CardioExchange Archive

During complementary presentations at the AHA, investigators provided new and updated study data from the BARI 2D trial.

Dr. Bernard Chaitman reported on findings regarding the secondary endpoints of cardiac death and myocardial infarction.  These findings suggest that patients similar to those in the PCI stratum benefit more from intensive medical therapy alone.  In contrast, patients with more extensive coronary disease, similar to those in the CABG stratum, benefited more from prompt revascularization via CABG along with intensive medical therapy and insulin sensitizing therapy.

Dr. Mark Hlatky reported results of a cost-effectiveness analysis suggesting that prompt revascularization overall increases cost among patients with type 2 diabetes and stable coronary disease.  In particular, intensive medical therapy with delayed revascularization, as needed, is more cost-effective and preferred for patients similar to those in the PCI arm.

The main findings of both the secondary endpoints and cost-effectiveness studies were published ahead of print in Circulation.

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.

In a randomized trial of early versus delayed feedback of a performance-based report card to hospital corporations, early feedback was associated with a lower 30-day MI mortality rates but no change in the primary composite outcomes, including MI and HF process-of-care indicators.  Dr. Fred Masoudi provides a brief summary of the main findings.

The FOCUS trial randomized 2,016 patients (mean age 82 years) with high cardiovascular risk undergoing hip fracture surgery to either an aggressive or restrictive post-operative transfusion strategy.  Transfusions were administered to maintain a hemoglobin above 10 g/dL in the aggressive arm and 8 g/dL in the restrictive arm.  In the restrictive arm, transfusions were also permitted to treat active signs or symptoms of anemia.  Investigators reported at the AHA Scientific Sessions that there was no significant difference between either strategy in cardiovascular outcomes during the index hospitalization.

Despite recent data suggesting no significant effect on outcomes when combining the use of clopidogrel and proton-pump inhibitors (PPIs), the issue remains contentious.  Today, the FDA updated clopidogrel’s label to warn against its concurrent use with omeprazole.  The agency reported that omeprazole can reduce clopidogrel’s effect by nearly half, according to new manufacturer-conducted studies.  Concerns were also raised about esomeprazole, a component of omeprazole, although there were no official statements made regarding PPIs other than omeprazole.
 

J-point elevation in the inferior leads of a standard 12-lead electrocardiogram “is not an innocuous finding in middle-aged subjects,” according to a study presented at the AHA and published online in the New England Journal of Medicine.

Using national databases to assess outcomes in some 11,000 Finnish patients followed for an average of 30 years after a baseline ECG, researchers noted the following:

J-point elevation occurred in roughly 6% of subjects (3.5% in inferior leads and 2.4% in lateral leads).
Elevations in inferior leads were most often found among men and smokers.
J-point elevations of 0.1 mV in inferior leads were associated with significantly higher adjusted risks for death from cardiac causes (relative risk, 1.28) and arrhythmia (RR, 1.43).
Elevations of more than 0.2 mV in inferior leads were associated with a higher risk for death from any cause (RR, 1.54) and markedly higher risks for cardiac death (RR, 2.98) and arrhythmia (RR, 2.92). (See ECGS in 2 males with J-point elevations greater than 0.2 mV in the inferior leads.)
Elevations in lateral leads were only of borderline significance.

Dr. Don Lloyd-Jones presented findings from a study of the ARIC, Cardiovascular Health Study, and Framingham cohorts on lifetime risk for sudden cardiac death.  In addition to established cardiovascular risk factors, male sex and black race in men were associated with significantly increased risk.  Overall lifetime risks were relatively high, including 1 in 8 for men and 1 in 24 for women.

During Tuesday morning’s Late-Breaking Clinical Trials session, investigators presented results of the HEALL trial.  In this study, 3,846 patients with NYHA II-IV heart failure and LVEF ≤40% were randomized to losartan 150 mg versus 50 mg daily.  Over a median follow-up period of 4.7 years, patients in the higher-dose losartan arm had a significantly reduce rate of hospital readmission and a non-significant reduction in mortality.  The higher dose of losartan was also more likely than the lower dose to cause renal impairment, hypotension, and hyperkalemia, but not higher rates of discontinuing therapy.

Apropos of our recent blog on work hours, see this post in the Boston Globe.

What are your thoughts?

If a reputable program goes on probation, how would this effect your willingness to apply?

How do you feel about educational changes — including limiting conferences so that programs may be more compliant?

At the Monday morning Late-Breaking Clinical Trials Session, Dr. Ather Anis presented results of a Massachusetts-based study designed to compare outcomes for patients receiving primary PCI for STEMI at hospitals with versus without on-site cardiac surgery.  At 30 days, recurrent MI and need for revascularization were more common for patients at a hospitals without on-site cardiac surgery.  At 1 year, revascularization rates remained higher among patients without versus with on-site cardiac surgery, but there was no significant difference in mortality or recurrent MI.