Counterintuitive Advice About Staying Alive After A Heart Attack 1

An interventional cardiologist– the cardiologists who put in stents and usually treat heart attack patients in the first few hours– asked an electrophysiologist– the cardiologists who treat arrhythmias– whether wearable defibrillators should be used post-MI. Here’s what that electrophysiologist, Edward J. Schloss, the medical director of cardiac electrophysiology at Christ Hospital in Cincinnati, OH, replied. It is a good example of how sometimes a procedure or a therapy that seems, intuitively, to be worthwhile and beneficial, may actually not be beneficial at all. Here’s his response, which he originally posted on Twitter:

Click here to read the full post on Forbes.

 

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Controversial Trial Finds No Benefit For Expensive Medicines Company Drug Reply

Although there is broad consensus in the medical community that primary PCI is the best treatment for heart attack patients when it can be delivered promptly, there is no agreement about the best accompanying drug regimen, which usually entails a combination of antiplatelet and antithrombotic drugs. The role of one antithrombotic, bivalirudin (Angiomax, The Medicines Company) has been particularly uncertain because it is far more expensive than its alternative, unfractionated heparin.

HEAT-PPCI was designed to help settle this problem.

Click here to read the full post on Forbes.

 

Intensive Insulin Therapy Saves Lives– But Is The Finding Still Relevant? 1

A trial that started back in 1990 continues to demonstrate a significant mortality advantage for intensive insulin therapy in heart attack (MI) patients. But experts say the trial design is so outdated that the findings should have no influence on clinical practice today.

During the years 1990 through 1993 the Swedish DIGAMI I (Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infaction 1) trial randomized 620 MI patients with elevated glucose levels to either intensive insulin treatment or conventional therapy. Earlier results from the trial showed beneficial effects, including improved survival, for patients in the intensive treatment arm.

Now, a paper published in The Lancet Diabetes & Endocrinology, presents 20-year followup results showing an average 2.3 year increase in survival for patients in the treatment arm (median survival 7.0 years versus 4.7 years, HR 0.83, CI 0.70-0.98, p=0.27).

Click here to read the entire post on Forbes, including an extensive comment from Darren McGuire.

 

High-Sensitivity Troponin Test Could Identify Low Risk Chest Pain Patients In The ED Reply

Approximately 15-20 million people in Europe and the United States go to the emergency department every year with chest pain. Many can be discharged early if they are not having an acute coronary syndrome. A large new single-center observational study, presented at the American College of Cardiology meeting in Washington, DC and published simultaneously in the Journal of the American College of Cardiology, provides fresh evidence that high-sensitivity cardiac troponin T (hs-cTnT) may be useful in helping identify chest pain patients in the emergency department who do not need to be admitted to the hospital.

Click here to read the full post on Forbes.

 

Surviving A Heart Attack: Location And Time Make A Big Difference Reply

Two studies published this week offer fresh evidence that your life may depend on where and when you have a heart attack.

1. Heart attack patients in the United Kingdom are more likely to die than heart attack patients in Sweden, according to a study published in the Lancet.

2. Heart attack patients are more likely to die if they reach the hospital at night or on the weekends, according to a study published in the BMJ.

… 

Click here to read the full post on Forbes.

 

Merck’s Vorapaxar Gets Positive FDA Review Reply

A few years ago a novel antiplatelet agent from Merck seemed all but dead. Vorapaxar, a thrombin receptor antagonist, was widely thought to have no future after unacceptably high serious bleeding rates were found in two large clinical trials studying the drug in a wide variety of acute and chronic cardiovascular patients. But hopes for the drug resurfaced with a new analysis of one of those trials, the TRA2P trial. Now the FDA appears willing to give the drug a renewed lease on life.

Click here to read the full story on Forbes.

 

Veterans Study Finds HIV To Be An Independent Risk Factor For MI Reply

Although it has long been suspected that people with the HIV virus are at increased risk for cardiovascular (CV) disease, reliable data has not been available. Now a new study published online in JAMA Internal Medicine provides a much clearer picture of the relationship between CV disease and HIV.

In an accompanying editorial, Patrick Mallon writes that “the results demonstrate a clear and consistent excess risk of MI (approximately 50% increase) in HIV-positive people across a range of age groups, with the association between HIV status and MI remaining significant when controlled for a number of covariates…” Since the cause of this increased risk is not understood, he argues, “presuming that interventions used in the general population to reduce the risk of MI will translate into similar reductions in MI incidence in HIV-positive populations is arguably naive.”

Click here to read the full story on Forbes.

Timing Of Heart Attacks Shifted In New Orleans After Katrina 3

Prior to Hurricane Katrina, heart attacks in New Orleans followed a well-known circadian and septadian (today’s word of the day, meaning day of the week) pattern, with predictable increases on Mondays and in the morning hours. Now a new study finds that the notorious 2005 hurricane dramatically altered that pattern for at least three years, shifting the pattern to a much greater than expected occurrence over nights and weekends.

Read my full story on Forbes.

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New Guidelines Define State-of-the-Art STEMI Care Reply

New guidelines published online today in Circulation and the Journal of the American College of Cardiology provide an efficient overview of the best treatments for STEMI patients. (Click here to download the PDFs of the full version (64 pages) or the executive summary  (27 pages) of the 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction.)

“We’re looking to a future where more patients survive with less heart damage and function well for years thereafter,” said Patrick O’Gara, the chair of the guidelines writing committee, in a press release. “We hope the guidelines will clarify best practices for healthcare providers across the continuum of care of STEMI patients.”

The new document strongly supports the establishment and maintenance of regional systems to treat STEMI, which should include assessment and continuous quality improvement programs.

Primary PCI remains the preferred method of reperfusion when it can be performed by experienced operators in a timely fashion. For people who can’t receive primary PCI within 120 minutes of arrival, fibrinolytic therapy should be given within 12 hours of the the onset of symptoms.

The first medical contact (FMC)-to-device time should be 90 minutes at PCI-capable hospitals. Patients who arrive at non PCI-capable hospitals should be transported to a PCI-capable hospital within 30 minutes and should be treated with a FMC-to-device system goal of 120 minutes of less.

Drug-eluting stents should not be used in patients who can’t or won’t comply with long-term dual antiplatelet therapy (DAPT). After receiving a stent patients should receive DAPT with aspirin and either clopidogrel, prasugrel, or ticagrelor.

Click here to read the AHA press release…

Expert Consensus Document Offers Advice On Troponin Tests Reply

A newly published document provides practical advice on the use of the popular and potent troponin tests. The Expert Consensus Document on Practical Clinical Considerations in the Interpretation of Troponin Elevations was developed by the American College of Cardiology Foundation in collaboration with several other societies to help address the many complex issues raised by the introduction of the tests in clinical practice.

Sanjay Kaul, a co-author of the document, said the document does not contain new information, but was written to respond to the request of clinicians “for help regarding the considerations for ordering, interpreting, and using troponin as a decision aid in the management of patients with ACS and non-ACS conditions.” The document provides “a roadmap for the proper use of troponin in the setting of appropriate clinical context. The hope is to avoid unnecessary testing and referral as well as inappropriate utilization of downstream diagnostic and therapeutic interventions.”

The document helps physicians understand when they should order troponin tests and how to interpret the results. The recommendations are designed to work in coordination with the recently updated universal definition of MI, and provide detailed information about the use of troponins in acute coronary syndromes, PCI, CABG, and a variety of nonischemic clinical conditions.

“There are many things that can cause damage to the heart muscle that would allow troponin to leak in the circulation where we can measure it, and it’s not always due to heart attack,” said L. Kristin Newby, the co-chair of the writing committee, in an ACC press release. “So if we are indiscriminate in how we order these tests or we aren’t paying attention to the clinical scenario before us, we may miss something important.”

“We need to be thinking about why we are ordering the troponin test before we order it,” said Newby. “We hope this document provides a road map to help clinicians be more deliberate when ordering these tests and interpreting the results.”
Click here to read the ACC press release…

Unrecognized MI: More Prevalent And Dangerous Than Previously Suspected 2

Unrecognized myocardial infarction (UMI) is more prevalent, and is associated with a worse prognosis, than may be generally understood, according to a new study published in JAMA.

Studying an elderly (67-93 years of age) population in Iceland, Erik Schelbert and colleagues used ECG and cardiac magnetic resonance (CMR) to detect UMI. CMR was more effective than ECG at detecting UMI. The study established that UMI was twice as prevalent as recognized MI (RMI):

  • No MI: 74%
  • RMI: 10%
  • Unrecognized MI by ECG: 5%
  • Unrecognized MI by CMR: 17%

Diabetics were more likely to have UMI detected by CMR than by ECG. After 6.4 years of followup, mortality was higher in the RMI and UMI groups than in the group without MI:

  • RMI: 33% (CI 23% to 43%)
  • UMI: 28% (CI 21% to 35%)
  • No MI: 17%, (CI 15% to 20%)

After adjusting for other factors, UMI by CMR, but not UMI by ECG, significantly improved risk stratification for mortality. People with UMI by CMR were less likely than people with RMI to take cardiac drugs.

According to the authors, the large percentage of UMIs has not been understood in the past due to previous reliance on ECG data; thus “a significant public health burden” has not been fully appreciated.

Click here to read the JAMA press release…

Troponin Test May Allow Rapid MI Rule-Out in the Emergency Department Reply

More than three-quarters of people with chest pain can be triaged within an hour of arrival at the emergency department with a novel strategy utilizing high-sensitivity cardiac troponin (hs-cTnT), according to a study from Switzerland published in the Archives of Internal Medicine. The strategy is promising, according to anaccompanying editorial, but much work remains before it can be implemented in clinical practice.

Tobias Reichlin and colleagues first studied 436 patients and developed a treatment algorithm utilizing hs-cTnT baseline changes and absolute changes over the initial hour. The algorithm was then tested in a second validation cohort of 436 patients, with the following results:

  • 60% were classified as “rule-out”
  • 17% were classified as “rule-in”
  • 23% required further observation
  • Overall sensitivity and negative predictive value: 100% for rule-out
  • Specificity for rule-in: 97%
  • Positive predictive value for rule-in: 84%
  • Prevalence of MI in the observational group:  8%
  • 30-day survival: 99.8% in the rule-out group, 98.6% in the observational group, and 95.3% in the rule-in group

The authors claim that their strategy “may obviate the need for prolonged monitoring and serial blood sampling in 3 of 4 patients.”

In an accompanying comment, L. Kristin Newby writes that the Swiss study “is a major advance in understanding the application of hsTn testing that with continued development could substantially improve evaluation of ED patients with suspected MI.” However, she notes that the excellent results obtained in this initial study will probably not be equalled in the real world. In addition, she writes, “although touted as ‘simple’ by the authors, the need for multicomponent algorithms that are different for rule-in and rule-out and that vary by age group or other parameters will challenge application by busy clinicians unlikely to remember or accurately process the proposed algorithm. As such, it will be imperative that hsTn algorithms, if validated, are built into clinical decision support layered onto electronic health records so that testing results are provided electronically to physicians along with the algorithmic interpretation to allow systematic application in triage and treatment.”
Click here to read the press release from Archives…

Meta-Analysis Compares Drug-Eluting and Bare-Metal Stents for Primary Angioplasty Reply

A new meta-analysis comparing drug-eluting stents (DES) and bare-metal stents (BMS) in patients with myocardial infarction has provoked opposing take-away messages from an author of the study and an editorialist. The authors emphasize the reduction in target-vessel revascularization (TVR) associated with DES, but the editorialist focuses on several potential DES weaknesses suggested by the study.

In the paper, published in Archives of Internal Medicine, members of the Drug-Eluting Stent in Primary Angioplasty (DESERT) Cooperation pooled patient data from more than 11 clinical trials in which more than 8,600 patients were randomized to either sirolimus-eluting or paclitaxel-eluting stents or BMS.  After a mean follow-up of 1201 days, DES was associated with a significant reduction in TVR but there were no significant differences in death, reinfarction, or stent thrombosis (ST):

  • TVR: 12.7% for DES vs 20.1% for BMS, HR 0.57, CI 0.50-0.66, p<.001
  • Mortality: 8.5% vs 10.2%, HR 0.85, CI 0.70- 1.04, p = .11
  • Reinfarction: 9.4% vs 5.9%, HR 1.12, CI 0.88-1.41, p = .36
  • Stent thrombosis: 5.8% vs 4.3%, HR 1.13, CI 0.86-1.47, p = .38

However, after two years there was a significant increase in the risk of stent thrombosis associated with the DES group (HR 2.81, CI 1.28-6.19, p=0.04).

The findings, write the authors,

provide strong evidence of the beneficial effects of SES and PES during primary PCI in STEMI. With follow- up as late as 6 years, a robust and sustained decrease in TVR was noted with use of these DES. Although the rates of late reinfarction and ST progressively increased, with the difference becoming statistically significant after 2 years in patients receiving SES and PES, the HR for mortality, while not significantly different between DES and BMS, favored DES.

Click to continue reading, including a comment from Gregg Stone…

Metaanalysis: Air Pollutants Raise Short Term Risk of MI Reply

Air pollution significantly raises the short-term seven-day risk of myocardial infarction (MI), according to a new metaanalysis published in JAMA. Hazrije Mustafic and colleagues analyzed data from 34 studies and found a significant increase in the relative risk (RR) of MI for all the main air pollutants except ozone:

  • carbon monoxide: RR 1.048, CI 1.026-1.070
  • nitrogen dioxide: 1.011, 1.006-1.016
  • sulfur dioxide: 1.010, 1.003- 1.017
  • PM10: 1.006, 1.002-1.009
  • PM2.5: 1.025, 1.015-1.036)
  • ozone: 1.003, 0.997-1.010
The authors acknowledged that the magnitude of increased risk was small, but calculated that because of the broad exposure of the population to air pollution the attributable fraction ranged from 0.6% to 4.5% for the different pollutants.
Click here to read the press release from JAMA…