CardioExchange Archive

The AHA Scientific Sessions in Orlando this past week certainly provided interventionists with a lot to think about. Here are some of the presentations that caught my attention:

1. Cangrelor Not Beneficial in ACS Patients Receiving Clopidogrel and PCI (see discussion here)

2. (F)Utility of Platelet Assays (see discussion here): The POPULAR trial evaluated 6 platelet assays in clopidogrel-pretreated patients undergoing elective PCI. Three tests were able to identify patients at higher risk for death, MI, stent thrombosis or stroke at 1 year: light transmittance aggregometry (LTA), VerifyNow P2Y12 and Plateleworks. In contrast, 3 tests did not distinguish patients with and without ischemic events: IMPACT-R, INNOVANCE PFA P2Y and the PFA/Collagen ADP tests. None were able to predict major or minor bleeding.

3.   Primary PCI Safe in Hospitals Without Cardiac Surgery (see discussion here): In an AHA late breaking prospective, observational study, STEMI patients in Massachusetts who underwent primary PCI at hospitals without cardiac surgery on site (SOS) had similar rates of death, MI and target vessel revascularization at 1 year compared to those who underwent primary PCI at hospitals with cardiac SOS. Of note, the hospitals without cardiac SOS had to perform at least 300 diagnostic caths and 36 primary PCIs annually, which are low minimum requirements.

4. Clopidogrel Doesn’t Improve Early Graft Results (see discussion here): In patients undergoing multivessel CABG, the CASCADE trial showed that the addition of clopidogrel to aspirin immediately after surgery did not reduce graft intimal hyperplasia or improve graft patency, as assessed by intravascular ultrasound and angiography performed one year post-CABG.

5. NSAID Ineffective In Preventing Tamponade Post-CABG (see discussion here): In the POPE Study of 196 pts at high risk of tamponade following CABG, – those with moderate or large effusion by echo 8-30 days after surgery —  administration of NSAID (diclofenac) for 14 days was no more effective than placebo in reducing the volume of pericardial fluid or preventing tamponade. Many physicians prescribe an NSAID to the post-CABG patient with moderate or large pericardial effusion hoping it will accelerate resolution of the effusion and prevent tamponade. This well-performed, randomized, controlled trial shows that an NSAID is ineffective in these patients.

6. Better Cognitive Function with OPCABG Then PCI (see discussion here): In the Octopus Study, patients referred for PCI were randomized to PCI (with bare metal stent) or off-pump CABG (OPCABG). After 7.5 yrs of follow up, cognitive function was better in the OPCABG than the PCI-treated patients. Unfortunately, cognitive function was not assessed at baseline in the 201 patients studied.

7. More From BARI2D (see discussion here): The BARI2D study and associated substudies were presented at the AHA. In Type 2 diabetic patients, those randomized to intensive medical therapy — to reach target HgA1c, blood pressure, and serum cholesterol goals – had similar 4 year outcomes (composite death, MI, CVA) to those referred for prompt revascularization in addition to medical therapy, except in the patients with extensive coronary disease (3 vessel CAD), in whom prompt CABG resulted in fewer nonfatal MIs than intensive medical therapy. BARI2D quality of life analysis: Compared to medical therapy, the patients who underwent prompt revascularization with CABG had a small improvement in  perception of wellness that persisted throughout the 4 year followup. BARI2D economic analysis: Prompt revascularization was associated with $10,000 increase in cost over the 4 years compared to medical therapy. For the different revascularization procedures, there was a ~$20,000 higher cost with CABG and ~$6000 higher cost with PCI compared to intensive medical therapy.

8. STICH In Time (see discussion here): In the STICH trial, 1000 patients with CHF (LVEF <35%) were randomized to CABG with or without surgical ventricular remodeling (SVR) with no benefit of SVR on the primary endpoint of death and hospitalization. Analyzing global and regional ventricular function, investigators were unable to identify a subgroup of patients who benefitted from addition of SVR to coronary revascularization at the time of CABG. 

9. HEAALing Best With High Dose ARB (see discussion here): In the HEAAL study in CHF patients with depressed LVEF who are intolerant of an ACE inhibitor, treatment with high dose (150mg) losartan was better than low dose (50mg) losartan in reducing death and hospitalization for CHF over 5 years of follow-up.  Unfortunately, high dose losartan was associated with more hyperkalemia, hypotension, and renal insufficiency than low dose losartan, although it rarely led to drug discontinuation.

10.  “Pumping Iron” in CHF Patients (see discussion here): In the FAIR HF trial In patients with iron deficiency and chronic CHF without anemia, intravenous iron repletion – administered weekly until iron deficiency corrected, then monthly – improved exercise tolerance, symptoms, NYHA functional class, and self reported quality of life without adverse side effects, compared to placebo. The benefits were observed after only 4 weeks of treatment.   

11. Continuous Flow HeartMate II (see discussion here): According to the HEARTMATE II study, in patients with advanced CHF, continuous-flow LV assist devices result in better survival – with freedom from stroke, device failure and complications – then pulsatile devices.  In addition, treatment with continuous flow devices resulted in better exercise capacity, functional class and quality of life than treatment with pulsatile devices.