Exercise-Induced Cardiac Troponin I Increase and Incident Mortality and Cardiovascular Events

Exercise-induced troponin I elevations above the 99th percentile after 30 to 55 km of walking independently predicted higher mortality and cardiovascular events in a cohort of older long-distance walkers.

source: AHA Journal

Summary

Exercise-Induced Cardiac Troponin I Increase and Incident Mortality and Cardiovascular Events

[Posted 13/Oct/2020]

AUDIENCE: Cardiology, Internal Medicine, Emergency Medicine

KEY FINDINGS: Exercise-induced Troponin I elevations above the 99th percentile after 30 to 55 km of walking independently predicted higher mortality and cardiovascular events in a cohort of older long-distance walkers. Exercise-induced increases in troponin may not be a benign physiological response to exercise, but an early marker of future mortality and cardiovascular events.

BACKGROUND: Blood concentrations of cardiac troponin above the 99th percentile are a key criterion for the diagnosis of acute myocardial injury and infarction. Troponin concentrations, even below the 99th percentile, predict adverse outcomes in patients and the general population. Elevated troponin concentrations are commonly observed after endurance exercise, but the clinical significance of this increase is unknown. The association between post exercise Troponin I concentrations and clinical outcomes in long-distance walkers was examined.

DETAILS: We measured cardiac Troponin I concentrations in 725 participants (61 [54-69] yrs) before and immediately after 30 to 55 km of walking. We tested for an association between post exercise Troponin I concentrations above the 99th percentile (>0.040 µg/L) and a composite end point of all-cause mortality and major adverse cardiovascular events (myocardial infarction, stroke, heart failure, revascularization, or sudden cardiac arrest). Continuous variables were reported as mean ± standard deviation when normally distributed or median [interquartile range] when not normally distributed. Participants walked 8.3 [7.3-9.3] hours at 68±10% of their maximum heart rate. Baseline Troponin I concentrations were >0.040 µg/L in 9 participants (1%). Troponin I concentrations increased after walking (P<.001), with 63 participants (9%) demonstrating a post exercise troponin concentration >0.040 µg/L. During 43 [23-77] months of follow-up, 62 participants (9%) experienced an end point; 29 died and 33 had major adverse cardiovascular events. Compared with 7% with post exercise Troponin I <=0.040 µg/L (log-rank P<.001), 27% of participants with post exercise Troponin I concentrations >0.040 µg/L experienced an end point. The hazard ratio was 2.48 (95% CI, 1.29-4.78) after adjusting for age, sex, cardiovascular risk factors (hypertension, hypercholesterolemia or diabetes mellitus), cardiovascular diseases (myocardial infarction, stroke, or heart failure), and baseline Troponin I concentrations.

Our Most Popular Apps

The Washington Manual - Cardiology Subspecialty Consult
Swanton's Cardiology A Concise Guide to Clinical Practice
Cardiac Care Unit Guide

Source: Aengevaeren, V. L., Hopman, M. T. E., Thompson, P. D., Bakker, E. A., George, K. P., Thijssen, D. H. J., & Eijsvogels, T. M. H. (2019). Exercise-Induced Cardiac Troponin I Increase and Incident Mortality and Cardiovascular Events. Circulation, 140(10), 804-814. https://doi.org/10.1161/CIRCULATIONAHA.119.041627

Published: Sep 2020


The Expected 30-Year Benefits of Early Versus Delayed Primary Prevention of Cardiovascular Disease by Lipid Lowering

Substantial reduction in expected atherosclerotic cardiovascular disease risk in the next 30 years is achievable by intensive lipid lowering in individuals in their 40s and 50s with non-HDL-C >=160 mg/dL.

source: Circulation

Summary

The Expected 30-Year Benefits of Early Versus Delayed Primary Prevention of Cardiovascular Disease by Lipid Lowering

[Posted 19/Oct/2020]

AUDIENCE: Cardiology, Internal Medicine, Emergency Medicine

KEY FINDINGS: Substantial reduction in expected atherosclerotic cardiovascular disease risk in the next 30 years is achievable by intensive lipid lowering in individuals in their 40s and 50s with non-HDL-C >=160 mg/dL. For many, the question of when to start lipid lowering might be more relevant than whether to start lipid lowering.

BACKGROUND: Lipid-lowering recommendations for prevention of atherosclerotic cardiovascular disease rely principally on estimated 10-year risk. We sought to determine the optimal time for initiation of lipid lowering in younger adults as a function of expected 30-year benefit.

DETAILS: Data from 3148 National Health and Nutrition Examination Survey (2009-2016) participants, age 30 to 59 years, not eligible for lipid-lowering treatment recommendation under the most recent US guidelines, were analyzed. We estimated the absolute and relative impact of lipid lowering as a function of age, age at initiation, and non-high-density lipoprotein cholesterol (HDL-C) level on the expected rates of atherosclerotic cardiovascular disease over the succeeding 30 years. We modeled expected risk reductions based on shorter-term effects observed in statin trials (model A) and longer-term benefits based on Mendelian randomization studies (model B). In both models, potential reductions in predicted 30-year atherosclerotic cardiovascular disease risk were greater with older age and higher non-HDL-C level. Immediate initiation of lipid lowering (ie, treatment for 30 years) in 40- to 49-year-old patients with non-HDL-C >=160 mg/dL would be expected to reduce their average predicted 30-year risk of 17.1% to 11.6% (model A; absolute risk reduction [ARR], 5.5%) or 6.5% (model B; ARR 10.6%). Delaying lipid lowering by 10 years (treatment for 20 years) would result in residual 30-year risk of 12.7% (A; ARR 4.4) or 9.9% (B; ARR 7.2%) and delaying by 20 years (treatment for 10 years) would lead to expected mean residual risk of 14.6% (A; ARR 2.6%) or 13.9% (B; ARR 3.2%). The slope of the achieved ARR as a function of delay in treatment was also higher with older age and higher non-HDL-C level.

Our Most Popular Resources

Source: Pencina, M., Pencina, K., Lloyd-Jones, D., Catapano, A. L., Thanassoulis, G., & Sniderman, A. D. (2020). The Expected 30-year Benefits of Early Versus Delayed Primary Prevention of Cardiovascular Disease by Lipid Lowering. Circulation. https://doi.org/10.1161/circulationaha.120.045851

Published: Aug 2020


Angiotensin Receptor-Neprilysin Inhibition Based on History of Heart Failure and Use of Renin-Angiotensin System Antagonists

Among patients admitted for acute decompensated HF, S/V was safe and well tolerated, led to a significantly greater reduction in N-terminal pro-B-type natriuretic peptide, and improved clinical outcomes compared with enalapril irrespective of previous HF history or ACE inhibitor or ARB treatment.

source: J Am Coll Cardiol.

Summary

Angiotensin Receptor-Neprilysin Inhibition Based on History of Heart Failure and Use of Renin-Angiotensin System Antagonists

[Posted 07/Oct/2020]

AUDIENCE: Cardiology, Internal Medicine, Emergency Medicine

KEY FINDINGS: Among patients admitted for acute decompensated HF, S/V was safe and well tolerated, led to a significantly greater reduction in N-terminal pro-B-type natriuretic peptide, and improved clinical outcomes compared with enalapril irrespective of previous HF history or ACE inhibitor or ARB treatment.

BACKGROUND: The PIONEER-HF (comParIson Of sacubitril/valsartaN versus Enalapril on Effect on nt-pRo-bnp in patients stabilized from an acute Heart Failure episode) trial demonstrated the efficacy and safety of sacubitril/valsartan (S/V) in stabilized patients with acute decompensated heart failure (HF) and reduced ejection fraction. The study sought to determine whether and how prior HF history and treatment with an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) affected the results.

DETAILS: The PIONEER-HF trial was a prospective, multicenter, double-blind, randomized clinical trial enrolling 881 patients with an ejection fraction <=40%. Patients were randomly assigned 1:1 to in-hospital initiation of S/V (n = 440) versus enalapril (n = 441). Pre-specified subgroup analyses were performed based on prior HF history (i.e., de novo HF vs. worsening chronic HF) and treatment with an ACE inhibitor or ARB (i.e., ACE inhibitor or ARB-yes vs. ACE inhibitor or ARB-no) at admission. At enrollment, 303 (34%) patients presented with de novo HF and 576 (66%) patients with worsening chronic HF. A total of 421 (48%) patients had been treated with an ACE inhibitor or ARB, while 458 (52%) had not been treated with an ACE inhibitor or ARB. N-terminal pro-B-type natriuretic peptide declined significantly in all 4 subgroups (p < 0.001), with greater decreases in the S/V versus the enalapril arm (p < 0.001). There was no interaction between prior HF history (p = 0.350) or ACE inhibitor or ARB treatment (p = 0.880) and the effect of S/V versus enalapril on cardiovascular death or rehospitalization for HF. The incidences of adverse events were comparable between S/V and enalapril across all 4 subgroups.

Our Most Popular Apps

The Washington Manual - Cardiology Subspecialty Consult
Swanton's Cardiology A Concise Guide to Clinical Practice
Cardiac Care Unit Guide

Source: Ambrosy, A. P., Braunwald, E., Morrow, D. A., DeVore, A. D., McCague, K., Meng, X., … Velazquez, E. J. (2020). Angiotensin Receptor-Neprilysin Inhibition Based on History of Heart Failure and Use of Renin-Angiotensin System Antagonists. Journal of the American College of Cardiology, 76(9), 1034-1048. https://doi.org/10.1016/j.jacc.2020.06.073

Published: Aug 2020


Cost-effectiveness of Contemporary Statin Use Guidelines With or Without Coronary Artery Calcium Assessment in African American Individuals

A CAC assessment-guided strategy for statin therapy appears to be cost-effective compared with initiating statin therapy in all African American individuals at intermediate risk for atherosclerotic cardiovascular disease and may provide greater quality-adjusted life expectancy at a lower cost.

source: JAMA

Summary

Cost-effectiveness of Contemporary Statin Use Guidelines With or Without Coronary Artery Calcium Assessment in African American Individuals

[Posted 05/Oct/2020]

AUDIENCE: Cardiology, Internal Medicine, Emergency Medicine

KEY FINDINGS: A CAC assessment-guided strategy for statin therapy appears to be cost-effective compared with initiating statin therapy in all African American individuals at intermediate risk for atherosclerotic cardiovascular disease and may provide greater quality-adjusted life expectancy at a lower cost than a non-CAC assessment-guided strategy when there is a strong patient preference to avoid the need for daily medication. Coronary artery calcium testing may play a role in shared decision-making regarding statin use.

BACKGROUND: Clinical and economic consequences of statin treatment guidelines supplemented by targeted coronary artery calcium (CAC) assessment have not been evaluated in African American individuals, who are at increased risk for atherosclerotic cardiovascular disease and less likely than non-African American individuals to receive statin therapy. To evaluate the cost-effectiveness of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline without a recommendation for CAC assessment vs the 2018 ACC/AHA guideline recommendation for use of a non-0 CAC score measured on one occasion to target generic-formulation, moderate-intensity statin treatment in African American individuals at risk for atherosclerotic cardiovascular disease.

DETAILS: A microsimulation model was designed to estimate life expectancy, quality of life, costs, and health outcomes over a lifetime horizon. African American-specific data from 472 participants in the Jackson Heart Study (JHS) at intermediate risk for atherosclerotic cardiovascular disease and other US population-specific data on individuals from published sources were used. In a model-based economic evaluation informed in part by follow-up data, the analysis was focused on 472 individuals in the JHS at intermediate risk for atherosclerotic cardiovascular disease; mean (SD) age was 63 (6.7) years. The sample included 243 women (51.5%) and 229 men (48.5%). Of these, 178 of 304 participants (58.6%) who underwent CAC assessment had a non-0 CAC score. In the base-case scenario, implementation of 2013 ACC/AHA guidelines without CAC assessment provided a greater quality-adjusted life expectancy (0.0027 QALY) at a higher cost ($428.97) compared with the 2018 ACC/AHA guideline strategy with CAC assessment, yielding an incremental cost-effectiveness ratio of $158,325/QALY, which is considered to represent low-value care by the ACC/AHA definition. The 2018 ACC/AHA guideline strategy with CAC assessment provided greater quality-adjusted life expectancy at a lower cost compared with the 2013 ACC/AHA guidelines without CAC assessment when there was a strong patient preference to avoid use of daily medication therapy. In probability sensitivity analyses, the 2018 ACC/AHA guideline strategy with CAC assessment was cost-effective compared with the 2013 ACC/AHA guidelines without CAC assessment in 76% of simulations at a willingness-to-pay value of $100,000/QALY when there was a preference to lose 2 weeks of perfect health to avoid 1 decade of daily therapy.

Our Most Popular Resources

Source: Spahillari, A., Zhu, J., Ferket, B. S., Hunink, M. G. M., Carr, J. J., Terry, J. G., … Pandya, A. (2020). Cost-effectiveness of Contemporary Statin Use Guidelines with or without Coronary Artery Calcium Assessment in African American Individuals. JAMA Cardiology, 5(8), 871-880. https://doi.org/10.1001/jamacardio.2020.1240

Published: Aug 2020


Association of Sex With Severity of Coronary Artery Disease, Ischemia, and Symptom Burden in Patients With Moderate or Severe Ischemia

Women in the ISCHEMIA trial had more frequent angina, independent of less extensive CAD, and less severe ischemia than men. These findings reflect inherent sex differences in the complex relationships between angina, atherosclerosis, and ischemia that may have implications for testing and treatment of patients with suspected stable ischemic heart disease.

source: JAMA

Summary

Association of Sex With Severity of Coronary Artery Disease, Ischemia, and Symptom Burden in Patients With Moderate or Severe Ischemia

Secondary Analysis of the ISCHEMIA Randomized Clinical Trial

[Posted 30/Sep/2020]

AUDIENCE: Cardiology, Internal Medicine, Emergency Medicine

KEY FINDINGS: Women in the ISCHEMIA trial had more frequent angina, independent of less extensive CAD, and less severe ischemia than men. These findings reflect inherent sex differences in the complex relationships between angina, atherosclerosis, and ischemia that may have implications for testing and treatment of patients with suspected stable ischemic heart disease.

BACKGROUND: While many features of stable ischemic heart disease vary by sex, differences in ischemia, coronary anatomy, and symptoms by sex have not been investigated among patients with moderate or severe ischemia. The enrolled ISCHEMIA trial cohort that underwent coronary computed tomographic angiography (CCTA) was required to have obstructive coronary artery disease (CAD) for randomization. Aim of study was to describe sex differences in stress testing, CCTA findings, and symptoms in ISCHEMIA trial participants.

DETAILS: This secondary analysis of the multicenter ISCHEMIA randomized clinical trial analyzed baseline characteristics of patients with stable ischemic heart disease. Individuals were enrolled from July 2012 to January 2018 based on local reading of moderate or severe ischemia on a stress test, after which blinded CCTA was performed in most. Core laboratories reviewed stress tests and CCTAs. Participants with no obstructive CAD or with left main CAD of 50% or greater were excluded. Those who met eligibility criteria including CCTA (if performed) were randomized to a routine invasive or a conservative management strategy (N = 5179). Angina was assessed using the Seattle Angina Questionnaire. Analysis began October 1, 2018. Of 8518 patients enrolled, 6256 (77%) were men. Women were more likely to have no obstructive CAD (<50% stenosis in all vessels on CCTA) (353 of 1022 [34.4%] vs 378 of 3353 [11.3%]). Of individuals who were randomized, women had more angina at baseline than men (median [interquartile range] Seattle Angina Questionnaire Angina Frequency score: 80 [70-100] vs 90 [70-100]). Women had less severe ischemia on stress imaging (383 of 919 [41.7%] vs 1361 of 2972 [45.9%] with severe ischemia; 386 of 919 [42.0%] vs 1215 of 2972 [40.9%] with moderate ischemia; and 150 of 919 [16.4%] vs 394 of 2972 [13.3%] with mild or no ischemia). Ischemia was similar by sex on exercise tolerance testing. Women had less extensive CAD on CCTA (205 of 568 women [36%] vs 1142 of 2418 men [47%] with 3-vessel disease; 184 of 568 women [32%] vs 754 of 2418 men [31%] with 2-vessel disease; and 178 of 568 women [31%] vs 519 of 2418 men [22%] with 1-vessel disease). Female sex was independently associated with greater angina frequency (odds ratio, 1.41; 95% CI, 1.13-1.76).

Our Most Popular Apps

The Washington Manual - Cardiology Subspecialty Consult
Swanton's Cardiology A Concise Guide to Clinical Practice
Cardiac Care Unit Guide

Source: Reynolds, H. R., Shaw, L. J., Min, J. K., Spertus, J. A., Chaitman, B. R., Berman, D. S., … Hochman, J. S. (2020). Association of Sex with Severity of Coronary Artery Disease, Ischemia, and Symptom Burden in Patients with Moderate or Severe Ischemia: Secondary Analysis of the ISCHEMIA Randomized Clinical Trial. JAMA Cardiology, 5(7), 773–786. https://doi.org/10.1001/jamacardio.2020.0822

Published: Aug 2020


Influence of Sex on Platelet Reactivity in Response to Aspirin

Agonist-dependent sex differences in platelet responses to aspirin was observed. Despite higher cyclooxygenase-1 inhibition, daily aspirin exposure resulted in a paradoxical attenuation of platelet inhibition in response to epinephrine and ADP over time in women but not in men.

source: J Am Heart Ass

Summary

Influence of Sex on Platelet Reactivity in Response to Aspirin

[Posted 22/Sep/2020]

AUDIENCE: Cardiology, Internal Medicine, Emergency Medicine

KEY FINDINGS: Agonist-dependent sex differences in platelet responses to aspirin. Despite higher cyclooxygenase-1 inhibition, daily aspirin exposure resulted in a paradoxical attenuation of platelet inhibition in response to epinephrine and ADP over time in women but not in men.

BACKGROUND: There are sex differences in the efficacy and safety of aspirin for the prevention of myocardial infarction and stroke. Whether this is explained by underlying differences in platelet reactivity and aspirin response remains poorly understood.

DETAILS: Healthy volunteers (n=378,208 women) and patients with coronary artery disease or coronary artery disease risk factors (n=217, 112 women) took aspirin for 4 weeks. Light transmittance aggregometry using platelet-rich plasma was used to measure platelet reactivity in response to epinephrine, collagen, and ADP at baseline, 3 hours after the first aspirin dose, and after 4 weeks of daily aspirin therapy. A subset of patients underwent pharmacokinetic and pharmacodynamic assessment with levels of salicylate and cyclooxygenase-1-derived prostaglandin metabolites and light transmittance aggregometry in response to arachidonic acid and after ex vivo exposure to aspirin. At baseline, women had increased platelet aggregation in response to ADP and collagen. Innate platelet response to aspirin, assessed with ex vivo aspirin exposure of baseline platelets, did not differ by sex. Three hours after the first oral aspirin dose, platelet aggregation was inhibited in women to a greater degree in response to epinephrine and to a lesser degree with collagen. After 4 weeks of daily therapy, despite higher salicylate concentrations and greater cy-clooxygenase-1 inhibition, women exhibited an attenuation of platelet inhibition in response to epinephrine and ADP.

Our Most Popular Resources

Source: Friede, K., Infeld, M., Tan, R., Knickerbocker, H., Myers, R., Dubois, L., ... Voora, D. (2020). Influence of Sex on Platelet Reactivity in Response to Aspirin. Journal of the American Heart Association (JAHA), 9(14), e014726. https://doi.org/10.1161/JAHA.119.014726

Published: July 2020


Ticagrelor is Not Superior to Clopidogrel in Patients with Acute Coronary Syndromes Undergoing PCI

In the observational study, treatment with ticagrelor was not superior to clopidogrel in patients with acute coronary syndromes treated with PCI.

source: AHA Journal

Summary

Ticagrelor is Not Superior to Clopidogrel in Patients With Acute Coronary Syndromes Undergoing PCI: A Report from Swedish Coronary Angiography and Angioplasty Registry

[Posted 15/Sep/2020]

AUDIENCE: Cardiology, Internal Medicine, Emergency Medicine

KEY FINDINGS: In this observational study, treatment with ticagrelor was not superior to clopidogrel in patients with acute coronary syndromes treated with PCI.

BACKGROUND: Ticagrelor reduces ischemic end points in acute coronary syndromes. However, outcomes of ticagrelor versus clopidogrel in real-world patients with acute coronary syndromes treated with percutaneous coronary intervention (PCI) remain unclear. We sought to examine whether treatment with ticagrelor is superior to clopidogrel in unselected patients with acute coronary syndromes treated with PCI.

DETAILS: Data from SCAAR (Swedish Coronary Angiography and Angioplasty Registry) for PCI performed in Västra Götaland County, Sweden was collected. The database contains information about all PCI performed at 5 hospitals (~20% of all data in SCAAR). All procedures between January 2005 and January 2015 for unstable angina/non-ST-segment-elevation myocardial infarction and ST-segment-elevation myocardial infarction was included. We used instrumental variable 2-stage least squares regression to adjust for confounders. The primary combined end point was mortality or stent thrombosis at 30 days, secondary end points were mortality at 30 days and 1-year, stent thrombosis at 30 days, in-hospital bleeding, in-hospital neurologic complications and long-term mortality. A total of 15 097 patients were included in the study of which 2929 (19.4%) were treated with ticagrelor. Treatment with ticagrelor was not associated with a lower risk for the primary end point (adjusted odds ratio [aOR], 1.20; 95% CI, 0.87–1.61; P=0.250). Estimated risk of death at 30 days (aOR, 1.18; 95% CI, 0.88–1.64; P=0.287) and at 1-year (aOR, 1.28; 95% CI, 0.86–1.64; P=0.556) was not different between the groups. The risk of in-hospital bleeding was higher with ticagrelor (aOR, 2.88; 95% CI, 1.53–5.44; P=0.001).

Our Most Popular Apps

The Washington Manual - Cardiology Subspecialty Consult
Swanton's Cardiology A Concise Guide to Clinical Practice
Cardiac Care Unit Guide

Source: http:// Völz, S., Petursson, P., Odenstedt, J., Ioanes, D., Haraldsson, I., Angerås, O., … Omerovic, E. (2020). Ticagrelor is Not Superior to Clopidogrel in Patients With Acute Coronary Syndromes Undergoing PCI: A Report from Swedish Coronary Angiography and Angioplasty Registry. Journal of the American Heart Association, 9(14), e015990. https://doi.org/10.1161/JAHA.119.015990

Published: July 2020


New Electrocardiographic Algorithm for the Diagnosis of Acute Myocardial Infarction in Patients With Left Bundle Branch Block

In patients with left bundle branch block referred for primary percutaneous coronary intervention, the BARCELONA algorithm was specific and highly sensitive for the diagnosis of AMI, leading to a diagnostic accuracy comparable to that obtained by ECG in patients without left bundle branch block.

source: AHA Journal

Summary

New Electrocardiographic Algorithm for the Diagnosis of Acute Myocardial Infarction in Patients With Left Bundle Branch Block

[Posted 08/Sep/2020]

AUDIENCE: Cardiology, Internal Medicine, Emergency Medicine

KEY FINDINGS: In patients with left bundle branch block referred for primary percutaneous coronary intervention, the BARCELONA algorithm was specific and highly sensitive for the diagnosis of AMI, leading to a diagnostic accuracy comparable to that obtained by ECG in patients without left bundle branch block.

BACKGROUND: Current electrocardiographic algorithms lack sensitivity to diagnose acute myocardial infarction (AMI) in the presence of left bundle branch block.

DETAILS: A multicenter retrospective cohort study including consecutive patients with suspected AMI and left bundle branch block, referred for primary percutaneous coronary intervention between 2009 and 2018. Pre-2015 patients formed the derivation cohort (n=163, 61 with AMI); patients between 2015 and 2018 formed the validation cohort (n=107, 40 with AMI). A control group of patients without suspected AMI was also studied (n=214). Different electrocardiographic criteria were tested. A total of 484 patients were studied. A new electrocardiographic algorithm (BARCELONA algorithm) was derived and validated. The algorithm is positive in the presence of ST deviation >=1 mm (0.1 mV) concordant with QRS polarity, in any lead, or ST deviation >=1 mm (0.1 mV) discordant with the QRS, in leads with max (R|S) voltage (the voltage of the largest deflection of the QRS, ie, R or S wave) <=6 mm (0.6 mV). In both the derivation and the validation cohort, the BARCELONA algorithm achieved the highest sensitivity (93%-95%), negative predictive value (96%-97%), efficiency (91%-94%) and area under the receiver operating characteristic curve (0.92-0.93), significantly higher than previous electrocardiographic rules (P<0.01); the specificity was good in both groups (89%-94%) as well as the control group (90%).

Our Most Popular Resources

Source: Di Marco, A., Rodriguez, M., Cinca, J., Bayes-Genis, A., Ortiz-Perez, J. T., Ariza-Solé, A., … Anguera, I. (2020). New Electrocardiographic Algorithm for the Diagnosis of Acute Myocardial Infarction in Patients With Left Bundle Branch Block. Journal of the American Heart Association, 9(14), e015573. https://doi.org/10.1161/JAHA.119.015573

Published: July 2020


Randomized Comparison of the Polymer-Free Biolimus-Coated BioFreedom Stent with the Ultrathin Strut Biodegradable Polymer Sirolimus-Eluting Orsiro Stent

The biolimus A9-coated BioFreedom polymer-free stent did not meet criteria for noninferiority for major adverse cardiovascular events at 12 months when compared with the ultrathin strut biodegradable polymer sirolimus-eluting Orsiro stent in an all-comers population.

source: Circulation

Summary

Randomized Comparison of the Polymer-Free Biolimus-Coated BioFreedom Stent With the Ultrathin Strut Biodegradable Polymer Sirolimus-Eluting Orsiro Stent in an All-Comers Population Treated With Percutaneous Coronary Intervention

[Posted 01/Sep/2020]

AUDIENCE: Cardiology, Internal Medicine, Emergency Medicine

KEY FINDINGS: The biolimus A9-coated BioFreedom polymer-free stent did not meet criteria for noninferiority for major adverse cardiovascular events at 12 months when compared with the ultrathin strut biodegradable polymer sirolimus-eluting Orsiro stent in an all-comers population

BACKGROUND: In patients with increased bleeding risk, the biolimus A9-coated BioFreedom stent, a stainless-steel drug-coated stent free from polymer, has shown superiority compared with a bare-metal stent. The aim of this study was to investigate whether the BioFreedom stent is noninferior to a modern ultrathin strut biodegradable polymer cobalt-chromium sirolimus-eluting Orsiro stent in an all-comers patient population treated with percutaneous coronary intervention.

DETAILS: A large-scale, registry-based, randomized, multicenter, single-blind, 2-arm, noninferiority trial was conducted. The primary end point, major adverse cardiovascular events, was defined as the composite of cardiac death, myocardial infarction not related to any segment other than the target lesion, or target lesion revascularization within 1 year, analyzed by intention-to-treat. The trial was powered to assess noninferiority for major adverse cardiovascular events of the BioFreedom stent compared with the Orsiro stent with a predetermined noninferiority margin of 0.021. 3151 patients were assigned to treatment with the BioFreedom stent (1572 patients, 1966 lesions) or to the Orsiro stent (1579 patients, 1985 lesions). Five patients were lost to follow-up because of emigration (99.9% follow-up rate). Mean age was 66.3±10.9, diabetes mellitus was seen in 19.3% of patients, and 53% of the patients had acute coronary syndromes. At 1 year, intention-to-treat analysis showed that 79 (5.0%) patients, who were assigned the BioFreedom stent, and 59 (3.7%), who were assigned the Orsiro stent, met the primary end point (absolute risk difference 1.29% [upper limit of one-sided 95% CI 2.50%]; Pnoninferiority=0.14). Significantly more patients in the BioFreedom stent group had target lesion revascularization than those in the Orsiro stent group (55 [3.5%] vs 20 [1.3%], rate ratio 2.77 [95% CI, 1.66–4.62]; P<0.0001).

Our Most Popular Apps

The Washington Manual - Cardiology Subspecialty Consult
Swanton's Cardiology A Concise Guide to Clinical Practice
Cardiac Care Unit Guide

Source: Jensen, L. O., Maeng, M., Raungaard, B., Kahlert, J., Ellert, J., Jakobsen, L., … Andersen, H. R. (2020). Randomized Comparison of the Polymer-Free Biolimus-Coated BioFreedom Stent With the Ultrathin Strut Biodegradable Polymer Sirolimus-Eluting Orsiro Stent in an All-Comers Population Treated With Percutaneous Coronary Intervention. Circulation, 141(25), 2052–2063. https://doi.org/10.1161/circulationaha.119.040241

Published: July 2020


Comparative Efficacy and Safety of Oral P2Y12 Inhibitors in Acute Coronary Syndrome

Prasugrel and ticagrelor reduced ischemic events and increased bleeding in comparison with clopidogrel. A significant mortality reduction was observed with ticagrelor only. There was no efficacy and safety difference between prasugrel and ticagrelor.

source: Circulation

Summary

Comparative Efficacy and Safety of Oral P2Y12 Inhibitors in Acute Coronary Syndrome

[Posted 26/Aug/2020]

AUDIENCE: Cardiology, Internal Medicine, Emergency Medicine

KEY FINDINGS: Prasugrel and ticagrelor reduced ischemic events and increased bleeding in comparison with clopidogrel. A significant mortality reduction was observed with ticagrelor only. There was no efficacy and safety difference between prasugrel and ticagrelor.

BACKGROUND: New randomized, controlled trials have become available on oral P2Y12 inhibitors in acute coronary syndrome. Current evidence comparing the efficacy and safety profile of prasugrel, ticagrelor, and clopidogrel in acute coronary syndrome was evaluated by a meta-analysis of randomized controlled trials.

DETAILS: A network meta-analysis and direct pairwise comparison analysis of efficacy and safety outcomes from 12 randomized controlled trials including a total of 52,816 patients with acute coronary syndrome was performed. In comparison with clopidogrel, ticagrelor significantly reduced cardiovascular mortality (hazard ratio [HR], 0.82 [95% CI, 0.72-0.92]) and all-cause mortality (HR, 0.83 [95% CI, 0.75-0.92]), whereas there was no statistically significant mortality reduction with prasugrel (HR, 0.90 [95% CI, 0.80-1.01] and HR, 0.92 [95% CI, 0.84-1.02], respectively). In comparison with each other, there were no significant differences in mortality (HR prasugrel versus ticagrelor, 1.10 [95% CI, 0.94-1.29] and 1.12 [95% CI, 0.98-1.28]). In comparison with clopidogrel, prasugrel reduced myocardial infarction (HR, 0.81 [95% CI, 0.67-0.98]), whereas ticagrelor showed no risk reduction (HR, 0.97 [95% CI, 0.78-1.22]). Differences between prasugrel and ticagrelor were not statistically significant. Stent thrombosis risk was significantly reduced by both ticagrelor and prasugrel versus clopidogrel (28%-50% range of reduction). In comparison with clopidogrel, both prasugrel (HR, 1.26 [95% CI, 1.01-1.56]) and ticagrelor (HR, 1.27 [95% CI, 1.04-1.55]) significantly increased major bleeding. There were no significant differences between prasugrel and ticagrelor for all outcomes explored.

Our Most Popular Resources

Source: Navarese, E. P., Khan, S. U., Kolodziejczak, M., Kubica, J., Buccheri, S., Cannon, C. P., … James, S. (2020). Comparative Efficacy and Safety of Oral P2Y12 Inhibitors in Acute Coronary Syndrome: Network Meta-Analysis of 52,816 Patients from 12 Randomized Trials. Circulation. https://doi.org/10.1161/circulationaha.120.046786

Published: July 2020


Effect of Evolocumab on Type and Size of Subsequent Myocardial Infarction

Low-density lipoprotein cholesterol lowering with evolocumab was highly effective in reducing the risk of MI. This reduction with evolocumab included benefit across multiple subtypes of MI related to plaque rupture, smaller and larger MIs, and both STEMI and non–STEMI.

source: JAMA

Summary

Effect of Evolocumab on Type and Size of Subsequent Myocardial Infarction

A Prespecified Analysis of the FOURIER Randomized Clinical Trial

[Posted 18/Aug/2020]

AUDIENCE: Cardiology, Internal Medicine, Emergency Medicine

KEY FINDINGS: Low-density lipoprotein cholesterol lowering with evolocumab was highly effective in reducing the risk of MI. This reduction with evolocumab included benefit across multiple subtypes of MI related to plaque rupture, smaller and larger MIs, and both STEMI and non-STEMI. These data are consistent with the known benefit of low-density lipoprotein cholesterol lowering and underscore the reduction in clinically meaningful events.

BACKGROUND: The PCSK9 inhibitor evolocumab reduced major vascular events in the Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Subjects With Elevated Risk (FOURIER) trial, yet the types and sizes of myocardial outcomes in FOURIER have not been previously explored.

DETAILS: Patients were randomized to evolocumab or placebo and followed up for a median of 2.2 years. The study included 27,564 patients with stable atherosclerotic disease receiving statin therapy. Clinical end points were evaluated by the Thrombolysis in Myocardial Infarction clinical events committee. Rates presented are 3-year Kaplan-Meier estimates. Data were collected from 2013 to 2016 and analyzed from June 2017 to December 2019. Myocardial infarction was defined based on the third universal MI definition, and further classified according to MI type (universal MI subclass, ST-segment elevation myocardial infarction [STEMI] vs non-STEMI) and by MI size (determined by peak troponin level). A total of 27,564 patients were randomized, with a mean (SD) age of 62.5 (9.0) years, and 20,795 (75%) were male. Of these, 1107 patients experienced a total of 1288 MIs. Most MIs (68%) were atherothrombotic (type 1), with 15% from myocardial oxygen supply-demand mismatch (type 2) and 15% percutaneous coronary intervention-related (type 4). Sudden death (type 3) and coronary artery bypass grafting-related (type 5) accounted for a total of 21 MIs (<2%). Evolocumab significantly reduced the risk of first MI by 27% (4.4% vs 6.3%; hazard ratio [HR], 0.73; 95% CI, 0.65-0.82; P < .001), type 1 by 32% (2.9% vs 4.5%; HR, 0.68; 95% CI, 0.59-0.79; P < .001), and type 4 by 35% (0.8% vs 1.1%; HR, 0.65; 95% CI, 0.48-0.87; P = .004), with no effect on type 2 (0.9% vs 0.8%; HR, 1.09; 95% CI, 0.82-1.45; P = .56). Most MIs (688 [59.8%]) had troponin levels greater than or equal to 10 times the upper limit of normal. The benefit was highly significant and consistent regardless of the size of MI with a 34% reduction in MIs with troponin level greater than or equal to 10 times the upper limit of normal (2.6% vs 3.7%; HR, 0.66; 95% CI, 0.56-0.77; P < .001) and a 36% reduction in the risk of STEMI (1.0% vs 1.5%; HR, 0.64; 95% CI, 0.49-0.84; P < .001).

Our Most Popular Apps

The Washington Manual - Cardiology Subspecialty Consult
Swanton's Cardiology A Concise Guide to Clinical Practice
Cardiac Care Unit Guide

Source: Wiviott, S. D., Giugliano, R. P., Morrow, D. A., De Ferrari, G. M., Lewis, B. S., Huber, K., … Sabatine, M. S. (2020). Effect of Evolocumab on Type and Size of Subsequent Myocardial Infarction: A Prespecified Analysis of the FOURIER Randomized Clinical Trial. JAMA Cardiology, 5(7), 787-793. https://doi.org/10.1001/jamacardio.2020.0764

Published: July 2020


Specialty: 

Pediatrics Internal Medicine Nursing Pharmacy Gastroenterology Ob/Gyn Ophthalmology Nephrology Emergency Medicine Family Medicine Breaking Medical News Hematology/Oncology Infectious Disease Neurology Cardiology Endocrinology General Surgery General Interests Psychiatry