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Journal and News Scan
Patients with prior coronary artery bypass graft surgery (CABG) who present with an acute coronary syndrome have a high risk for recurrent events. Whether intensive antiplatelet therapy with ticagrelor might be beneficial compared with clopidogrel is unknown. In this substudy of the PLATO trial, the authors studied the effects of randomized treatment dependent on history of CABG. Prior–CABG patients presenting with acute coronary syndrome are a high–risk cohort for death and recurrent cardiovascular events but have a lower risk for major bleeding. Similar to the results in no–prior–CABG patients, ticagrelor was associated with a reduction in ischemic events without an increase in major bleeding. Methods Patients participating in PLATO were classified according to whether they had undergone prior CABG. The trial's primary and secondary end points were compared using Cox proportional hazards regression. Results Of the 18,613 study patients, 1,133 (6.1%) had prior CABG. Prior-CABG patients had more high-risk characteristics at study entry and a 2-fold increase in clinical events during follow-up, but less major bleeding. The primary end point (composite of cardiovascular death, myocardial infarction, and stroke) was reduced to a similar extent by ticagrelor among patients with (19.6% vs 21.4%; adjusted hazard ratio [HR], 0.91 [0.67, 1.24]) and without (9.2% vs 11.0%; adjusted HR, 0.86 [0.77, 0.96]; Pinteraction = .73) prior CABG. Major bleeding was similar with ticagrelor versus clopidogrel among patients with (8.1% vs 8.7%; adjusted HR, 0.89 [0.55, 1.47]) and without (11.8% vs 11.4%; HR, 1.08 [0.98, 1.20]; Pinteraction = .46) prior CABG.
The authors review the rationale for platelet function testing and its application in monitoring patients on antiplatelet therapy. They also review recent clinical trials of newer antiplatelet agents. On the basis of this review, they reach conclusions on the current role of antiplatelet function testing in monitoring modern antiplatelet therapy and the role of the new antiplatelet agents in the treatment of ACS. Recent clinical trials have indicated that newer antiplatelet agents have advantages over clopidogrel in the treatment of ACS. Platelet function testing gives us a guide to the timing, efficacy, and variability of therapy and can correlate with poor patient outcomes; however, the use of antiplatelet function testing to tailor therapy does not seem appropriate.
- The authors reviewed recent publications on platelet function testing and clinical trials of newer antiplatelet therapies compared with clopidogrel.
- Platelet function testing is complex, but there is now a bedside test, VerifyNow.
- High platelet reactivity has been associated with worse cardiovascular outcomes in patients undergoing percutaneous coronary intervention.
- Recent clinical trials have not found any advantage in outcomes in patients who have their therapy adjusted by monitoring their platelet function.
- Newer agents, prasugrel, ticagrelor, and cangrelor, produce more rapid, complete, less variable effects on platelet function than clopidogrel.
- Prasugrel was found to improve outcomes compared with clopidogrel in patients with ACS undergoing percutaneous intervention.
- Ticagrelor is beneficial in all patients with ACS and reduces cardiovascular mortality compared with clopidogrel.
- Cangrelor improves outcomes in patients undergoing stenting.
- Recent studies to assess the role of platelet function monitoring of the effects of clopidogrel and modifying treatments have not been successful.
This paper describes the 1-year results of the CADUCEUS randomized trial on the effect of intracoronary delivery of cardiosphere derived cells (CDC) 1.5 to 3 months after myocardial infarction. Safety endpoints were similar in both groups. Patients treated with CDC had smaller scar size, an increase in viable myocardium and improved regional function of infarcted myocardium than those in the control group. Global ventricular function did not change from baseline to follow up in either group.
In this meta-analysis of five randomized trials comprising 958 patients, the authors study the effect of double versus single antiplatelet therapy on graft occlusion in patients undergoing coronary artery bypass graft surgery. Vein grafts in patients on double antiplatelet therapy were significantly less likely to occlude that those in patients on single therapy at up to 1-year follow up. This effect was not seen in arterial grafts. Safety data on bleeding was inconsistent.
This retrospective study from Vienna examined the correlation between length of extracted thrombi and outcomes after pulmonary endarterectomy in 110 pts. The extent of thrombus extraction was inversely correlated with PVR. PVR in the early postoperative period was the only predictor of survival and freedom from lung transplant.
This study used state-wide registries in 11 southern states to evaluate outcomes of NSCLC treatment among black and white patients. More blacks were diagnosed at later stages. Survival for men was worse than for women, adjusted for covariates (HR 1.41). Lung cancer mortality was similar for blacks and whites (HR 0.99).
This Ontario-based collaboration used meta-analyses of data from prospective trials to outline CT screening recommendations for individuals at increased risk for lung cancer. Most guidelines are in line with recommendations from the Lung Cancer Screening Study, but important deviations were identified and justified.
In this promising investigation, investigators found that C4d, a degradation product of complement activation, assessed in bronchoalveolar lavage and plasma, predicts the presence of lung cancer compared with non-cancer patients. They found a shorter survival in patients with high levels in the plasma. Plasma C4d levels were reduced after surgical resections, which means C4d may be useful as a marker of recurrence after resection.
An instant guide to Valve in Valve procedures for clinicians
Quick, clear and concise information about heart valves and Valve in Valve therapy. A guide you wish you always had at your fingertips.
Valve in Valve app was developed as a collaboration between the technology company UBQO and Dr. Vinayak (Vinnie) Bapat, Consultant Cardiac Surgeon at St. Thomas' Hospital, London, UK.
Valve in Valve app provides information specific for a clinical scenario, quickly and simply. This will help in the planning of and performing a Valve in Valve case. The application navigates the user through important aspects of surgical and TAVI valve design, which are vital for a successful Valve in Valve procedure. The app logically steps through the possible combinations to give the user specific information needed to perform the procedure.
Success of a Valve in Valve procedure is based on correct identification of the surgical valve, choosing the correct size of the TAVI valve and its subsequent accurate placement. Surgical valves vary in appearance under fluoroscopy and also in their internal diameter. Similarly TAVI valves differ in their appearances and available sizes.
Knowledge about all the surgical valves that have been implanted in the last two decades is minimal but relevant to the Valve in Valve therapy. Users can now familiarise themselves with important design information about surgical and TAVI valves; they can also select the valve and find out which size of TAVI valve could be used and how it is best placed during a Valve in Valve procedure.
If the valve type is unknown, the App also guides the user through a series of steps where they can identify the surgical valve type and then use the information available for it.
The Valve In Valve app can be used to plan a case and confirm suitability for this procedure and reduces the need to trawl through vast amounts of literature to find information specific to the clinical scenario. The information is also available without the need for an internet connection and will enhance the users understanding of various aspects of this procedure. We hope this will result in improved results and better outcomes for patients.
- Design information for multiple types of surgical valve
- Sizing information for multiple types of surgical valve
- Real life and fluoroscopic images of all the surgical valves
- Design information about TAVI valve designs
- Sizing information for these TAVI valves
- Guides the user through a stepped process to help choose a specific valve, then the size and lastly the important dimensions to plan a Valve in Valve procedure
- Image based guidance for the ideal placement of a TAVI valve
- Video examples of actual placement of a TAVI valve
- Discusses important design considerations in detail to improve understanding of the Valve in Valve procedure
The STICH trial compares medical therapy to medical therapy + CABG for ischemic cardiomyopathy. In this study of over 1,200 there were 462 deaths during a median f/u period of nearly 5 years. CABG reduced the risk of sudden death and death due to pump failure; overall cardiovascular death was reduced by CABG but not significantly (p=0.09). There was a substantial early increase in mortality in pts undergoing CABG; the protective effects of CABG were evident primarily after 2 years.