Oral antiplatelet therapy for atherothrombotic disease: Current evidence and new directions.
Am Heart J. 2011 Mar;161(3):450-61
Authors: White HD
Despite the proven efficacy of dual antiplatelet therapy with aspirin an…

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High-risk patients with ST-elevation myocardial infarction derive greatest absolute benefit from primary percutaneous coronary intervention: Results from the Primary Coronary Angioplasty Trialist versus Thrombolysis (PCAT)-2 Collaboration.
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Association of systolic blood pressure with mortality in patients with heart failure with reduced ejection fraction: A complex relationship.
Am Heart J. 2011 Mar;161(3):567-73
Authors: Ather S, Chan W, Chillar A, Aguilar D, Pr…

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Atrial fibrillation, anticoagulation, fall risk, and outcomes in elderly patients.

Am Heart J. 2011 Feb;161(2):241-6

Authors: Sellers MB, Newby LK

Atrial fibrillation (AF) affects 2.5 million patients in the United States. The incidence of this condition increases with age, such that approximately 5% of people >65 years of age have AF. Because of the lack of organized atrial contraction and thrombus formation in the left atrium, patients with AF are at increased risk of stroke. The estimated risk of stroke among all AF patients is 5% per year. Among patients without mitral stenosis, there is a graded relationship of stroke risk with the number of CHADS(2) risk factors. Warfarin is the recommended treatment for embolic stroke prophylaxis in AF in intermediate- to high-risk patients. However, elderly patients who are deemed to be at risk of falls are often not started on warfarin therapy secondary to a perceived higher risk of bleeding complications. These risks have been evaluated, but conclusive data regarding the risk-benefit trade-off are elusive. This review summarizes available data on the use of warfarin in elderly patients with AF, focusing on the risk of bleeding, and will specifically address the utility of falls risk assessment in the decision to initiate warfarin therapy for AF.

PMID: 21315204 [PubMed - in process]

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Incidence and clinical consequences of acquired thrombocytopenia after antithrombotic therapies in patients with acute coronary syndromes: Results from the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial.

Am Heart J. 2011 Feb;161(2):298-306.e1

Authors: Caixeta A, Dangas GD, Mehran R, Feit F, Nikolsky E, Lansky AJ, Aoki J, Moses JW, Steinhubl SR, White HD, Ohman EM, Manoukian SV, Fahy M, Stone GW

The aim of the study was to investigate the incidence and clinical consequences of acquired thrombocytopenia in patients with acute coronary syndromes (ACS) in the ACUITY trial.

PMID: 21315212 [PubMed - in process]

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Certoparin versus unfractionated heparin to prevent venous thromboembolic events in patients hospitalized because of heart failure: A subgroup analysis of the randomized, controlled CERTIFY study.

Am Heart J. 2011 Feb;161(2):322-8

Authors: Tebbe U, Schellong SM, Haas S, Gerlach HE, Abletshauser C, Sieder C, Bramlage P, Riess H

Despite the elevated risk for developing venous thromboembolic events in patients with heart failure, there are no randomized, double-blind, controlled trial data on the comparison of low-molecular-weight heparin with unfractionated heparin (UFH) in this patient population.

PMID: 21315215 [PubMed - in process]

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Prognostic value of sensitive troponin T in patients with stable and unstable angina and undetectable conventional troponin.

Am Heart J. 2011 Jan;161(1):68-75

Authors: Ndrepepa G, Braun S, Mehilli J, Birkmeier KA, Byrne RA, Ott I, Hösl K, Schulz S, Fusaro M, Pache J, Hausleiter J, Laugwitz KL, Massberg S, Seyfarth M, Schömig A, Kastrati A

High-sensitivity cardiac troponin assays enable the measurement of cardiac troponin concentrations in the majority of patients with coronary artery disease. The objective of this study was to investigate the prognostic value of sensitive cardiac troponin in patients with stable and unstable angina presenting with undetectable levels of conventional troponin.

PMID: 21167336 [PubMed - in process]

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Troponin-positive, MB-negative patients with non-ST-elevation myocardial infarction: An undertreated but high-risk patient group: Results from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network-Get With The Guidelines (NCDR ACTION-GWTG) Registry.

Am Heart J. 2010 Nov;160(5):819-25

Authors: Kontos MC, de Lemos JA, Ou FS, Wiviott SD, Foody JM, Newby LK, Chen A, Roe MT

BACKGROUND: Despite the 2000 and 2007 redefinition of myocardial infarction (MI), patients who are troponin (Tn) positive ([+]) but MB negative ([-]) may not be considered to have MI, particularly in the absence of known coronary disease (prior MI or revascularization; coronary artery disease [CAD]). How this affects treatment and outcomes has not been well described. METHODS: Direct arrival patients with non-ST elevation MI (NSTEMI) enrolled in the American College of Cardiology NCDR ACTION-GWTG Registry were included. Patients missing marker data who were Tn (-) and had CAD were excluded. Troponin (+) patients were categorized as MB (+) (n = 11,563) or MB (-) (n = 4,501). Treatments and in-hospital outcomes were compared between the 2 groups using logistic regression. RESULTS: Of the 16,064 NSTEMI patients, 28% were MB (-). The MB (-) patients were older (median age 68 vs 65 years) and had more comorbidities (hypertension 71% vs 66%, diabetes 31% vs 27%, heart failure 22% vs 19%; all Ps < .01). After adjusting for baseline characteristics, MB (-) patients were significantly less likely to receive clopidogrel, antithrombins, glycoprotein IIb/IIIa antagonists, or angiography (all Ps < .001). In-hospital mortality was lower in MB (-) patients (3.8% vs 4.9%, P < .01), which remained significant after adjusting for baseline variables (odds ratio 0, 69, 95% CI 0.6-0.9, P = .002). CONCLUSIONS: Patients without known CAD who have NSTEMI and are MB (-) have a higher risk profile but are less likely to receive guideline-recommended acute pharmacologic treatment than those who are MB (+). Given the relatively high mortality in this group, increased emphasis on improving quality of care in Tn (+)/MB (-) patients is warranted.

PMID: 21095267 [PubMed - in process]

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“Do GRACE (Global Registry of Acute Coronary events) risk scores still maintain their performance for predicting mortality in the era of contemporary management of acute coronary syndromes?”.

Am Heart J. 2010 Nov;160(5):826-834.e3

Authors: Abu-Assi E, Ferreira-González I, Ribera A, Marsal JR, Cascant P, Heras M, Bueno H, Sánchez PL, Arós F, Marrugat J, García-Dorado D, Peña-Gil C, González-Juanatey JR, Permanyer-Miralda G

BACKGROUND: Although the GRACE risk scores (RS) are the preferred scoring system for risk stratification in acute coronary syndromes (ACS), little is known whether these RS still maintain their performance in the current era. We aimed to investigate this issue in a contemporary population with ACS. METHODS: The study population composed of patients enrolled in the MASCARA national registry. The GRACE RS were calculated for each patient. Discrimination and calibration were evaluated with the C statistic and the Hosmer-Lemeshow test, in the whole population and according to the type of ACS, risk strata, and whether the patient had a history of diabetes and/or chronic renal failure. We determined if left ventricular ejection fraction (LVEF) provides incremental prognostic information above that established by the RS and whether percutaneous coronary intervention (PCI) during admission affects the performance of the score for predicting 6-month mortality. RESULTS: The 5,985 patients constituted the validation cohort for the in-hospital mortality RS and 5,635 the validation cohort for the 6-month mortality RS. Overall, both GRACE RS demonstrated excellent discrimination (C > 0.80) and calibration (all P values in Hosmer-Lemeshow >.1). Although similar results were seen in all subgroups, the 6-month mortality RS performed significantly less well in patients undergoing PCI compared to those patients who did not (C = 0.73 vs 0.76, P < .004). Adding LVEF to the RS did not convey significant prognostic information. CONCLUSIONS: The GRACE RS for predicting in-hospital and 6-month mortality still maintain their excellent performance in a contemporary cohort of patients with ACS. Further studies are needed to investigate the performance of the 6-month mortality GRACE score in patients undergoing in-hospital PCI. Left ventricular ejection fraction did not convey significant information over that provided by the RS.

PMID: 21095268 [PubMed - in process]

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Early and late outcome prediction of death in the emergency room setting by point-of-care and laboratory assays of cardiac troponin I.

Am Heart J. 2010 Nov;160(5):835-41

Authors: Venge P, Ohberg C, Flodin M, Lindahl B

BACKGROUND: Point-of-care (POC) assays of cardiac troponins are common in the emergency department setting. The question raised was as follows: What is the clinical impact of the results of POC assays of cardiac troponins as compared with sensitive laboratory assays? METHODS: Patients admitted consecutively to the emergency department (N = 1,069) and on whom cardiac troponins were requested as part of their clinical work-up were included. Cardiac troponin I (cTnI) was measured by the POC assays-i-Stat (Abbott Diagnostics, Abbott Park, IL) and Stratus CS (Siemens Healthcare Diagnostics, Deerfield, IL)-and by the laboratory assays-Access AccuTnI (Beckman Coulter, Fullerton, CA) and Architect cTnI (Abbott Diagnostics). Results were related to early (14 days) and late outcome (median 3.3 months, range 0.1-35) as to death. RESULTS: The laboratory assays identified more patients (P < .001) with elevated levels than the two POC assays (39%-74% vs 20%-27%). Adopting the 99th percentiles upper reference limit, the Access AccuTnI identified 88% and Architect cTnI identified 81% of all patients who died of cardiovascular disease as compared with 50% and 54% for i-Stat and Stratus CS, respectively (P < .001). Negative predictive values for the laboratory assays were 97% as compared with 89% to 93% for the POC assays. Negative likelihood ratios were 0.25 (CI 0.15-0.041) and 0.59 to 0.68 (CI 0.47-0.79), respectively. CONCLUSIONS: The current POC cTnI assays are less sensitive for outcome prediction of patients with myocardial injury. The clinical judgment of the patient with suspected myocardial ischemia should not solely rely on results from POC assays. If a clinical suspicion of myocardial injury remains despite negative cTnI results with the POC assays, such results should be complemented by results from sensitive laboratory assays.

PMID: 21095269 [PubMed - in process]

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Uric acid level and allopurinol use as risk markers of mortality and morbidity in systolic heart failure.

Am Heart J. 2010 Nov;160(5):928-33

Authors: Wu AH, Ghali JK, Neuberg GW, O’Connor CM, Carson PE, Levy WC

BACKGROUND: Previous studies have not extensively examined the association of hyperuricemia and adverse outcomes in systolic heart failure (HF) in relation to xanthine oxidase inhibitor therapy. METHODS: The Prospective Randomized Amlodipine Survival Evaluation study included New York Heart Association class IIIB or IV patients with left ventricular ejection fraction <30%. For analysis, the population was divided into uric acid quartiles among nonallopurinol users (2.2-7.1, >7.1-8.6, >8.6-10.4, >10.4 mg/dL) and those using allopurinol. Multivariate Cox regression modeling was performed to identify predictors of mortality. Uric acid quartile and allopurinol groups were referenced to the lowest uric acid quartile. RESULTS: A total of 1,152 patients were included. In general, patients in the allopurinol group and in the highest uric acid quartile had indicators of more severe HF, including worse renal function and greater proportion of New York Heart Association class IV patients, and greater diuretic use. The allopurinol group and highest uric acid quartile had the highest total mortality (41.7 and 42.4 per 100 person-years, respectively) and combined morbidity/mortality (45.6 and 51.0 per 100 person-years, respectively). Allopurinol use and highest uric acid quartile were independently associated with mortality (hazard ratio [HR] 1.65, 95% CI 1.22-2.23, P = .001 and HR 1.35, 95% CI 1.07-1.72, P = .01, respectively) and combined morbidity/mortality (uric acid quartile 4 vs 1: HR 1.32, 95% CI 1.06-1.66, P = .02; allopurinol use: HR 1.48, 95% CI 1.11-1.99, P = .008). CONCLUSION: Elevated uric acid level was independently associated with mortality in patients with severe systolic HF, even when accounting for allopurinol use.

PMID: 21095282 [PubMed - in process]

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Long-term outcomes after drug-eluting stent for the treatment of ostial left anterior descending coronary artery lesions.

Am Heart J. 2010 Nov;160(5):973-8

Authors: Capranzano P, Sanfilippo A, Tagliareni F, Capodanno D, Monaco S, Sardella G, Giordano A, Sangiorgi GM, Tamburino C

BACKGROUND: Although drug-eluting stents (DES) have reduced restenosis in a broad range of lesions, there is limited data, from relatively small studies, on the safety and efficacy of DES for isolated ostial left anterior descending (LAD) stenoses. In addition, in the setting of these high-risk lesions, there is the issue of the potential involvement of the left main (LM) bifurcation, requiring subsequent revascularization for a lesion involving this critical location. METHODS: Patients with a de novo isolated unprotected ostial LAD stenoses treated with DES were included. Evaluated end points were cardiac death, nonfatal myocardial infarction, overall target lesion revascularization (TLR), and the reintervention for a restenotic lesion located at the LM segment adjacent to the stent (TLR-LM). RESULTS: A total of 162 patients were included: 95 underwent focal ostial LAD stenting and 67 stenting from the distal LM into the LAD ostium. The 2-year Kaplan-Meier estimates of cardiac death, nonfatal myocardial infarction, overall TLR, and TLR-LM were 2.6%, 2.1%, 8.3%, and 4.7%, respectively. Overall TLR and TLR-LM rates were higher in the focal ostial LAD stenting group. There was a trend toward an independent increased risk of TLR associated with focal ostial stenting. In addition, final minimal luminal diameter trended to be independently associated with TLR. CONCLUSION: The present study showed that DES for isolated ostial LAD lesions is a feasible, safe, and effective treatment strategy. In addition, this study suggested the hypothesis that a default distal LM-LAD stenting, rather than focal ostial stenting, might provide more favorable outcomes. Nevertheless, larger specifically designed studies are needed.

PMID: 21095288 [PubMed - in process]

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Influence of transfer-in rates on quality of care and outcomes at receiving hospitals in patients with non-ST-segment elevation myocardial infarction.

Am Heart J. 2010 Sep;160(3):405-11

Authors: Mehta RH, Chen AY, Ohman EM, Gibler WB, Peterson ED, Roe MT,

BACKGROUND: Patients with non-ST-segment elevation myocardial infarction (NSTEMI) are frequently transferred to tertiary hospitals for angiography and/or revascularization from hospitals lacking such capabilities. Given that patients who undergo invasive cardiac procedures are younger and have fewer comorbidities compared with those managed medically, the relative proportion of transfer-in patients at tertiary hospitals may influence comparisons of quality and guidelines adherence. METHODS: We evaluated 142,092 NSTEMI patients treated at 396 revascularization-capable sites in the CRUSADE National Quality Improvement Initiative from 2001 to 2006. Transfer-in patients were included if they arrived at the receiving hospital after their first presentation to a different hospital. Hospitals were categorized into tertiles based upon their transfer-in rates (low, intermediate, and high) and adherence to practice guidelines recommendations for NSTEMI. In-hospital clinical outcomes were compared across hospital tertiles. RESULTS: Acute and discharge composite guidelines adherence scores improved at hospitals with an increasing proportion of transfer-in patients, both for transferred as well as for directly admitted patients. These better adherence scores were inversely associated with overall mortality, with the lowest mortality observed in patients at hospitals with the highest transfer-in rates. However, once adjusted for baseline confounders, the mortality rates for patients in the hospitals in the highest transfer-in tertile did not differ significantly compared with the sites in the lowest transfer-in tertile (odds ratio 1.02, 95% CI 0.90-1.16). CONCLUSIONS: Our findings show that the proportion of NSTEMI patients transferred into revascularization-capable hospitals varies significantly. Hospitals with a higher proportion of transfer-in patients tend to provide higher overall quality of NSTE acute coronary syndrome care; they also have lower overall in-hospital mortality, which may, in part, be related to the lower-risk baseline characteristics of patients at these hospitals.

PMID: 20826246 [PubMed - in process]

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Temporal trend of in-hospital major bleeding among patients with non ST-elevation acute coronary syndromes.

Am Heart J. 2010 Sep;160(3):420-7

Authors: Elbarouni B, Elmanfud O, Yan RT, Fox KA, Kornder JM, Rose B, Spencer FA, Welsh RC, Wong GC, Goodman SG, Yan AT

BACKGROUND: Although randomized controlled trials support the use of intensive medical and invasive therapies for non-ST segment elevation acute coronary syndromes (NSTE-ACS), major bleeding is a serious treatment complication. We sought to determine the temporal trend of in-hospital major bleeding among patients with NSTE-ACS, in relation to the evolving management pattern. METHODS: We identified 14 111 NSTE-ACS patients enrolled in 4 successive, prospective, multicenter registries (ACS I, 1999-2001; ACS II, 2002-2003; GRACE, 2004-2007; and CANRACE, 2008) in Canada between 1999 and 2008. We collected data on patient characteristics, use of cardiac medications and procedures on standardized case report forms. In all registries, major bleeding was defined a priori as life threatening or fatal bleeding, bleeding requiring transfusion of ≥2 U of packed red cells, or resulting in an absolute decrease in hemoglobin of >30g/L. RESULTS: A total of 14 111 patients had a final diagnosis of NSTE-ACS and were included in this study (3294 in the ACS-I registry, 1956 in the ACS-II registry, 7543 in GRACE, and 1318 in CANRACE). Over time, there was a substantial increase in the use of dual anti-platelet (aspirin and thienopyridine) therapy (P for trend <.001), and in rates of in-hospital cardiac catheterization and percutaneous coronary intervention (both Ps for trend <.001). Overall, major bleeding was relatively infrequent (1.7%). There was no significant increase in the unadjusted rates of major bleeding over time (P for trend = .19). In multivariable analysis adjusting for GRACE risk score and intensive treatment, enrolment period was not an independent predictor of bleeding (P for trend = .98). There was no interaction between the enrolment period and the use of intensive medical and invasive management. CONCLUSION: Despite more widespread use of dual anti-platelet therapies and invasive cardiac procedures in the management of NSTE-ACS, the rate of major bleeding remains relatively low and has not increased significantly over time. Our findings suggest that physicians selectively target treatment for their patients, and these evidence-based therapies can be safely administered to ACS patients in clinical practice.

PMID: 20826248 [PubMed - in process]

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β-Blocker use following myocardial infarction: Low prevalence of evidence-based dosing.

Am Heart J. 2010 Sep;160(3):435-442.e1

Authors: Goldberger JJ, Bonow RO, Cuffe M, Dyer A, Rosenberg Y, O’Rourke R, Shah PK, Smith SC,

BACKGROUND: Quality improvement programs have shown increased use of β-blockers post-myocardial infarction (MI), but there are no data on whether appropriate doses are administered. METHODS: In a prospective registry that enrolled consecutive patients with MI, we evaluated β-blocker dosing at discharge after MI and 3 weeks later and assessed clinical predictors for treatment with very low doses. We studied 1,971 patients (70.8% male) with a mean age of 63.9 ± 13.7 years, of whom 48.2% had an ST-elevation MI. RESULTS: β-Blocker utilization rates following MI were 93.2% at discharge: 20.1% received <25% of target dose, 36.5% received 25% of target dose, 26.4% received 26% to 50% of target dose, and 17.0% received >50% of target dose. Between discharge and 3 weeks, 76.4% had no change in β-blocker dose, with 11.9% and 11.6% having their dose reduced and increased, respectively. Absence of hypertension, acute percutaneous coronary intervention, older age, and no angiotensin-converting enzyme inhibitor therapy were consistent predictors of treatment with very low β-blocker doses. CONCLUSIONS: Underdosing of β-blockers is highly prevalent among patients post-MI. This represents an important opportunity in quality improvement for the care of patients who have suffered an MI.

PMID: 20826250 [PubMed - in process]

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