Faculty Bibliography

OBJECTIVE: To compare the efficacy and safety of dual antiplatelet therapy (DAPT) and triple therapy (TT, dual antiplatelet plus warfarin) in patients with myocardial infarction (MI) or PCI with stenting (PCI-S) who also require chronic oral anticoagulation. BACKGROUND: Recommendations for the optimal antiplatelet/anticoagulant treatment regimen for patients undergoing PCI-S or MI who also require oral anticoagulation are largely based on evidence from observational studies and expert opinions. METHODS: A systematic search was performed for studies comparing TT vs. DAPT in patients post PCI-S or MI and requiring chronic anticoagulation. Primary outcome was all-cause mortality. Secondary outcomes were ischemic stroke, major bleeding, MI, and stent thrombosis. Pooled relative risks (RR) were calculated using random effects model. RESULTS: A total of 17 studies were included, with 14,921 patients [TT: 5,819(39%) and DAPT: 9,102(61%)] and a mean follow-up of 1.6 years. The majority of patients required oral anticoagulation for atrial fibrillation. Compared to DAPT, patients treated with TT had no significant difference in all-cause mortality [RR: 0.81, 95% confidence interval (CI): 0.61-1.08, P = 0.15], MI [RR 0.74, 95% CI: 0.51-1.06, P = 0.10], and stent thrombosis [RR 0.67, 95% CI: 0.35-1.30, P = 0.24]. Patients treated with TT had significantly increased risk of major bleeding [RR 1.20, 95% CI: 1.03-1.39, P = 0.02], whereas the risk for ischemic stroke was significantly lower [RR 0.59, 95% CI: 0.38-0.92, P = 0.02]. CONCLUSIONS: All-cause mortality appears similar in patients treated with TT or DAPT although TT was associated with higher rates of major bleeding and a lower risk for ischemic stroke. (c) 2015 Wiley Periodicals, Inc.

Background: Coronary artery disease (CAD) and left ventricular hypertrophy (LVH) are prevalent in the chronic kidney disease (CKD) and renal transplant population. We hypothesised that the myocardial oxygenation response to stress would be impaired in CKD Methods: Fifty-three subjects: twenty-three subjects with CKD, ten renal transplant (RT) recipients, ten hypertensive (HT) controls, and ten normal controls without known heart disease underwent CMR scanning at 3T. The RT and HT groups also had late gadolinium CMR to assess infarction/ replacement fibrosis. The CKD group underwent 2D echocardiography strain to assess fibrosis. Results: A total of 2898 myocardial segments (1200 segments in CKD patients, 552 segments in RT, 480 segments in HT, and 666 segments in normal controls) were compared using linear mixed modelling. Diabetes mellitus (p= 0.47) and hypertension (p= 0.57) were similar between CKD, RT, and HT groups. The mean BOLD SI change was significantly lower in the CKD and RT groups compared to HT controls and normal controls (-0.89 +/- 10.63 in CKD versus 5.66 +/- 7.87 in RT versus 15.54 +/- 9.58 in HT controls, p< 0.0001). BOLD SI Change was associated with eGFR (beta= 0.16, 95% CI= 0.10 to 0.22, p<0.0001). Left ventricular mass index and left ventricular septal wall diameter was similar between the CKD pre-dialysis, RT, and HT groups. None of the CKD patients had impaired global longitudinal strain (GLS) and none of the RT group had late gadolinium hyperenhancement. Conclusion: Myocardial oxygenation response to stress is impaired in CKD and RT patients, and unlikely to be solely accounted for by the presence of diabetes mellitus