SMARTphone-based, early cardiac REHABilitation in patients with acute coronary syndromes [SMART-REHAB Trial]: A randomized controlled trial protocol

© 2016 The Author(s). Background: There are well-documented treatment gaps in secondary prevention of coronary heart disease and no clear guidelines to assist early physical activity after acute coronary syndromes (ACS). Smartphone technology may provide an innovative platform to close these gaps. This paper describes the study design of a randomized controlled trial assessing whether a smartphone-based secondary prevention program can facilitate early physical activity and improve cardiovascular health in patients with ACS. Methods: We have developed a multi-faceted, patient-centred smartphone-based secondary prevention program emphasizing early physical activity with a graduated walking program initiated on discharge from ACS admission. The program incorporates; physical activity tracking through the smartphone's accelerometer with interactive feedback and goal setting; a dynamic dashboard to review and optimize cardiovascular risk factors; educational messages delivered twice weekly; a photographic food diary; pharmacotherapy review; and support through a short message service. The primary endpoint of the trial is change in exercise capacity, as measured by the change in six-minute walk test distance at 8-weeks when compared to baseline. Secondary endpoints include improvements in cardiovascular risk factor status, psychological well-being and quality of life, medication adherence, uptake of cardiac rehabilitation and re-hospitalizations. Discussion: This randomized controlled trial will use a smartphone-phone based secondary prevention program to emphasize early physical activity post-ACS. It will provide evidence regarding the feasibility and utility of this innovative platform in closing the treatment gaps in secondary prevention. Trial registration: The trial was retrospectively registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) on April 4, 2016. The registration number is ACTRN12616000426482

Optimising Clinical Outcomes in Patients with Acute Coronary Syndromes

© 2019 Matias Benjamin YudiIschaemic heart disease remains the leading cause of death worldwide despite significant advances in diagnosis and treatment. Over the past two decades, interventional and medical therapies have been tested through rigorous large scale randomized controlled trials. These data form the backbone of national and international guidelines. However, there are still numerous controversial issues in the short- and long-term management of patients with acute coronary syndromes (ACS) and there are limitations in translation of scientific evidence into clinical practice. Using a well-established multi-centre interventional cardiology registry, this thesis focuses on contentious issues in the management of ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndromes (NSTEACS). The topics addressed range from the safety of pretreatment with dual antiplatelet therapy in STEMI and NSTEACS, to the impact of door-to-balloon time in high-risk patients and the long-term prognostic significance of optimal medical therapy and smoking cessation. In addition, single-centre studies were used to explore in detail the management of patients older than 85 years with acute coronary syndromes and the impact of periprocedural myocardial infarction on long-term mortality. Finally, through a randomized controlled trial of a smartphone based cardiac rehabilitation program, this thesis underscores the value of an innovative model to optimize secondary prevention of coronary artery disease

Comparative efficacy of eptifibatide and abciximab in primary angioplasty study

Rohan Jayasinghe1 Matias Yudi1 Sanjay Jayasinghe21Cardiology Department, Gold Coast Hospital, Griffith University, Queensland, Australia; 2Centre for Immunisation Research, Sydney, AustraliaBackground: Primary percutaneous intervention is the safest and most effective treatment modality for acute ST-segment elevation myocardial infarction (MI) in centers where catheterization facilities exist. Intravenous glycoprotein IIb/IIIa inhibitor therapy during the procedures has been proven to provide added benefits. For the two agents, abciximab and eptifibatide, commonly used in this context, there is only limited comparative data available for the clinicians. Hitherto, there is no data published from the Asia–Pacific region on this topic.Method: A retrospective comprehensive analysis was carried out, comparing patients who were treated with abciximab (n = 125) and eptifibatide (n = 125) during primary angioplasty over a 3-year period. The primary outcome measure was in-hospital mortality. The other outcome measures studied include MI, stroke, blood transfusion, contrast nephropathy, significant bleeding, and vascular complications. A comparative cost analysis was carried out to ascertain the average overall differential cost.Results: In-hospital mortality, MI, stroke, blood transfusion, contrast nephropathy, significant bleeding, and vascular complication were observed at a higher rate in the patients who were treated with abciximab. However, these differences did not reach statistical significance. Due to the higher cost per unit and longer hospital stay, therapy with abciximab costs more than that with eptifibatide.Conclusions: Both abciximab and eptifibatide are safe and effective adjunct therapeutic agents in the setting of primary angioplasty. However, there is a trend toward higher adverse event with the former agent that was not statistically significant. Therapy with abciximab costs more per patient.Keywords: abciximab, eptifibatide, PCI, STEM

Long-term prognostic significance of periprocedural myonecrosis in patients with stable coronary artery disease undergoing elective percutaneous coronary intervention

The clinical significance of myonecrosis, measured by cardiac troponin, in the context of percutaneous coronary intervention (PCI) is a matter of ongoing debate. The lack of substantial scientific evidence in this domain is apparent from the ever-changing definitions of periprocedural myocardial infarction and the uncertainty regarding its prognostic relevance.Myonecrosis due to PCI is common and occurs in up to 40% of cases, depending on the definition and biomarker used5. In the Third Universal Definition of Myocardial Infarction (MI), the cutoff cardiac troponin level to diagnose myonecrosis increased from 3 to 5 times the upper reference limit (URL). In contrast to previous definitions, troponin elevation needs to be associated with clinical, electrocardiographic, angiographic or cardiac imagingrelated evidence of ischaemia to be classified as a periprocedural MI, or type 4a MI. However, the occurrence of post-PCI chest pain without troponin elevation and troponin elevation without chest pain, angiographic complications or other signs of ischaemia is well documented. The Society of Cardiovascular Angiography and Interventions (SCAI) has proposed an alternative definition of “clinically significant myocardial infarction” requiring troponin levels of ≥70x upper limit of normal (ULN) or ≥35x ULN with electrocardiographic evidence of infarction