D. Burgess

Incidence and predictors of silent myocardial infarction in type 2 diabetes and the effect of fenofibrate: an analysis from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study.

AIMS To determine the incidence and predictors of, and effects of fenofibrate on silent myocardial infarction (MI) in a large contemporary cohort of patients with type 2 diabetes in the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study. METHODS AND RESULTS Routine electrocardiograms taken throughout the study were assessed by Minnesota-code criteria for the presence of new Q-waves without clinical presentation and analysed with blinding to treatment allocation and clinical outcome. Of all MIs, 36.8% were silent. Being male, older age, longer diabetes duration, prior cardiovascular disease (CVD), neuropathy, higher HbA(1c), albuminuria, high serum creatinine, and insulin use all significantly predicted risk of clinical or silent MI. Fenofibrate reduced MI (clinical or silent) by 19% [hazard ratio (HR) 0.81, 95% confidence interval (CI) 0.69-0.94; P = 0.006], non-fatal clinical MI by 24% (P = 0.01), and silent MI by 16% (P = 0.16). Among those having silent MI, fenofibrate reduced subsequent clinical CVD events by 78% (HR 0.22, 95% CI 0.08-0.65; P = 0.003). CONCLUSION Silent and clinical MI have similar risk factors and increase the risk of future CVD events. Fenofibrate reduces the risk of a first MI and substantially reduces the risk of further clinical CVD events after silent MI, supporting its use in type 2 diabetes.

Paclitaxel drug-eluting balloons to recurrent in-stent stenoses in autogenous dialysis fistulas: a retrospective study.

Purpose To assess the effect of the Medtronic paclitaxel drug-eluting balloon (DEB) on re-intervention to in-stent stenoses in autogenous dialysis arteriovenous fistulas (AVFs). Background AVF is the optimum haemodialysis access. The commonest problem is stenosis, preventing maturation, causing inadequate dialysis or precipitating occlusion. Conventional angioplasty has a high recurrence rate. Successful drug elution in the coronary circulation led us to use DEBs in recurrent AVF stenoses since 2010. Methods This is a retrospective study, based on prospective audit data, using DEBs on recurrent in-stent stenotic lesions in the AVF circuit of our haemodialysis population. To analyse the effect of DEBs on re-intervention, we created two Kaplan–Meier curves. The first curve compares the last “disease-free-interval” pre-DEB intervention to the first “disease-free interval” post-DEB, giving us “re-intervention-free percentage at 12 months” pre- and post-DEB. The second curve takes into account the multiple pre- and post-DEB interventions to the index lesion, and uses a marginal proportional hazards model to estimate the hazard ratio for “DEBpresent vs. DEBabsent”. Results From 1 September 2010 to 1 December 2013, we treated 625 AVF stenoses with endovascular techniques. In 86 of these stenoses, DEBs were used. Of the 86 DEB interventions, 37 were included for this study, 49 were excluded. In the study group, there was a significant difference in “re-intervention-free percentage at 12 months” before and after DEB: 19% vs. 69%. The hazard ratio for “DEBpresent” vs. “DEBabsent” was 0.23 (95% CI 0.14 to 0.36, p<0.001). Conclusions This retrospective study suggests that DEBs significantly reduce re-intervention on recurrent in-stent AVF stenoses.

Juxta-anastomotic stenting with aggressive angioplasty will salvage the native radiocephalic fistula for dialysis

OBJECTIVE This study describes our technique of aggressive angioplasty with juxta-anastomotic stenting (JXAS) in the autogenous arteriovenous fistula and reviews our outcomes with this technique in its mature form. METHODS We developed a JXAS technique during the last 7 years. Since 2006, we have placed 135 JXASs. The study period reviews 68 consecutive JXASs placed from 2008 to 2012 using the mature technique. We retrospectively analyzed the prospectively collected data. Thirty-three fistulas received JXAS for failure to mature, and 35 were mature but inadequately dialyzing fistulas (problem fistulas). The JXAS technique involves (1) treating the JXA segment as a unit, (2) aggressive angioplasty with rupture of stenoses, and (3) placement of an uncovered nitinol stent. RESULTS Technical success was 97%. Of the fistulas that had failed to mature, 75% were brought to maturity by 6 months and 88% by 12 months. Adequate dialysis was achieved in all 35 problem fistulas immediately postoperatively. Assisted fistula patency was 90% at 2 years and 80% at 4 years. CONCLUSIONS JXAS is an effective technique for maturing and maintaining the wrist radiocephalic arteriovenous fistula.

Multicentre, randomised, blinded, control trial of drug-eluting balloon vs Sham in recurrent native dialysis fistula stenoses

Background: Endovascular treatment of autogenous arteriovenous haemodialysis fistula stenosis has high reintervention rates. We investigate the effect of drug-eluting balloons in the treatment of recurrent haemodialysis fistula stenosis. Methods: This is a randomised, controlled, investigator-initiated and run, prospective, blinded, multicentre trial. Patients with recurrent autogenous arteriovenous haemodialysis fistula stenosis received standard endovascular treatment plus drug-eluting balloon or standard endovascular treatment plus uncoated balloon (Sham). Primary endpoint was late lumen loss in trial area on ultrasound at 6 weeks, 3, 6 and 12 months. Secondary endpoints were freedom from reintervention to the Index Trial Area and decline in fistula flow (Qa). Interim analysis was performed at 6 months (unblinded due to timeliness). Results: Patients with 132 recurrent stenoses (48% in bare Nitinol stents) were randomised with 70 receiving drug-eluting balloon and 62 Sham. At 6 months, decline in late lumen loss was 0.23 ± 0.03 mm/month for Sham and 0.045 ± 0.03 mm/month for drug-eluting balloon arm, a significant difference (0.18 mm, p = 0.0002). At 12 months, this difference persisted at 0.12 mm (p = 0.0003). At 6 months, significant difference in late lumen loss for instent restenoses (p = 0.0004) was observed, with non-significant difference for unstented restenoses (p = 0.065). Mean time for freedom from reintervention was 10.14 months for Sham versus 42.39 months for drug-eluting balloon (p = 0.001). The same was shown for instent (p = 0.014) and unstented (p = 0.029) restenoses. Qa decline rate at 6 months was 36.89 mL/min/month (Sham) and 0.41 mL/min (drug-eluting balloon). The difference was significant (36.48 mL/min; p = 0.02) and persisted to 12 months (p = 0.44). Conclusion: Paclitaxel drug-eluting balloon significantly delays restenosis after angioplasty for recurrent autogenous arteriovenous haemodialysis fistula stenosis, persisting to 12 months. Drug-eluting balloon significantly increases freedom from reintervention at 12 months with these effects true in stented and unstented fistulas.

ACCURACY OF INTERPRETING FAX TO EMAIL ST-ELEVATION MYOCARDIAL INFARCTION ELECTROCARDIOGRAMS VIEWED ON SMARTPHONES

Timely review and interpretation of 12-lead electrocardiogram (ECG) reduces the time to reperfusion in acute ST-segment elevation myocardial infarction (STEMI). Smartphones are becoming an integral part of a wide variety of medical disciplines, and may be an ideal tool for timely assessment of ECG