The elderly constitute an increasing proportion of acute myocardial infarction patients and have disproportionately high mortality and morbidity. Those with heart failure or impaired left ventricular ...left ventricular function after acute myocardial infarction have high complication and mortality rates. Little is known about outcomes with contemporary therapies in these patients.
The Valsartan in Acute Myocardial Infarction Trial (VALIANT) randomized 14,703 patients with heart failure and/or left ventricular ejection fraction <40% to receive captopril, valsartan, or both. Mortality and a composite end point, including cardiovascular mortality, readmission for heart failure, reinfarction, stroke, and resuscitated cardiac arrest, were compared for the age groups of <65 (n=6988), 65 to 74 (n=4555), 75 to 84 (n=2777), and > or =85 (n=383) years. With increasing age, 3-year mortality almost quadrupled (13.4%, 26.3%, 36.0%, and 52.1%, respectively), composite end-point events more than doubled (25.2%, 41.0%, 52.3%, and 66.8%), and hospital admissions for heart failure almost tripled (12.0%, 23.1%, 31.3%, and 35.4%). Outcomes did not differ between the 3 study treatments in any age group. Adverse events associated with captopril and valsartan were more common in the elderly and in patients receiving combination therapy. With increasing age, use of aspirin, beta-blockers, and statins declined, and use of digoxin, calcium-channel blockers, and non-potassium-sparing diuretics increased. On 3-year multivariable analysis, each 10-year age increase was associated with a hazard ratio of 1.49 (95% CI, 1.426 to 1.557; P<0.0001) for mortality and an odds ratio of 1.38 (95% CI, 1.31 to 1.46; P<0.0001) for readmission with heart failure.
Outcomes remained poor in elderly patients with heart failure and/or impaired left ventricular systolic function after acute myocardial infarction, although most received beta-blockers and all received an ACE inhibitor and/or an angiotensin receptor blocker. Better therapies and increased use of aspirin, beta-blockers, and statins are needed in this important and increasing patient group.
This case presentation concerns a woman known to have fibromuscular dysplasia (FMD) who presented with an acute coronary syndrome (ACS). The coronary angiogram was considered to be normal. However, ...as spontaneous coronary artery dissection (SCAD) has a close association with FMD, subsequent meticulous review of the angiogram revealed a dissection within the circumflex coronary artery. SCAD causes 10% of ACS seen in women under 55 years of age. Both FMD and SCAD are underdiagnosed and SCAD may be overlooked or misdiagnosed on coronary angiography. The recommended management of SCAD differs from that of the usual presentations of ACS. For this reason, one should be alert to the possibility of SCAD when confronted by ACS in a younger woman, especially when she is known to have FMD.
Warfarin in non-valvular atrial fibrillation Dalby, Anthony J; Wessels, Pieter; Opie, Lionel H
SAMJ: South African Medical Journal,
12/2013, Letnik:
103, Številka:
12
Journal Article
Recenzirano
Odprti dostop
The development of novel oral anticoagulants that are effective alternatives to warfarin in non-valvular atrial fibrillation (AF) is a welcome advance. However, a variety of unresolved problems with ...their use, and not least with their cost, make it important to re-evaluate the use of warfarin as it will likely remain the anticoagulant of choice in South African patients with non-valvular AF for the foreseeable future. In this article, we review the correct clinical use of warfarin. Guidance is provided on commencing warfarin treatment, maintenance dosing, the recommended steps when temporary withdrawal of treatment is necessary, the management of bleeding, and the use of warfarin in chronic kidney disease. Techniques for changing from warfarin to one of the new oral anticoagulants and vice versa are included.
Previous trials of PCSK9 (proprotein convertase subtilisin-kexin type 9) inhibitors demonstrated reductions in major adverse cardiovascular events, but not death. We assessed the effects of ...alirocumab on death after index acute coronary syndrome.
ODYSSEY OUTCOMES (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) was a double-blind, randomized comparison of alirocumab or placebo in 18 924 patients who had an ACS 1 to 12 months previously and elevated atherogenic lipoproteins despite intensive statin therapy. Alirocumab dose was blindly titrated to target achieved low-density lipoprotein cholesterol (LDL-C) between 25 and 50 mg/dL. We examined the effects of treatment on all-cause death and its components, cardiovascular and noncardiovascular death, with log-rank testing. Joint semiparametric models tested associations between nonfatal cardiovascular events and cardiovascular or noncardiovascular death.
Median follow-up was 2.8 years. Death occurred in 334 (3.5%) and 392 (4.1%) patients, respectively, in the alirocumab and placebo groups (hazard ratio HR, 0.85; 95% CI, 0.73 to 0.98; P=0.03, nominal P value). This resulted from nonsignificantly fewer cardiovascular (240 2.5% vs 271 2.9%; HR, 0.88; 95% CI, 0.74 to 1.05; P=0.15) and noncardiovascular (94 1.0% vs 121 1.3%; HR, 0.77; 95% CI, 0.59 to 1.01; P=0.06) deaths with alirocumab. In a prespecified analysis of 8242 patients eligible for ≥3 years follow-up, alirocumab reduced death (HR, 0.78; 95% CI, 0.65 to 0.94; P=0.01). Patients with nonfatal cardiovascular events were at increased risk for cardiovascular and noncardiovascular deaths ( P<0.0001 for the associations). Alirocumab reduced total nonfatal cardiovascular events ( P<0.001) and thereby may have attenuated the number of cardiovascular and noncardiovascular deaths. A post hoc analysis found that, compared to patients with lower LDL-C, patients with baseline LDL-C ≥100 mg/dL (2.59 mmol/L) had a greater absolute risk of death and a larger mortality benefit from alirocumab (HR, 0.71; 95% CI, 0.56 to 0.90; P
=0.007). In the alirocumab group, all-cause death declined with achieved LDL-C at 4 months of treatment, to a level of approximately 30 mg/dL (adjusted P=0.017 for linear trend).
Alirocumab added to intensive statin therapy has the potential to reduce death after acute coronary syndrome, particularly if treatment is maintained for ≥3 years, if baseline LDL-C is ≥100 mg/dL, or if achieved LDL-C is low.
URL: https://www.clinicaltrials.gov . Unique identifier: NCT01663402.
Background Bleeding is a major limitation of antithrombotic therapy among invasively managed non–ST-segment elevation acute coronary syndromes (NSTE-ACS) patients; therefore, we examined the use of ...radial access and its association with outcomes among NSTE-ACS patients. Methods Clinical characteristics and geographic variation in radial access were examined, as well as its association with bleeding, red blood cell transfusion and ischemic outcomes (96-hour death/myocardial infarction/recurrent ischemic/thrombotic bailout; 30-day death/myocardial infarction; 1-year death) in the EARLY versus delayed, provisional eptifibatide in acute coronary syndromes trial. Results Of 9126 patients, 13.5% underwent radial-access catheterization. Female sex, age, weight, and prior revascularization were inversely associated with radial access, and its use varied widely by country (2%-97%). There were fewer GUSTO severe/moderate bleeds and red blood cell transfusions in the radial access group; however, it was attenuated after adjustment (odds ratio 0.73, 95% confidence intervals CI 0.50-1.06, P = .094 and 1.00 0.71-1.40 P = .991). Ischemic outcomes did not differ by access site. Conclusions In this post hoc analysis of a large clinical trial, there was significant international variation in use of radial access for NSTE-ACS patients undergoing invasive management, and it was preferentially used in those at lower risk for bleeding. Radial approach was not associated with a significant reduction in either bleeding or ischemic outcomes. Further study is needed to determine whether wider application of radial approach to acute coronary syndrome patients at high risk for bleeding improves overall outcomes.
The 2019 European Society of Cardiology Guideline on chronic coronary syndromes(1) defines coronary artery disease (CAD) as the result of atherosclerotic plaque accumulation in the ...epicardial coronary arteries. The disease is chronic and progressive, characterised by long quiescent periods punctuated by acute exacerbations. The chronic coronary syndromes are categorised as (i) stable angina or dyspnoea, (ii) new-onset heart failure or left ventricular dysfunction and suspected CAD, (iii) stable symptomatic or asymptomatic patients less than 1 year after acute coronary syndrome or revascularisation, (iv) stable symptomatic or asymptomatic patients more than 1 year after diagnosis or revascularisation, (v) patients with vasospastic or microvascular angina, and (vi) asymptomatic patients whose CAD is detected at screening.
There have been previous warning signs of epidemiological transition from infection to coronary heart disease in other parts of Africa,5 but the expected rapid transition to an epidemic of coronary ...heart disease6 has not yet happened in black people in Soweto, despite high rates of risk factors and slowly increasing education and income. Soweto is probably also experiencing the major rise in the incidence of tuberculous pericarditis and the advent of HIV-associated cardiomyopathy and myocardial infarction related to antiretroviral therapy that is happening in otherparts of Africa.7 Sliwa and colleagues' results are relevant to many areas of the world that face similar threats and the emergence of epidemics of heart disease.
Efficacy and Safety of Enoxaparin Versus Unfractionated Heparin in Patients With ST-Segment Elevation Myocardial Infarction Also Treated With Clopidogrel Marc S. Sabatine, David A. Morrow, Anthony ...Dalby, Mathias Pfisterer, Tibor Duris, Jose Lopez-Sendon, Sabina A. Murphy, Runlin Gao, Elliott M. Antman, Eugene Braunwald, for the EXTRACT–TIMI 25 Investigators In patients with ST-segment elevation myocardial infarction in the EXTRACT–TIMI 25 (Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment–Thrombolysis In Myocardial Infarction 25) trial, enoxaparin (ENOX) compared with unfractionated heparin (UFH) significantly reduced the rate of death, recurrent myocardial infarction, recurrent myocardial ischemia, or stroke, both in patients treated with clopidogrel (10.8% vs. 13.9%, adjusted odds ratio ORadj 0.70, p = 0.013) and in patients not treated with clopidogrel (13.3% vs. 15.3%, ORadj 0.85, p = 0.003). The excess risk of TIMI major bleeding seen with ENOX versus UFH was numerically but not statistically significantly higher in patients treated with clopidogrel, and there was no significant excess of intracranial hemorrhage with ENOX over UFH regardless of clopidogrel use. Thus, ENOX offers a consistent net clinical benefit over UFH irrespective of concomitant treatment with clopidogrel.
Peripheral artery disease (PAD) is associated with heightened ischemic and bleeding risk in patients with prior myocardial infarction (MI).
This study evaluated the efficacy and safety of ticagrelor ...on major cardiovascular (CV) events and major adverse limb events in patients with PAD and a prior MI.
PEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin—Thrombolysis In Myocardial Infarction 54) randomized 21,162 patients with prior MI (1 to 3 years) to ticagrelor 90 mg twice daily, ticagrelor 60 mg twice daily, or placebo, all on a background of low-dose aspirin. History of PAD was obtained at baseline. Occurrences of major adverse cardiovascular events (MACE) (defined as CV death, MI, or stroke) and major adverse limb events (MALE) (defined as acute limb ischemia or peripheral revascularization for ischemia) were recorded in follow-up.
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 than those without (n = 6,663; 19.3% vs. 8.4%; p < 0.001), which persisted after adjusting for baseline differences (adjusted hazard ratio: 1.60; 95% confidence interval: 1.20 to 2.13; p = 0.0013), and 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, patients with PAD had a greater absolute risk reduction of 4.1% (number needed to treat: 25) due to their higher absolute risk. The absolute excess of TIMI major bleeding was 0.12% (number needed to harm: 834). The 60-mg dose had particularly favorable outcomes for CV and all-cause mortality. Ticagrelor (pooled doses) reduced the risk of MALE (hazard ratio: 0.65; 95% confidence interval: 0.44 to 0.95; p = 0.026).
Among stable patients with prior MI, those with concomitant PAD have heightened ischemic risk. In these patients, ticagrelor reduced MACE, with a large absolute risk reduction, and MALE. (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin PEGASUS-TIMI 54; NCT01225562)
The South African Heart Association (SA Heart®) was established in 1999. Prior to 1999, 2 professional societies represented the interests of cardiologists and cardiac surgeons in South Africa – the ...South African Cardiac Society and the South African Society of Cardiac Practitioners. The latter was formed in 1985 by cardiologists in private practice to serve the interests of private practitioners. At the time, the South African Cardiac Society was based mainly in the academic training institutions and the need arose to have a representative body addressing the needs of private practice. In the late 1990's it became clear that the 2 societies were competing for the same support from industry and were diluting each other’s influence. The realisation that strength lay in unity led to an amalgamation of the 2 societies in 1999 – to form the SA Heart® Association. In this commentary, Dr Tony Dalby provides us with a personal reflection of the history of the South African Society of Cardiac Practitioners. In future issues of the SA Heart® Journal, we will feature similar personal reflections to document the history of the South African Cardiac Society and the South African Heart Association.
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