October 20th, 2010
FDA Approves Dabigatran for Stroke Prevention in Atrial Fibrillation
Larry Husten, PHD
The FDA announced on Tuesday that it has approved Pradaxa (dabigatran, Boehringer Ingelheim) for the prevention of stroke and blood clots in patients with atrial fibrillation. The drug will be available in 75-mg and 150-mg capsules.
“Unlike warfarin, which requires patients to undergo periodic monitoring with blood tests, such monitoring is not necessary for Pradaxa,” said Norman Stockbridge, the director of the FDA’s Division of Cardiovascular and Renal Products, in an FDA press release.
Comments are closed on this post, but please join the conversation at our Dabigatran Resource Round-Up.
October 19th, 2010
DES: Top Six Things You Should Know
CardioExchange Editors, Staff
Finding it hard to keep up with all of the new DES research? Interventional Cardiology Co-Moderator Rick Lange offers this brief tutorial on the “top six things every cardiologist should know about DES.” Would you add anything to Rick’s list? Tell us your thoughts
October 19th, 2010
Study Finds Link Between Invasive Dental Treatments and CV Events
Larry Husten, PHD
A new study adds to the evidence linking periodontal disease to cardiovascular events, suggesting a common basis in acute inflammation. In a report in the Annals of Internal Medicine, Caroline Minassian and colleagues analyzed a Medicaid database of 1175 patients discharged with ischemic stroke or MI who had received invasive dental treatment. They observed a small but significant increase in CV risk the first 4 weeks after the dental procedure, with a gradual return to the baseline risk within 6 months. The authors write that their findings “lend support to the hypothesis that inflammation may play an important role in the occurrence of vascular events,” but they also point out that other factors may play a role, since people who undergo dental procedures may stop taking aspirin prior to the procedure and may receive NSAIDs after the procedure.
In an accompanying editorial, Howard Weitz and Geno Merli note that despite recommendations that aspirin should not be discontinued prior to a dental procedure, “our personal experience is that dental practitioners frequently request patients to withhold aspirin before periodontal therapy and dental extraction.” They cite a study in Ireland that found that 90% of practitioners stopped antiplatelet therapy prior to an extraction. The Annals study, they write, should serve as “an important reminder to continue cardioprotective antiplatelet agents if at all possible before and after dental procedures in patients who are receiving these agents. That is something that we can really sink our teeth into.”
October 19th, 2010
FDA Advisors Recommend No Changes for Aranesp
Larry Husten, PHD
The FDA Cardiovascular and Renal Advisory Committee has endorsed the status quo for Aranesp (darbepoetin alfa). The committee met on Monday to discuss the Trial to Reduce Cardiovascular Events with Aranesp Therapy (TREAT) and voted 15-1-1 against withdrawal of the indication for chronic kidney disease (CKD) patients not on dialysis. The committee also voted against adoption of the control arm of TREAT (rescue darbepoetin alfa when hemoglobin dropped below 9 g/dl) as the indication for the drug and said that the drug did not require further restrictions against use in dialysis patients or in patients with CKD with a history of stroke.
October 18th, 2010
“Um”
Westby G Fisher, MD
CardioExchange welcomes this guest post reprinted with permission from Dr. Westby Fisher, an electrophysiologist practicing at NorthShore University HealthSystem, Evanston, IL and a Clinical Associate Professor of Medicine at University of Chicago’s Pritzker School of Medicine. This piece originally appeared on his blog, Dr. Wes.
I never like to hear “Um…” from nurses or industry representatives during surgical procedures.
Most people think that the worst thing you could hear while undergoing a surgical procedure is “Oops…” or “Sh*t”, but I would have to politely disagree.
You see, people working in EP labs and operating rooms never want to sound hysterical if they’ve recognized a problem during a surgical procedure. To do so might startle the operating physician and make them tense or angry. Instruments have flown for less.
So nurses and industry representatives are carefully trained to first say “Um…”
“Um, is his lead impedance always so high?”
“Um, is his blood pressure always 60 systolic?”
“Um, you wouldn’t have connected the atrial lead in the ventricular port and the ventricular lead in the atrial port, would you?”
But savvy surgeons recognize “Um” and act quickly, politely stating the obvious:
“High impedance? Boy, those old leads don’t hold up like the newer ones. Looks like we’ll be placing a new one…”
“Sixty? What do you expect when they’ve been NPO all night? Could we start some dopamine, please?”
“Leads reversed? Just making sure you were awake…”
So beware of “Um” and for surgeons, be prepared to act accordingly.
October 18th, 2010
New CPR Guidelines Replace A-B-C with C-A-B
Larry Husten, PHD
Chest compressions gain pride of place (and trump alphabetical order) in the newly published and much-anticipated updated guidelines for CPR from the AHA. The new guidelines replace the traditional A-B-C (Airway-Breathing-Compressions) with C-A-B (Compressions-Airway-Breathing), recommending that “chest compressions be the first step for lay and professional rescuers to revive victims of sudden cardiac arrest.” The 16-part guidelines are published online in Circulation. (The AHA has also made available a document summarizing the key changes from the 2005 recommendations.)
The new guidelines recommend that compressions should be started immediately on people who are unresponsive and not breathing. In addition, chest compressions should be performed at a rate of at least 100 times per minute ─ slightly faster than previously recommended. The rescuers should push deeper into the chest, should not stop compressions, and should avoid excessive ventilation.
“For more than 40 years, CPR training has emphasized the ABCs of CPR, which instructed people to open a victim’s airway by tilting their head back, pinching the nose and breathing into the victim’s mouth, and only then giving chest compressions,” said Michael Sayre, co-author of the guidelines and chairman of the American Heart Association’s Emergency Cardiovascular Care (ECC) Committee, in an AHA press release. “This approach was causing significant delays in starting chest compressions, which are essential for keeping oxygen-rich blood circulating through the body. Changing the sequence from A-B-C to C-A-B for adults and children allows all rescuers to begin chest compressions right away.”
October 14th, 2010
Meta-Analysis Lends More Support to Compression-Only CPR
Larry Husten, PHD
There’s new evidence supporting the movement away from traditional bystander CPR in favor of chest-compression-only CPR. In a paper appearing online in the Lancet, Michael Hüpfl, Harald F Selig, and Peter Nagele report the results of two separate meta-analyses. In the first meta-analysis, the investigators combined data from 3 randomized trials comparing compression-only CPR to standard CPR as directed by dispatcher instructions. The rate of survival to hospital discharge was 14% in the standard CPR group compared to 12% in the compression-only group (risk ratio 1.22, p=0.40).
However, in the second meta-analysis, the authors analyzed results from 7 observational cohort studies and found no difference between the two CPR techniques, with an 8% survival in each group. The authors noted that the second meta-analysis did not investigate dispatcher-assisted CPR. They concluded that their findings “support the idea that emergency medical services dispatch should instruct bystanders to focus on chest-compression-only CPR in adults with out-of- hospital cardiac arrest.”
In an accompanying comment, Jerry Nolan and Jasmeet Soar write that for adult cardiac arrest cases, the dispatcher should provide instructions on compression-only CPR: “the ‘kiss of life’ should be replaced by ‘Keep It Simple, Stupid’.”
October 14th, 2010
Want to Blog with Other Fellows at the AHA?
Andrew M. Kates, MD and James De Lemos, MD
CardioExchange is looking for a few cardiology fellows who are planning to attend the AHA meeting on November 13-17 to blog at the meeting. If you’re interested, drop us a line. Let us know the dates that you plan to be at the meeting and any subspecialty or research interest that you might have.
The only compensation we offer is a highly enjoyable experience. See our previous Fellows’ meeting blogs at the 2010 ACC and the 2010 ESC meetings.
We look forward to hearing from you.
James and Andy
October 13th, 2010
No Conflict, No Interest
Shanti Bansal, MD
On a brisk, cold evening I boarded an overnight plane from my hometown to Cincinnati. Once I landed, a gentleman dressed in a black suit with a grin over his face was waiting for me at the airport to drive me to my hotel. The driver led me through green untouched pastures and over a river and through bustling neighborhoods. I asked to be dropped off at the hotel prior to going to the classroom and the driver reluctantly accepted noting that I might be late for the lectures.
Some weeks prior, TheCompany Inc. (the names in this post have been modified) had offered me an educational course on atrial fibrillation which I agreed to attend. The driver dropped me off on TheCompany’s perfectly manicured grounds adjacent to a nondescript building. There, I entered a classroom designed specifically for educating physicians. Our first speaker was Ajay, who has made significant contributions to the field of atrial fibrillation. He reviewed slides on anatomy, physiology, and ablation strategies pertaining to atrial fibrillation. He spoke to a group of fellows and community electrophysiologists in the middle of the classroom as black suited representatives from TheCompany sat on either side.
The message was clear: atrial fibrillation is a problem and ablation is a necessary evil. When Ajay was lost for words, he made a quick furtive glance at the black suited representatives, who provided clarification. It was clear the slides he and the other speakers were presenting were written by TheCompany and the message was orchestrated carefully. After several hours of lectures, we filed into a laboratory filled with TheCompany’s devices and tools. We spent many hours working with TheCompany’s ablation catheters and software with Ajay and TheCompany’s representatives by our side. They were all eager to show us how to use their tools clinically.
After two days of listening to Ajay, other prominent electrophysiologists, and TheCompany representatives, I was ready to go back to my hometown. On my car ride back, I was reflective. I was asked to participate in an educational event that was designed in part to showcase TheCompany’s products and in part to educate physicians. What is the role of industry in educating physicians on the clinical use of their technology? As an academic physician, where do you draw the line between your message and one of industry’s? As a participant how do you separate marketing from medicine? Watching the rolling hills of Cincinnati go by from my car, I felt a little disenchanted but confess that I was eager to use what I had learned over the weekend.
October 13th, 2010
Sequencing Study Identifies Gene Mutations Tied to Hypolipidemia
Larry Husten, PHD
By sequencing all protein-coding regions of the genome in two people with combined hypolipidemia, researchers have identified a gene that may lead to a new method to lower LDL cholesterol. The report by Kiran Musunuru and colleagues, published in the New England Journal of Medicine, has its origins in a study started in 1994 of a family with hypobetalipoproteinemia not caused by an APOB variant. Whole-exome sequencing in two siblings from the family identified two independent nonsense mutations of ANGPTL3, which “normally acts to increase plasma levels of triglycerides, LDL cholesterol, and HDL cholesterol,” the authors write.
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