Afleveringen
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The application value of Metoprolol combined with Dagalizin in enhancing cardiac function and ventricularremodeling in patients with acute myocardial infarction after percutaneous coronary intervention.
J Clin Emerg, 2024, 25(4): 170-174. doi:10.13201/j.issn.1009-5918.2024.04.003
Abstract
To discuss the application value of metoprolol combined with daglizin in improving cardiac function and ventricular remodeling in patients with acute myocardial infarction(AMI) after percutaneous coronary intervention(PCI).
A total of 86 patients with acute myocardial infarction I- percutaneous coronary intervention from January 2022 to October 2023 were selected and divided into experimental group(43 cases) and control group(43 cases) according to a random table. Patients in the control group were given metoprolol + conventional treatment and patients in the experimental group were given combined treatment with daglizin on this basis. The cardiac function(left ejection fraction[LVEF], heart index[CI], stroke output[SV]), ventricular remodeling(left ventricular end-diastolic volume[LVEDV], left ventricularend-systolic volume[LVESV], left ventricular end-diastolic diameter[LVEDD]) and laboratory parameters(N-terminal B-type natriuretic peptideprecursor[NT-proBNP], hypersensitive C-reactive protein[hs-CRP], interleukin-6[IL-6]), adverse cardiovascular events and adverse events were compared between the two groups.
After treatment, the left ejection fraction, heart index and stroke output of the two groups were significantly higher than those before treatment, and the left ejection fraction, heart index and stroke output in the experimental group were significantly higher than those in the control group(P < 0.05). After treatment, the Left ventricular end-diastolic volume, left ventricular end-systolic volume, left ventricular end-diastolic diameter,N-terminal B-type natriuretic peptide precursor, hypersensitive C-reactive protein and interleukin-6of the two groups were significantly lower than those before treatment, and Left ventricular end-diastolic volume, left ventricular end-systolic volume, leftventricular end-diastolic diameter, N-terminal B-type natriuretic peptide precursor, hypersensitive C-reactive protein and interleukin-6in the experimental group were significantly lower than those in the control group(P < 0.05). The incidence of adverse cardiovascular events in the experimental group was significantly lower than that in the control group(P < 0.05). The adverse events rate of the two groups was basically the same(P>0.05).
Metoprolol combined with daglizin can improve cardiacfunction and ventricular remodeling in patients with acute myocardial infarction (AMI) after percutaneous coronary intervention(PCI), which is beneficial for prognosis improvement, and it is worthy of clinical promotion.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy,validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, whichyou should exercise in evaluating the information on this website
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Impact of cardiac rehabilitation on ventricular-arterial coupling and left ventricular function in patients withacute myocardial infarction
PLoS One . 2024 Apr 4;19(4):e0300578. doi:10.1371/journal.pone.0300578
Abstract
To maintain efficient myocardial function, optimalcoordination between ventricular contraction and the arterial system is required. Exercise-based cardiac rehabilitation (CR) has been demonstrated toimprove left ventricular (LV) function. This study aimed to investigate the impact of cardiac rehabilitation on ventricular-arterial coupling (VAC) and its components, as well as their associations with changes in LV function in patients with acute myocardial infarction (AMI) and preserved or mildly reduced ejection fraction (EF). Effective arterial elastance (EA) and index (EAI) werecalculated from the stroke volume and brachial systolic blood pressure. Effective left ventricular end-systolic elastance (ELV) and index (ELVI) were obtained using the single-beat method. The characteristic impedance (Zc) of the aortic root was calculated after Fourier transformation of both aortic pressure and flow waveforms. Pulse wave separation analysis was performed to obtain the reflection magnitude (RM). An exercise-based, outpatient cardiac rehabilitation(CR) program was administered for up to 6 months. Twenty-nine patients were studied. However, eight patients declined to participate in the cardiac rehabilitation program and were subsequently classified as the non- cardiac rehabilitation group. At baseline, E' velocity showed significant associations with EAI (beta -0.393; P = 0.027) and VAC (beta -0.375; P =0.037). There were also significant associations of LV global longitudinal strain (LV GLS) with EAI (beta 0.467;P = 0.011). Follow-up studies after a minimum of 6 months demonstrated a significant increase in E' velocity (P = 0.035), improved EF (P = 0.010), andLV GLS (P = 0.001), and a decreased EAI (P = 0.025) only in the cardiac rehabilitation group. Changes in E' velocitywere significantly associated with changes in EAI (beta -0.424; P = 0.033). Increased aortic afterload and ventricular-arterial mismatch were associated with a negative impact on both left ventricular diastolic and systolic function. The outpatient cardiac rehabilitation program effectively decreased aortic afterload and improved left ventricular diastolic and systolic dysfunction in patients with acute myocardial infarction and preserved or mildly reduced Ejection Fraction.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy,validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, whichyou should exercise in evaluating the information on this website
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Zijn er afleveringen die ontbreken?
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Prognostic Impact of Early Administration of β-Blockers in Critically Ill Patients with Acute Myocardial Infarction
J Clin Pharmacol . 2024 Apr;64(4):410-417.doi: 10.1002/jcph.2370.
Abstract
In critically ill patients with acute myocardialinfarction (AMI), the relationship between the early administration of β-blockers and the risks of in-hospital and long-term mortality remains controversial. Furthermore, there are conflicting evidences for the efficacy of the early administration of intravenous followed by oral β-blockers in acute myocardial infarction. We conducted a retrospective analysis of critically ill patients with acute myocardial infarction who received the early administration of β-blockers within 24 hours of admission. The data were extracted from the Medical Information Mart for Intensive Care IV database. We enrolled 2467 critically ill patients with AMI in the study, with 1355 patients who receivedthe early administration of β-blockers and 1112 patients who were non-users. Kaplan-Meier survival analysis and Cox proportional hazards models showed that the earlyadministration of β-blockers was associated with a lower risk of in-hospital mortality (adjusted hazardratio [aHR] 0.52; 95% confidence interval [95%CI] 0.42-0.64), 1-year mortality (aHR 0.54, 95%CI 0.47-0.63), and 5-year mortality (aHR 0.60, 95%CI0.52-0.69). Furthermore, the early administration of both oral β-blockers and intravenous β-blockers followed by oral β-blockers may reduce the mortality risk, compared with non-users. The risks of in-hospital and long-term mortality were significantly decreased in patients who underwent revascularization with the early administration of β-blockers. We found thatthe early administration of β-blockers could lower the risks of in-hospital and long-term mortality. Furthermore, the early administration of both oral β-blockers and intravenous β-blockers followed by oral β-blockers may reduce the mortality risk, compared with non-users. Notably, patients who underwent revascularization with the early administration of β-blockers showed the lowest risks of in-hospital and long-term mortality.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy,validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, whichyou should exercise in evaluating the information on this website
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Ticagrelor was associated with lower fracture risk than clopidogrel in the dual anti-platelet regimen among patients with acute coronary syndrome treated with percutaneous coronary intervention
J Endocrinol Invest. 2024 Apr;47(4):895-902.doi: 10.1007/s40618-023-02205-1
Abstract
Purpose: Patients with coronary artery disease haveincreased fracture risks. P2Y12 inhibitors may impact fracture risks. We compared the fracture risks associated with ticagrelor and clopidogrel in dualanti-platelet therapy (DAPT).
Methods: We identified all adults who underwentfirst-ever percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) between 2010 and 2017 from a territory-wide PCI registry in Hong Kong.Following 1:1 propensity-score matching for baseline characteristics, patients were followed up till event occurrence, death, or 30 June 2022. Outcomes ofinterest were major osteoporotic fractures (MOF) identified by validated ICD-9-CM codes. Cox proportional hazards regression was used to compute the hazard ratio (HR) for major osteoporotic fractures associated with ticagrelor versus clopidogrel use.
Results: 3018 ticagrelor users and 3018 clopidogrel users were identified after propensity-score matching (mean age: 61.4 years; 84.1% men). Upon median follow-up of 6.5 years, 59 ticagrelor users and 119 clopidogrel users sustained major osteoporotic fractures (annualized fracture risks: 0.34 % and 0.56%, respectively).Ticagrelor use was associated with lower risks of major osteoporotic fractures (HR 0.60, 95%CI 0.44-0.83; p =0.002). Consistent hazard ratios were observed for fractures over vertebrae, hip and upper limbs. Subgroup analyses showed no interaction according to age, sex, presence of diabetes, presence of chronic kidney disease and prior fracture history.
Conclusion: Among adults who underwent first-ever percutaneous coronary intervention for acute coronary syndrome, ticagrelor use in the dual anti-platelet therapy was associated with a lower risk of major osteoporoticfractures compared with clopidogrel. Our results support the use of ticagrelor in the dual anti-platelet therapy from the perspective of bone health.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the informationon this website
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2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee.
J Am Coll Cardiol 2024;Mar 8:[Epub ahead of print].
In line with recent evidence and guidelines, therecommended core guideline-directed medical therapy (GDMT) for chronic heart failure (HF) includes an angiotensin II receptor/neprilysin inhibitor (ARNI), evidence-based beta-blocker, sodium-glucose cotransporter (SGLT) inhibitor, and mineralocorticoid antagonist (MRA). When feasible, early and rapid initiation of these therapies and titration to maximally tolerated doses within 3 months is recommended. While no specific order of initiation or titration of guideline-directed medical therapy is mandated, the following is some useful guidance a)Start with low doses of core therapies.
b) Delay beta-blocker initiation until HF is compensated.
c) ARNIs and SGLT inhibitors may reduce diuretic needs.
d) MRA and SGLT inhibitors may have minimal BP effects.
e) Mild declines in eGFR don't always require medicationcessation.
Difficulties with adherence to recommended HF therapies can be multifactorial. Effective strategies to improve adherence should be targeted to individual patient needs. Strategies include patient education,simplification of overall medication regimen, reduction of cost and access barriers, medication reminders, utilization of clinical pharmacist, and cognitive behavioral therapies. In addition to managing cardiovascular (CV) comorbidities, attention should be paid to addressing non-CV comorbidities that impact HF outcomes such as diabetes, chronic kidney disease, sleep-disorderedbreathing, iron deficiency, and viral infections (prevention with vaccination).
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of anyscientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on thiswebsite.
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Myocardial infarction drives trainedimmunity of monocytes, accelerating atherosclerosis
Eur Heart J . 2024 Mar 1;45(9):669-684.
Abstract
Background and aims: Survivors of acute coronarysyndromes face an elevated risk of recurrent atherosclerosis-related vascular events despite advanced medical treatments. The underlying causes remainunclear. This study aims to investigate whether myocardial infarction -induced trained immunity in monocytes could sustain proatherogenic traits and expedite atherosclerosis.
Methods: Apolipoprotein-E deficient (ApoE-/-) miceand adoptive bone marrow transfer chimeric mice underwent MI or myocardial ischaemia-reperfusion (IR). A subsequent 12-week high-fat diet (HFD) regimenwas implemented to elucidate the mechanism behind monocyte trained immunity. In addition, classical monocytes were analysed by flow cytometry in the blood of enrolled patients.
Results: In MI and IR mice, blood monocytes and bonemarrow-derived macrophages exhibited elevated spleen tyrosine kinase (SYK), lysine methyltransferase 5A (KMT5A), and CCHC-type zinc finger nucleicacid-binding protein (CNBP) expression upon exposure to a HFD or oxidized LDL (oxLDL) stimulation. MI induced trained immunity was transmissible by transplantation of bone marrow to accelerateatherosclerosis in naive recipients. KMT5A specifically recruited monomethylation of Lys20 of histone H4 (H4K20me) to the gene body of SYK and synergistically transactivated SYK with CNBP. In vivo small interfering RNA (siRNA) inhibition of KMT5A or CNBP potentially slowed post-MI atherosclerosis. Sympathetic denervation with 6-hydroxydopamine reduced atherosclerosis and inflammation after MI. Classical monocytes from STEMI patients withadvanced coronary lesions expressed higher SYK and KMT5A gene levels.
Conclusions: The findings underscore the crucial roleof monocyte trained immunity in accelerated atherosclerosis after myocardial infarction, implying that spleen tyrosine kinase in blood classical monocytesmay serve as a predictive factor for the progression of atherosclerosis in STEMI patients.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of anyscientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on thiswebsite.
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P2Y12 Inhibitor Monotherapy vs DualAntiplatelet Therapy After Deployment of a Drug-Eluting Stent: The SHARE Randomized Clinical Trial
JAMA Netw Open. 2024 Mar 4;7(3):e240877
Abstract
Importance: P2Y12 inhibitor monotherapy after dualantiplatelet therapy (DAPT; a P2Y12 inhibitor plus aspirin) for a brief duration has recently emerged as an attractive alternative for patients undergoing percutaneous coronary intervention with a drug-eluting stent.
Objective: To investigate whether P2Y12 inhibitormonotherapy after 3 months of DAPTwas noninferior to 12 months of DAPT following percutaneous coronary intervention with a drug-eluting stent.
Design, setting, and participants: The Short-TermDual Antiplatelet Therapy After Deployment of Bioabsorbable Polymer Everolimus-Eluting Stent (SHARE) open-label, noninferiority randomized clinicaltrial was conducted from December 15, 2017, toDecember 14, 2020. Final 1-year clinical follow-up was completed in January 2022. This study was a multicenter trial that was conducted at 20 hospitals inSouth Korea. Patients who underwent successful percutaneous coronary intervention with bioabsorbable polymer everolimus-eluting stents were enrolled.
Interventions: Patients were randomly assigned toreceive P2Y12 inhibitor monotherapy after 3 months of DAPT (n = 694) or 12 months of Dual Antiplatelet Therapy (n = 693).
Main outcomes and measures: The primary outcome was a net adverse clinical event, a composite of major bleeding and major adverse cardiac and cerebrovascular events (cardiac death, myocardial infarction, stentthrombosis, stroke, or ischemia-driven target lesion revascularization) between 3 and 12 months after the index percutaneous coronary intervention. The majorsecondary outcomes were major adverse cardiac and cerebrovascular events and major bleeding. The noninferiority margin was 3.0%.
Results: Of the total 1452 eligible patients, 65patients were excluded before the 3-month follow-up, and 1387 patients were assigned to P2Y12 inhibitor monotherapy or Dual Antiplatelet Therapy Between 3and 12 months of follow-up, the primary outcome occurred in 9 patients in the P2Y12 inhibitor monotherapy group and in 16 patients in the Dual Antiplatelet Therapy group .The major secondaryoutcomes major adverse cardiac and cerebrovascular events occurred in 8 patients in the P2Y12 inhibitormonotherapy group and in 12 patients inthe Dual Antiplatelet Therapy group . Major bleeding occurred in 1 patient in the P2Y12 inhibitor monotherapy group and in 5 patients in the Dual Antiplatelet Therapy group
Conclusions and relevance: In patients with coronaryartery disease undergoing percutaneous coronary intervention with the latest generation of drug-eluting stents, P2Y12 inhibitor monotherapy after 3-month DualAntiplatelet Therapy was not inferior to 12-month Dual Antiplatelet Therapy for net adverse clinical events. Considering the study population and lower-than-expected event rates, further research is required in other populations.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding theaccuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medicaljudgment, which you should exercise in evaluating the information on this website.
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Beta-blocker therapy in heart failurewith preserved ejection fraction (B-HFpEF): A systematic review and meta-analysis
Curr Probl Cardiol. 2024 Mar;49(3):102376
Abstract
Introduction: While beta-blockers are considered thecornerstone of treatment for heart failure with reduced ejection fraction, the same may not apply to patients with heart failure with preserved ejection fraction. To date, the benefit of beta-blockers remains uncertain, and there is no current consensus on their effectiveness. This study sought to evaluate the efficacy of beta-blockers on mortality and rehospitalization among patientswith HFpEF.
Methods: A systematic review and meta-analysis ofrandomized or observational cohort studies examined the efficacy of beta-blocker therapy in comparison with placebo, control, or standard medical care in patients with HFpEF, defined as left ventricular ejection fraction ≥50 %. The main endpoints were mortality (i.e., all-cause and cardiovascular), rehospitalization (i.e., all-cause and for heart failure) and a composite of the two.
Results: Out of the 13,189 records initiallyidentified, 16 full-text records met the inclusion criteria and were analyzed recruiting a total of 27,188 patients. The mean age range was 62-84 years old,predominantly female, with HFpEF in which 63.4 % of patients received a beta-blocker and 36.6 % did not. The pooled analysis of included cohort studies, of variable follow-up durations, showed a significant reduction inall-cause mortality by 19 % whereas rehospitalization for heart failure or its composite with all-cause mortality were similar between the beta-blockerand control groups.
Conclusion : This meta-analysis showed that beta-blocker therapy has the potential to reduce all-causemortality in patients with HFpEF based on observational studies. Nevertheless, it did not affect rehospitalization for heart failure or its composite with all-cause mortality. Large scale randomized trials are needed to clarify thisuncertainty.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding theaccuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STAR UPDATE podcast. Youshould not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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The efficacy and safety of aspirin-ticagrelor vs. aspirin-clopidogrel in ischemic stroke patients withcerebral artery stenting
Clin Neurol Neurosurg . 2024 Mar 3:239:108229.
Abstract
Objective: First, the efficacy and safety ofaspirin-ticagrelor after cerebral artery stenting in ischemic stroke patients is controversial. Second, there is a gap in the research on guiding twoantiplatelet therapy after stenting based on the CYP2C19 genotype.
Methods: This retrospective study included patientswho underwent cerebral artery stenting at the First Affiliated Hospital of Chongqing Medical University from January 2019 to February 2023. We dividedthem into the aspirin-clopidogrel group and aspirin-ticagrelor group and carefully collected baseline information laboratory data and imaging resultsfrom the patients. The efficacy outcomes were 30 days recurrent stroke, 90 days recurrent stroke, and 180 days recurrent stroke, and the safety outcome wasintracranial hemorrhage. T-tests or Fisher's tests were performed for study outcomes in both groups of patients.
Outcome: A total of 372 patients were included. Forefficacy outcomes, aspirin-ticagrelor was associated with a reduced risk of 180 days recurrent stroke, in patients with CYP2C19 LOF allele and CYP2C19intermediate metabolic genotype compared with aspirin-clopidogrel. There was no significant difference in the rate of intracranial hemorrhage between patientswith aspirin-clopidogrel and aspirin-ticagrelor, regardless of overall, CYP2C19 LOF allele carriers or CYP2C19 intermediate metabolizer. No significant differences were found between the two on other efficacy and safety outcomes.
Conclusion: A cohort study found that aspirin-ticagrelorwas significantly superior to aspirin-clopidogrel in reducing 180 days recurrent stroke in CYP2C19 LOF allele carriers and CYP2C19 intermediatemetabolizers. There was no significant difference between aspirin-ticagrelor and aspirin-clopidogrel in the risk of intracranial hemorrhage in terms of ICHrates.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of anyscientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on thiswebsite.
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A novel score to predict in-hospital mortality for patients with acute coronary syndrome and out-of-hospital cardiacarrest: the FACTOR study
Clin Res Cardiol . 2024 Feb 8. doi: 10.1007/s00392-023-02367-1.
Abstract
Introduction: Acute coronary syndromes (ACS) represent a substantial global healthcare challenge. In its most severe form,it can lead to out-of-hospital cardiac arrest (OHCA). Despite medical advancements, survival rates in OHCA patients remain low. Further, the prediction of outcomes in these patients poses a challenge to all health care providers involved. This study aims at developing a score with variablesavailable on admission to assess in-hospital mortality of patients with OHCA undergoing coronary angiography.
Method: All patients with OHCA due to ACS admitted toa tertiary care center were included. A multivariate logistic regression analysis was conducted to explore the association between clinical variables and in-hospital all-cause mortality. A scoring system incorporating variables available uponadmission to assess individual patients' risk of in-hospital mortality was developed (FACTOR score). The score was then validated.
Results: A total of 291 patients were included in thestudy, with a median age of 65 [56-73] years, including 47 women (16.2%). The in-hospital mortality rate was 41.2%. A prognostic model was developed in the derivation cohort (n = 138) and included the following variables: age, downtime,first detected rhythm, and administration of epinephrine. The area under the curve for the FACTOR score was 0.823 (95% CI 0.737-0.894) in the derivation cohort and 0.828 (0.760-0.891) in the validation cohort (n = 153).
Conclusion: The FACTOR score demonstrated a reliableprognostic tool for health care providers in assessing in-hospital mortality of OHCA patients. Early acknowledgement of a poor prognosis may help in patient management and allocation of resources.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of anyscientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Factors Associated With Myocardial Infarction in a Rural Population With Peripheral Arterial Diseases
Angiology. 2024 Feb 6:33197241232608. doi:10.1177/00033197241232608.
Abstract
Peripheral arterial disease (PAD) studies in ruralpopulations are limited. The incidence of myocardial infarction (MI) is higher in patients with PAD. This study examined the association between sociodemographic and clinical risk factors and MI in patients with PAD in Central Appalachia, comprising of 230 countries across six states in the United States. Data from electronic medical records of 13,455 patients with PAD were extracted from a large health system in CentralAppalachia. Bivariate and logistic regression analyses were conducted. The final sample consisted of 5574 patients with PAD, of whom 24.85% were also diagnosed with MI. The mean age was 71 ± 11.23 years, and the majority were male (56.40%). After adjusting for confounders, patients with hypertension hadthree times higher odds of MI (adjusted Odds Ratio [aOR] = 3.21; 95% CI: 2.50-4.14) compared with those without hypertension. The likelihood of MI increased by 51% among patients with diabetes (aOR = 1.51; 95% CI: 1.33-1.71),34% among ever-smokers (aOR = 1.34; 95% CI: 1.18-1.52), and 45% in males (aOR = 1.45; 95% CI: 1.27-1.65). Hypertension, diabetes, smoking, and male sex were identified as significant risk factors for MI. Screening and effective management of these risk factors in rural areas could potentially prevent MIincidence among patients with PAD.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of anyscientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Secondary Prevention Therapies in Real-World Patients with Myocardial Infarction: Eligibility Based on RandomizedTrials Supporting European and American Guideline
Am J Med . 2024 Feb;137(2):137-146.e10. doi:10.1016/j.amjmed.2023.09.021
Abstract
Objective: We aimed to evaluate the applicability ofthe eligibility criteria of randomized controlled trials (RCTs) cited in guideline recommendations in a real-world cohort of patients receiving secondary prevention after acute myocardial infarction from the EPICOR registries.
Methods: Recommendations provided by American andEuropean guidelines for acute myocardial infarction were classified into general (applying to all patients) and specific (applying to patients with left ventricular dysfunction or heart failure). Randomized controlled trials cited in these recommendations were selected, and their entry criteria were applied to our international cohort of 18,117 patients.
Results: There were 91.5% patients eligible for betablockers (84.6% for general, and 5.9% for specific recommendations), 97.7% eligible for renin-angiotensin system inhibitor (angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers [ACEI/ARB]) recommendations(69.9% for general, 27.9% for specific) and 4.1% eligible for mineralocorticoid receptor antagonists (only specific recommendations). The percentages of patients with eligibility criteria who were discharged with a prescription ofthe recommended therapies were 80%-85% for beta blockers, 70%-75% for ACEI/ARB, and 29% for mineralocorticoid receptor antagonists. There were large regional variations in the percentage of eligible patients and in those receiving themedications (eg, 95% in Northern Europe and 57% in Southeast Asia for beta blockers).
Conclusion: Most real-world acute myocardial infarction patients are eligible for secondary prevention therapy in bothgeneral and specific guideline recommendations, and the percentage of those on beta blockers and ACEI/ARB at hospital discharge is high. There are large regional variations in the proportion of patients receiving recommended therapies. Local targeted interventions are needed for quality improvement.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of anyscientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Ticagrelor versus Clopidogrel in Endovascular therapy for Cerebral Aneurysms: A Systematic Review andMeta-analysis
World Neurosurg . 2024 Feb 9:S1878-8750(24)00210-9
Abstract
Background: Antiplatelet therapy is pivotal inendovascular treatment for intracranial aneurysms. However, there is a lack of studies comparing ticagrelor to clopidogrel in patients with aneurysms undergoing endovascular therapy. Additionally, the existing literature lacks adequate sample size, significant subgrouping, and follow-up, making our studyimportant to cover these gaps.
Methods: We searched five databases to collect allrelevant studies. Categorical outcomes were pooled as relative risk (R.R.) with a 95% confidence interval (CI). In the single-arm meta-analysis, outcomes were pooled as proportions and their corresponding 95% CI.
Results: This comprehensive analysis of 18 studiesinvolving 2,427 patients. For thromboembolic events, the pooled (R.R.) did not show significant differences, whether considering overall events. A similar pattern was observed for thromboembolic events stratified by aneurysmal rupturestatus, with no significant differences in overall events. Hemorrhagic events did not also exhibit significant differences in previously mentionedstratifications. Furthermore, there were no substantial differences in death and mRS (0-2) on discharge between Ticagrelor and Clopidogrel. Single-arm meta-analyses for Ticagrelor demonstrated low rates of thromboembolic events,hemorrhage, death, and favorable mRS scores, with associated confidence intervals. Main line of endovascular treatment did not significantly affect either thromboembolic or hemorrhagic outcomes with Ticagrelor and Clopidogrel.
Conclusion: We found no significant differences inkey outcomes like thromboembolic events, hemorrhagic events, mortality rates, and favorable mRS (0-2) upon discharge in the studied patients between Ticagrelor and Clopidogrel. Moreover, the single-arm meta-analysis for Ticagrelor revealed low rates of thromboembolic events, hemorrhage, mortality,and high rates of favorable mRS scores.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of anyscientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Predictive value of the thrombotic risk criteria proposed in the 2023 ESC guidelines for the management of ACS: insights from a large PCI registry
Eur Heart J Cardiovasc Pharmacother. 2024 Jan5;10(1):11-19. doi: 10.1093/ehjcvp/pvad069
Abstract
Aim: To assess the value of the thrombotic risk criteria proposed in the 2023 guidelines of the European Society of Cardiology (ESC) for the management of acute coronary syndrome (ACS) to predict the ischaemic risk after percutaneous coronary intervention (PCI).
Methods and results: Consecutive patients with acuteor chronic coronary syndrome undergoing PCI at a large tertiary-care center from 2014 to 2019 were included. Patients were stratified into low, moderate, or high thrombotic risk based on the ESC criteria. The primary endpoint wasmajor adverse cardiovascular events (MACEs) at 1 year, a composite of all-cause death, myocardial infarction (MI), and stroke. Secondary endpoints included major bleeding. Among 11 787 patients, 2641 (22.4%) were at low-risk, 5286 (44.8%) at moderate risk, and 3860 (32.7%) at high-risk. There was anincremental risk of MACE at 1 year in patients at moderate (hazard ratios (HR) 2.53, 95% confidence interval (CI) 1.78-3.58) and high-risk (HR 3.39, 95% CI 2.39-4.80) as compared to those at low-risk, due to higher rates of all-cause death and MI. Major bleeding rates were increased in high-risk patients (HR1.59, 95% CI 1.25-2.02), but similar between the moderate and low-risk group.The Harrell's C-index for MACE was 0.60.
Conclusion: The thrombotic risk criteria of the 2023ESC guidelines for ACS enable to stratify patients undergoing PCI in categories with an incremental 1 year risk of MACE; however, their overall predictive ability for MACE is modest. Future studies should confirm the value of thesecriteria to identify patients benefiting from an extended treatment with a second antithrombotic agent.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy,adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on thiswebsite.
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Beta-blocker therapy in heart failure with preserved ejection fraction (B-HFpEF): a systematic review and meta-analysis
Curr Probl Cardiol . 2024 Jan 4:102376. doi:10.1016/j.cpcardiol.2024.102376.
Abstract
Introduction: While beta-blockers are considered thecornerstone of treatment for heart failure with reduced ejection fraction, the same may not apply to patients with heart failure with preserved ejection fraction (HFpEF). To date, the benefit of beta-blockers remains uncertain, and there is no current consensus on their effectiveness. This study sought toevaluate the efficacy of beta-blockers on mortality and rehospitalization among patients with HFpEF.
Methods: A systematic review and meta-analysis ofrandomized or observational cohort studies examined the efficacy of beta-blocker therapy in comparison with placebo, control, or standard medical care in patients with HFpEF, defined as left ventricular ejection fraction ≥50%. The main endpoints were mortality (i.e., all-cause and cardiovascular),rehospitalization (i.e., all-cause and for heart failure) and a composite of the two.
Results: Out of the 13,189 records initially identified, 16 full-text records met the inclusion criteria and were analyzedrecruiting a total of 27,188 patients. The mean age range was 62 - 84 years old, predominantly female, with HFpEF in which 63.4% patients received a beta-blocker and 36.6% did not. The pooled analysis of included cohort studies, of variable follow-up durations, showed a significant reduction in all-causemortality by 19% (odds ratio (OR) 0.81; 95% confidence interval (CI): 0.65-0.99, p=0.044) whereas rehospitalization for heart failure (OR 1.13; 95% CI: 0.91-1.41, p=0.27) or its composite with all-cause mortality (OR 1.01; 95% CI: 0.78-1.32, p=0.92) were similar between the beta-blocker and control groups.
Conclusion: This meta-analysis showed that beta-blocker has the potential to reduce all-cause mortality in patients withHFpEF based on observational studies. Nevertheless, rehospitalization for heart failure or its composite with all-cause mortality. Large scale randomized trials are needed to clarify this uncertainty.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute foryour own medical judgment, which you should exercise in evaluating the information on this website
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One year clinical outcome of dual anti-platelet therapy with the Novel Ticagrelor plus Aspirin versus Clopidogrelplus Aspirin for Endovascular Intervention of patients with Intracranial Aneurysm: A meta-analysis
J Stroke Cerebrovasc Dis. 2024 Jan;33(1):107491.
Abstract
Background: The use of stents to treat un-rupturedintracranial aneurysms was first approved in the year 2002 in the United States as a Humanitarian Device Exemption. Antiplatelet therapy is mandatory following stent placement. Dual antiplatelet therapy (DAPT) with aspirin and clopidogrelhas been the first line agents for the prevention of thromboembolic events following neuro-endovascular procedures. However, clopidogrel hypo-responsiveness has often been observed. In this analysis, we aimed tosystematically compare one year clinical outcome of DAPT with the Novel Ticagrelor plus Aspirin versus Clopidogrel plus Aspirin for Endovascular Intervention of patients with Intracranial Aneurysm.
Methods: Online electronic databases were searchedfrom June 2023 till July 2023 for relevant studies which compared DAPT with ticagrelor or clopidogrel for endovascular intervention in patients with intracranial aneurysm. The endpoints which were analyzed were classified into thromboembolic and hemorrhagic events. A fixed and a random effect statistical model were used during data analysis respectively. Risk ratio (RR) with 95 % confidence interval (CI) was used to represent the data following analysis.
Results: Five studies with a total number of 893participants were included in this analysis. Three hundred and fifty eight (358) participants were assigned to the ticagrelor group whereas 535 participants were assigned to clopidogrel group. Participants' enrollment period ranged from the year 2009 to 2019. Our results showed that during a meanfollow-up time period of one year, DAPT with ticagrelor was associated with significantly lower thromboembolic events with RR: 0.33, 95 % CI: 0.16 - 0.68; P = 0.003. In addition, at one year, DAPT with ticagrelor was not associatedwith any increase in hemorrhagic events (RR: 0.66, 95 % CI: 0.29 - 1.50; P = 0.32) when compared to DAPT with clopidogrel.
Conclusion: At one year, DAPT with ticagrelor wasassociated with significantly lower thromboembolic events without any increase in hemorrhagic events when compared to clopidogrel associated DAPT for endovascular intervention of patients with intracranial aneurysm. However, eventhough ticagrelor-associated DAPT use appeared to be more effective and safe, this hypothesis should only be confirmed in larger upcoming trials.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy,adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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The Prognostic impact of treatmentsevolution in STEMI
Int J Cardiol. 2024 Jan 1:394:131352. doi:10.1016/j.ijcard.2023.131352
Abstract
Objective: To evaluate in a real-world primary percutaneous coronary intervention (pPCI) registry the impact of the evolution of evidence-based treatments on prognosis.
Methods: STEMI patients undergoing pPCI at theUniversity Hospital of Trieste, Italy, were enrolled. The first cohort (old treatments cohort) included STEMI patients treated between January-2007 and December-2012, and the second cohort (new treatments cohort), between January-2013 andDecember-2020. Inverse Probability of Treatment Weighting (IPTW) Cox regression models as well as multivariable Cox regression models were performed to assess the risk of a composite primary endpoint (PE) of all cause death, reinfarction and re-PCI at 5 years.
Results: A total of 2425 STEMI patients were enrolled. At multivariable Cox regression, the new-treatments cohort had lower risk of PE and mortality. Weighted (IPTW) Cox proportional hazard models confirmed the lower risk of the new treatments cohort for PE (HR 0.72; 95% CI 0.56-0.91, p = 0.007) and 5-year mortality (HR 0.70, 95%CI 0.54-0.91, p =0.009). When considering both clinical and procedural variables, complete revascularization (HR 0.46, 95%CI 0.27-0.80, p = 0.006) and the administration of prasugrel or ticagrelor (HR 0.72, 95%CI 0.52-0.99, p = 0.013) wereindependent predictors of PE as well as of 5-year mortality. Patients receiving prasugrel or ticagrelor or drug eluting stent were at lower risk of 1-year stent thrombosis (HR 0.50, 95%CI 0.28-0.90, p = 0.021).
Conclusions: In a real-word STEMI population theprognosis of patients has improved in the last decades, and this was associated to the use of new antithrombotic treatments and to the implementation of complete revascularization.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy,adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Prognostic significance of medical therapy in patients with heart failure with reduced ejection fraction
ESC Heart Fail. 2023 Dec;10(6):3677-3689. doi: 10.1002/ehf2.14559
Abstract
Aims: The use of guideline-directed medical therapy(GDMT) among patients with heart failure (HF) with reduced ejection fraction (HFrEF) remains suboptimal. The SMYRNA study aims to identify the clinical factors for the non-use of GDMT and to determine the prognostic significance ofGDMT in patients with HFrEF in a real-life setting.
Methods and results: The SMYRNA study is aprospective, multicentre, and observational study that included outpatients with HFrEF. Patients were divided into three groups according to the status of GDMT at the time of enrolment: (i) patients receiving all classes of HF medications including renin-angiotensin system (RAS) inhibitors, beta-blockers,and mineralocorticoid receptor antagonists (MRAs); (ii) patients receiving any two classes of HF medications (RAS inhibitors and beta-blockers, or RAS inhibitors and MRAs, or beta-blockers and MRAs); and (iii) either patients receiving class of HF medications (only one therapy) or patients not receivingany class of HF medications. The primary outcome was a composite of hospitalization for HF or cardiovascular death. The study population consisted of 1062 patients with HFrEF, predominantly men (69.1%), with a median age of 68(range: 20-96) years. RAS inhibitors, beta-blockers, and MRAs were prescribed in 76.0%, 89.4%, and 55.1% of the patients, respectively. The proportions of patients receiving target doses of guideline-directed medications were 24.4% for RAS inhibitors, 11.0% for beta-blockers, and 11.1% for MRAs. Overall, 491 patients (46.2%) were treated with triple therapy, 353 patients (33.2%) were treated with any two classes of HF medications, and 218 patients (20.6%) werereceiving only one class of HF medication or not receiving any HF medication. Patient-related factors comprising older age, New York Heart Association functional class, rural living, presence of hypertension, and history of myocardial infarction were independently associated with the use or non-use ofGDMT. During the median 24-month period, the primary composite endpoint occurred in 362 patients (34.1%), and 177 of 1062 (16.7%) patients died. Patients treated with two or three classes of HF medications had a decreased risk of hospitalization for HF or cardiovascular death compared with those patients receiving ≤1 class of HF medication [hazard ratio (HR): 0.65; 95% confidence interval (CI): 0.49-0.85; P = 0.002, and HR: 0.61; 95% CI: 0.47-0.79; P < 0.001, respectively].
Conclusions: The real-life SMYRNA study provided comprehensive data about the clinical factors associated with the non-use of GDMT and showed that suboptimal GDMT is associated with an increased risk of hospitalization for HF or cardiovascular death in patients with HFrEF.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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De-escalation of Antiplatelet Therapy After Percutaneous Coronary Intervention in East Asian Patients With AcuteCoronary Syndrome
Clin Ther. 2023 Dec 8:S0149-2918(23)00305-3.doi: 10.1016/j.clinthera.2023.08.004
Abstract
Purpose: East Asian individuals have a lower risk of thromboembolic events while potentially carrying a higher riskof bleeding events compared with non-Asian individuals. The aim of the present analysis was to investigate the effectiveness and safety of the de-escalation of antiplatelet therapy compared with standard dual antiplatelet therapy (DAPT)in East Asian patients undergoing percutaneous coronary intervention (PCI).
Methods: Randomized controlled trials comparing de-escalation with DAPT in patients with acute coronarysyndrome (ACS) were retrieved from electronic databases from their inception until March 2022. Outcomes included major adverse cardiovascular events (MACE), ischemic events, major bleeding, minor bleeding, and any bleeding. Subgroupanalyses based on treatment strategy were conducted. Statistical analysis was performed by using Review Manager version 5.4.
Findings: Eight randomized controlled trials from 539 potentially relevant publications with a total of 15,744 East Asian patients were included. Pooled data from these studies founda significantly lower MACE (0.82; 95% CI, 0.69-0.98) and major bleeding event (0.62; 95% CI, 0.46-0.82) in de-escalation than standard-DAPT without heterogeneity. Subgroup analysis was divided into DAPT followed by P2Y12 inhibitor monotherapy and a reducing dose of P2Y12 inhibitors. DAPT followed byP2Y12 inhibitor monotherapy had a 48% lower incidence of major bleeding events than standard DAPT (0.52; 95% CI, 0.27-1.00); there was no significant difference in major bleeding (0.99; 95% CI, 0.55-1.76) between the reducingdose of P2Y12 inhibitors and standard DAPT.
Implications: De-escalation is a promising and potentially optimal antiplatelet therapy for patients from EastAsia with PCI. DAPT followed by P2Y12 inhibitor monotherapy might be a safer and equally effective approach compared with standard DAPT in East Asian patients with PCI.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Effect of beta-blockers and exercise restriction on the prevention of sudden cardiac death in pediatric hypertrophiccardiomyopathy
JCardiol. 2023 Dec 2:S0914-5087(23)00288-5. doi: 10.1016/j.jjcc.2023.11.009.
Abstract
Background: Risk assessment tools and effective prevention strategies for sudden cardiac death (SCD) in pediatric patients with hypertrophic cardiomyopathy (HCM) have not been established. This study aimed to evaluate the efficacy of beta-blockers and exercise restriction for SCD prevention in this population.
Methods: We retrospectively reviewed the medicalrecords of patients aged <18 years who were diagnosed with HCM at our center between January 1996 and December 2021. SCD and aborted SCD were defined as SCD equivalents. We divided patients based on whether they were prescribedbeta-blockers or exercise restriction and compared the outcomes among the groups. The primary outcome was the overall survival (OS), and the secondary outcome was the cumulative SCD equivalent rate. Outcomes were analyzed usingKaplan-Meier curves and Cox proportional hazard analysis. We also compared patients according to the occurrence of SCD equivalents to identify SCD risk predictors.
Results: Among the 43 included patients [mean age,7.7 (1.6-12.1) years; 23 male individuals], SCD equivalents occurred in 13 patients over 11.2 (4.5-15.6) years of follow-up, among whom 12 were resuscitated and 1 died. The OS rate was significantly higher in the beta-blocker and exercise restriction groups than in the non-beta-blocker and non-exercise restriction groups (81.3 % vs. 19.1 %, p < 0.01 and 57.4 % vs.12.7 %, p < 0.01, respectively). Among the 13 patients with SCD equivalents, 5 had 9 recurrent SCD equivalents. A significant difference was observed between the SCD equivalent and non-SCD equivalent groups in the history of suspected arrhythmogenic syncope (p < 0.01) in the univariable but not inthe multivariable analysis.
Conclusions: Beta-blockers and exercise restrictionmay decrease the risk of SCD in pediatric patients with HCM and should be considered for SCD prevention in this population, particularly because predicting SCD in these patients remains challenging.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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