Warning: Neck Adjustments Might Lead To Stroke 2

After a neck adjustment — also known as cervical manipulative therapy and typically employed by chiropractors and other healthcare providers — people are at increased risk for cervical dissections (tears), which can lead to stroke, according to a scientific statement released by the American Heart Association/American Stroke Association. Although a cause-and-effect relationship is far from being proved, the groups say that healthcare providers should tell their patients about the association before starting the procedure.

Click here to read the full post on Forbes.

 

Superficial dissection of the right side of th...

Superficial dissection of the right side of the neck, showing the carotid and subclavian arteries. (Photo credit: Wikipedia)

About these ads

Clot Busters For Stroke Gain More Support Reply

Although thrombolysis for ischemic stroke has been widely recognized as beneficial, its use has been limited because of concerns about its effects on patients treated after 3 hours, on older patients, and on patients with mild and with severe strokes. Now a new metaanalysis published in the Lancet offers evidence that the use of thrombolysis should be more aggressively pursued.

Click here to read the full post on Forbes.

 

 

Cardiovascular Disease Declines in Rich Countries but Grows Elsewhere Reply

A new Global Cardiovascular Disease (CVD) Atlas portrays a divided world where rich countries are gradually freeing themselves from the yoke of CVD but where many poor and middle-income countries are still struggling.

Ischemic heart disease and stroke were the two biggest contributors to the global burden of disease in 2010, accounting for 5.2% and 4.1%, respectively, of all disability adjusted life years (DALYs)….

Click here to read the full post on Forbes.

 

FDA Once Again Rejects New Indication For Rivaroxaban Reply

The third time wasn’t the charm. The FDA today turned turned down– for the third time– the supplemental New Drug Application (sNDA) for rivaroxaban (Xarelto, Johnson & Johnson) for use in acute coronary syndrome patients to reduce MI, stroke or death. In addition, the FDA– for the second time– turned down the sNDA for rivaroxaban in the same population for the reduction of stent thrombosis.

Click here to read the full post on Forbes.

 

Problems Persist Despite Gains In Oral Anticoagulant Use Reply

Although significant progress has been made in recent years, a new survey from the European Society of Cardiology finds that there are still too many atrial fibrillation patients who are not taking the best medications to reduce their elevated risk of stroke. Many elderly patients are not receiving oral anticoagulants and overall too many patients are still taking aspirin, despite the fact that it is not recommended for this group of patients.

In a paper published in the American Journal of Medicine, Gregory YH Lip and colleagues analyzed data from more than 3,100 patients surveyed in the Euro Observational Research Programme on Atrial Fibrillation from February 2012 to March 2013.

Click here to read the entire 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.

 

Large Study Finds Favorable Risk-Benefit Profile For The New Anticoagulants Reply

A very large new meta-analysis finds a favorable risk-benefit for the new oral anticoagulant drugs in the setting of atrial fibrillation. The findings, published online in the Lancet, were remarkably consistent for all four of the new agents which have been fighting to replace warfarin, which was the only oral anticoagulant available for decades until the arrival of the new agents. Although warfarin is inexpensive, it has numerous interactions with other drugs and foods and requires regular monitoring and dose adjustments. The new agents can be taken once or twice a day and do not require dose changes.

Christian Ruff and colleagues combined data from the nearly 72,000 patients randomized in the four large mega-trials: RE-LY, which studied dabigatran (Pradaxa, Boehringer-Ingelheim); ROCKET AF, which studied rivaroxaban (Xarelto, Johnson & Johnson); ARISTOTLE, which studied apixaban (Eliquis, Pfizer and BristolMyers Squibb); and ENGAGE-AF-TIMI 48, which studied edoxaban (Daiichi Sankyo).

Click here to read the full post on Forbes.

Take Your Blood Pressure Pills Or Increase Your Risk Of Stroke Reply

A large new observational study demonstrates that people who don’t take their antihypertensive medications are much more likely to have a stroke. The new study, published in the European Heart Journal, used nationwide prescription, hospital and mortality records from 73,527 hypertensive patients in Finland.

The Finnish investigators compared 26,704 patients who were hospitalized or died of stroke with 46,823 patients who did not have an event. The stroke patients were older, less educated, had lower income, and were more likely to have diabetes or cancer than controls.

After adjusting for baseline differences between the groups, patients who were non-adherent were two to four times more likely to die from stroke or be hospitalized for stroke than their adherent counterparts.

Click here to read the full story on Forbes.

 

Some Patients With Minor Stroke Or TIA May Benefit From Early Clopidogrel And Aspirin Reply

Some people with minor ischemic stroke or transit ischemic attack (TIA) may benefit from dual antiplatelet therapy with aspirin and clopidogrel, according to a large new study from China published in the New England Journal of Medicine. In the immediate period following a TIA or minor stroke people are at high risk for having a major stroke. Aspirin is known to cause a modest reduction in recurrent events. More potent antiplatelet agents like clopidogrel may also be beneficial, but have not been well studied in the early phase and may increase the risk of bleeding complications, including the conversion of an ischemic stroke into a worse hemorrhagic stroke.

Investigators in the CHANCE (Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events) trial randomized 5,170 patients within 24 hours of a minor ischemic stroke or high-risk TIA to three months of treatment with either clopidogrel and aspirin or placebo and aspirin. At 90 days the rate of stroke was 8.2% in the combination group versus 11.7% in the aspirin-alone group (hazard ratio 0.68, CI 0.57-0.81, p<0.001). There were also significant reductions…

Click here to read the full story on Forbes.

 

Controversial PFO Closure Trials Published In NEJM Reply

Two controversial trials testing PFO closure with the Amplatzer PFO Occluder (St. Jude Medical) in patients with cryptogenic stroke, first presented last fall at the TCT meeting, have now been published in the New England Journal of Medicine. Both trials missed their primary endpoints but contained suggestions of possible benefit. The results appear unlikely to resolve the ongoing controversy over the value, or lack of value, of this procedure, but, as an accompanying editorial states, both advocates and critics of PFO closure will find source material for their arguments in these papers.

In the accompanying editorial, Steven Messé and David Kent write that both trials suffered from slow enrollment, “which was probably due to widespread off-label use of atrial septal closure devices.” They note that RESPECT and PC, like the only other randomized trial in the field, CLOSURE 1, did not show significant benefits in the main intention-to-treat analysis, but did present some evidence of possible benefit.

They conclude:

…we are left for the moment to make decisions under conditions of uncertainty. In such circumstances, evidentiary standards vary among decision makers — patients, clinicians, authors of practice guidelines, and regulatory authorities — depending not only on the interpretation of the results, but also on the potential consequences of their decisions. Some of them may interpret the data as supporting closure of a patent foramen ovale as a viable therapeutic option, even while conceding the failure of trials to show the superiority of closure over medical therapy. Yet given the prevalence of patent foramen ovale in the general population, the enormous potential for overuse of percutaneous closure of a patent foramen ovale, and the relatively low risk of stroke in patients who are treated medically, the routine use of this therapy seems unwise without a clearer view of who, if anyone, is likely to benefit…. Randomized studies of closure may come to an end, however, if the Amplatzer device is approved. Thus, all eyes will be on the regulatory agencies to see how they will interpret these results in light of their own evidentiary standards.

Click here to read the entire story on Forbes.

 

Amplatzer

 

 

 

Following An Embargo Break PREVAIL Trial Won’t Be Presented At ACC 2

UPDATED–The already complicated story behind the PREVAIL trial, which was designed to confirm the safety and efficacy of the Watchman left atrial appendage closure device, just got even more complicated. This morning, after the trial’s sponsor, Boston Scientific, prematurely distributed to investors a press release summarizing the results of the trial, the ACC announced that the scheduled presentation of the results at the main opening session of the meeting would not take place.

 

By way of background, last week the trial’s sponsor, Boston Scientific, first announced that the  principal investigator of the trial, David Holmes, would only “present the acute procedural safety results” from the trial. Then the company reversed itself two days later and announced that Holmes would present all three co-primary endpoints.

Holmes intended presentation this morning at the ACC in San Francisco makes clear why there was so much confusion. (The slides from his presentation have been made available to the media.) Although the trial results appear largely positive, the trial missed one of its three primary endpoints, and experts will likely spend a lot of time and energy trying to interpret the results.

Click here to read the full story on Forbes.

Stop Sign

 

 

 

Two Experts Help Sort Out The New Generation Of Anticoagulants Reply

Don’t miss this very practical discussion about the new generation of anticoagulants and the short term loan costs to cover them over on CardioExchange. Here are a few excerpts.

Christian Thomas Ruff:

I believe the addition of the 3 currently approved novel anticoagulants (dabigatran, rivaroxaban, and apixaban) will eventually translate into a greater proportion of eligible patients being treated; it certainly has in my practice…

Although I think it is important to continue to develop reversal agents for the novel anticoagulants, I don’t think the lack of such an agent is sufficient reason to avoid using a novel anticoagulant.

I think that price is one of the most important factors that has hindered uptake of the novel agents. Although these drugs may well be “cost-effective” in complicated analyses that focused on the costs and benefits to society at large, it is the out of pocket expense for the drugs that really matters to patients…

Andrew E. Epstein:

 It is highly unlikely that a direct comparison of the new anticoagulants will ever be done. Thus, we will have to choose between one or another based on pharmacokinetics, convenience, and perhaps formulary availability. Substudy analyses are also important…

I am concerned that although the elderly often have the most to gain from the new anticoagulants, they are also the patients at greatest risk for bleeding, especially if renal function is labile with drugs cleared by the kidneys. For such patients, warfarin should be considered.

Achieving CLOSURE: Final Act of PFO Closure Device Reply

You can choose from a myriad of metaphors– closing the book, sealing the deal, fixing a hole– but the story is simple: the publication of CLOSURE 1 in the New England Journal of Medicine is the final act of the long and sad melodrama of the CLOSURE 1 trial. As initially reported at the American Heart Association in 2010, Anthony Furlan and the CLOSURE I investigators randomized 909 patients with crytpogenic stroke to either medical therapy or PFO closure with the STARFlex Septal Closure System. There were no significant difference in the composite endpoint or its components(stroke or TIA in the first two years, death from any cause during the first 30 days, or death from neurologic causes between 31 days and 2 years):

Composite end point: 5.5% in the closure group versus 6.8% in the medical-therapy group (HR 0.78, CI 0.45 to 1.35, p=0.37)

  • Stroke: 2.9% vs 3.1% (p=0.79)
  • TIA: 3.1% vs 4.1% (p=0.44).
  • Deaths at 30 days and deaths from neurological events at 2 years: zero in both groups
As expected there were more major vascular complications related to the procedure in the treatment group, as well as a higher incidence of atrial fibrillation:
  • Major vascular procedural complicaton : 3.2% vs 0% (p<0.001)
  • Atrial fibrillation: 5.7% vs 0.7% (p<0.001)

In an accompanying editorial, S. Claiborne Johnston discusses the troubling issues raised by the trial. Because of off-label use of closure devices, enrollment in the trial took 5 years and forced a reduction in the sample size of the trial. He continues:

During the 9 years it took for the results of this trial to be reported, approximately 80,000 patients have had a patent foramen ovale closed with the use of a device at an average cost of $10,000 per procedure. Even if only half these patients were treated by this method for the purpose of preventing stroke, it would suggest that during that period of time $400 million was spent on a procedure that had no apparent benefit, to say nothing of the potential clinical risks involved. By limiting the use of device closure to within the remaining clinical trials, such an expense could be curtailed and completion of these trials might be accelerated. In this setting, a strategy of withholding reimbursement for unproven device therapy unless such treatment is part of a randomized trial seems justified.