Faculty Bibliography

AIMS/OBJECTIVE:The aim of this study was to report whether the superiority of the everolimus-eluting stent (EES) vs. the paclitaxel-eluting stent (PES) at one-year follow-up in the Taxus Element versus Xience Prime in a Diabetic Population (TUXEDO)-India trial was sustained at longer-term follow-up. METHODS AND RESULTS/RESULTS:One thousand eight hundred and thirty (1,830) patients with diabetes mellitus and coronary artery disease were randomised to EES vs. PES. Follow-up data up to two years were available in 1,701 (92.9%) patients. The primary endpoint was target vessel failure (TVF), defined as the composite of cardiac death, target vessel myocardial infarction (TV-MI), or ischaemia-driven target vessel revascularisation (TVR). Treatment with EES had a lower two-year rate of TVF (4.3% vs. 6.6%, p=0.03). Of the secondary endpoints, EES significantly reduced any MI (1.6% vs. 3.5%, p=0.01), TV-MI (0.7% vs. 3.1%, p=0.0001), ST (0.4% vs. 2.2%, p=0.001), cardiac death or target vessel MI (2.9% vs. 4.8%, p=0.04) and TLR (1.9% vs. 3.7%, p=0.02), compared with PES. Between one year and two years, no significant differences in the clinical outcomes were observed (pinteraction >0.05). CONCLUSIONS:In this adequately powered trial, the benefits of EES vs. PES in a diabetic population seen at one year were maintained at two years.

BACKGROUND: The recent AHA/ACC guidelines on duration of dual anti-platelet therapy (DAPT) recommend DAPT for 1 year in patients presenting with an acute coronary syndrome, with a Class IIb recommendation for continuation. We aim to assess the evidence for these recommendations using a meta-analytic approach. METHODS: We searched electronic databases for randomized trials comparing short-term (12 months) DAPT in patients with an acute coronary syndrome undergoing percutaneous coronary intervention. We evaluated all-cause mortality, cardiovascular mortality, myocardial infarction, stent thrombosis and major bleeding. A random effects model was used to calculate pooled relative risk (RR) and 95% confidence intervals (CI). RESULTS: We included 8 trials comprising of 12,917 patients with an acute coronry syndrome; 5 trials compared short-term vs 12 months/extended DAPT, whereas 3 trials compared 12 months vs extended DAPT. There was no significant difference in cardiovascular mortality (RR: 1.04, 95% CI: 0.67-1.60), MI (RR: 1.08, 95% CI: 0.79-1.47) or major bleeding (RR: 0.91, 95% CI: 0.49-1.69) between short-term versus 12 months/extended DAPT. However, compared to extended DAPT, 12 months DAPT showed significantly higher risk of myocardial infarction (RR: 2.00, 95% CI: 1.47-2.73) but reduced risk of major bleeding (RR: 0.58, 95% CI: 0.34-0.98). All-cause mortality was found to be similar between 12 months vs extended DAPT. CONCLUSIONS: In acute coronary syndrome, short-term DAPT may be reasonable for some patients whereas extended DAPT may be appropriate in select others. An individualized approach is needed taking into account the competing risks of bleeding and ischemic events.

Aims: Post-stroke hypertension is associated with poor short-term outcome, although the results have been conflicting. Our objective was to evaluate the association of blood pressure (BP) and in-hospital outcomes in patients with acute ischaemic stroke. Methods and results: Patients in the Get With The Guidelines-Stroke registry with acute ischaemic stroke were included. Admission systolic and diastolic BP was used to compute mean arterial pressure (MAP) and pulse pressure (PP). The outcomes of interest were: in-hospital mortality, not discharged home, inability to ambulate independently at discharge and haemorrhagic complications due to thrombolytic therapy. A total of 309 611 patients with an ischaemic stroke were included. There was a J-shaped/U-shaped relationship between systolic BP and outcomes. Both lower and higher systolic BP values, compared with a central reference value, had higher risk of in-hospital death [e.g. adjusted odds ratio (95% confidence interval) (OR[CI]) = 1.16[1.13-1.20] for 120 vs. 150 mmHg and 1.24[1.19-1.30] for 200 vs. 150 mmHg], not discharged home (OR[CI] = 1.11[1.09-1.13] for 120 vs. 150 mmHg and 1.15[1.12-1.18] for 200 vs. 150 mmHg), inability to ambulate independently at discharge (OR[CI] = 1.16[1.13-1.18] for 120 vs. 150 mmHg and 1.09[1.06-1.11] for 200 vs. 150 mmHg). However, risk of haemorrhagic complications of thrombolytic therapy was lower with lower systolic BP (OR[CI] = 0.89[0.83-0.97] for 120 vs. 150 mmHg), while higher with higher systolic BP (OR[CI] = 1.21[1.11-1.32] for 200 vs. 150 mmHg). The results were largely similar for admission diastolic BP, MAP, and PP. Conclusion: In patients hospitalized with ischaemic stroke, J-shaped, or U-shaped relationships were observed between BP variables and short-term outcomes. However, haemorrhagic complications with thrombolytic therapy were lower with lower BP.

Background: We sought to examine long-term outcomes in patients admitted for a myocardial infarction (MI) based on whether they experienced community acquired acute kidney injury (CAAKI), hospital acquired acute kidney injury (HAAKI), or no acute kidney injury (no AKI).
Method(s): Methods: Retrospective parallel cohort analysis of Veterans admitted for acute MI between 2005 and 2008. Data was obtained from the corporate data warehouse (CDW) using the VA Informatics and Computing Infrastructure (VINCI) computing environment. AKI was determined by assessing for changes in serum creatinine according to the KDIGO AKI classification system. Outcomes were death, hospitalization for cardiovascular (CV) events (MI, congestive heart failure, or stroke).
Result(s): Results: 11,580 patients with an MI were identified. Of these patients 15.1% had CAAKI, 14.5% had HAAKI and 70.4% had no AKI. Patients who developed AKI (CAAKI or HAAKI) were older, and had greater number of comorbidities as well as severity of initial admission (ICU stay, ventilation requirement or dialysis requirement) than no AKI. Patients with CAAKI were less likely to get cardiac catheterization during admission than those with HAAKI or no AKI (44.7%, 57.9%, 67.3%, respectively, p<0.001). Mortality was higher in both AKI groups as compared to the no AKI group at 5 year follow-up (adjusted HR and 95%CI: CAAKI 1.96, 1.83-2.09; HAAKI 1.60, 1.50-1.72). Patients with AKI (CA or HA) were more likely to have a repeat CV hospitalization than patients with no AKI (CAAKI adjusted HR 1.14 p=0.004; HAAKI adjusted HR 1.11, p=0.02; no difference between AKI groups).
Conclusion(s):
Conclusion(s): In patients admitted with an acute MI, the presence of CAAKI was associated with long term outcomes as poor as HAAKI. Further research is needed to understand these associations

Influenza B is a rare cause of myocarditis that is usually caused by histiocytic and mononuclear cellular infiltrates. We describe a 22-year-old female patient presenting with fulminant myopericarditis secondary to influenza B infection that deteriorated to cardiogenic shock. Endomyocardial biopsy results yielded myocardial necrosis through complement-mediated cellular injury without evidence of interstitial infiltrates. The rare cause of this patient's disease, along with the unique pathologic findings, are an important reminder of the diversity of potential findings in myocarditis.

This retrospective cohort study compared blood pressure (BP) control (BP <140/90 mm Hg) and all-cause mortality between US- and foreign-born blacks. We used data from a clinical data warehouse of 41 868 patients with hypertension who received care in a New York City public healthcare system between 2004 and 2009, defining BP control as the last recorded BP measurement and mean BP control. Poisson regression demonstrated that Caribbean-born blacks had lower BP control for the last BP measurement compared with US- and West African-born blacks, respectively (49% vs 54% and 57%; P<.001). This pattern was similar for mean BP control. Caribbean- and West African-born blacks showed reduced hazard ratios of mortality (0.46 [95% CI, 0.42-0.50] and 0.28 [95% CI, 0.18-0.41], respectively) compared with US-born blacks, even after adjustment for BP. BP control rates and mortality were heterogeneous in this sample. Caribbean-born blacks showed worse control than US-born blacks. However, US-born blacks experienced increased hazard of mortality. This suggests the need to account for the variations within blacks in hypertension management.