202 research outputs found
Differences in the development of nitrate tolerance and in its reversal with N-acetylcisteine between arterial and venous vessels in man
Neoatherosclerosis and plaque rupture as triggers for very late stent thrombosis in a bare-metal stent
Very late stent thrombosis has been increasingly described in the drug eluting stent era. A 56-year-old male presented with anterior ST-elevation myocardial infarction, he received a bare-metal stent in the left anterior descending artery in 2010. We obtained an optical coherence tomography scan, showing ruptured neoatherosclerotic plaque with thrombus
Exercise test as predictor of the effects of physical training on survival in post-MI patients
Ischaemic and bleeding complications with new, compared to standard, ADP-antagonist regimens in acute coronary syndromes: a meta-analysis of randomized trials
Background: Platelets play a pivotal role in the
pathogenesis of acute coronary syndromes (ACS)
and their inhibition remains a mainstay therapy in
this setting. We aimed to perform a meta-analysis of
randomized trials to evaluate the benefits of new
oral antiplatelet regimens to block platelet ADPreceptors
compared to standard-dose clopidogrel
(300 mg loading dose followed by 75 mg/daily).
Methods: We obtained results from all randomized
trials enrolling patients with ACS. Primary endpoint
was mortality. Secondary endpoints were myocardial
infarction and definite in-stent thrombosis.
Safety endpoint was the risk of major bleeding complications.
We prespecified subanalyses according
to new antiplatelet drugs (prasugrel/ticagrelor),
high-dose clopidogrel (600 mg) and patients undergoing
percutaneous coronary intervention.
Results: A total of seven randomized trials were
finally included in the meta-analysis (n = 58 591).
We observed a significant reduction in mortality
(2.9% vs. 3.4%, OR= 0.87, 95% CI 0.79–0.95,
P = 0.002), recurrent myocardial infarction (4.2%
vs. 5.2%, OR= 0.80, 95% CI 0.74–0.87,
P < 0.0001), definite in-stent thrombosis (0.9% vs.
1.7%, OR= 0.52, 95% CI 0.43–0.63, P < 0.0001).
The benefits in mortality and reinfarction were
driven by the treatment with prasugrel or ticagrelor,
without a significant difference in terms of major
bleeding complications as compared to standarddose
clopidogrel (5% vs. 4.7%, OR= 1.06 95% CI
0.96–1.17, P = 0.25).
Conclusions: This meta-analysis showed that new
oral antiplatelet regimens are associated with a significant
reduction in mortality, reinfarction and
in-stent thrombosis in ACS patients without an overall
increase of major bleeding when treated with
new antiplatelet drugs
Prasugrel overcomes high on-clopidogrel platelet reactivity in the acute phase of acute coronary syndrome and maintains its antiplatelet potency at 30-day follow-up
Background: The aim of this study was to assess antiplatelet effect of prasugrel in acute coronary syndrome (ACS) patients with high on-treatment platelet reactivity (HTPR) on clopidogrel, undergoing percutaneous coronary intervention (PCI).Methods: A prospective, platelet reactivity-guided, parallel-group, open-label study including 71 patients pretreated with clopidogrel 600 mg and assigned either to prasugrel (30 mg loading dose, 10 mg maintenance dose; n = 46) or clopidogrel (150 mg maintenance dose for 6 days and thereafter 75 mg maintenance dose; n = 25) regimen, based on vasodilator-stimulated phosphoprotein (VASP)-assessed platelet reactivity index (PRI; > 50% vs. ≤ 50%) measured next morning post-PCI.Results: Median PRI value after switch to prasugrel sharply declined at 24 h (70.0 [61.3–75.6] vs. 11.9 [6.8–25.7]%; p < 0.000001) and slightly but significantly rose between 24 h and 30 days (27.9 [15.5–46.8]%; p < 0.0006). In contrast, median PRI values in the clopidogrel group were similar at baseline and at 24 h (25.1 [13.7–40.2] vs. 22.0 [18.4–36.8]%; p = NS) and then modestly rose at 30 days (30.3 [20.4–45.7]%; p < 0.03). The prevalence of HTPR decreased in the prasugrel group between baseline and 24 h measurements (100.0 vs. 4.3%; p < 0.0001). Rates of patients with HTPR at 24 h and 30 days were similar in both groups, so were the tendencies in patterns of platelet inhibition evaluated with multiple electrode aggregometry as compared with the VASP assay.Conclusions: Our study indicates that prasugrel overcomes HTPR on clopidogrel in the acute phase of interventionally treated ACS and maintains its antiplatelet potency in 30-day follow-up. Potential clinical benefits of personalized antiplatelet prasugrel-based therapy warrant further investigation in clinical ACS trials.
Low-molecular-weight heparins vs. unfractionated heparin in the setting of percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis
Summary. Background: The aim of the current study was to
perform two separate meta-analyses of available studies
comparing low-molecular-weight heparins (LMWHs) vs.
unfractionated heparin (UFH) in ST-elevation myocardial
infarction (STEMI) patients treated (i) with primary percutaneous
coronary intervention (pPCI) or (ii) with PCI after
thrombolysis. Methods: All-cause mortality was the prespecified
primary endpoint and major bleeding complications
were recorded as the secondary endpoints. Relative risk (RR)
with a 95%confidence interval (CI) and absolute risk reduction
(ARR) were chosen as the effect measure. Results: Ten studies
comprising 16 286 patients were included. The median followup
was 2 months for the primary endpoint. Among LMWHs,
enoxaparin was the compound most frequently used. In the
pPCI group, LMWHs were associated with a reduction in
mortality [RR (95% CI) = 0.51 (0.41–0.64), P < 0.001,
ARR = 3%] and major bleeding [RR (95% CI) = 0.68
(0.49–0.94), P = 0.02, ARR = 2.0%] as compared with
UFH. Conversely, no clear evidence of benefits with LWMHs
was observed in the PCI group after thrombolysis. Metaregression
showed that patients with a higher baseline risk had
greater benefits from LMWHs (r = 0.72, P = 0.02). Conclusions:
LMWHs were associated with greater efficacy and safety
than UFH in STEMI patients treated with pPCI, with a
significant relationship between risk profile and clinical benefits.
Based on this meta-analysis, LMWHs may be considered as a
preferred anticoagulant among STEMI patients undergoing
pPCI
Meta-Analysis of Impact of Different Types and Doses of Statins on New-Onset Diabetes Mellitus
Recent reports indicate that statins are associated with an increased risk for new-onset
diabetes mellitus (DM) compared with placebo and that this relation is dose dependent. The
aim of this study was to perform a comprehensive network meta-analysis of randomized
controlled trials (RCTs) investigating the impact of different types and doses of statins on
new-onset DM. RCTs comparing different types and doses of statins with placebo were
searched for using the MEDLINE, Embase, and Cochrane databases. A search of RCTs
pertinent to this meta-analysis covering the period from November 1994 to October 2012
was conducted by 2 independent investigators using the MEDLINE, Cochrane, Google
Scholar, and Embase databases as well as abstracts and presentations from major cardiovascular
meetings. Seventeen RCTs reporting the incidence of new-onset DM during statin
treatment and including a total of 113,394 patients were identified. The RCTs compared
either a statin versus placebo or high-dose versus moderate-dose statin therapy. Among
different statins, pravastatin 40 mg/day was associated with the lowest risk for new-onset
DM compared with placebo (odds ratio 1.07, 95% credible interval 0.86 to 1.30).
Conversely, rosuvastatin 20 mg/day was numerically associated with 25% increased risk for
DM compared with placebo (odds ratio 1.25, 95% credible interval 0.82 to 1.90). The impact
on DM appeared to be intermediate with atorvastatin 80 mg/day compared with placebo
(odds ratio 1.15, 95% credible interval 0.90 to 1.50). These findings were replicated at
moderate doses. In conclusion, different types and doses of statins show different potential
to increase the incidence of DM. 2013 Elsevier Inc. All rights reserved. (Am J Cardiol
2013;111:1123e1130
Early Aggressive Versus Initially Conservative Treatment in Elderly Patients With Non–ST-Segment Elevation Acute Coronary Syndrome A Randomized Controlled Trial
ObjectivesThis study sought to determine the risk versus benefit ratio of an early aggressive (EA) approach in elderly patients with non–ST-segment elevation acute coronary syndromes (NSTEACS).BackgroundElderly patients have been scarcely represented in trials comparing treatment strategies in NSTEACS.MethodsA total of 313 patients ≥75 years of age (mean 82 years) with NSTEACS within 48 h from qualifying symptoms were randomly allocated to an EA strategy (coronary angiography and, when indicated, revascularization within 72 h) or an initially conservative (IC) strategy (angiography and revascularization only for recurrent ischemia). The primary endpoint was the composite of death, myocardial infarction, disabling stroke, and repeat hospital stay for cardiovascular causes or severe bleeding within 1 year.ResultsDuring admission, 88% of the patients in the EA group underwent angiography (55% revascularization), compared with 29% (23% revascularization) in the IC group. The primary outcome occurred in 43 patients (27.9%) in the EA group and 55 (34.6%) in the IC group (hazard ratio [HR]: 0.80; 95% confidence interval [CI]: 0.53 to 1.19; p = 0.26). The rates of mortality (HR: 0.87; 95% CI: 0.49 to 1.56), myocardial infarction (HR: 0.67; 95% CI: 0.33 to 1.36), and repeat hospital stay (HR: 0.81; 95% CI: 0.45 to 1.46) did not differ between groups. The primary endpoint was significantly reduced in patients with elevated troponin on admission (HR: 0.43; 95% CI: 0.23 to 0.80), but not in those with normal troponin (HR: 1.67; 95% CI: 0.75 to 3.70; p for interaction = 0.03).ConclusionsThe present study does not allow a definite conclusion about the benefit of an EA approach when applied systematically among elderly patients with NSTEACS. The finding of a significant interaction for the treatment effect according to troponin status at baseline should be confirmed in a larger size trial. (Italian Elderly ACS Study; NCT00510185
Clinical governance of patients with acute coronary syndromes
Aims Using the principles of clinical governance, a patient-centred approach intended to promote holistic quality improvement, we designed a prospective, multicentre study in patients with acute coronary syndrome (ACS). We aimed to verify and quantify consecutive inclusion and describe relative and absolute effects of indicators of quality for diagnosis and therapy. Methods and results Administrative codes for invasive coronary angiography and acute myocardial infarction were used to estimate the ACS universe. The ratio between the number of patients included and the estimated ACS universe was the consecutive index. Co-primary quality indicators were timely reperfusion in patients admitted with ST-elevation ACS and optimal medical therapy at discharge. Cox-proportional hazard models for 1-year death with admission and discharge-specific covariates quantified relative risk reductions and adjusted number needed to treat (NNT) absolute risk reductions. Hospital codes tested had a 99.5% sensitivity to identify ACS universe. We estimated that 7344 (95% CI: 6852-7867) ACS patients were admitted and 5107 were enrolled-i.e. a consecutive index of 69.6% (95% CI 64.9-74.5%), which varied from 30.7 to 79.2% across sites. Timely reperfusion was achieved in 22.4% (95% CI: 20.7-24.1%) of patients, was associated with an adjusted hazard ratio (HR) for 1-year death of 0.60 (95% CI: 0.40-0.89) and an adjusted NNT of 65 (95% CI: 44-250). Corresponding values for optimal medical therapy were 70.1% (95% CI: 68.7-71.4%), HR of 0.50 (95% CI: 0.38-0.66), and NNT of 98 (95% CI: 79-145). Conclusion A comprehensive approach to quality for patients with ACS may promote equitable access of care and inform implementation of health care delivery. Registration ClinicalTrials.Gov ID NCT0425553
- …