...in previous small clinical series analyzing the effect of therapeutic hypothermia (TH) in patients who undergo PPCI, it was observed that there was an increased rate of stent thrombosis (ST) in ...TH- compared with non-TH-treated patients (2). In the present observational study, even under the prelude of greater hemodynamic support and a higher frequency of hemorrhagic complications in the PPCI-TH-treated patients, the incidence of ST was almost identical to that of patients not treated with TH. ...under the need of further prospective trials, we believe that adequate antithrombotic management could be achieved in this population with both the progressive introduction of third-generation P2Y12 inhibitors and consideration that the route (intravenous aspirin and crushed nasogastric P2Y12) (5) and time (before PPCI) of administration may influence the final result.
Background The Universal Definition of Myocardial Infarction recommends the 99th percentile concentration of cardiac troponin in a normal reference population as part of the decision threshold to ...diagnose type 1 spontaneous myocardial infarction. Adoption of this recommendation in contemporary worldwide practice is not well known. Methods We performed a cohort study of 276 hospital laboratories in 31 countries participating in the National Heart, Lung, and Blood Institute sponsored International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial. Each hospital laboratory's troponin assay manufacturer and model, the recommended assay's 99th percentile upper reference limit (URL) from the manufacturer's package insert, and the troponin concentration used locally as the decision level to diagnose myocardial infarction was ascertained. Results Twenty-one unique troponin assays from 9 manufacturers were used by the surveyed hospital laboratories. The ratio of the troponin concentration used locally to diagnose myocardial infarction to the assay manufacturer-determined 99th percentile URL was <1 at 19 (6.6%) laboratories, equal to 1 at 91 (31.6%) laboratories, >1 to ≤5 at 101 (35.1%) laboratories, >5 to ≤10 at 34 (11.8%) laboratories and >10 at 43 (14.9%) laboratories. The variability in troponin decision level for myocardial infarction relative to the assay 99th percentile URL was present for laboratories in and outside of the United States, as well as for high- and standard-sensitivity assays. Conclusions There is substantial hospital level variation in the troponin threshold used to diagnose myocardial infarction; only one-third of hospital laboratories currently follow the Universal Definition of Myocardial Infarction consensus recommendation for use of troponin concentration at the 99th percentile of a normal reference population as the decision level to diagnose myocardial infarction. This variability across laboratories has important implications both for the diagnosis of myocardial infarction in clinical practice as well as adjudication of myocardial infarction in clinical trials.
Abstract Background Peripheral artery disease (PAD) has been associated with heightened ischemic and bleeding risk in patients with prior myocardial infarction (MI). Objective s: In PEGASUS-TIMI 54, ...a trial of patients with prior MI, we evaluated the efficacy and safety of ticagrelor on major cardiovascular and major adverse limb events in PAD patients. Methods PEGASUS TIMI-54 randomized 21,162 pts with prior MI (1-3 yrs) to ticagrelor 90 mg BID, 60 mg BID, or placebo, all with low-dose aspirin. History of PAD was obtained at baseline. Occurrence of major adverse cardiovascular events (MACE, defined as CV death, MI or stroke) as well as major adverse limb events (MALE, defined as acute limb ischemia or peripheral revascularization for ischemia) were recorded in follow-up. Results A total of 1,143 patients (5%) had known PAD. In the placebo arm, those with PAD (N=404) had higher rates of MACE at 3 years compared to those without (19.3% vs 8.4%, p<0.001), which persisted after adjusting for baseline differences (HRadj 1.60, 95% CI 1.20-2.13 p=0.0013). Patients with known PAD randomized to placebo had higher rates of acute limb ischemia (1.0% vs 0.1%) and peripheral revascularization procedures (9.15% vs 0.46%). Whereas the relative risk reduction in MACE with ticagrelor was consistent regardless of PAD, due to their higher absolute risk of MACE, patients with PAD had a greater absolute risk reduction of 4.1% (NNT of 25). The absolute excess of TIMI major bleeding was 0.12% (NNH of 834). The 60 mg dose had particularly favorable outcomes for CV and all-cause mortality. Ticagrelor (doses pooled) reduced the risk of major adverse limb outcomes (HR 0.65, 95% CI 0.44-0.95, p=0.026). Conclusions In stable patients with prior MI, concomitant PAD is associated with heightened ischemic risk. In these patients ticagrelor appeared to reduce MACE with a large absolute risk reduction. Ticagrelor also significantly reduced major adverse limb outcomes.
Objectives Our aim was to identify shortcomings in the management of patients with both atrial fibrillation (AF) and heart failure (HF). Background AF and HF often coincide in cardiology practice, ...and they are known to worsen each other's prognosis, but little is known about the quality of care of this combination. Methods In the observational Euro Heart Survey on AF, 5,333 AF patients were enrolled in 182 centers across 35 European Society of Cardiology member countries in 2003 and 2004. A follow-up survey was performed after 1 year. Results At baseline, 1,816 patients (34%) had HF. Recommended therapy for HF with left ventricular systolic dysfunction (LVSD) with a beta-blocker and either an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker was prescribed in 40% of HF patients, while 29% received the recommended drug therapy for both LVSD-HF and AF, consisting of the combination of a beta-blocker, either ACEI or angiotensin II receptor blocker, and oral anticoagulation. Rate control was insufficient with 40% of all HF patients with permanent AF having a heart rate ≤80 beats/min. In the total cohort, HF patients had a higher risk for mortality (9.5% vs. 3.3%; p < 0.001), (progression of) HF (24.8% vs. 5.0%; p < 0.001), and AF progression (35% vs. 19%; p < 0.001) during 1-year follow-up. Of all recommended drugs for AF and LVSD-HF, only ACEI prescription was associated with improved survival during 1-year follow-up (odds ratio: 0.51 95% confidence interval: 0.31 to 0.85; p = 0.011). Conclusions The prescription rate of guideline-recommended drug therapy for AF and LVSD-HF is low. Randomized controlled trials targeting this highly prevalent subgroup with AF and HF are warranted.
Acute coronary syndromes (ACS), either ST-elevation myocardial infarction or non–ST-elevation ACS, are still one of the most common cardiac emergencies with substantial morbidity and mortality. The ...availability of evidence-based treatments, such as early and intense platelet inhibition and anticoagulation, and timely reperfusion and revascularization, has substantially improved outcomes in patients with ACS. The implementation of streamlined processes of care for patients with ST-elevation myocardial infarction and non–ST-elevation ACS over the last decade including both appropriate tools, especially cardiac troponin, for rapid diagnosis and risk stratification and for decision support, and the widespread availability of modern antithrombotic and interventional treatments, have reduced morbidity and mortality to unprecedented low levels. These changes in the process of care require a synchronized approach, and research using a team-based strategy and effective regional networks has allowed healthcare systems to provide modern treatments for most patients with ACS. There are still areas needing improvement, such as the delivery of care to people in rural areas or with delayed time to treatment.
Mortality and morbidity in acute coronary syndromes (ACSs), caused principally by plaque erosion or rupture leading to thrombus formation and myocardial ischemia, have been reduced by a combination ...of antithrombotic agents (antiplatelet drugs and anticoagulants) and early revascularization. Aspirin is the foundation antiplatelet agent. New P2Y12 receptor inhibitors (prasugrel and ticagrelor) have clear benefits compared with clopidogrel for dual antiplatelet therapy, and cangrelor or vorapaxar, a thrombin receptor inhibitor, may be of value in specific settings. Anticoagulation uses 1 of 4 choices: bivalirudin, unfractionated heparin, enoxaparin, and fondaparinux. Moreover, some patients (such as those who have chronic atrial fibrillation) require triple therapy with aspirin, clopidogrel, plus an anticoagulant, frequently a vitamin K antagonist. New oral anticoagulants have been shown to be at least as effective as vitamin K antagonists in atrial fibrillation and led to fewer bleeding complications. Finally, the combination of aspirin, clopidogrel, and low-dose rivaroxaban has recently been approved by the European Medicines Agency (but not the Food and Drug Administration) for secondary prevention after ACS. Several strategies have been developed to balance the potential benefit of antithrombotic therapy against the risk of bleeding complications, for example, radial access in coronary angiography or restricted use of combination therapy, and others are under investigation, such as discontinuation of aspirin. This overview summarizes the current status of antithrombotic therapy in ACS and describes strategies currently explored to optimize its benefit/risk ratio.
Double Orifice Mitral Valve García-Blas, Sergio, MD; Salinas, Pablo, MD; Domínguez, Francisco J., MD ...
Journal of the American College of Cardiology,
02/2013, Letnik:
61, Številka:
5
Journal Article
Recenzirano
Odprti dostop
The functional effect is limited to 2 small jets of mild mitral regurgitation, 1 in each hole, as seen in the color Doppler 2- and 3-dimensional images (C, top and bottom panels; Online Video 5).
Background p38 mitogen-activated protein kinase (MAPK) mediates cytokine production and amplification of the inflammatory cascade. Through inhibition of p38 MAPK, losmapimod appears to attenuate the ...inflammatory response in the vascular wall and thus may help stabilize plaques. Study design The LATITUDE-TIMI 60 trial is a randomized, double-blind, placebo-controlled, parallel-group, multicenter study planned to be conducted in a 3-stage design. Overall, the trial is designed to include 25,500 patients hospitalized with non–ST-elevation or ST-elevation myocardial infarction (MI) randomized to oral losmapimod (7.5 mg twice daily) versus matching placebo. Part A consists of a leading cohort (n = 3,500) that will provide an initial assessment of safety and exploratory efficacy before progressing to part B. Part B (n = ~22,000) of the study is event driven and will provide the primary assessment of efficacy. An independent safety review will be conducted after 3,500 patients in part B1 to determine whether a more focused schedule of clinic visits and laboratory assessments can be implemented (part B2). All patients are to be treated with study drug until week 12 and followed up until week 24. The primary end point is the composite of cardiovascular death, MI, or severe recurrent ischemia requiring urgent coronary revascularization. The key secondary end point is the composite of cardiovascular death or MI. The trial is designed to provide ≥90% power for the primary end point. Conclusions The LATITUDE-TIMI 60 trial will determine the efficacy and safety of short-term p38 MAPK inhibition with losmapimod in acute MI. The trial design adopts a stepwise approach to decision making and collection of data.
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