Almanac 2013: acute coronary syndromes

Nestabilni plak u koronarnim arterijama je najčešći uzrok akutnog koronarnog sindroma (AKS) koji se može manifestirati kao nestabilna angina, infarkt miokarda bez elevacije ST-segmenta i infarkt miokarda s elevacijom ST-segmenta (STEMI), ali se također može manifestirati i kao iznenadni srčani zastoj zbog ishemijom izazvane tahiaritmije. Smrtnost AKS je značajno smanjena u posljednjih nekoliko godina, posebice od njegovih najtežih manifestacija, STEMI i srčanog zastoja. Ovaj trend će se najvjerojatnije nastaviti zbog terapijskog napretka novijeg datuma koji uključuje i nove antitrombocitne lijekove kao što prasugrel, tikagrelor i kangrelor.Unstable coronary artery plaque is the most common underlying cause of acute coronary syndromes (ACS) and can manifest as unstable angina, non-ST segment elevation infarction, and ST elevation myocardial infarction (STEMI), but can also manifest as sudden cardiac arrest due to ischaemia induced tachyarrhythmias. ACS mortality has decreased significantly over the last few years, especially from the more extreme manifestations of ACS, STEMI, and cardiac arrest. This trend is likely to continue based on recent therapeutic progress which includes novel antiplatelet agents such as prasugrel, ticagrelor, and cangrelor

Almanac 2013: novel non-coronary cardiac interventions

Aktualne inovacije u intervencijskoj kardiologiji dramatično su proširile terapijske mogućnosti za srčane bolesnike. Intervencijska kardiologija više nije ograničena na liječenje koronarne bolesti srca već je moguće liječiti bolesti zalistaka, raditi na prevenciji moždanog udara, liječenju arterijske hipertenzije, itd. Jedna od najvažnijih novih mogućnosti liječenja je perkutano liječenje aortne stenoze (transkateterska implantacija aortne valvule), budući da je bolest aortne valvule vrlo čest problem u bolesnika starije životne dobi, a mnogi od njih imaju visok rizik od operacije. Isto tako, mitralna regurgitacija je često povezana s pojavom komorbiditeta koji čine operaciju visokorizičnom. MitraClip je obećavajuće perkutano alternativno rješenje za kirurški popravak ili zamjenu srčanog zaliska. Ostali postupci koji se spominju u ovom preglednom članku su perkutano zatvaranje aurikule lijevog atrija kao nefarmakološka terapija za prevenciju moždanog udara, renalna denervacija za rezistentnu arterijsku hipertenziju. U ovom se članku pojašnjavaju osnovni principi ovih postupaka, najvažnije kliničke studije uz dodatne kliničke podatke o svakom od njih.Recent innovations in interventional cardiology have dramatically expanded the therapeutic options for patients with cardiac conditions. Interventional cardiology is no longer limited to the treatment of coronary artery disease but allows also treatment of valvular disease, stroke prevention, hypertension, etc. One of the most important new treatment options is the percutaneous treatment for aortic valve stenosis (transcatheter aortic valve implantation), since aortic valve disease is a rather common problem in elderly patients, with many of them at high risk for surgery. Similarly, mitral regurgitation is often associated with comorbidities which make surgery high risk. The MitraClip is a promising percutaneous alternative to surgical valve repair or replacement. Other procedures discussed in this review are the percutaneous left atrial appendage closure as a nonpharmacologic therapy to prevent strokes, and renal denervation for resistant hypertension. This review explains the basic principles of these procedures, the most important clinical evidence, and also provides additional recent clinical data on each of these them

Almanac 2013: novel non-coronary cardiac interventions

Aktualne inovacije u intervencijskoj kardiologiji dramatično su proširile terapijske mogućnosti za srčane bolesnike. Intervencijska kardiologija više nije ograničena na liječenje koronarne bolesti srca već je moguće liječiti bolesti zalistaka, raditi na prevenciji moždanog udara, liječenju arterijske hipertenzije, itd. Jedna od najvažnijih novih mogućnosti liječenja je perkutano liječenje aortne stenoze (transkateterska implantacija aortne valvule), budući da je bolest aortne valvule vrlo čest problem u bolesnika starije životne dobi, a mnogi od njih imaju visok rizik od operacije. Isto tako, mitralna regurgitacija je često povezana s pojavom komorbiditeta koji čine operaciju visokorizičnom. MitraClip je obećavajuće perkutano alternativno rješenje za kirurški popravak ili zamjenu srčanog zaliska. Ostali postupci koji se spominju u ovom preglednom članku su perkutano zatvaranje aurikule lijevog atrija kao nefarmakološka terapija za prevenciju moždanog udara, renalna denervacija za rezistentnu arterijsku hipertenziju. U ovom se članku pojašnjavaju osnovni principi ovih postupaka, najvažnije kliničke studije uz dodatne kliničke podatke o svakom od njih.Recent innovations in interventional cardiology have dramatically expanded the therapeutic options for patients with cardiac conditions. Interventional cardiology is no longer limited to the treatment of coronary artery disease but allows also treatment of valvular disease, stroke prevention, hypertension, etc. One of the most important new treatment options is the percutaneous treatment for aortic valve stenosis (transcatheter aortic valve implantation), since aortic valve disease is a rather common problem in elderly patients, with many of them at high risk for surgery. Similarly, mitral regurgitation is often associated with comorbidities which make surgery high risk. The MitraClip is a promising percutaneous alternative to surgical valve repair or replacement. Other procedures discussed in this review are the percutaneous left atrial appendage closure as a nonpharmacologic therapy to prevent strokes, and renal denervation for resistant hypertension. This review explains the basic principles of these procedures, the most important clinical evidence, and also provides additional recent clinical data on each of these them

Almanac 2013: acute coronary syndromes

Nestabilni plak u koronarnim arterijama je najčešći uzrok akutnog koronarnog sindroma (AKS) koji se može manifestirati kao nestabilna angina, infarkt miokarda bez elevacije ST-segmenta i infarkt miokarda s elevacijom ST-segmenta (STEMI), ali se također može manifestirati i kao iznenadni srčani zastoj zbog ishemijom izazvane tahiaritmije. Smrtnost AKS je značajno smanjena u posljednjih nekoliko godina, posebice od njegovih najtežih manifestacija, STEMI i srčanog zastoja. Ovaj trend će se najvjerojatnije nastaviti zbog terapijskog napretka novijeg datuma koji uključuje i nove antitrombocitne lijekove kao što prasugrel, tikagrelor i kangrelor.Unstable coronary artery plaque is the most common underlying cause of acute coronary syndromes (ACS) and can manifest as unstable angina, non-ST segment elevation infarction, and ST elevation myocardial infarction (STEMI), but can also manifest as sudden cardiac arrest due to ischaemia induced tachyarrhythmias. ACS mortality has decreased significantly over the last few years, especially from the more extreme manifestations of ACS, STEMI, and cardiac arrest. This trend is likely to continue based on recent therapeutic progress which includes novel antiplatelet agents such as prasugrel, ticagrelor, and cangrelor

The impact of the coronary collateral circulation on mortality: a meta-analysis

Aims The coronary collateral circulation as an alternative source of blood supply has shown benefits regarding several clinical endpoints in patients with myocardial infarction (MI) such as infarct size and left ventricular remodelling. However, its impact on hard endpoints such as mortality and its impact in patients with stable coronary artery disease (CAD) is more controversial. The purpose of this systematic review and meta-analysis was to explore the impact of collateral circulation on all-cause mortality. Methods and results We searched MEDLINE, EMBASE, ISI Web of Science (2001 to 25 April 2011), and conference proceedings for studies evaluating the effect of coronary collaterals on mortality. Random-effect models were used to calculate summary risk ratios (RR). A total of 12 studies enrolling 6529 participants were included in this analysis. Patients with high collateralization showed a reduced mortality compared with those with low collateralization [RR 0.64 (95% confidence interval 0.45-0.91); P= 0.012]. The RR for ‘high collateralization' in patients with stable CAD was 0.59 [0.39-0.89], P= 0.012, in patients with subacute MI it was 0.53 [0.15-1.92]; P= 0.335, and for patients with acute MI it was 0.63 [0.29-1.39]; P= 0.257. Conclusions In patients with CAD, the coronary collateralization has a relevant protective effect. Patients with a high collateralization have a 36% reduced mortality risk compared with patients with low collateralizatio

The Clinical Utility of a Precision Medicine Blood Test Incorporating Age, Sex, and Gene Expression for Evaluating Women with Stable Symptoms Suggestive of Obstructive Coronary Artery Disease: Analysis from the PRESET Registry.

Background: Evaluating women with symptoms suggestive of coronary artery disease (CAD) remains challenging. A blood-based precision medicine test yielding an age/sex/gene expression score (ASGES) has shown clinical validity in the diagnosis of obstructive CAD. We assessed the effect of the ASGES on the management of women with suspected obstructive CAD in a community-based registry. Materials and Methods: The prospective PRESET (A Registry to Evaluate Patterns of Care Associated with the Use of Corus® CAD in Real World Clinical Care Settings) Registry (NCT01677156) enrolled 566 patients presenting with symptoms suggestive of stable obstructive CAD from 21 United States primary care practices from 2012 to 2014. Demographics, clinical characteristics, and referrals to cardiology or further functional and/or anatomical cardiac studies after ASGES testing were collected for this subgroup analysis of women from the PRESET Registry. Patients were followed for 1-year post-ASGES testing. Results: This study cohort included 288 women with a median age 57 years. The median body mass index was 29.2, with hyperlipidemia and hypertension present in 48% and 43% of patients, respectively. Median ASGES was 8.5 (range 1-40), with 218 (76%) patients having low (≤15) ASGES. Clinicians referred 9% (20/218) low ASGES versus 44% (31/70) elevated ASGES women for further cardiac evaluation (odds ratio 0.14, p < 0.0001, adjusted for patient demographics and clinical covariates). Across the score range, higher ASGES were associated with a higher likelihood of posttest cardiac referral. At 1-year follow-up, low ASGES women experienced fewer major adverse cardiac events than elevated ASGES women (1.3% vs. 4.2% respectively, p = 0.16). Conclusions: Incorporation of ASGES into the diagnostic workup demonstrated clinical utility by helping clinicians identify women less likely to benefit from further cardiac evaluation

The collateral circulation of the heart

Abstract The coronary arteries have been regarded as end arteries for decades. However, there are functionally relevant anastomotic vessels, known as collateral arteries, which interconnect epicardial coronary arteries. These vessels provide an alternative source of blood supply to the myocardium in cases of occlusive coronary artery disease. The relevance of these collateral arteries is a matter of ongoing debate, but increasing evidence indicates a relevant protective role in patients with coronary artery disease. The collateral circulation can be assessed by different methods; the gold standard involves intracoronary pressure measurements. While the first clinical trials to therapeutically induce growth of collateral arteries have been unavailing, recent pilot studies using external counterpulsation or growth factors such as granulocyte colony stimulating factor (G-CSF) have shown promising results.http://deepblue.lib.umich.edu/bitstream/2027.42/112630/1/12916_2013_Article_799.pd

Local versus general anesthesia for transcatheter aortic valve implantation (TAVR) – systematic review and meta-analysis

BACKGROUND: The hypothesis of this study was that local anesthesia with monitored anesthesia care (MAC) is not harmful in comparison to general anesthesia (GA) for patients undergoing Transcatheter Aortic Valve Implantation (TAVR). TAVR is a rapidly spreading treatment option for severe aortic valve stenosis. Traditionally, in most centers, this procedure is done under GA, but more recently procedures with MAC have been reported. METHODS: This is a systematic review and meta-analysis comparing MAC versus GA in patients undergoing transfemoral TAVR. Trials were identified through a literature search covering publications from 1 January 2005 through 31 January 2013. The main outcomes of interest of this literature meta-analysis were 30-day overall mortality, cardiac-/procedure-related mortality, stroke, myocardial infarction, sepsis, acute kidney injury, procedure time and duration of hospital stay. A random effects model was used to calculate the pooled relative risks (RR) with 95% confidence intervals. RESULTS: Seven observational studies and a total of 1,542 patients were included in this analysis. None of the studies were randomized. Compared to GA, MAC was associated with a shorter hospital stay (-3.0 days (-5.0 to -1.0); P = 0.004) and a shorter procedure time (MD -36.3 minutes (-58.0 to -15.0 minutes); P <0.001). Overall 30-day mortality was not significantly different between MAC and GA (RR 0.77 (0.38 to 1.56); P = 0.460), also cardiac- and procedure-related mortality was similar between both groups (RR 0.90 (0.34 to 2.39); P = 0.830). CONCLUSION: These data did not show a significant difference in short-term outcomes for MAC or GA in TAVR. MAC may be associated with reduced procedural time and shorter hospital stay. Now randomized trials are needed for further evaluation of MAC in the setting of TAVR