high intensity interval exercise for coronary heart disease patients… may 30... · 2010-11-12 ·...

High-Intensity Interval Exercise Best Prescription for Cardiac Rehab

Optimization of High Intensity Interval Exercise in Coronary Heart Disease.

Guiraud T, Juneau M, et al:

Eur J Appl Physiol 2010; 108 (March): 733-740

High intensity interval exercise for coronary heart disease patients, with brief bouts of maximal aerobic power alternating with passive rest, is beneficial for cardiac rehabilitation.

Background: Exercise for coronary heart disease (CHD) during cardiac rehabilitation (CR) has been moderate-intensity continuous training (MCT), or 40% to 80% of maximal oxygen uptake (VO2max). High-intensity interval exercise (HIIE), which involves repeated 30 to 300 second bouts of aerobic exercise at 85% to 100% of VO2max interspersed by recovery periods of equal or shorter duration, is occasionally used. No studies have shown which HIIE protocol is optimal. Objective: To compare 4 HIIE protocols to ascertain the best one for CHD in terms of safety, comfort, time spent near VO2max, and time to exhaustion. Design: Cohort study. Participants:19 stable CHD patients (17 males) aged 65±8 years. Methods: At baseline, each patient underwent a maximal graded exercise test (max EST) starting at 60 W and increasing by 15 W every minute until exhaustion. Maximal aerobic power (MAP) was that of the last completed stage. Patients followed 4 randomly-ordered, single, 35-minute HIIE sessions separated by ≥72 hours, all with exercise phases at 100% of MAP, but with different interval durations (15 seconds for exercise and recovery for mode A and B, 60 seconds for exercise and recovery for mode C and D) and type of recovery (passive or 0% of MAP for A and C, and active or 50% of MAP for B and D). Results: No patients developed ventricular arrhythmias. Of patients, 4 had myocardial ischemia during max EST and 3 had angina during all HIIE sessions. ST-segment depression (<2 mm) and angina resolved during passive recovery in A and C. Of patients, 63% completed 35 minutes of exercise in A, while only 16% in B, 42% in C, and 0% in D. (A>B, C, D; P <0.05). Passive recovery (A and C) had a longer time to exhaustion (1724±482 seconds and 1525±533 seconds, respectively) compared to active recovery (B=733±490 seconds, D=836± 505 seconds). Of patients, 13(68%), 17(98%), 15(79%), and 14(73%) reached VO2max in A, B, C, D, respectively. Time exercising above 80% VO2max was the same for all modes. Of patients, 18 rated A as the preferred mode. Conclusions: Alternating 15 seconds at MAP and 15 seconds passive recovery appears to be the optimal HIIE session for patients with CHD in terms of safety, patient comfort, time spent near VO2max, and time to exhaustion. Reviewer's Comments: HIIE might be safer than continuous aerobic training above the ischemic threshold because of the intermittent rather than prolonged periods of ischemia. Intermittent periods of ischemia might lead to ischemic pre-conditioning as during warm-up angina. Brief, repetitive episodes of ischemia have also been shown to promote collateral formation in animals. Further study is warranted in this area to optimize CR protocols for CHD patients. (Reviewer-Debra L. Braverman, MD). © 2010, Oakstone Medical Publishing

Keywords: High Intensity Interval Exercise, Cardiac Rehabilitation, Coronary Heart Disease

Print Tag: Refer to original journal article

Does Chronic Oral Anticoagulation Reduce Mortality Risk After MI?

Long-Term Effect of Chronic Oral Anticoagulation With Warfarin After Acute Myocardial Infarction.

Haq SA, Heitner JF, et al:

Am J Med 2010; 123 (March): 250-258

Chronic oral anticoagulation does not reduce mortality post-myocardial infarction.

Background: Single or dual antiplatelet therapy is the currently-practiced antithrombotic regimen status-post acute myocardial infarction (MI). Usage of additional chronic oral anticoagulation (OAC) is often patient, institution, or cardiologist specific, as it remains unclear whether additional OAC improves patient outcomes. Objective: To assess the risk and benefit of long-term OAC status-post recent MI. Design: Meta-analysis of 10 randomized clinical trials. Methods: Data were analyzed comparing warfarin-containing OAC regimens with or without aspirin with non-OAC regimens with or without aspirin for patients with recent myocardial infarction. Primary end point was defined as all-cause mortality, but other end points were also individually examined. These included recurrent infarction, stroke, and major bleeding. Odds ratio (OR) (fixed effect, OR <1 indicates benefit for OAC) for death and other ischemic and hemorrhagic complications at the longest interval of follow-up available was then calculated. Results: There were 24,542 patients included in the pooled data, of which 14,062 were assigned to OAC and 10,480 to no OAC. Patients were followed for 3 to 63 months, and reperfusion therapy was administered to 6009 patients (25%). Death occurred in 2424 patients (9.9%), comprised of 1279 patients in the OAC group and 1145 in the no-OAC group (OR 0.97; 95% CI, 0.88 to 1.05; P =0.43). There were 2430 new infarctions (9.9%) with no significant difference between groups (P =0.18). There was also significantly more major bleeding in the OAC group (P <0.001). However, stroke occurred in 578 patients (2.4%), 271 in the OAC group and 307 in the no OAC group (P =0.001). A subset of patients (n=11,920) randomized to aspirin versus aspirin and OAC underwent separate analyses, with the results being very similar. Conclusions: Among approximately 25,000 patients with recent MIs meta-analyzed, OAC with or without aspirin did not reduce mortality or reinfarction, as compared with placebo or aspirin. There is reduction in stroke, but there is an association with significantly more major bleeding. Reviewer's Comments: In this meta-analysis in approximately 25,000 patients for nearly 90,000 patient years, oral anticoagulation was found to not reduce all-cause death or re-infarction. Epidemiological data supports the association of a potential benefit in reducing factor VII levels to reduce the risk of vascular thrombotic events. Low-dose warfarin appears reasonable. However, in this meta-analysis, the INR ranged from 1.5 to 4, and no benefit was seen. A possible explanation is that rupture of a stable plaque results in platelet activation and aggregation, and warfarin has a limited role in preventing this type of a thrombotic cascade. A potential study limitation is that patient subsets, such as those with large anterior wall myocardial infarctions and left ventricular thrombus, could not be adequately assessed for possible benefits of oral anticoagulation therapy. (Reviewer-Suraj Maraj, MD). © 2010, Oakstone Medical Publishing

Keywords: Chronic Oral Anticoagulation, Warfarin, Acute Myocardial Infarction, Long-Term Effect


Statins Can Be Effective in Very Elderly Patients

Cardiovascular and Cancer Mortality in Very Elderly Post-Myocardial Infarction Patients Receiving Statin Treatment.

Gränsbo K, Melander O, et al:

J Am Coll Cardiol 2010; 55 (March 30): 1362-1369

Statins reduce cardiovascular mortality in the elderly without increasing cancer risk.

Background: The vast majority of coronary deaths occur in patients aged >65 years. Despite the proven beneficial effects of statins in reducing cardiovascular mortality post-myocardial infarction (MI), a large percentage of elderly patients are not prescribed statins. Objective: To study whether statin treatment was safe and efficacious in very elderly patients (aged >80 years). Methods: All consecutive patients aged >80 years admitted with a diagnosis of acute MI between 1999 to 2003 and included in the Register of Information and Knowledge about Swedish Heart Intensive care Admissions (RIKS-HIA) were studied. A total of 14,907 patients were available for survival analysis (population A). All patients who died within 14 days from baseline (population B, n=12,320) and patients who died within 365 days (population C, n=6738) were excluded and were analyzed separately. Results: All-cause mortality was significantly lower in patients receiving statin treatment in population A (relative risk [RR] 0.55), population B (RR 0.62), and population C (RR 0.64). Cardiovascular mortality and mortality from acute MI was also lower in statin-treated patients. There was no increase in cancer mortality in the statin treatment group. Conclusions: There was a significant reduction in all-cause, cardiovascular, and acute MI mortality in the very elderly patients treated with statins without an increase in cancer mortality. Reviewer's Comments: Statin use among elderly patients is underutilized likely due to exclusion of elderly patients from clinical trials and from fear of inducing adverse effects. However, older patients are at a higher risk of adverse cardiac events and should derive more benefit from statin treatment. An analysis from the PROSPER (PROspective Study of Pravastatin in the Elderly at Risk) examining statin therapy in patients aged 70 to 82 years found a decrease in cardiovascular events with statin treatment, but there was a concern for increased cancer incidence. Despite the limitations of a registry study with short median follow-up (296 days), this study, taken together with other meta-analyses of large statin trials fail to show an increase in cancer deaths with statins. Furthermore, the benefits of statin therapy appear to be profound in this high-risk group. (Reviewer-Anoop C. Parameswaran, MD). © 2010, Oakstone Medical Publishing

Keywords: Elderly, Myocardial Infarction, Statins


Assessing MR Severity By Echo May Be More Art Than Science

Reproducibility of Proximal Isovelocity Surface Area, Vena Contracta, and Regurgitant Jet Area for Assessment of Mitral

Regurgitation Severity.

Biner S, Rafique A, et al:

J Am Coll Cardiol Img 2010; 3 (March): 235-243

There is only modest reliability of vena contracta and proximal isovelocity surface area measurements for assessing mitral regurgitation severity.

Background: Regurgitant lesions are often difficult to accurately quantify. Recommendations from the American Society of Echocardiography for evaluating the severity of mitral regurgitation (MR) include assessment of color Doppler regurgitant jet area, vena contracta (VC) width, and effective regurgitant orifice area using proximal isovelocity surface area (PISA). A number of technical factors can affect these measurements. Objective: To assess the interobserver variability of VC and PISA measurements and the reproducibility of jet area to assess MR severity. Methods: 18 cardiologists from 11 university hospitals reviewed echocardiograms performed by a single, experienced sonographer on 16 consecutive patients referred to the Cedars Sinai Medical Center for surgical correction of MR. MR was graded as severe or non-severe. Results: Average age was 69±12 years, and half of patients had degenerative MR and the other half had functional MR. The interobserver agreement on the severity of MR was only fair, and was 75±16% (kappa 0.32) for jet area based method, 75±15% (kappa 0.28) for VC measurement and 78±15% (kappa 0.37) for PISA measurements. Interobserver variability was similar among cardiologists practicing in single versus multiple institutions. By multivariate analysis, the only predictor of significant agreement among cardiologists on MR severity was the presence of a central jet for PISA measurement and the presence of an identifiable regurgitant orifice for the VC method. Conclusions: There is significant interobserver variability when using VC and PISA measurements to assess MR severity, and these measurements are only modestly reliable. The presence of a central jet and identifiable regurgitant orifice may improve reliability of PISA and VC measurements respectively. Reviewer's Comments: The distinction of severe from non-severe MR is clinically important as this may affect subsequent decisions to repair or replace the valve. The distinction between moderate and severe MR is sometimes difficult to make. Although quantitation of MR severity by methods such as VC and PISA methods are encouraged, this study shows that in real world practice, these measurements can be variable, and inter-observer agreement is sub-optimal. Thus, it is important to integrate multiple pieces of information such as mitral inflow profile, pulmonary vein inflow, jet area, PISA, VC, etc when assessing MR severity. An accompanying editorial rightly stresses the importance of assessing the hemodynamic effects of chronic severe MR and to question the diagnosis of severe MR in the absence of left atrial or left ventricular dilation. (Reviewer-Anoop C. Parameswaran, MD). © 2010, Oakstone Medical Publishing

Keywords: Mitral Regurgitation, Vena Contracta, Proximal Isovelocity Surface


Atrial Fibrillation Worsens Dementia

Atrial Fibrillation Is Independently Associated With Senile, Vascular, and Alzheimer's Dementia.

Bunch TJ, Weiss JP, et al:

Heart Rhythm 2010; 7 (April): 433-437

Atrial fibrillation is independently associated with all forms of dementia and leads to an increased mortality rate in these patients.

Background: Alzheimer's disease (AD), vascular dementia (VD), and atrial fibrillation (AF) are increasingly prevalent problems in the elderly and share common risk factors of diabetes, hypertension, smoking, and systemic inflammation. An association between AF and AD has been suggested and AF is believed to be independently associated to cognitive decline. Objective: To evaluate the risk of AF and dementia and secondarily assess impact on mortality. Design: Retrospective study. Methods: A comprehensive healthcare database was utilized at the study site. Over 37,000 patients were included with a mean of 5 years of follow-up. Patients with pre-existing AF or dementia were excluded. The database was queried based on ICD-9 codes and by searching EKG, ambulatory monitor, and event monitor data for AF. Mortality was assessed by querying the database and verified through the Social Security database. Results: Over 10,000 (27%) patients developed AF and 1,535 (4.1%) developed dementia during the 5-year follow-up. Patients with AF were older and more likely to have hypertension, coronary artery disease, renal failure, heart failure, and prior strokes than patients without AF. There was an increased incidence of all types of dementia in patients with AF with a mean time to onset of dementia of approximately 1200 days. The highest risk of AD occurred in those ≤70 with AF. Dementia also was associated with increased mortality which was further amplified by the presence of AF. These results were also increased in those ≤70 years of age. Conclusions: AF is independently associated with risk of dementia. AD and AF appear to cumulatively increase mortality and all results appear more frequent in patients with AF ≤70 years of age. Reviewer's Comments: This large study provides support to smaller previous studies evaluating this topic and has findings that many of us see in our own practice. AF appears to be a systemic illness that can have far-reaching implications beyond the arrhythmia itself. The study has several limitations; namely, it is a retrospective study relying strongly on data from a health care database and it does not suggest causality. If causality is suspected, mechanisms such as cerebral microembolic disease, systemic inflammation, or decreased cerebral perfusion from heart failure may play a role. It is interesting that younger people had a higher associated risk. Aggressive early intervention for AF may one day prove beneficial. (Reviewer-Sumeet K. Mainigi, MD). © 2010, Oakstone Medical Publishing

Keywords: Atrial Fibrillation, Dementia, Alzheimer's Disease


Cardiac CT-- A Promising Risk Stratification Tool

Prognostic Value of 64-Slice Cardiac Computed Tomography. Severity of Coronary Artery Disease, Coronary

Atherosclerosis, and Left Ventricular Ejection Fraction.

Chow BJW, Wells GA, et al:


Coronary artery severity, left ventricular ejection fraction, and total plaque score assessed by cardiac CT provides incremental prognostic value over clinical variables.

Background: Cardiac computed tomography angiography (CTA) is a rapidly evolving tool for non-invasive assessment of coronary artery disease (CAD). While it has been shown to be accurate in detecting CAD, there are only a few small studies looking at its prognostic significance. Objective: To assess the prognostic significance and incremental value of CAD severity, coronary atherosclerotic burden, and left ventricular ejection fraction (LVEF) assessed by CTA. Design: Single-center prospective study. Participants: 2172 consecutive symptomatic patients with clinical indications for CTA. Methods: Consecutive patients between 2006 and 2008 in a single center in Ottawa, Canada were assessed. The presence and degree of CAD, total plaque score, left ventricular volumes, and LVEF were measured. Patients were prospectively followed for 16.8±8.3 months. Primary outcome measure was a composite of all major cardiac adverse events (MACE; cardiac death and non-fatal myocardial infarction). A composite of all-cause mortality and non-fatal myocardial infarction were assessed as secondary outcomes. Results: Patients had a mean age of 56±11.8 years; 52.6% were men with a 33.4±34.4% pre-test probability of CAD. There were 34 MACE (11 cardiac deaths, 23 non-fatal myocardial infarctions) during follow-up, with 27 all-cause deaths. Only 0.2% of patients with no CAD had MACE, whereas 0.8% of patients with non-obstructive CAD had MACE. Of patients, 3.7% with obstructive CAD and 4.1% with high-risk CAD (those with left main ≥50%, 3-vessel or 2-vessel disease ≥70% with proximal left anterior descending coronary artery disease) experienced MACE. CAD severity was an independent predictor of adverse events (hazard ratio [HR] 3.02) after adjusting for clinical variables. Likewise, addition of LVEF provided incremental prognostic information (HR 1.47) over severity of CAD. Total plaque score had incremental prognostic value (HR 1.17) over LVEF and CAD severity for all-cause mortality and non-fatal myocardial infarction. Conclusions: CTA derived CAD severity, LVEF and total plaque score had significant and incremental predictive value over clinical risk predictors. Reviewer's Comments: With increasing emphasis on cost-effectiveness and reduction of radiation from medical imaging, any new cardiac imaging modality should not only be effective in diagnosing CAD, but should also have incremental prognostic value over readily available clinical data. This study demonstrates that the absence of CAD provides excellent prognosis with an annual event rate of <0.4%. Severity of CAD, plaque burden, and a 10% reduction in LVEF, all of which can be readily obtained from CTA, provides incremental prognostic value over clinical variables. Use of hard end points was a strength of this study. However, this was a single-center trial with limited events, and larger multi-center trials are needed to confirm these findings. (Reviewer-Anoop C. Parameswaran, MD). © 2010, Oakstone Medical Publishing

Keywords: Computed Tomography, Prognosis, Cardiac Death


Atrial Fib Ablation Appears More Successful in Males

Outcomes and Complications of Catheter Ablation for Atrial Fibrillation in Females.

Patel D, Mohanty P, et al:

Heart Rhythm 2010; 7 (February): 167-172

Atrial fibrillation ablation procedures may be associated with lower success in female patients.

Background: Over the past decade, there has been a steady increase in the number of catheter ablation procedures for the management of atrial fibrillation (AF). Most reports on the efficacy and safety of these procedures include overwhelming majorities of male patients. Little is known about outcomes in female patients. Objective: To evaluate outcomes associated with AF ablation in females in comparison with findings in a male cohort. Design: Retrospective data analysis. Methods: All females undergoing an AF ablation procedure at 5 large medical centers between 2005 and 2008 were analyzed. Male patients who underwent AF ablation during the same time period served as the comparison arm in this study. The technical details of the ablation procedure were standardized to a great degree between participating centers and represented the current standard. All patients were discharged on warfarin anticoagulation. Follow-up was quarterly for the first year then semi-annually. Holter monitors were used to verify AF recurrences. Episodes of AF lasting >1 minute, off anti-arrhythmic drugs, after an 8-week post-procedure blanking period were considered as procedure failures. Results: The number of female patients (n=518) represented 16% of the total AF ablation population (n=3265). They tended to be older, failed more anti-arrhythmic drugs, and more likely to have long-lasting, persistent AF. Incidence of prior strokes and hypertension was higher in females while incidence of diabetes and coronary artery disease was lower. Women tended to be referred for the procedure later in the course of the disease. During ablation procedures, women were noted to have a higher incidence of non-pulmonary vein (PV) arrhythmogenic foci compared to men (50% vs 16%; P =0.001). With follow-up of 24±16 months, women were less likely to have procedural success (69% vs 78% for men). AF recurrence in female patients was associated with higher body mass index (BMI), persistent AF (versus paroxysmal AF), and the presence of non-PV firing sites. Those with non-paroxysmal AF and non-PV foci were twice as likely to have ablation failure. Women were found to have a higher incidence of vascular complications (hematomas and pseudo-aneurysms). There were no deaths related to the procedure. Conclusions: Women undergo AF ablation procedures much less frequently compared to men. They are much more likely to have arrhythmogenic foci outside the pulmonary veins. Overall, women tend to have lower success rates and relatively higher incidence of vascular complications post-procedure. Reviewer's Comments: These data are based on a small cohort of female patients but points out some very interesting findings. It almost seems that the pathogenesis and natural history of AF in women is markedly different compared to men. This may influence the planning and approach to catheter-based treatment options in women with AF in the future. (Reviewer-Khalid Almuti, MD). © 2010, Oakstone Medical Publishing

Keywords: Outcome, Atrial Fibrillation Ablation, Women


Test Modestly Predictive of Ischemic Events After Elective PCI

Comparison of Platelet Function Tests in Predicting Clinical Outcome in Patients Undergoing Coronary Stent Implantation.

Breet NJ, van Werkum JW, et al:

JAMA 2010; 303 (February 24): 754-762

Although residual platelet reactivity testing in stable patients undergoing PCI identifies risks for stent thrombosis and other ischemic events, its overall contribution is modest.

Background: Platelet inhibition with dual antiplatelet therapy, generally aspirin and clopidogrel, has resulted in decreased stent thrombosis and ischemic events post percutaneous coronary intervention (PCI) with stenting. Prior small, prospective studies have shown that increased platelet reactivity, despite treatment with dual antiplatelet therapy, is associated with increased ischemic events post PCI. Many prior studies utilized light transmission aggregometry (LTA) to assess residual platelet reactivity, though more recently point-of-care tests have become available. Objective: To compare the ability of several different platelet function tests including LTA to predict stent thrombosis and other ischemic events in patients pretreated with clopidogrel undergoing PCI with stenting. Design: Prospective study. Participants: 1069 consecutive patients scheduled for elective PCI. Methods: Patients who were pretreated with aspirin and clopidogrel were included if they had normal platelet count, not taking NSAIDS or dipyridamole, and treated with glycoprotein IIb/IIIa inhibitor. Medication adherence was assessed at outpatient visits. Blood was collected for platelet function testing immediately prior to PCI. Primary end point was a composite of death, myocardial infarction, stent thrombosis, and ischemic stroke at 12 months. Primary safety end point was major and minor bleeding. Tests evaluated were: LTA, IMPACT-R, VerifyNow P2Y12, PFA-100, and Plateletworks. Results: Initially, 1328 patients were eligible with 1069 consecutive patients enrolled; 12-month outcomes were available for 1067 (99.8%) patients. The receiver operating characteristic curve analysis demonstrated that LTA, VerifyNow P2Y12, and Plateletworks were able to identify patients at risk for events. IMPACT-R and PFA did not. Conclusions: Independent predictors of events included older age, left ventricular dysfunction, prior coronary artery bypass grafting, stent length and number of stents, graft stenting, bifurcation stents and clopidogrel loading dose. No test predicted bleeding. Overall, the contribution of the platelet function test results to the risk model was modest. Reviewer's Comments: Though LTA has been widely studied and has been able to identify patients at risk for ischemic events, it is cumbersome and not suitable for routine practice. Plateletworks was found to be discriminating in this study, but it requires performance within 10 minutes of blood draw, also not ideal for routine practice. An abnormal VerifyNow P2Y12 test result has been found to be predictive of ischemic events in prior studies as well, and it is practical. However, the positive predictive value for an abnormal test result is low, particularly among stable patients. This was the largest study of stable patients undergoing PCI tested for residual platelet reactivity. The contribution of the tests to the overall risk model was modest. The authors do not recommend routine testing in stable patients for PCI. Also, data regarding the correct treatment of patients with high residual reactivity are currently limited. Future clinical studies are expected to shed further light on this issue. (Reviewer-Parul B. Patel, MD). © 2010, Oakstone Medical Publishing

Keywords: Stents, Clopidogrel, Percutaneous Coronary Intervention


Don't Watch and Wait When Aortic Stenosis Is Very Severe

Early Surgery Versus Conventional Treatment in Asymptomatic Very Severe Aortic Stenosis.

Kang D-H, Park S-J, et al:

Circulation 2010; 121 (April 6): 1502-1509

Early aortic valve surgery improves long-term survival in asymptomatic patients with very severe aortic stenosis.

Background: Management of asymptomatic aortic stenosis (AS) remains controversial. Sudden death occurs in approximately 1% of patients per year. However, surgery has attendant risks of morbidity and mortality, though less in recent years due to improved techniques. Design: Prospective study. Participants: 197 consecutive asymptomatic patients with “very severe” AS. Methods: A prospective registry was set up in 1996 and later queried for patients with "very severe" asymptomatic AS defined as aortic valve area ≤0.75 cm2 and either peak aortic velocity ≥4.5 m/sec or mean aortic valve gradient ≥50 mm Hg on Doppler examination. Patients were excluded because of dyspnea, syncope, angina, ejection fraction (EF) <50%, moderate or severe aortic regurgitation, significant mitral disease, malignancy, and age > 85. Pre-existing coronary disease was also an exclusion, though 6 patients with incidentally discovered coronary artery disease (at preoperative angiography) were included. Early surgery or conventional treatment was at the discretion of the treating physician. Results: 102 patients had early surgery with no operative mortality; 95 had conventional treatment. During follow-up there were no cardiac and 3 non-cardiac deaths in the surgical group, as compared with 18 cardiac and 10 non-cardiac deaths in the conventional group. Estimated 6-year survival and cardiac mortality-free survival were 98% and 100% in the surgical group versus 68% and 76% in the conventional group (P <0.001). Of sudden death cases, 7 were asymptomatic at the last exam, as were 7 cases of heart failure death. Additionally, 57 propensity score-matched pairs were examined, with similar results; estimated 6-year survival and cardiac mortality-free survival were 96% and 100% in the surgical group versus 65% and 74% in the conventional group. Of patients in the conventional group, 46 underwent late surgery; they had significantly more left ventricular dysfunction in the immediate postoperative period than did the early surgery group. Conclusions: In this study, early aortic valve surgery improved long-term survival in asymptomatic patients with very severe AS. Further, >80% of survivors in the conventionally-treated group eventually came to surgery. Reviewer's Comments: This research strongly supports early valve replacement in asymptomatic patients with very severe AS. This is in line with other work showing high event rates and risk of rapid deterioration in this population. One problem in caring for such patients is in knowing that they are truly asymptomatic. Many are sedentary and others probably dismiss mild symptoms as due to other causes. Given the very low surgical mortality with current techniques, it just makes sense to operate early when AS is "very severe." Several other points of interest: half of all patients had bicuspid valves, confirming other work; degree of calcification correlated with mortality in the conventional group; though the group as a whole showed hemodynamic progression, there was much inter-individual variation. Interestingly, survival varied significantly according to gender with women showing better survival than men, a finding left unexplained. (Reviewer-Gregg S. Pressman, MD). © 2010, Oakstone Medical Publishing

Keywords: Severe Aortic Stenosis, Early Surgery, Conventional Therapy


Is There a Preferred Repair for Abdominal Aortic Aneurysm?

Endovascular Versus Open Repair of Abdominal Aortic Aneurysm.

The United Kingdom EVAR Trial Investigators:

N Engl J Med 2010; April 30 (): epub ahead of print

There appears to be no significant benefit with endovascular repair over surgical repair of abdominal aortic aneurysm.

Background: With an increasingly aging population, abdominal aortic aneurysm (AAA) is becoming more common especially in older men. With the risk of rupture increasing with size, repair is recommended -- frequently endovascular or open surgical repair. Prior studies have shown benefit with endovascular repair as compared to open surgical repair for 30-day mortality. Follow-up was short in these studies. The EndoVascular Repair 1 trial (EVAR1) was designed to compare long-term outcomes of endovascular repair versus open repair of large AAAs. Design: Large randomized trial. Participants: 1252 patients with AAA. Methods: Patients aged >60 years with an AAA >5.5 cm in diameter by CT were recruited for the EVAR1 trial if they fit anatomic and clinical criteria for surgical and endovascular repair. These patients were randomized to either open surgical or endovascular repair. They were followed up with CTs at 1 and 3 months and annually thereafter. Primary end point was all-cause mortality. Results: There were no significant differences between groups at baseline. Mean age was 74.1±6.1 years and 90% were men. Mean diameter of AAA was 6.4±0.9 cm. All patients were followed until September 2009. Median follow-up until death or end of study was 6 years. The 30-day mortality was 1.8% in the endovascular group and 4.3% in the open surgical repair group. Of patients, 2.3% in the endovascular repair and 6% in the open surgical repair group died during hospitalization for the repair. At study end, there was no significant difference in the total mortality (7.5 and 7.7 deaths per 100 person years in the endovascular repair group and open surgical repair group, respectively). Graft-related complications and re-interventions were 3 to 4 times more common in the endovascular group. Endovascular repair was $8000 more costly than open surgical repair for the primary repair and cost $5000 more in 8 years of follow-up. Conclusions: Endovascular repair was associated with lower operative mortality, but there was no significant difference in total mortality or aneurysm-related mortality in the long term when compared to open surgical repair. Moreover, graft-related complications and re-interventions were more common and more costly in the endovascular group. Reviewer's Comments: This trial shows that even though initial procedural mortality is much lower in the endovascular group, the benefit is lost in the long term due to increased graft-related complications and aneurysm related mortality. With this current evidence, a patient with AAA, if they fit criteria for surgical therapy, would benefit in the long term more from surgical repair than with endovascular repair and would be cheaper. (Reviewer-Pradeep S. Arumugham, MD). © 2010, Oakstone Medical Publishing

Keywords: Abdominal Aortic Aneurysms, Treatment


It's Hard to Beat Statins

Effects of Combination Lipid Therapy in Type 2 Diabetes Mellitus.

The Accord Study Group:

N Engl J Med 2010; 362 (April 29): 1563-1574

While fenofibrate added to simvastatin does not reduce cardiovascular events in diabetics, it might still have usefulness in the subset with low HDL and high triglycerides.

Background: Diabetics are at high risk for cardiovascular events, even when treated with statins. Objective: To test the hypothesis that fibrate therapy added on to statin would further lower risk of cardiovascular outcomes. Participants: 5518 patients were studied; all had type 2 diabetes. Methods: Age was 40 to 79 years if cardiovascular disease was present, age 55 to 79 when only subclinical disease or ≥2 risk factors were present. In addition low-density lipoprotein (LDL) was 60 to180 mg/dL; high-density lipoprotein (HDL) had to be <55 for women/blacks and <50 for others; and triglycerides (TG) were <750 mg/dL if no lipid lowering therapy, otherwise <400. Subjects were randomized to fenofibrate (adjusted according to glomerular filtration rate) or placebo; all received open-label simvastatin according to guidelines. Primary outcome was myocardial infarction (MI), stroke, or cardiovascular death. Secondary outcomes included unstable angina, death from heart failure, and all-cause mortality. Results: Mean follow-up was 4.7 years. Mean LDL fell from 100.0 to 81.1 in the fenofibrate group, and from 101.1 to 80.0 in the placebo group; HDL increased slightly from 38 to 41 in both groups. TG decreased from 164 to 122 with fenofibrate versus 160 to 144 with placebo. There was no significant difference between groups for primary outcome, its individual components, or all-cause mortality. Among pre-specified subgroups, there appeared to be possible harm for women versus men, but possible benefit for those with low HDL (≤34) and high TG (≥204). Severe elevations of creatine kinase (>10 times normal) and elevations of alanine aminotransferase (>3 times normal) occurred with similar frequency in both groups. Mean creatinine increased from 0.93 to 1.10 on fenofibrate. Conclusions: Use of fenofibrate in type 2 diabetics already receiving simvastatin did not reduce risk of MI, stroke, or cardiovascular death. It is still possible that the subgroup with low HDL/high TG benefits from combined statin and fenofibrate therapy. On the other hand, this study raises the possibility of harm from the combination in women, and reminds us that the drug increases creatinine levels. Reviewer's Comments: For years the cardiology community has debated the importance of TG in coronary disease and its treatment. Several trials have observed possible benefit to lowering TG, particularly when HDL is low, as was suggested in this study. However, primary end point was not met in this trial. This may be because mean TG levels were not very high or because it's difficult to lower event rates below those observed on statin therapy. It may also be that certain sub fractions within the group of compounds measured as TG are more atherogenic than others. For now, it's hard to argue that adding fenofibrate to statin therapy will benefit most coronary disease patients. (Reviewer-Gregg S. Pressman, MD). © 2010, Oakstone Medical Publishing

Keywords: Fenofibrate, Simvastatin, Diabetes, Cardiovascular Disease


Mitral Prolapse -- Don't Ignore the Annulus

Mitral Annular Dynamics in Myxomatous Valve Disease: New Insights With Real-Time 3-Dimensional Echocardiography.

Grewal J, Suri R, et al:

Circulation 2010; 121 (March 30): 1423-1431

Average size and dynamics of the mitral annulus are altered in myxomatous disease promoting regurgitation.

Background: The mitral valve has a complex 3-dimensional (3D) configuration, often described as a saddle-shape. Real-time 3D transesophageal echocardiography (RT3DE) allows high quality imaging of the mitral annulus throughout the cardiac cycle. Objective: To describe annular size and configuration in patients with myxomatous mitral valve disease (MVD), comparing it to normals and those with ischemic mitral regurgitation (IMR). Methods: RT3DE was performed in 32 patients undergoing surgical repair of MVD (including 12 who also had post-repair RT3DE) comparing results with 10 patients with IMR and 15 control subjects with no structural heart disease. Annular measurements were performed in early-, mid-, and late-diastole, and early-, mid-, and late-systole. Anterior annulus measurement by RT3DE was validated by comparison with direct measurement at the time of surgery (mean difference, 0.1±0.1 mm; P =0.73; 95%CI, ±4.4 mm). Results: MVD patients had larger average annular circumference and area than controls; there was no significant difference in average annular height or saddle-shape depth (ratio of height to intercommissural diameter). When dynamic motion was examined, controls showed an early-systolic annular area contraction (due to a decrease in anteroposterior diameter, P =0.04) along with an increase in annular height (P <0.001) leading to a deeper saddle-shape. In MVD patients, the annulus was larger throughout the cardiac cycle. From diastole to systole there was no change in anteroposterior diameter but intercommissural diameter increased markedly, increasing annular circumference and area. Saddle-shape deepening occurred later and was less than in controls (P <0.0001). Post repair, annular circumference, area, and anteroposterior and intercommissural diameters were reduced (all P <0.001); however the annulus remained dynamic with a systolic increase in intercommissural diameter, circumference, and annular area (all P <0.01). In diastole, IMR patients displayed anteroposterior annular enlargement similar to MVD; however, intercommissural diameter was not increased; IMR diastolic area (P =0.05) and circumference (P =0.03) were smaller than in MVD as was annular height. Anteroposterior diameter was unchanged throughout systole and annular height remained lower than in MVD and controls. Conclusions: Annular enlargement takes different forms in different diseases. While anteroposterior diameter is similar in IMR and MVD, MVD patients have greater IMR and cardiomyopathy can now be extended to MVD and may be a common mechanism of early-systolic regurgitation. Dynamic changes in the MVD annulus lead to increased leaflet separation thus contributing to mitral regurgitation. Reviewer's Comments: The first descriptions of the mitral valve as saddle-shaped completely changed our thinking about mitral valve disease and led to a new definition of mitral prolapse. This new research extends our knowledge of valve function by accounting for changes in annulus structure and motion. (Reviewer-Gregg S. Pressman, MD). © 2010, Oakstone Medical Publishing

Keywords: Mitral Annulus, Myxomatous, 3-Dimensional Echocardiography


Cycle, Treadmill Equally Useful in Cardiac Rehab

Prognostic Value of Cycle Exercise Testing Prior to and After Outpatient Cardiac Rehabilitation.

Di Valentino M, Maeder MT, et al:

Int J Cardiol 2010; 140 (April 1): 34-41

Symptom-limited cycle exercise testing provides useful parameters for cardiac rehabilitation and specific measurements, such as workload, are independent predictors of mortality.

Background: Determining peak oxygen consumption (VO2) prior to cardiac rehabilitation (CR) allows individualization of the training program and is the most important predictor of cardiac and all-cause mortality in coronary artery disease (CAD) patients. Prognostic value of maximal cycle exercise workload prior to CR and changes in cycle exercise capacity during and after CR are not well characterized. Objective: To assess the value of cycle exercise testing parameters in CR and their utility in prediction of cardiovascular and all-cause mortality. Design: Cohort study. Participants: 2146 CR patients (93% CAD, 86% percutaneous coronary intervention, 24% coronary artery bypass surgery, 15% valve surgery). Methods: All patients had symptom-limited upright cycle ergometer exercise tests at CR entry. Exercise capacity, chronotropic index (calculated as [peak heart rate (HR) - resting HR]/[max age-predicted HR - resting HR]*100), and increase in systolic blood pressure during exercise (ΔBPsys) were measured. CR consisted of endurance training on treadmills or bicycle ergometers at 60% to 80% of maximal HR achieved at the baseline exercise test. Of patients, 1853 (86%) had cycle exercise test at CR completion. Results: Exercise capacity increased in non-survivors and survivors. Peak HR, percent predicted HR achieved, chronotropic index, peak exercise SPB, and ΔBPsys increased only in survivors. Annual cardiovascular and all-cause mortality rates were 0.8% and 1.2%, respectively. Lower maximal workload was an independent predictor of all-cause and cardiovascular mortality at CR entry. Lower maximal workload at end of CR, and lower increase in peak HR from entry to end of CR were independent predictors of all-cause mortality. Lower ΔBPsys and lower increase in peak HR between entry and end of CR were independent predictors of cardiovascular mortality. No follow-up exercise test was an independent predictor of all-cause and cardiovascular mortality. Conclusions: Symptom-limited cycle exercise testing before and after CR affords vital predictive information. In particular, cycle ergometer workload before and after CR is a strong independent predictor of mortality. Reviewer's Comments: This large cohort study confirmed an excellent long-term outcome after CR. Maximal baseline bicycle workload was an independent predictor of cardiovascular and all-cause mortality, which is in agreement with previous studies of treadmill testing and peak VO2 measurements. These data support the widespread use of cycle ergometer testing in the setting of CR not only for training prescription but also for prognostic testing. Patients who did not undergo a test at the end of CR were sicker at baseline than those who did. Failure to have the second test might be a surrogate for more severe cardiac disease, suboptimal compliance, and/or depression. The favorable prognostic value of an increase in peak heart rate during CR is likely because it reflects a general training effect and absence of symptoms such as angina and dyspnea that limit the achievement of higher heart rates. (Reviewer-Debra L. Braverman, MD). © 2010, Oakstone Medical Publishing

Keywords: Cardiac Rehabilitation, Cycle Exercise Testing


Implanting Defibrillators in Advanced Heart Failure May Have Benefits

Is There Benefit in Implanting Defibrillators in Patients With Severe Heart Failure?

Salukhe TV, Briceno NI, et al:

Heart 2010; 96 (April): 599-603

Current trials do not show a tendency for relative risk reduction status-post defibrillator implantation to be smaller in patients with severe heart failure.

Background: Current practice guidelines recommend withholding implantable cardioverter defibrillators (ICD) from patients with severe heart failure. The belief is that these patients’ deaths are non-sudden in nature. The assumption then is that if severe heart failure patients did not benefit from ICD implantation, there should be a trend towards reduced preventability of deaths in the more severe heart failure subgroups within existing randomized control ICD trials. Objective: To test the hypothesis that severe heart failure patients’ deaths are not preventable by ICD. Methods: 6 trials were identified with an enrollment of 7873 patients, with 2734 patients randomly assigned to receive an ICD. All trials compared ICD therapy with either conventional or anti-arrhythmic drug therapy. Reduction in mortality in the ICD arm varied between 5.6% and 31%, with all trials showing a reduction or trend in reduction in mortality in patients receiving the ICD. All trials provided data separated into higher and lower ejection fraction subgroups, while 5 trials provided data separated into higher and lower New York Heart Association (NYHA) class patient subgroups. Results: In patients subcategorized by NYHA class, there was no significant difference in z-score (P =0.922) between patients with mild-to-moderate and severe heart failure. Also, in patients in the left ventricular ejection fraction (LVEF) group, there was no significant difference between z-scores (P =0.170). Therefore, both these observations suggest no attenuation of benefit of ICD implantation in patients with higher NYHA class or lower LVEF. Conclusions: Current randomized-trial populations do not show a tendency for the relative risk reduction status-post ICD implantation to be smaller in patients with severe heart failure. Further prospective studies are warranted. Reviewer's Comments: This is an important study which questions our assumptions. It is currently believed that patients with severe heart failure are more likely to die from progressive heart failure rather than from a sudden cardiac event secondary to a lethal cardiac arrhythmia. However, although a greater proportion of patients with NYHA class IV heart failure die from progression of heart failure, incidence of defibrillator-preventable arrhythmic death is at least as high as in those patients with less severe heart failure. Current guidelines recommend that ICD implantation is inappropriate in patients with NYHA class IV heart failure. There may be a potential bias in our assumptions, since patients with NYHA class IV heart failure who die are unlikely to be classified as sudden death unless a ventricular arrhythmia was monitored. This paper shows that in current landmark trial data there is no definite evidence to indicate that patients with severe heart failure would not benefit from placement of an ICD. (Reviewer-Suraj Maraj, MD). © 2010, Oakstone Medical Publishing

Keywords: Defibrillators, Implantation, Severe Heart Failure, Risk Reduction


Drink to Good Health!

Alcohol Consumption and Mortality in Patients With Cardiovascular Disease: A Meta-Analysis.

Costanzo S, Di Castelnuovo A, et al:


Drinking 5 to 10 g per day of alcohol reduces all-cause and cardiovascular mortality in those with cardiovascular disease.

Background: Light to moderate alcohol consumption has been shown to have favorable effects on cardiovascular mortality in healthy people. Data on whether patients with established cardiovascular disease will derive similar benefits is scarce. Objective: To assess effects of alcohol consumption on cardiovascular and total mortality. Design: Meta-analysis. Methods: Out of 54 studies identified by searching PubMed and EMBASE, 8 reporting primary outcomes for coronary artery disease, acute myocardial infarction, or stroke were identified. Secondary events included were cardiovascular or all-cause mortality. Two meta-analyses were conducted; one included 7 studies reporting cardiovascular mortality and another included 7 studies reporting all-cause mortality. Results: From 7 studies comprising 12, 819 patients looking at cardiovascular mortality, a ‘J' shaped relationship was observed between alcohol consumption and cardiovascular mortality. Maximum protective effect was seen with 5 to 10 g/day of alcohol consumption, with benefits seen up to 26 g/day, beyond which there was potential harm. Among 16,398 patients in 7 studies looking at all-cause mortality, a similar ‘J' shaped relationship was seen between alcohol consumption and all-cause mortality. Relative risk reduction for cardiovascular and all-cause mortality with 5-10 g/day of alcohol consumption was around 22%. Conclusions: Light to moderate alcohol consumption has beneficial effects in those with established cardiovascular disease. Reviewer's Comments: This meta-analysis provides reasonable evidence that the beneficial effects of light to moderate alcohol consumption seen in healthy subjects extend to those with established cardiovascular disease. This paper carries all the inherent limitations of a meta-analysis. None of the studies included were randomized trials; however, a randomized intervention trial on alcohol consumption will never be ethically possible. As practitioners, we can inform our patients that 1 drink per day for women and 2 drinks per day for men are not harmful to their health. However, as the authors point out, those who do not drink should not be encouraged to start drinking since data on controlled intervention trials with alcohol are lacking. (Reviewer-Anoop C. Parameswaran, MD). © 2010, Oakstone Medical Publishing

Keywords: Alcohol, Cardiovascular Disease, Meta-Analysis


Insurance Concerns, Finances Important to MI Patients Seeking Medical Help

Health Care Insurance, Financial Concerns in Accessing Care, and Delays to Hospital Presentation in Acute Myocardial

Infarction.

Smolderen KG, Spertus JA, et al:

JAMA 2010; 303 (April 14): 1392-1400

Financial concerns and lack of insurance play a significant role in the pre-hospital delay time among patients with acute myocardial infarction.

Background: There are not many studies that have looked at the relationship between patients’ health insurance status and financial concerns and their utilization of healthcare system in a timely fashion in emergency conditions. Objective: To examine the relationship of health insurance, finances, and healthcare utilization during acute myocardial infarction (AMI). Design: Prospective study. Participants: 3721 patients with AMI from 2005 to 2008 at 24 U.S. hospitals. Methods: Patients were included if they had elevated cardiac enzymes within 24 hours of admission and other evidence of AMI, including ischemic symptoms or ECG changes. Insurance status of the patients was evaluated using medical records and patient interview. They were divided into 3 broad categories of insured without financial concerns, insured with financial concerns, and uninsured. Primary outcome of this study was time to hospital presentation from onset of symptoms. Time periods were also divided into 3 categories of <2 hours, 2-6 hours, or >6 hours. Results: Of patients, 2294 had insurance without financial concerns (61.7%), 689 were insured with financial concerns (18.5%), and 738 had no insurance (19.8%). The insured group without financial concern had 39.3% pre-hospital delays >6 hours. That is compared to 44.6% and 48.6% of the insured with financial concerns and the uninsured, respectively. There were significant baseline differences among groups. The insured with financial concerns and the uninsured tend to be younger, non-white, single, and less educated. Even after adjusting for the baseline variables, the pre-hospital delay time among groups were significantly different. Conclusions: Financial concerns and lack of insurance play a significant role in the pre-hospital delay time among patients with AMI. Reviewer's Comments: There have been previous studies that looked at non-modifiable variables such as age, race, and sex and their role in pre-hospitalization delays. This study however points out an important modifiable variable in patients with a serious medical condition and their health care utilization. While there are many factors affecting the pre-hospitalization delay in individual patients, health insurance and financial concerns should not be a deciding factor for patients seeking medical care in a developed country such as the United States. Furthermore, this delayed presentation has detrimental effects in patient outcomes and therefore leads to longer hospital stay, more complications, and eventually higher costs. Of note also, one exclusion criterion in this study was death before arrival to the hospital. This may have underestimated the number of patients with financial difficulties who delayed their care too long. It will be interesting to have a parallel study in a country with free healthcare and compare their pre-hospital delay time, cost, and outcomes. (Reviewer-Behnam Bozorgnia, MD). © 2010, Oakstone Medical Publishing

Keywords: Health Care Insurance, Financial Concerns, Delays To Hospital Presentation, Acute Myocardial Infarction


Determining Best Treatment for Patients With Long QT Syndrome

Risk of Fatal Arrhythmic Events in Long QT Syndrome Patients After Syncope.

Jons C, Moss AJ, et al:

J Am Coll Cardiol 2010; 55 (February 23): 783-788

Some patients with long QT syndrome and syncope may not be adequately protected with beta blocker therapy alone and should be considered for a defibrillator.

Background: Long QT syndromes (LQTS) are channelopathies that increase the risk of sudden cardiac death (SCD). Syncope may be the initial presentation (annual incidence of 5%) and is the strongest predictor of future fatal events. Little data exist to further risk stratify patients within the syncope group in regards to the risk of future SCD. Objective: To determine characteristics of LQTS patients presenting with syncope that predispose them to a higher risk of future fatal events and to investigate the efficacy of beta-blockers (BB) in reducing the risk of serious arrhythmic events (SAE). Participants: 1059 patients from a LQTS registry with QTc >450 and documented syncope. Methods: A positive LQTS genotype was present in 445 patients. Use of BB was documented at baseline and during follow-up. Primary end point was any life-threatening cardiac event. In patients with implantable cardioverter defibrillators (ICDs; n=212), appropriate ICD shocks were included. Results: 849 patients were in the no SAE group and 210 in the SAE group. The SAE group used BB therapy less frequently; 210 SAEs were documented (39% in patients receiving BB therapy). The SAE group had a higher use of ICDs likely indicative of serious clinical presentations. Statistical analysis identified the occurrence of a syncopal episode on BB therapy as the most important risk factor for SAE (hazard ratio [HR] 3.6). Patients who started BB therapy after the initial syncopal episode with no further syncopal episodes had a relatively low risk. Conversely, patients experiencing further syncopal episodes despite BB therapy had a higher risk of SAE equaling the risk in patients who never started BB. BB use was found to be generally protective against SAE. In patients not taking BB, multiple syncopal episodes predicted a worse prognosis. Patients with severe QTc prolongation (ie >500ms) had a significant increase in the risk of SAE after syncope. The subgroup of female patients aged 14 to 40 years had almost twice the risk compared to males of the same age. A separate analysis in all patients on BB therapy indicated that the risk of SAE was similar in males and females aged <13 years. Thereafter, the risk decreases markedly in males but remains elevated in females. Conclusions: LQTS patients presenting with a first syncopal episode benefit from treatment with BB. Those with multiple syncopal episodes despite BB are at an increased risk of SAE and should be considered for ICD implantation. The risk of further syncopal episodes on BB decreases after puberty in males but not females. Reviewer's Comments: The issue of which LQTS patients require an ICD is very difficult for the treating physician. This study sheds some light on how to appropriately risk-stratify patients presenting with syncope despite medical therapy. (Reviewer-Khalid Almuti, MD). © 2010, Oakstone Medical Publishing

Keywords: Risk Assessment, Long QT Syndromes, Syncope


Breast Arterial Calcium on Mammogram -- Marker for CAD?

Usefulness of Breast Arterial Calcium Detected on Mammography for Predicting Coronary Artery Disease or

Cardiovascular Events in Women With Angina Pectoris and/or Positive Stress Tests.

Penugonda N, Billecke SS, et al:

Am J Cardiol 2010; 105 (February 1): 359-361

Breast arterial calcium as determined by mammography is not a useful predictor of coronary artery disease in intermediate to high risk patients

Background: Studies have been done to show a relation between breast arterial calcium (BAC) and coronary artery disease (CAD) using coronary artery calcium as a marker of CAD. However, results are conflicting. Objective: To examine the usefulness of BAC to predict CAD and cardiovascular (CV) events. Design: Retrospective chart review of 94 women undergoing mammography and cardiac catheterization within a 3-year period. Methods: Cardiac catheterization films and mammograms were independently reviewed for the presence of CAD and BAC respectively. Clinically significant CAD was defined as ≥50% stenosis of a major epicardial coronary artery. They further compared CV risk factors, history of revascularization, and history of myocardial infarction (MI) between women with and without BAC. Results: BAC was more prevalent in older women. There was an inverse correlation with current or previous smoking. There was no significant difference in the presence of CAD, or CV risk factors between patients with and without BAC. Also, patients with BAC had a lesser history of acute MI and were less likely to undergo revascularization. Presence of coronary calcium was no greater in patients with and without BAC. These results were statistically significant. Conclusions: BAC was not positively associated with CV risk factors, documented CAD, or acute CV events. Results further suggested that presence of BAC by mammography was not a useful predictor of CAD in intermediate to high risk patients. Reviewer's Comments: In my opinion, this was a well-conduced study. Some limitations include small numbers, retrospective study, and no long-term follow-up available. All women were referred for catheterization in the study and therefore were at intermediate to high risk for CAD. Also, the authors did not explore the use of BAC on screening mammogram as a predictor of CAD in asymptomatic patients. They mention that lack of a clear association in their study might stem from differences in the pathogenic nature of calcium deposition in breast versus coronary arteries. Coronary calcium is localized to the intimae and it contributes to arterial narrowing, compared to BAC that is uniformly located in the media and is considered a benign entity not associated with inflammation or plaque instability. Further, long-term studies with large numbers are needed to better elucidate the relationship between BAC and CAD. (Reviewer-Sahil Mehta, MD). © 2010, Oakstone Medical Publishing

Keywords: Coronary Artery Disease, Chest Pain, Mammogram, Breast Arterial Calcium


Cilostazol Enhances Antiplatelet Effect of Clopidogrel, Aspirin Post MI

Adding Cilostazol to Dual Antiplatelet Therapy Achieves Greater Platelet Inhibition Than High Maintenance Dose

Clopidogrel in Patients With Acute Myocardial Infarction: Results of the Adjunctive Cilostazol Versus High Maintenance

Dose Clopidogrel in Patients With AMI (ACCEL-AMI) Study.

Jeong Y-H, Hwang J-Y, et al:

Circ Cardiovasc Interv 2010; 3 (February): 17-26

Cilostazol added to standard dual-antiplatelet therapy with clopidogrel is more effective in inhibiting platelets than doubling the clopidogrel dose.

Background: After percutaneous coronary intervention (PCI) with stenting, dual antiplatelet therapy with clopidogrel is indicated to reduce the risk of ischemic events, especially stent thrombosis. This is of particular importance in post-myocardial infarction (MI) patients because they are at increased risk for future events. Tests for high residual platelet reactivity while on dual antiplatelet therapy have identified an even higher risk group among patients post-MI. An intensified antiplatelet regimen with either high clopidogrel maintenance dose (150 mg) or prasugrel has been suggested as potential therapy for such high-risk patients. A prior study of stable patients in which cilostazol was added to standard dual antiplatelet therapy after stenting showed a significant decrease in platelet reactivity by light transmission aggregometry (LTA). Whether this “triple therapy” is effective in reducing platelet reactivity among post-MI patients is not known. Objective: To compare the effects of triple therapy with cilostazol to high clopidogrel maintenance dose therapy and standard dual antiplatelet therapy in patients post-acute MI treated with coronary stenting. Design: Prospective randomized trial with three arms. Participants: 90 post-acute MI patients. Methods: Patients were treated with standard loading and maintenance doses of clopidogrel and aspirin and then underwent coronary stenting. Predischarge platelet aggregation was assessed by LTA, after which patients were randomized. Platelet aggregation was reassessed at 30 days as were ischemic and bleeding events. Primary end point was the difference in maximal platelet aggregation by LTA predischarge and at 30 days. Results/Conclusions: Patients were randomized to 1 of 3 treatment arms. Predischarge, there were no significant differences in platelet aggregation between groups. At 30 days, triple therapy with cilostazol significantly lowered maximal platelet aggregation compared to the standard and high clopidogrel maintenance dose groups. There were no significant differences in ischemic events or major bleeding at 30 days. Reviewer's Comments: Triple therapy with standard dose clopidogrel, aspirin, and cilostazol was significantly more effective in inhibiting platelets post-PCI for acute MI compared to dual antiplatelet therapy with high maintenance dose clopidogrel (150mg daily). Though this is a small study with limited clinical follow-up, it is hypothesis generating. Large-scale studies are needed to determine whether increased platelet inhibition assessed in this manner results in improved clinical outcomes. Finding a balance between risk for ischemic events and bleeding will be important. (Reviewer-Parul B. Patel, MD). © 2010, Oakstone Medical Publishing

Keywords: Platelet Reactivity Testing, Coronary Stenting, Cilostazol


Endovascular Not Best Repair Option for Abdominal Aneurysm Patients

Endovascular Repair of Aortic Aneurysm in Patients Physically Ineligible for Open Repair.

The United Kingdom EVAR Trial Investigators:

N Engl J Med 2010; April 30 (): epub ahead of print

Endovascular repair of abdominal aortic aneurysm does not offer long-term mortality benefit and is more expensive in patients ineligible for surgical repair.

Background: Abdominal aortic aneurysm (AAA) is increasing in prevalence especially in older men. Endovascular aneurysm repair was initially developed for patients with AAA who are not candidates for open surgical repair. There are no large randomized trials with long-term follow-up evaluating endovascular repair versus no repair in these patients. Objective: To assess outcomes of patients undergoing endovascular repair because they were physically ineligible for open surgical repair. Design: Randomized trial. Participants: 404 patients recruited from 1999 to 2004. Methods: Patients aged ≥60 years with an AAA ≥5.5cm by CT were screened for clinical and anatomic criteria for surgical as well as endovascular repair. Patients not eligible for surgical repair were randomized to the EndoVascular Repair 2 (EVAR 2) trial (endovascular repair versus no repair). Patients were followed up with a CT scan in 1 month, 3 months, and annually thereafter. Primary outcome was all-cause mortality. Aneurysm-related death, graft complications, and graft related re-interventions were also assessed. Results: 197 patients were randomized to the endovascular repair group and 207 patients to the no-repair group. Both groups were well matched at baseline. Mean age was 77 years and 86% were men. Mean AAA size was 6.7cm. Median follow-up until death or the end of study was 3.1 years. Of patients, 179(90%) in the endovascular group underwent endovascular repair, 70(33%) in the no-repair group underwent aneurysm repair during follow-up, for worsening symptoms or aneurysm size. The 30-day mortality was 7.3% in the endovascular group. Aneurysm-related deaths were more in the endovascular repair group in the first 6 months which was counter balanced by a decrease in these deaths in long-term follow-up. Total mortality did not differ significantly (21.0 deaths/100 person years versus 22.1 deaths/100 person years in the endovascular and no-repair group, respectively). Almost half of patients that survived repair had graft-related complications and approximately one third had re-interventions during follow up. Endovascular repair was more expensive ($14,867) than no repair during follow up. Conclusions: Even though aneurysm-related mortality was lower in the repair group, this did not translate to improvements in total mortality as compared to no repair. Moreover, in the long term, endovascular repair was considerably more expensive than no repair and a significant number of these patients had graft-related complications and re-interventions. Reviewer's Comments: AAA patients who are ineligible for open surgical repair have few options for treatment. Endovascular repair in this group of patients does not show long-term mortality benefit, has more complications, and is more expensive. Close follow up of patients with repair when necessary may be a better choice. (Reviewer-Pradeep S. Arumugham, MD). © 2010, Oakstone Medical Publishing

Keywords: Abdominal Aortic Aneurysm, Endovascular Repair, Open Surgical Repair


high intensity interval exercise for coronary heart disease patients… may 30... · 2010-11-12 ·...

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