Among patients with diabetes and stable heart disease, those with troponin T levels of 14 ng per liter or more had a 5-year rate of cardiovascular death, MI, or stroke of 27%, versus 13% in those ...with lower levels, but received no benefit from prompt revascularization.
Cardiac troponin concentration is the preferred marker of myocardial necrosis.
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Elevated concentrations of cardiac troponin have a strong association with an adverse prognosis in patients with acute coronary syndromes and are used to identify patients who are likely to benefit from an early invasive management strategy.
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High-sensitivity assays that allow the measurement of very low cardiac troponin levels in patients with stable heart disease are now available for clinical and research use. These low, previously undetectable troponin concentrations have shown strong associations with myocardial infarction, stroke, and death in a variety of primary and secondary prevention populations, including in . . .
Dalcetrapib, an inhibitor of cholesteryl ester transfer protein, raises HDL cholesterol levels. In this clinical trial involving patients with an acute coronary syndrome, dalcetrapib had no ...beneficial effect on clinical outcomes, despite raising HDL cholesterol levels.
High-density lipoproteins (HDLs) participate in the process of cellular cholesterol efflux and may have additional protective effects against atherothrombosis.
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An inverse association between levels of HDL cholesterol and incident events of coronary heart disease has been shown in observational studies
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and persists in most post hoc analyses and meta-analyses of trials of statin therapy for patients with cardiovascular risk factors, chronic cardiovascular disease, or recent acute coronary syndrome.
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However, it remains uncertain whether pharmacologic intervention that raises HDL cholesterol levels results in decreased cardiovascular risk.
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Moreover, changes in HDL cholesterol levels may not reflect changes in the . . .
The ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) postulated that patients with stable coronary artery disease (CAD) and moderate or ...severe ischemia would benefit from revascularization. We investigated the relationship between severity of CAD and ischemia and trial outcomes, overall and by management strategy.
In total, 5179 patients with moderate or severe ischemia were randomized to an initial invasive or conservative management strategy. Blinded, core laboratory-interpreted coronary computed tomographic angiography was used to assess anatomic eligibility for randomization. Extent and severity of CAD were classified with the modified Duke Prognostic Index (n=2475, 48%). Ischemia severity was interpreted by independent core laboratories (nuclear, echocardiography, magnetic resonance imaging, exercise tolerance testing, n=5105, 99%). We compared 4-year event rates across subgroups defined by severity of ischemia and CAD. The primary end point for this analysis was all-cause mortality. Secondary end points were myocardial infarction (MI), cardiovascular death or MI, and the trial primary end point (cardiovascular death, MI, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest).
Relative to mild/no ischemia, neither moderate ischemia nor severe ischemia was associated with increased mortality (moderate ischemia hazard ratio HR, 0.89 95% CI, 0.61-1.30; severe ischemia HR, 0.83 95% CI, 0.57-1.21;
=0.33). Nonfatal MI rates increased with worsening ischemia severity (HR for moderate ischemia, 1.20 95% CI, 0.86-1.69 versus mild/no ischemia; HR for severe ischemia, 1.37 95% CI, 0.98-1.91;
=0.04 for trend,
=NS after adjustment for CAD). Increasing CAD severity was associated with death (HR, 2.72 95% CI, 1.06-6.98) and MI (HR, 3.78 95% CI, 1.63-8.78) for the most versus least severe CAD subgroup. Ischemia severity did not identify a subgroup with treatment benefit on mortality, MI, the trial primary end point, or cardiovascular death or MI. In the most severe CAD subgroup (n=659), the 4-year rate of cardiovascular death or MI was lower in the invasive strategy group (difference, 6.3% 95% CI, 0.2%-12.4%), but 4-year all-cause mortality was similar.
Ischemia severity was not associated with increased risk after adjustment for CAD severity. More severe CAD was associated with increased risk. Invasive management did not lower all-cause mortality at 4 years in any ischemia or CAD subgroup. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01471522.
In this clinical trial involving patients with established cardiovascular disease, the addition of niacin to intensive statin therapy provided no additional clinical benefit over a period of 3 years, ...despite favorable changes in lipid levels.
More than 18 million North Americans have coronary heart disease, and despite profound advances in both pharmacologic and interventional management, both morbidity and mortality remain appreciable.
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Elevated low-density lipoprotein (LDL) cholesterol levels are an established predictor of the risk of coronary heart disease. Multiple primary and secondary prevention trials have shown a significant reduction of 25 to 35% in the risk of cardiovascular events with statin therapy
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; however, residual risk persists despite the achievement of target LDL cholesterol levels.
Epidemiologic studies have shown that, in addition to elevated LDL cholesterol levels, low levels of high-density lipoprotein (HDL) cholesterol . . .
This trial compared a restrictive hemoglobin threshold with a liberal threshold for blood transfusion among hip-surgery patients with risk factors for CVD. The liberal strategy resulted in more ...transfusions and did not reduce death or inability to walk independently.
In the United States, more than 17 million red-cell units are collected annually, and 15 million units are transfused.
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Blood transfusions are frequently given to surgical patients and to the elderly.
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Yet, the indications for postoperative transfusion have not been adequately evaluated and remain controversial. Most clinical trials have been small.
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One adequately powered trial involving adults in intensive care units showed a nonsignificant decrease in 30-day mortality with a restrictive transfusion strategy, as compared with a liberal strategy (18.7% vs. 23.3%).
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However, the effect of a restrictive approach on functional recovery or risk of myocardial infarction in patients . . .
Summary Background Blood transfusion might affect long-term mortality by changing immune function and thus potentially increasing the risk of subsequent infections and cancer recurrence. Compared ...with a restrictive transfusion strategy, a more liberal strategy could reduce cardiac complications by lowering myocardial damage, thereby reducing future deaths from cardiovascular disease. We aimed to establish the effect of a liberal transfusion strategy on long-term survival compared with a restrictive transfusion strategy. Methods In the randomised controlled FOCUS trial, adult patients aged 50 years and older, with a history of or risk factors for cardiovascular disease, and with postoperative haemoglobin concentrations lower than 100 g/L within 3 days of surgery to repair a hip fracture, were eligible for enrolment. Patients were recruited from 47 participating hospitals in the USA and Canada, and eligible participants were randomly allocated in a 1:1 ratio by a central telephone system to either liberal transfusion in which they received blood transfusion to maintain haemoglobin level at 100 g/L or higher, or restrictive transfusion in which they received blood transfusion when haemoglobin level was lower than 80 g/L or if they had symptoms of anaemia. In this study, we analysed the long-term mortality of patients assigned to the two transfusion strategies, which was a secondary outcome of the FOCUS trial. Long-term mortality was established by linking the study participants to national death registries in the USA and Canada. Treatment assignment was not masked, but investigators who ascertained mortality and cause of death were masked to group assignment. Analyses were by intention to treat. The FOCUS trial is registered with ClinicalTrials.gov , number NCT00071032. Findings Between July 19, 2004, and Feb 28, 2009, 2016 patients were enrolled and randomly assigned to the two treatment groups: 1007 to the liberal transfusion strategy and 1009 to the restrictive transfusion strategy. The median duration of follow-up was 3·1 years (IQR 2·4–4·1 years), during which 841 (42%) patients died. Long-term mortality did not differ significantly between the liberal transfusion strategy (432 deaths) and the restrictive transfusion strategy (409 deaths) (hazard ratio 1·09 95% CI 0·95–1·25; p=0·21). Interpretation Liberal blood transfusion did not affect mortality compared with a restrictive transfusion strategy in a high-risk group of elderly patients with underlying cardiovascular disease or risk factors. The underlying causes of death did not differ between the trial groups. These findings do not support hypotheses that blood transfusion leads to long-term immunosuppression that is severe enough to affect long-term mortality rate by more than 20–25% or cause of death. Funding National Heart, Lung, and Blood Institute.
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