MedicalResearch.com Interview with:
Nayan Agarwal MD
Intervention Cardiology Fellow,
University of Florida,
MedicalResearch.com: What is the background for this study? Response: Long term anticoagulation is indicated in patients with mechanical heart valves, prior thromboembolic events, atrial fibrillation etc, to prevent recurrent thrombo-embolic episodes. About 20-30% of these patients also have concomitant ischemic heart disease requiring percutaneous coronary intervention (PCI).
Post PCI, patients require treatment with dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor) to prevent stent thrombosis. Thus, these patients may end up needing triple antithrombotic therapy with oral anticoagulant (OAC) and DAPT, which increases the bleeding risk.
Both American College of Cardiology(ACC) and European Society of Cardiology (ESC), currently recommend triple therapy in these patients. Recently new evidence has emerged that such patients can be managed with dual therapy of a single antiplatelet (SAPT) and OAC. Hence, we decided to do a systematic review of these studies to evaluate safety and efficacy of dual therapy of SAPT and OAC against triple therapy of DAPT and OAC.
MedicalResearch.com Interview with: Dr. Amit Navin Vora MD, MPH
Third Year Cardiovascular Fellow
John Hopkins University
Medical Research: What is the background for this study? What are the main findings?Response: Current guidelines recommend timely reperfusion in patients presenting with ST-elevation myocardial infarction, with primary PCI being the preferred method if delivered in an expedient fashion. Otherwise, guidelines recommend that eligible patients should be treated with fibrinolysis prior to transfer to a PCI capable hospital. In our study, we used Google Maps to estimate drive times between the initial presenting hospital and the PCI-capable hospital looked at the association between estimated drive time and reperfusion strategy (primary PCI or fibrinolysis) selection.
We found that less than half of eligible patients with an estimated drive time of more than 30 minutes received primary PCI in time, and only half of patients with more than an hour’s drive received lytics before transfer. This suggests that neither primary PCI nor pre-transfer fibrinolytic therapy is being used optimally. Among eligible patients with a drive time of 30-120 minutes, we found no significant mortality difference but higher bleeding risk among patients receiving lytics prior to transfer; this increased bleeding risk was focused in patients that required rescue PCI.
MedicalResearch.com Interview with
Dr. Mary T. Hawn MD
Center for Surgical, Medical Acute Care Research, and Transitions,
Birmingham Veterans Affairs Medical Center
University of Alabama at Birmingham, BirminghamMedical Research: What are the main findings?Dr. Hawn: The main findings of the study are that the recommendations made in the guidelines published by the American College of Cardiology / American Heart Association in 2007 were effective at reducing postoperative major adverse cardiac events following noncardiac surgery in patients with a cardiac stent.1 These guidelines recommended the delay of noncardiac surgeries in patients with a drug-eluting stent for 365 days if the surgery was not emergent or the delay of surgery for 4 to 6 weeks among patients with a bare metal stent. In addition to a 26% reduction in postoperative major adverse cardiac events, we also found an increase in the time between drug-eluting stent placement and non-cardiac surgery consistent with the guideline recommendations.
MedicalResearch.com Interview with Steven M. Bradley, MD, MPH
Veterans Affairs, Eastern Colorado Health CareSystem
Medical Research: What are the main findings of the study?Dr. Bradley: In 539 hospitals participating in the CathPCI Registry that performed elective coronary angiography on more than 500,000 patients, 22% of patients were asymptomatic at the time of coronary angiography. We observed marked variation in the hospital rate of angiography performed in asymptomatic patients, ranging from 0.2% to 66.5%, suggesting broad variation in the quality of patient selection for coronary angiography across hospitals. Additionally, hospitals with higher rates of asymptomatic patients at diagnostic angiography also had higher rates of inappropriate PCI, due to greater use of PCI in asymptomatic patients. These findings suggest that patient selection for diagnostic angiography is associated with the quality of patient selection for PCI as determined by Appropriate Use Criteria. By addressing patient selection upstream of the catheterization laboratory, we may improve on the optimal use of both angiography and PCI.
MedicalResearch.com Interview with: Cheol Whan Lee andSeung-Jung Park
Division of Cardiology, Asan Medical Center,
University of Ulsan
Medical Research: What are the main findings of the study?Answer: The time window of DES (drug-eluting stent) failure is widely variable from soon after DES implantation to several years after DES implantation. We observed patients with late DES failure are commonly presented with acute coronary syndrome. We hypothesized that temporal patterns of DES failure may be different, and analyzed all patients with first DES failure at our institution. We found that late drug-eluting stent failure is more likely to progress to acute myocardial infarction, aggressive angiographic patterns, and worse outcomes following retreatment.
MedicalResearch.com: What are the main findings of the study?Dr. Raber: The main finding of the clinical study is that the benefit of a biolimus-eluting stent using a biodegradable polymer (Biomatrix, BES) regarding MACE (cardiac death, target vessel MI, TLR) continued to accrue during the second year of follow-up, actually with a similar relative risk reduction as observed during the first year. After one year, the timepoint at which most patients stopped dual antiplatelet therapy (DAPT), no difference in safety (cardiac death, myocardial infarction, stent thrombosis) was observed between BES and the control group (bare metal stent, BMS). This largely confirms the principle concept of biodegradable polymer stent platforms.
The results of the imaging substudy provide a mechanistic explanation for the observed benefit with BES. Specifically, BES showed a lower neointimal thickness, a low frequency of uncovered and malapposed stent struts (OCT) and the absence of positive remodeling (IVUS) at 13 months follow-up.
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