Quick Links
Heart Failure
Patients with heart failure often have depression and this is associated with increased hospitalisation and mortality. The SADHART-CHF (Sertraline Against Depression and Heart Disease in Chronic Heart Failure) trial was a randomised, double-blind, placebo-controlled trial of sertraline versus placebo for 12 weeks in 469 patients. The primary endpoints were change in depression severity and composite cardiovascular status at 12 weeks. Sertraline and placebo both improved depression scoring equally and neither made any significant difference to cardiovascular outcomes. Fairly depressing results, but good news for placebo.
O’Connor and others JACC 56:692-99.
Coronary Intervention
Guidelines are a double edged sword – we all like to quote them when they agree with us, but dismiss them when we think differently, stating that you assess patients on their ‘individual merits’. A recent guideline from the European Society of Cardiology addresses the interesting problem of antithrombotic / antiplatelet management in PCI patients with AF. Take home messages include several recent studies indicating that uninterrupted warfarin, instead of heparin bridging therapy, provides a favourable balance between bleeding and ischaemic complications, especially when the PCI is performed radially. The authors also suggest that triple therapy with aspirin, clopidogrel and warfarin appears to be the best option to prevent stent thrombosis and thromboembolism. I suspect most interventionists feel uncomfortable with the concept of triple therapy and the associated bleeding risk and would opt for bare metal, titanium covered, antibody-coated or biodegradable polymer stents with their shorter requirement for dual antiplatelet therapy. The patients would take aspirin and clopidogrel for one month following the PCI and then change to aspirin and warfarin for life. The combination of warfarin and clopidogrel is less tested. Alternatives in patients with high bleeding risk include balloon angioplasty alone, drug-coated ballloon angioplasty or CABG. The bottom line is that the guidelines are based on expert opinion with little supporting randomised data.
Lip and others European Heart Journal 31(11):1311-8
Intravascular ultrasound has taught us a lot about coronary artery disease and PCI. It is very useful for assessing vessel size, plaque burden, plaque morphology (virtual histology) and also telling us why things go wrong. A recent small IVUS study from South Korea examined images from 30 patients with confirmed very late stent thrombosis (>1 year). 23 had drug eluting stents (DES), whilst the remainder were bare metal (BMS). Events tended to occur earlier with BMS (108.4+/- 26.5 months) compared to DES (33.2 +/- 12.5 months). There was less neointima in the DES than the BMS, as expected. Acquired malapposition (also termed positive remodelling) was only seen in the DES group – the stents had been well deployed on initial post PCI IVUS. Malapposition likely develops when the vessel wall pulls away from the stent struts due to positive remodeling or thrombus resorption. Neointimal or plaque rupture was seen equally in both groups. Very late stent thrombosis in DES may be due to delayed arterial healing with incomplete endothelialization and persistent fibrin or to stent-vessel wall malapposition. Atherosclerotic lesions within BMS may progress to tight stenosis and/or rupture. Optical coherence tomography will provide further insights.
Lee and Others JACC Cardiovascular Interventions 55:1936-42.
Thrombus aspiration in PPCI seems to have been universally accepted by interventionists on the basis of one trial (TAPAS, N Engl J Med 2008;358:557-67) whilst others showed no benefit (Circulation. 2006;114:40-47, JACC 48:244-52). A major predictor of no-reflow in PPCI is increasing time to treatment. An Italian group has pooled data from three prospective trials comparing thrombus aspiration with standard PCI. Thrombus aspiration limits the adverse effects of time to treatment, suggesting it is beneficial.
De Vita and others Heart 96:1287-90.
The HORIZONS-AMI (Harmonizing Outcomes with RevasculariZatiON and Stents in Acute Myocardial Infarction) trial continues to produce published sub-studies. The original trial showed that bivalirudin decreased major bleeding, 30-day and 1-year mortality in patients undergoing primary percutaneous intervention (PPCI) when compared with unfractionated heparin (UFH) plus glycoprotein IIb/IIIa inhibitors (GPI). The latest study divided the patients into risk tertiles according to the CADILLAC bleeding risk score. The mortality rates in the bivalirudin and UFH plus GPI arms, respectively, were 0.4% and 1.2% (p = 0.09) in the low-risk group, 4.2% and 4.1% (p = 0.99) in the intermediate-risk group, and 8.4% and 15.9% (p = 0.01) in the high-risk group. Among high-risk patients, there was also a decreased rate of recurrent myocardial infarction in patients randomized to bivalirudin as compared to UFH plus GPI (3.6% vs. 7.9%, p = 0.04). It would appear that the patients who benefit the most from bivalirudin are those at the highest bleeding risk, though the usual caveats when dealing with subgroup analysis should be considered. In these austere times, the cost advantage may also be important.
Parodi and others JACC Cardiovascular Interventions 3:796-802.
Confectionary
Good and bad news for chocolate lovers. A new observational study of >19,000 patients from Germany demonstrates that some chocolate is good for you, lowering BP and cardiovascular disease (39% relative risk reduction (RRR) in stroke or MI), compared to those that eat no chocolate. However, too much chocolate is bad for you due to the fat and sugar. Dark chocolate has the highest content of flavanoids and procyanids, both associated with lower cardiovascular risk, as well as the highest antioxidant capacity. The exact types and amounts of chocolate are still to be elucidated. I imagine recruitment for further studies will be straightforward.
Buijsse and others European Heart Journal 31 (13): 1616-1623.
Valvular Heart Disease
The Ross procedure is an operation for aortic stenosis in which the patient’s own pulmonary valve is transferred to the aortic position as an autograft and a tissue prosthesis placed in the pulmonary position. Advantages are perceived to be better longevity than aortic homograft replacements and the avoidance of anticoagulation compared with mechanical prosthesis. The operation has many devotees worldwide, but been regarded as somewhat niche by most surgeons in the UK.
A randomised single centre trial of autograft vs. homograft in 228 patients aged 18-69 found survival to be significantly better in the autograft group (97 vs 83% at 10 years).
Ismail El-Hamamsy and others Lancet 376: 524–31
Now that PCI is being performed in many DGH hospitals in the UK, a significant proportion of interventionists based in surgical centres are developing transcatheter aortic valve implantation (TAVI) programs to fill their time. There are two mainstream devices approved in the UK - Edwards (Edwards Lifesciences, Nyon, Switzerland) and Medtronic CoreValve (Luxembourg City, Luxembourg). The CoreValve is delivered retrogradely and percutaneously (femoral or axillary artery) whilst the Edwards can be delivered percutaneously or transapically. They are available in different, but limited sizes and have certain patient and anatomical requirements. Edwards currently have 22- and 24-F, soon to be 18- and 19-F; CoreValve is 18-F, as well as certain aortic valve annular criteria (18 to 25 mm and 20 to 27 mm, respectively).
A small, but valuable study from Leicester analysed 100 consecutive patients using transthoracic and transoesophageal echocardiography and invasive angiography to asses their suitability for TAVI. 97% of patients were suitable for one of the options. Edwards’ suitability was 28% for Edwards-Sapien transfemoral, 78% for Edwards Novaflex transfemoral, and 88% for Edwards-Sapien transapical. Medtronic CoreValve suitability was 84% for transfemoral and 89% using additional transaxillary and direct aortic approaches. We now await the results of the trials to tell us which patients we will be routinely offering this breakthrough therapy to.
Jilaihawi and others. JACC Cardiovascular Interventions 3:859-66.
Sudden Cardiac Death
Understandably it’s not always been easy to get quality data on the effect of interventions in cardiopulmonary resuscitation. In the past this doesn’t seem to have stopped some fairly strident views being expressed and great importance placed on the exact adherence to protocols. One area of uncertainty is what value respiratory support provides.
Two papers recently published provide valuable data of high quality to guide future practise.
In one study, over 1200 Swedish patients resuscitated in the community from cardiopulmonary arrest were randomly assigned compression only or standard CPR survival was similar in both groups (8.7 vs. 7%).
In a similar trial bystanders were instructed to administer compression only or standard CPR in 1941 North American victims of out of hospital arrest. Again there was no significant difference in outcomes (12.5 vs. 11% survival to discharge).
Neither of these studies examined the utility of rescue breathing by trained healthcare professionals.
Leif Svensson and others N Engl J Med 363:434-42
Thomas D Rea and others N Engl J Med 363:423-33.
In the search for predictors of sudden cardiac death two factors which consistently show value are ejection fraction and non sustained VT. In a study on the effect of Ranolazine (an anti anginal) on outcomes in non ST elevation the trial designers usefully conducted seven days ambulatory ECG monitoring. Analysis of this data reveals four to seven beats and eight or more beats of NSVT is associated with a hazard ratio for sudden cardiac death of 2.3 and 2.7%. In patients with Ejection fractions under 40% this equates to a risk of sudden death of 2.8% (0-3 beats NSVT), 6.1% (4-8 beats) and 12.2% (>7 beats) after twelve months follow up.
Benjamin M. Scirica and others Circulation. 122:455-462
The potential benefits of an implantable defibrillator without the complication of transvenous leads are significant; easier extraction, lower risk of endocardial infection and even a simpler implant. The drawbacks are also well documented; less (if any) pacing, challenges with detection, higher defibrillation thresholds.
The results of a trial of a commercially available, wholly extravascular system are encouraging. The authors first established the optimum implant position (axilliary active can and left parasternal lead), then proceeded to demonstrate acceptable performance in 55 standard ICD indication recipients including 12/12 appropriately detected and successfully treated clinical ventricular arrhythmias.
Gust H. Bardy and others N Engl J Med 363:36-44
