CLINICAL
NEWS JACC in a FLASH
Sapien XT and the Sapien 3 valves,
study authors did note a difference in
risk between patients taking warfarin (1.8%) and those not taking warfarin (10.7%). A larger THV was also
associated with an increased THV
thrombosis risk (p = 0.03). In multivariable analysis, the use of a 29
mm THV and no post-TAVR warfarin
treatment, independently predicted
THV thrombosis. Treatment with
warfarin effectively reverted THV
thrombosis and normalized THV
function in 85% of patients.
“Although often subclinical, THV
thrombosis may have important clinical implications,” the study authors
said. “Future studies are warranted
to assess whether tailored post-TAVR
antithrombotic therapy can reduce
the incidence of THV thrombosis.”
Hansson NC, Grove EL, Andersen HR, et
al. J Am Coll Cardiol. 2016;doi:10.1016/j.
jacc.2016.08.010
Beta-Blockers
Following
Angioplasty Show
Little Benefit for
Some Older Patients
Following coronary angioplasty, betablockers did not significantly improve
mortality rates or reduce the number
of future cardiovascular incidents for
older patients with stable angina but
no history of heart attack or heart
failure, according to a study published
in JACC: Cardiovascular Interventions.
Using data from the NCDR CathPCI
Registry linked with Medicare information, researchers examined records
from 755,215 patients from 1,443
sites between January 2005 and March
2013. Of this group, 71.4% received a
prescription for beta-blockers, medication used to control blood pressure
and other heart-related conditions. The
patients on beta-blockers tended to be
younger, female, and more likely to
have a history of hypertension, diabetes, high cholesterol, smoking, dialysis,
and prior angioplasty.
After adjusting for age, gender,
body mass index, smoking status,
hypertension, and other variables,
16
CardioSource WorldNews: Interventions
researchers found no significant
differences in outcomes at 30 days.
Mortality rates and the occurrence of
cardiac events were both under 1%.
At the 3-year mark, patients taking
beta-blockers had the following outcomes compared to those who were not:
• Mortality rate: 14% vs. 13.3%
• Incidence of heart attack: 4.2%
vs. 3.9%
• Occurrence of stroke: 2.3% vs. 2%
• Occurrence of a revascularization
procedure: 18% vs. 17.8%
The study also found that at 3 years,
8% of patients taking beta-blockers
were readmitted to the hospital due
to HF, compared to 6.1% of patients
not on this medication. The use of
beta-blockers for angioplasty patients
treated for stable angina increased
over the 8-year study period.
Stable angina, a symptom of coronary artery disease, is characterized
by chest pain associated with activity
or emotional stress. It typically occurs
when the heart doesn’t get as much
blood as it needs, usually the result of
one or more blocked arteries.
Apurva A. Motivala, MD, the study’s
lead author and an interventional cardiologist affiliated with New York-Presbyterian Hospital/Columbia University,
said the apparent lack of efficacy of
beta-blockers in this group of patients
may seem counterintuitive.
Motivala also said that because these
patients had a higher prevalence of traditional risk factors that lead to adverse
cardiac events, it is possible that without
beta-blockers, they would not have done
as well. The reasons for the increased
incidence of hospital readmissions due
to HF in this group remain unclear and
require further study.
In an accompanying editorial, Anthony G. Nappi, MD, a cardiologist at
Albany Stratton VA Medical Center, and
William F. Boden, MD, professor of
medicine at Albany Medical College and
chief of medicine at Albany Stratton VA
Medical Center, said that some of the
findings may be the result of selection
bias with respect to which patients
received a beta-blocker prescription.
But the editorial writers said that
by focusing on a Medicare population,
the investigators may have controlled
for some of the selection bias, though
data are lacking on overall beta-blocker
adherence.
They also said that the increased
frequency in beta-blocker prescriptions
over time “is perhaps not surprising”
and part of changing ideas about optimal medical therapy for coronary artery
disease. This study, along with others,
raises questions about the continued
role of beta-blockers in patients with
coronary artery disease undergoing
angioplasty, especially since there is no
evidence of clinical benefit in patients
without prior heart attack or HF.
“Clinicians will need to decide
whether they will continue to
extrapolate older scientific evidence
of beta-blocker efficacy in selected
post-heart attack populations from
an earlier era prior to the advent of
angioplasty and optimal medical
therapy,” Nappi and Boden wrote.
“Perhaps such treatment decisions
need to be guided by physician judgment and hence individualized to the
level of patient benefit versus risk,
because definitive evidence is either
imperfect or lacking.”
Motivala AA, Parikh V, Roe M, et al. J Am
Coll Cardiol Intv. 2016;9(16):1639-48.
Does Smartphone
Messaging Streamline Transfer of MI
Patients?
Smartphone communication between
hospitals may significantly reduce the
time it takes for myocardial infarction
patients to receive treatment after a
hospital transfer, according to a research letter published Sept 19 in JACC.
Jin Joo Park, MD, and colleagues
examined 114 patients with ST-ele-
vated myocardial infarction (STEMI)
transferred from 16 hospitals that
were unable to perform percutaneous
coronary intervention (PCI). Five of
the hospitals, which treated 50 of the
patients, participated in smartphone
app-based social network system (SNS)
to coordinate the hospital transfer while
the others communicated with a nonsmartphone based STEMI hotline.
The researchers found patients
needing a hospital transfer received
PCI on average 27 minutes faster
when their medical teams used SNS
to coordinate the hospital transfer
compared to teams communicating
with the STEMI hotline. There was
no difference in door-to-device time at
the PCI hospital in patients arriving
on weekdays. However, during offhours, that time was 15 minutes less
in the patients using SNS. Results also
showed that the time spent in transit
between the two hospitals was similar in both groups. The time spent at
the first hospital before being transferred was numerically shorter in the
SNS-activated group, but this difference was not statistically significant.
Moving forward, Park and his team
are planning a randomized clinical
trial to provide a more rigorous evaluation of the potential impact of SNS
use on these outcomes.
“SNS activation is a simple and
cost-effective method suitable for
broad utilization and implementation among health care providers to
reduce the total ischemic time for
transferred STEMI patients,” said Dr.
Park. “In my opinion, SNS activation
can potentially save lives without using new resources in the health care
system.” ■
Park J, Yoon C, Suh J, et al. J Am Coll Cardiol.
2016;68(13):1490-2.
September/October 2016