CardioExchange Archive

August 20th, 2010

Door to Balloon (D2B) Time: The Wrong Performance Measure?

Richard A. Lange, MD, MBA

The authors of a recently published study evaluated the association between system delay (i.e., time from the patient’s first contact with the health care system to initiation of reperfusion) and outcome in STEMI patients transported by EMS and treated with primary PCI.  Some patients were triaged directly to a PCI center, whereas others were transported to their […]

---

August 9th, 2010

The GP IIb/IIIa Inhibitor Wars: Not Ready To Surrender

Richard A. Lange, MD, MBA and Peter B Berger, MD

Although two recent studies (EVA-MI and SCAAR) report that eptifibatide is as effective as abciximab with respect to myocardial reperfusion and clinical events in patients undergoing primary PCI, the thoughtful and balanced editorial accompanying them points out that the studies “ought not be considered convincing or as level 1 evidence” that the GP IIb/IIIa inhibitors […]

---

July 12th, 2010

Clopidogrel vs. Prasugrel: How Effective? How Risky?

Richard A. Lange, MD, MBA

Here are the issues: The FDA has posted a black box warning that people with reduced CYP2C19 liver enzyme function (2% to 14% of the U.S. population) cannot effectively convert clopidogrel to its active form, which reduces its effectiveness in ACS patients. CYP2C19 function doesn’t influence prasugrel’s effectiveness. The AHA and ACC do not support routine CYP2C19 […]

---

June 25th, 2010

Start The Timer!

Richard A. Lange, MD, MBA

In a province-wide evaluation of STEMI care in Quebec, primary PCI was the preferred method of reperfusion therapy: 80% of patients who underwent reperfusion received primary PCI, whereas 20% were given fibrinolytic therapy. Disappointingly, PCI was performed > 90 minutes after presentation in 68% of recipients; fibrinolysis was performed >30 minutes in 54%. Time to reperfusion had a […]

---

June 4th, 2010

Carotid  Stenosis: Stent, Remove or Don’t Touch?

Richard A. Lange, MD, MBA

The Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) compared carotid stenting with endarterectomy in patients with symptomatic or asymptomatic carotid stenoses. The risk of the composite primary outcome — stroke, MI, or death — was similar for both treatments over the 2.5 years of follow-up. What’s the nitty gritty? Periprocedural stroke was more likely after stenting, […]

---

May 13th, 2010

All this talk about migraines and PFO closure is giving me a headache!

Richard A. Lange, MD, MBA

Despite a previous randomized trial showing no improvement in migraine headaches with PFO closure, a new study disputes these findings. In patients with refractory migraines (aura in 80%) and at high risk of right-to-left shunting (all had an atrial septal aneurysm, eustachian valve, large shunt, and coagulation abnormalities), PFO closure significantly improved migraine symptoms. Howie Herrmann is […]

---

March 19th, 2010

“Doc, I’m so confused. Do I stop or continue the clopidogrel?”

Richard A. Lange, MD, MBA

A recent study suggested that clopidogrel can be discontinued 12 months after drug-eluting stent placement. What do I tell my patient who had a drug eluting stent placed a year ago?  He’s not the only one who’s confused.  I’m concerned that the study was underpowered and the duration of follow-up too short to provide a firm conclusion about the appropriate […]

---

March 11th, 2010

Low Diagnostic Yield of Elective Coronary Angiography

Richard A. Lange, MD, MBA

According to a recent study, of almost 400,000 patients referred for elective coronary angiography, only 38% had obstructive CAD.  Those with a positive noninvasive test before angiography were only moderately more likely to have obstructive CAD than those who did not undergo any testing (41% vs 35%, respectively).  However, in a comment in Journal Watch, […]

---

March 1st, 2010

If It’s Your Carotid, Endarterectomy or Stenting?

Richard A. Lange, MD, MBA

The results from 2 carotid endarterectomy vs stenting trials are in….and they are disparate.  ICSS showed worse outcome with carotid stenting (higher rates of the composite of stroke, death, and procedural MI) versus carotid endarterectomy, whereas CREST showed similar efficacy and safety for both. Interestingly, in both studies the rate of nondisabling stroke was significantly […]

---

January 24th, 2010

Is the FDA too Lax?

Richard A. Lange, MD, MBA

A recent review reports that cardiovascular devices are not subjected to nearly the same level of scrutiny as drugs, raising concern about the true safety and efficacy of approved new technologies. Do you think this has placed patients at risk, or is it a welcome difference from the lengthy and onerous approval process that delays the implementation of potentially highly […]

---