Long-term use of dual antiplatelet therapy for the secondary prevention of atherothrombotic events: Meta-analysis of randomized controlled trials.

BACKGROUND: The potential benefit of long-term dual antiplatelet therapy (DAPT) for secondary prevention of atherothrombotic events is unclear. Data from different randomized controlled trials (RCT) using different agents in different subgroups showed inconsistent results. METHODS: We performed a systematic review and meta-analysis from RCTs that tested different prolonged durations of DAPT for secondary prevention. Long term DAPT arm was defined as those receiving DAPT for more than 12months. Long-term aspirin arm was defined as those receiving either aspirin alone long term or DAPT for less than 12months. RESULTS: The use of long term DAPT was associated with a significant decrease in composite of death, myocardial infarction (MI) and stroke (6.08% vs. 6.71%; odds ratio OR=0.86 [0.78-0.94]; P=0.001). This reduction of death, MI and stroke was mainly noticed in patients with prior MI or stroke, but not with PAD or multiple risk factors. The reduction was seen with post PCI patients with prasugrel and only in those with prior MI with clopidogrel and ticagrelor. Long-term use of DAPT was associated with significant increase in major bleeding (1.47% vs. 0.88%; OR=1.65 [1.23-2.21]; P=0.001). CONCLUSION: Long-term use of DAPT for secondary prevention is associated with lower risk of death, MI and stroke beneficial especially in patients with prior MI and stroke, but it is associated with increased risk of bleeding. Prolonging DAPT requires careful assessment of the trade-off between ischemic and bleeding complications and should probably be reserved for patients with higher risk for atherothrombotic events.

Comparison of percutaneous coronary intervention with drug eluting stents versus coronary artery bypass grafting in patients with multivessel coronary artery disease: Meta-analysis of six randomized controlled trials.

OBJECTIVE: To compare outcomes of percutaneous coronary intervention (PCI) with drug eluting stent (DES) and Coronary Artery Bypass Grafting (CABG) in patients with multivessel Coronary Artery Disease (CAD) using data from randomized controlled trials (RCT). BACKGROUND: PCI and CABG are established strategies for coronary revascularization in the setting of ischemic heart disease. Multiple RCTs have compared outcomes of the two modalities in patients with multivessel CAD. METHODS: We did a meta-analysis from six RCTs in the contemporary era comparing the effectiveness of PCI with DES to at 1 year, 2 years and 5 years respectively. RESULTS: Compared to CABG, at one year PCI was associated with a significantly higher incidence of TVR (RR=2.31; 95% CI: [1.80-2.96]; P=<0.0001), lower incidence of stroke (RR=0.35; 95% CI: [0.19-0.62]; P=0.0003), and no difference in death (RR=1.02; 95% CI: [0.77-1.36]; P=0.88) or MI (RR=1.16; 95% CI: [0.72-1.88]; P=0.53). At 5 years, PCI was associated with a higher incidence of death (RR=1.3; 95% CI: [1.10-1.54]; P=0.0026) and MI (RR=2.21; 95% CI: [1.75-2.79]; P=<0.0001). While the higher incidence of MI with PCI was noticed in both diabetic and non-diabetics, death was increased mainly in diabetic patients. CONCLUSION: In patients with multi-vessel CAD, PCI with DES is associated with no significant difference in death or MI at 1 or 2 years. However at 5 years, PCI is associated with higher incidence of death and MI.

Aortocoronary Saphenous Vein Graft Aneurysm with Fistula to the Right Atrium: Percutaneous Management of Surgical Complication.

Aneurysmal dilatation of aortocoronary saphenous vein grafts (SVG) is a rare but known complication after coronary artery bypass grafting (CABG). They are most commonly found incidentally, although some may present with unstable angina or myocardial infarction (MI). Rarely, these aneurysms can develop into fistulas to the neighboring cardiac chambers. We report the case of a 66-year old woman with a history of CABG in 1996 with a left internal mammary artery (LIMA) graft to the left anterior descending and a SVG to distal right coronary artery presenting with non-ST segment elevation myocardial infarction (NSTEMI) complicated with congestive heart failure. Selective Coronary and Graft angiography showed an aneurysm in the mid SVG with a fistula into the right atrium (RA) resulting in a significant left to right shunt. The significant left to right shunt diverted blood flow from right coronary artery territory resulting in recurrent ischemia and angina and introduced a significant volume overload on the right ventricle resulting in over heart failure. Secondary to the course of LIMA graft along the sternum, surgery was not an option. Secondary to continued symptoms percutaneous intervention was performed with placement of two 6.0 x 50 mm Viabahn self-expanding covered stent with aggressive post-dilation resulting in successful closure with no residual flow. Percutaneous intervention is shown to be an effective approach to manage both aortocoronary fistula and grafts ruptures and is associated with better outcomes than surgical and conservative options. To the best of our knowledge, this is the first reported case of a successful closure of fistulous communication of a SVG aneurysm to the RA utilizing multiple peripheral covered stents.

Short, Intermediate and long term outcomes of CABG vs. PCI with DES in Patients With Multivessel Coronary Artery Disease. Meta-Analysis of Six Randomized Controlled Trials.

OBJECTIVE: Comparing outcomes of percutaneous coronary intervention (PCI) with drug eluting stent (DES) and Coronary Artery Bypass Grafting (CABG) in patients with multivessel Coronary Artery Disease (CAD) using data from randomized controlled trials (RCT). BACKGROUND: PCI and CABG are established strategies for coronary revascularization in the setting of ischemic heart disease. Multiple RCT have compared outcomes of the two modalities in patients with multivessel CAD. METHODS: We did a meta-analysis from six RCT in the contemporary era comparing the effectiveness of PCI with DES to at 1 year, 2 years and 5 years respectively. RESULTS: Compared to CABG, at one year PCI was associated with a significantly higher incidence of TVR (RR= 2.31; 95% CI: [1.80 - 2.96]; P=<0.0001), lower incidence of stroke (RR= 0.35; 95% CI: [0.19 - 0.62]; P=0.0003), and no difference in death (RR= 1.02; 95% CI: [0.77 - 1.36]; P= 0.88) or MI (RR= 1.16; 95% CI: [0.72 - 1.88]; P= 0.53). At 5 years, PCI was associated with a higher incidence of death (RR= 1.3; 95% CI: [1.10 - 1.54]; P= 0.0026) and MI (RR= 2.21; 95% CI: [1.75 - 2.79]; P=<0.0001). While the higher incidence of MI with PCI was noticed in both diabetic and non-diabetics, death was increased mainly in diabetic patients. CONCLUSION: In patients with multi-vessel CAD, PCI with DES is associated with no significant difference in death or MI at 1 or 2 years. However at 5 years, PCI is associated with higher incidence of death and MI.

Meta-analysis of three randomized controlled trials comparing coronary artery bypass grafting with percutaneous coronary intervention using drug-eluting stenting in patients with diabetes.

OBJECTIVES: Coronary artery bypass grafting (CABG) was found to be the preferred strategy of revascularization in patients with diabetes in the bare-metal stent (BMS) era. The introduction of drug-eluting stents (DESs) led to a significant reduction in the rates of repeat revascularization (RRV) when compared with BMSs. We did a collaborative analysis of data from randomized controlled trials in the contemporary era to compare CABG versus percutaneous coronary intervention using DESs in diabetic patients. METHODS: We performed a systematic review and meta-analysis from randomized trials in the contemporary era comparing PCI with DESs with CABG in diabetic patients with multivessel disease. A comprehensive literature search (1 January 2003 to 18 May 2013) identified randomized controlled trials that reported long-term outcomes comparing PCI using DESs with CABG in 2974 diabetic patients. RESULTS: At 1 year, PCI was associated with a significant increase in the incidence of RRV [2.48 (1.56-3.94); P ≤0.0001], lower incidence of stroke [relative risk (RR) = 0.43 (0.19-0.81); P = 0.017], and no difference in death or myocardial infarction (MI). At 5 years, PCI was still associated with a lower incidence of stroke, but was associated with a significant increase in the incidence of death [RR = 1.36 (1.11-1.66); P = 0.0033] and MI [RR = 2.01 (1.54-2.62); P ≤0.0001]. CONCLUSIONS: In patients with diabetes, PCI was associated with no difference in death and MI at 1 year. However, at 5 years, PCI was associated with a higher incidence of death and MI. PCI was associated with a higher incidence of RRV but a lower incidence of stroke.

Cost-effectiveness Assessment of Cardiac Interventions: Determining a Socially Acceptable Cost Threshold.

Health care is a vital good for which there is an infinite demand. However, societal resources are finite and need to be distributed efficiently to avoid waste. Thus, the relative value of an intervention - cost compared to its effectiveness- needs to be taken into consideration when deciding which interventions to adopt. Cost-effectiveness analysis provides the crucial information which guides these decisions. As the field of medicine and indeed cardiology move forward with innovations which are effective but often expensive, it becomes imperative to employ these cost-effectiveness analytic tools, not with the intention of denying vital health services but to ascertain what the society willing to pay for.

Antiplatelet therapy in patients undergoing percutaneous coronary intervention: economic considerations.

Percutaneous coronary intervention (PCI) is one of the most common medical procedures performed for treatment of coronary artery disease. Antiplatelet medications as adjunctive therapy for PCI are used routinely, with indications for specific agents or their combinations varying depending on the clinical scenario. While the cost-effectiveness of well-established agents has been extensively studied, newer drugs have not been evaluated as thoroughly. In addition, the clinical application of some antiplatelet drugs has recently changed, thus making older studies of cost effectiveness less applicable to the current landscape of clinical practice. This article reviews cost-effectiveness considerations of antiplatelet therapies in the treatment of coronary artery disease in patients undergoing PCI. Aspirin, P2Y12 inhibitors including clopidogrel and the newer agents prasugrel and ticagrelor, as well as glycoprotein (GP) IIb/IIIa inhibitors, are discussed. Overall, the use of dual antiplatelet therapy with aspirin and a P2Y12 inhibitor in patients undergoing PCI improves ischaemic outcomes and appears to be cost effective. The few available studies suggest that the recently approved medications prasugrel and ticagrelor are cost-effective alternatives to clopidogrel. However, no direct comparison between these two newer agents is available. The indications for GP IIb/IIIa inhibitors have changed in the current PCI era, and there is a paucity of cost-effectiveness data for their use in contemporary care.

Dramatic improvement in hypoxemic respiratory failure after patent foramen ovale closure in a patient with obesity hypoventilation syndrome.

We report a case of a patient with pulmonary hypertension who presented with acute hypoxemic respiratory failure. The patient had continued refractory hypoxemia despite a prolonged ICU admission that included ventilatory support, and empiric therapy for pulmonary embolism and pneumonia. Transthoracic echocardiography (TTE) revealed a patent foramen ovale (PFO), which after percutaneous closure resulted in profound improvement in hypoxemia and clinical status.

Practical considerations of percutaneous ventricular assist devices.

Percutaneous ventricular assist devices are increasingly used today, allowing the scope of left ventricular support to move out of the operating room and into the interventional suite and cardiovascular care unit. This has given patients requiring short-term therapy an opportunity to undergo high-risk procedures and provide a failing left ventricular support until native recovery can occur. A growing body of evidence exists that demonstrates device efficacy and safety, as well as its potential clinical importance, a topic that will be reviewed here. Additionally, many providers seek a resource for technical considerations and troubleshooting. We also aim to provide insight into such considerations.

Postoperative pericardial calcification causing diastolic coronary compression.

Diastolic compression of the coronary arteries is a rare and likely acquired finding. Previous reports hypothesized that the artery becomes compressed against epicardial and pericardial scarring during ventricular filling, which leads to reduced coronary blood flow and clinical ischemia. We present two cases of isolated diastolic coronary artery compression resulting from contact against postoperative pericardial reflections that became calcified during the course of 10 to 20 years.

Exercise blood pressure and future cardiovascular death in asymptomatic individuals.

BACKGROUND: Individuals with exaggerated exercise blood pressure (BP) tend to develop future hypertension. It is controversial whether they have higher risk of death from cardiovascular disease (CVD). METHODS AND RESULTS: A total of 6578 asymptomatic Lipid Research Clinics Prevalence Study participants (45% women; mean age, 46 years; 74% with untreated baseline BP <140/90 mm Hg [nonhypertensive]) performing submaximal Bruce treadmill tests were followed for 20 years (385 CVD deaths occurred). Systolic and diastolic BP at rest, Bruce stage 2, and maximal BP during exercise were significantly associated with CVD death. When we compared multivariate hazard ratios and 95% confidence intervals per 10/5-mm Hg BP increments, the association was strongest for rest BP (systolic, 1.21 [1.14 to 1.27]; diastolic, 1.20 [1.14 to 1.26]), then Bruce stage 2 BP (systolic, 1.09 [1.04 to 1.14]; diastolic, 1.09 [1.05 to 1.13]), then maximal exercise BP (systolic, 1.06 [1.01 to 1.10]; diastolic, 1.04 [1.01 to 1.08]). Overall, exercise BP was not significant after adjustment for rest BP. However, hypertension status modified the risk associated with exercise BP (P(interaction)=0.03). Among nonhypertensives, whether they had normal BP (<120/80 mm Hg) or prehypertension, Bruce stage 2 BP >180/90 versus < or =180/90 mm Hg carried increased risk independent of rest BP and risk factors (adjusted hazard ratio for systolic, 1.96 [1.40 to 2.74], P<0.001; diastolic, 1.48 [1.06 to 2.06], P=0.02) and added predictive value (net reclassification improvement, systolic, 12.0% [-0.1% to 24.2%]; diastolic, 9.9% [-0.3% to 20.0%]; relative integrated discrimination improvement, 14.3% and 12.0%, respectively). CONCLUSIONS: In asymptomatic individuals, elevated exercise BP carried higher risk of CVD death but became nonsignificant after accounting for rest BP. However, Bruce stage 2 BP >180/90 mm Hg identified nonhypertensive individuals at higher risk of CVD death.