August 30th, 2013
Will New Scanner Technology Reduce Radiation from CT Angiography?
Kavitha M Chinnaiyan, M.D., Gilbert L Raff, BS, MD and John Ryan, MD
CardioExchange’s John Ryan interviews Kavitha Chinnaiyan and Gilbert L. Raff about their study group’s nonrandomized investigation of using new scanner technology to reduce radiation from coronary CT angiography in the context of an ongoing quality-improvement program. The study is published in Circulation: Cardiovascular Imaging.
THE STUDY
Investigators prospectively followed 11,901 patients at 15 Michigan centers participating in the Advanced Cardiovascular Imaging Consortium (ACIC). CT angiography (CTA) radiation doses and image quality were compared between a baseline control period and two follow-up periods, both of which involved continuous education, feedback, and mandatory participation in the initiative. The median radiation dose remained unchanged from the control period to the first follow-up period, suggesting that ongoing application of a best-practice algorithm simply sustained previously achieved dose targets. Newer scanning technology was introduced during the first follow-up period, and a significant 31% incremental reduction in the radiation dose was documented during the second follow-up period. The percentage of diagnostic quality scans did not change significantly between the two follow-up periods.
THE INTERVIEW
Ryan: You studied how radiation-reduction strategies are lowering the radiation dose received by patients undergoing coronary CTA. Can you provide some information about the intervention?
Chinnaiyan and Raff: This study was a follow-up to a previously published analysis of data from 15 sites participating in ACIC, a statewide quality initiative sponsored by Blue Cross Blue Shield Blue Care Network of Michigan. In that study, the implementation of a best-practice algorithm for performing coronary CTA resulted in 53% reduction in radiation dose.
In the present study, we found that continued implementation of the best-practice algorithm via a monitoring-feedback loop allowed the lower dose to be sustained; adoption of newer scanner technology was then associated with incremental reduction of the dose by 31%. The educational interventions (best-practice algorithm) included adequate pre-scan heart-rate control, decreased scan length, EKG-dose modulation (when applicable), and most important, lower tube voltage in appropriate patients. In the second study, the educational intervention included implementation of new scanner technology that had become available or had improved since the first study. Newer scanner technologies associated with incremental dose reductions were prospective gating, high-pitch helical or single-heartbeat volumetric scanning, and adaptive statistical iterative reconstruction (ASIR).
Ryan: It is often difficult to attribute improvements to a particular program in an observational study because many things are changing simultaneously when the program is implemented. How confident are you that the intervention caused the improvement?
Chinnaiyan and Raff: We agree that this is a limitation of a study such as ours. Multiple extraneous factors could have influenced the results, but throughout the study period, we had real-time observation of a temporal relation between the median radiation dose at each site and the status of the educational program at that site. Monitoring of doses occurred on a quarterly basis; when a site was found to have higher median doses, this was reported back with assistance to uncover and correct specific practices.
Ryan: Can you characterize the magnitude of the improvement?
Chinnaiyan and Raff: Although coronary CTA is an excellent noninvasive tool with growing data on diagnostic and prognostic utility, exposure to ionizing radiation is a significant limitation of this technology. The enthusiasm for the potential cost savings and convenience of coronary CTA has been tempered by significant concerns about the doses of radiation received by patients. At ACIC’s inception, the median radiation dose across the 15 sites was 21 mSv. At the end of the present study, the median dose was 4.9 mSv. Thus, within 4 years, there was a 77% dose reduction through education and adoption of new scanner technology. This study — performed in a collaborative setting of a network of physicians, allied healthcare personnel, and third-party payers — shows that thoughtful interventions can significantly improve the safety profile of diagnostic imaging.
Ryan: Much of the improvement is due to new scanner technology. Should patients be asking about the scanner — and how should they interpret the result?
Chinnaiyan and Raff: It is important for patients to be aware of their cumulative radiation doses from all diagnostic procedures. To this end, inquiring about the average dose would provide them with information about the expected dose from a coronary CTA scan. However, multiple individual factors contribute to a patient’s dose exposure, such as heart rate, body-mass index, arrhythmias during the scan, inability to receive heart rate–lowering medications, and so on. Thus, even if the average radiation dose at a given center is comparatively low, it does not guarantee that every patient’s exposure to radiation will be low. In addition, discussing the merits of a particular scanner may not be feasible when a hospital or center uses several different scanners for coronary CTA. Ideally, providing accurate dose information to patients would require a collaborative approach whereby referring physicians, appointment centers, patient-preparation personnel, CT technologists, and reading physicians are well versed in the expected dose nuances of a given scanner.
JOIN THE DISCUSSION
What are your thoughts about the promise for newer scanning technology to reduce radiation doses from diagnostic scans? Does this study influence your opinion?
August 29th, 2013
Inexpensive Accelerometer Could Help Monitor Progress After Heart Surgery
Larry Husten, PHD
An inexpensive off-the-shelf fitness monitor can help physicians monitor and perhaps customize their treatment of patients after heart surgery, according to a new study from the Mayo Clinic published in the Annals of Thoracic Surgery.
Wireless accelerometer in ankle strap. (©2013 The Society of Thoracic Surgeons. Reprinted with permission)
Although the mobility of patients after surgery has long been recognized as a significant predictor of outcome, the authors of the study note that “there are multiple barriers to acquiring and reporting functional assessments during hospitalization.” Currently, information about mobility is obtained intermittently, often through nursing notes. Wireless data, by contrast, “are objective, acquired, and displayed nearly continuously.”
The new study tested whether a wireless accelerometer (the $100 Fitbit) could measure mobility in the recovery period after heart surgery. The Fitbit was attached to the ankles of 149 patients after they were moved from the intensive care unit to a regular hospital room.
As expected, patients who were later discharged to go home walked much further than patients who were discharged to a skilled nursing facility or home health care. The difference between the groups emerged on the first day of the study and persisted throughout the hospital stay. On day two, for instance, patients who ended up going home on their own walked 675 steps, compared with 108 steps for the other groups. In addition, patients with the shortest length of hospital stay walked significantly more than the patients with the longest stays.
The investigators write that although their results “are not unexpected,” they are nevertheless valuable as a “first demonstration that remote monitoring of mobility is effective to assess hospital surgical recovery.”
They conclude:
“Wireless monitoring of mobility after major surgery was easy and practical. There was a significant relationship between the number of steps taken in the early recovery period, length of stay, and dismissal disposition in an older cardiac surgery population. This opens the door for changing recovery models and improving outcomes in surgical practice.”
In a press release, the senior author of the study and the chair of surgery at Mayo, Claude Deschamps, said:
“The integration of these types of technologies with the ability to acquire, aggregate, and report data in ways that make it readily actionable will change how health care is delivered and managed. The benefits this technology brings to most elderly hospitalized patients will be tremendous. The technology is already robust and reliable, and the next 3 years will bring the software integration to allow the data to easily populate electronic medical records or patient dashboards.”
August 29th, 2013
Statins Reduce Cardiovascular Events in Elders Without Established CVD
Nicholas Downing, MD
Statins are associated with lower risks for myocardial infarction and stroke among elders without established cardiovascular disease, according to a meta-analysis in the Journal of the American College of Cardiology.
The analysis included eight randomized, placebo-controlled trials comprising nearly 25,000 patients aged 65 and older without CVD at baseline. During 3.5 years’ follow-up, statin use was associated with a 39% reduction in the risk for MI and a 24% reduction in the risk for stroke. The researchers estimate that 24 patients would need to be treated for 1 year to prevent one MI, and 42 to prevent one stroke.
There was a trend toward a reduction in mortality, but this did not reach statistical significance.
The researchers say their study “provides first time evidence” that statins’ cardiovascular benefits extend to people aged 65 and older without CVD.
August 29th, 2013
Managing Hypertension – Not as Easy as It Once Seemed
Paul A. Bergl, MD
CardioExchange welcomes this guest post from Dr. Paul Bergl, Chief Resident at the University of Chicago Medical Center. This piece originally appeared on the NEJM Journal Watch blog, Insights on Residency Training.
Hypertension…
As a medical student, I never really understood the fuss over it. Practicioners had an excellent and concise guide in the JNC-7 to handle all of the major aspects of this disease. The JNC-7 guidelines were algorithmic, and a helpful table of compelling indications for antihypertensive agents couldn’t make life any easier.
I soon realized a little more finesse was required of the internist-in-training. JNC-7 didn’t tell the whole story. My attendings all had slightly different opinions on the optimal strategies for control, and these approaches might contradict my antihypertensive gospel.
Hydrochlorothiazide was replaced by chlorthalidone after a preceptor noted, “All of the important studies on thiazides were done with chlorthalidone.” After adopting its use, I found another internist who advised, “Chlorthalidone just causes more hypokalemia. There’s no reason to believe HCTZ is inferior.” So, back to HCTZ. Soon after, I learned that calcium-channel blockers were a preferred option for isolated systolic hypertension in elders. “Diuretics just make older patients dizzy, dehydrated, and hyponatremic.” And the advice continued to accumulate in the form of these little pearls.
To complicate matters further, various societies and expert-written guidelines also had a slightly different take on the ideal systolic and diastolic pressures. I was becoming dizzy myself. Do I target a systolic blood pressure of 130 mm Hg in patients with diabetes? Or was that patients with CKD? Or is the diastolic blood pressure more important? And does it really matter?
Well, if JNC-8 looks anything like the Eurpoean Society of Hypertension/European Society of Cardiology joint guidelines that are so nicely summarized in Joanne Foody’s NEJM Journal Watch article, we can all breathe a sigh of relief. As Dr. Foody highlights, these guidelines emphasize a more universal blood pressure target of 140/90 mm Hg and a greater focus on global cardiovascular risk. I haven’t gotten through the whole document, but I was also glad that these guidelines allow for more lenient control in elders. And these guidelines are not at all prescriptive in the choice of antihypertensive medications.
A brief report in Physician’s First Watch on a common class of antihypertenisves also caught my eye this past week. Staff writer Amy Orciari Herman reported on the recent JAMA Internal Medicine article by Christopher Li et al showing an association between long-standing calcium channel blocker (CCB) use and risk for breast cancer.
The article gave me pause for one major reason: I really fell in love with CCB’s as a house officer. CCB’s struck me as an affordable, convenient, and efficacious antihypertensive class. Amlodipine in particular seemed to promise worry-free prescribing to this young physician. Patients liked the once-daily dosing and small pill size. Since amlodipine required no periodic electrolyte checks and side effects are uncommon, I would gladly discharge a patient from the hospital on it. If the patient was lost to follow-up, I probably wouldn’t be on the hook for an adverse drug effect.
Or maybe I will be. This population cohort study suggests an elevated risk of breast cancer with CCB’s. While this study doesn’t prove causality, it should make us all a little more circumspect about the antihypertensives we choose.
In the end, these articles gave me a chance to reflect on what we ought to teach residents about managing hypertension. I expect I will keep my teaching simple in the coming years:
- Go for 140/90 in everyone; be a little more lax in those with advanced age.
- Make sure your choice of an antihypertensive is rational.
- Every drug has side effects and risk; make sure your choice to treat hypertension is rational.
August 28th, 2013
New Drug Found Safe and Effective in Pulmonary Arterial Hypertension — But Does It Save Lives?
Larry Husten, PHD
Macitentan, a new drug for pulmonary arterial hypertension (PAH), appears to be safe and effective, but it is unclear whether it offers any significant advantages over currently available drugs. The drug, a dual endothelin-receptor antagonist, is under development from Actelion as an enhanced version of bosentan (Tracleer). The results of a phase 3 trial, SERAPHIN (Study with an Endothelin Receptor Antagonist in Pulmonary Arterial Hypertension to Improve Clinical Outcome), have now been published in the New England Journal of Medicine.
In the trial, 742 patients with PAH were randomized to one of three groups: a daily dose of 3 mg of macitentan, a daily dose of 10 mg of macitentan, or placebo. The primary endpoint (the time to the first occurrence of a composite endpoint of death, atrial septostomy, lung transplantation, initiation of treatment with intravenous or subcutaneous prostanoids, or worsening of pulmonary arterial hypertension) was significantly reduced in the two treatment arms:
- Placebo: 46.4%
- Macitentan 3 mg: 38.0% (hazard ratio compared with placebo: 0.70, CI 0.52-0.96, p=0.01)
- Macitentan 10 mg: 31.4% (HR compared with placebo: 0.55, CI 0.39-0.76, p<0.001)
A similar pattern was observed for the secondary endpoint of death due to PAH or hospitalization for PAH:
- Placebo: 33.6%
- Macitentan 3 mg: 26.0% (HR compared with placebo: 0.67, CI 0.46-0.97, p=0.01)
- Macitentan 10 mg: 20.7% HR compared with placebo: 0.50, CI 0.34-0.75, p<0.001)
At 6 months, the 6-minute walk distance had decreased by 9.4 m in the placebo group and increased by 7.4 m in the low-dose macitentan group and by 12.5 m in the high-dose group. These results are similar to those seen with other PAH drugs in earlier trials.
The authors write that previous drugs for PAH have been approved on the basis of short-term trials that have had exercise capacity as the primary endpoint. They claim that SERAPHIN is the first trial to test the long-term impact on morbidity and mortality of a PAH drug, and conclude that “macitentan significantly reduced morbidity and mortality among patients with pulmonary arterial hypertension.”
However, PAH researcher Stephen Archer takes issue with this claim:
At first glance one would assume that this means fewer patients in the macitentan group died during the study. In fact the endpoint they refer to is a composite endpoint and the significance (versus placebo) is driven by reduced incidence of worsening PAH and hospitalization in the macitentan arm. In fact, the all-cause mortality rates are virtually identical to those in the placebo group (6.6 vs 6.8%). Cardiologists will recall that Haber’s 1982 NEJM digoxin trial was considered “negative” by many, even though digoxin significantly reduced hospitalizations in left heart failure patients, all because digoxin did not reduce mortality. So is SERAPHIN a negative trial? Or based on the predefined composite endpoint they chose, positive? By choosing an inhomogeneous endpoint (where outcomes are very dissimilar in impact to the patient-death vs hospitalization or worsening PAH) a bias is created toward a positive finding. Whether such composite endpoints are acceptable is a matter of opinion; however, improvement in this composite endpoint should not be called a “reduction in mortality” … which has but one meaning.
August 28th, 2013
American Heart Association Announces Late-Breaking Clinical Trials
Larry Husten, PHD
There are still a few days left in August, and the European Society of Cardiology meeting doesn’t start until this weekend in Amsterdam. Nevertheless, the American Heart Association has released the list of late-breaking clinical trials for its annual meeting in November.
Late-Breaking Clinical Trials 1: Acute Cardiovascular and Cerebrovascular Care
- Sunday, Nov 17, 2013, 4:00 PM – 5:19 PM
Moderators:
- Lance Becker, Philadelphia, PA
- Stephen Bernard, Melbourne, Australia
4:00 PM: Nitrites in Acute Myocardial Infarction
- Nishat Siddiqi, Univ of Aberdeen, Aberdeen, United Kingdom
- Discussant: Kenneth Bloch, Boston, MA
4:13 PM: Blood Pressure Reduction Among Acute Ischemic Stroke Patients: A Randomized Controlled Clinical Trial
- Jiang He, Tulane Univ, New Orleans, LA
- Discussant: Cathy A Sila, Cleveland, OH
4:35 PM: Randomized Clinical Trial of Pre-hospital Induction of Mild Hypothermia in Out-of-Hospital Cardiac Arrest Patients Using a Rapid Infusion of 4oC Normal Saline
- Francis Kim, Univ of Washington, Seattle, WA
- Discussant: Maaret Castrén, Stockholm, Sweden
4:57 PM: Target Temperature Management 33°C versus 36°C after Out-of-hospital Cardiac Arrest, a Randomized, Parallel Group, Assessor Blinded Clinical Trial
- Niklas Nielsen, Helsingborg Hosp, Lund Univ, Helsingborg, Sweden
- Discussant: Benjamin S Abella, Philadelphia, PA
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Late-Breaking Clinical Trials 2: Prevention: From Schools to Countries
- Monday, Nov 18, 2013, 9:00 AM -10:28 AM
Moderators:
- Donna K Arnett, Birmingham, AL
- Lynne Braun, Chicago, IL
9:00 AM: Promotion of Cardiovascular Health in Preschool Children: 36-month Cohort Follow-up
- Jaime Céspedes, Fundación CardioInfantil Insto de Cardiología, Bogotá, Colombia
- Discussant: Gerard R Martin, Washington, DC
9:22 AM: Randomized Trial of Social Network Lifestyle Intervention for Obesity: MICROCLINIC Intervention Results and 16-Month Followup
- Eric L Ding, Harvard Sch of Public Health, Boston, MA
- Discussant: Lawrence J Appel, Baltimore, MD
9:44 AM: Multifaceted Intervention to Improve Medication Adherence and Secondary Prevention Measures (Medication Study) After Acute Coronary Syndrome Hospital Discharge
- Michael Ho, VA Eastern Colorado Health Care System, Denver, CO
- Discussant: Nancy Albert, Cleveland, OH
10:06 AM: China Rural Health Initiative – Sodium Reduction Study: the Effects of a Community-Based Sodium Reduction Program on 24hr Urinary Sodium and Blood Pressure in Rural China
- Nicole Li, The George Inst for Global Health, Sydney, Australia
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Late-Breaking Clinical Trials 3: Medical and Surgical Approaches to Improving Heart Failure Outcomes
- Monday, Nov 18, 2013, 10:45 AM -12:13 PM
Moderators:
- Frederick A Masoudi, Aurora, CO
- Adrian F Hernandez, Durham, NC
10:45 AM: Atrial Antitachycardia Pacing and Managed Ventricular Pacing Reduce the Endpoint Composed by Death, Cardiovascular Hospitalizations and Permanent Atrial Fibrillation Compared to Conventional Dual Chamber Pacing in Bradycardia Patients: Results of the Minerva Randomized Study
- Giuseppe Boriani, Univ of Bologna, Policlinico S.Orsola-Malpighi, Bologna, Bologna, Italy
- Discussant: Anthony Tang, Victoria, BC, Canada
11:07 AM: Renal Optimization Strategies Evaluation in Acute Heart Failure (ROSE AHF) Trial
- Horng H Chen, MAYO Clinic, Rochester, MN
- Discussant: Marco Metra, Brescia, Italy
11:29 AM: Severe Ischemic Mitral Regurgitation: Is it Better to Repair or Replace the Valve?
- Michael A Acker, Hosp of the Univ of Pennsylvania, Philadelphia, PA
- Discussant: Timothy J Gardner, Newark, DE
11:51 AM: Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT)
- Marc A. Pfeffer, Brigham & Women’s Hosp, Harvard, Boston, MA
- Discussant: Margaret M Redfield, Rochester, MN
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Late-Breaking Clinical Trials 4: Therapeutic Advances in Coronary and Peripheral Vascular Disease.
- Monday, Nov 18, 2013, 3:45 PM – 5:13 PM
Moderators:
- John G Harold, Washington, DC
- Mark A Creager, Boston, MA
3:45 PM: One Year Mortality in STEMI Patients Randomized to Primary PCI or a Pharmaco-invasive Strategy. The Stream 1 Year Follow-up
- Peter Sinnaeve, Univ of Leuven, Leuven, Belgium
- Discussant: Harold Dauerman, Burlington, VT
4:07 PM: Secretory Phospholipase A2 Inhibition with Varespladib and Cardiovascular Events in Patients with an Acute Coronary Syndrome: Results of the VISTA-16 Study
- Stephen Nicholls, South Australian Health and Medical Res Inst, Adelaide, Australia
- Discussant: Philippe Gabriel Steg, Paris, France
4:29 PM: Randomized Comparison of Endovascular Revascularization Plus Supervised Exercise Therapy Versus Supervised Exercise Therapy Only in Patients With Peripheral Artery Disease and Intermittent Claudication: Results of the Endovascular Revascularization and Supervised Exercise (ERASE) Trial
- Farzin Fakhry, Erasmus MC, Rotterdam, Netherlands
- Discussant: Mary McDermott, Chicago, IL
4:51 PM: A Randomized Multicenter Clinical Trial of Renal Artery Stenting in Preventing Cardiovascular and Renal Events: Results of the CORAL Study
- Christopher J Cooper, Univ of Toledo, Toledo, OH
- Discussant: Thomas Zeller, Bad Krozingen, Germany
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Late-Breaking Clinical Trials 5: New Strategies for Atrial Fibrillation Patients: Rhythm and Thrombosis
- Tuesday, Nov 19, 2013, 10:45 AM -12:03 PM
Moderators:
- Augustus O Grant, Durham, NC
- Keith A Fox, Edinburgh, United Kingdom
10:45 AM: RADAR-AF Trial. A Randomized Multicenter Comparison of Radiofrequency Catheter Ablation of Drivers versus Circumferential Pulmonary Vein Isolation in Patients with Atrial Fibrillation
- Felipe Atienza, Hosp Gregorio Maranon, Madrid, Spain
- Discussant: Mark Link, Boston, MA
11:07 AM: A Randomized Trial Comparing Genotype-Guided Dosing of Warfarin to Standard Dosing: The EU Pharmacogenetics of Anticoagulant Therapy (EU-PACT) Warfarin Study
- Munir Pirmohamed, Univ of Liverpool, Liverpool, United Kingdom
11:17 AM: The Clarification of Optimal Anticoagulation through Genetics (COAG) Trial
- Stephen E. Kimmel, Univ PA Sch of Med, Philadelphia, PA
11:27 AM: Discussant of EU-PACT Warfarin Study and COAG Trial: Patrick T. Ellinor, Boston, MA
11:41 AM: ENGAGE AF-TIMI 48 Primary Results
- Robert P Giugliano, Brigham and Women’s Hosp, Boston, MA
- Discussant: Elaine Hylek, Boston, MA
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August 28th, 2013
Remote Ischemic Preconditioning for CABG: An Investigator’s Perspective
Gerd Heusch, Prof. Dr. med. Dr.h.c. and John Ryan, MD
CardioExchange’s John Ryan interviews Gerd Heusch about his study group’s randomized trial, published in the Lancet, of remote ischemic preconditioning before coronary artery bypass graft surgery. (See CardioExchange’s news coverage here and a prior discussion of the trial here.)
THE STUDY
Researchers randomized 329 patients with triple vessel CAD undergoing elective, isolated first-time CABG to receive remote ischemic preconditoning (rIPC; consisting of 3 cycles of inflation of a blood-pressure cuff for 5 minutes, followed by 5 minutes of reperfusion) or no preconditioning. In the first 72 hours after CABG, serum cardiac troponin I (cTnI) levels were 17% lower in the rIPC group than the control group (a significant difference). Clinical benefits were not evident at 30 days, but rIPC was associated with significantly lower rates of cardiac and all-cause mortality at 1 year. The rIPC group’s hazard ratio for 1-year all-cause mortality, compared with the control group, was 0.27 (95% CI, 0.08–0.98; P=0.046).
THE INTERVIEW
Ryan: Your study is impressive but small. Do we need validation before adopting this approach into routine practice?
Heusch: Indeed, our study was a single-center trial. In addition, the primary endpoint was troponin release, and the trial was not statistically powered for the secondary endpoints, including mortality, during follow-up. Validation with a multicenter trial that has mortality as a primary endpoint is needed before remote preconditioning is recommended for routine clinical practice.
Ryan: You enrolled participants for more than 4 years, and the intervention is innocuous. Why did it take so long to get 329 patients?
Heusch: We used very strict inclusion criteria to avoid all potential interference with the remote preconditioning phenomenon in our proof-of-principle study. Therefore, we selected the study participants from almost 3000 consecutive CABG patients.
Ryan: Can you explain why patients with diabetes were initially excluded, as well as the issue about cardioprotective signaling?
Heusch: Diabetes has been shown to interfere with cardioprotective signaling and to attenuate cardioprotection in several experimental studies. It is currently not clear whether diabetes interferes with the transfer of the protective signal from the ischemic/reperfused arm to the heart and/or with the activation of the molecular protection program in the heart. In our proof-of-principle study, we therefore wanted to avoid such interference and initially excluded patients with diabetes. Our ongoing studies now include patients with diabetes.
Ryan: The mortality benefit seems too good to be true — and difficult to link with the troponin difference. Also, many of the deaths seem unrelated. How do you interpret that finding?
Heusch: Indeed, the mortality benefit from remote preconditioning in our study is fairly large, almost out of proportion with the moderate level of cardioprotection suggested by the 17% reduction in troponin release. We explain this discrepancy by emphasizing the systemic nature of the remote preconditioning phenomenon, which appears to protect not only the heart but also the kidneys (we found also better postoperative kidney function) and other organs (there were no strokes with remote preconditioning, compared with one stroke among the controls).
Ryan: You note that some trials of this approach have not led to benefits. What precisely did you do that was effective that the others did not?
Heusch: One important confounder that we identified is the choice of anesthesia. The remote preconditioning phenomenon is operative with isoflurane anesthesia, but not with propofol. Most negative studies have used propofol in at least one of their protocols.
JOIN THE DISCUSSION
What’s your view on remote ischemic preconditioning for CABG, given the study author’s remarks about this randomized trial?
August 28th, 2013
Platelet Reactivity Testing: Do You or Don’t You?
Richard A. Lange, MD, MBA and L. David Hillis, MD
In the multicenter ADEPT DES study, investigators used theVerifyNow point-of-care assay (Accumetrics, San Diego, CA, USA) to assess platelet reactivity (by P2Y12 reaction units; PRU) in patients after successful PCI. The investigators found that high platelet reactivity in patients on clopidogrel was not an independent predictor of mortality, and that PRU did not provide utility beyond baseline risk profile in assessing the patients’ propensity for death.
Sorry, there are no polls available at the moment.
- Why or why not?
- If you do, how do you use that information?
- Will the ADEPT DES study affect your use of platelet reactivity testing?
August 27th, 2013
Selections from Richard Lehman’s Literature Review: August 27th
Richard Lehman, BM, BCh, MRCGP
CardioExchange is pleased to reprint this selection from Dr. Richard Lehman’s weekly journal review blog at BMJ.com. Selected summaries are relevant to our audience, but we encourage members to engage with the entire blog.
Ann Intern Med 20 Aug 2013 Vol 159
BP and Mortality in U.S. Veterans with CKD (pg. 233): Following Ray Moynihan et al’s measured argument in the BMJ against labelling 11% of adults as having “chronic kidney disease,” there have been lots of responses from single interest people to the effect that this is so that we can target them for special preventive treatment, including tighter control of blood pressure. This study of US Veterans with CKD introduces some observational evidence into the debate. Lowering diastolic BP in these people below 70 is associated with higher mortality, irrespective of the systolic pressure. The best outcomes were seen with diastolics between 70 and 89, and systolics between 130 and 159 Hg. Note that last figure. Male “patients with CKD”—mostly healthy asymptomatic people—are quite OK to run a systolic BP up to 159, and not OK to run a diastolic below 70. These figures bear no relation to any targets set by tunnel-vision committees of specialists and CKD “champions,” and apply equally to those with albuminuria and those without.
JAMA 21 Aug 2013 Vol 310
Improved BP Control Associated with a Large-Scale Hypertension Program (pg. 699): A structured hypertension management programme by Kaiser Permanente in the USA achieves better BP control than usual care. Strange indeed had it been otherwise. There’s not much for NHS doctors to learn from here: keep collecting the QOF BP points.
August 27th, 2013
Fuster Discusses His Plans for JACC
Valentin Fuster, MD
Last week the ACC announced that renowned cardiologist Valentin Fuster would be the next editor-in-chief of the Journal of the American College of Cardiology. Fuster kindly agreed to answer a few questions about the state of medical journals and his plans for the journal.
What is the future of the printed form of the journal?
Fuster: It will slowly decrease. The younger generation will be going less and less to the printed page. How long it will take to be completely banished, if it is ever banished, is hard to say, but the trend is clear.
What are your aspirations for JACC? How would you like it to be different in two years from where it is today?
Fuster: JACC is going to be patient centered and will be completely translational in two different directions, from basic science to the patient and from global health and epidemiology to the patient. These two extremes will merge into the patient. This is a critical issue to me and will be central to my mission.
As an example, let’s take Marfan syndrome. One aspect is the genetics and the molecular basis of the disease that leads to the dissection of the aorta. On the other hand, there is the worldwide experience with the use of ARBs and beta blockers for the prevention of aortic disease in Marfan patients. So these are two completely distinct directions.
At the end of each article there will be a summary with two statements. The first will look at the topic and point to where we go from here, more to the molecular area or to the global area. The other statement will consider the article and its impact on competencies that are so important today in clinical practice.
Under your leadership will JACC be a more international journal? If so, what is your strategy for that?
Fuster: I think it will become more international. I am very involved internationally. This will be reflected in the editorial board of the journal and it will be reflected in the invited articles.
Do you expect there to be more JACC journals in the future?
Fuster: Yes. I can’t say more, but there are three possible new journals that we are thinking about now.
Do you think that clinicians are reading journals less now than in the past?
Fuster: There is no question that people are reading journals less and turning more to the web. People are getting a lot of information without reading a journal.
Do you have plans for the JACC website?
Fuster: Yes. I already have discussed with the college about the specific plans.
How will you measure the success of the journal?
Fuster: I believe that there are many parameters. One is impact factor, of course, but I don’t think impact factor is or should be the ultimate and sole measure of a journal’s success. As you know, the impact factor has come under scrutiny and criticism. What matters most to me is how it increases readership and serves the patients through better education of physicians and fellows.
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