Antonio Gutierrez

Safety and efficacy of aerobic training in operable breast cancer patients receiving neoadjuvant chemotherapy: A phase II randomized trial

Abstract Background. To evaluate the safety and efficacy of moderate-to-high intensity aerobic training in breast cancer patients receiving neoadjuvant chemotherapy. Methods. Twenty patients with stage IIB–IIIC operable breast cancer were randomly assigned to receive doxorubicin plus cyclophosphamide (AC) or AC in combination with aerobic training (AC + AET) (n = 10/group) for 12 weeks. The AC+ AET group performed three supervised aerobic cycle ergometry sessions per week at 60%–100% of exercise capacity (VO2peak). Safety outcomes included exercise testing as well as treatment- and exercise training-related adverse events (AEs), whereas efficacy outcomes included cardiopulmonary function and patient-reported outcomes (PROs) as measured by a cardiopulmonary exercise test (CPET) and Functional Assessment of Cancer Therapy-Breast (FACT-B) scale. Results. Twelve non-significant ECG abnormalities and three non-life threatening events occurred during CPET procedures. One AE was reported during aerobic training. There were no significant between group differences for clinician-documented events (e.g. pain, nausea) or hematological parameters (ps > 0.05). Attendance and adherence rates to aerobic training were 82% and 66%, respectively. Intention-to-treat analysis indicated that VO2peak increased by 2.6 ± 3.5 ml/kg/min (+ 13.3%) in the AC + AET group and decreased by 1.5 ± 2.2 ml/kg/min (−8.6%) in the AC group (between group difference, p = 0.001). FACT-B increased 11.1 points in the AC + AET group compared to a 1.5 point decrease in the AC group (between group difference, p = 0.685). Conclusion. Moderate-to-high intensity aerobic training when conducted with one-on-one supervision is a safe adjunct therapy associated with improvements in cardiopulmonary function and select PROs during neoadjuvant chemotherapy.

Percutaneous coronary intervention in the elderly

In contemporary practice, more than one in five patients treated with percutaneous coronary intervention (PCI) are aged ≥75 years and the proportion of elderly individuals in the population is growing. The elderly have more cardiovascular risk factors and a greater burden of ischemic disease than younger patients needing PCI and, therefore, derive greater benefit from revascularization. However, they are also more likely to experience procedural complications, owing to age-related physiological changes, frailty, and comorbidities. This article reviews the outcomes of revascularization among the elderly and the impact of advances in PCI techniques and adjuvant pharmacotherapy on these outcomes. We also address clinical challenges that exist presently when considering PCI in the elderly, as well as future research needs to optimize revascularization outcomes in this population. To maximize the benefits of PCI in the elderly, providers should have explicit conversations with patients regarding goals of treatment. Once a decision to undergo PCI is reached, clinicians need to individualize care decisions, address modifiable risks such as bleeding, and pay careful attention to selection of the appropriate timing of PCI, and the type, timing, and dosing of adjuvant medical therapy.

Adoption of Transradial Percutaneous Coronary Intervention and Outcomes According to Center Radial Volume in the Veterans Affairs Healthcare System Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) Program

Background—Studies examining the association between radial approach and post–percutaneous coronary intervention (PCI) bleeding and mortality have reached conflicting conclusions. There are no current data about the use and outcomes of transradial PCI (r-PCI) in the Veterans Affairs system. Methods and Results—Consecutive veterans (n=24 143 patients) undergoing PCI in the Veterans Affairs between 2007 and 2010 were examined. On the basis of propensity to undergo r-PCI, 3 cohorts matched with veterans undergoing transfemoral access were constructed among sites performing ≥1 r-PCI, ≥50 r-PCI (high volume), and <50 r-PCI (low volume). Cox proportional hazard models were used to determine the association between PCI access site, blood transfusion, and mortality. The prevalence of r-PCI increased over time (2007=2.1%; 2010=8.8%). Overall, there was no difference in procedure success between matched groups (r-PCI 97.3% versus transfemoral PCI 96.6%; P=0.182), or in the risk of postprocedure transfusion or mortality. Among matched patients treated at high r-PCI volume sites, radial access was associated with a decreased risk of post-PCI blood transfusion (hazard ratio, 0.4; 95% confidence interval, 0.3–0.7; P<0.001), and no significant difference in the risk of mortality (hazard ratio, 0.7; 95% confidence interval, 0.4–1.3; P=0.279). Conclusions—Within the Veterans Affairs, the use of r-PCI increased over time. r-PCI may be associated with a significant decreased risk of post-PCI blood transfusion among higher volume r-PCI sites. These data demonstrate that potential benefits of r-PCI in terms of reduced post-PCI blood transfusions may be more pronounced at sites that routinely use radial access.

Impact of PACS and Voice-Recognition Reporting on the Education of Radiology Residents

Rationale and Objectives: The introduction of picture archiving and communication system (PACS) has decreased the time needed to interpret radiology examinations resulting in an increased workflow. Because of concerns that the increase in exam throughput and the use of voice recognition may have a negative impact upon radiology resident education, a survey was conducted to assess the impact of PACS and voice recognition. Materials and Methods: Residents at four diagnostic radiology training programs were surveyed. Survey topics included resident demographics, didactic and technical issues, and areas for improvement. Results: One hundred thirty-four residents were polled with 42 respondents (42/134, 31.3%). The majority have been using PACS for more than 1 year (29/41, 70.7%) to interpret 75–100% of cases (33/39, 84.6%). A majority believed PACS is a superior teaching tool to printed film (28/38, 73.7%). However, only a minority (9/40, 22.5%) indicated that PACS was always used to contain teaching files and to conduct departmental conferences (5/40, 12.5%). The majority of respondents believed PACS have decreased the time needed to interpret diagnostic examinations (33/41, 80.5%). A majority (80.6%, 25/31) indicated that voice recognition takes more time than the traditional dictation and transcription process, where 51.3% (20/39, 51.3%) felt that voice recognition works well less than 50% of the time. Conclusions: Residents believe that PACS has positively affected their learning experience but indicate that it can be better utilized for resident education. Residents believe that voice recognition is less reliable and more time consuming than the traditional dictation system.

Balancing the risks of stent thrombosis and major bleeding during primary percutaneous coronary intervention

This editorial refers to ‘Bivalirudin is superior to heparins alone with bailout GPIIb/IIIa Inhibitors in patients with ST-segment elevation myocardial infarction transported emergently for primary percutaneous coronary intervention: a pre-specified analysis from the EUROMAX trial’[†][1], by U. Zeymer et al ., on page 2460. Two feared peri-procedural complications of primary percutaneous coronary intervention (PCI) are stent thrombosis (ST) and major bleeding. Although rare, ST is associated with high rates of myocardial infarction and death.1 Potent antithrombotic therapy around the time of PCI markedly reduces the risk of ST, but increases bleeding hazard ( Figure 1 ). Historically, the anticoagulant of choice for PCI has been unfractionated heparin (UFH). Glycoprotein inhibitors (GPI) added to heparin significantly reduce peri-procedural ischaemic complications, but increase major bleeding and the need for transfusions. There has been a consistent association between major bleeding and increased mortality.2 In PCI for elective indications and across the spectrum of acute coronary syndrome (ACS), the direct thrombin inhibitor bivalirudin is non-inferior to heparin plus GPI with respect to overall ischaemic complications, but significantly decreases major bleeding. Figure 1 Balancing reductions in stent thrombosis with increases in major bleeding. PCI, percutaneous coronary intervention. In this issue of European Heart Journal , an important pre-specified analysis by Zeymer et al. uses the European Ambulance Acute Coronary Syndrome Angiography (EUROMAX) study population to compare patients receiving bivalirudin with patients receiving heparins [UFH or low-molecular weight heparin (LMWH)] with routine GPI use (defined as initiation before or during coronary angiography) and patients receiving heparins with only bailout GPI use (defined as initiation after the start of PCI). This study expands on the original EUROMAX findings by reporting a significant difference in the composite primary endpoint of death or major bleeding that favours bivalirudin over heparins with routine GPI use and heparins with bailout GPI use (5.1 vs. … [1]: #fn-1

Incidence, outcomes, and management of bleeding in non-ST-elevation acute coronary syndromes.

Antithrombotic and antiplatelet drugs and percutaneous interventions have decreased the ischemic outcomes of non-ST-elevation acute coronary syndromes, but they pose risks of bleeding. The authors review the scope of the problem and ways to prevent and manage bleeding in this situation. Powerful antithrombotic and antiplatelet drugs and percutaneous interventions pose risks of bleeding. Fortunately, the risk can be managed.

Progression of radial approach to PCI in the USA: from niche procedure to default approach

The transradial technique for coronary angioplasty and intervention has become popular because of its associated lower bleeding risk and access site complications compared with the femoral access approach. The radial artery has long been known to be the preferred site of access of many countries, except for the USA. Recent observational studies show that US catheterization laboratories are experiencing a paradigm shift favoring the transradial approach.

Atrial Fibrillation and Percutaneous Coronary Intervention: Stroke, Thrombosis, and Bleeding

Opinion statementCurrently available data suggest that patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) with stenting who do not continue oral anticoagulation are at increased risk for mortality and morbidity. In this patient population, therapy directed at reducing both thromboembolism (via oral anticoagulation) and stent thrombosis (via dual antiplatelet therapy) is necessary but is associated with an increased risk for bleeding. For patients with a high risk for thromboembolism based on published AF risk scores, the use of bare metal stents is recommended to minimize the duration of triple therapy. During the time period when triple therapy is used, the International Normalized Ratio (INR) should be maintained at the lower end of therapeutic range (2.0), and lower dose aspirin should be used. Finally, as newer oral anticoagulation agents such as dabigatran and rivaroxaban become available, further research will be required to determine their safety and efficacy in patients with AF undergoing PCI with stenting.

POLYVASCULAR DISEASE, DIABETES MELLITUS AND LONG-TERM VASCULAR RISK: INSIGHTS FROM THE IMPROVE-IT TIMI 40 TRIAL

Polyvascular disease and diabetes (DM) are each associated with increased early CV risk in patients with ACS. Whether these risks are additive over long-term follow up is unknown. We explored the long-term CV risk associated with polyvascular disease, DM and their combination in patients with ACS.