CardioExchange Archive

Prostate Cancer and Endocrine Therapy Linked to Increased Risk of Thromboembolic Disease: To assess the risk of thromboembolic disease in men with prostate cancer, Mieke Van Hemelrijck and colleagues analyzed data from the National Prostate Cancer Register in Sweden. They report, in a paper published online in Lancet Oncology, that men with prostate cancer had an elevated risk of thromboembolic disease. The highest risk was observed in those patients receiving endocrine therapy. In an accompanying comment, Phillip Saylor and Annemarie Fogerty conclude that “the data should increase clinical suspicion for venous thromboembolism in men with prostate cancer, and stimulate further study of the potential interactions between androgen deprivation and blood coagulation.”

The final results of the ARBITER 6-HALTS trial, which provoked an explosion of controversy upon initial publication last November, have now been published in the Journal of the American College of Cardiology. The trial compared ezetimibe to extended-release niacin in high-risk patients already taking statins. Villines et al. report the CIMT results on 315 patients enrolled in the trial — 208 who completed the full 14-month follow-up prior to the trial’s early termination, and 107 who had a mean treatment period of 7 months.
   Ezetimibe treatment did not reduce either mean CIMT or maximal CIMT compared to baseline measurements. By contrast, extended-release niacin resulted in significant reductions in mean CIMT and maximal CIMT compared to baseline. In addition, the trial investigators wrote that a strong “relationship between cumulative drug exposure and the CIMT effect” of niacin “supports an expected, direct relationship between increasing intensity of drug exposure (through a composite of dose, adherence, and time) and its effect on atherosclerosis.” In sharp contrast, “findings with ezetimibe [show] an unexpected inverse relationship between intensity of drug exposure and CIMT.”
Click here to view blogs and discussions about ARBITER 6-HALTS on CardioExchange.

Malpractice and Regional Variation: Fear of malpractice may help explain regional differences in healthcare utilization, including cardiac catheterization, according to a report in Circulation: Cardiovascular Quality and Outcomes. Lucas and colleagues asked 598 cardiologists “under what circumstances they would order a cardiac catheterization ‘for other than purely clinical reasons’.” Some 27% of the cardiologists said they would order a catheterization if they believed a colleague would do the same in a similar circumstance, and 24% said they would do so out of fear of malpractice.

Financial Worries Lead to Delays in Seeking Care for MI: Nearly 40% of patients in a registry of 3,721 U.S. acute MI patients were without insurance or were insured but had financial concerns. These patients were more likely to delay seeking care than patients who were insured without financial concerns, according to a report by Smolderen and colleagues in the Journal of the American Medical Association. The researchers also found that previously observed associations between delays and race, age, and sex  “were substantially attenuated after adjustment for insurance status and other social, psychological, and clinical variables in this study.” (The editor-in-chief of CardioExchange, Harlan Krumholz, is a co-author of the paper.)

Valve-in-Valve Approach to Fixing Failing Bioprosthetic Valves:
Webb and colleagues report in Circulation on their initial promising experience treating 24 patients with failing bioprosthetic valves employing a novel “valve-in-valve” percutaneous procedure. The group successfully restored valve function in all but one of the treated valves (aortic, mitral, pulmonary, and tricuspid). Thirty-day mortality was 4.2%. The authors conclude that “transcatheter valve-in-valve implantation is a reproducible option for the management of selected patients with bioprosthetic valve failure…. This finding may have important implications with regard to valve replacement in patients at prohibitive risk with conventional surgery.”
   
In an accompanying editorial, Blase Carabello writes that “percutaneous device therapy for VHD [valvular heart disease] is one of the most exciting events in cardiology in the last 50 years.” He discusses the “huge challenge” created by the rapid advances in the field and proposes a collaborative approach for choosing VHD therapy based on the “tumor board” model used in oncology.

Long-term outcome after endovascular abdominal aortic aneurysm repair is no better than open repair or no repair (in patients deemed unsuitable for open repair), according to results of the EVAR 1 and EVAR 2 trials published online in the New England Journal of Medicine. Previous trials had found short-term benefits for endovascular repair, but the long-term effects were unknown.
   
In the EVAR 1 (United Kingdom Endovascular Aneurysm Repair 1) trial, 1,252 patients with large abdominal aortic aneurysms were randomized to endovascular or open repair. Despite early results in favor of the less invasive procedure, at 6 years there was no significant difference in mortality between the two groups, while costs were higher in the endovascular repair group.
   
In EVAR 2, 404 patients who were considered ineligible for open repair were randomized to either endovascular repair or no repair. There was no difference in long-term mortality between the two groups, although there was a significant reduction in aneurysm-related mortality in the endovascular repair group.

ICDs and CRTs in Older Patients: Although older patients were excluded from most of the large device trials, a nationally representative database finds that one-fifth of patients receiving ICD and CRT devices were 80 years of age or older. In a report in Archives of Internal Medicine, Swindle et al. found that age over 80 was an independent predictor of in-hospital mortality. The authors conclude that “given trends in the demographics of heart failure and the costs of device therapy, additional studies are required to clarify the appropriateness of device implantation in older patients with heart failure, as well as the merits of less invasive options.”

Building a Better Vessel with Stem Cells: It’s still a long way from reaching clinical practice, but tissue engineers are making serious advances in their efforts to grow bypass grafts using stem cells. At the AHA’s Arteriosclerosis, Thrombosis and Vascular Biology Annual Conference now underway in San Francisco, Stephen McIlhenny reported on the successful in vivo test of grafts created from adult adipose-derived stem cells that were attached to the lumen of decellularized vein scaffolds. “The significant finding is that we can build a blood vessel from donor tissue and an animal’s own adult stem cells. Potentially, patients requiring bypass surgery could receive optimized grafts that would reduce their future complications,” McIlhenny said in an AHA press release.

CIMT in Risk Assessment: When added to traditional risk factors, CIMT (carotid intima-media thickness) and the presence or absence of plaque improve risk prediction, according to a paper from the ARIC (Atherosclerosis Risk in Communities) Study in the Journal of the American College of Cardiology. Vijay Nambi and colleagues report that they were able to reclassify nearly a quarter of more than 13,000 subjects with the added information from CIMT and plaque. The authors concluded that “ultrasound-based risk stratification strategies should be tested in clinical trials to evaluate whether improved prevention of cardiovascular events is possible.”

In an accompanying editorial comment, James Stein and Heather Johnson write that the study “closes the discussion about the incremental value of carotid ultrasound for CHD risk prediction in patients at intermediate risk, thus opening the door for outcomes research studies that are required to determine if atherosclerosis imaging truly is as helpful as its proponents believe.”

Survival After CABG — It’s Not Race or Sex, It’s Being Poor: Socioeconomic position (SEP) is far more important than race or sex in affecting long-term survival after CABG, according to a new report in Circulation: Cardiovascular Quality and Outcomes. Colleen Koch and colleagues studied 23,330 CABG patients and found that lower SEP was associated with a worse outcome. Race and sex were no longer significant factors after adjustment for SEP.  “We were surprised that consistently and pervasively, through every way of looking at the data, it turns out this isn’t about skin color or gender. It’s about being poor,” said Koch, in a press release issued by the American Heart Association.

Dronedarone Data Duel: Two separate papers in the Journal of the American College of Cardiology offer starkly contrasting views on the role of dronedarone in clinical practice. In a viewpoint and commentary, David Singh and colleagues review the dronedarone data and conclude that although dronedarone “has the ability to control both rhythm and rate” in AF patients, “the antiarrhythmic efficacy is quite modest compared with placebo and only half as effective compared with the gold standard amiodarone.” They note that the safety profile of the drug in low- and intermediate-risk stable patients is reassuring, however.

Singh et al. conclude that “treatment with antiarrhythmic drugs should generally be considered only when symptoms persist despite adequate rate control.” “When a rhythm-control strategy is desired,” they write that “the available data support only limited use of dronedarone for select patient populations, mostly as a second- or third-line agent in lieu of amiodarone.”

In sharp contrast, an accompanying editorial by Christian Torp-Pedersen and colleagues takes a much sunnier view of the drug. They point out that rhythm control is the strategy often chosen by patients and physicians and conclude that dronedarone is a reasonable option for intermediate-risk patients. And for low-risk patients, they write that “dronedarone provides the only antiarrhythmic drug with a large safety database to prove reasonable safety. The safety knowledge of dronedarone may result in patient and physician preference of dronedarone as first-line therapy, with a possible switch to amiodarone when sinus rhythm is no longer maintained.”

Every year around this time I spend hours thinking about what qualities go into making a good fellow and, equally important, how to figure out if an applicant has these qualities. When we review applications, we have only a few pieces of objective information such as academic pedigree, board scores, and publications; the rest is highly subjective half-truths from the personal statements and letters of recommendation. At the interview, we try to weed out the folks we think we’d have trouble working with and do the best we can to identify “research potential,” which we all know is a highly imperfect science!  
 
As the years roll by, I’ve developed more humility when attempting to identify research potential … my mistakes have been in both overestimating and underestimating applicants. At the same time, I’ve realized that by the time someone applies for a fellowship position, their character, intelligence, and clinical skills are fully formed — we’ve never gone wrong recruiting based on these factors. If I can verify these qualities from someone I trust at another institution, their word goes much farther than letters of recommendation. In the end, we’re recruiting colleagues to work with for at least 3 years, and for much longer for those who end up joining our faculty. 
 
The applicant has a much harder job … you have to sell yourself, without overselling, and at the same time figure out if the program meets your needs and goals. Although we faculty members feel like our information is limited, you are working from an even more limited database. 
 
We’d love to hear your thoughts on this dating game. How did you decide which programs would be best for you? Should fellows (and programs) go for the best or the best fit? Finally, momentum is building to move the fellowship match to later in residency…what do you think about this idea?