American Heart Journal

Effectiveness and safety of drug-eluting stents in vein grafts: A meta-analysis

Dominique Joyal, Kristian B. Filion, Mark J. Eisenberg — 2010-02-01

Background: The use of drug-eluting stents (DES) in degenerative vein grafts is currently an off-label indication. Recent studies have had conflicting results regarding the effectiveness and safety of this practice. The objective of this meta-analysis was to compare DES to bare-metal stents for the treatment of vein graft stenosis.Methods: PubMed and the Cochrane clinical trials database were systematically searched to identify all randomized controlled trials (RCTs) and observational studies examining DES for vein graft stenosis published in English between 2003 and 2009. Inclusion criteria included follow-up duration ≥6 months. Data were stratified by study design and pooled using random effects models.Results: Twenty studies were found to meet our inclusion criteria. Eighteen studies were observational and 2 were RCTs. In observational studies, DES were associated with a reduction in major adverse cardiac events (MACE) (odds ratio [OR] 0.50, 95% CI 0.35-0.72), death (OR 0.69, 95% CI 0.53-0.91), target vessel revascularization (TVR) (OR 0.54, 95% CI 0.37-0.79), and target lesion revascularization (TLR) (OR 0.54, 95% CI 0.37-0.78). The incidence of myocardial infarction was similar between groups. In the RCTs, pooled results were inconclusive because of small sample sizes.Conclusions: Although data from observational studies suggest that the use of DES for vein graft stenosis has favorable effects on MACE, death, TVR, and TLR, these data should be interpreted with caution due to their observational nature. Corresponding RCT data are inconclusive. There remains a need for large multicenter RCTs to address the effectiveness and safety of DES for vein graft stenosis.

Cardiac DeatH Prevention by aUtomated DefibrillatoRs in ChurcHes: Rationale and design of the CHURCH trial

2010-02-01

Early defibrillation programs by the use of automated external defibrillators (AEDs) located in high-attendance public places may improve survival and neurologic outcome of patients undergoing sudden cardiac arrest (SCA).We planned a prospective cohort study to assess the effectiveness of a public-access defibrillation program based on positioning of AEDs in churches and training of lay volunteers in Basic Life Support Defibrillation during a single-day 5-hour training session.The CHURCH project aims to promote a widespread diffusion of AEDs, to train a large number of lay volunteers in Basic Life Support Defibrillation, and to increase population awareness on the opportunities for sudden death prevention. The rationale of the study rests on a survey commissioned by the Diocese of Milan that found a high prevalence of elderly subjects (44.5% were >60 years old) attending holy services in the morning hours, when sudden death incidence peaks.The catchment areas of the 12 parishes included in the trial as of June 2008 include a population of 140,000. The projected incidence of AED-treatable SCA, based on the presence of trained volunteers in the churches during day hours, at the CHURCH participating sites was estimated at 8 episodes per year. To estimate an overall 30% mortality reduction from SCA after AED placement at the study sites with respect to conventional SCA management by the Emergency Medical Service, 25 SCA episodes will have to be treated during the 4-year study period.The CHURCH project might be of interest and applicable in every country where high-attendance worship places are present.

Randomized comparison between clinical evaluation plus N-terminal pro–B-type natriuretic peptide versus exercise testing for decision making in acute chest pain of uncertain origin

2010-02-01

Background: Exercise testing constitutes the usual tool for decision making in chest pain units. This policy implies logistical constrains. Our aim was to evaluate a new strategy, combining a clinical risk score and N-terminal pro–B-type natriuretic peptide (NT-proBNP), in patients presenting to the emergency department with chest pain, without ischemic electrocardiogram changes or troponin elevation.Methods: A total of 320 patients were randomized to either usual management, involving exercise testing, or a new strategy combining a clinical risk score and NT-proBNP without exercise testing. In the usual management, discharge decision was guided by the result of exercise test. In the new strategy, those patients with low clinical risk score and NT-proBNP were directly discharged. The primary outcome was hospitalization at the index episode. Secondary outcomes were cardiac events at 1 year.Results: A total of 110 patients (69%) were hospitalized using usual management in comparison with 90 (56%) in the new strategy (P = .03). There were no differences in death or myocardial infarction (n = 11, 6.9% vs n = 6, 3.8%, P = .3) or cardiac events (n = 38, 24% vs n = 28, 18%, P = .2). Revascularizations at the index episode were more frequent under usual management (18% vs 8%, P = .01), although the new strategy was associated with higher rate of planned postdischarge revascularizations (0.6% vs 5%, P = .04).Conclusions: A strategy combining clinical history and NT-proBNP is simpler and reduced initial emergency hospitalizations in patients with chest pain, in comparison with the usual strategy involving exercise testing. Larger studies to assess its impact on long-term hard end points are needed. (ClinicalTrials.gov NCT00493844)

Primary care practices and determinants of optimal anticoagulation management in a collaborative care model

2010-02-01

Background: In a collaborative care model (CCM) for managing oral anticoagulant therapy, patients are followed at a pharmacist-managed anticoagulation service and, once stabilized, are transferred to their primary care physician. The objective of this study was to describe physicians' clinical practices and the practice characteristics associated with better international normalized ratio (INR) control in a CCM.Methods: A telephone questionnaire about their practices was administered to 121 physicians exposed to a CCM. The physicians followed 121 patients for a mean of 14.5 weeks. The percentage of time within the exact INR target range was computed and dichotomized (≥ or < median time within target range). Determinants of better INR control were identified using logistic regression models.Results: The survey revealed that, after discharge from the pharmacist-managed anticoagulation service, patients are followed mainly by physicians and their secretaries. Physicians do not often consult other health professionals. Few report using technological resources to obtain INR results (39.7%), document medical follow-up (6.6%), or detect drug (32.2%) and food (9.9%) interactions. The median percentage of time within the exact INR target range was 84%. Determinants of better INR control include using computerized support to monitor patients (odds ratio [OR] 9.16, 95% CI 1.77-47.4) and detect drug interactions (OR 3.49, 95% CI 1.71-7.10) and consulting specialists (OR 5.92, 95% CI 1.49-32.48).Conclusions: Primary care physicians are poorly supported by technological and human resources to monitor patients on oral anticoagulant. Even in a CCM, interprofessional collaboration and better technological support may be associated with optimal INR control.

Routine use of fondaparinux in acute coronary syndromes: A 2-year multicenter experience

2010-02-01

Background: Fondaparinux has recently been approved in patients with acute coronary syndromes. The primary aim of this study was to describe the changes in use of anticoagulants between January 2006 and December 2007. The secondary aim was to compare 30-day mortality and rate of a combined end point (30-day death or major bleeding) according to the initial and final anticoagulant agent used.Methods: The rates of use of unfractionated heparin (UFH), enoxaparin, and fondaparinux were compared by periods of 1 month in a multicenter registry. The initial anticoagulant (first used at admission), the final anticoagulant (last used during hospitalization), and switches in anticoagulation were recorded. Temporal trends in monthly use of each anticoagulant were assessed; 30-day mortality rates and the combined end point were compared according to initial and final anticoagulant.Results: Among 2,874 patients included, the first anticoagulant used was UFH in 26%, enoxaparin in 59%, and fondaparinux in 15%. Respective figures for final anticoagulant were 17%, 56%, and 27%. Although 3 centers did not use fondaparinux (community centers with catheterization laboratory), the overall rate of use of fondaparinux, as initial and final anticoagulant, increased at the expense of the use of enoxaparin. We observed a growing proportion of patients with a switch from UFH to either enoxaparin or fondaparinux, ranging from 5% at the beginning to 25% at the end of the study. Patients treated with UFH were older, had more comorbidities, were at higher risk, and received fewer guidelines-recommended treatments. In patients submitted to angioplasty and treated with fondaparinux, a bolus of 60 IU/kg of UFH was added. After adjustment, 30-day mortality and combined end point rates were higher in patients treated with UFH. Irrespective of the type of acute coronary syndromes, patients treated with enoxaparin or fondaparinux had similar outcomes.Conclusions: Between 2006 and 2007, the use of fondaparinux in patients with acute coronary syndromes increased considerably, either because it was used instead of enoxaparin or because of a switch from UFH. Adjusted mortality in patients treated with fondaparinux was lower than with UFH and similar to enoxaparin.

Anger expression and risk of coronary heart disease: Evidence from the Nova Scotia Health Survey

Karina W. Davidson, Elizabeth Mostofsky — 2010-02-01

Background: Whereas some studies have found that anger increases the risk of incident coronary heart disease (CHD), others found anger to be protective. Prior studies did not account for different types of anger expression, which may be associated with opposing levels of cardiovascular risk. This study examines whether distinct types of anger expression differentially predict incident CHD.Methods: We conducted a population-based, observational prospective study of 785 randomly selected Canadian men and women (50% each) aged 46 to 92 years and free of CHD in 1995. Using videotaped interviews, trained coders rated 3 types of anger expression: constructive anger (discussing anger to resolve the situation), destructive anger justification (blaming others for one's anger), and destructive anger rumination (brooding over an anger-inducing incident). The association between anger expression type per SD and incident CHD was estimated using Cox proportional hazards models adjusted for sex, age, cardiovascular risk factors, depressive symptoms, hostility, and anxiety. Interactions of anger expression type and gender were also tested.Results: There were 115 incident CHD events (14.6%) during 6,584 person-years of follow-up. The association between clinically assessed constructive anger expression and CHD varied by gender (P for interaction = .02); higher levels were associated with a lower risk of incident CHD in men only (hazard ratio 0.58, 95% CI 0.43-0.80, P < .001), whereas higher levels of destructive anger justification was associated with a 31% increased risk of CHD in both sexes (hazard ratio 1.31, 95% CI 1.03-1.67, P = .03) and predicted CHD incidence independent of covariates and depressive symptoms, hostility, and anxiety.Conclusions: Decreased constructive anger in men and increased destructive anger justification in men and women are associated with increased risk of 10-year incident CHD.

Are quality improvements associated with the Get With the Guidelines-Coronary Artery Disease (GWTG-CAD) program sustained over time? A longitudinal comparison of GWTG-CAD hospitals versus non–GWTG-CAD hospitals

2010-02-01

Background: Previous reports have demonstrated that participation in GWTG-CAD, a national quality initiative of the American Heart Association, is associated with improved guideline adherence for patients hospitalized with CAD. We sought to establish whether these benefits from participation in GWTG-CAD were sustained over time.Methods: We used the Centers for Medicare and Medicaid Services Hospital Compare database to examine 6 performance measures and one composite score for 3 consecutive 12-month periods including aspirin and β-blocker on arrival/discharge, angiotensin-converting enzyme inhibitor (ACE-I) for left ventricular systolic dysfunction (LVSD), and adult smoking cessation counseling. The differences in guideline adherence between the GWTG-CAD hospitals (n = 440, 439, 429) and non–GWTG-CAD hospitals (n = 2,438, 2,268, 2,140) were evaluated for each 12-month period. A multivariate mixed-effects model was used to estimate the independent effect of GWTG-CAD over time adjusting for hospital characteristics.Results: Compared with non-GWTG hospitals, the GWTG-CAD hospitals demonstrated higher guideline adherence for 6 performance measures. The largest differences existed for (1) aspirin at arrival (2.3%, 2.1%, and 1.6% for each 12-month period, respectively), (2) aspirin at discharge (3.4%, 2.2%, and 2.3%), (3) β-blocker at arrival (3.4%, 2.9%, and 2.6%), and (4) β-blocker at discharge (2.8%, 1.8%, and 1.5%). In multivariate analysis, the GWTG-CAD hospitals were independently associated with better adherence for 4 of the 6 measures (the exceptions were ACE-I for LVSD and smoking cessation counseling). Superior performance was also found for the composite measures. Although there was some narrowing between groups, GWTG-CAD hospitals maintained superior guideline adherence than non–GWTG-CAD hospitals for the entire 3-year period (adjusted differences 1.8%, 1.6%, and 1.4%).Conclusions: Hospitals participating in GWTG-CAD had modestly superior acute cardiac care and secondary prevention measures performance relative to non–GWTG-CAD. These benefits of GWTG-CAD participation were sustained over time and independent of hospital characteristics.

Parity and risk of later-life maternal cardiovascular disease

2010-02-01

Background: Prior studies relating parity with maternal cardiovascular disease (CVD) have been performed in relatively small study samples without accounting for pregnancy-related complications associated with CVD.Methods: We examined the associations between parity and maternal risk of later-life CVD in a population-based cohort study using data from the Swedish population registers. Women born from 1932 to 1955 were followed until the occurrence of CVD, death, emigration, or end of follow-up (December 31, 2005). Cox proportional hazards models were used to estimate associations between parity and risk of CVD accounting for birth year, yearly income, education level, country of birth, hypertension (pregestational hypertension or gestational hypertension, with or without proteinuria), diabetes (type 1, type 2, or gestational diabetes), preterm birth, small for gestational age, and stillbirth.Results: During a median follow-up time of 9.5 years (range 0-23.5), there were 65,204 CVD events in the full sample of women. Among 1,332,062 women, parity was associated with CVD in a J-shaped fashion, with 2 births representing the nadir of risk (global P value < .0001). Upon accounting for pregnancy-related complications in a subset of women with at least 1 childbirth after 1973 (n = 590,725), the association of parity with CVD was similar. Compared with women with 2 childbirths, the multivariable-adjusted hazard ratios (95% CIs) for women with 1 and ≥5 births were 1.09 (1.03-1.15) and 1.47 (1.37-1.57), respectively.Conclusions: In conclusion, parity was associated with incident maternal CVD in a J-shaped fashion, even after accounting for socioeconomic factors and pregnancy-related complications.

Does aspirin use adversely influence intermediate-term postdischarge outcomes for hospitalized patients who are treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers? Findings from Organized Program to Facilitate Life-Saving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF)

2010-02-01

Background: Conflicting data exist regarding a potential deleterious association between aspirin (ASA) and angiotensin-converting enzyme inhibitors (ACEIs) when used concurrently in patients with heart failure (HF). How such an interaction may be influenced by underlying etiology of HF and whether it extends to patients treated with angiotensin receptor blockers (ARBs), however, are not known.Methods: Eligible patients from the OPTIMIZE-HF registry were dichotomized into those with ischemic or nonischemic HF. Potential associations between ASA and ACEI or ARB use and 60- to 90-day postdischarge outcomes were assessed using Cox proportional and logistic regression modeling. Models were adjusted for factors known to influence the outcome of interest and by propensity score for ACEI or ARB prescription after an index HF admission.Results: Mortality was not increased (hazard ratio [95% CI]) when ASA was used in conjunction with ACEI (0.51 [0.29-0.87]) or ARB (0.29 [0.09-0.96]) in patients with ischemic or nonischemic (ACEI 0.71 [0.42-1.21], ARB 1.42 [0.74-2.74]) HF. Regression model parameter estimates trended toward harm reduction, but interaction terms for mortality and a composite of mortality or rehospitalization were nonsignificant (P for all >.05).Conclusions: When combined with ACEI or ARB, ASA had no demonstrable adverse effect on intermediate-term postdischarge outcomes for patients with ischemic or nonischemic HF.

Mechanisms of the association between depressive symptoms and long-term mortality in heart failure

2010-02-01

Background: The long-term prognostic influence of depression on patients hospitalized for heart failure (HF) is unknown. No previous study has examined systematically the mechanisms of the relationship between depression and mortality in HF.Methods: Prospective study of 433 patients hospitalized for HF-related emergencies in 4 Spanish hospitals. Baseline depressive symptoms were assessed with the 10-item Geriatric Depression Scale (GDS). The association between depressive symptoms and mortality was summarized with hazard ratios (HRs) obtained from Cox regression, with sequential adjustment for possible mechanisms of the association.Results: Of the 433 study participants, 103 (23.8%) had major depression (GDS-10 ≥5) at baseline. During a mean follow-up of 5.7 years, 305 deaths (70%) occurred. Compared with those who were not depressed, subjects with major depression showed higher mortality (age and sex-adjusted HR 1.52, 95% CI 1.15-2.01). Subsequent adjustment for comorbidity reduced the HR to 1.45 (95% CI 1.10-1.93). Additional adjustment for severity of cardiac lesion and for lifestyles, foremost physical inactivity, led to a HR of 1.27 (95% CI 0.95-1.70). After further adjustment for pharmacologic treatment of HF and particularly for disability in instrumental activities of daily living, the HR dropped almost to the null value (HR 1.10, 95% CI 0.82-1.49).Conclusions: Depressive symptoms in patients hospitalized for HF are associated with higher long-term mortality; this association is largely explained by the frequent comorbidity, physical inactivity, and disability of these patients.

Influence of dedicated heart failure clinics on delivery of recommended therapies in outpatient cardiology practices: Findings from the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF)

2010-02-01

Background: National guidelines recommend heart failure (HF) disease management programs to facilitate adherence to evidence-based practices. This study examined the influence of dedicated HF clinics on delivery of guideline-recommended therapies for cardiology practice outpatients with HF and reduced left ventricular ejection fraction.Methods: IMPROVE HF, a prospective cohort study, enrolled 167 cardiology practices to characterize outpatient management of 15,381 patients with chronic systolic HF. Adherence to guideline-recommended HF therapies was recorded, and the presence of a dedicated HF clinic was assessed by survey. Multivariate models identified contributions to delivery of guideline-recommended HF therapies.Results: Of practices, 41.3% had a dedicated HF clinic. Practices with a dedicated HF clinic had greater adherence to 3 of 7 guideline-recommended HF therapy measures: angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (P = .02), β-blocker (P = .025), and HF education (P = .009). After adjustment, use of a dedicated HF clinic was associated with greater conformity in 2 of 7 measures: cardiac resynchronization therapy (P = .036) and HF education (P = .005) but not angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, β-blocker, aldosterone antagonist, implantable cardioverter-defibrillator therapy, and anticoagulation for atrial fibrillation.Conclusions: Use of dedicated HF clinics varied in cardiology outpatient practices and was associated with greater use of cardiac resynchronization therapy and HF education but not other guideline-recommended therapies.

Systematic review of trials using vasodilators in pulmonary arterial hypertension: Why a new approach is needed

2010-02-01

Background: In a previous metaanalysis on the approved treatments for pulmonary hypertension, we reported that all therapies caused small changes in 6-minute walk distance over a short period, with minimal effects on hemodynamics and no effect on survival. Since that last review, 10 new clinical trials with about 1,500 patients have been published, which has increased the statistical power of our observations.Methods: A systematic review of all clinical trials in pulmonary arterial hypertension was done.Results: The pooled effect of all treatments strategies (relative risk [95% CI], P) now shows a significant reduction of 39% (2%-62%, P = .041) in all-cause mortality. The benefits were confined only to patients with advanced disease for 16 weeks, regardless of which class of drug is used. When considering the effects within each drug family, no class of drug produced a statistically significant reduction in all-cause mortality. The improved survival bore no relationship with the change in 6-minute walk, the primary end point in most of the trials.Conclusions: The impact of vasodilators on long-term survival in pulmonary arterial hypertension remains uncertain. Future trials need to (a) adopt new trial designs that can better address clinical benefits, (b) use new end points that incorporate our best understanding of the disease rather than the ones that are easy to administer, and (c) include longer durations of study and other strategies to clarify if survival is affected.

Myocardial infarction and incidence of type 2 diabetes mellitus. Is admission blood glucose an independent predictor for future type 2 diabetes mellitus?

2010-02-01

Background: Although blood glucose levels in patients with acute myocardial infarction (AMI) are frequently elevated, studies investigating the future risk of type 2 diabetes mellitus (T2DM) in patients with AMI are scarce. We sought to investigate whether increased blood glucose levels on admission in nondiabetic patients with first AMI are predictive for future T2DM.Methods: We used the KORA MI register database in Augsburg, Germany, and included 1,239 nondiabetic patients aged 25 to 74 years who were admitted to hospital between 1998 and 2003 with a diagnosis of a first AMI and who had survived at least 28 days. Incident cases of T2DM and the date of diagnosis were validated by hospital records or by contacting the patient's treating physician.Results: A total of 108 cases of incident T2DM were registered during a mean follow-up of 4.7 years. Cox proportional hazards regression analysis was done, and admission blood glucose was divided into quartiles (Q). Compared to AMI patients with blood glucose on admission <111 mg/dL (Q1), patients with levels ≥153 mg/dL (Q4) showed an age and sex-adjusted relative risk of 2.76 (95% CI 1.61-4.75) for incident T2DM. This association was only slightly attenuated after multivariable adjustment (hazard ratio 2.59, 95% CI 1.49-4.49).Conclusions: Admission blood glucose in nondiabetic AMI patients could offer an initial screening tool during the short-term event to select those patients with high risk for future T2DM requiring a close monitoring of glucose metabolism.

Biventricular pacing improves cardiac function and prevents further left atrial remodeling in patients with symptomatic atrial fibrillation after atrioventricular node ablation

2010-02-01

Background: Randomized trials have demonstrated benefits of biventricular (BiV) pacing in patients with advanced heart failure, intraventricular conduction delay, and atrial fibrillation (AF) postatrioventricular (AV) node ablation. The AV Node Ablation with CLS and CRT Pacing Therapies for Treatment of AF trial (AVAIL CLS/CRT) was designed to demonstrate superiority of BiV pacing in patients with AF after AV node ablation, to evaluate its effects on cardiac structure and function, and to investigate additional benefits of Closed Loop Stimulation® (CLS) (BIOTRONIK, Berlin, Germany).Methods: Patients with refractory AF underwent AV node ablation and were randomized (2:2:1) to BiV pacing with CLS, BiV pacing with accelerometer, or right ventricular (RV) pacing. Echocardiography was performed at baseline and 6 months, with paired data available for 108 patients.Results: The RV pacing contributed to significant increase in left atrial volume, left ventricular (LV) end-systolic volume, and LV mass compared to BiV pacing. Ejection fraction decreased insignificantly with RV pacing compared to significant increase with BiV pacing. Interventricular dyssynchrony significantly decreased with BiV compared with RV pacing. Closed Loop Stimulation® did not result in additional echocardiographic changes; heart rate distribution was significantly wider with CLS. All groups showed significant improvement in 6-minute walk distance, quality-of-life score, and New York Heart Association class.Conclusion: In conclusion, RV pacing results in significant increase in left atrial volume, LV mass, and worsening of LV contractility compared to patients receiving BiV pacing post-AV node ablation for refractory AF. Closed Loop Stimulation® was not associated with additional structural changes but resulted in significantly wider heart rate distribution.

Analysis of the long-term effects of drug-eluting stents on coronary arterial wall morphology as assessed by virtual histology intravascular ultrasound

2010-02-01

Background: Animal models show impairment of arterial healing after drug-eluting stents (DES) compared with bare-metal stents (BMS). Virtual histology intravascular ultrasound (VH-IVUS) offers an opportunity to assess lesion morphology in vivo.Methods: We used VH-IVUS in 80 patients to assess long-term (median = 10 months) native artery vascular responses after 76 implantations of DES compared with 32 BMS. The presence of “necrotic core abutting the lumen” was evaluated at baseline and follow-up.Results: At baseline, necrotic core abutting the lumen through the stent struts was observed in 76% of DES and 75% of BMS. Although the percentage of necrotic core within the plaque behind the stents did not change during follow-up in DES (23% [18%, 28%] to 22% [17%, 27%], P = .57) or BMS (22% [19%, 27%] to 20% [12%, 26%], P = .29), necrotic core abutting the lumen through the stent struts decreased more in BMS (75% to 19%, P < .001) than DES (76% to 61%, P = .036) because of the lack of an overlying, protective neointima in DES-treated lesions. Furthermore, within the adjacent reference segments, the incidence of necrotic core abutting the lumen decreased in BMS-treated lesions (proximal 23% to 0%, P = .023; distal 21% to 0%, P = .023), but not in DES (proximal 22% to 17%, P = .48; distal 23% to 21%, P = .82).Conclusions: Serial VH-IVUS analysis of DES-treated lesions showed a greater frequency of unstable lesion morphometry at follow-up compared with BMS. The apparent mechanism was a suppression of the protective neointimal hyperplasia layer coupled with a lack of vulnerable plaque resolution at reference segments in DES compared with BMS.

Intracoronary thrombus formation after drug-eluting stents implantation: Optical coherence tomographic study

2010-02-01

Background: Intracoronary thrombus formation after drug-eluting stent (DES) implantation is not sufficiently evaluated.Methods: Optical coherence tomography (OCT) was performed in 226 patients (total DES n = 244, sirolimus-eluting stent [SES] n = 95, paclitaxel-eluting stent [PES] n = 62, zotarolimus-eluting stent [ZES] n = 87) after implantation (mean 11 months, range 3-66 months). Using OCT, we investigated the incidence and determinants of intracoronary thrombus.Results: Intracoronary thrombus was detected in 35 (14%) cases (27 SES [28%], 7 PES [11%], and 1 ZES [1%], P < .001) and was associated with longer stent, smaller stent diameter, and stents at bifurcation lesions. More uncovered stent struts (26 ± 23 vs 8 ± 17, P < .001) and malapposed stent struts (6 ± 14 vs 2 ± 6, P < .001) were also associated with intracoronary thrombus. Multiple logistic regression analysis found the following determinants of intracoronary thrombus: stent length ≥28 mm (odds ratio [OR] 7.31, 95% CI 1.79-29.86, P = .01), stent diameter <3.0 mm (OR 4.38, 95% CI 1.38-13.97, P = .01), and ≥8 uncovered struts in each stent (OR 3.29, 95% CI 1.07-10.17, P = .04).Conclusions: Length, size, and types of DES may be more important than clinical factors in intracoronary thrombus formation after DES implantations.

Triple antiplatelet therapy reduces ischemic events after drug-eluting stent implantation: Drug-Eluting stenting followed by Cilostazol treatment REduces Adverse Serious cardiac Events (DECREASE registry)

2010-02-01

Background: Cilostazol has reduced restenosis and repeat intervention after drug-eluting stent (DES) implantation. However, there is little data regarding impact of cilostazol on cardiac events after DES implantation. Therefore, we assessed the long-term efficacy and safety of cilostazol in patients undergoing successful DES implantation.Methods: The patients (n = 3,099) undergoing successful DES implantation were treated with triple (aspirin, clopidogrel, and cilostazol; triple group, n = 1,443) or dual (aspirin and clopidogrel; dual group, n = 1,656) antiplatelet therapy. We compared adverse outcomes (death, myocardial infarction [MI], or stent thrombosis) at 12 months using the inverse probability of treatment weighted (IPTW) for the entire cohort and propensity score matching.Results: After IPTW adjustment, 12-month death (hazard ratio [HR] 0.762, 95% CI 0.401-1.448, P = .4062) was not different between the 2 groups. However, 12-month MI (HR 0.233, 95% CI 0.077-0.703, P = .0097) and stent thrombosis (HR 0.136, 95% CI 0.035-0.521, P = .0036) were significantly lower in triple group with no difference of major bleeding (HR 0.969, 95% CI 0.443-2.119, P = .9372). In the propensity score–matched cohort (965 pairs), 12-month clinical outcomes were similar to those of IPTW adjustment. On extended Cox model, duration of triple antiplatelet therapy was associated with reduction of stent thrombosis (HR 0.056, 95% CI 0.003-0.916, P = .0433) and MI (HR 0.749, 95% CI 0.568-0.988, P = .0408).Conclusions: Triple antiplatelet therapy significantly reduced 12-month risks of stent thrombosis and MI after DES implantation compared with dual antiplatelet therapy without increased risk of bleeding complications. The longer duration of triple therapy after DES implantation was associated with the lower risk of stent thrombosis and MI.

The effect of obesity on quality of life in patients with diabetes and coronary artery disease

2010-02-01

Background: Obesity increases the risk of type 2 diabetes and coronary artery disease (CAD). Because all 3 conditions may reduce quality of life, the extent to which obesity, diabetes, and CAD independently affect quality of life is uncertain.Methods: Patients with type 2 diabetes and documented CAD participating in the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial at 45 clinical sites in the United States and Canada were studied in a cross-sectional analysis of baseline data. Quality of life was assessed with the Duke Activity Status Index, the energy/fatigue and health distress scales from the Medical Outcome Study, and overall self-rated health status.Results: Higher body mass index was significantly associated with worse scores on all 4 quality of life scales, even after adjustment for the severity of diabetes and CAD and other comorbid conditions. Use of insulin, angina, and current smoking were also associated with significantly lower quality of life on all 4 scales, independent of other factors.Conclusions: Obesity is associated with significantly reduced quality of life in patients with diabetes and CAD, independent of comorbid conditions.

Perioperative outcomes in reoperative cardiac surgery guided by cardiac multidetector computed tomographic angiography

2010-02-01

Background: Preoperative evaluation with contrast-enhanced multidetector computed tomographic angiography (MDCTA) is considered an “appropriate” indication based on expert consensus. We aimed to evaluate how the presurgical evaluation with MDCTA impacts the outcomes after reoperative cardiac surgery (RCS).Methods: We retrospectively studied 364 patients undergoing RCS between 2004 and 2008, including 137 referred for MDCTA. High-risk CT findings were defined as the presence of right ventricle or aorta <10 mm from the sternum or a bypass graft <10 mm from the sternum crossing the midline. The primary clinical end point was the composite of perioperative death, myocardial infarction (MI), stoke, and hemorrhage-related reoperation. Secondary end points included surgical procedural variables and the perioperative volume of bleeding and of red blood cell (RBC) transfusion.Results: Baseline clinical characteristics were similar between the 2 groups. Individuals referred for MDCTA showed a trend toward a lower incidence of the composite primary end point (17.5% vs 24.2%, P = .13), primarily related to a significantly lower incidence of perioperative MI (0% vs 5.7%, P = .002). Multidetector computed tomographic angiography was also associated with shorter perfusion (90 vs 110 minutes, P = .002), cross clamp time (63 vs 75 minutes, P = .003), and total time in intensive care unit (103 vs 148 hours, P = .04), and a lower volume of postoperative RBC transfusion (627 vs 824 mL, P = .09). These differences remained significant after adjustment for the Society of Thoracic Surgeons score and the performing surgeon.Conclusion: The use of MDCTA before RCS was associated with shorter perfusion and cross clamp time, shorter intensive care unit stays, and less frequent perioperative MI.

Association of statin prescription with small abdominal aortic aneurysm progression

2010-02-01

Background: Statins have been suggested to reduce expansion of abdominal aortic aneurysms (AAAs) independent of lipid-lowering effects.Methods: We assessed the association of statin treatment and serum low-density lipoprotein (LDL) concentrations with small AAA expansion. Six hundred fifty-two patients undergoing surveillance of small AAAs were entered into the study from 5 vascular centers. In a subset, fasting lipids (n = 451) and other biomarkers (n = 216) were measured. The AAA diameter was followed by ultrasound surveillance for a median of 5 years.Results: Three hundred forty-nine (54%) of the patients were prescribed statins. Adjusting for other risk factors, statin prescription was not associated with AAA growth (odds ratio [OR] 1.23, 95% CI 0.86-1.76). Above-median AAA growth was positively associated with initial diameter (OR 1.78 per 4.35-mm–larger initial aortic diameter, 95% CI 1.49-2.14) and negatively associated with diabetes (OR 0.37, 95% CI 0.22-0.62). Above-median serum LDL concentration was not associated with AAA growth. Patients receiving statins had lower serum C-reactive protein concentrations but similar matrix metalloproteinase–9 and interleukin-6 concentrations to those not prescribed these medications.Conclusions: We found no association between statin prescription or LDL concentration with AAA expansion. The results do not support the findings of smaller studies and suggest that statins may have no benefit in reducing AAA progression.

The right ventricular annular velocity reduction caused by coronary artery bypass graft surgery occurs at the moment of pericardial incision

2010-02-01

Background: Right ventricular (RV) long-axis function is known to be depressed after cardiac surgery, but the mechanism is not known. We hypothesized that intraoperative transesophageal echocardiography could pinpoint the time at which this happens to help narrow the range of plausible mechanisms.Method: Transthoracic echocardiography was conducted in 33 patients before and after elective coronary artery bypass graft. In an intensively monitored cohort of 9 patients, we also monitored RV function intraoperatively using serial pulsed wave tissue Doppler (PW TD) transesophageal echocardiography.Results: There was no significant difference in myocardial velocities from the onset of the operation up to the beginning of pericardial incision, change in RV PW TD S′ velocities 3% ± 2% (P = not significant).Within the first 3 minutes of opening the pericardium, RV PW TD S′ velocities had reduced by 43% ± 17% (P < .001). At 5 minutes postpericardial incision, 2 minutes later, the velocities had more than halved, by 54% ± 11% (P < .0001). Velocities thereafter remained depressed throughout the operation, with final intraoperative S′ reduction being 61% ± 11% (P < .0001).One month after surgery, in the full 33-patient cohort, transthoracic echocardiogram data showed a 55% ± 12% (P < .0001) reduction in RV S′ velocities compared with preoperative values.Conclusions: Minute-by-minute monitoring during cardiac surgery reveals that, virtually, all the losses in RV systolic velocity occurs within the first 3 minutes after pericardial incision. Right ventricular long-axis reduction during coronary bypass surgery results not from cardiopulmonary bypass but rather from pericardial incision.

Relationship between the logistic EuroSCORE and the Society of Thoracic Surgeons Predicted Risk of Mortality score in patients implanted with the CoreValve ReValving System—A Bern-Rotterdam Study

2010-02-01

Background: Surgical risk scores, such as the logistic EuroSCORE (LES) and Society of Thoracic Surgeons Predicted Risk of Mortality (STS) score, are commonly used to identify high-risk or “inoperable” patients for transcatheter aortic valve implantation (TAVI). In Europe, the LES plays an important role in selecting patients for implantation with the Medtronic CoreValve System. What is less clear, however, is the role of the STS score of these patients and the relationship between the LES and STS.Objective: The purpose of this study is to examine the correlation between LES and STS scores and their performance characteristics in high-risk surgical patients implanted with the Medtronic CoreValve System.Methods: All consecutive patients (n = 168) in whom a CoreValve bioprosthesis was implanted between November 2005 and June 2009 at 2 centers (Bern University Hospital, Bern, Switzerland, and Erasmus Medical Center, Rotterdam, The Netherlands) were included for analysis. Patient demographics were recorded in a prospective database. Logistic EuroSCORE and STS scores were calculated on a prospective and retrospective basis, respectively.Results: Observed mortality was 11.1%. The mean LES was 3 times higher than the mean STS score (LES 20.2% ± 13.9% vs STS 6.7% ± 5.8%). Based on the various LES and STS cutoff values used in previous and ongoing TAVI trials, 53% of patients had an LES ≥15%, 16% had an STS ≥10%, and 40% had an LES ≥20% or STS ≥10%. Pearson correlation coefficient revealed a reasonable (moderate) linear relationship between the LES and STS scores, r = 0.58, P < .001. Although the STS score outperformed the LES, both models had suboptimal discriminatory power (c-statistic, 0.49 for LES and 0.69 for STS) and calibration.Conclusions: Clinical judgment and the Heart Team concept should play a key role in selecting patients for TAVI, whereas currently available surgical risk score algorithms should be used to guide clinical decision making.

Correction

C. Jan Willem Borleffs — 2010-02-01

The article “Cardiac resynchronization therapy in patients with ischemic versus non-ischemic heart failure: Differential effect of optimizing interventricular pacing interval” (Am Heart J 2009:158;769-776) was published with an error in the fourth author's name. The correct author name is C. Jan Willem Borleffs, MD. We apologize for any confusion or inconvenience this has caused.

Correction

2010-02-01

The article “Patterns of management of atrial fibrillation complicating coronary artery bypass grafting: Results from the PRoject of Ex-vivo Vein graft ENgineering via Transfection IV (PREVENT-IV) Trial” (Am Heart J 2009:158;792-798) was published with an error in the Conclusions section of the Abstract. The last sentence should be corrected as follows: “The substantial variations in the management of post-CABG AF across sites are likely because of LACK OF definitive data on the most effective therapies, highlighting the need for clinical trials on rate versus rhythm control and on anticoagulation for AF in this setting.” We apologize for any confusion or inconvenience this has caused.

Correction

2010-02-01

The article “Achieving routine sub 30- minute door-to-balloon times in a high volume 24/7 primary angioplasty center with autonomous ambulance diagnosis and immediate catheter laboratory access” (Am Heart J 2009:158;829-835) was published with errors in the titles to . The legends for both figures however are correct. The figures should be corrected as follows:

Letter to the Editor

Aditya Mandawat, Sachin J. Shah, Saif S. Rathore — 2010-02-01

Blankenship et al report that ST-elevation myocardial infarction patients may be enrolled in clinical trials with no significant delay in door-to-balloon time. Specifically, the authors estimate an 11-minute trial enrollment–associated delay for patients presenting directly to a primary percutaneous coronary intervention (PCI) center and a 4-minute delay among patients arriving via interhospital transfer. The authors find these differences to be statistically nonsignificant and thus infer that “enrollment can be accomplished without significantly delaying therapy” for patients undergoing primary PCI. We respectfully disagree.

Electrocardiographic predictors of atrial fibrillation: Methodological considerations

Polychronis Dilaveris, Christodoulos Stefanadis — 2010-02-01

With great interest, we have read the article of Perez et al on the electrocardiographic (ECG) predictors of atrial fibrillation (AF). By using standard computerized methodology, they found that several ECG markers are independently predictive of future onset of AF. They introduced the P index, defined as the SD of P-wave duration across the 12 leads, as one of the strongest predictors of AF. Although these results are interesting, we believe that they should be considered cautiously because of the lack of manual verification of the automatic ECG measurements in this large cohort.

Response to letter by Drs Dilaveris and Stefanadis: Electrocardiographic predictors of atrial fibrillation: Methodological considerations

Marco V. Perez, Victor F. Froelicher — 2010-02-01

We would like to thank Drs Dilaveris and Stefanidis for their interest in and insightful comments regarding our recent study on the electrocardiographic (ECG) predictors of atrial fibrillation (AF). In their letter, they noted concerns regarding the automation of the ECG measurements without manual verification. We agree with the points raised and understand the limitations of computerized measurements. Although some automated measurements such as the QT interval have been shown to be reproducible, others such as degree of ST-segment deviation have been shown to be less accurate.

Letter to the Editor—Solomon about Laskey Study

Richard Solomon — 2010-02-01

“Nephrotoxicity of iodixanol versus iopamidol in patients with chronic kidney disease and diabetes mellitus undergoing coronary angiographic procedures,” Warren Laskey, Peter Aspelin, Charles Davidson, Michael Rudnick, Pierre Aubry, Sreenivas Kumar, Frank Gietzen, Marcus Wiemer, on behalf of the DXV405 Study Group, Am. Heart J. 2009;158:822-28.e3.

Laskey response to Solomon

Warren Laskey — 2010-02-01

We thank Dr Solomon for his constructive and insightful comments. We also agree that, from a clinical standpoint, the real “issue” is the clinical significance of contrast-induced nephropathy (CIN) (defined using the extent of change in creatinine level after exposure to contrast media). To date, the “associations” between the development of CIN and subsequent clinical events, either short-term or long-term, have been just that—associations. As such and given the impossibility of randomizing patients to CIN (the exposure), extant measures of association are likely to be confounded. Nothwithstanding this important methodological detail, the suggestion that the definition of CIN be “loosened” to include lesser degrees of change in serum creatinine level compared to the “classic” ≥0.5 mg/dL increase raises the concern regarding loss of specificity of such an approach. Unfortunately, without having a “gold standard” to refer to, the risk of introducing false-positive (smaller) increases in creatinine level remains a real, albeit unquantifiable (due to the absence of a gold standard), source of measurement bias.

2010-02-01

Editorial Board

2010-02-01

Information for Readers

2010-02-01

American Heart Journal

Effectiveness and safety of drug-eluting stents in vein grafts: A meta-analysis

Cardiac DeatH Prevention by aUtomated DefibrillatoRs in ChurcHes: Rationale and design of the CHURCH trial

Randomized comparison between clinical evaluation plus N-terminal pro–B-type natriuretic peptide versus exercise testing for decision making in acute chest pain of uncertain origin

Primary care practices and determinants of optimal anticoagulation management in a collaborative care model

Routine use of fondaparinux in acute coronary syndromes: A 2-year multicenter experience

Anger expression and risk of coronary heart disease: Evidence from the Nova Scotia Health Survey

Are quality improvements associated with the Get With the Guidelines-Coronary Artery Disease (GWTG-CAD) program sustained over time? A longitudinal comparison of GWTG-CAD hospitals versus non–GWTG-CAD hospitals

Parity and risk of later-life maternal cardiovascular disease

Mechanisms of the association between depressive symptoms and long-term mortality in heart failure

Influence of dedicated heart failure clinics on delivery of recommended therapies in outpatient cardiology practices: Findings from the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF)

Systematic review of trials using vasodilators in pulmonary arterial hypertension: Why a new approach is needed

Myocardial infarction and incidence of type 2 diabetes mellitus. Is admission blood glucose an independent predictor for future type 2 diabetes mellitus?

Biventricular pacing improves cardiac function and prevents further left atrial remodeling in patients with symptomatic atrial fibrillation after atrioventricular node ablation

Analysis of the long-term effects of drug-eluting stents on coronary arterial wall morphology as assessed by virtual histology intravascular ultrasound

Intracoronary thrombus formation after drug-eluting stents implantation: Optical coherence tomographic study

Triple antiplatelet therapy reduces ischemic events after drug-eluting stent implantation: Drug-Eluting stenting followed by Cilostazol treatment REduces Adverse Serious cardiac Events (DECREASE registry)

The effect of obesity on quality of life in patients with diabetes and coronary artery disease

Perioperative outcomes in reoperative cardiac surgery guided by cardiac multidetector computed tomographic angiography

Association of statin prescription with small abdominal aortic aneurysm progression

The right ventricular annular velocity reduction caused by coronary artery bypass graft surgery occurs at the moment of pericardial incision

Relationship between the logistic EuroSCORE and the Society of Thoracic Surgeons Predicted Risk of Mortality score in patients implanted with the CoreValve ReValving System—A Bern-Rotterdam Study

Correction

Correction

Correction

Letter to the Editor

Electrocardiographic predictors of atrial fibrillation: Methodological considerations

Response to letter by Drs Dilaveris and Stefanadis: Electrocardiographic predictors of atrial fibrillation: Methodological considerations

Letter to the Editor—Solomon about Laskey Study

Laskey response to Solomon

Contents

Editorial Board

Information for Readers