Meta-analysis of death and myocardial infarction in the DEFINE-FLAIR and iFR-SWEDEHEART trials: a hypothesis generating note of caution

In patients with coronary heart disease, revascularization can improve symptoms and in certain high-risk subgroups may improve prognosis. Coronary angiography provides anatomical information and the physiological significance of a stenosis can be determined using fractional flow reserve (FFR). Decisions on the need for and mode of revascularization can be optimized using FFR, however this involves administering adenosine to induce hyperemia. Generally, this test is well tolerated, but in some healthcare systems adenosine is either not licensed, unavailable, or expensive, limiting the use of FFR-guided management

Safety of the Deferral of Coronary Revascularization on the Basis of Instantaneous Wave-Free Ratio and Fractional Flow Reserve Measurements in Stable Coronary Artery Disease and Acute Coronary Syndromes.

OBJECTIVES: The aim of this study was to investigate the clinical outcomes of patients deferred from coronary revascularization on the basis of instantaneous wave-free ratio (iFR) or fractional flow reserve (FFR) measurements in stable angina pectoris (SAP) and acute coronary syndromes (ACS). BACKGROUND: Assessment of coronary stenosis severity with pressure guidewires is recommended to determine the need for myocardial revascularization. METHODS: The safety of deferral of coronary revascularization in the pooled per-protocol population (n = 4,486) of the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) and iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome) randomized clinical trials was investigated. Patients were stratified according to revascularization decision making on the basis of iFR or FFR and to clinical presentation (SAP or ACS). The primary endpoint was major adverse cardiac events (MACE), defined as the composite of all-cause death, nonfatal myocardial infarction, or unplanned revascularization at 1 year. RESULTS: Coronary revascularization was deferred in 2,130 patients. Deferral was performed in 1,117 patients (50%) in the iFR group and 1,013 patients (45%) in the FFR group (p < 0.01). At 1 year, the MACE rate in the deferred population was similar between the iFR and FFR groups (4.12% vs. 4.05%; fully adjusted hazard ratio: 1.13; 95% confidence interval: 0.72 to 1.79; p = 0.60). A clinical presentation with ACS was associated with a higher MACE rate compared with SAP in deferred patients (5.91% vs. 3.64% in ACS and SAP, respectively; fully adjusted hazard ratio: 0.61 in favor of SAP; 95% confidence interval: 0.38 to 0.99; p = 0.04). CONCLUSIONS: Overall, deferral of revascularization is equally safe with both iFR and FFR, with a low MACE rate of about 4%. Lesions were more frequently deferred when iFR was used to assess physiological significance. In deferred patients presenting with ACS, the event rate was significantly increased compared with SAP at 1 year.info:eu-repo/semantics/publishedVersio

Thrombus aspiration during ST-segment elevation myocardial infarction.

To access publisher's full text version of this article. Please click on the hyperlink in Additional Links field.The clinical effect of routine intracoronary thrombus aspiration before primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) is uncertain. We aimed to evaluate whether thrombus aspiration reduces mortality.We conducted a multicenter, prospective, randomized, controlled, open-label clinical trial, with enrollment of patients from the national comprehensive Swedish Coronary Angiography and Angioplasty Registry (SCAAR) and end points evaluated through national registries. A total of 7244 patients with STEMI undergoing PCI were randomly assigned to manual thrombus aspiration followed by PCI or to PCI only. The primary end point was all-cause mortality at 30 days.No patients were lost to follow-up. Death from any cause occurred in 2.8% of the patients in the thrombus-aspiration group (103 of 3621), as compared with 3.0% in the PCI-only group (110 of 3623) (hazard ratio, 0.94; 95% confidence interval [CI], 0.72 to 1.22; P=0.63). The rates of hospitalization for recurrent myocardial infarction at 30 days were 0.5% and 0.9% in the two groups, respectively (hazard ratio, 0.61; 95% CI, 0.34 to 1.07; P=0.09), and the rates of stent thrombosis were 0.2% and 0.5%, respectively (hazard ratio, 0.47; 95% CI, 0.20 to 1.02; P=0.06). There were no significant differences between the groups with respect to the rate of stroke or neurologic complications at the time of discharge (P=0.87). The results were consistent across all major prespecified subgroups, including subgroups defined according to thrombus burden and coronary flow before PCI.Routine thrombus aspiration before PCI as compared with PCI alone did not reduce 30-day mortality among patients with STEMI. (Funded by the Swedish Research Council and others; ClinicalTrials.gov number, NCT01093404.).Swedish Research Council, Swedish Association of Local Authorities and Regions, Terumo Medical Corporation, Medtronic, Vascular Solutions, Swedish Heart-Lung Foundation/20100178/ B0010401 Biotronik, Stentys, Abbott Vascular, St. Jude Medical, Boston Scientific, EPS Vascular, Cardiac Dimensions, AstraZeneca, Edwards Lifesciences

A pressão coronária (às vezes) mente. . .

Comment on: Comparative analysis of fractional flow reserve and instantaneous wave-free ratio: Results of a five-year registry. [Rev Port Cardiol. 2018]info:eu-repo/semantics/publishedVersio

Clinical decision support system (CDSS) – effects on care quality

Purpose – Despite their efficacy, some recommended therapies are underused. The purpose of this paper is to describe clinical decision support system (CDSS) development and its impact on clinical guideline adherence. Design/methodology/approach - A new CDSS was developed and introduced in a cardiac intensive care unit (CICU) in 2003, which provided physicians with patient-tailored reminders and permitted data export from electronic patient records into a national quality registry. To evaluate CDSS effects in the CICU, process indicators were compared to a control group using registry data. All CICUs were in the same region and only patients with acute coronary syndrome were included. Findings – CDSS introduction was associated with increases in guideline adherence, which ranged from 16 to 35 per cent, depending on the therapy. Statistically significant associations between guideline adherence and CDSS use remained over the five-year period after its introduction. During the same period, no relapses occurred in the intervention CICU. Practical implications – Guideline adherence and healthcare quality can be enhanced using CDSS. This study suggests that practitioners should turn to CDSS to improve healthcare quality. Originality/value – This paper describes and evaluates an intervention that successfully increased guideline adherence, which improved healthcare quality when the intervention CICU was compared to the control group

Systematic review and meta-analysis of optimal P2Y₁₂ blockade in dual antiplatelet therapy for patients with diabetes with acute coronary syndrome

Background: Patients with diabetes are at increased risk of acute coronary syndromes (ACS) and their mortality and morbidity outcomes are significantly worse following ACS events, independent of other comorbidities. This systematic review sought to establish the optimum management strategy with focus on P2Y₁₂ blockade in patients with diabetes with ACS. Methods: MEDLINE (1946 to present) and EMBASE (1974 to present) databases, abstracts from major cardiology conferences and previously published systematic reviews were searched to June 2014. Relevant randomised control trials with clinical outcomes for P2Y₁₂ inhibitors in adult patients with diabetes with ACS were scrutinised independently by 2 authors with applicable data was extracted for primary composite end point of cardiovascular death, myocardial infarction (MI) and stroke; enabling calculation of relative risks with 95% CI with subsequent direct and indirect comparison. Results: Four studies studied clopidogrel in patients with diabetes, with two (3122 patients) having primary outcome data showing superiority of clopidogrel against placebo with RR0.84 (95% CI 0.72–0.99). Irrespective of management strategy, the newer agents prasugrel (2 studies) and ticagrelor (1 study) had a lower primary event rate compared with clopidogrel; RR 0.80 (95% CI 0.66 to 0.97) and RR 0.89 (95% CI 0.77 to 1.02), respectively. When ticagrelor was indirectly compared with prasugrel, there was a trend to an improved primary outcome with prasugrel (RR 1.11 (95% CI 0.94 to 1.31)) particularly in those managed with percutaneous coronary intervention (PCI) (RR 1.23 (95% CI 0.95 to 1.59)). Prasugrel demonstrated a statistical superiority with prevention of further MI with RR 1.48 (95% CI 1.11 to 1.97). This was not at the expense of increased major thrombolysis in MI (TIMI) bleeding rates RR 0.94 (95% CI 0.59 to 1.51). Conclusions: This meta-analysis shows the addition of a P2Y₁₂ inhibitor is superior to placebo, with a trend favouring the use of prasugrel in patients with diabetes with ACS, particularly those undergoing PCI

Patient well-being undergoing coronary angiography and percutaneous coronary intervention

Bakgrund: Kranskärlssjukdom uppträder vid förträngning i hjärtats koronarartärer orsakat av ateroskleros. Koronarangiografi och perkutan koronarintervention (PCI) är en angiografi respektive intervention av hjärtats koronarartärer. Med hjälp av Seldingertekniken har PCI kommit att idag vara den primära behandlingsmetoden i samband med akut hjärtinfarkt. Koronarangiografi har ett stort diagnostiskt värde i tidigt stadie av kranskärlssjukdom. För att kunna bemöta patienten och främja en god vård i samband med en koronarangiografi och/eller PCI förutsätts att vårdgivaren har kunskap kring vad som påverkar patientens välbefinnande under undersökningen och behandlingen. Syfte: Syftet är att identifiera faktorer som påverkar patientens grad av välbefinnande i samband med koronarangiografi samt PCI. Metod: En beskrivande litteraturöversikt baserad på elva vetenskapliga artiklar med kvantitativ- respektive kvalitativ ansats som kvalitetsgranskats utifrån Friberg (2012) samt Willman, Stoltz & Bathsevani (2011). Resultat: Analys av likheter i resultatinnehåll resulterade i fem teman som samtliga är faktorer som påverkar patientens välbefinnande i samband med koronarangiografi och PCI; upplevelsen av smärta, upplevelsen av oro och rädsla, känslan av trygghet, känslan av delaktighet och känslan av hopp. Resultatet visar att majoriteten av patienter som genomgår en koronarangiografi och/eller PCI upplever smärta samt oro och rädsla i samband med angiografin/interventionen. En stor andel patienter upplevde röntgensjuksköterskans närvaro bidragande till en känsla av trygghet. I resultatet framkommer även att olika grader av delaktighet och hopp påverkar välbefinnandet hos patienten i samband med angiografin och interventionen. Slutsats: Känslan av trygghet, delaktighet och hopp kan främjas av röntgensjuksköterskan genom adekvat information, bevarande av patientens integritet samt genom att skapa en god relation med patienten. Smärta, oro och rädsla kan lindras av röntgensjuksköterskan genom att bejaka patientens komfort i interventionssalen samt uppmärksamma och identifiera rädslor hos patienten. Mötet i det akuta skedet mellan röntgensjuksköterskan och patienten kan bidra till att dessa faktorer inte främjas och lindras till fullo. Patienten intar en passiv roll och kan uppleva sin delaktighet begränsad av tidsbrist och otillräcklig information