Bivalirudin in the Treatment of Coronary Artery Disease

Periprocedural anticoagulation continues to be a vital aspect in the management of coronary artery disease. Bivalirudin is a relatively new drug that has caught much attention in the last decade, especially in the context of percutaneous coronary intervention for acute coronary syndromes. Multiple clinical trials have shown the efficacy, safety profile and limitations of bivalirudin in contrast to previously used heparin and glycoprotein IIb/IIIa inhibitors. These trials have included patients with moderate to high-risk stable angina, unstable angina, non-ST-elevation and ST-elevation myocardial infarctions requiring PCI. The growing body of evidence on bivalirudin has also improved the understanding of its applicability and efficacy over other hirudin-based anticoagulants, however continual review of more recent evidence is important in order to integrate bivalirudin more widely across the various guidelines. This article aims to study the cross-section of the evidence base to date on the clinical use, efficacy and risks related to the use of bivalirudin and attempts to provide the clinician with a practical overview of the role of bivalirudin in the most recent guidelines

Abciximab in the treatment of coronary artery disease

Antiplatelet therapy constitutes a cornerstone in the strategies aimed at the effective management of acute coronary syndrome. Abciximab is the oldest and most commonly used intravenous antiplatelet agent in this context, in particular when an invasive strategy is adopted. It is very commonly used in more unstable and high-risk patients. Trials have proven the event-free survival benefits of using abciximab in the right context. This agent also has some adverse outcomes associated with its use that the clinicians need to be well aware of and take precautions against. The comparative cost efficacy with its use too is of significance. There is a growing evidence base on the different ways abciximab is used and the benefits and risks thereof. Since the development and introduction of novel anticoagulants and more potent oral anti-platelet agents, the place of abciximab in the treatment of acute coronary syndrome today needs to be reviewed and clearly defined. This review attempts to study the cross-section of the evidence base to date on the clinical use, efficacy and risks related to the use of abciximab and spotlight the most recent guidelines published by the different global peak bodies to provide a practical overview to the clinician

Intermittent fasting for cardiovascular disease risk factor reduction: A narrative review of current evidence

BackgroundThe metabolic syndrome (MetSy), which is defined by the spectrum of obesity, insulin resistance and dyslipidaemia, is recognised as a major contributor to the overall risk of developing cardiovascular disease. Intermittent fasting (IF), which encompasses dieting plans with varying schedules of fasting, may be an effective method of reducing the burden of MetSy and the consequent cardiovascular events in the face of a worsening obesity epidemic in the contemporary society.AimsDespite the widespread public interest there is a serious lack of scientific understanding of the evidence base and the safe, optimal recommendations. This has created a level of public confusion that we endeavour to address by this narrative review of the published literature.Methods This narrative literature review summarises the current findings and suggests which regimens may be more effective and where future research in this area should be focused.Results Although the ideal regimen for IF remains unclear, there is promising evidence that alternate day fasting or modified fasting regimens, paired with or without continuous caloric restriction, may be more effective than continuous caloric restriction alone.ConclusionIF has been shown in the small number of human clinical trials discussed here to be an alternative to continuous caloric restriction in reducing the factors that contribute to the development of cardiovascular disease.Long-term randomised, controlled trials comparing continual caloric restriction and IF are required to objectively assess energy intake, energy expenditure, adherence, disease outcomes and metabolic factors

Australian cardiac rehabilitation exercise parameter characteristics and perceptions of high-intensity interval training: a cross-sectional survey

Purpose: This study explored current demographics, characteristics, costs, evaluation methods, and outcome measures used in Australian cardiac rehabilitation (CR) programs. It also determined the actual usage and perceptions of high-intensity interval training (HIIT). Methods: A cross-sectional observational web-based survey was distributed to 328 Australian CR programs nationally. Results: A total of 261 programs completed the survey (79.6% response rate). Most Australian CR programs were located in a hospital setting (76%), offered exercise sessions once a week (52%) for 6–8 weeks (49%) at moderate intensity (54%) for 46–60 min (62%), and serviced 101–500 clients per annum (38%). HIIT was reported in only 1% of programs, and 27% of respondents believed that it was safe while 42% of respondents were unsure. Lack of staff (25%), monitoring resources (20%), and staff knowledge (18%) were the most commonly reported barriers to the implementation of HIIT. Overall, Australian CR coordinators are unsure of the cost of exercise sessions. Conclusion: There is variability in CR delivery across Australia. Only half of programs reassess outcome measures postintervention, and cost of exercise sessions is unknown. Although HIIT is recommended in international CR guidelines, it is essentially not being used in Australia and clinicians are unsure as to the safety of HIIT. Lack of resources and staff knowledge were perceived as the biggest barriers to HIIT implementation, and there are inconsistent perceptions of prescreening and monitoring requirements. This study highlights the need to educate health professionals about the benefits and safety of HIIT to improve its usage and patient outcomes

High-intensity interval training versus moderate-intensity continuous training within cardiac rehabilitation:a systematic review and meta-analysis

Aerobic capacity has been shown to be inversely proportionate to cardiovascular mortality and morbidity and there is growing evidence that high-intensity interval training (HIIT) appears to be more effective than moderate-intensity continuous training (MICT) in improving cardiorespiratory fitness within the cardiac population. Previously published systematic reviews in cardiovascular disease have neither investigated the effect that the number of weeks of intervention has on cardiorespiratory fitness changes, nor have adverse events been collated.We aimed to undertake a systematic review and meta-analysis of randomized controlled trials (RCTs) within the cardiac population that investigated cardiorespiratory fitness changes resulting from HIIT versus MICT and to collate adverse events.A critical narrative synthesis and meta-analysis was conducted after systematically searching relevant databases up to July 2017. We searched for RCTs that compared cardiorespiratory fitness changes resulting from HIIT versus MICT interventions within the cardiac population.Seventeen studies, involving 953 participants (465 for HIIT and 488 for MICT) were included in the analysis. HIIT was significantly superior to MICT in improving cardiorespiratory fitness overall (SMD 0.34 mL/kg/min; 95% confidence interval [CI; 0.2-0.48]; p6-week duration. Programs of 7-12 weeks' duration resulted in the largest improvements in cardiorespiratory fitness for patients with coronary artery disease. HIIT appears to be as safe as MICT for CR participants

Implantable Cardioverter Defibrillators

Background ICD/BVP indications are expanding. They are expensive devices and historically, morbidities associated with their use were high. The starting experience at the Gold Coast Hospital is being reviewed. Methods A retrospective chart review of all the ICD/BVPs implanted in the Gold Coast Hospital from June 2007 to June 2008, with special emphasis on device indications and complications. Results Devices implanted were (31). Primary prevention devices (67 per cent), secondary prevention devices (33 per cent). Indications were: Non-ischemic Dilated Cardiomyopathy (35 per cent), Out-of-hospital Cardiac Arrest (26 per cent), Conscious VT (13 per cent), Ischemic Dilated Cardiomyopathy (10 per cent), In-hospital Cardiac Arrest (6 per cent), Long-QT Syndrome (6%) and Catecholamine-related Polymorphic VT (3 per cent). Major complications reported; lung contusion (1), left hemothorax (1), failed coronary sinus lead positioning (2), lead re-positioning (2), atrial lead removal (1), left subclavian vein thrombosis (1), lead malfunction leading to VT under sensing and syncope (1). Device-administered therapies were eight; Inappropriate discharges (5), Appropriate discharges (1), successful Anti-tachycardia Pacing (2). Conclusions We believe that ICDs are very effective life-saving devices but unfortunately they still are very expensive and their use can be associated with significant morbidities especially during the learning curve