Cardiology News
Fixed-dose enoxaparin thromboprophylaxis feasible for morbidly obese
Current practice guidelines recommend utilizing weight-based dosing of LMWH in obese patients, but do not provide specific dosing guidance and US researchers say that enoxaparin administered at a 0.5-mg/kg dose may be effective at preventing thrombosis in morbidly obese patients without increasing the risk for bleeding.
Comparison of Outcomes With Cardiac Surgery and Paclitaxel-Eluting Stents in Diabetic and Non Diabetic Patients
A study out of the Journal of the American College of Cardiology compared contemporary surgical revascularization (coronary artery bypass graft surgery [CABG]) versus TAXUS Express (Boston Scientific, Natick, Massachusetts) paclitaxel-eluting stents (PES) in diabetic and nondiabetic patients with left main and/or 3-vessel disease. The overall 1-year major adverse cardiac and cerebrovascular event rate was higher among diabetic patients treated with PES compared with CABG, but the revascularization method did not impact the death/stroke/myocardial infarction rate for nondiabetic patients (6.8% CABG vs. 6.8% PES, p = 0.97) or for diabetic patients (10.3% CABG vs. 10.1% PES, p = 0.96). These exploratory results may extend the evidence for PES use in selected patients with less complex left main and/or 3-vessel lesions.
Detection of elevated right atrial pressure using a simple bedside ultrasound measure
Accurate assessment of right atrial pressure (RAP) often requires invasive measurement. With normal RAP, Valsalva increases right internal jugular vein (RIJV) cross sectional area (CSA) 20% to 30%. With high RAP, when venous compliance is low, an article this months American Heart Journal hypothesized that the increase in CSA would be blunted and could be detected non-invasively with bedside ultrasound. Overal it showed that an increase in RIJV CSA >17% during Valsalva effectively rules out elevated RAP. This simple bedside technique may be useful to assess central venous pressure and reduce the need for invasive pressure measurement.
Resolution of ST-segment depression: a new prognostic marker in ST-segment elevation myocardial infarction
An article out of the European Heart Journal evaluatee the prognostic impact of ST depression resolution among patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary PCI in the Assessment of Pexelizumab in Acute Myocardial Infarction (APEX-AMI) trial. When compared with patients with both STE-R and STD-R≥50%, patients with both STE-R and STD-R<50% had the worst outcomes [hazard ratios (HR) 90 day death: 2.54; 95% confidence intervals (CI): 1.71–3.77; HR 90 day composite: 2.18; 95% CI: 1.63–2.91]. Overall when ST depression is present in STEMI patients undergoing primary PCI, ST Depression-Resolution <50% provides independent prognostic value that is incremental to ST elevation-Resolution.
No Benefit Seen with Early Invasive Versus Selective Invasive Management in Patients With Non–ST-Segment Elevation Acute Coronary Syndrome
A study out of the Journal of the American College of Cardiology present the 5-year clinical outcomes according to treatment strategy with additional risk stratification of the ICTUS (Invasive versus Conservative Treatment in Unstable coronary Syndromes) trial. 1,200 patients were randomly assigned to an early invasive or selective invasive strategy. The outcomes were the composite of death or myocardial infarction (MI) and its individual components. Risk stratification was performed with the FRISC (Fast Revascularization in InStability in Coronary artery disease) risk score. At 5-year follow-up, revascularization rates were 81% in the early invasive and 60% in the selective invasive group. Cumulative death or MI rates were 22.3% and 18.1%, respectively. In patients presenting with NSTE-ACS and elevated troponin T, we could not demonstrate a long-term benefit of an early invasive strategy in reducing death or MI. (Invasive versus Conservative Treatment in Unstable coronary Syndromes [ICTUS].
Sympathetic Nonadrenergic Transmission Contributes to Autonomic Dysreflexia in Spinal Cord–Injured Individuals
Autonomic dysreflexia is a hypertensive episode in spinal cord–injured individuals induced by exaggerated sympathetic activity and thought to be -adrenergic mediated. -Adrenoceptor antagonists have been a rational first choice; nevertheless, calcium channel blockers are primarily used in autonomic dysreflexia management. However, -adrenoceptor blockade may leave a residual vasoconstrictor response to sympathetic nonadrenergic transmission unaffected. The aim was to assess the -adrenergic contribution and, in addition, the role of supraspinal control to leg vasoconstriction during exaggerated sympathetic activity provoked by autonomic dysreflexia in spinal cord–injured individuals and by a cold pressure test in control individuals. These results indicate that the leg vascular resistance increase during autonomic dysreflexia in spinal cord–injured individuals is not entirely -adrenergic mediated and is partly explained by nonadrenergic transmission, which may, in healthy subjects, be suppressed by supraspinal control.
Routine testing in patients with asymptomatic elevated blood pressure in the ED
There are no clear recommendations for the diagnostic evaluation of patients who present to the emergency department (ED) with asymptomatic elevated blood pressure. In patients presenting with asymptomatic elevated blood pressure in the ED, we measured the prevalence of abnormalities on a basic metabolic profile (BMP) that led to hospital admission as well as the prevalence of diminished renal function. One hundred sixty-seven patients with asymptomatic elevated BP were studied and Twelve patients were admitted due to abnormal results on the BMP. Twenty-seven patients met the secondary outcome measure of diminished renal function. In a homogenous African American population presenting to the ED with asymptomatic elevated BP, there is a relatively high prevalence of abnormalities on the BMP that led to hospital admission. We suggest routine testing of a serum creatinine should be strongly considered in a largely African American patient population with asymptomatic elevated BP in the ED.
Optimization of initial energy for cardioversion of atrial tachyarrhythmias with biphasic shocks
Optimization of initial energy for cardioversion of atrial tachyarrhythmias with biphasic shocks. Recommendations for optimal first-shock energies with biphasic waveforms are conflicting. We evaluated prospectively the relation between type and duration of atrial tachyarrhythmias and the probability of successful cardioversion with a specific biphasic shock waveform to develop recommendations for the initial energy setting aiming at the lowest total cumulative energy with 2 or less consecutive shocks.
Cardioversion was successful in 448 patients (cumulative efficacy, 99 %). In patients with AFL/AT, the lowest total cumulative energy was attained with an initial energy setting of 50 J. In patients with AF, lowest values were achieved with an initial energy of 100 J for arrhythmia durations of 2 days or less and an initial energy of 150 J for arrhythmia durations of more than 2 days.
We recommend an initial energy setting of 50 J in patients with AFL/AT, of 100 J in patients with AF 2 days or less, and of 150 J with AF more than 2 days.
ST-segment depression in aVR as a predictor of culprit artery and infarct size in acute inferior wall ST-segment elevation myocardial infarction
ST-segment depression in lead aVR in acute inferior wall ST-segment elevation myocardial infarction (STEMI) has recently been suggested as a predictor of left circumflex (LCx) artery involvement. The purpose of this study is to evaluate the clinical significance of aVR depression during inferior wall STEMI. The sensitivity and specificity of aVR depression as a predictor of LCx infarction were 53% and 86%, respectively. In patients with right coronary artery infarction, aVR depression was associated with increased cardiac enzymes and the involvement of a large posterolateral branch, which may explain the larger infarction. ST-segment depression in lead aVR in inferior wall STEMI predicts LCx infarction or larger RCA infarction involving a large posterolateral branch.
Plasma B-type natriuretic peptide reduction predicts long-term response to levosimendan therapy in acutely decompensated chronic heart failure
A study in the International Journal of Cardiology sought to identify predictors of long-term response to levosimendan therapy among patients' baseline features and treatment-induced changes in acutely decompensated chronic heart failure (ADHF Compared to standard therapy, levosimendan induced a significant improvement in NYHA class (F
=37.529, p<0.001), B-type natriuretic peptide (BNP, F=22.917, p<0.001), left ventricular ejection fraction (F=23.561, p<0.001), transmitral E deceleration time. In the levosimendan group, treatment-induced percent BNP change was the best predictor of events (OR=0.970, 95% CI=0.954–0.986, p<0.001). A cut-off for BNP change of 58% predicted events with 87% sensitivity and 83% specificity. Event-free survival was longer in patients with a BNP reduction ≥58% (median, 135 versus 43 days, p=0.0001). JAMA: Levosimendan vs Dobutamine for Patients With Acute Decompensated Heart Failure
Omeprazole and clopidogrel: Should clinicians be worried?
The US Food and Drug Administration has issued a warning that omeprazole (Prilosec) reduces the antiplatelet activity of clopidogrel (Plavix) by about 50%. However, the warning is based largely on ex vivo data. Preliminary results from a randomized clinical trial revealed no effect on cardiovascular outcomes when omeprazole was given with clopidogrel. We recommend that physicians continue to prescribe a proton pump inhibitor for patients receiving dual antiplatelet therapy who are at risk of gastrointestinal bleeding or have an indication for use of a proton pump inhibitor.
Long-Term Prognosis of Patients Diagnosed With Brugada Syndrome
Brugada syndrome is characterized by ST-segment elevation in the right precordial leads and an increased risk of sudden cardiac death (SCD). Fundamental questions remain on the best strategy for assessing the real disease-associated arrhythmic risk, especially in asymptomatic patients. In the largest series of Brugada syndrome patients thus far
1029 patients were recruited in 11 tertiary centers in 4 European countries. The cardiac event rate per year was 7.7% in patients with aborted SCD, 1.9% in patients with syncope, and 0.5% in asymptomatic patients showing event rates in asymptomatic patients were low. Inducibility of ventricular tachyarrhythmia and family history of SCD were not predictors of cardiac events.
Enoxaparin Anticoagulation Monitoring in the Catheterization Laboratory Using a New Bedside Test
A study out of the Journal of the American College of Cardiology evaluated the ability of the bedside test Hemochron Jr. Hemonox (International Technidyne Corporation, Edison, New Jersey) to identify patients with insufficient anti-Xa activity level in the catheterization laboratory in 296 unselected patients undergoing catheterization and/or PC. When using Hemonox CT to discriminate patients with anti-Xa level <0.5 IU/ml a 94.9% sensitivity and a 73.3% specificity to detect patients with inadequate anti-Xa level. Hemonox CT appears to be a fast and reliable bedside test for detecting patients insufficiently anticoagulated and needing adjustment of anticoagulation therapy with enoxaparin before PCI.
African-American Women Have a Higher Risk for Developing Peripartum Cardiomyopathy
A study out of the Journal of the American College of Cardiology assessed whether African-American women are at increased risk of having peripartum cardiomyopathy. Peripartum cardiomyopathy is a heart disease of unknown cause that affects young women, often with devastating consequences. The frequency of peripartum cardiomyopathy varies markedly between African and non-African regions. A case-control study was performed and showed African-American women had a 15.7-fold higher relative risk of peripartum cardiomyopathy than non–African Americans. Other significant univariate risk factors were hypertension and having had >2 previous pregnancies. African-American ethnicity remained a significant risk factor for peripartum cardiomyopathy when other risk factors were considered in multivariable and stratified analyses. Although the frequency of peripartum cardiomyopathy (185 of 100,000 deliveries) at this center was higher than in previous U.S. reports, it was comparable to the frequency in countries with more women of African descent (100 to 980 of 100,000). Analysis of other U.S. studies confirmed that the frequency of peripartum cardiomyopathy was significantly higher among African-American women.
Study fails to link saturated fat, heart disease
The saturated fat found mainly in meat and dairy products has a bad reputation, but a new analysis of published studies finds no clear link between people's intake of saturated fat and their risk of developing heart disease.
Déjà vu? Experts debate new data on diuretic/CCB combo and MI risk
Low-risk hypertensive patients taking a combination of diuretics and calcium-channel blockers (CCBs) had a higher risk of MI than users of other common two-drug BP-lowering regimens in a new case-control study published online January 25, 2010 in BMJ. Lead author Dr Inbal Boger-Megiddo (University of Washington, Seattle) told heartwire she cannot determine "whether the findings indicate a positive effect of one group of drugs or a negative effect of another." But the new study "raises a good clinical question that we should address in further trials," she says. "We should definitely look into secondary hypertension and the fact that all drug groups, while being comparable in terms of their BP-lowering effects, are not necessarily comparable in terms of cardiovascular outcomes."
Red Yeast Rice Comparable to Pravastatin for Statin-intolerant Patients
Red-yeast-rice extract is as well tolerated as pravastatin in patients who previously developed a statin-associated myalgia and withdrew from therapy, research shows [1]. Withdrawals from the red-yeast-rice and pravastatin treatment arms were low; and both groups achieved comparable reductions in LDL-cholesterol levels, report researchers.
Red blood cell distribution width and 1-year mortality in acute heart failure
Red blood cell distribution width (RDW) predicts mortality in chronic heart failure (HF) and stable coronary artery disease. The prognostic value of RDW in more acute settings such as acute HF, and its relative prognostic value compared with more established measures such as N-terminal pro-brain natriuretic peptide (NT-proBNP), remains unknown. In a cohort of 205 patients with acute HF, independent predictors of RDW were identified using linear regression analysis and showed red blood cell distribution width is frequently elevated among patients with acute HF and does not appear to be associated with nutritional status, transfusion history, or inflammation. Red blood cell distribution width independently predicts 1-year mortality in acute HF. The value of RDW appears additive to other established prognostic variables such as NT-proBNP.
Restenosis Halved by Drug Eluting Stents in Diabetic Patients
Patients with diabetes mellitus have more extensive coronary artery disease, more disease progression, and restenosis. The use of drug-eluting stents (DES) in these patients is widespread, despite uncertain long-term safety and efficacy. All consecutive patients with diabetes mellitus in Sweden who underwent percutaneous coronary intervention were entered into the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) during 2003–06 with complete follow-up for 1–4 years and the results showed that myocardial infarction was significantly less common with DES in patients who received only one stent with a restenosis rate was 50% lower in DES-treated patients. DES was associated with reduced restenosis rates in all subgroups of diabetic patients with the greatest benefit in stent diameters <3 mm or stent length >20 mm. The number of lesions treated with DES to prevent one restenosis ranged from 11 to 47 in various subgroups.
FDA Reviewers Oppose CHF Indication for Beta-Blocker
In a harshly-worded document prepared for a meeting of FDA advisers, reviewers said there was no convincing evidence to support the use of the beta-blocker nebivolol (Bystolic) for treatment of heart failure in patients ages 70 and older.
Treatment of Aspirin-Resistant Patients With Omega-3 Fatty Acids Versus Aspirin Dose Escalation
Omega-3 fatty acids decrease the availability of platelet arachidonic acid (AA) and indirectly thromboxane A2 formation. A study out of the Journal of the American College of Cardiology was conducted to evaluate whether addition of omega-3 fatty acids or increase in aspirin dose improves response to low-dose aspirin among patients who are aspirin resistant. It was shown that plasma levels of thromboxane B2 were also reduced in both groups (56.8% reduction in the omega-3 fatty acids group, and 39.6% decrease in the aspirin group). Twelve patients (80%) who received omega-3 fatty acids and 11 patients (73%) who received aspirin 325 mg were no longer aspirin resistant after treatment.
Rosuvastatin in the Prevention of Stroke Among Men and Women With Elevated Levels of C-Reactive Protein
Prior primary prevention trials of statin therapy that used cholesterol criteria for enrollment have not reported significant decreases in stroke risk. We evaluated whether statin therapy might reduce stroke rates among individuals with low levels of cholesterol but elevated levels of high-sensitivity C-reactive protein.In Justification for the Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER), 17 802 apparently healthy men and women with low-density lipoprotein cholesterol levels <130 mg/dL and high-sensitivity C-reactive protein levels 2.0 mg/L were randomly allocated to rosuvastatin 20 mg daily or placebo and then followed up for the occurrence of a first stroke. After a median follow-up of 1.9 years (maximum, 5.0 years), rosuvastatin resulted in a 48% reduction in the hazard of fatal and nonfatal stroke as compared with placebo.
