Gregory R. Giugliano

Meta-analysis of corticosteroid treatment in acute myocardial infarction.

Acute and chronic inflammation play a central role in the pathophysiology of atherosclerosis. Corticosteroids are the gold standard anti-inflammatory agent and may have a role in treating acute myocardial infarction. However, concern exists regarding the potential for impaired wound healing and wall thinning. The MEDLINE and PreMEDLINE databases were searched for articles from 1966 through May 2002. A total of 186 articles and 16 English-language publications were identified. A meta-analysis of mortality in controlled trials was performed. Sensitivity analyses and 2 tests for publication bias were used to test the robustness of the results. Sixteen studies involving 3,793 patients were reviewed. Most studies were small (<100 patients) and revealed conflicting efficacy using surrogate outcome measures, such as infarct size. No clear association with myocardial rupture was observed. Meta-analysis of 11 controlled trials (2,646 patients) revealed a 26% decrease in mortality with corticosteroids (odds ratio 0.74, 95% confidence interval [CI] 0.59 to 0.94; p = 0.015). Sensitivity analyses limited to large studies and randomized controlled trials revealed odds ratios of 0.76 (95% CI 0.53 to 1.09) and 0.95 (95% CI 0.72 to 1.26), respectively. Two tests revealed no evidence for publication bias. Thus, the review of available clinical studies demonstrated no harm and a possible mortality benefit of corticosteroids in acute myocardial infarction.

High-dose atorvastatin does not negatively influence clinical outcomes among clopidogrel treated acute coronary syndrome patients—A Pravastatin or Atorvastatin Evaluation and Infection Therapy–Thrombolysis in Myocardial Infarction 22 (PROVE IT–TIMI 22) analysis

BACKGROUND Clopidogrel is inactive in vitro and is metabolized by hepatic cytochrome P-450-3A4 to produce active metabolites. Unlike pravastatin, atorvastatin is a statin that is subject to metabolism by cytochrome P-450-3A4, and drug-drug interactions with other potent inhibitors of this cytochrome system have been demonstrated. However, the clinical impact of this interaction has created debate. METHODS In the PROVE IT-TIMI 22 study, 4162 patients with an acute coronary syndrome within the preceding 10 days were randomly assigned in a 1:1 fashion to pravastatin 40 mg or atorvastatin 80 mg daily. The primary efficacy outcome measure was the time from randomization until the first occurrence of a component of the primary end point: death from any cause, myocardial infarction, documented unstable angina requiring rehospitalization, revascularization with either percutaneous coronary intervention or coronary artery bypass grafting, or stroke. RESULTS At 30 days, there was a trend for less occurrence of the primary end point in patients randomized to atorvastatin compared with pravastatin, irrespective of whether they were taking clopidogrel. This becomes significant at 2-year follow-up in clopidogrel-treated patients (21.66 % vs 26.18% P = .0091). There was no evidence of interaction in the clopidogrel/no clopidogrel subgroup for the primary end point (interaction P = .65) or the components of the composite. CONCLUSION In conclusion, the beneficial affects of atorvastatin 80 mg in reducing the primary end point at 2 years is independent of coadministration with clopidogrel.

A prospective multicenter registry of laser therapy for degenerated saphenous vein graft stenosis: the COronary graft Results following Atherectomy with Laser (CORAL) trial

PURPOSE The primary aim of this study was to prospectively evaluate the safety and efficacy of Excimer laser atherectomy as a primary treatment strategy in consecutively eligible patients presenting for percutaneous coronary intervention (PCI) of degenerated saphenous vein graft (SVG) lesions using a multicenter registry. Prior single-center experience suggested that laser atherectomy may decrease acute procedural complications during treatment of degenerated SVGs, including lesions not amenable to distal protection devices (DPDs). METHODS AND MATERIALS The COronary graft Results following Atherectomy with Laser investigators enrolled 98 patients at 18 centers between June 23, 2003, and October 4, 2004, with greater than 50% stenosis of an SVG who presented for PCI due to angina pectoris or objective evidence of myocardial ischemia in a concordant myocardial distribution. Laser atherectomy was planned. Patients were excluded if the operator planned to utilize a DPD. Inclusion and exclusion criteria were aligned to those in the Saphenous vein graft Angioplasty Free of Emboli Randomized (SAFER) trial. RESULTS The primary end point [30-day major adverse cardiac events (MACE)] occurred in 18/98 (18.4%) patients driven primarily by non-q-wave myocardial infarction. Major procedural complications included no reflow (n=5) and major dissection (n=1). No perforations occurred. Univariate predictors of 30-day MACE included lesion length, vessel angulation, plaque burden, SVG degeneracy score, number of laser pulses used, and larger-sized laser catheters. CONCLUSIONS This study demonstrated that Excimer laser atherectomy of diseased SVGs is feasible with results comparable to the 30-day MACE in the control population from the SAFER trial. Whether the addition of laser to embolic protection devices is of any clinical utility remains to be tested in future studies.

ST segment elevation myocardial infarction as a presenting feature of thrombotic thrombocytopenic purpura.

Myocardial infarction with ST segment elevation (STE) on electrocardiography (ECG) is a common presentation in emergency rooms across the world. Myocardial injury and necrosis are infrequently the initial presentation in patients with thrombotic thrombocytopenic purpura (TTP). A 48-year-old woman presented with STE myocardial infarction from outside hospital for primary percutaneous coronary intervention. However, her clinical picture was not consistent. Rapid evaluation revealed symptoms associated with microangiopathic hemolytic anemia, thrombocytopenia, acute kidney injury with waxing and waning mental status. A diagnosis of TTP was made with low ADAMST-13 activity. Plasmapheresis was initiated along with intravenous steroid therapy. The patient had a full recovery and went home after full recovery of left ventricular ejection fraction and normal myocardial perfusion studies. Rapid evaluation is needed to identify infrequent causes of STE myocardial infarction. As swift protocols are activated in the emergency room and catheterization laboratories to ensure quality control, it is equally important to integrate all aspects of the patients clinical and objective data to detect unusual disease entities.

Acute renal artery occlusion: making the case for renal artery revascularization

Atherosclerotic renal artery disease is a common disease entity that may be identified in patients with difficult-to-control hypertension and/or chronic kidney disease but is probably underdiagnosed. Current evidence from both observational and randomized studies offers mixed results regarding the support for renal artery revascularization. There is lack of equipoise with regard to the efficacy of renal artery revascularization among the interventional and renal communities, as well as disagreements on the appropriate endpoints to measure in clinical trials, which have led to selection bias confounding the scant available data. We report a patient who does not fit any clinical trial inclusion criteria with acute on chronic kidney injury and new-onset heart failure whose symptoms and renal function improved significantly after renal artery intervention.

Postoperative Atrial Fibrillation Is Not Associated With an Increase Risk of Stroke or the Type and Number of Grafts: A Single-Center Retrospective Analysis

Atrial fibrillation (AF) and atrial flutter are the 2 most common types of dysrhythmia in patients undergoing coronary artery bypass graft (CABG) surgery and are associated with increased morbidity and mortality. We sought to explore the association between the type and quantity of bypass grafts and cardiovascular outcomes in patients with postoperative AF (POAF).

Door-to-Balloon Time: Are We Evaluating the Wrong Metric?

To the Editor: In ST-segment elevation myocardial infarction, reperfusion with primary percutaneous coronary intervention (pPCI) is a time-sensitive process. On the basis of current American College of Cardiology/American Heart Association guidelines ([1][1]), door-to-balloon time (D2B) has become

Recombinant nematode anticoagulant protein c2 in non-ST segment elevation acute coronary syndrome and beyond

Patients with acute coronary syndromes (ACS) have high recurrent ischemic event rates despite management with current guideline-based therapies. Recombinant nematode anticoagulant protein (rNAP)c2 provides factor Xa-dependent inhibition of the tissue factor/factor VIIa complex acting proximally on the clotting cascade. It may be administered either intravenously or subcutaneously and has an elimination half-life of approximately 50-60 h. rNAPc2 reduces thrombin formation in patients undergoing elective percutaneous coronary interventions (PCI) and in patients with non-ST segment elevation ACS managed with an early invasive strategy, while bleeding rates are comparable with currently used anticoagulants. Patients receiving rNAPc2 undergoing emergent coronary artery bypass surgery within 96 h of dosing have increased rates of major bleeding. Some heparin coadministration may be necessary to avoid PCI-related thrombotic complications. Large-scale trials are needed to confirm these findings and to evaluate the impact of rNAPc2 on clinical events.

The heavy LEGACY: Should weight management be part of every atrial fibrillation clinic?

As the global burden of atrial fibrillation (AF) and its attendant economic impact on the healthcare system surges, there is increasing interest in the secondary prevention of AF with various therapies. Of the several identified risk factors for AF, obesity is an important contributor that may be managed with intensive lifestyle modification. Prior studies have demonstrated the short-term and long-term benefits of weight loss in reduction of AF symptoms. In the LEGACY study [Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort: A Long-Term Follow-Up Study], the investigators evaluated the long-term effects of a weight management program on AF symptoms. Of the 355 patients included in this cohort, outcomes such as AF symptom burden, arrhythmia-free survival, inflammatory markers and structural cardiac changes all appear to have improved in the intense weight loss group as compared to the 2 other groups. Further, the benefits of weight loss appear to be lost when > 5% weight fluctuation (WF) occurred over the 5-year follow-up period. In this review, we discuss the design of the weight management clinic and its impact on the management of AF in the LEGACY study. Given that weight management appears to be an effective intervention that will not have the marketing and financial push that pharmaceutical and device based therapies enjoy, it behooves administrators of AF clinics to develop innovative funding strategies to incorporate weight management programs in order to improve patient-centered outcomes.

Influence of Low‐Dose Aspirin (81 mg) on the Incidence of Definite Stent Thrombosis in Patients Receiving Bare‐Metal and Drug‐Eluting Stents

Dual antiplatelet therapy with aspirin plus clopidogrel is the mainstay of therapy in patients undergoing percutaneous coronary intervention (PCI). However, the optimal dose of aspirin following PCI has not been established.