A Requiem for Routine Clot Removal During Heart Attacks Reply

Using a stent to open a blocked coronary artery is the treatment of choice in the early period of a heart attack (myocardial infarction). A limitation is the risk of dislodging part of the clot, leading to new downstream blockages of smaller vessels. One strategy that has been under development for a long time is thrombectomy, in which a device extracts the clot prior to the delivery of the stent. Following earlier success in small trials, the benefits of thrombectomy became controversial when a large trial, TASTE, found no evidence of benefit for the procedure.

TOTAL (Trial of Routine Aspiration Thrombectomy with PCI versus PCI Alone in Patients with STEMI), one of the largest trials ever to test a medical device, was presented at the American College of Cardiology meeting in San Diego and published simultaneously in the New England Journal of Medicine.

Click here to read the full post on Forbes.

 

 

 

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Cardiology Group Withdraws ‘Choosing Wisely’ Recommendation Reply

In the end it wasn’t wisdom for the ages. The American College of Cardiology said today that it was withdrawing one of its five recommendations in the “Choosing Wisely” campaign.  In 2012 the ACC recommended that heart attack patients should have only their culprit artery unblocked. It said that patients and caregivers should question whether complete revascularization of all nonculprit lesions in heart attack patients should be performed.

The original recommendation was based on non-randomized studies suggesting that treating all significantly blocked vessels in heart attack patients could be harmful. “However,” the ACC now states, “over the last two years, new science has emerged showing potential improvements for some patients in their overall outcomes as a result of complete revascularization.”

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Controversial Trial Finds No Benefit For Expensive Medicines Company Drug Reply

Although there is broad consensus in the medical community that primary PCI is the best treatment for heart attack patients when it can be delivered promptly, there is no agreement about the best accompanying drug regimen, which usually entails a combination of antiplatelet and antithrombotic drugs. The role of one antithrombotic, bivalirudin (Angiomax, The Medicines Company) has been particularly uncertain because it is far more expensive than its alternative, unfractionated heparin.

HEAT-PPCI was designed to help settle this problem.

Click here to read the full post on Forbes.

 

New Study Lends Support For Alternative Heart Attack Treatment Strategy 2

It is generally agreed that the best treatment for heart attack patients is to immediately reperfuse the blocked artery with a stent. But many people live in areas where this strategy, known as primary PCI, is not available within the time frame when it produces the greatest benefit. Previous studies have found good short term outcomes in patients who receive a pharmaco-invasive strategy, in which patients first receive fibrinolytic therapy including a clot-busting drug and then later undergo angiography. Now long-term results from a large real-world study show that this strategy may be an acceptable alternative for some patients when immediate primary PCI is not available.

In a paper published in Circulation, French researchers report the 5 year mortality findings from nearly 1,500 STEMI patients enrolled in the 2005 cohort of FAST-MI (The French Registry on Acute ST-Elevation and Non–ST-Elevation Myocardial Infarction).

Click here to read the full post on Forbes.

 

All Dressed Up And No Place To Go: False-Positive Activation Of The Cath Lab For Primary PCI Reply

Primary PCI is widely recognized as the best early option for patients with  ST-segment elevation myocardial infarction (STEMI). However, efforts to deliver primary PCI to the broadest possible population inevitably result in an increased number of false-positive activations of the cardiac catheterization laboratory. Now, a new studypublished in the Archives of Internal Medicine finds that the rate of false-positive activations is higher than expected.

James McCabe and colleagues analyzed data from 411 STEMI activations at two primary PCI centers. More than one-third — 36% — were judged to be false-positive. Patients with high BMIs or with chest pain or pressure at presentation were less likely to have a false-positive activation. The following factors were independently associated with an increased risk for a false-positive STEMI activation:

  • Left ventricular hypertrophy on ECG: adjusted odds ratio (AOR) 3.15, CI 1.55- 6.40, p=0.001
  • History of coronary disease: AOR 1.93, CI 1.04-3.59, p=0.04
  • History of  illicit drug abuse: AOR 2.67, CI 1.13-6.26, p=0.02
The authors conclude:
While a certain percentage of false-positive STEMI activations are essential to ensuring adequate diagnostic sensitivity, the point of equipoise between necessary diagnostic sensitivity and patient safety requires further investigation, particularly in light of increasing resource limitations.
In an accompanying commentary, Fouad Bachour and Richard Asinger note that the higher-than-expected rate of false-positives in the study may be partly due to “the variability of definitions.” They recommend that primary PCI programs adopt “a systematic protocol for the diagnosis and emergent treatment of STEMI including pivotal medical history for comorbid features, patient preference, continuous review of clinical experience, and direct feedback.” They suggest that an “acceptable rate of inappropriate activations … is probably in the 15% to 20% range.”
     —CardioExchange News

Meta-Analysis Compares Drug-Eluting and Bare-Metal Stents for Primary Angioplasty Reply

A new meta-analysis comparing drug-eluting stents (DES) and bare-metal stents (BMS) in patients with myocardial infarction has provoked opposing take-away messages from an author of the study and an editorialist. The authors emphasize the reduction in target-vessel revascularization (TVR) associated with DES, but the editorialist focuses on several potential DES weaknesses suggested by the study.

In the paper, published in Archives of Internal Medicine, members of the Drug-Eluting Stent in Primary Angioplasty (DESERT) Cooperation pooled patient data from more than 11 clinical trials in which more than 8,600 patients were randomized to either sirolimus-eluting or paclitaxel-eluting stents or BMS.  After a mean follow-up of 1201 days, DES was associated with a significant reduction in TVR but there were no significant differences in death, reinfarction, or stent thrombosis (ST):

  • TVR: 12.7% for DES vs 20.1% for BMS, HR 0.57, CI 0.50-0.66, p<.001
  • Mortality: 8.5% vs 10.2%, HR 0.85, CI 0.70- 1.04, p = .11
  • Reinfarction: 9.4% vs 5.9%, HR 1.12, CI 0.88-1.41, p = .36
  • Stent thrombosis: 5.8% vs 4.3%, HR 1.13, CI 0.86-1.47, p = .38

However, after two years there was a significant increase in the risk of stent thrombosis associated with the DES group (HR 2.81, CI 1.28-6.19, p=0.04).

The findings, write the authors,

provide strong evidence of the beneficial effects of SES and PES during primary PCI in STEMI. With follow- up as late as 6 years, a robust and sustained decrease in TVR was noted with use of these DES. Although the rates of late reinfarction and ST progressively increased, with the difference becoming statistically significant after 2 years in patients receiving SES and PES, the HR for mortality, while not significantly different between DES and BMS, favored DES.

Click to continue reading, including a comment from Gregg Stone…