November 24th, 2009
2009 AHA/ACC Updated STEMI Guidelines Released
Richard A. Lange, MD, MBA
The release of a new update to the STEMI guidelines was announced at the AHA Scientific Sessions. Guidelines committee members report that the update incorporates evidence from key trials that have emerged over the past two years. Changes include a greater emphasis on organized systems of emergency care, triage and transfer for PCI, and the possible roles of stenting the left main, thrombectomy, and fractional flow reserve. Medication updates include prasugrel as a possible alternative to clopidogrel and the use of bivalirudin, with or without heparin pretreatment, for primary PCI.
November 24th, 2009
The Rescue Page — An Essential Element of Today’s Health Care Delivery System
Juan J. Rivera, MD, MHS
As the doctor begins to talk to his patient about smoking cessation, he receives the first “rescue” page. He immediately knows that he has violated — again — the 15-minute-per-patient rule, a rule that surprisingly even patients in the waiting area expect their doctors to follow. Nurses, administrators, and patients coalesce into one giant chronometer, timing every move the doctor makes. We are living in a time-efficiency era in medicine — nothing wrong with that if we provide good care.
The rescue page serves a crucial function in today’s health care delivery system. It is an exit strategy, giving the physician an excuse to end the session and avoid wasteful practices (like talking to patients about disease prevention) that generate more headaches than profit for the clinic. The rescue page is analogous to the psychiatrist’s clock in a Hollywood movie, helping patients recognize the end of a session. “Time’s up … we’ll continue discussing your suicidal ideation next week.”
The doctor continues to discuss the risks of smoking and describe cessation strategies. “Beep…beep…beep!” A second rescue page interrupts the conversation. This time, it reads “S.O.S.” The doctor is under pressure, and the patient is becoming uncomfortable, feeling unworthy of the doctor’s time. By the time the pager stops beeping, both patient and doctor want to end the session. A third rescue page would be too much. Shared dissatisfaction is unavoidable.
The next patient enters, an obese 50-year-old man complaining of chest pain. The physician can tell that this patient is a talker and fears another rescue page situation. Determined to keep to 15 minutes, he repeatedly interrupts the man’s efforts to describe his symptoms. The patient awkwardly answers, as the doctor-turned-prosecutor fires question after question, trying to stick to the script. After a useless 10-minute interrogation and a pitiful physical examination, the doctor makes the decision the system expects. He replaces words with orders for a battery of tests. As his patient sets off on the not uncommon path of possibly unnecessary testing and potentially avoidable complications, the doctor glumly contemplates his efficiency. If only he would have listened…
The rescue page reflects the shortsighted priorities imposed by a system that reimburses aggressive and invasive strategies, promotes quantity over quality, and limits disease prevention and lifestyle counseling. The beeping of the rescue page should remind us how this system directly influences patient care and the doctor-patient relationship.
November 24th, 2009
Pharmacist-Physician Collaboration Could Reduce BP in Hypertensive Patients
Larry Husten, PHD
A pharmacist-physician team approach to managing hypertension is “highly effective,” reports Archives of Internal Medicine.
Six community-based, family medicine residency clinics were randomized to be either intervention or control sites (some 400 patients with uncontrolled hypertension were enrolled). In the intervention group, clinical pharmacists were encouraged to assess patients’ medication and blood pressure routinely, and they made in-person recommendations to physicians based on national guidelines. In the control group, pharmacists abstained from patient care but did answer physicians’ general questions.
By 6 months, BP was under control in more patients at intervention versus control sites (64% vs. 30%). Mean BP was reduced by 20.7/9.7 mm Hg in the intervention group, possibly because more antihypertensive drugs were added, the authors say. Rates of adherence to national guidelines did not differ between the groups.
The authors say their results suggest that “clinics or health systems with clinical pharmacists should consider reallocation of duties to provide more direct patient management to significantly improve BP control.”
November 23rd, 2009
AHA Roundup
Harlan M. Krumholz, MD, SM
In an unofficial survey of attendees, the most striking feature of this year’s AHA Scientific Sessions was how few attendees there were and how empty the exhibit hall was. The ARBITER study came in a somewhat distant second. With an official estimated total attendance (including exhibitors) just under 22,000, the meeting still drew a robust crowd, but well off of its highs (total attendance in 2006 was nearly 29,000, and it’s declined each year since). Maybe Orlando isn’t very exciting. Maybe it’s the economy. Maybe it’s that cardiology is splitting into subspecialties, each with their own meetings. Or maybe we just don’t need to physically gather in one place to exchange views and socialize new knowledge given what sites like theheart.org, Cardiosource, and–yes–CardioExchange can do.
Regardless of the attendance numbers, however, a lot of new and important information was presented at the meeting. And regardless of whether you attended or not, we hope you’ll find our coverage useful and our conversation lively.
One sad note before we summarize our coverage: The meeting ended in mourning as we learned about the untimely death of our colleague Ken Baughman. NEJM Senior Deputy Editor Tad Campion spoke for all of us in writing that Ken “exemplified excellence, dedication, and fine judgement in all he did.” We extend our sympathies to Ken’s family, friends, and colleagues.
Here’s our coverage:
What Role for Ezetimibe–You Be the Arbiter
We asked ARBITER lead author Allen Taylor the questions we thought were most important about this study, and there’s still time for you to ask your questions or add your perspectives–will you still use ezetimibe in practice? How? When? Why?
Cangrelor is No Clear CHAMPION in Acute Coronary Syndromes
Interventional Group Moderator Richard Lange hosts a discussion between lead CHAMPION investigator Robert Harrington and invited editorialist Adnan Kastrati. Listen in or join in.
On PACE to Maintain LV Function
The CardioExchange Editors ask questions of Cheuk-Man Yu, lead author of PACE–a multicenter, manufacturer-sponsored trial of right ventricular pacing versus cardiac resynchronization therapy in patients with preserved LV function. Have your say on this issue.
Interventional Round-Up
Richard Lange offers his succinct take on 11 of the most interesting stories in interventional cardiology. Did you attend these sessions or others? We welcome you to post your comments.
More News from AHA
CardioExchange Associate Editor Susan Cheng offers some other quick takes from the meeting:
A Challenge To Uptitrate Losartan in Heart Failure
Continuous May Be Better Than Pulsatile Flow For Destination VADs
Intravenous Iron Therapy Improves Symptoms in Heart Failure
Early Data on Trans-Catheter Aortic Valve Implantations
Ticagrelor in STEMI
Platelet Function Tests in Practice
Battling Depression Following CABG
Antiplatelet Therapy Following CABG
Primary PCI for STEMI At Hospitals With or Without Back-Up Cardiac Surgery
Lifetime Risk for SCD Higher in Men and Blacks
Early Repolarization in Inferior Leads Might Signal Trouble Ahead
Cardiovascular Outcomes Similar Between Aggressive and Restrictive Post-Operative Transfusion Strategies
New and Updated Results from BARI 2D
November 23rd, 2009
FDA Investigating Possible Link Between Sibutramine and Cardiovascular Events
Larry Husten, PHD
The FDA has issued an early communication regarding a possible increased risk for adverse cardiovascular events associated with sibutramine (Meridia), a prescription drug used to manage obesity.
A postmarketing study was conducted in some 10,000 obese patients with stable heart disease or type 2 diabetes plus another risk factor. Preliminary findings show more cardiovascular events occurred in patients who took sibutramine compared with placebo (11.4% vs. 10.0%).
Pending further data analysis, the FDA recommends following current labeling instructions to avoid the drug in patients with histories of coronary artery disease, congestive heart failure, arrhythmia, or stroke. In addition, the FDA notice says, “healthcare professionals should continue to evaluate the benefits and risks of sibutramine, taking into account individual patient medical histories.”
November 20th, 2009
AHA Interventional Recap
Richard A. Lange, MD, MBA
The AHA Scientific Sessions in Orlando this past week certainly provided interventionists with a lot to think about. Here are some of the presentations that caught my attention:
1. Cangrelor Not Beneficial in ACS Patients Receiving Clopidogrel and PCI (see discussion here)
2. (F)Utility of Platelet Assays (see discussion here): The POPULAR trial evaluated 6 platelet assays in clopidogrel-pretreated patients undergoing elective PCI. Three tests were able to identify patients at higher risk for death, MI, stent thrombosis or stroke at 1 year: light transmittance aggregometry (LTA), VerifyNow P2Y12 and Plateleworks. In contrast, 3 tests did not distinguish patients with and without ischemic events: IMPACT-R, INNOVANCE PFA P2Y and the PFA/Collagen ADP tests. None were able to predict major or minor bleeding.
3. Primary PCI Safe in Hospitals Without Cardiac Surgery (see discussion here): In an AHA late breaking prospective, observational study, STEMI patients in Massachusetts who underwent primary PCI at hospitals without cardiac surgery on site (SOS) had similar rates of death, MI and target vessel revascularization at 1 year compared to those who underwent primary PCI at hospitals with cardiac SOS. Of note, the hospitals without cardiac SOS had to perform at least 300 diagnostic caths and 36 primary PCIs annually, which are low minimum requirements.
4. Clopidogrel Doesn’t Improve Early Graft Results (see discussion here): In patients undergoing multivessel CABG, the CASCADE trial showed that the addition of clopidogrel to aspirin immediately after surgery did not reduce graft intimal hyperplasia or improve graft patency, as assessed by intravascular ultrasound and angiography performed one year post-CABG.
5. NSAID Ineffective In Preventing Tamponade Post-CABG (see discussion here): In the POPE Study of 196 pts at high risk of tamponade following CABG, – those with moderate or large effusion by echo 8-30 days after surgery — administration of NSAID (diclofenac) for 14 days was no more effective than placebo in reducing the volume of pericardial fluid or preventing tamponade. Many physicians prescribe an NSAID to the post-CABG patient with moderate or large pericardial effusion hoping it will accelerate resolution of the effusion and prevent tamponade. This well-performed, randomized, controlled trial shows that an NSAID is ineffective in these patients.
6. Better Cognitive Function with OPCABG Then PCI (see discussion here): In the Octopus Study, patients referred for PCI were randomized to PCI (with bare metal stent) or off-pump CABG (OPCABG). After 7.5 yrs of follow up, cognitive function was better in the OPCABG than the PCI-treated patients. Unfortunately, cognitive function was not assessed at baseline in the 201 patients studied.
7. More From BARI2D (see discussion here): The BARI2D study and associated substudies were presented at the AHA. In Type 2 diabetic patients, those randomized to intensive medical therapy — to reach target HgA1c, blood pressure, and serum cholesterol goals – had similar 4 year outcomes (composite death, MI, CVA) to those referred for prompt revascularization in addition to medical therapy, except in the patients with extensive coronary disease (3 vessel CAD), in whom prompt CABG resulted in fewer nonfatal MIs than intensive medical therapy. BARI2D quality of life analysis: Compared to medical therapy, the patients who underwent prompt revascularization with CABG had a small improvement in perception of wellness that persisted throughout the 4 year followup. BARI2D economic analysis: Prompt revascularization was associated with $10,000 increase in cost over the 4 years compared to medical therapy. For the different revascularization procedures, there was a ~$20,000 higher cost with CABG and ~$6000 higher cost with PCI compared to intensive medical therapy.
8. STICH In Time (see discussion here): In the STICH trial, 1000 patients with CHF (LVEF <35%) were randomized to CABG with or without surgical ventricular remodeling (SVR) with no benefit of SVR on the primary endpoint of death and hospitalization. Analyzing global and regional ventricular function, investigators were unable to identify a subgroup of patients who benefitted from addition of SVR to coronary revascularization at the time of CABG.
9. HEAALing Best With High Dose ARB (see discussion here): In the HEAAL study in CHF patients with depressed LVEF who are intolerant of an ACE inhibitor, treatment with high dose (150mg) losartan was better than low dose (50mg) losartan in reducing death and hospitalization for CHF over 5 years of follow-up. Unfortunately, high dose losartan was associated with more hyperkalemia, hypotension, and renal insufficiency than low dose losartan, although it rarely led to drug discontinuation.
10. “Pumping Iron” in CHF Patients (see discussion here): In the FAIR HF trial In patients with iron deficiency and chronic CHF without anemia, intravenous iron repletion – administered weekly until iron deficiency corrected, then monthly – improved exercise tolerance, symptoms, NYHA functional class, and self reported quality of life without adverse side effects, compared to placebo. The benefits were observed after only 4 weeks of treatment.
11. Continuous Flow HeartMate II (see discussion here): According to the HEARTMATE II study, in patients with advanced CHF, continuous-flow LV assist devices result in better survival – with freedom from stroke, device failure and complications – then pulsatile devices. In addition, treatment with continuous flow devices resulted in better exercise capacity, functional class and quality of life than treatment with pulsatile devices.
November 20th, 2009
Remembering to Hold the Salt
Joseph S. Ross, MD, MHS
I think we can all agree that counseling patients on diet is one of the least rewarding parts of being a doctor. Nobody likes telling adults what they can and cannot eat. And sometimes the recommendations seem so obvious that, to us, it borders on nagging.
Of course patients with hypertension and heart failure should avoid salt.
Of course patients with heart disease should avoid high-fat food.
Of course patients with diabetes should avoid sugar.
But a recent study in the American Journal of Medicine caught my eye. Hummel and colleagues examined data from a multi-hospital collaborative effort to improve quality of inpatient care for heart failure patients. Their findings reinforce the need to not only address the “doctory” issues, such as therapeutic decisions, with patients but also to nag them about diet.
When the researchers looked at the discharge counseling given to heart failure patients, they found that those with preserved systolic ejection fraction function (≥50%) were less likely than those with diminished function (<40%) to receive counsel on weight monitoring (33% vs. 43%) and sodium restriction (42% vs. 53%). Rates of following other ACC/AHA discharge recommendations — e.g., provide a medication list and a plan for worsening symptoms — were approximately the same in the two groups. Most interestingly, the heart failure patients with preserved systolic function who received discharge counseling on sodium-restricted diet had lower odds of 30-day death or readmission. No other discharge recommendations predicted 30-day outcomes.
To me, this was a reminder:
Of course patients with heart failure should avoid salt — but we have to remember to tell them, again and again.
So when you are rounding on your heart failure patients (and patients with hypertension, heart disease, diabetes, and so on) or seeing them in your office, do you make the five minutes to reinforce dietary restrictions and discuss what’s right and what’s wrong to eat? Do you distribute dietary handouts or ask the nurses to provide counseling instead?
November 19th, 2009
Dr. Ken Baughman’s Death Mourned
Larry Husten, PHD
Kenneth L. Baughman, Director of Advanced Heart Disease at Brigham and Women’s Hospital, was struck and killed by a car while jogging on Monday in Orlando, where he was attending the AHA Scientific Sessions. He was 63.
Dr. Baughman was also an Associate Editor of the New England Journal of Medicine and was previously Director of the Cardiology Division at the Johns Hopkins Hospital. He was a recognized leader in academic cardiology and a master clinician who had cared for thousands of patients and mentored generations of trainees. He was beloved and revered by all who knew him.
Dr. Baughman is remembered as an avid athlete and a dedicated husband, father, and grandfather. He is survived by his wife Cheryl, sons Matthew and Christopher, daughters-in-law Michelle and Holly, and four grandchildren. On behalf of the staff of the New England Journal of Medicine and CardioExchange, we extend our deepest sympathies to his family, friends, and colleagues.
More information is available in the Boston Globe obituary here and related story here.
November 18th, 2009
At the AHA: Intravenous Iron Therapy Improves Symptoms in Heart Failure
Larry Husten, PHD
In the FAIR-HF trial, NYHA II/III heart failure patients with LVEF ≤40 to 45% and iron deficiency benefited from intravenous iron with respect to symptoms, functional capacity, and quality of life but not survival. Dr. Fred Masoudi summarizes the findings. Editorialist Dr. William Dec weighs in.
November 18th, 2009
At the AHA: Continuous May Be Better Than Pulsatile Flow For Destination VADs
Larry Husten, PHD
Among 200 patients ineligible for heart transplantation in the HeartMate II study, continuous-flow LVAD therapy was associated with a lower rate of the primary endpoint, freedom from stroke or device failure, when compared to pulsatile-flow destination therapy at 2 years. Dr. William Abraham summarizes the findings and editorialist Dr. James Fang weighs in.
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