January 3rd, 2010
Top Cardiology Stories of 2009
Harlan M. Krumholz, MD, SM
Dear Readers,
This year the annual Journal Watch Cardiology Top Stories feature has a new dimension. We are presenting two lists — one from us and one from you. To create the Journal Watch Cardiology 2009: Editors’ Choice list, our editors voted for the stories that they believe to be most important to you and your practices. For the Top 10 Most Read Online list, we looked at which cardiology stories were viewed most often by Journal Watch registered users and subscribers.
Surprisingly, the lists have only one story in common — it concerns diabetes treatment in patients with coronary artery disease. The story Journal Watch users read most often discussed the number of patients who would be eligible for statin treatment if criteria suggested by the JUPITER trial results were adopted; your second most read story was about travel and venous thromboembolism. By contrast, the most important article in the editors’ opinion analyzed the use of cardiac resynchronization therapy to prevent heart failure. Overall, the most read stories demonstrate the broader primary care interests of the Journal Watch subscribers as a whole.
We hope that you will peruse these lists and see how they fit with your own assessment of the most important developments in cardiology during 2009. Some of these studies — ARBITER, for example — engendered quite a bit of controversy. You might find your own personal favorite in one of these lists or feel that some valuable pearls managed to escape our attention. Let us know what you think by commenting on this story today.
Cardiology Top Stories of 2009: Editors’ Choice
Cardiac Resynchronization Therapy to Prevent Heart Failure: Gathering Momentum
Mark S. Link, MD
MADIT-CRT findings demonstrate a benefit of resynchronization in patients with NYHA class I or II heart failure.
Reviewing: Moss AJ et al. N Engl J Med 2009 Sep 1
Directing Coronary Intervention Using Fractional Flow Reserve
Beat J. Meyer, MD
Assessing the functional relevance of an angiographic stenosis before PCI could improve safety and reduce costs.
Reviewing: Tonino PAL et al. for the FAME Study Investigators. N Engl J Med 2009 Jan 15; 360:213
Ellis SG. N Engl J Med 2009 Jan 15; 360:292
Prasugrel vs. Clopidogrel in Patients with ST-Segment-Elevation MI
Beat J. Meyer, MD
A substudy of TRITON-TIMI 38 confirms the main trial findings that prasugrel is more efficacious but might be less safe than clopidogrel.
Reviewing: Montalescot G et al. Lancet 2009 Feb 28; 373:723
Stone GW. Lancet 2009 Feb 28; 373:695
ARBITER 6-HALTS: A Surprise Knockout
Harlan M. Krumholz, MD, SM
Niacin’s clear win over ezetimibe as an adjunct to statin therapy challenges assumptions about lipid management.
Reviewing: Taylor AJ et al. N Engl J Med 2009 Nov 16
Darbepoetin α in Patients with Type 2 Diabetes, Chronic Kidney Disease, and Anemia
Paul S. Mueller, MD, MPH
The drug provides little benefit and might cause harm.
Reviewing: Pfeffer MA et al. N Engl J Med 2009 Oct 30
Treating Diabetes and Coronary Artery Disease
Harlan M. Krumholz, MD, SM
Prompt revascularization or initial medical therapy? Insulin sensitization or provision? From the BARI 2D trial, no strategy emerged a clear winner.
Reviewing: Frye RL et al. for the BARI 2D Study Group. N Engl J Med 2009 Jun 11; 360:2503
Boden WE and Taggart DP. N Engl J Med 2009 Jun 11; 360:2570
Can Thienopyridines and Proton-Pump Inhibitors Peacefully Coexist?
Harlan M. Krumholz, MD, SM
An observational analysis of trial data confirms the functional interaction but provides no evidence of adverse clinical effects.
Reviewing: O’Donoghue ML et al. Lancet 2009 Sep 1
Surgical Ventricular Reconstruction: Function Fails to Follow Form
Harlan M. Krumholz, MD, SM
This procedure did not improve clinical outcomes in CABG patients.
Reviewing: Jones RH et al. for the STICH Hypothesis 2 Investigators. N Engl J Med 2009 Mar 29
Eisen HJ. N Engl J Med 2009 Mar 2
Exercise Training in Patients with LV Systolic Dysfunction
Frederick A. Masoudi, MD, MSPH
Data from a large randomized trial demonstrate that exercise therapy is safe, but the health gains are modest.
Reviewing: O’Connor CM et al. JAMA 2009 Apr 8; 301:1439
Flynn KE et al. JAMA 2009 Apr 8; 301:1451
Which Revascularization Strategy is Best for Severe Coronary Artery Lesions?
Howard C. Herrmann, MD
Results of the SYNTAX trial failed to show that PCI is noninferior to CABG in patients with 3-vessel or left main disease.
Reviewing: Serruys PW et al. for the SYNTAX Investigators. N Engl J Med 2009 Feb 18
Lange RA and Hillis LD. N Engl J Med 2009 Feb 18
Cardiology Top Stories of 2009: Most Read
Who Might Be Eligible to Receive Statins for Primary Prevention?
JoAnne M. Foody, MD
Roughly four out of five older Americans might, according to results of the JUPITER trial.
Reviewing: Spatz ES et al. Circ Cardiovasc Qual Outcomes 2009 Jan; 2:41
Travel and Venous Thromboembolism
Joel M. Gore, MD
Results of a meta-analysis showed a significant elevation in risk that increased with the duration of the journey.
Reviewing: Chandra D et al. Ann Intern Med 2009 Aug 4; 151:180
Statins for Primary Prevention: Homing in on Effectiveness
Harlan M. Krumholz, MD, SM
A new meta-analysis bolsters the case for benefit.
Reviewing: Brugts JJ et al. BMJ 2009 Jun 30; 338:b2376
Nonsteroidal Anti-Inflammatory Drug Use in Patients with Heart Failure
Frederick A. Masoudi, MD, MSPH
Compelling evidence for avoiding NSAIDs underscores the challenges of pain management in these patients.
Reviewing: Gislason GH et al. Arch Intern Med 2009 Jan 26; 169:141
You’ll Faint When You See the Bill
Frederick A. Masoudi, MD, MSPH
The most expensive tests for evaluating syncope usually don’t influence diagnosis or management, and the least expensive — and most useful — test is underused.
Reviewing: Mendu ML et al. Arch Intern Med 2009 Jul 27; 169:1299
Proton Pump Inhibitors and Clopidogrel: Bad Company?
JoAnne M. Foody, MD
In a large observational cohort of ACS patients, this drug combination was associated with poorer outcomes than was clopidogrel alone.
Reviewing: Ho PM et al. JAMA 2009 Mar 4; 301:937
A Closer Look at Aspirin for Primary Prevention
Harlan M. Krumholz, MD, SM
A meta-analysis of individual patient data from six trials uncovers no clear benefit.
Reviewing: Collins R et al. for the Antithrombotic Trialists’ (ATT) Collaboration. Lancet 2009 May 30; 373:1849
Algra A and Greving JP. Lancet 2009 May 30; 373:1821
Vitamin K for Warfarin-Induced Hypocoagulation
Joel M. Gore, MD
Low-dose vitamin K conferred no more clinical benefit than placebo, despite lowering INRs more rapidly.
Crowther MA et al. Ann Intern Med 2009 Mar 3; 150:293
Treating Diabetes and Coronary Artery Disease
Harlan M. Krumholz, MD, SM
Prompt revascularization or initial medical therapy? Insulin sensitization or provision? From the BARI 2D trial, no strategy emerged a clear winner.
Reviewing: Frye RL et al. for the BARI 2D Study Group. N Engl J Med 2009 Jun 11; 360:2503
Boden WE and Taggart DP. N Engl J Med 2009 Jun 11; 360:2570
TIPS for Reducing Cardiovascular Risk
JoAnne M. Foody, MD
In a large feasibility trial, one small pill had favorable effects on many important risk markers.
Reviewing: Yusuf S et al. for The Indian Polycap Study (TIPS). Lancet 2009 Mar 30
Cannon CP. Lancet 2009 Mar 30
January 3rd, 2010
CardioExchange in 2010
Harlan M. Krumholz, MD, SM
Happy New Year! On behalf of everyone at CardioExchange, I want to thank you for being part of our experiment. I hope that all of you have seen the potential for what a community of cardiologists led by a group of independent experts can do to improve patient care.
CardioExchange is still very much a work in progress, and we realize that many of you are still trying to figure out what this site is and what needs it fulfills in your busy days. And we know that many of you have been confused about where to find information on CardioExchange and have experienced technical problems. We apologize for the problems and appreciate your patience. We’re working aggressively to correct those glitches (especially for people using older browsers) over the coming weeks. We also have several enhancements to tell you about:
- Starting today, we’re adding summaries of the key cardiology news from Larry Husten–editor of theheart.org from 1999 through 2008, and now the sole creator of CardioBrief.
- We’re enhancing our case discussion series to be led by James Fang, MD, of Case Western University. We’re looking to discuss the vexing cases that trouble us day in and day out, where the data and guidelines are unclear or contradictory. See our current case, for which we’ll be bringing expert views in soon. Or send us a case to discuss.
- In the coming weeks, we’ll be making it easier for you to invite friends and colleagues to join CardioExchange.
- We’ll be implementing a complete redesign to the site–with improved navigation–by late winter.
- We’ll be adding new groups beyond our current three of Prevention, Interventional Cardiology, and Fellowship Training by the time of the American College of Cardiology meeting.
CardioExchange will continue to be a work in progress, and we hope that you will come along with us to help shape this independent and exciting space for our profession. It will only reach its potential with the participation of you and your colleagues.
Best wishes to you and yours in 2010.
January 2nd, 2010
Israeli Cardiologists Withdraw from ISCHEMIA
Larry Husten, PHD
Israeli cardiologists have decided they won’t participate in the ISCHEMIA trial, the planned NIH-funded follow-up to COURAGE. Click here to read an article in the Israeli newspaper Haaretz, or additional coverage on CardioBrief.
December 18th, 2009
Deciding When to Bridge
Anju Nohria, MD and James Fang, MD
A 61-year-old man presented with 6 hours of chest pain and ECG changes consistent with an acute anterior-wall myocardial infarction. His cardiac troponin I was 59 ng/mL. Urgent angiography revealed an occluded LAD and 70% proximal OM1, 70% proximal OM2, and 90% proximal RCA stenoses. He was taken to the catheterization laboratory, where an attempt to open the LAD was complicated by a dissection, resulting in TIMI grade 1 flow. A right heart catheterization revealed elevated filling pressures and a low cardiac output, requiring intraaortic balloon pump (IABP) placement and transfer to a tertiary facility. An echo at the time of transfer revealed an LVEF of 10-15% (LVEDD, 5.3 cm), with global hypokinesis and apical akinesis. A PET scan showed viable myocardium, except in the mid- to distal LAD territory. Attempts to wean the IABP resulted in hypotension and increased mitral regurgitation.
Questions:
- Would you recommend revascularization of the OM and RCA territories or move directly to ventricular assist device support as a bridge to transplantation?
- If revascularization was the appropriate step, would you recommend percutaneous rather than surgical revascularization, given his recent AMI?
- If VAD was the appropriate decision, would you recommend a PVAD as a bridge to stability or move directly to an implantable LVAD?
Response:
James Fang, MD
High risk cardiac surgery is an increasingly common clinical dilemma in cardiovascular practice and is difficult to study since there is great heterogeneity across scenarios. Therefore, we are often left with decision making based on what we know of physiology and anecdotal clinical experience.
In this gentleman’s case, it appears that in addition to advanced coronary artery disease, dynamic mitral regurgitation is playing an important role. I suspect that his ischemic heart disease, poor ventricular function, and mechanical dyssynchrony from the infarct all contribute to his mitral regurgitation. His need for an IABP would support this line of thought. Finally, he may have significant stunning from his recent infarct and some of his ventricular function may recover spontaneously with time. With all of that in mind, here’s what I’d recommend:
I would favor surgical revascularization and mitral valve repair rather than going straight to VAD since there is likely both stunning and hibernation accounting for the severe LV dysfunction (particularly since the ventricle is not dilated). His dependence on an IABP and previous PET scan would preclude the need to assess contractile reserve, although knowing his contractile reserve (e.g. dobutamine echo) would be ideal. Although cardiac surgery is risky in this patient, the need for post-cardiotomy support turns out to be relatively rare unless it is a “salvage” situation. Both the STS database and INTERMACS registry have noted these dramatic advances in cardiac surgery.
Although PCI is less “traumatic”, there are several reasons to favor CABG/MVA: a) PCI may not adequately address the issue of dynamic mitral regurgitation, b) clopidogrel will be required for months afterward if DESs are used (complicating post operative procedures, including VAD), c) there may be benefit to placing LAD graft because of watershed myocardial territories despite the lack of PET viability in immediate LAD zone. That being said, if the patient had multiple comorbities (i.e. advanced age, pulmonary disease, malignancy, etc) that would excessively increase their perioperative risk, then multivessel PCI would be reasonable as a palliative strategy.
PVAD may be preferable if needed at the time of CABG/MVA since it can be placed without need for cardiopulmonary bypass, thus shortening total ischemic time. Also, since stunning may be important here, removal of a VAD is greatly simplified when a percutaneous device is used. Finally, PVADs can be used to bridge to surgical VADs, e.g. bridge to a decision.
Follow-Up:
Anju Nohria, MD
The patient was assessed and deemed eligible for left-ventricular assist device (LVAD) therapy and cardiac transplantation. After significant discussion with the patient and his family, the patient was referred for surgical revascularization, with LVAD back-up if needed. The patient arrested upon induction of anesthesia. After 3 minutes of resuscitation, he was emergently placed on cardiopulmonary bypass. Pericardial exposure revealed 200 mL to 300 mL of fresh blood, and relief of the tamponade physiology improved the patient’s hemodynamics. He underwent repair of the left anterior descending (LAD) perforation, 4-vessel bypass with a saphenous vein graft (SVG) to the first diagonal and LAD, SVG to the obtuse marginal branch, and SVG to the posterior descending artery. He also had mitral valve replacement with a Biocor porcine valve.
Postoperatively, the patient required prolonged intra-aortic balloon pump (IABP) support and vasopressor therapy with epinephrine, milrinone, and norepinephrine. He developed coagulase-negative Staphylococcus bacteremia, which required discontinuation of the IABP and antibiotic therapy. He also developed bilateral foot gangrene, requiring bilateral amputation of metatarsals. Multiple screens for heparin-induced antibodies were negative.
The patient was discharged to a rehabilitation facility. A follow-up echo revealed global hypokinesis (EF, 20%; LVEDD, 5.4 cm) with mid-distal anterior, apical, and basal-inferior akinesis. He had a well-seated mitral prosthesis with trivial regurgitation. He is currently tolerating low-dose beta-blocker and ACE-inhibitor therapy.
Conclusion:
James Fang, MD
At first glance, the poor outcome could be viewed as an indictment of the high-risk CABG approach, as opposed to a straight-to-LVAD strategy, but I suggest that the outcome reflects the high-risk nature of any cardiac surgery in unstable heart disease. It is likely that both coronary perforation/tamponade leading to cardiac arrest and postoperative vasoplegia with its attendant morbidity would also have complicated a straight-to-VAD approach.
Bleeding complications of cardiovascular interventions and therapeutics are increasingly recognized as independent predictors of poor outcomes. Recent evidence from ACS trials suggests that bleeding complications rival the index event in morbidity and mortality. In this case, tamponade from the coronary perforation and anticoagulation transformed the operative situation from urgent to salvage, substantially increasing the magnitude of the resultant morbidity and mortality, and would have done so, regardless of procedure. Post-operative vasoplegia commonly complicates heart failure surgery and may be the consequence of prolonged low-output, inflammatory cytokines and long-acting oral vasodilators. Methylene blue has been used in these situations with variable success, and I wonder if it was used in this case.
Cardiac surgery is a high-risk endeavor when there is preoperative hemodynamic or ischemic instability and significant LV dysfunction. Some may view this case as evidence of a clinical equipoise that only a randomized trial can resolve. Although it was logistically difficult, the SHOCK trial demonstrated that such studies are feasible. Would the patient have done better with primary VAD therapy? Would you have enrolled this patient into a randomized, clinical trial of high-risk CABG versus LVAD therapy?
December 18th, 2009
The CT Scan Is Out of the Bag
Brahmajee Kartik Nallamothu, MD, MPH
No doubt you’ve read about the FDA’s October announcement that it was investigating more than 200 cases of excess radiation exposure — at 8 times the expected level — during perfusion CT scans of the brain at a Los Angeles area medical center. In some patients, the excess exposure resulted in hair loss and reddening of the skin, which were the clues that first raised concerns. What you may not know is that, in early December, the FDA expanded its probe to include at least 50 additional cases of excess exposure, now implicating more than one manufacturer of scanners (and, possibly, healthcare facilities outside California). You might be wondering what other data are out there about radiation exposure from CT scans — and what you as a clinician should do in response.
First, for a bulleted list of what the FDA is recommending to facilities, radiologists, and radiology technologists in light of recent events, click here. Those recommendations by the FDA focus on perfusion CT scans, but the long-term implications of its investigation may be broader, as suggested by findings from two new studies in the Archives of Internal Medicine.
One, by Smith-Bindman and colleagues, documented tremendous variation in radiation doses delivered by the 11 most common types of diagnostic CT scans at four facilities in San Francisco. Remarkably, large variations were found both across and within facilities for the same type of CT study. Effective doses for coronary CT angiograms, for example, varied more than 5-fold, and the median dose was more than twice as high as what can be achieved with simple protocol changes, as outlined in a JAMA article earlier this year. The take-home point for me is that we need to start standardizing commonly used CT imaging protocols to reduce both the magnitude of, and the variation in, radiation exposure. As the authors note, such standards have been successfully adopted and regulated by the FDA for mammography but do not exist yet for CT scans.
The other study, by Berrington de González and colleagues, used risk models to estimate that CT scans performed in 2007 will ultimately result in 29,000 excess cancers. Although one could quibble with these estimates, the article reports one cold-hard fact that is simply staggering: In 2007, the number of CT scans performed in the U.S. was about 72 million, nearly half in people younger than 55. Clearly, the use of CT scans (not to mention other advanced imaging techniques) has become pervasive in the everyday practice of clinical medicine.
How is all this news affecting my daily practice? First, I’ve started to discuss up front the potential long-term risks from radiation exposure — particularly in the outpatient setting — rather than waiting for patients to ask me about them. I take this opportunity to put those risks in proper perspective. For most patients with an appropriate clinical indication for an imaging test such as a CT scan, the small risk for cancer several years away is far outweighed by the immediate benefit of performing the test. I pause and explain to the patient — and to myself — why I’m doing the test and how that information will help us make the best decisions about his or her care. Second, I have started to look back more carefully at the number of imaging tests associated with radiation that a patient has undergone (something, I must admit, I was less likely to do a few years ago). In some cases, I now consider alternative tests that do not use ionizing radiation, such as echocardiography and MRI, and that could answer the same clinical question.
Now, it’s your turn to share your experiences with your colleagues. Tell us:
Have you changed your practice patterns in ordering imaging tests, particularly CT scans? If so, how?
Have patients or referring providers raised the issue of CT-scan safety with you in the last several weeks or months? What have they said?
If you perform or refer patients for CT angiography, does your imaging center implement standard measures to minimize the radiation dose?
December 18th, 2009
Avoiding Wrong Meds in Dialysis Patients Having PCI: The Expert’s Recommendations
Richard A. Lange, MD, MBA
According to a recent study, almost one-fourth of dialysis patients undergoing PCI receive an antithrombotic agent (enoxaparin or eptifibatide) that is contraindicated in individuals with renal disease, resulting in excessive major bleeding and death.
In a CardioExchange blog, the study’s lead author notes that this error was more likely to occur in hospitals that were rural or non-teaching or that had lower procedural volumes. He recommends (a) using EMR to avoid this and (b) providing safety seminars in residency/fellowship training programs.
Will such strategies be effective in the hospital settings where this error is most likely to occur?
December 16th, 2009
To Recommend Aspirin or Not to Recommend Aspirin, That Is the Question
Joseph S. Ross, MD, MHS
The debate over the use of aspirin in primary prevention of cardiovascular events among adults with no known cardiovascular disease continues to grow. In March, the United States Preventive Services Task Force assigned Class A recommendations to encourage:
Men 45-79 to use aspirin when potential MI benefit outweighs potential GI harm
Women 55-79 to use aspirin when potential stroke benefit outweighs potential GI harm
No controversy yet. As before, physicians are being told that aspirin is a “must use” drug among patients at moderate risk of either MI or stroke.
However, since the USPSTF recommendation, several studies have presented data that contradict this Class A recommendation, including a meta-analysis from the Oxford Antithrombotic Treatment Trialists (ATT) published in the Lancet.
This analysis is particularly interesting because previous meta-analyses only made use of summary-level data. However, through a collaborative agreement established among principal investigators of the large trials of aspirin for primary prevention, subject-level data (n=95,000) was made available for this paper. This agreement allowed for reliable comparisons of both the benefits and risks of aspirin in important groups, such as older adults, adults with diabetes, and others at increased risk of coronary heart disease. I recently collaborated on a research paper published in Archives of Internal Medicine that advocated for the availability of subject-level data for meta-analysis for purposes such as this.
The Oxford ATT found that aspirin was not associated with a reduced rate of vascular death but was associated with a 12% relative risk reduction per year in the primary prevention of serious vascular events. However, the absolute event rates per year were low (0·51% for aspirin recipients vs. 0·57% for controls), and the absolute risk reduction was reported as 0.07% (NNT>1000 for 1 year of treatment). This reduction was due mainly to fewer non-fatal myocardial infarctions. Complicating matters, aspirin was also associated with more major gastrointestinal and extra-cranial bleeds, with an absolute harm increase of 0.03% per year.
Within the pre-specified sub-group analyses, there was no significant heterogeneity in their findings: the risk reduction in primary prevention of serious vascular events was similar regardless of patient age, sex, BMI, past medical history of diabetes, hypertension, hyperlipidemia, or predicted 5-year CHD risk.
Perhaps we will have a better understanding when the results of ASPREE, ACCEPT-D, and ASCEND are available. We can only hope that the principal investigators enter into the same collaborative agreement and share subject-level data for meta-analysis.
Nevertheless, given this more precise examination of existing data, I cannot see how aspirin can remain a “must-use” drug for primary prevention of cardiovascular events among patients at moderate risk of either MI or stroke since there is minimal net effect on serious vascular events and no effect on mortality.
Do you agree? And what will you suggest to your primary care colleagues, like me, who are making decisions as to whether to recommend aspirin among large groups of patients with no known cardiovascular disease?
December 16th, 2009
When the Right Med Is Wrong: Treating PCI Patients Undergoing Dialysis
thomastsai and Richard A. Lange, MD, MBA
We welcome Tom Tsai, MD, MSc, to this forum to talk about his article in last week’s JAMA: Contraindicated Medication Use in Dialysis Patients Undergoing Percutaneous Coronary Intervention (JAMA. 302:2458). We asked him our questions, and encourage you to ask yours.
CardioExchange Editors: Your study found that nearly a quarter of dialysis patients undergoing PCI received contraindicated antithrombotic medications. Why do you think this practice exists?
Tsai: There are practical considerations that make the contraindicated medications easier to administer. For example, enoxaparin is administered either as an IV bolus or SQ injection without the need for a continuous IV drip which is the case for UF heparin when patients are treated for ACS (as was the case with 60% of our study population). Eptifibatide is typically the GPI IIbIIIa of choice for most hospitals and cath labs sans STEMI and is the medication of choice for upstream use. Additionally, from a systems perspective, those clinical pathway pre-printed order sets used in many hospitals to ensure the use of evidence based strategies–a type of ”cook book medicine”–can actually lead to errors if they aren’t sophisticated enough to protect against caveats that make an evidence-based therapy in your average ACS patient an inappropriate therapy in subset of that population, such as dialysis patients.
CardioExchange Editors: Was this a practice that predominated at certain hospitals or did it occur with the same frequency at most institutions?
Tsai: Certain hospital characteristics were associated with the use of contraindicated antithrombotic use, namely rural location, non-teaching institutions, and lower procedural volumes. Whether this represented a knowledge gap or more frequent use of pre-printed order sets in these institutions or still other factors is unknown.
CardioExchange Editors: What steps do you recommend individuals or institutions take to end this practice? You mention educational efforts, but practically speaking, what should happen quickly?
Tsai: First, institutions that have pre-printed order sets or ACS pathways on their EMR ordering systems should examine them carefully for medication orders that do not account for factors such as dialysis or renal function. It requires an amendment of these order sets and should prompt the review of all other order sets that may be at risk for a similar error. This is low-hanging fruit. More generally, residency/fellowship training programs should have patient safety seminars that focus on the issue of medication errors and patient safety. This study only illustrates a small slice of two larger epidemics in the practice of medicine: (1) the application of clinical-trial data to populations where the agent has not been validated, and (2) the failure to master the litany of contraindications in our ever-growing armamentarium.
CardioExchange Editors: So we’re very curious to hear from the CardioExchange community: What questions or perspectives do you have? Do practices like this happen at your institution? What insights do you have about avoiding such errors?
December 16th, 2009
New Guidelines
Andrew M. Kates, MD
How closely do you watch for new guidelines? It seems as if every week new guidelines are published on a variety of topics including atrial fibrillation, valve disease, STEMI and NSTEMI, and, most recently, the use of perioperative beta blockers. Between guidelines, appropriateness criteria and various position papers, it can be extremely challenging to keep abreast of the most recent “standards of care.”
How closely do you scrutinize these publications? Do you know what data the recommendations are based upon? When I first put together a talk on perioperative beta blockade (back in 2001), it seemed that almost everyone should be on a beta-blocker. Now, with the incorporation of data from several recent studies (including POISE and DECREASE), that just is not the case.
What are your thoughts on making sense of all this – how do you incorporate new recommendations? What’s more, do you think that guidelines lag behind the data? Should we wait for these publications to change how we treat our patients?
December 16th, 2009
FDA Advisers Recommend Expanded Use of Rosuvastatin
JoAnne M. Foody, MD
The Associated Press reports that, based on the JUPITER study, an FDA panel of advisers has recommended expansion of rosuvastatin. The FDA is expected to decide whether to act on this recommendation in 2010. According to the report, Astra Zeneca will develop an approach to use rosuvastatin in all patients at risk for heart disease based on hypertension and family history. This is beyond the group of patients that were studied in JUPITER which only assessed older patients with hsCRP above 2mg/dL. Do you agree with this approach, should rosuvastatin use be expanded to all at risk without hsCRP testing? How will you implement in your practice?
NEJM — Recent Cardiology Articles- Celiac-Artery Dissection September 17, 2026A 72-year-old man with hypertension, hyperlipidemia, and a stable ascending aortic aneurysm presented with sudden-onset, severe chest pain. CTA of the chest, abdomen, and pelvis showed a celiac-artery dissection.
- Complete Revascularization Guided by Functional Coronary Angiography in STEMI September 10, 2026Among patients with ST-segment elevation myocardial infarction and multivessel disease, physiology-guided angiography led to a lower risk of major cardiovascular events than conventional angiography-guided treatment.
- Oveporexton for Narcolepsy Type 1 — Results from Two Phase 3 Trials September 9, 2026In two placebo-controlled trials, oveporexton improved wakefulness, reduced daytime sleepiness, and lowered the cataplexy rate among patients with narcolepsy type 1. Increased urinary frequency and transient insomnia were common.
- Immediate Ambulatory Electrocardiographic Monitoring in Syncope August 31, 2026Among patients with syncope that remained unexplained after evaluation in the ED, immediate initiation of 14-day ECG monitoring did not result in significantly fewer patient-reported syncope episodes at 1 year than standard care.
- Catheter-Directed Thrombolysis in Intermediate-High–Risk Pulmonary Embolism August 31, 2026Catheter-directed thrombolysis led to a lower risk of death, recurrent pulmonary embolism, or cardiorespiratory decompensation or collapse at 7 days than anticoagulation alone in intermediate-high–risk acute pulmonary embolism.
- Celiac-Artery Dissection September 17, 2026