Monthly Archives: July 2014

Extended-Release Niacin with Laropiprant

HPS2-THRIVE trial

Among patients with atherosclerotic vascular disease, the addition of extended-release niacin–laropiprant to statin-based LDL cholesterol–lowering therapy did not significantly reduce the risk of major vascular events but did increase the risk of serious adverse events.  

Effects of Extended-Release Niacin with Laropiprant in High-Risk Patients — NEJM.

cpr

Sudden cardiac death

What is sudden cardiac death (SCD) ?

Sudden cardiac death is defined as natural death from cardiac causes, heralded by abrupt loss of consciousness within 1 hour of the onset of an
acute change in cardiovascular status. Related terms are sudden cardiac arrest and cardiovascular collapse. Sudden cardiac arrest means abrupt cessation of cardiac
mechanical function, which may be reversed by prompt intervention but will lead to death in its absence. Cardiovascular collapse means sudden loss of effective
blood flow due to cardiac and/or peripheral vascular such as cardiac arrest or syncope.

What is the relation to heart disease?

preexisting heart disease may or maynot have been known to be present. The mode of death is natural rapid and unexpected.

What are the symptoms?

Prodromes occuring weeks or months before an event are not very accurate to predict SCD. Sudden onset of chest pain, dyspnea, palpitation, lightheadedness
often precede the onset of cardiac arrest and eventual death.

How big is the problem?

For an adult population 35 years of age and older, the overall incidence of sudden cardiac death is 0.1% to 0.2% per year (that means in a country like India
12,00,000 to 24,00,000 people die suddenly from natural cardiac causes each year). Among people who have disease of coronary arteries of heart around 50% die
suddenly and unexpectedly. Even in developed countries where there is a decrease in total number of deaths due to coronary artery disease, the proportion of
deaths that are sudden and unexpected has remained same. These examples highlight the extent of the problem.

Who are at increased risk?

The conditions increasing the risk of sudden cardiac death are

  1. Coronary artery disease- Myocardial infarction, Angina etc
  2. Myocardial diseases and heart failure- e.g. dilated cardiomyopathy, ischemic cardiomyopathy etc
  3. Hypertrophy of ventricular myocardium – hypertrophic cardiomyopathy, left ventricular hypertrophy due to hypertension, etc
  4. Inflammatory diseases of heart- viral myocarditis, sarcoidosis, amyloidosis,
  5. Arrhythmogenic right ventricular dysplasia
  6. Diseases of cardiac valves- Aortic stenosis/insufficiency, mitral valve prolapse
  7. Electrical diseases of heart – long QT syndrome, Brugada syndrome, idiopathic ventricular fibrillation etc.
Mechanism of Sudden death

In 80% of cases sudden cardiac death is caused by ventricular tachycardia (VT) or ventricular fibrillation (VF) and in 20% of cases
SCD is caused by bradycardia. Patients having tachycardia have a relatively better outcome and chances of survival than those having bradycardia.

Management

The acute management of cardiac arrest is cardiopulmonary resusitation. More information about latest guidelines of CPR can be found
here

Prevention

Prevention of SCD is divided into two parts: Secondary prevention and Primary prevention. Secondary prevention means preventing further cardiac arrest
in people who have survived one cardiac arrest. Primary prevention means preventing cardiac arrest in people who have rish factors for cardiac arrest
but so far haven’t suffered a cardiac arrest.
Implantable cardioverter-defibrillator(ICD) is a device shown to be effective in secodary and primary prevention of SCD. This device is implanted like
a pacemaker and it gives an electrical shock from inside of the heart to abort an episode of VT or VF. It also has pacing function to support when the
heart rate falls.
Clinical trials like AVID, CASH, CIDS have shown effectiveness of ICD in secondary prevention of SCD. Clinical trials like MADIT, CABG-Patch, MUSTT, DEFINITE and
SCD-HeFT have shown benefit odf ICD in SCD.
Many modifications of the device has come like- subcutaneous ICD and wearable ICD.

Electrophysiological study
EPS and radiofrequency ablation can be done in selected patients to prevent further episodes of cardiac arrest.

Summary: sudden cardiac death is a devastating event resulting in rapid, unexpected and natural death due to cardiac causes. It can occur in persons
with known or unknown heart disease. Effective therapies are available. Increasing awareness about the condition and early therapy can result in
reduction of risk of sudden cardiac death
Keyword: Sudden cardiac death, sudden cardiac arrest, implantable cardioverter defibrillator (ICD), coronary artery disease, heart failure, heart disease, cardiology.

Top 10 Cardiology articles of the week (07.07.14-13.07.14)

1.Comprehensive Analysis of Mortality Among Patients Undergoing TAVR: Results of the PARTNER Trial
J Am Coll Cardiol. 2014;64(2):158-168

2. Glycosylated hemoglobin A1c as a marker predicting the severity of coronary artery disease and early outcome in patients with stable angina
Lipids Health Dis. 2014; 13: 89

3.Association Between Intensification of Metformin Treatment With Insulin vs Sulfonylureas and Cardiovascular Events and All-Cause Mortality Among Patients With Diabetes
JAMA. 2014;311(22):2288-2296

4.Association of Bariatric Surgery With Long-term Remission of Type 2 Diabetes and With Microvascular and Macrovascular Complications
JAMA. 2014;311(22):2297-2304

5.Prophylaxis against Venous Thromboembolism in Ambulatory Patients with Cancer

N Engl J Med 2014; 370:2515-2519

6.CardioDex: First human experience of thermal arterial closure

7. Minimizing femoral artery access complications during percutaneous coronary intervention: A comprehensive review

8.Complications related to transhepatic venous access in the catheterization laboratory—A single center 12-year experience of 124 procedures

9.Early outcomes of alcohol septal ablation for hypertrophic obstructive cardiomyopathy

10.Percutaneous Mitral Valve Repair for Mitral Regurgitation in High-Risk Patients Results of the EVEREST II Study
J Am Coll Cardiol. 2014;64(2):172-181

Top 10 Cardiology articles of the week (30.6.14- 6.7.14)

1. Prospective Randomized Evaluation of the Watchman Left Atrial Appendage Closure Device in Patients With Atrial Fibrillation Versus Long-Term Warfarin Therapy : The PREVAIL Trial.
In this trial, LAA occlusion was noninferior to warfarin for ischemic stroke                                      prevention or systemic embolism >7 days’ post-procedure. Although noninferiority                was not achieved for overall efficacy, event rates were low and numerically                                      comparable in both arms. Procedural safety has significantly improved. This trial provides additional data that LAA occlusion is a reasonable alternative to warfarin therapy for stroke prevention in patients with NVAF who do not have an absolute contraindication to short-term warfarin therapy.
Read more
2.Stent Thrombosis in New-Generation Drug-Eluting Stents in Patients With STEMI Undergoing Primary PCI A Report From SCAAR.

Patients treated with n-DES (new generation DES)  have a lower risk of early/late ST  (stent thrombosis) than patients treated with BMS. The risk of very late ST  is low and comparable between n-DES and BMS up to 3 years of follow-up, whereas o-DES  (older generation DES) treatment is associated with an increased risk of very late ST. The current STEMI guidelines might require an update in light of the results of this and other recent studies.

Read more

 

3.Clinical Outcomes and Improved Survival in Patients With Protein-Losing Enteropathy After the Fontan Operation.

http://content.onlinejacc.org/article.aspx?articleID=1886825
4.Hypertrophic Cardiomyopathy Present and Future, With Translation Into Contemporary Cardiovascular Medicine
http://content.onlinejacc.org/article.aspx?articleID=1886834

 
5.Dual antiplatelet therapy in patients with stable coronary artery disease in modern practice: Prevalence, correlates and impact on prognosis
(from the CORONOR study)
About one-quarter of patients with stable coronary artery disease (CAD) are prescribed dual antiplatelet therapy (DAPT), probably due to factors such as MI or revascularization within recent years, diffuse atherosclerosis, and DES implantation. Nonetheless, these patients are no more likely to be protected against future ischemic events than those receiving aspirin or clopidogrel alone.

Read more
6.Use of the REG1 anticoagulation system in patients with acute coronary syndromes undergoing percutaneous coronary intervention:results from the phase II RADAR-PCI study.
High-level factor IXa inhibition in ACS patients undergoing PCI, with at least 50% reversal, has a favourable bleeding profile and appears effective at suppressing ischaemic events and thrombotic complications. Larger phase trials in PCI are warranted.
See more
7.Sitagliptin Use in Patients With Diabetes and Heart Failure: A Population-Based Retrospective Cohort Study.
There is considerable uncertainty about the safety of sitagliptin in patients with T2DM and HF, and current guidelines from the American Diabetes Association suggest caution with the use of antihyperglycemics in patients with HF. This study adds to the mounting evidence that DPP-4 inhibitors may increase the risk of HF, challenging a platform of basic science data that DPP-4 inhibition may actually have a beneficial impact on cardiovascular function.
Read more

 
8.Lifetime Prevalence of Congenital Heart Disease in the General Population from 2000 to 2010

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9.Insulin pump treatment compared with multiple daily injections for treatment of type 2 diabetes (OpT2mise): a randomised open-label controlled trial

 

 
10.Long-term Survival in Patients Undergoing Percutaneous Interventions With or Without Intracoronary Pressure Wire Guidance or Intracoronary Ultrasonographic Imaging: A Large Cohort Study
In this large observational study, FFR-guided PCI and IVUS-guided PCI were not associated with improved long-term survival compared with standard angiography-guided PCI. The use of FFR was associated with the implantation of fewer stents.
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