Faculty Bibliography

Outcomes of percutaneous coronary intervention (PCI) versus medical therapy (MT) in the management of stable ischemic heart disease (SIHD) remain controversial, with some but not all studies showing improved results in patients with ischemia. We sought to elucidate whether PCI improves mortality compared to MT in patients with objective evidence of ischemia (assessed using noninvasive imaging or its invasive equivalent). We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing PCI to MT in patients with SIHD. To maintain a high degree of specificity for ischemia, studies were only included if ischemia was defined on the basis of noninvasive stress imaging or abnormal fractional flow reserve. The primary outcome was all-cause mortality. We identified 3 RCTs (Effects of Percutaneous Coronary Interventions in Silent Ischemia After Myocardial Infarction II, Fractional Flow Reserve versus Angiography for Multivessel Evaluation 2, and a substudy of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation trial) enrolling a total of 1,557 patients followed for an average of 3.0 years. When compared with MT in this population of patients with objective ischemia, PCI was associated with lower mortality (hazard ratio 0.52, 95% confidence interval 0.30 to 0.92, p = 0.02). There was no evidence of study heterogeneity or bias among included trials. In this meta-analysis of published RCTs, PCI was shown to have a mortality benefit over MT in patients with SIHD and objective assessment of ischemia using noninvasive imaging or its invasive equivalent. In conclusion, this study provides insight into the management of a higher-risk SIHD population that is the focus of the ongoing International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial.

The recent IMProved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) is the first study to demonstrate a significant benefit of another medication (ezetimibe) on top of statin therapy in patients who have recently experienced an acute coronary syndrome. Despite the fact that ezetimibe lead to positive results on the primary endpoint, the clinical benefit translated to real-life practice is only modest at best. However, this is the first major trial to demonstrate a significant benefit of a lipid medication in addition to statins. We explore the strengths and weaknesses of IMPROVE-IT in the context of current day acute coronary syndrome practice, where high dose statins are now widely prescribed.

BACKGROUND:: Observational studies and clinical trials have shown associations of diet and high blood pressure (BP). However, prospective studies on the association between dietary patterns and longitudinal BP change are lacking, especially in low-income populations. METHOD:: We evaluated the association of dietary patterns and food groups with longitudinal change of BP in 10 389 participants in the Health Effects of Arsenic Longitudinal Study, with a median of 6.7 years of follow-up. Dietary information was obtained through a previously validated food-frequency questionnaire. BP was measured at baseline and at each biennial follow-up using the same method. RESULT:: Each standard deviation (SD) increase for the 'gourd vegetable' dietary pattern score was related to a slower annual change of 0.08, 0.04, and 0.05 mmHg in SBP, DBP, or pulse pressure, respectively. Each SD increase in the 'balanced' dietary pattern score was related to a decreasing annual change of 0.06 mmHg (P = 0.012) and 0.08 mmHg in SBP and pulse pressure (P < 0.001). On the contrary, one SD increase in 'western' dietary pattern score was related to a greater annual increase of 0.07 (P = 0.005) and 0.05 mmHg in SBP and pulse pressure (P = 0.013). Higher intake of fruits and vegetables was associated with a slower rate of change in annual SBP and pulse pressure, whereas higher meat intake was related to a more rapid increase in annual pulse pressure. CONCLUSION:: The findings suggest that dietary patterns play a significant role in the rate of BP change over time in a low-income population.

BACKGROUND: COURAGE and BARI-2D have questioned the utility of routine revascularization for the prevention of cardiovascular events in patients with stable ischemic heart disease (SIHD). On the other end of the spectrum, a routine invasive strategy in patients with acute coronary syndrome (ACS) is superior to a conservative strategy. The impact of the above trials on the trend in percutaneous coronary intervention (PCI) volume for SIHD and ACS is not known. METHODS: Data from the 2001-2011 Nationwide Inpatient Sample for discharges with PCI were used. The trend in PCI volume over time was analyzed, especially in relation to the COURAGE (2007) and the BARI-2D (2009) trials. Age and gender adjusted PCI rates were calculated using direct standardization method. RESULTS: Among the 8,150,764 PCI procedures, there was a steady increase in PCI volumes until the publication of the COURAGE/BARI-2D trials after which the volume decreased. Compared to the peak volume of 909,331 in 2006, PCI volume declined by 38% to 562,036 in 2011 (P<0.0001); driven by a 60% decrease in PCI for SIHD from 409,199 in 2006 to 160,707 in 2011 (P<0.0001). Moreover, there was a 20% decrease in PCI for ACS from 500,132 in 2006 to 401,330 in 2011 (P<0.0001) driven by a significant decrease in PCI for unstable angina. Results were similar in diabetics with a decline in the volume after BARI-2D trial, although the decline was less dramatic. CONCLUSION: The 11-year trend indicates a substantial impact of COURAGE/BARI-2D on SIHD PCI volumes with an unintended consequence of lower PCI volumes for ACS.

Hypertension is a major modifiable risk factor for cardiovascular morbidity and mortality. Despite more than five decades of hypertension treatment, there still exist both a lack of evidence and a clear consensus to answer a fundamental question: What is the optimal blood pressure target in patients with hypertension? Early epidemiologic studies suggested the notion of the lower the blood pressure, the better the outcomes; however, others have demonstrated a J-curve phenomenon with worse outcomes at both low and very high blood pressures. Although the existence of such a J-curve remains a topic of debate, there is now increasing recognition of target organ heterogeneity wherein the optimal blood pressure depends on the target organ in question. For cardiac protection, the current body of evidence does not support a systolic blood pressure goal of lower than 130-140 mmHg. For cerebrovascular protection, however, lower blood pressure seems to be better with a sustained reduction in events down to a systolic blood pressure of 110-120 mmHg. The J-curve phenomenon is therefore both fact and fiction based on the target organ in question.

BACKGROUND: In the SHOCK trial an invasive strategy of early revascularization was associated with a significant mortality benefit at 6-months when compared with initial stabilization in patients with cardiogenic shock complicating acute myocardial infarction. Our objectives were to evaluate the data on real world practice and outcomes of invasive vs. conservative management in patients with cardiogenic shock. METHODS: We analyzed data from the Nationwide Inpatient Sample (NIS) between 2002 to 2011 with primary discharge diagnosis of acute myocardial infarction and secondary diagnosis of cardiogenic shock. Propensity score matching was used to assemble a cohort of patients managed invasively (with cardiac catheterization, percutaneous coronary intervention or coronary artery bypass graft surgery) vs. conservatively with similar baseline characteristics. The primary outcome was in-hospital mortality. RESULTS: We identified 60833 patients with cardiogenic shock of which 20644 patients (10322 in each group) with similar propensity scores, including 11,004 elderly patients (>/= 75 years), were in the final analysis. Patients who underwent invasive management had a 59% lower odds of in-hospital mortality (37.7% vs. 59.7%; OR=0.41; 95% CI 0.39-0.43; P<0.0001) when compared with those managed conservatively. This lower mortality was consistently seen across all tested subgroups; specifically in the elderly (>/= 75 years) (44.0% vs. 63.6%; OR=0.45; 95% CI 0.42-0.49; P<0.0001) and those younger than 75 years (30.6% vs. 55.1%; OR=0.36; 95% CI 0.33-0.39; P<0.0001) although the magnitude of risk reduction differed (Pinteraction <0.0001). CONCLUSIONS: In this largest cohort of patients with cardiogenic shock complicating acute myocardial infarction, patients managed invasively had significantly lower mortality when compared with those managed conservatively, even in the elderly. Our results emphasize the need for aggressive management in this high-risk subgroup.

Background: The safety of drug eluting stents (DES) vs. bare metal stents (BMS) in the perioperative setting, a heightened state of inflammation and thrombosis is not well defined. Methods: All adults undergoing NCS within 1 year following percutaneous coronary intervention (PCI) in Massachusetts between April 1, 2004 and September 30, 2007 were identified from an administrative claims database. Patient were divided into those who received BMS vs. DES at index PCI. Primary net clinical outcome was death, myocardial infarction (MI) or bleeding within 30-days of NCS. Primary clinical outcome was 30-day death or MI. Results: Among 8415 (22% BMS) patients that satisfied our inclusion criteria, 1838 BMS patients were matched with 3565 DES patients with similar propensity scores. In the DES cohort, the 30-day primary net clinical outcome rate was lower with longer time from PCI to NCS (P=0.02) with lowest rates if NCS was performed after 90 days from PCI (Event rate 8.57% 7.53%, 5.21%, 5.75% for 1-30, 31-90, 91-180 and 181-365 days from PCI to NCS). However, in the BMS cohort, the event rate was uniformly high regardless of the time from PCI to NCS (P=0.60) (Event rate 8.20%, 6.58%, 8.05%, 8.82% for 1-30, 31-90, 91-180 and 181-365 days from PCI to NCS). There was no significant difference between DES and the BMS group for 30-day primary net clinical outcome (6.64% vs. 7.89%; P=0.10), but there was a 26% lower odds of primary clinical outcome (OR=0.74, 95% CI 0.58-0.94) with DES when compared with BMS, driven mainly by differences in event rates when NCS was performed >90 days post PCI. Conclusion: DES implantation was not associated with higher adverse events after NCS. Moreover, the incidence of adverse events following NCS was lower when NCS was performed >90 days post DES implantation suggesting that it may not be necessary to wait until 12 months post PCI with DES before NCS. (c) 2014 Wiley Periodicals, Inc.