients that still needs to be clarified. As the population ages, these issues become more pervasive and of widespread concern. This review summarizes the current literature on DES therapy in the elderly, with a focus on effectiveness and safety profiles of DES versus bare metal stents.
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Affiliation(s)
- Samip Vasaiwala
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
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Hoenig MR, Aroney CN, Scott IA. Early invasive versus conservative strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. Cochrane Database Syst Rev 2010:CD004815. [PMID: 20238333 DOI: 10.1002/14651858.cd004815.pub3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND In patients with unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI) two strategies are possible, either a routine invasive strategy where all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularization; or a conservative strategy where medical therapy alone is used initially, with selection of patients for angiography based on clinical symptoms or investigational evidence of persistent myocardial ischemia. OBJECTIVES To determine the benefits of an invasive compared to conservative strategy for treating UA/NSTEMI in the stent era. SEARCH STRATEGY The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 1), MEDLINE and EMBASE were searched (1996 to February 2008) with no language restrictions. SELECTION CRITERIA Included studies were prospective trials comparing invasive with conservative strategies in UA/NSTEMI. DATA COLLECTION AND ANALYSIS We identified five studies (7818 participants). Using intention-to-treat analysis with random-effects models, summary estimates of relative risk (RR) with 95% confidence interval (CI) were determined for primary end-points of all-cause death, fatal and non-fatal myocardial infarction, all-cause death or non-fatal myocardial infarction, and refractory angina. Further analysis of included studies was undertaken based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. Heterogeneity was assessed using Chi(2) and variance (I(2) statistic) methods. MAIN RESULTS In the all-study analysis, mortality during initial hospitalization showed a trend to hazard with an invasive strategy (RR 1.59, 95% CI 0.96 to 2.64). The invasive strategy did not reduce death on longer-term follow up. Myocardial infarction rates assessed at 6 to 12 months (5 trials) and 3 to 5 years (3 trials) were significantly decreased by an invasive strategy (RR 0.73, 95% CI 0.62 to 0.86; and RR 0.78, 95% CI 0.67 to 0.92 respectively). The incidence of early (< 4 month) and intermediate (6 to 12 month) refractory angina were both significantly decreased by an invasive strategy (RR 0.47, 95% CI 0.32 to 0.68; and RR 0.67, 95% CI 0.55 to 0.83 respectively), as were early and intermediate rehospitalization rates (RR 0.60, 95% CI 0.41to 0.88; and RR 0.67, 95% CI 0.61 to 0.74 respectively). The invasive strategy was associated with a two-fold increase in the RR of peri-procedural myocardial infarction (as variably defined) and a 1.7-fold increase in the RR of (minor) bleeding with no hazard of stroke. AUTHORS' CONCLUSIONS Compared to a conservative strategy for UA/NSTEMI, an invasive strategy is associated with reduced rates of refractory angina and rehospitalization in the shorter term and myocardial infarction in the longer term. However, the invasive strategy is associated with a doubled risk of procedure-related heart attack and increased risk of bleeding and procedural biomarker leaks. Available data suggest that an invasive strategy may be particularly useful in those at high risk for recurrent events.
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Affiliation(s)
- Michel R Hoenig
- Royal Brisbane and Women's Hospital, Herston, Brisbane, Australia, 4029
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Goto K, Lansky AJ, Fahy M, Cristea E, Feit F, Ohman EM, White HD, Alexander KP, Bertrand ME, Desmet W, Hamon M, Mehran R, Stone GW. Predictors of outcomes in medically treated patients with acute coronary syndromes after angiographic triage: an Acute Catheterization And Urgent Intervention Triage Strategy (ACUITY) substudy. Circulation 2010; 121:853-62. [PMID: 20142447 DOI: 10.1161/circulationaha.109.877944] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Outcomes of patients presenting with acute coronary syndromes are improved with an early invasive approach; however, approximately one third of these patients are treated medically after angiographic screening. We sought to assess the predictors of adverse cardiac events in patients with acute coronary syndrome assigned to medical management. METHODS AND RESULTS This substudy of the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial included 4491 acute coronary syndrome patients treated medically after angiographic triage. Rates of bleeding and composite ischemia (death, myocardial infarction, revascularization) were compared among the 3 antithrombotic treatment arms. Composite ischemia occurred in 399 patients (9.5%) at 1 year. Treatment with bivalirudin glycoprotein IIb/IIIa inhibitors significantly reduced major bleeding at 30 days (2.5% bivalirudin monotherapy; P=0.005, 2.0% bivalirudin plus glycoprotein IIb/IIIa inhibitors; P=0.0002 versus 4.4% heparin with glycoprotein IIb/IIIa inhibitors). Composite ischemic events at 1 year were not significantly different in the 3 groups (bivalirudin monotherapy, 9.6%; bivalirudin plus glycoprotein IIb/IIIa inhibitors, 9.7%; heparin plus glycoprotein IIb/IIIa inhibitors, 9.1%). Independent predictors of composite ischemia were mostly angiographic factors at 30 days, including jeopardy score and coronary ectasia, and at 1 year, including previous percutaneous coronary intervention, jeopardy score, coronary ectasia, and increasing number of diseased vessels. CONCLUSIONS Among the ACUITY acute coronary syndrome patients treated medically after angiographic triage, bivalirudin therapy significantly reduced bleeding complications compared with heparin without any negative impact on ischemic outcomes at 1 year. The most powerful predictors of ischemic outcomes were angiographic rather than traditional clinical parameters, supporting the early use of angiographic screening in the moderate- and high-risk but medically treated acute coronary syndrome population. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00093158.
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Affiliation(s)
- Kenji Goto
- Cardiovascular Research Foundation, 111 E 59th St, 11th Floor, New York, NY 10022, USA
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Clark AL, Lammiman MJ, Goode K, Cleland JG. Is taking part in clinical trials good for your health? A cohort study. Eur J Heart Fail 2009; 11:1078-83. [DOI: 10.1093/eurjhf/hfp133] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Andrew L. Clark
- Department of Academic Cardiology; Castle Hill Hospital; Castle Road Cottingham Hull HU16 5JQ UK
| | - Michael J. Lammiman
- Department of Academic Cardiology; Castle Hill Hospital; Castle Road Cottingham Hull HU16 5JQ UK
| | - Kevin Goode
- Department of Academic Cardiology; Castle Hill Hospital; Castle Road Cottingham Hull HU16 5JQ UK
| | - John G.F. Cleland
- Department of Academic Cardiology; Castle Hill Hospital; Castle Road Cottingham Hull HU16 5JQ UK
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Berger JS, Frye CB, Harshaw Q, Edwards FH, Steinhubl SR, Becker RC. Impact of clopidogrel in patients with acute coronary syndromes requiring coronary artery bypass surgery: a multicenter analysis. J Am Coll Cardiol 2008; 52:1693-701. [PMID: 19007688 DOI: 10.1016/j.jacc.2008.08.031] [Citation(s) in RCA: 143] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Revised: 06/27/2008] [Accepted: 08/11/2008] [Indexed: 01/17/2023]
Abstract
OBJECTIVES The purpose of our multicenter study was to examine the impact of pre-operative administration of clopidogrel on reoperation rates, incidence of life-threatening bleeding, inpatient length of stay, and other bleeding-related outcomes in acute coronary syndrome (ACS) patients requiring cardiopulmonary bypass (coronary artery bypass graft surgery [CABG]) in a broad cross section of U.S. hospitals. BACKGROUND There is relative uncertainty about the relationship between clopidogrel and CABG-associated outcomes in the setting of ACS. METHODS A retrospective cohort analysis was performed of randomly selected ACS patients requiring CABG in 14 hospitals across the U.S. Patients exposed to clopidogrel were compared with those not exposed to clopidogrel within 5 days prior to surgery. RESULTS Of the 596 patients enrolled in the study, 298 had been exposed to clopidogrel within 5 days (Group A). Patients in Group A were more than 3-fold more likely to require reoperation for assessment of bleeding than patients not exposed to clopidogrel (6.4% vs. 1.7% Group B, p = 0.004). Major bleeding occurred in 35% of Group A patients versus 26% of Group B patients (p = 0.049). Length of stay was greater in Group A compared with Group B (9.7 +/- 6.0 days vs. 8.6 +/- 4.7 days, unadjusted p = 0.016). After logistic regression analysis, clopidogrel exposure within 5 days of CABG was the strongest predictor of reoperation (odds ratio [OR]: 4.60, 95% confidence interval [CI]: 1.45 to 14.55) and major bleeding (OR: 1.824, 95% CI: 1.106 to 3.008). CONCLUSIONS After ACS, patients who undergo CABG within 5 days of receiving clopidogrel are at increased risk for reoperation, major bleeding, and increased length of stay. These risks must be balanced by the clinical benefits of clopidogrel use demonstrated in randomized clinical trials.
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Affiliation(s)
- Jeffrey S Berger
- Division of Cardiology, Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina 27705, USA
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31
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Sangiorgi G, Romagnoli E, Biondi-Zoccai G, Margheri M, Tamburino C, Barbagallo R, Falchetti E, Vittori G, Agostoni P, Cosgrave J, Colombo A. Percutaneous coronary implantation of sirolimus-eluting stents in unselected patients and lesions: clinical results and multiple outcome predictors. Am Heart J 2008; 156:871-8. [PMID: 19061700 DOI: 10.1016/j.ahj.2008.06.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2007] [Accepted: 06/22/2008] [Indexed: 02/05/2023]
Abstract
BACKGROUND Sirolimus-eluting stents (SES) prevent restenosis and repeat percutaneous coronary intervention (PCI), but safety data in unselected patients are limited, especially for intermediate-term follow-up. METHODS All patients undergoing SES implantation at 4 Italian centers were enrolled into a dedicated database. Baseline, procedural, and outcome data at discharge and at follow-up were abstracted. Outcomes of interest were the occurrence of major adverse cerebrocardiovascular events (MACCE) at 6 months, as well as long-term event-free survival and multivariable event predictors. RESULTS One thousand four hundred twenty-four patients were enrolled (2,915 lesions, treated with 3,305 stents). Specifically, 1,074 (75.4%) subjects had multivessel disease, 399 (28.1%) had diabetes, 89 (6.3%) had ST-elevation myocardial infarction, and 44 (3.1%) underwent unprotected left main intervention. At 6 months, MACCE had occurred in 121 (9.0%) patients. After a median of 48.7 months (first-third quartile 41.8-55.3), MACCE-free survival was 69.2%+/-2.6%, with definite stent thrombosis occurring acutely in 6 (0.4%), subacutely in 11 (0.8%), after 30 days in 12 (0.8%), and cumulatively in 28 (2.0%). Major multivariable outcome predictors were diabetes (target lesion revascularization [TLR], MACCE), ejection fraction (TLR, MACCE), and maximal balloon length (TLR). CONCLUSIONS This large cohort of unselected patients supports the overall safety of unrestricted percutaneous SES implantation, as shown by the low rates of stent thrombosis. Event attrition remains, however, high at long-term follow-up, driven mainly by target vessel revascularization, with diabetes and ejection fraction as the most important prognostic factors.
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Somkin CP, Altschuler A, Ackerson L, Tolsma D, Rolnick SJ, Yood R, Weaver WD, Von Worley A, Hornbrook M, Magid DJ, Go AS. Cardiology clinical trial participation in community-based healthcare systems: obstacles and opportunities. Contemp Clin Trials 2008; 29:646-53. [PMID: 18397842 PMCID: PMC2615791 DOI: 10.1016/j.cct.2008.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Revised: 02/21/2008] [Accepted: 02/25/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND The objective of our study was to examine cardiologists' and organizational leaders' interest in clinical trial participation and perceived barriers and facilitators to participation within ten diverse non-profit healthcare delivery systems. Trials play a pivotal role in advancing knowledge about the safety and efficacy of cardiovascular interventions and tests. Although cardiovascular trials successfully enroll patients, recruitment challenges persist. Community-based health systems could be an important source of participants and investigators, but little is known about community cardiologists' experiences with trials. METHODS We interviewed 25 cardiology and administrative leaders and mailed questionnaires to all 280 cardiologists at 10 U.S. healthcare organizations. RESULTS The survey received a 73% response rate. While 60% of respondents had not participated in any trials in the past year, nearly 75% wanted greater participation. Cardiologists reported positive attitudes toward trial participation; more than half agreed that trials were their first choice of therapy for patients, if available. Almost all leaders described their organizations as valuing research but not necessarily trials. Major barriers to participation were lack of physician time and insufficient skilled research nurses. CONCLUSIONS Cardiologists have considerable interest in trial participation. Major obstacles to increased participation are lack of time and effective infrastructure to support trials. These results suggest that community-based health systems are a rich source for cardiovascular research but additional funding and infrastructure are needed to leverage this resource.
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Affiliation(s)
- Carol P. Somkin
- Division of Research, Kaiser Permanente Northern California, Oakland, California, U.S.A
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, California, U.S.A
| | - Lynn Ackerson
- Division of Research, Kaiser Permanente Northern California, Oakland, California, U.S.A
| | | | | | - Robert Yood
- Meyers Primary Care Institute, Worcester, Massachusetts, U.S.A
| | - W. Douglas Weaver
- Division of Cardiology, Henry Ford Health System, Detroit Michigan, U.S.A
| | - Ann Von Worley
- Lovelace Clinic Foundation, Albuquerque, New Mexico, U.S.A
| | - Mark Hornbrook
- Kaiser Permanente Center for Health Research, Portland, Oregon, U.S.A
| | - David J. Magid
- Clinical Research Unit, Kaiser Permanente Colorado, Denver, Colorado, U.S.A
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California, U.S.A
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Sheiban I, Sillano D, Biondi-Zoccai GG, De Servi S, Tamburino C, Marzocchi A, Trevi GP, Moretti C. A prospective multicentre observational study on the management of unprotected left main coronary artery disease: rationale and design of the Registro Italiano sul Trattamento del tronco comune non protetto study. J Cardiovasc Med (Hagerstown) 2008; 9:826-30. [PMID: 18607249 DOI: 10.2459/jcm.0b013e3282fce7c0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The optimal approach for a significant unprotected left main coronary stenosis is debated in light of the recent progresses of percutaneous coronary intervention. However, bypass surgery is still considered the first choice treatment. Randomized trials comparing percutaneous intervention and bypass grafting are ongoing, yet patient selection will limit their applicability. We designed a prospective multicentre registry, which will include patients with unprotected left main disease independent of the subsequent medical, interventional or surgical treatment. OBJECTIVE The aim of this study is to evaluate prospectively the prevalence, treatment, and prognosis of patients with unprotected left main stenosis. STUDY DESIGN More than 30 Italian care centres will participate. Patients with unprotected left main stenosis will be enrolled, excluding those with only mild atherosclerotic irregularities or patent grafts. The primary endpoint will be the 12-month occurrence of major adverse cardiac and cerebral events (MACCE, i.e. the composite of death, non-fatal myocardial infarction, stroke, or coronary revascularization by percutaneous intervention or bypass surgery). Secondary endpoints will be the occurrence of individual components of the primary endpoint at 1, 6, 24, and 60 months, the rate of major adverse cardiac and cerebral events without stroke, functional class, and quality of life. Analyses will be stratified according to lesion severity, as well as other patient, lesion, and procedural characteristics. EXPECTED RESULTS AND IMPLICATIONS: This multicentre prospective registry of patients with unprotected left main coronary stenosis treated medically, percutaneously or surgically will provide important and updated data on the prevalence, therapeutic choices, and prognosis of this important patient population.
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Affiliation(s)
- Imad Sheiban
- Division of Cardiology, University of Turin, Turin, Italy.
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35
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Chew DP, Amerena JV, Coverdale SG, Rankin JM, Astley CM, Soman A, Brieger DB. Invasive management and late clinical outcomes in contemporary Australian management of acute coronary syndromes: observations from the ACACIA registry. Med J Aust 2008; 188:691-7. [DOI: 10.5694/j.1326-5377.2008.tb01847.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2006] [Accepted: 02/28/2008] [Indexed: 11/17/2022]
Affiliation(s)
- Derek P Chew
- Flinders University, Adelaide, SA
- Flinders Medical Centre, Adelaide, SA
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Chan MY, Becker RC, Harrington RA, Peterson ED, Armstrong PW, White H, Fox KAA, Ohman EM, Roe MT. Noninvasive, medical management for non-ST-elevation acute coronary syndromes. Am Heart J 2008; 155:397-407. [PMID: 18294472 DOI: 10.1016/j.ahj.2007.11.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Accepted: 11/12/2007] [Indexed: 11/16/2022]
Abstract
Despite emphasis on the use of invasive management strategies for patients with non-ST-elevation acute coronary syndromes (NSTE ACS) in recent practice guidelines, 27% to 56% of NSTE ACS patients do not undergo diagnostic angiography, and a further 45% to 78% do not undergo revascularization procedures during the initial hospitalization. These medically managed patients (also termed noninvasive management) have a greater frequency of medical comorbidities and high-risk clinical characteristics and are less likely to receive guideline-recommended medications, compared with patients who undergo revascularization procedures. The rates of short and long-term adverse outcomes are also substantially higher in medically managed NSTE ACS patients, but more widespread implementation of contemporary medical therapies in this population is limited by exclusion of medically managed patients from many randomized clinical trials.
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Affiliation(s)
- Mark Y Chan
- Duke Clinical Research Institute, Durham, NC 27705, USA.
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37
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Sangiorgi GM, Biondi-Zoccai GGL, Agostoni P, Antoniucci D, Grube E, Di Mario C, Reimers B, Tamburino C, Cosgrave J, Colombo A. Appraising the effectiveness and safety of paclitaxel-eluting stents in over 1,000 very high-risk patients: overall results of the Taxus in Real-life Usage Evaluation (TRUE) registry. EUROINTERVENTION 2007; 3:333-9. [PMID: 19737714 DOI: 10.4244/eijv3i3a61] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Paclitaxel-eluting stents (PES) have been proved safe and effective in selected patients undergoing percutaneous coronary interventions (PCI). However, there is uncertainty on the performance of PES in real-world patients at higher risk for major adverse cardiovascular events (MACE) or restenosis. We conducted a multicentre registry enrolling very high-risk subjects treated with PES. METHODS AND RESULTS We enrolled 1,065 consecutive patients undergoing PES implantation, provided that the target lesion treated with the PES was an unprotected left main (N=113), a true bifurcation (N=219), a chronic total occlusion (CTO, N=183), a long lesion (>28 mm, N=283), in a small vessel (<2.75 mm, N=417), or the patient had medically-treated diabetes mellitus (N=315). Clinical events were adjudicated at 1 and 7 months, and 4 to 8-month angiographic follow-up was recommended for core-lab quantitative coronary angiography. The primary end-point was the 7-month occurrence of MACE, i.e., the composite of cardiac death, non-fatal myocardial infarction (MI), coronary artery bypass grafting (CABG) and percutaneous target vessel revascularisation (TVR). A total of 2,116 lesions were treated with 2.0+/-1.2 Taxus per patient and 46.4+/-30 total Taxus length per patient. One total Taxus length per patient. One-month MACE occurred in 4.3% of patients, with 0.4% cardiac death, 3.3% myocardial infarction (MI), 0.1% coronary artery bypass grafting (CABG), and 0.8% target vessel revascularisation (TVR) PCI. Seven-month events were as follows: MACE 20.4%, cardiac death 1.2%, MI 4.2%, CABG 1.2%, TVR-PCI 15.4% and target lesion revascularisation (TLR)-PCI 10.9%. Binary restenosis occurred in 20.7% out of the 1,071 lesions undergoing follow-up angiography. Finally. stent thrombosis (ST) was reported with a 0.8% 12-month cumulative rate (0.3% acute, 0.3% subacute, and 0.2% <6 months, but no thrombosis >6 months). CONCLUSIONS This registry, enrolling 1,065 high-risk patients treated with PES, confirms the satisfactory performance of this device, especially given the overall profile of enrolled subjects and the limited number of stent thromboses.
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38
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Guía de Práctica Clínica para el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol 2007. [DOI: 10.1157/13111518] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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39
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Bottorff MB, Nutescu EA, Spinler S. Antiplatelet Therapy in Patients with Unstable Angina and Non–ST-Segment-Elevation Myocardial Infarction: Findings from the CRUSADE National Quality Improvement Initiative. Pharmacotherapy 2007; 27:1145-62. [PMID: 17655514 DOI: 10.1592/phco.27.8.1145] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Evidence-based clinical practice guidelines encapsulate current knowledge to guide health care professionals in the treatment of patients with unstable angina or non-ST-segment-elevation myocardial infarction (NSTEMI), yet adherence to guideline recommendations is suboptimal. Guideline adherence may be improved by quality improvement programs such as the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation?) National Quality Improvement Initiative of the American College of Cardiology-American Heart Association Guidelines. The CRUSADE data have been analyzed to demonstrate that overall guideline adherence is directly associated with mortality and that improvement in guideline adherence saves lives. Also, the CRUSADE data have determined that the real-life mortality risk associated with unstable angina and NSTEMI is greater than suggested by clinical trials. The newer antiplatelet drugs recommended in early intervention and discharge treatment strategies are underused across many segments of the unstable angina-NSTEMI population. Glycoprotein IIb-IIIa inhibitors are underused in high-risk populations, and clopidogrel is markedly underused in patients who are medically managed rather than undergoing percutaneous coronary intervention or coronary artery bypass graft surgery. In addition, often the specialty of the treating physician and the status of the hospital influence the use of antiplatelet therapy. The reasons for underprescribing of antiplatelet drugs by physicians are not entirely clear but may be related to a lack of guideline familiarity and understanding, as well as factors such as drug novelty, safety, and cost. Continued education and data dissemination are therefore vital in promoting the prescription of guideline-recommended drugs, both in the early hospitalization phase and as patients transition to community-based care. The role of the pharmacist is pivotal in ensuring adherence to clinical guidelines by interacting with both the physician and patient.
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Affiliation(s)
- Michael B Bottorff
- College of Pharmacy, University of Cincinnati Medical Center, Cincinnati, Ohio 45267, USA.
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40
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Chew DP, Amerena J, Coverdale S, Rankin J, Astley C, Brieger D. Current management of acute coronary syndromes in Australia: observations from the acute coronary syndromes prospective audit. Intern Med J 2007; 37:741-8. [PMID: 17645500 DOI: 10.1111/j.1445-5994.2007.01435.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute coronary syndromes (ACS) management is now well informed by guidelines extrapolated from clinical trials. However, most of these data have been acquired outside the local context. We sought to describe the current patterns of ACS care in Australia. METHODS The Acute Coronary Syndrome Prospective Audit study is a prospective multi-centre registry of ST-segment elevation myocardial infarction (STEMI), high-risk non-ST-segment elevation ACS (NSTEACS-HR) and intermediate-risk non-ST-segment elevation ACS (NSTEACS-IR) patients, involving 39 metropolitan, regional and rural sites. Data included hospital characteristics, geographic and demographic factors, risk stratification, in-hospital management including invasive services, and clinical outcomes. RESULTS A cohort of 3402 patients was enrolled; the median age was 65.5 years. Female and non-metropolitan patients comprised 35.5% and 23.9% of the population, respectively. At enrolment, 756 (22.2%) were STEMI patients, 1948 (57.3%) were high-risk NSTEACS patients and 698 (20.5%) were intermediate-risk NSTEACS patients. Evidence-based therapies and invasive management use were highest among suspected STEMI patients compared with other strata (angiography: STEMI 89%, NSTEACS-HR 54%, NSTEACS-IR 34%, P < 0.001) (percutaneous coronary intervention: STEMI 68.1%, NSTEACS-HR 22.2%, NSTEACS-IR 8.1%, P < 0.001). In hospital mortality was low (STEMI 4.0%, NSTEACS-HR 1.8%, NSTEACS-IR 0.1%, P < 0.001), as was recurrent MI (STEMI 2.4%, NSTEACS-HR: 2.8%, NSTEACS-IR 1.2%, P = 0.052). CONCLUSION There appears to be an 'evidence-practice gap' in the management of ACS, but this is not matched by an increased risk of in-hospital clinical events. Objective evaluation of local clinical care is a key initial step in developing quality improvement initiatives and this study provides a basis for the improvement in ACS management in Australia.
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Affiliation(s)
- D P Chew
- Department of Cardiology, Flinders University, Flinders Medical Centre, Adelaide, South Australia.
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41
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Jaber WA, Holmes DR. Outcome and quality of care of patients who have acute myocardial infarction. Med Clin North Am 2007; 91:751-68; xii-xiii. [PMID: 17640546 DOI: 10.1016/j.mcna.2007.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Coronary artery disease is the number-one killer in developed countries, with lifetime prevalence of up to 50% in American men, and is the topic of much medical literature. Recently, multiple therapies have emerged to save lives after acute myocardial infarction (AMI), backed by well-conducted studies; however, appropriate implementation of therapy guidelines is less than optimal. Recent efforts have focused on improving the quality of care (QC) after AMI in order to improve outcomes. This article illustrates how outcome after AMI is related to QC, describes the underuse of evidence-based therapies, and discusses factors associated with poor guideline adherence. It also reviews current quality improvement projects, and some available means to measure and optimize the QC for patients with AMI.
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Affiliation(s)
- Wissam A Jaber
- Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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42
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Alexander KP, Newby LK, Cannon CP, Armstrong PW, Gibler WB, Rich MW, Van de Werf F, White HD, Weaver WD, Naylor MD, Gore JM, Krumholz HM, Ohman EM. Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 2007; 115:2549-69. [PMID: 17502590 DOI: 10.1161/circulationaha.107.182615] [Citation(s) in RCA: 476] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Age is an important determinant of outcomes for patients with acute coronary syndromes (ACS); however, community practice reveals a disproportionately lower use of cardiovascular medications and invasive treatment even among elderly patients with ACS who would stand to benefit. Reasons include limited trial data to guide the care of older adults and uncertainty about benefits and risks, particularly with newer medications or invasive treatments and in the setting of advanced age or complex health status. METHODS AND RESULTS This 2-part American Heart Association scientific statement summarizes evidence on patient heterogeneity, clinical presentation, and treatment of non-ST-elevation ACS in relation to age (< 65, 65 to 74, 75 to 84, and > or = 85 years). In addition, we review methodological issues that influence the acquisition and application of evidence to the elderly patients treated in community practice. A writing group combining international cardiovascular and geriatric perspectives convened to summarize available data from trials (5 combined Virtual Coordinating Center for Global Collaborative Cardiovascular Research [VIGOUR] trials) and 3 registries (Global Registry of Acute Coronary Events, National Registry of Myocardial Infarction, and the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines national quality improvement initiative [CRUSADE]) to provide a conceptual framework for future work in the care of the elderly with acute cardiac disease. Treatment for non-ST-segment-elevation ACS (Part I) and ST-segment-elevation myocardial infarction (Part II) are reviewed. In addition, ethical considerations pertaining to acute care and secondary prevention are considered (Part II). The primary goal is to identify the areas in which sufficient evidence is available to guide practice, as well as to determine areas that warrant further study. Although treatment-related benefits should rise in an elderly population with high disease risk, data to assess these benefits are limited, outcomes of importance vary, and heterogeneity among the elderly increases treatment-related risks. Although a uniform approach to care in the oldest of the old is unlikely, understanding the major contributors to benefits and risks from treatment will advance the ability to apply guideline-based care in this subset of patients. CONCLUSIONS Although a few recent trials have described treatment effects in older patients, others continue to exclude patients on the basis of age. Going forward, prospective trials should enroll elderly subjects proportionate to their prevalence among the treated population to define risk and benefit. Findings from age subgroup analyses should be reported in a consistent manner across trials, including absolute and relative risks for efficacy and safety. Outcomes of particular relevance to the elderly, such as quality of life, physical function, and independence, should also be considered. Creatinine clearance should be calculated for every elderly patient to enable appropriate dosing. In addition, physicians need an understanding of conditions unique to older patients (eg, frailty, cognitive impairment) that influence treatment goals and outcomes. With these efforts, treatment risks can be minimized, and benefits can be placed in the health context of the elderly patient with ACS.
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43
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Bosch X, Delgado V, Verbal F, Bórquez E, Loma-Osorio P, Díez-Aja S, Miranda-Guardiola F, Sanchís J. Causes of ineligibility in randomized controlled trials and long-term mortality in patients with non-ST-segment elevation acute coronary syndromes. Int J Cardiol 2007; 124:86-91. [PMID: 17408780 DOI: 10.1016/j.ijcard.2006.12.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2006] [Revised: 10/30/2006] [Accepted: 12/30/2006] [Indexed: 11/17/2022]
Abstract
PURPOSE To determine the long-term mortality of patients with non-ST-segment elevation acute coronary syndromes (NSTEACS) that are eligible versus those not eligible in randomized controlled trials (RCT), and how each exclusion criteria is associated with outcome. METHODS Common causes of exclusion in six published RCT on intravenous antithrombotic therapy were prospectively assessed in a cohort of 452 consecutive patients with NSTEACS that were followed for up to 3 years. RESULTS Forty-one percent of patients had one or more exclusion criteria establishing the ineligible group. These patients were older, more likely to have coronary risk factors, ischemic ECG changes, heart failure at admission, higher creatinine levels and a lower ejection fraction than eligible patients. There were no differences between both groups in the antithrombotic treatment received or in the performance of revascularization procedures during hospitalization or in the prescription of antiplatelet treatment and beta-blockers at discharge. Cumulative 3-year mortality rate was 25% in ineligible patients compared to 9% in eligible patients (p<0.001). The hazard ratio (HR) of mortality was of 9.1 (95% CI: 4.5-18.7) for severe renal dysfunction; 6.0 (3.3-11.4) for concomitant non-vascular diseases; 3.0 (1.6-5.5) for contraindications to anticoagulation; 2.5 (1.1-5.7) for heart failure; and 2.3 (1.1-4.6) for prior cerebrovascular disease. After adjusting for baseline differences, ineligible patients had a HR of total mortality of 1.88 (1.04-3.38), and of cardiac mortality of 2 (1.01-3.98). CONCLUSION Patients with NSTEACS who are ineligible in RCT have a higher risk profile and a two-fold adjusted long-term mortality than eligible patients, especially those with comorbid conditions and those with contraindications to anticoagulation.
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Affiliation(s)
- Xavier Bosch
- Department of Cardiology, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain.
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Alexander KP, Chen AY, Newby LK, Schwartz JB, Redberg RF, Hochman JS, Roe MT, Gibler WB, Ohman EM, Peterson ED. Sex Differences in Major Bleeding With Glycoprotein IIb/IIIa Inhibitors. Circulation 2006; 114:1380-7. [PMID: 16982940 DOI: 10.1161/circulationaha.106.620815] [Citation(s) in RCA: 195] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Glycoprotein (GP) IIb/IIIa inhibitors are beneficial in patients with non–ST-segment elevation acute coronary syndromes (NSTE ACS); their safe use in women, however, remains a concern. The contribution of dosing to the observed sex-related differences in bleeding is unknown.
Methods and Results—
We explored the relationship between patient sex, GP IIb/IIIa inhibitor use, dose, and bleeding in 32 601 patients with NSTE ACS across 400 CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) hospitals, of whom 18 436 were treated. GP IIb/IIIa inhibitor dose was defined as excessive if not reduced when creatinine clearance was <50 mL/min for eptifibatide or <30 mL/min for tirofiban. Major bleeding was defined as a hematocrit drop ≥0.12, need for transfusion, or intracranial bleeding. Major bleeding was adjusted for clinical factors and antithrombotic dose. The risk for bleeding attributable to excess GP IIb/IIIa dose was determined by sex using prevalence and adjusted odds ratios (ORs). Women had higher rates of major bleeding than men among those treated with GP IIb/IIIa inhibitors (15.7% versus 7.3%,
P
<0.0001) and among those not treated (8.5% versus 5.4%,
P
<0.0001). Despite similar serum creatinine levels, creatinine clearance averaged 20 points lower among treated women than men. Treated women were also more likely to receive excess GP IIb/IIIa doses than men (46.4% versus 17.2%,
P
<0.0001; adjusted OR 3.81, 95% confidence interval [CI] 3.39 to 4.27). Excess dosing was associated with increased risk of bleeding in women (OR 1.72, 95% CI 1.30 to 2.28) and men (OR 1.27, 95% CI 0.97 to 1.66); however, bleeding risk attributable to dosing was much higher in women (25.0% versus 4.4%).
Conclusions—
Women experience more bleeding than men whether or not they are treated with GP IIb/IIIa inhibitors; however, because of frequent excessive dosing in women, up to one fourth of this sex-related risk difference in bleeding is avoidable. Appropriate dosing will improve care of all patients with NSTE ACS, with a particular benefit for women.
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Affiliation(s)
- Karen P Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27715, USA.
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Hoenig MR, Doust JA, Aroney CN, Scott IA. Early invasive versus conservative strategies for unstable angina & non-ST-elevation myocardial infarction in the stent era. Cochrane Database Syst Rev 2006:CD004815. [PMID: 16856061 DOI: 10.1002/14651858.cd004815.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND In patients with unstable angina and non-ST-elevation myocardial infarction (UA/NSTEMI) two strategies are possible: a routine invasive strategy where all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularization; or a conservative strategy where medical therapy alone is used initially with selection of patients for angiography based on clinical symptoms or investigational evidence of persistent myocardial ischemia. OBJECTIVES To determine the benefits of an invasive compared to a conservative strategy for treating UA/NSTEMI in the stent era. SEARCH STRATEGY The Cochrane Central Register of Controlled Trials (Issue 3 2005), MEDLINE and EMBASE were searched from 1996 to September 2005 with no language restrictions. SELECTION CRITERIA Included studies were prospective trials comparing invasive with conservative strategies in UA/NSTEMI. DATA COLLECTION AND ANALYSIS We identified 5 studies (7818 participants). Using intention-to-treat analysis with random effects models, summary estimates of relative risk (95% confidence interval [CI]) were determined for primary end-points of all-cause death, fatal and non-fatal myocardial infarction; all-cause death or non-fatal myocardial infarction; and refractory angina. Further analysis of included studies was undertaken based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. Heterogeneity was assessed using chi-square and variance (I(2)) methods. MAIN RESULTS In the all-study analysis, mortality during initial hospitalization showed a trend to hazard with an invasive strategy; relative risk 1.59 (95% CI 0.96 to 2.64). Mortality and myocardial infarction assessed at 2-5 years in two trials were significantly decreased by an invasive strategy with relative risk of 0.75 (95% CI 0.62 to 0.92) and 0.75 (95% CI 0.61 to 0.91) respectively. The composite end-point of death or non-fatal myocardial infarction was significantly decreased by an invasive strategy at several time points after initial hospitalization. The incidence of early (<4 months) and intermediate (6-12 months) refractory angina were both significantly decreased by an invasive strategy; relative risk 0.47 (95% CI 0.32 to 0.68) and 0.67 (95% CI 0.55 to 0.83) respectively, as were early and intermediate rehospitalization rates with relative risk 0.60 (95% CI 0.41 to 0.88) and 0.67 (95% CI 0.61 to 0.74) respectively. The invasive strategy was associated with a two-fold increase in the relative risk of peri-procedural myocardial infarction (as variably defined) and a 1.7-fold increase in the relative risk of bleeding. AUTHORS' CONCLUSIONS An early invasive strategy is preferable to a conservative strategy in the treatment of UA/NSTEMI.
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Affiliation(s)
- M R Hoenig
- Centre for Research in Vascular Biology, Australian Institute for Bioengineering and Nanotechnology, University of Queensland, Brisbane, QLD, Australia 4072.
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46
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Roth-Cline MD. Clinical trials in the wake of Vioxx: requiring statistically extreme evidence of benefit to ensure the safety of new drugs. Circulation 2006; 113:2253-9. [PMID: 16684875 DOI: 10.1161/circulationaha.105.604512] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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47
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Roe MT, Peterson ED, Newby LK, Chen AY, Pollack CV, Brindis RG, Harrington RA, Christenson RH, Smith SC, Califf RM, Braunwald E, Gibler WB, Ohman EM. The influence of risk status on guideline adherence for patients with non-ST-segment elevation acute coronary syndromes. Am Heart J 2006; 151:1205-13. [PMID: 16781220 DOI: 10.1016/j.ahj.2005.08.006] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2005] [Accepted: 08/03/2005] [Indexed: 12/22/2022]
Abstract
BACKGROUND Practice guidelines for patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS) recommend targeting evidence-based therapies for the highest-risk patients. We characterized guideline adherence for NSTE ACS by risk status. METHODS We analyzed inhospital treatments and outcomes for 77760 patients with NSTE ACS (ischemic ST-segment changes and/or positive cardiac markers) included in the CRUSADE initiative from January 2001 to September 2003 at 457 US hospitals. Compliance with the American College of Cardiology/American Heart Association Class guideline recommendations for NSTE ACS was evaluated in subgroups of eligible patients without listed contraindications at increased risk for mortality and among risk categories designated by an adapted version of the PURSUIT risk model designed to predict inhospital mortality. RESULTS Inhospital mortality was increased in patients with diabetes mellitus (5.8% vs 4.3%), renal insufficiency (10.0% vs 3.9%), signs of congestive heart failure on presentation (10.6% vs 3.1%), and age > or = 75 years (8.6% vs 2.7%), compared with patients without these features. Use of guideline-recommended acute medications, invasive cardiac procedures, and discharge medications and interventions was significantly lower in patients with these high-risk features. Patients designated as high-risk for inhospital mortality were less likely to be treated with guideline-recommended therapies compared with low-risk and moderate-risk patients. CONCLUSIONS Patients with NSTE ACS with the highest risk of mortality are less likely to receive guideline-recommended therapies and interventions. These findings highlight the need to clarify guideline recommendations for high-risk patients and to develop novel quality improvement approaches that target undertreated subgroups of patients with NSTE ACS.
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Affiliation(s)
- Matthew T Roe
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27705, USA.
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48
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Alexander KP, Peterson ED. Treatment of Non?ST-Elevation Acute Coronary Syndrome in the Elderly: Current Practice and Future Opportunities. ACTA ACUST UNITED AC 2006; 15:42-9. [PMID: 16415646 DOI: 10.1111/j.1076-7460.2006.04642.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The care of elderly patients with non-ST-elevation acute coronary syndrome is challenging, given the wide variability in physiologic condition and preferences among this patient group. Due to a higher burden of comorbidity, the elderly face high risks for death and complications from non-ST-elevation acute coronary syndrome relative to younger patients. Accordingly, they also have greater potential benefits from effective therapies. Antithrombotic therapy, invasive cardiac care, lipid lowering, and prevention advice, however, are all used less often in the elderly, even when no contraindications exist. Attention to individualized dosing and safety monitoring is also important for elderly patients. Increased awareness of the beneficial impact of therapies on outcomes in the elderly, along with vigilance for adverse events, should enable care to move from the state of uncertainty to opportunity in this high-risk population.
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Affiliation(s)
- Karen P Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27710, USA.
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Yang X, Alexander KP, Chen AY, Roe MT, Brindis RG, Rao SV, Gibler WB, Ohman EM, Peterson ED. The Implications of Blood Transfusions for Patients With Non–ST-Segment Elevation Acute Coronary Syndromes. J Am Coll Cardiol 2005; 46:1490-5. [PMID: 16226173 DOI: 10.1016/j.jacc.2005.06.072] [Citation(s) in RCA: 160] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2005] [Revised: 06/21/2005] [Accepted: 06/27/2005] [Indexed: 11/27/2022]
Abstract
OBJECTIVES In a large contemporary population of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS), we sought to describe blood transfusion rates (overall and in patients who did not undergo coronary artery bypass grafting [CABG]), patient characteristics and practices associated with transfusion, variation among hospitals, and in-hospital outcomes in patients receiving transfusions. BACKGROUND The use of antithrombotic agents and invasive procedures reduces ischemic complications but increases risks for bleeding and need for blood transfusion in patients with NSTE ACS. METHODS We evaluated patient characteristics and transfusion rates in the overall population (n = 85,111) and determined outcomes and factors associated with need for transfusion in a subpopulation of patients who did not undergo CABG (n = 74,271) from 478 U.S. hospitals between January 1, 2001, and March 31, 2004. RESULTS A total of 14.9% of the overall and 10.3% of the non-CABG population underwent transfusion during their hospitalization. Renal insufficiency and advanced age were strongly associated with the likelihood of transfusion. Interhospital transfusion rates varied significantly. Non-CABG patients who received transfusions had a greater risk of death (11.5% vs. 3.8%) and death or reinfarction (13.4% vs. 5.8%) than patients who did not undergo transfusion. CONCLUSIONS Transfusion is common in the setting of NSTE ACS, and patients who undergo transfusion are sicker at baseline and experience a higher risk of adverse outcomes than their nontransfused counterparts. Given the wide variation in transfusion practice, further efforts to understand patient and process factors that result in bleeding and need for transfusion in NSTE ACS are needed.
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Affiliation(s)
- Xin Yang
- Division of Cardiology and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina 27715, USA
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