Christopher P. Cannon

Approach to the Patient with Chest Pain

Acute chest pain is one of the most common reasons for presentation to the emergency department (ED), accounting for approximately 7 million ED visits annually in the United States. This presentation suggests acute coronary syndrome (ACS), but after diagnostic evaluation, only 15% to 25% of patients with acute chest pain actually have ACS. The difficulty lies in discriminating patients with ACS or other life-threatening conditions from patients with noncardiovascular, non–life-threatening chest pain. The diagnosis of ACS is missed in approximately 2% of patients, leading to substantial consequences— for example, the short-term mortality for patients with acute myocardial infarction (MI) who are mistakenly discharged from the ED increases twofold over that expected for patients who are admitted to the hospital. For patients with a low risk of complications, however, these concerns must be balanced against the costs and inconvenience of admission and against the risk of complications from tests and procedures with a low probability of improving patient outcomes. Several recent advances have enhanced the accuracy and efficiency of the evaluation of patients with acute chest pain, including better blood markers for myocardial injury, decision aids to stratify patients according to their risk of complications, early and even immediate exercise testing and radionuclide scanning for lower risk patient subsets (see Chap. 17), multislice computed tomography for the anatomic evaluation of coronary artery disease, pulmonary embolism, and aortic dissection (see Chap. 19), and the use of chest pain units and critical pathways for efficient and rapid evaluation of lower-risk patients.

21. Cardiac Ischemic Outcomes and Hospitalizations in Patients with Type 2 Diabetes and Recent Acute Coronary Syndrome Treated with Alogliptin or Placebo: New Insights from the EXAMINE Trial (13-OR)

SamenvattingBackground: Concerns have been raised regarding adverse cardiovascular outcomes with new therapies for type 2 diabetes (T2DM). The EXAMINE trial studied the effect of the DPP-4 inhibitor alogliptin on major CV events in patients with T2DM and recent acute coronary syndromes. Herein we present data on all cardiac ischemic events and cardiovascular hospitalizations (CVHs) in EXAMINE. Methods: Data from all 5380 patients randomized in EXAMINE were used. The incident rates of MI and unstable angina, coronary revascularization, CVH, and composites of these ischemic endpoints were calculated.

20. Major Cardiovascular Outcomes in the EXAMINE Trial According to ACE Inhibitor Use (12-OR)

SamenvattingActivation of the sympathetic nervous system through substance P via DPP-4 inhibition (DPP-4i) in the presence of higher dose ACE inhibition (ACEi) has led to hypothetical concerns of the cardiovascular (CV) safety of these 2 classes of drugs used together. We evaluated adjudicated CV events in EXAMINE, a trial of patients with type 2 diabetes (T2DM) and recent acute coronary syndrome (ACS) according to ACEi use. Patients were randomly assigned to receive alogliptin or placebo added to existing anti-hyperglycemic and CV therapies. Risks of CV death, nonfatal MI and stroke (MACE), and CV death or hospitalized HF (HHF) were analyzed using a Cox proportional hazards model in patients by baseline ACEi use. EXAMINE random ized 5380 patients, 3323 (62%) of whom were using an ACE inhibitor (1681 on alogliptin; 1642 on placebo). Composite rates of MACE were similar for alogliptin vs. placebo with ACEi [11.4% vs. 11.8%, HR = 0.97, 95% CI, 0.79-1.19, p = 0.76] and without ACEi use at baseline [11.2% vs. 11.9%, HR = 0.94, 95% CI, 0.73-1.21, p = 0.62]. The composite of CV death or HHF in patients on ACEi at baseline occurred in 6.8% of patients on alogliptin vs. 7.2% on placebo [HR = 0.93, 95% CI, 0.72-1.2, p = 0.57]. Alogliptin showed no effect on HHF alone in ACEi treated patients, 3.3% vs. 3.1%, (HR = 1.07, 95% CI, 0.73-1.56, p = 0.75) for alogliptin vs. placebo, respectively. Additionally, there was no impact of higher vs. lower doses of ACEi on CV event rates. There were also no differences for these endpoints in patients without ACEi use at baseline. Analyses according to pre-randomization history of HF and ACEi use at baseline showed MACE occurring in 13.9% and 16.5% of patients on alogliptin vs. placebo, respectively [HR = 0.87, 95% CI, 0.63-1.19, p = 0.38] and CV death or HHF in 12.0% and 13.2% of patients on alogliptin vs. placebo, respectively [HR = 1.02, 95% CI, 0.72-1.44, p = 0.92]. In conclusion, CV outcomes were not different for alogliptin compared with placebo in high CV risk patients with T2DM treated with ACE inhibitors in the EXAMINE Trial.