CardioSource WorldNews Interventions | Page 29

An interesting European Society of Cardiology meeting in Rome . ( In terms of special guests , the Pope will indeed be hard to top .) Yes , the United States was well-represented , but in terms of interventional stories here ( rushed to print , as you can tell by the date you ’ re holding this in your hands ), America barely makes it to the page . Even the AMERICA trial was done in France ! Sigh . It ’ s truly the World of Cardiology in the 21 st Century .
Bolstering the Role of Aggressive Interventions Even after a non-ST elevation myocardial infarction ( NSTEMI ), aggressive use of percutaneous coronary intervention ( PCI ) and stenting makes a big difference in achieving positive outcomes , according to the results of an analysis of nearly 400,000 NSTEMI patients living in England and Wales .
Marlous Hall , PhD , from the University of Leeds , England , and colleagues analyzed data from the Myocardial Ischemia National Audit Project ( MINAP ) from 2003-2004 to 2012-2013 . Over this period , fewer patients had intermediate-tohigh GRACE risk scores ( decreasing from 87.2 % to 82.0 %) and the proportion of patients at the lowest risk increased ( 4.2 % to 7.6 %; p = 0.01 for trend ). As you remember , the GRACE score incorporates age , cardiac arrest , ST-segment deviation , biomarker elevation , blood pressure , heart rate , heart failure , and renal function .
Improvements in baseline GRACE risk scores through the years had a strong opposing force : the prevalence of diabetes , hypertension , cerebrovascular disease , chronic obstructive pulmonary disease , chronic renal failure , a previous invasive coronary strategy , and current or ex-smoking status all increased ( all p < 0.001 for all ).
During the study period , use of guideline-indicated care increased , as did increased use of an invasive coronary strategy ( even after adjusting for changes in clinical risk and pharmacological therapies ), and patients experienced a significant decrease in 180- day all-cause mortality ( 10.8 % to 7.6 %).
In analyzing the reasons for the improved outcomes , investigators found that the reduction in baseline acute coronary syndrome ( ACS ) risk , increase in comorbidities , and use of guidelineindicated therapies did not fully explain the relative 3.2 % year-by-year increase in 6-month survival rate throughout the study period .
As seen in international registries , these improvements were significantly and independently associated with use of an invasive coronary strategy . Specifically , an invasive coronary strategy , defined as coronary angiography , PCI , or coronary artery bypass graft ( CABG ) surgery , increased from 42.7 % to 78.6 % over the course of the study ( p < 0.001 ).
In an accompanying commentary , Erin Bohula , MD , DPhil , and Elliott Antman , MD , of the TIMI study group and Brigham and Women ’ s Hospital , Boston , wrote , “ Hall and colleagues have demonstrated that under optimal conditions with universal access to health care in a high-income region , the use of guideline-directed invasive coronary strategies and pharmacotherapy is associated with improved outcomes . It is time to translate the success of MINAP to low- and middle-income countries and health care systems , where the resources are limited but the needs are the greatest .” – Journal of the American Medical Association
A Comeback for BMS ? While some observers argue there is little role for bare metal stents ( BMS ) today , the Norwegian Coronary Stent Trial ( NORSTENT ) contends that BMS should not be retired yet . It is the largest single randomized trial evaluating second-generation drug-eluting stentsc ( DES ) versus newer BMS in a pragmatic , broadly inclusive , properly-powered , and inexpensive trial that ( perhaps most importantly ) was not industry sponsored .
Between Sept . 15 , 2008 , and Feb . 14 , 2011 , all patients undergoing PCI in Norway were evaluated for enrollment . Eligible patients were mostly defined as having stable angina or ACS and lesions amenable for either DES or BMS . Of 12,425 adults who met the eligibility criteria , 9,013 ( 72.5 %) were randomly assigned to either BMS or DES implantation .
After a median of 5 years of follow-up , there were no significant between-group differences in the primary composite outcome of death from any cause or nonfatal spontaneous myocardial infarction ( MI ) ( TABLE 1 next page ), nor were there differences in the individual endpoints of death , MI , stroke , or hospitalization for unstable angina .
In an accompanying commentary to the concurrently published online results , Eric R . Bates , MD , of the University of Michigan Medical Center , Ann Arbor , noted that this confirmed historical evidence that coronary stenting has never shown a reduction
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