Prasugrel versus Clopidogrel for Acute Coronary Syndromes without Revascularization

Background The effect of intensified platelet inhibition for patients with unstable angina or myocardial infarction without ST-segment elevation who do not undergo revascularization has not been delineated. Methods In this double-blind, randomized trial, in a primary analysis involving 7243 patients under the age of 75 years receiving aspirin, we evaluated up to 30 months of treatment with prasugrel (10 mg daily) versus clopidogrel (75 mg daily). In a secondary analysis involving 2083 patients 75 years of age or older, we evaluated 5 mg of prasugrel versus 75 mg of clopidogrel. Results At a median follow-up of 17 months, the primary end point of death from cardiovascular causes, myocardial infarction, or stroke among patients under the age of 75 years occurred in 13.9% of the prasugrel group and 16.0% of the clopidogrel group (hazard ratio in the prasugrel group, 0.91; 95% confidence interval [CI], 0.79 to 1.05; P = 0.21). Similar results were observed in the overall population. The prespecified analysis of multiple recurrent ischemic events (all components of the primary end point) suggested a lower risk for prasugrel among patients under the age of 75 years (hazard ratio, 0.85; 95% CI, 0.72 to 1.00; P = 0.04). Rates of severe and intracranial bleeding were similar in the two groups in all age groups. There was no significant between-group difference in the frequency of nonhemorrhagic serious adverse events, except for a higher frequency of heart failure in the clopidogrel group. Conclusions Among patients with unstable angina or myocardial infarction without ST- segment elevation, prasugrel did not significantly reduce the frequency of the primary end point, as compared with clopidogrel, and similar risks of bleeding were observed. (Funded by Eli Lilly and Daiichi Sankyo; TRILOGY ACS ClinicalTrials.gov number, NCT00699998.)

Coronary to Bronchial Artery Fistula: Are We Treating it Right?

Fistulas between coronary artery and bronchial artery may be present from birth, with few hemodynamic consequences, and may remain closed due to similarity of the filling pressures at these 2 sites.(1) They can also be secondary to pulmonary artery occlusive disease or chronic pulmonary inflammation.(2,3) These pulmonary changes may cause a dilation of the fistula and make it functional, causing angina pectoris by coronary steal syndrome, which is the most common symptom. The presentation may also be composed of episodes of hemoptysis, heart failure, and infective endocarditis. However, most patients remain asymptomatic. The ones that need treatment may not have a good response to the medical management, requiring an intervention. This can be done using embolization coils, stents grafts, and performing surgical ligation of the fistulas.(2-4) J INVASIVE CARDIOL 2012;24(11):E303-E304

Eating behavior and nutritional status in patients who underwent coronary angioplasty

Introduction: The identification of stages of dietary change and the factors affecting food choices can direct more effective nutritional intervention against coronary heart disease progression. Objective: Identify the stages of change of eating behavior and its relation with nutritional status, food consumption and previous cardiovascular events in patients who underwent coronary angioplasty. Methods: A cross-sectional study with 200 hospitalized patients from a specialized cardiology hospital, after elective coronary angioplasty. They were applied an algorithm that identifies the provision of change of eating habits for a healthier pattern. Variables measured were stages of change of eating behavior, nutritional status, food consumption and cardiovascular events (previous myocardial infarction or angioplasty). It was realized comparison of averages by analysis of variance or Student's test and Chi-square test for qualitative variables. Value of significance was taken at 5%. Results: The patients were classified in the following stages: 36% maintenance, 26% preparation, 17% precontemplation, 12% action and 9% contemplation. It was observed higher cardiovascular events in maintenance/action group (p = 0.04), higher consumption of calories (p = 0.04), meat/eggs (p = 0.01) and sweets (p = 0.03) in preparation stage, comparing to maintenance group, and no association between nutritional status and stages of change (p = 0.13), although 62% of the individuals in maintenance stage were overweight. Conclusions: This work contributed to identifying the stages of change and conditions that favor changes in eating pattern. Even patients that classified themselves into the maintenance stage need to adjust their eating habits in order to reach a healthy weight.

Biliary Drainage in Patients With Unresectable, Malignant Obstruction Where ERCP Fails Endoscopic Ultrasonography-Guided Choledochoduodenostomy Versus Percutaneous Drainage

Background: Endoscopic retrograde cholangiopancreatography may fail because of malignant involvement of the second portion of the duodenum and the major papilla. Alternatives include percutaneous transhepatic biliary drainage (PTBD) or surgical bypass. Endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CD) has been reported as an alternative. Objective: To prospectively compare EUS-CD and PTBD in patients with unresectable malignant biliary obstruction. Design: Prospective and randomized study. Setting: Tertiary center. Main Outcome Measurements: Success and efficacy comparison EUS-CD with PTBD. Results: Twenty-five subjects were randomized (13 EUS-CD and 12 PTBD). Mean age was 67 years (SD, 11.9). The 2 groups were similar before intervention in terms of quality of life [EUS-CD (58.3) vs. PTBD (57.8); P = 0.78], total bilirubin (16.4 vs. 17.2; P = 0.7), alkaline phosphatase (539 vs. 518; P = 0.7), and gamma-glutamyl transferase (554.3 vs. 743.5; P = 0.56). All procedures were technically and clinically successful in both groups. At 7-day follow-up there was a significant reduction in total bilirubin in both the groups (EUS-CD, 16.4 to 3.3; P = 0.002 and PTBD, 17.2 to 3.8; P = 0.01), although no difference was noted comparing the 2 groups (EUS-CD to PTBD; 3.3 vs. 3.8; P = 0.2). There was no difference between the complication rates in the 2 groups (P = 0.44), EUS-CD (2/13; 15.3%) and PTBD (3/12; 25%). Costs were similar in the 2 groups also ($5673-EUS-CD vs. $7570-PTBD; P = 0.39). Limitations: Small sample size and single center study. Conclusions: EUS-CD can be an effective and safe alternative to PTBD with similar success, complication rate, cost, and quality of life.

Health education intervention in early and late postmenopausal Brazilian women

Aim To identify aspects of health in postmenopausal Brazilian women using a health-related educational program provided by a multidisciplinary team as part of the primary care approach for early and late postmenopausal symptoms. Design A prospective cohort was formed with 69 postmenopausal women; they were divided into groups corresponding to early (n = 32) and late postmenopause (n = 37) through gynecological and clinical evaluations. We administered the Kuppermann-Blatt Menopausal Index and the Women's Health Questionnaire before and after health education instructions. Results The average age for the onset of menopause was 47.9 years (n = 69). Fifty women (72.5%) in this study had completed their primary education, 78.3% (n = 54) performed manual labor, and 60.9% (n = 42) showed concomitant chronic illnesses. After attending a series of health-related presentations, the mean weight of the women was reduced by 3.54% in early postmenopausal women (p < 0.001) and by 2.06% in the late postmenopausal group (p < 0.001). The mean abdominal circumference was reduced by 1.75% (p < 0.001) in the early postmenopausal group. In addition, the total score in the Kuppermann-Blatt Menopausal Index decreased by 34.38% in the early and by 33.33% in the late postmenopausal groups. According to the Women's Health Questionnaire, there was a decrease in the domain Depressive mood by 0.839 to 0.700 (p < 0.001) in the early and by 0.814 to 0.648 (p < 0.001) in the late postmenopausal groups. Conclusion Regardless of improving menopausal symptoms and anthropometric parameters, the effects of the multidisciplinary team activities in early postmenopausal women may be similar to those in late postmenopausal women.

Association between UCP2 A55V polymorphism and risk of cardiovascular events in patients with multi-vessel coronary arterial disease

Background UCP2 (uncoupling protein 2) plays an important role in cardiovascular diseases and recent studies have suggested that the A55V polymorphism can cause UCP2 dysfunction. The main aim was to investigate the association of A55V polymorphism with cardiovascular events in a group of 611 patients enrolled in the Medical, Angioplasty or Surgery Study II (MASS II), a randomized trial comparing treatments for patients with coronary artery disease and preserved left ventricular function. Methods The participants of the MASS II were genotyped for the A55V polymorphism using allele-specific PCR assay. Survival curves were calculated with the Kaplan–Meier method and evaluated with the log-rank statistic. The relationship between baseline variables and the composite end-point of cardiac death, acute myocardial infarction (AMI), refractory angina requiring revascularization and cerebrovascular accident were assessed using a Cox proportional hazards survival model. Results There were no significant differences for baseline variables according genotypes. After 2 years of follow-up, dysglycemic patients harboring the VV genotype had higher occurrence of AMI (p=0.026), Death+AMI (p=0.033), new revascularization intervention (p=0.009) and combined events (p=0.037) as compared with patients carrying other genotypes. This association was not evident in normoglycemic patients. Conclusions These findings support the hypothesis that A55V polymorphism is associated with UCP2 functional alterations that increase the risk of cardiovascular events in patients with previous coronary artery disease and dysglycemia.

A behavioral intervention in a cohort of Japanese-Brazilians at high cardiometabolic risk

OBJECTIVE: To assess the effect of a health promotion program on cardiometabolic risk profile in Japanese-Brazilians. METHODS: A total of 466 subjects from a study on diabetes prevalence conducted in the city of Bauru, southeastern Brazil, in 2000 completed a 1-year intervention program (2005-2006) based on healthy diet counseling and physical activity. Changes in blood pressure and metabolic parameters in the 2005-2006 period were compared with annual changes in these same variables in the 2000-2005 period. RESULTS: During the intervention, there were greater annual reductions in mean (SD) waist circumference [-0.5(3.8) vs. 1.2(1.2) cm per year, p<0.001], systolic blood pressure [-4.6(17.9) vs. 1.8(4.3) mmHg per year, p<0.001], 2-hour plasma glucose [-1.2(2.1) vs. -0.2(0.6) mmol/L per year, p<0.001], LDL-cholesterol [-0.3(0.9) vs. -0.1(0.2) mmol/L per year, p<0.001] and Framingham coronary heart disease risk score [-0.25(3.03) vs. 0.11(0.66) per year, p=0.02] but not in triglycerides [0.2(1.6) vs. 0.1(0.42) mmol/L per year, p<0.001], and fasting insulin level [1.2(5.8) vs. -0.7(2.2) IU/mL per year, p<0.001] compared with the pre-intervention period. Significant reductions in the prevalence of impaired fasting glucose/impaired glucose tolerance and diabetes were seen during the intervention (from 58.4% to 35.4%, p<0.001; and from 30.1% to 21.7%, p= 0.004, respectively). CONCLUSIONS: A one-year community-based health promotion program brings cardiometabolic benefits in a high-risk population of Japanese-Brazilians.

Drug eluting balloons

Ever since the first percutaneous transluminal angioplasty (PTA) was carried out in Switzerland in 1977, restenosis remains a major drawback of this minimally invasive treatment intervention. Numerous attempts to increase vessel patency after PTA have included systemic medications and endovascular brachytherapy, but these techniques have not met our expectations in preventing restenosis. Nitinol stents have been shown to reduce rates of restenosis and target lesion revascularization in patients undergoing endovascular treatment of long femoropopliteal obstructions. Despite further technical refinements in nitinol stent technology, restenosis occurs in approximately every third patient undergoing femoropopliteal stenting. Similarly, initial clinical trials with drug-eluting stents have failed to indicate restenosis inhibition in femoropopliteal segment. Unfortunately, restenosis rates after below-the-knee PTA and stenting have been reported to be even higher than those following femoropopliteal revascularization. Current concepts for the prevention and treatment of restenosis after PTA or stenting include the sustained release of antiproliferative paclitaxel into the vessel wall. Drug eluting balloons are a promising, novel technology aimed at inhibiting restenosis after PTA. Its clinical efficacy in reducing restenosis has already been proven for coronary arteries as well as for the femoropopliteal segment. The purpose of this article is to review the clinical utility of drug-eluting balloons for lower limb endovascular interventions.

Progression of coronary artery disease during long-term follow-up of the Swiss Interventional Study on Silent Ischemia Type II (SWISSI II)

Background: This study evaluates cardiovascular risk factors associated with progression of coronary artery disease (CAD) in patientswith silent ischemia followingmyocardial infarction. Hypothesis: Coronary artery disease only progresses slowly with comprehensive risk factor intervention. Methods: A total of 104 of 201 patients (51.7%) of the Swiss Interventional Study on Silent Ischemia Type II (SWISSI II) with baseline and follow-up coronary angiography were included. All patients received comprehensive cardiovascular risk factor intervention according to study protocol. Logistic regression was used to evaluate associationsbetween baseline cardiovascular risk factors and CAD progression. Results: The mean duration of follow-upwas 10.3 ± 2.4 years. At baseline, 77.9% of patients were smokers, 45.2% had hypertension, 73.1% had dyslipidemia, 7.7% had diabetes, and 48.1% had a family history of CAD. At last follow-up, only 27 patients of the initial 81 smokers still smoked, only 2.1% of the patients had uncontrolled hypertension, 10.6%of the patientshad uncontrolled dyslipidemia, and 2.1%of the patientshad uncontrolled diabetes. Coronary artery disease progression was found in up to 81 (77.9%) patients. Baseline diabetes and younger age were associatedwith increased odds of CAD progression.The time intervalbetween baseline and follow-up angiography was also associatedwith CAD progression. Conclusion: Coronary artery disease progressionwas highly prevalent in these patients despite comprehensive risk factor intervention. Further research is needed to optimize treatment of known risk factors and to identify other unknown and potentiallymodifiable risk factors.

Percutaneous cement augmentation for the treatment of depression fractures of the tibial plateau

The management of insufficiency fractures of the tibial plateau in osteoporotic patients can be very challenging, since it is difficult to achieve a stable fixation, an essential condition for the patients' early mobilization. We present a minimally invasive technique for the treatment of proximal tibial plateau fractures, "tibiaplasty", using percutaneous polymethylmethacrylate augmentation. Five osteoporotic patients (7 fractures) with a non-traumatic insufficiency tibial plateau fracture were treated with this technique at the authors' institution from 2006 to 2008. The patients' median age was 79 (range 62-88) years. The intervention was performed percutaneously under general or spinal anesthesia; after the intervention, immediate full weight bearing was allowed. The technique was feasible in all patients and no complications related to the intervention were observed. All patients reported a relevant reduction in pain, were able to mobilize with full weight bearing and would undergo the operation again. No secondary loss of reduction or progression of arthrosis was observed in radiological controls; no revision surgery was required. Our initial results indicate that tibiaplasty is a good treatment option for the management of insufficiency in tibial plateau fractures in osteoporotic patients. The technique is minimally invasive, safe and allows immediate mobilization without restrictions. In our group of patients, we found excellent early to mid-term results.

Percutaneous aortic valve replacement: valvuloplasty studies in vitro

Valvuloplasty of the aortic valve is currently used in selected patients for severe calcified aortic valve disease, but clinical effectiveness is low and complication rate remains high. In this study, the total particle load after valvuloplasty and the embolization risk of calcific debris into the coronary arteries was analyzed in an in vitro model.

Catheter ablation of stable ventricular tachycardia before defibrillator implantation in patients with coronary heart disease (VTACH): a multicentre randomised controlled trial

In patients with ventricular tachycardia (VT) and a history of myocardial infarction, intervention with an implantable cardioverter defibrillator (ICD) can prevent sudden cardiac death and thereby reduce total mortality. However, ICD shocks are painful and do not provide complete protection against sudden cardiac death. We assessed the potential benefit of catheter ablation before implantation of a cardioverter defibrillator.

Stitched to the heart--till intervention do us part

The case report describes the situation where a venous infusion catheter was inadvertently stitched to the lateral wall of the right atrium during valve replacement. A dual percutaneous approach was used to first sever the catheter at the suture and then remove both ends safely. The risk of tearing the suture which would have resulted in tamponade had to be avoided.