Faculty Bibliography

BACKGROUND: Drug-eluting stents (DES) have been in clinical use for nearly a decade; however, the relative short- and long-term efficacy and safety of DES compared with bare-metal stents (BMS) and among the DES types are less well defined. METHODS AND RESULTS: PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized clinical trials, until March 2012, that compared any of the Food and Drug Administration-approved durable stent and polymer DES (sirolimus-eluting stent [SES], paclitaxel-eluting stent [PES], everolimus-eluting stent [EES], zotarolimus-eluting stent [ZES], and ZES-Resolute [ZES-R]) with each other or against BMS for de novo coronary lesions, enrolling at least 100 patients and with follow-up of at least 6 months. Short-term (PES approximately ZES>BMS), with a >42% probability that EES had the lowest target-vessel revascularization rate. There was no increase in the risk of any long-term safety outcomes, including stent thrombosis, with any DES (versus BMS). In addition, there was reduction in myocardial infarction (all DES except PES versus BMS) and stent thrombosis (with EES versus BMS: Rate ratio, 0.51; 95% credibility interval, 0.35-0.73). The safest DES appeared to be EES (>86% probability), with reduction in myocardial infarction and stent thrombosis compared with BMS. Short-term outcomes were similar to long-term outcomes, with SES, ZES-R, and everolimus-eluting stent being the most efficacious and EES being the safest stent. CONCLUSIONS: DES are highly efficacious at reducing the risk of target-vessel revascularization without an increase in any safety outcomes, including stent thrombosis. However, among the DES types, there were considerable differences, such that EES, SES, and ZES-R were the most efficacious and EES was the safest stent.

Aims: Previous studies have demonstrated an increase in the amount of radiation administered when utilising the radial artery versus the femoral artery for access. However, radiation exposure between experienced radial and femoral operators is not well defined. Methods and results: We retrospectively analysed 1,922 patients who underwent coronary angiography with or without percutaneous coronary intervention (PCI) and had radiation dose data available for analysis at a tertiary care center from October 2010 to June 2011. Experienced operators were defined as those that perform more than >75 PCIs a year with more 95% of cases performed using the transradial or transfemoral approach for at least 5 years. The outcomes of interest were fluoroscopy time (FT) and dose area product (DAP). Analysis was performed separately for diagnostic only procedures and procedures PCI. Data is presented as median [interquartile range], and statistical analysis was performed using the Mann-Whitney U test. Of the 1,922 patients, 1,565 (81.4%) cases were performed by experienced femoral operators and 357 (18.6%) cases were performed experienced radial operators. The majority of these cases (65.3%) underwent a diagnostic coronary angiogram only (989 femoral and 266 radial). For diagnostic coronary angiography, both total dose area product (DAP) and fluoroscopy time (FT) were significantly higher in transradial versus transfemoral approaches (6038 [3158-8884] vs. 5240 [3517-7429] Gym², p<0.001 and 6.2 [4.0-10.2] vs. 3.6 [2.7-5.4] min, p=0.02). For procedures involving PCI, DAP was not significantly different in transradial versus transfemoral approaches (16,842 [12,017-24,532] vs. 15,577 [10,089-22,203] Gym², p=0.06) although FT was significantly higher (20.4 [13.3-29.6] vs. 14.0 [9.9-20.71] min, p<0.001). Conclusions: In a contemporary cohort of patients undergoing coronary angiography with or without PCI, the transradial approach was associated with higher radiation exposure when compared with transfemoral approach, even in cases performed by experienced operators. While transradial procedures has other advantages (reduced access site complications/bleeding), the amount of radiation administered should be borne in mind while caring for such patients

Introduction: The majority of patients with hypertension require combination therapy to achieve their blood pressure (BP) goal. Studies have consistently shown that polypharmacy and complex treatment regimens have a detrimental effect on treatment compliance, adherence and persistence (herein referred to as treatment adherence). Areas covered: This paper reviews the available clinical evidence, as well as guidelines, which propose combinations of an angiotensin II receptor blocker (ARB) or an angiotensin-converting enzyme (ACE) inhibitor plus a calcium channel blocker (CCB) or diuretic. Expert opinion: ARBs are associated with better tolerability compared with ACE inhibitors, and data suggest that ARB/CCB combinations may be better tolerated than CCB monotherapy. The use of true once-daily single-pill combination therapy with effective and well-tolerated agents will reduce pill burden, simplify treatment regimens and improve treatment adherence, which will, in turn, help patients to reach and maintain their BP target and achieve the short- and long-term treatment goal of cardiovascular risk reduction

The purpose of this study was to evaluate the prognostic value of stress echocardiography in patients with angiographically significant coronary artery disease (CAD). Two hundred sixty patients (mean age 63 +/- 10 years, 58% men) who underwent stress echocardiography (41% treadmill, 59% dobutamine) and coronary angiography within 3 months and without intervening coronary revascularization were evaluated. All patients had significant CAD as defined by coronary stenosis >/=70% in major epicardial vessels or branches (45% had single-vessel disease, and 55% had multivessel disease). The left ventricle was divided into 16 segments and scored on a 5-point scale of wall motion. Patients with abnormal results on stress echocardiography were defined as those with stress-induced ischemia (increase in wall motion score of >/=1 grade). Follow-up (3.1 +/- 1.2 years) for nonfatal myocardial infarction (n = 23) and cardiac death (n = 6) was obtained. In patients with angiographically significant CAD, stress echocardiography effectively risk stratified normal (no ischemia, n = 91) in contrast to abnormal (ischemia, n = 169) groups for cardiac events (event rate 1.0%/year vs 4.9%/year, p = 0.01). Multivariate logistic regression analysis identified multivessel CAD (hazard ratio 2.53, 95% confidence interval 1.16 to 5.51, p = 0.02) and number of segments in which ischemia was present (hazard ratio 4.31, 95% confidence interval 1.29 to 14.38, p = 0.01) as predictors of cardiac events. A Cox proportional-hazards model for cardiac events showed small, significant incremental value of stress echocardiography over coronary angiography (p = 0.02) and the highest global chi-square value for both (p = 0.004). In conclusion, in patients with angiographically significant CAD, (1) normal results on stress echocardiography conferred a benign prognosis (event rate 1.0%/year), and (2) stress echocardiographic results (no ischemia vs ischemia) added incremental prognostic value to coronary angiographic results, and (3) stress echocardiography and coronary angiography together provided additive prognostic value, with the highest global chi-square value

The objective of this study was to assess whether statin therapy is associated with a reduction in ventricular tachyarrhythmias. Statins have been shown to be beneficial beyond their cholesterol-lowering effects. These pleiotropic effects have been implicated in the protection against atrial fibrillation and the reduction in appropriate implantable cardioverter-defibrillator therapy in patients with coronary artery disease. This meta-analysis was conducted to evaluate whether statins were associated with a reduction in ventricular tachyarrhythmias in patients with coronary artery disease or nonischemic cardiomyopathy. The Medline and Cochrane databases were searched for studies in human subjects published in the English language between 1985 and February 2010. Studies were included in our analysis if they provided data regarding the association between the use of statins and the incidence of ventricular tachycardia/ventricular fibrillation (VT/VF) in patients with coronary artery disease or nonischemic cardiomyopathy. The occurrence of ventricular arrhythmias was defined as the VT/VF occurrence or appropriate implantable cardioverter-defibrillator therapy for VT/VF. Of the 166 identified articles, nine prospective studies with 150,953 patients enrolled met our inclusion criteria and were included in this analysis. Using a random effects model, statin therapy was associated with a 31% reduction in the risk of VT/VF when compared with the group not on statin therapy (pooled relative risk = 0.69, 95% confidence interval, 0.58-0.83; heterogeneity I = 57.3%). There was a low likelihood of publication bias in this analysis (Egger's test P = 0.957). Statin use in patients with coronary artery disease or nonischemic cardiomyopathy is associated with a 31% reduction in the development of ventricular tachyarrhythmias

OBJECTIVES: The purpose of this study was to assess whether inotropic contractile reserve (ICR) during dobutamine stress echocardiography (DSE) could risk-stratify patients with human immunodeficiency virus (HIV) cardiomyopathy and predict improvement of left ventricular ejection fraction (LVEF). BACKGROUND: HIV cardiomyopathy is an important cause of heart failure and death. ICR is associated with better survival and improvement of LVEF in patients with ischemic and nonischemic cardiomyopathies. However, the prognostic value of ICR in patients with HIV cardiomyopathy is unknown. METHODS: Patients with HIV cardiomyopathy and a LVEF <45% who were referred for DSE were enrolled. ICR was evaluated by the delta wall motion score index (DeltaWMSI), calculated as the difference between rest and peak WMSI. Patients were followed for cardiac death and change in LVEF on follow-up. RESULTS: Sixty patients (75% men; age, 54 +/- 9 years) with HIV cardiomyopathy (mean LVEF, 28 +/- 11%) formed the study group. After 2.4 +/- 2.1 years, 11 cardiac deaths occurred (event rate of 7.6%/year). A receiver-operating characteristic curve identified a DeltaWMSI of 0.38 as an optimal cut point for the presence of ICR, with a specificity of 88% and a sensitivity of 73% for the prediction of cardiac death. On univariable analysis, the absence of ICR (hazard ratio: 6.6; 95% confidence interval: 1.93 to 22.62; p = 0.003) and New York Heart Association functional class IV (hazard ratio: 7.2; 95% confidence interval: 2.20 to 23.65; p = 0.001) were the only predictors of cardiac death. After 2.1 +/- 1.8 years, 41 patients had a follow-up echocardiogram. LVEF improvement from baseline occurred in 23 patients (56%), more so in patients with ICR than without ICR. A DeltaWMSI of 0.59 predicted improvement in the LVEF with a specificity of 78% and a sensitivity of 74%. CONCLUSIONS: The presence of ICR during DSE can risk-stratify and predict subsequent improvement in LVEF in patients with HIV cardiomyopathy