|Year : 2003 | Volume
| Issue : 1 | Page : 2
|Date of Web Publication||22-Jun-2010|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Cardiovascular News. Heart Views 2003;4:2
ASCOT reveals statins beneficial in hypertension
10,305 hypertensive patients participating in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) who had average or below-average cholesterol (6.5 millimols per liter or less) were randomly allocated 10-mg atorvastatin or placebo in addition to blood-pressure-lowering therapy. These patients were at moderately high risk of cardiovascular disease (having three or more risk factors in addition to high blood pressure), and were aged between 40 and 80 years (average age 63 years). Planned five-year follow-up assessed the primary endpoint of death from CHD and non-fatal heart attack.
This benefit emerged in the first year of follow-up. As well as a reduction in the primary end point (myocardial infarction/fatal coronary heart disease) fatal and nonfatal stroke, total cardiovascular events, and total coronary events were also significantly lowered. Treatment was stopped after 3.3 years when it became clear that atorvastatin had benefits over placebo (100 primary events compared with 154, respectively - a relative risk reduction of 36%). Treatment with atorvastatin also reduced the risk of stroke and total cardiovascular events, with all benefits occurring in the first year of treatment.
The study findings may have implications for future lipid-lowering guidelines.
Lancet 2003;1149 - 1158
Statins reduce perioperative mortality in noncardiac surgery
Patients undergoing major vascular surgery are at increased risk of perioperative mortality due to underlying coronary artery disease. It is hypothesized that statins may reduce perioperative mortality by improving lipid profile and stabilization of coronary plaques on the vascular wall.
To evaluate the association between statin use and perioperative mortality, investigators performed a case-controlled study among the 2,816 patients who underwent major vascular surgery from 1991 to 2000 at the Erasmus Medical Center. Case subjects were all 160 (5.8%) patients who died during the hospital stay after surgery. From the remaining patients, 2 controls were selected for each case and were stratified according to calendar year and type of surgery. For cases and controls, information was obtained regarding statin use before surgery, the presence of cardiac risk factors, and the use of other cardiovascular medication.
A vascular complication during the perioperative phase was the primary cause of death in 104 (65%) case subjects. Statin therapy was significantly less common in cases than in controls (8% versus 25%; P<0.001). The adjusted odds ratio for perioperative mortality among statin users as compared with nonusers was 0.22 (95% confidence interval 0.10 to 0.47). Similar results were obtained in subgroups of patients according to the use of cardiovascular therapy and the presence of cardiac risk factors.
The study provides evidence that statin use reduces perioperative mortality in patients undergoing major vascular surgery.
Intracoronary Abciximab superior to intravenous in reducing MACE
The effect of intracoronary bolus abciximab on major adverse cardiac events was compared to intravenous application in 403 consecutive patients with acute myocardial infarction or unstable angina undergoing coronary angioplasty.
A 20-mg bolus of abciximab was given intravenously in 109 patients and intracoronarily in 294 patients. There were no differences between the groups with regard to diabetes mellitus, cardiogenic shock, successful intervention, or preprocedural and postprocedural TIMI flow. At 30 days, the incidence of MACE (death, myocardial infarction, urgent revascularization) was significantly lower in the patients with intracoronary compared with intravenous administration of abciximab (10.2% versus 20.2%; P<0.008), which was independent from stenting in multivariate analysis. The effect was most pronounced in patients with preprocedural TIMI 0/1 flow (MACE: intracoronary 11.8% versus intravenous 27.5%, P<0.002; n=273).
The study concludes that in patients with acute myocardial infarction or unstable angina undergoing emergency coronary angioplasty, intracoronary bolus application of abciximab is associated with a reduction of MACE compared with the standard intravenous bolus application of abciximab.
BNP identifies high risk non ST elevation acute coronary syndrome
B-type natriuretic peptide holds promise for risk stratification. The use of B-type natriuretic peptide (BNP alone and with cardiac troponin I (cTnI),) for risk assessment and clinical decision making in patients with non-ST elevation acute coronary syndromes (ACS) was evaluated. 1,676 patients with non-ST elevation ACS were randomized to early invasive versus conservative management.
Patients with elevated BNP (>80 pg/ml; N = 320) were at higher risk of death at seven days (2.5% vs. 0.7%, P = 0.006) and six months (8.4% vs. 1.8%, p < 0.0001). The association between BNP and mortality at six months (adjusted odds ratio [OR] 3.3; 95% confidence interval [CI] 1.7 to 6.3) was independent of important clinical predictors, including cTnI and congestive heart failure (CHF). Patients with elevated BNP had a fivefold higher risk of developing new CHF by 30 days (5.9% vs. 1.0%, p < 0.0001). B-type natriuretic peptide added prognostic information to cTnI, discriminating patients at higher mortality risk among those with negative (OR 6.9; 95% CI 1.9 to 25.8) and positive (OR 4.1; 95% CI 1.9 to 9.0) baseline cTnI results. No difference was observed in the effect of invasive versus conservative management when stratified by baseline levels of BNP (pinteraction ž 0.6).
The study concluded that elevated BNP (>80 pg/ml) at presentation identifies patients with non-ST elevation ACS who are at higher risk of death and CHF and adds incremental information to cTnI.
J Am Coll Cardiol 2003;41:1264 - 1272
Increased plasma natriuretic pedtide reflects symptom-onset in AS
The association between natriuretic peptide levels, disease severity, and cardiac symptoms was assessed in patients with aortic stenosis (AS).
Seventy-four patients with isolated AS underwent independent assessment of symptoms, transthoracic echocardiography, and measurement of plasma levels of atrial natriuretic peptide, brain natriuretic peptide (BNP), and N-BNP. Natriuretic peptide levels were also measured in 100 clinically normal control subjects. The aortic valve area was smaller in symptomatic patients (n=45) than in asymptomatic patients (n=29; mean, 0.71±0.23 cm2 and 0.99±0.31 cm2, respectively; P<0.0001). Plasma natriuretic peptide levels were higher in symptomatic patients than in asymptomatic patients (for N-BNP: median, 112 versus 33 pmol/L, P=0.0002).
After adjustment for age, sex, serum creatinine, aortic valve area, and left ventricular ejection fraction, N-BNP levels were 1.74 times higher (95% confidence interval, 1.12 to 2.69) for symptomatic than asymptomatic patients with AS (P=0.014). Natriuretic peptide levels increased with the New York Heart Association class (for N-BNP median values were 13, 34, 105, and 202 pmol/L for normal control subjects, class I, class II, and class III/IV patients, respectively; interquartile ranges for the same patients were 8 to 21, 16 to 58, 57 to 159, and 87 to 394 pmol/L; P<0.0001). Similar associations were observed for BNP and atrial natriuretic peptide.
Plasma natriuretic peptide levels are elevated in symptomatic patients with aortic stenosis. Measurement of natriuretic peptides may complement clinical and echocardiographic evaluation of patients with aortic stenosis.
GP IIb/IIIa inhibition with tirofiban before angiolpasty improves outcome
The TIGER-PA pilot trial evaluated the safety, feasibility, and utility of early tirofiban administration before planned primary angioplasty in patients presenting with acute myocardial infarction.
A total of 100 patients presenting with acute myocardial infarction were randomized to either early administration of tirofiban in the emergency room or later administration in the catheterization laboratory. The primary outcome measures were initial TIMI grade flow, corrected TIMI frame counts, and TIMI grade myocardial perfusion ("blush"). Thirty-day major adverse cardiac events were also assessed. Angiographic outcomes demonstrate a significant improvement in initial TIMI grade flow, corrected TIMI frame counts, and TIMI grade myocardial perfusion when patients are given tirofiban in the emergency room before primary angioplasty. The rate of 30-day major adverse cardiac events suggests that early administration may be beneficial.
This pilot study suggests that early administration of tirofiban improves angiographic outcomes and is safe and feasible in patients undergoing primary angioplasty for acute myocardial infarction.
Meta-analysis comparing CABG & PTCA favors CABG
A meta-analysis of 13 randomized trials on 7,964 patients comparing PTCA with CABG.found a 1.9% absolute survival advantage favoring CABG over PTCA for all trials at five years (p < 0.02), but no significant advantage at one, three, or eight years.
In subgroup analysis of multivessel disease, CABG provided significant survival advantage at both five and eight years. Patients randomized to PTCA had more repeat revascularizations at all time points (risk difference [RD] 24% to 38%, p < 0.001); with stents, this RD was reduced to 15% at one and three years. Stents also resulted in a significant decrease in nonfatal myocardial infarction at three years when compared with CABG. For diabetic patients, CABG provided a significant survival advantage over PTCA at 4 years but not at 6.5 years.
The analysis suggests that, when compared with PTCA, CABG is associated with a lower five-year mortality, less angina, and fewer revascularization procedures. For patients with multivessel disease, CABG provided a survival advantage at five to eight years, and for diabetics, a survival advantage at four years. The addition of stents reduced the need for repeat revascularization by about half.
J Am Coll Cardiol 2003;41:1293 - 1304
New clinical syndrome: pulmonary vein stenosis post AF catheter ablation
Pulmonary vein isolation is a new, effective, and curative procedure for selected patients with atrial fibrillation. Pulmonary vein stenosis is a potential complication and may lead to symptoms that are often underrecognized.
A retrospective study was undertaken to describe the clinical course and symptoms associated with pulmonary vein stenosis developing after ablation in the pulmonary veins.
Three months after ablation, patients underwent routine screening for pulmonary vein stenosis with spiral computed tomography. Screening was considered earlier if symptoms suggestive of stenosis developed and was repeated at 6 and 12 months if any pulmonary vein narrowing was observed. Pulmonary vein angiography and dilatation were offered to patients with severe (>70%) stenosis.
Of 335 patients referred for catheter ablation of drug-refractory atrial fibrillation, severe pulmonary vein stenosis was detected in 18 patients (5%) at three to six months after ablation. Eight of these 18 patients (44%) were asymptomatic, but 8 (44%) reported shortness of breath, 7 (39%) reported cough, and 5 (28%) reported hemoptysis. Radiologic abnormalities were present in 9 patients (50%) and led to diagnoses of pneumonia (4 patients), lung cancer (1 patient), and pulmonary embolism (2 patients).
Pulmonary vein stenosis was not considered in any patient during the initial work-up. Dilatation of the affected vein was performed in 12 patients. Postintervention lung perfusion scans revealed significant improvement in lung flow.
The study concludes that severe pulmonary vein stenosis after catheter ablation of atrial fibrillation is associated with respiratory symptoms that frequently mimic more common diseases, often leading to erroneous diagnostic and therapeutic procedures. Awareness of this syndrome is important for proper and prompt management.
Ann Intern Med 2003;138:634-638
MRI useful in assessing pulmonary vein anatomy pre & post catheter AF ablation
A study involving 28 patients sought to define the technique and results of magnetic resonance imaging (MRI) of pulmonary vein (PV) anatomy before and after catheter ablation of atrial fibrillation (AF) was undertaken.
Twenty-eight patients with AF underwent ablation. Patients underwent gadolinium-enhanced MRI before and 6 weeks after their procedures. A control group of 27 patients also underwent MRI. Variant PV anatomy was observed in 38% of patients. AF patients had larger PV diameters than control subjects, but no difference was observed in the size of the PV ostia among AF patients. The PV ostia were oblong in shape with an anteroposterior dimension less than the superoinferior dimension. The left PVs had a longer "neck" than the right PVs. A detectable PV narrowing was observed in 24% of veins. The severity of stenosis was severe in 1 vein (1.4%), moderate in 1 vein (1.4%), and mild in 15 veins (21.1%). All patients were asymptomatic, and none required treatment.
This study demonstrates that AF patient have larger PVs than control subjects and demonstrates the value of MRI in facilitating AF ablation. The benefits of preprocedural MRI of PVs include the ability to evaluate the number, size, and shape of the PVs. MRI also provides an assessment of the severity of PV stenosis.
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