2,013 patients were randomly assigned to receive bare-metal, zotarolimus-eluting, paclitaxel-eluting, or everolimus-eluting stent implantation. At 30 days, patients in each stent group were randomly allocated to receive up to 6 or 24 months clopidogrel therapy on top of aspirin. The primary endpoint was a composite of death from any cause, myocardial infarction or cerebrovascular accident. The cumulative risk of the primary outcome at 2 years was 10.1% with the 24-month dual antiplatelet therapy, as compared to 10.0% with the 6-month dual antiplatelet therapy (hazard ratio, 0.98; 95% CI, 0.74 to 1.29; P = 0.91). The individual risks of death, myocardial infarction, cerebrovascular accident or stent thrombosis did not differ between the study groups. However, there was a consistent greater risk of haemorrhage in the 24-month clopidogrel group according to all pre-specifed bleeding definitions including the recently proposed Bleeding Academic Research Consortium classification.
The authors describe that China has experienced the largest human migration in history and that provincial analysis of its urbanization trends shows shifting and accelerating rural-to-urban migration across the country and accompanying rapid increases in city size and population. According to the reported data, a growing disease burden in urban areas attributable to nutrition and lifestyle choices (2, 3) is identified as a major public health challenge, as are troubling disparities in health-care access, vaccination coverage, and accidents and injuries in China's rural-to-urban migrant population. Urban environmental quality, including air and water pollution (4) contributes to disease both in urban and in rural areas, and traffic-related accidents pose a major public health threat as the country becomes increasingly motorized.
A previous trial (2) demonstrated that 6-month adjunctive use of celecoxib reduced target-lesion revascularization (TLR) without increased thrombotic risk. In a larger prospective, randomized trial, Kang et al. aimed to confirm the effects of 3-month celecoxib in patients receiving drug-eluting stent (DES) implantation.
PubMed, Scopus, and the Web of Science were searched for randomized controlled trials of dabigatran that reported on MI or ACS as secondary outcomes. The fixed-effects Mantel-Haenszel (M-H) test was used to evaluate the effect of dabigatran on MI or ACS. Associations were expressed as odds ratios (ORs) and their 95% CIs.Seven trials were selected (N = 30 514), including 2 studies of stroke prophylaxis in atrial fibrillation, 1 in acute venous thromboembolism, 1 in ACS, and 3 of short-term prophylaxis of deep venous thrombosis. Control arms included warfarin, enoxaparin, or placebo administration.
Dabigatran was significantly associated with a higher risk of MI or ACS than that seen with agents used in the control group (dabigatran, 237 of 20 000 [1.19%] vs control, 83 of 10 514 [0.79%]; ORM-H, 1.33; 95% CI, 1.03-1.71; P = .03). The risk of MI or ACS was similar when using revised RE-LY trial results (ORM-H, 1.27; 95% CI, 1.00-1.61; P = .05) or after exclusion of short-term trials (ORM-H, 1.33; 95% CI, 1.03-1.72; P = .03). Risks were not heterogeneous for all analyses (I2 = 0%; P .30) and were consistent using different methods and measures of association.
Author: Eric Topol M.D.
Publication Date: January 31, 2012
This book describes the increasingly important interface between data digitalization and medicine. A particular focus is the impact of sequencing the human genome, but other topics including electronic medical records, evidence-based medicine, and imaging are covered as well.
The author is a well-known practicing cardiologist, the director of the Scripps Translational Science Institute, and a respected voice in cardiovascular medicine. He predicts a profound impact of the ‘Digital Revolution’ on the practice of medicine. The book is written for a general audience, and in fact the author describes that this 'revolution' will depend in large part on “digital-natives” outside the medical profession.
Arch Intern Med. 2012 Feb 27; 172(4): 312-9.
CAD remains a leading cause of morbidity and mortality worldwide. Previous studies have demonstrated a lack of PCI benefit in patient with stable CAD (1). In the current paper, the authors from Division of Cardiovascular Medicine, Department of Medicine, State University of New York-Stony Brook School of Medicine describe results from a meta-analysis of all randomized clinical trials comparing initial coronary stent implantation with medical therapy to determine the effect on death, nonfatal myocardial infarction (MI), unplanned revascularization, and persistent angina (2).
Eight prospective randomized trials enrolling a total of 7229 patients were identified. Three trials enrolled stable patients after MI, whereas 5 studies enrolled patients with stable angina and/or ischemia on stress testing. Mean weighted follow-up was 4.3 years. The respective event rates for death with stent implantation and medical therapy were 8.9% and 9.1% (OR, 0.98; 95% CI, 0.84-1.16); for nonfatal MI, 8.9% and 8.1% (OR, 1.12; 95% CI, 0.93-1.34); for unplanned revascularization, 21.4% and 30.7% (OR, 0.78; 95% CI, 0.57-1.06); and for persistent angina, 29% and 33% (OR, 0.80; 95% CI, 0.60-1.05).
The authors concluded that initial stent implantation for stable CAD shows no evidence of benefit compared with initial medical therapy for prevention of death, nonfatal MI, unplanned revascularization, or angina.
1. Boden WE, O'Rourke RA, Teo KK, et al. COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356:1503-16.
2. Stergiopoulos K, Brown DL. Initial Coronary Stent Implantation With Medical Therapy vs Medical Therapy Alone for Stable Coronary Artery Disease: Meta-analysis of Randomized Controlled Trials. Arch Intern Med. 2012 Feb 27;172(4):312-9.
3. Boden WE. Mounting Evidence for Lack of PCI Benefit in Stable Ischemic Heart Disease:What More Will It Take to Turn the Tide of Treatment? Arch Intern Med. 2012;172:319-21.
4. Redberg RF. Informed Strategies for Treating Coronary Disease. Arch Intern Med. 2012 Feb 27;172(4):321. No abstract available.
The authors summarize that medicare beneficiaries who underwent CCTAin a non-acute setting were more likely to undergo subsequent invasive cardiacprocedures and have higher CAD-related spending than patients who underwentstress testing.
Contribution of the human immunodeficiency virus/acquired immunodeficiency syndrome epidemic to de novo presentations of heart disease in the Heart of Soweto Study cohort
In this study from the Facultyof Health Sciences, Hatter Institute for Cardiovascular Research in Africa andIIDMM, University of Cape Town, Cape Town, South Africa, the authors describedata from the Heart of Soweto Study investigating cardiac manifestations of HIV/AIDS to de novo presentations of heart disease in an urban African community.
518 of5328 de novo cases of heart disease were identified as HIV-positive (9.7%) with54% of these prescribed highly active anti-retroviral therapies onpresentation. The most common primary diagnosis attributable to HIV/AIDS wasHIV-related cardiomyopathy (196 cases, 38%). An additional 128 cases (25%) werediagnosed with pericarditis/pericardial effusion followed by a range of otherconcurrent diagnoses, including 42 cases (8.1%) of HIV-related pulmonaryarterial hypertension. Only 14 of all 581 cases of coronary artery disease(CAD) (2.4%, mean age 41 ± 13 years) were confirmed HIV-positive.
Coronary Ostia and Relationship to Valve Leaflets CT allows to assess therelationship between leaflet height and distance between annulus and coronaryostia, which identifies patients at risk for coronary occlusion during the TAVIprocedure. The movie files demonstrate cine-loops reconstructed at multiplephases of the cardiac cycle. This movie shows the relationship between thecoronary ostia and the valve leaflets.
Computed Tomography in the Evaluation for Transcatheter Aortic Valve Implantation (TAVI)
Paul Schoenhagen, Jörg Hausleiter, StephanAchenbach, Milind Y. Desai, E. Murat Tuzcu
3D quantitative coronaryangiography (3D QCA) and its registration with 3D optical coherence tomography(OCT). A and B are the two angiographic views; C is the reconstructed vesselsegment in color-coded fashion; D. is the OCT cross-sectional viewcorresponding to the middle (red) marker; E is the OCT longitudinal view; and Fis the 3D OCT image. After the registration, the corresponding markers indifferent views (A, B, C, D, and F) were synchronized, allowing the assessmentof lumen dimensions from both imaging modalities at every correspondingposition along the vessel segment.
QCA, IVUS and OCT in interventional cardiology in 2011
JohanH.C. Reiber, Shengxian Tu, Joan C. Tuinenburg, Gerhard Koning, Johannes P.Janssen, Jouke Dijkstra