So , in case you have a situation where you have very complex anatomy , you may end up with very complex stenting procedures .” In that case , he said , “ It ’ s safe to wait 2 days .”
Gentle , Graded Reperfusion Fails Speaking of Dr . Engstrøm , he was at ACC . 16 to present another trial looking at whether abrupt reperfusion by angioplasty may itself damage the heart muscle . “ The thinking was that performing reperfusion in a gentle , graded fashion would protect the heart against reperfusion injury ,” he said .
In a word : no . “ All we found was that the number of patients who ended up with left ventricular ejection fraction above 45 % was larger in the group who received ischemic post-conditioning ,” said Dr . Engstrøm . The DANAMI-3 iPOST trial evaluated ischemic post-conditioning , involving 30-second bursts of blood flow interspersed with 30-second pauses to restore blood flow to the heart of 617 patients undergoing primary PCI . Results were compared to 617 patients randomized to conventional primary PCI . Use of iPOST during primary angioplasty failed to reduce the primary composite endpoint of all-cause mortality and hospitalization for HF . Ischemic post-conditioning did reduce the secondary endpoint of all-cause mortality by 25 % but this did not reach statistical significance .
“ This may translate into improved survival over more years of follow-up ,” Dr . Engstrøm said . ( Patients were followed for a minimum of 2 years , with an average follow-up of 39 months ).
EARLY-BAMI Has No Punch While on the subject of failed trials , intravenous beta blockers before primary PCI is safe ; it just doesn ’ t offer any clinical benefit .
There was reason for optimism . In 2013 , the Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction ( METOCARD-CINC ) evaluated early intravenous metoprolol and suggested active therapy was associated with reduced infarct size and improved left ventricular ( LV ) function among patients with anterior STEMI undergoing reperfusion with PPCI .
The Early Beta-blocker Administration before primary PCI in STEMI ( EARLY-BAMI ) trial was conducted in the Netherlands and Spain . Investigators enrolled patients ( average age 62 ; 75 % male ) with acute STEMI symptoms of < 12 hours duration who were randomly assigned to receive metoprolol ( n = 336 ) or placebo ( n = 346 ) before PCI . The STEMI could be in any distribution , not limited to anterior infarction like METOCARD-CINC .
Of the patients randomized , 342 ( 55 %) had the primary endpoint assessment of infarct size by magnetic resonance imaging ( MRI ) at 30 days . Among these patients , there was no effect of pre-PPCI intravenous metoprolol on infarct size ( 15.3 % vs . 14.9 %; p = 0.616 ). However , patients who did not undergo MRI were different ( older , more often women , and had fewer first contacts at a referring hospital or PCI center ) from those who did , which may have resulted in bias in the primary endpoint assessment .
First-author Vincent Roolvink , MD , Isala Klinieken , Zwolle , Netherlands , said , “ Early intravenous metoprolol before primary PCI was not associated with reduction in infarct size although it did reduce the incidence of malignant arrhythmias in the acute phase and was not associated with an increase in adverse events .”
Also , he noted that EARLY-BAMI may not be the end of beta blockers for acute STEMI patients . “ I think there is still room for another large trial that includes patients at higher risk , with large heart size , who are given a higher dose of a beta blocker than we used in this study and as soon as possible after diagnosis to see if beta blockers have any place in STEMI patients .”
“ Invasive Procedure ? Sure , Go for It ” Guidelines emphasize shared decision-making between clinician and patient when determining the best approach for managing coronary artery disease ( CAD ). So , what happens when patients are asked what to do ? You might think they want a prescription and a discharge . Yet , when asked for their preferences , many CAD patients prefer more invasive measures over medical therapy . One downside : these patients tend to underestimate the risk of complications associated with invasive procedures .
The data come from investigators at the Duke Clinical Research Institute ( DCRI ), who surveyed 98 patients undergoing angiography . Only 6 % of patients said their physician should make treatment decisions alone . A similar-sized group ( 9 %) of very independent patients said they wanted to decide on their own . That left 85 % of patients preferring some form of shared decision-making .
Earlier research on ambulatory patients with CAD suggested patients show a preference for medical management compared with PCI or coronary artery bypass graft surgery ( CABG ). In this study , Jacob Doll , MD , and colleagues wanted to explore the preferences of CAD patients undergoing coronary angiography .
Most patients said they would prefer PCI to medical therapy alone or CABG if they were offered a choice by their physician . Obviously , patients were already about to undergo an invasive procedure , which might explain the discrepancy with previous data suggesting patients generally prefer less invasive
treatments .
What concerns Dr . Doll is the lack of knowledge within this population . Most patients underestimated the risk of major complications ( death , MI , or stroke ) associated with PCI ( which was underestimated by 70 % of the patients
EARLY-BAMI has been accepted for publication in JACC and can be read online by scanning the code . surveyed ) and CABG ( 91 % missed the mark in estimating risk ).
“ There ’ s not a lot of knowledge out there ,” said Dr . Doll . “ It ’ s not obvious to patients how risky some of these therapies really are .”
Also , Don ’ t Ask Patients to Estimate Their CV Risk Patients can provide a lot of information and , as just seen , they may tell you a more invasive approach is fine with them ; but , don ’ t bother asking them to estimate their own risk . Ann Marie Navar , MD , also of DCRI , and colleagues surveyed 2,856 U . S . patients 40 years of age and older without cardiovascular disease to estimate their 10-year risk . They then compared the patient answers with risk as determined using the calculator recommended by the current 2013 ACC / AHA Guidelines . The researchers found no correlation between patients ’ estimates of their risk and calculated CVD risk estimates . Only 27.3 % of patients estimated their risk within 10 points of their calculated risk , and most people overestimated their risk of heart disease .
“ We were surprised by this , because other studies have shown high rates of ‘ optimistic bias ,’ where people think they are healthier than they really are ,” said Dr . Navar . Women and younger adults tended to overestimate their risk , while men and older adults , on average , underestimated their risk .
Given that most individuals overestimate their risk , the researchers noted the possible unintended consequences of interventions that focus on communicating 10-year risk to patients . “ What happens when you tell someone who thinks they have an 80 % chance of heart attack or stroke in the next 10 years that it ’ s only 10 %?” Dr . Navar asked . “ We need to better understand how what we tell patients about risk affects their behavior .”
Valve Hemodynamic Deterioration in TAVR Patients Evidence of valve deterioration after TAVR got a lot of attention at the 2015 TCT meeting . At ACC . 16 , there were reassuring data presented from the DCRI in an analysis of data from the Society of Thoracic Surgeons ( STS )/ ACC TVT Registry™ . Sreekanth Vemulapalli , MD , conducted a retrospective study of 10,099 registry patients to determine whether TAVR valve deterioration is associated with adverse cardiac events .
He and his colleagues detected valve deterioration following TAVR in 2.1 % of patients in the first 30 days and in 2.5 % of patients in the 30-day
ACC Scientific Statement on Knowledge Gaps in Cardiovascular Care of the Older Adult
A review of current guidelines revealed a pervasive lack of evidence to guide clinical decision making in older patients with cardiovascular disease . This document summarizes current guidelines as they apply to older adults and identifies critical gaps in knowledge . Michael Rich , MD , writing committee co-chair , was interviewed at ACC . 16 .
24 CardioSource WorldNews : Interventions May / June 2016