Интересные ссылки

[Maltsev]

[Изображения доступны только зарегистрированным пользователям]

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--
С Уважением,
Мальцев А.А.

[Maltsev]

Прошу прощения, забыл вставить аннотацию к картинке:

Unadjusted Kaplan-Meier survival curves up to 10 years from index hospitalization, stratified by type of ACS presentation. MMD = mild myocardial damage (defined by elevated creatine kinase [CK]-MB relative index [MBRI] with normal total CK); UA = unstable angina; NSTEMI = non-ST-elevation myocardial infarction; STEMI = ST-elevation myocardial infarction


--
С Уважением,
Мальцев А.А.

[Maltsev]

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Фултекст в пдф-формате тут:
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Или тут:
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--
С Уважением,
Мальцев А.А.

[Maltsev]

Angiography Versus Intravascular Ultrasound-Directed Stent Placement (AVID)


[Ссылки доступны только зарегистрированным пользователям ]

Russo RJ, Silva PD, Teirstein PS, et al. A randomized controlled trial of angiography versus intravascular ultrasound-directed bare-metal coronary stent placement (The AVID Trial). Circ Cardiovasc Intervent 2009;2:113-23.

В середине девяностых у А. Коломбо были несколько иные результаты подобного исследования... Кроме того, есть ряд вопросов по тактике интервенций в данном исследовании.

--
С Уважением,
Мальцев А.А.

[Maltsev]

[Ссылки доступны только зарегистрированным пользователям ]

--
С Уважением,
Мальцев А.А.

[Chevychelov]

О времени:
Any Delay in Door-to-Balloon Time Associated With Increased In-Hospital Mortality CME

News Author: Michael O'Riordan
CME Author: Charles P. Vega, MD, FAAFP


CME Released: 05/29/2009; Valid for credit through 05/29/2010

May 29, 2009 — For patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), any delay in the door-to-balloon time is associated with an increased risk of in-hospital mortality, even when patients are treated within 90 minutes of admission, according to the results of a new study [1].

Physicians could further reduce mortality among these patients by "minimizing door-to-balloon time to the greatest extent possible," even among those treated within times recommended by the clinical guidelines, according to investigators. The researchers point out, however, that the results more accurately support the finding of benefit from quicker treatment rather than an increased harm from "delayed" treatment, based on this observational study.

"Our data suggest that there is no 'floor' to the mortality reduction that can be achieved by reducing time to treatment," write Dr Saif Rathore (Yale University School of Medicine, New Haven, CT) and colleagues in the May 20, 2009 issue of BMJ. "As such, further reductions in door-to-balloon times, even below the 90-minute benchmark endorsed by clinical practice guidelines, offer the potential to significantly reduce mortality."

The analysis, from the American College of Cardiology-sponsored National Cardiovascular Data Registry, consisted of 43 801 patients with STEMI undergoing PCI in 2005 and 2006. The purpose of the study, according to investigators, was to determine the shape of the relation between mortality and door-to-balloon times and whether or not further reductions in hospital delays could reduce mortality.

The average door-to-balloon time was 83 minutes, and in-hospital mortality was 4.6%. For patients who died, the door-to-balloon time was 14 minutes longer than for patients who survived. Overall, longer door-to-balloon times were associated with increased mortality, which ranged from 3.0% for those treated within 30 minutes to 10.3% for those treated within four hours. The findings were similar when patients presenting in shock were excluded from the analysis.

Estimated In-Hospital Mortality by Door-to-Balloon Times Time (min) Adjusted mortality*
15 2.9 (2.8-3.1)
30 3.0 (2.9-3.2)
60 3.5 (3.4-3.6)
90 4.3 (4.2-4.4)
120 5.6 (5.4-5.7)
180 8.4 (8.2-8.7)
240 10.3 (10.0-10.7)


*Adjusted for age, sex, race, findings on presentation, medical history, procedural characteristics, angiographic findings, and hospital factors

The authors note that the increased risk associated with delayed treatment is consistent with pathophysiological research, including studies showing that necrosis largely depends on the duration of ischemia. Patients with long door-to-balloon times have longer vessel occlusion, resulting in more necrosis, they add.

To heartwire , Rathore noted that because this was an observational study, they do not necessarily know if there were delays in treatment per se and that the door-to-balloon times might have been as good as they could have been.

"What I think our data show, and the message we'd like people to take from the paper, is that shorter door-to-balloon times appear to be associated with a mortality reduction and that this can support the interpretation that as fast and safe as possible should be our new standard for primary PCI," he commented.

Reference
Rathore SS, Cutis JP, Chen J, et al. Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: a national cohort study. BMJ 2009; 339:b1807. Abstract
Clinical Context


Time is a critical element of care of the patient with STEMI, as a longer period of ischemia promotes higher degrees of muscle necrosis. Current guidelines therefore recommend that these patients receive primary PCI within 90 minutes of presentation to the medical system.

However, there remains a question whether even faster treatment might promote better outcomes. Results from research into this subject are mixed, with some studies suggesting mortality from myocardial infarction is elevated only after a treatment delay of 1 hour or more. There are limited data regarding outcomes from interventions at less than 90 minutes.

The current study examines time to treatment as a linear continuous variable to assess mortality rates after STEMI.

Study Highlights

Study data were drawn from the American College of Cardiology National Cardiovascular Data Registry, which collects information from more than 600 centers in the United States.
Specifically, researchers analyzed the cases of adult patients with STEMI who received primary PCI between 2005 and 2006. Patients who were transferred from another hospital or who first received fibrinolytic therapy were excluded from study evaluation.
The main outcome of the study was the influence of door-to-balloon time on patient mortality rates during hospitalization. This result was adjusted to account for multiple potential confounders, including demographic data, medical history, hospital characteristics, procedural characteristics of reperfusion therapy, and angiographic findings.
43,801 patients contributed data to the study analysis. The median age of subjects was 59 years, 27.9% were women, and 84.7% of subjects were white.
The median door-to-balloon time was 83 minutes, and 57.9% of subjects received treatment within 90 minutes of presentation.
Variables associated with longer door-to-balloon times included female sex, nonwhite race, older age, and higher co-prevalence of chronic illness.
Patients with a shorter door-to-balloon time had a lower incidence of cardiogenic shock and a higher percentage of stenoses of the left main and left anterior descending coronary arteries. Treatment during a weekday and hospitalization at an urban center were other factors associated with a shorter door-to-balloon time.
The overall in-hospital mortality rate was 4.6%. Mortality rates associated with specific door-to-balloon times are as follows:
Less than 60 minutes: 3.2%
60 to 89 minutes: 3.7%
90 to 119 minutes: 4.6%
120 minutes or longer: 7.7%
Adjusted analyses demonstrated a significant and nonlinear trend toward higher mortality rates with longer door-to-balloon times.
Reduction in the average door-to-balloon time from 90 minutes to 60 minutes yielded a 0.8% mean reduction in hospital mortality rates, whereas a further reduction to 30 minutes yielded a 0.5% reduction in mortality rates.
Clinical Implications

Current recommendations for the treatment of STEMI include a door-to-balloon time of 90 minutes or less.
The current study suggests that any delay in the treatment of STEMI with primary PCI results in a higher risk for in-hospital mortality.

[Chevychelov]

О времени 2:
AHA/ASA Science Advisory Recommends Use of tPA Between 3 and 4.5 Hours After Stroke CME

News Author: Susan Jeffrey
CME Author: Laurie Barclay, MD

Authors and Disclosures

CME Released: 05/29/2009; Valid for credit through 05/29/2010 Print This



May 29, 2009 — A new science advisory from the American Heart Association (AHA)/American Stroke Association (ASA) has given the green light to the use of tissue plasminogen activator (tPA) to treat acute ischemic stroke between 3 and 4.5 hours after symptom onset.


Specific recommendations for administration of intravenous tPA to patients with acute ischemic stroke are laid out in current guidelines by the American Heart Association Stroke Council. Although tPA has been shown to be highly effective in improving neurologic outcomes in patients meeting selection criteria, most patients with ischemic stroke present after the currently approved 3-hour time limit for administration and therefore do not receive tPA.

If patients could be effectively treated with tPA in the period after 3 hours from the onset of stroke symptoms, more patients could potentially benefit from this intervention. The ECASS-3 has provided new findings on outcomes when tPA is given in the 3- to 4.5-hour window after onset of stroke symptoms.

Study Highlights

The AHA Stroke Council/ASA issued a science advisory regarding use of tPA in acute ischemic stroke.
Patients deemed to be eligible for tPA treatment within 3 hours of stroke onset should be treated as recommended in the 2007 guidelines.
Because the likelihood of improvement is greater with earlier treatment, delays in evaluation and starting therapy should be avoided, although a time window of more than 3 hours for treatment has now been formally tested.
In the 2008 ECASS-3, a multicenter, randomized, placebo-controlled trial, some patients were treated successfully with tPA up to 4.5 hours after stroke symptoms began.
Eligible patients who can be treated 3 to 4.5 hours after onset of stroke symptoms should receive tPA. This is a class I recommendation, level of evidence B.
Eligibility criteria for treatment 3 to 4.5 hours after stroke onset are similar to those for persons treated at earlier periods, with additional exclusion criteria.
These additional exclusion criteria are age older than 80 years, use of oral anticoagulants regardless of INR, baseline National Institutes of Health Stroke Scale score of more than 25, or a history of both stroke and diabetes.
Patients with any 1 or more of the above additional exclusion criteria should not receive tPA within the 3- to 4.5-hour window.
Compared with other methods of thrombus dissolution or removal, the relative usefulness of tPA in the 3- to 4.5-hour window has not been established.
In patients with the mentioned exclusion criteria, the efficacy of treatment with intravenous tPA within 3 to 4.5 hours after stroke onset is not yet determined and requires further research (class IIb recommendation, level of evidence C).
Patients treated with tPA 3 to 4.5 hours after ischemic stroke should receive ancillary care similar to that described in the 2007 AHA Stroke Council Guidelines.
These recommendations are based on peer-reviewed publications and should be reevaluated following release of findings from regulatory agency review of detailed, nonpublicly available data.
Clinical Implications

Eligible patients who can be treated 3 to 4.5 hours after onset of ischemic stroke symptoms should receive tPA, as well as ancillary care similar to that described in the 2007 AHA Stroke Council guidelines. Eligibility criteria for treatment 3 to 4.5 hours after stroke onset are similar to those for persons treated at earlier periods, with additional exclusion criteria.
These additional exclusion criteria are age older than 80 years, use of oral anticoagulants regardless of INR, baseline National Institutes of Health Stroke Scale score of more than 25, or a history of both stroke and diabetes.

[Yariko]

[Ссылки доступны только зарегистрированным пользователям ]
Elevated coronary calcium scores are associated with higher residual platelet aggregation after clopidogrel treatment in patients with stable angina pectoris
Christof Burgstahler, Tobias Geisler, Stephan Lindemann, Harald Brodoefel, Anja Reimann, Martin Heuschmid, Meinrad Gawaz, Stephen Schroeder
High coronary calcium scores are known to be associated with elevated all-cause mortality. Moreover, low response to clopidogrel influences cardiovascular outcome after coronary stent placement. We sought to evaluate whether elevated calcium scores measured by cardiac computed tomography are associated with a higher residual platelet aggregation (RPA) after treatment with clopidogrel. Thus, in 62 patients coronary calcium scoring was measured prior to stent implantation. RPAwas assessed by ADP (20 μmol/L)-induced aggregometry at least 6 h after administration of a loading dose of 600 mg clopidogrel. We found a significant correlation between ASE and RPA (r2=0.135, p=0.0033, slope 7.809±2.549). Patients within the first quartile of ASE had significantly lower RPA after administration of clopidogrel than other patients (pb0.05). Establishing a threshold of 200 ASE responsiveness to clopidogrel could be predicted with a positive predictive value of 80% and a specificity of 91%. In conclusion, we could
demonstrate that patients with a low coronary plaque burden are more likely to have low RPA. Coronary calcium scoring might help to identify low responders to clopidogrel prior to stent placement and aggregometry.
Int J Cardiol 2009;135(1):132-135.

[Yariko]

[Ссылки доступны только зарегистрированным пользователям ]

Frequency and Prognostic Significance of Pericarditis Following Acute Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention

Massimo Imazio MDa, , , Alessandro Negro MDa, Riccardo Belli MDa, Federico Beqaraj MDa, Davide Forno MDa, Massimo Giammaria MDa, Rita Trinchero MDa, Yehuda Adler MDb and David Spodick MDc

Prospective data were collected from 743 consecutive patients with ST-segment elevation acute myocardial infarctions (AMIs) treated with primary percutaneous coronary intervention (mean age 65.3 ± 11.6 years, 36.7% women). Early post-AMI pericarditis was diagnosed in 31 patients (4.2%; mean age 62.1 ± 13.4 years, 41.9% women), with an increasing prevalence according to presentation delay (p <0.001): 1.7% for <3 hours, 5.4% for 3 to 6 hours, and 13.6% for >6 hours. Late post-AMI pericarditis (Dressler syndrome) was recorded in only 1 patient (0.1%). On multivariate analysis, patients with presentation times >6 hours (odds ratio 4.4, 95% confidence interval 2.0 to 9.8, p <0.001) and primary percutaneous coronary intervention failure (odds ratio 2.8, 95% confidence interval 1.1 to 7.4, p = 0.032) were at increased risk for developing early post-AMI pericarditis. Although pericarditis is associated with a larger infarct size, in-hospital and 1-year mortality and major adverse cardiac events were similar in patients with and without pericarditis. In conclusion, early primary percutaneous coronary intervention may reduce the occurrence of early post-AMI pericarditis within the first 3 hours of symptom onset. Early post-AMI pericarditis remains a marker of larger infarct size but without independent prognostic significance.

[Igor73]

Появился некий эвиденс в тактике ведения пациентов с СД и ИБС. До сих пор РКИ по этой теме отсутствовали, в наличии были данные субанализов и регистры.
NEJM в on-line first версии опубликовал результаты исследования BARI 2D (аналог Куража у пациентов с СД), в котором пациентов с диабетом рандомизировали в группу медикаментозной терапии и группу реваскуляризации (АКШ или ТБКА, где 61% DES). Результаты превзошли самые смелые ожидания - [Ссылки доступны только зарегистрированным пользователям ]

[cerebellum]

Я извиняюсь, что без ссылки в непрофильной теме. Чуть-чуть пофлужу на усмотрение модераторов, тем более отказывается работать одобрялка.

Уважаемый Игорь Петрович!
Спасибо за интересный обзор Но по поводу Вашего постинга..

Хоть и роль DES даже у диабетиков спорная, их % представляется немаловажным.

Among 765 patients in the revascularization group who underwent PCI, procedures were attempted on a mean (±SD) of 1.5±0.8 lesions. Of these procedures, 20.7% involved a multivessel intervention; 34.7% of the patients received a drug-eluting stent, and 56.0% received a bare-metal stent; the other 9.3% did not receive a stent. After drug-eluting stents became available in April 2003, 61.0% of the initial PCI procedures involved the use of such stents.

(Исследование началось 01.01.2001)
Если я понимаю правильно, то лишь с 2003 года 61% интервенций включали DES (что не означает, что реваскуляризация проводилось только DES, м.б. была и комбинация DES & BMS).
А окончательный % DES все-таки составляет скорее 1/3, чем 2/3.


p.s.: в посте уважаемой Юноны Владиславовны впервые обратил внимание на степени MDa, MDb и MDc. Буду признателен, если кто-либо в ЛС объяснит их значение. Спасибо

[Chevychelov]

Что нужно практическому врачу? Определенность!
Naproxen Best NSAID for Heart-Disease Patients

News Author: Sue Hughes
Author: Charles P. Vega, MD, FAAFP

June 8, 2009 — One of the first large studies to look at the safety of different nonsteroidal anti-inflammatory drugs (NSAIDs) specifically in patients with heart disease has found that naproxen appears to have better cardiovascular safety than diclofenac, ibuprofen, and higher doses of rofecoxib (Vioxx, Merck) and celecoxib (Celebrex, Pfizer) [1].

The study, published in the May 2009 issue of Circulation: Cardiovascular Quality and Outcomes, was conducted by a group led by Dr Wayne Ray (Vanderbilt University School of Medicine, Nashville, TN).

They explain that the cardiovascular safety of NSAIDs is highly controversial, with several studies suggesting increased cardiovascular risk associated with the new COX-2 inhibitors and also some older traditional NSAIDs, and that this issue is particularly important for patients with existing serious coronary heart disease, whose baseline risk of adverse cardiovascular events is increased. In addition, many of these patients take low-dose aspirin, which may interact with the NSAID.


Results showed that cardiovascular safety was best for naproxen, which had a lower incidence rate ratio (IRR) for serious cardiovascular disease than non-NSAID users. In contrast, there was evidence that cardiovascular risk was increased for users of the other study NSAIDs.

Incidence Rate Ratios (IRRs) for Serious CV Disease or Serious CV Disease and Death for Users of Various NSAIDS vs Non-NSAID Users Drug IRR (serious CV disease) IRR (serious CV disease/death)
Naproxen 0.88 0.91
Ibuprofen 1.18 1.14
Diclofenac 1.27 1.38
Celecoxib 1.03 0.99
Rofecoxib 1.19 1.07

Relative to NSAID nonusers, serious coronary heart disease risk increased with short-term (less than 90 days) use for ibuprofen, diclofenac, celecoxib, and rofecoxib, but not for naproxen. The authors note that this is in contrast to a widely publicized post hoc analysis of the APPROVE trial data, interpreted by some as suggesting no risk for use of less than 18 months. But they point out that observational studies of rofecoxib have reported increased risk within the first month of therapy, and in the VICTOR trial, rofecoxib patients had increased risk after a mean duration of 7.4 months. "Thus, our findings add to the evidence that at least one of the mechanisms for increased cardiovascular risk is acute," they say.


In an accompanying editorial [2], Dr Daniel Solomon (Brigham and Women's Hospital, Boston, MA) says that this study breaks new ground in focusing on patients with known cardiovascular disease. As arthritis and cardiovascular disease commonly coexist, studying the cardiovascular safety of NSAIDs in this subgroup is of great public-health value, he comments.

Noting that the relative risks for rofecoxib were consistently lower when death from any cause was also included in the end point, Solomon suggests that this raises the possibility that death from gastrointestinal bleeds may have been reduced in persons using rofecoxib. He says this leads to questions about how to measure the overall safety of a drug. "Cardiovascular safety in patients with known cardiovascular disease is tremendously important, but clinicians and patients should focus on 'net' safety," he writes. But he adds that this is difficult concept to understand and even harder to measure.

Solomon continues that the use of NSAIDs in patients with cardiovascular disease is concerning because of the cardiovascular and gastrointestinal toxicities associated with these agents, but until newer analgesics are developed, these agents will continue to be used in this patient group.

While more information will come from the PRECISION trial, a large randomized comparison of celecoxib, naproxen, and ibuprofen in patients at moderate cardiovascular risk, these results will not be available until 2011 or later, and thus, until then, doctors will continue to rely on well-done pharmacoepidemiology to help answer questions about the relative safety of various analgesic strategies in important subgroups of patients, Solomon says.

He concludes that the current study "gives us new and useful information from an observational study focusing on an important subgroup with known cardiovascular disease" and that "diclofenac use should be limited in this group and naproxen appears relatively safe, but non-NSAID analgesic strategies might also be considered."

This study was funded by an unrestricted grant from Pfizer. Ray has consulted with plaintiff's attorneys and insurance companies regarding rofecoxib. Two other authors were employees of Pfizer when this research began, and other authors have received research support from Merck, AstraZeneca, Novartis, and Pfizer. Solomon receives salary support for research from Amgen and Abbott. He serves as an unpaid member of the executive committee of the Pfizer-sponsored PRECISION trial, and he serves as an unpaid member of the data safety monitoring board of a Pfizer-sponsored trial investigating a non-NSAID analgesic for osteoarthritis.

References
Ray WA, Varas-Lorenzo C, Chung CP, et al. Cardiovascular risks of nonsteroidal antiinflammatory drugs in patients after hospitalization for serious coronary heart disease. Circ Cardiovasc Qual Outcomes 2009; 2:155-163.
Solomon D H. Searching for a safe analgesic in patients with cardiovascular disease. Circ Cardiovasc Qual Outcomes 2009; 2:146-147.
Clinical Context


There has been significant attention to the cardiovascular risks associated with NSAIDs and particularly the risk associated with COX-2 inhibitors. In a previous systematic review and meta-analysis by McGettigan and Henry, which was published in the October 4, 2006, issue of the Journal of the American Medical Association, the researchers found that rofecoxib significantly increased the risk for cardiovascular events, and this risk increased with higher doses of rofecoxib. Moreover, the risk for cardiovascular events with rofecoxib was evident in the first month of treatment. However, the researchers also found no significant association between celecoxib and the risk for cardiovascular events.

This systematic review also noted a higher risk for cardiovascular events in patients who received older, nonselective NSAIDs, particularly diclofenac. The current study examines this issue in patients at a high risk for events because of preexisting coronary heart disease.

Study Highlights

Researchers used 3 large patient databases in Canada, the United States, and the United Kingdom to examine disease and prescription data in adults between the ages of 40 and 89 years who had been hospitalized for acute MI, coronary heart revascularization, or unstable angina pectoris.
All participants were enrolled in a health plan, which provided full medication information to the study database, and all subjects had at least 1 prescription or outpatient visit record. Patients with a history of other potentially life-threatening illness were excluded from study analysis.
The primary outcome of the study was the relationship between the use of NSAIDs and incident MI or cardiac death. Participants were analyzed from day 45 after their initial cardiovascular event for this outcome, and researchers accounted for participants' comorbid conditions in the study analysis.
48,566 adults had data for analysis. The mean age was 65 years, and 58% of the cohort consisted of men. The qualifying hospitalization was for acute MI in 40% of subjects, and coronary revascularization and unstable angina pectoris accounted as reasons for the qualifying hospitalization in another 40% and 20% of subjects, respectively.
The baseline cardiovascular risk score was similar in adults who did and did not use NSAIDs.
There were 111,162 person-years of follow-up and 3600 coronary heart disease events during this period.
Compared with adults who did not use NSAIDs, the use of naproxen was associated with nonsignificant reductions in the rates of serious coronary heart disease events and cardiovascular disease/death.
Conversely, users of diclofenac experienced significantly higher rates of serious coronary heart disease events (IRR, 1.44) and cardiovascular disease/death (IRR, 1.52) vs adults who received naproxen.
Compared with the use of naproxen, the use of ibuprofen also increased the risk for cardiovascular disease/death (IRR, 1.25).
Even high-dose naproxen was not associated with a higher risk for cardiovascular disease. However, users of higher dose of high-dose celecoxib and rofecoxib had a higher risk for serious coronary heart disease vs subjects who received high-dose naproxen (IRR, 1.61 and 2.29, respectively).
The NSAIDs noted were associated with a higher risk for coronary heart disease events when the duration of use was less than 90 days but not with longer periods of use.
Subgroup analysis failed to alter the main outcome of the study.
Clinical Implications

In a previous meta-analysis, rofecoxib was found to increase the risk for cardiovascular events in a dose-dependent fashion, and this risk was apparent within 1 month of the initiation of therapy. However, celecoxib was not associated with a significantly increased risk for cardiovascular events.
In the current study, the use of naproxen was not associated with a higher risk for coronary heart disease events or cardiac death in patients with a history of coronary heart disease. However, ibuprofen; high-dose celecoxib; high-dose rofecoxib; and, most significantly, diclofenac, did increase this risk.

[Maltsev]

First-in-man use of polymer-free valsartan-eluting stents in small coronary vessels: a comparison to polymer-free rapamycin (2%)-eluting stents.

[Ссылки доступны только зарегистрированным пользователям ]

Что интересно: исследование "First-in-man" а уже сразу артерии малого диаметра (<2.5 мм)...


--
С Уважением,
Мальцев А.А.

[Maltsev]

[Ссылки доступны только зарегистрированным пользователям ]

--
С Уважением,
Мальцев А.А.

[Maltsev]

[Ссылки доступны только зарегистрированным пользователям ]

--
C Уважением,
Мальцев А.А.