Hani Jneid

Evolution of the American College of Cardiology/American Heart Association Clinical Guidelines.

BACKGROUNDnThe American College of Cardiology (ACC) and the American Heart Association (AHA) have been developing clinical guidelines to assist practicing clinicians.nnnOBJECTIVESnThe goal of this study was to evaluate changes in ACC/AHA guideline recommendations between 2008 and 2014.nnnMETHODSnThe previous and current ACC/AHA guideline documents that were updated between 2008 and June 2014 were compared to determine changes in Class of Recommendation (COR) and Level of Evidence (LOE). Each recommendation was classified as new, dropped, revised, or unchanged, and the changes in evidence were examined.nnnRESULTSnDuring the study period, 11 guideline documents (9 disease based and 2 interventional procedure based) were updated. The total number of recommendations decreased from 2,067 to 1,869 (321 fewer recommendations in disease-based guidelines and 123 additional recommendations in interventional procedure-based guidelines). The recommendation class distribution of the updated guidelines was 50.1% Class I (previously 50.8%), 39.4% Class II (previously 35.4%), and 10.4% Class III (previously 13.8%) (p = 0.001). The LOE distribution among updated versions was 15.0% for LOE: A (previously 13.3%), 50.8% for LOE: B (previously 41.4%), and 34.2% for LOE C (previously 45.3%) (p < 0.001). Among all guidelines, 859 recommendations were new, 1,339 were dropped, 881 were unchanged in COR and LOE, and 129 were revised. Of the revised guidelines, 75 recommendations had an increase in LOE (the majority from LOE: C to LOE: B); 34 recommendations had a decrease in LOE; and 20 recommendations had class changes. LOE increases were justified by introduction of new randomized controlled trials, new studies, and new meta-analyses.nnnCONCLUSIONSnThe ACC/AHA guideline recommendations are undergoing significant changes, becoming more evidence based and scientifically robust with a tendency to exclude recommendations with insufficient scientific evidence.

Is 2015 the Primetime Year for Prehypertension? Prehypertension: A Cardiovascular Risk Factor or Simply a Risk Marker?

The Comparative Risk Assessment module of the World Health Organizations Global Burden of Disease 2000 study[1][1] conducted a systematic assessment of changes in population health resulting from modifying exposure to 26 risk factors. These included atherosclerotic risk factors such as high blood

Chagas Cardiomyopathy is Associated With Higher Incidence of Stroke: A Meta-analysis of Observational Studies

BACKGROUNDnChagas disease (CD) has been associated with an elevated risk of stroke, but current data are conflicting and prospective controlled studies are lacking. We performed a systematic review and meta-analysis examining the association between stroke and CD.nnnMETHODSnPubmed, Embase, Cochrane Central, Latin American database, and unpublished data were searched with the use of the following terms: (Chagas OR American trypanosomiasis) AND (dilated OR ischemic OR idiopathic OR nonChagasic OR stroke OR cerebrovascular). We included studies that reported prevalence or incidence of stroke in a CD group compared with a non-CD control group. Odds ratios (ORs) and their 95% confidence intervals (CIs) were computed with the use of a random-effects model.nnnRESULTSnA total of 8 studies and 4,158 patients were included, of whom 1,528 (36.7%) had CD. Risk of stroke was elevated in the group of patients with CD (OR 2.10, 95% CI 1.17-3.78). Similar results were observed in a subanalysis of cardiomyopathy patients (OR 1.74, 95% CI 1.02-3.00) and in sensitivity analysis with removal of each individual study. Furthermore, exclusion of studies at higher risk for bias also yielded consistent results (OR 1.70, 95% CI 1.06-2.71). Subanalysis restricted to studies that included patients with the indeterminate form found no significant difference in the stroke prevalence between CD and non-CD patients (OR 3.10, 95% CI 0.89-10.77).nnnCONCLUSIONSnCD is significantly associated with cerebrovascular events, particularly among patients with cardiomyopathy. These findings underline the need for prospective controlled studies in patients with Chagas cardiomyopathy to ascertain the prognostic significance of cerebrovascular events and to evaluate the role of therapeutic anticoagulation in primary prevention.

Impact of the metabolic syndrome on high-sensitivity C reactive protein levels in patients with acute coronary syndrome

OBJECTIVEnUnderlying predisposition for a heightened inflammatory response is postulated as one of the mechanisms for elevated high-sensitivity C reactive protein (hs-CRP) levels in patients with acute coronary syndrome (ACS). It is unclear whether metabolic syndrome (MetS) may cause a predisposition for heightened hs-CRP response in patients with ACS. The aim of this study is to investigate the interaction between hs-CRP levels and presence of MetS in patients with and without ACS.nnnMETHODSnTwo hundred and seventy-three consecutive patients presenting with a first ACS event and 261 MetS patients without any ACS event were included to the study. The study participants were divided into three groups as MetS (+) ACS (-) [n=261], MetS (-) ACS (+) [n=110], and MetS (+) ACS (+) [n=163]. Median levels of hs-CRP were compared between and within the three groups.nnnRESULTSnHs-CRP levels were lowest in MetS (+) ACS (-) subjects and highest in MetS (+) ACS (+) patients. Factors associated with hs-CRP levels were troponin elevation, presence of ACS, body mass index (BMI), and presence of MetS (R(2)=0.26, p<0.01). Predictors of elevated hs-CRP levels (>0.3mg/dl) were the presence of ACS (OR=3.6, 95% CI=1.9-6.5, p<0.01), presence of MetS (OR=2.1, 95% CI=1.0-4.0, p=0.02), troponin elevation (OR=5.7, 95% CI=2.8-11.5, p<0.01) and BMI (OR=1.1, 95% CI=1.0-1.1, p<0.01).nnnCONCLUSIONSnThe presence of MetS had an impact on the increase in hs-CRP levels observed with an ACS event in the study population. These findings suggested that a heightened baseline inflammatory status of MetS may predispose ACS patients to an augmented hs-CRP response.

Renal insufficiency, bleeding and prescription of discharge medication in patients undergoing percutaneous coronary intervention in the National Heart, Lung, and Blood Institute (NHLBI) Dynamic Registry

AIMSnTo establish the relationship between renal insufficiency, bleeding and prescription of cardiovascular medication.nnnMETHODS AND RESULTSnThis was a prospective, multi-center, cohort study of consecutive patients undergoing PCI during three NHLBI Dynamic Registry recruitment waves. Major and minor bleeding, access site bleeding and rates of prescription of cardiovascular medication at discharge were determined based on estimated glomerular filtration rate (eGFR). Renal insufficiency was an independent predictor of major adverse cardiovascular events (MACE). Bleeding events and access site bleeding requiring transfusion were significantly associated with degrees of renal insufficiency (p<0.001). There was an incremental decline in prescription of cardiovascular medication at discharge proportionate to the degree of renal impairment (aspirin, thienopyridine, statin, coumadin (overall p<0.001), beta blocker (overall p=0.003), ACE inhibitor (overall p=0.02). Bleeders were less likely to be discharged on a thienopyridine (95.4% versus 89.9% for bleeding, p<0.001 and 95.3% versus 87.9% for access site bleeding, p=0.005), but not aspirin (96.3% versus 96.2%, p=0.97 and 96.3% versus 93.6%, p=0.29 respectively). Failure to prescribe anti-platelet therapy at discharge was strongly associated with increased MACE at one year.nnnCONCLUSIONSnRenal insufficiency is associated with bleeding in patients undergoing PCI. Patients with renal insufficiency are less likely to receive recommended discharge pharmacotherapy.

Acute Coronary Syndromes: Unstable Angina and Non–ST Elevation Myocardial Infarction

Non-ST elevation acute coronary syndromes (NSTE-ACS) encompass the clinical entities of unstable angina and non-ST elevation myocardial infarction. Several advances have occurred over the past decade, including the emergence of new antiplatelet and antithrombotic therapies and novel treatment strategies, leading to marked improvements in mortality. However, there has also been an increased incidence in NSTE-ACS as a result of the use of high-sensitivity troponins and the increase in cardiovascular risk factors. This article provides a focused update on contemporary management strategies pertaining to antiplatelet, antithrombotic, and anti-ischemic therapies and to revascularization strategies in patients with ACS.

Interplay Between Time of Presentation, Timeliness of Reperfusion, and Outcome After ST-Segment–Elevation Myocardial Infarction

Disparities in care and outcomes among patients presenting with acute ST-segment–elevation myocardial infarction (STEMI) during off-hours remain a matter of considerable interest because they uncover gaps in the healthcare system and opportunities for improvement.nnArticle see p 656nnIn the report by Dasari et al,1 the investigators revisited care processes and outcomes among patients presenting with STEMI during off-hours (weeknights, weekends, and holidays) in contemporary clinical practices. They used the Acute Coronary Treatment and Intervention Outcomes Network registry-Get With the Guidelines database to compare STEMI performance measures during off- versus on-hours at 447 US hospitals between 2007 and 2010. The investigators reported similar rates of early aspirin use and attainment of door-to-ECG ≤10 minutes and door-to-needle ≤30 minutes in both groups.1 However, patients undergoing primary percutaneous coronary intervention (pPCI) during off-hours experienced slower mechanical reperfusion, were less likely to achieve timely door-to-balloon (D2B ≤90 minutes), and had higher risk of adjusted all-cause mortality.1nnThe current report1 is the latest of several investigations in the field2–5 and demonstrates notable improvements in care. Compared with earlier reports,3,5 the investigators report salient findings including shorter D2B and door-to-needle times overall and during off-hours and smaller time differential in D2B between off- and on-hours.1 A remarkable finding in their study is that >97% of patients received pPCI as the reperfusion therapy, which reflects the widespread adoption of this superior reperfusion strategy. This is in contrast to prior reports such as the one from the National Registry for Myocardial Infarction registry (2000–2006) in which the use of pPCI, although progressively increasing over time, accounted for slightly >64% of reperfusion therapies at PCI-capable hospitals.6 Additional in-hospital periprocedural adverse outcomes (bleeding, stroke, shock, etc) were also comparable among patients undergoing pPCI …

Transcatheter or Surgical Aortic Valve Replacement in Patients With Chronic Lung Disease? The Answer, My Friend, Is Blowin’ in the Wind

In Bob Dylans iconic song, Blowin’ in the Wind , the refrain “The answer, my friend, is blowin’ in the wind” has been described as “impenetrably ambiguous: either the answer is so obvious it is right in your face, or the answer is as intangible as the wind.”[1][1] The treatment of

Drug-eluting balloons versus everolimus-eluting stents for in-stent restenosis: A meta-analysis of randomized trials

OBJECTIVESnIndividual randomized trials comparing drug-eluting balloons (DEB) versus everolimus-eluting stents (EES) for in-stent restenosis (ISR) were underpowered for clinical end-points. The objective of this study was to compare the clinical outcomes of DEB versus EES for any ISR.nnnMATERIALS & METHODSnElectronic databases were searched for randomized trials which compared DEB versus EES for any ISR (i.e., drug eluting or bare metal stents). Summary estimate risk ratios (RRs) were constructed using a DerSimonian and Laird random effects model.nnnRESULTSnFive trials with 962 patients were included. In-segment minimum lumen diameter (MLD) was lower with DEB (standardized mean difference -0.24, 95% confidence interval [CI] -0.46 - -0.01) on angiographic follow-up at a mean of 8.6u202fmonths. There was no statistically significant difference in the risk of target vessel revascularization (TVR) at 1u202fyear (RR 1.15, 95% CI 0.60-2.19), but TVR was increased with DEB at 3u202fyears (RR 1.87, 95% CI 1.15-3.03). The risk of target lesion revascularization (TLR) was statistically increased with DEB (RR 2.17, 95% CI 1.13-4.19) at a mean of 24.4u202fmonths. There was no difference in the risk of MI, stent thrombosis, cardiac mortality and all-cause mortality between both groups.nnnCONCLUSIONnIn patients with any type of ISR, DEB was associated a similar risk of TVR at 1-year, but increased risk of TVR and TLR at longer follow-up, as compared with EES. The quality of evidence was moderate, suggesting the need for further randomized trials with longer follow-up to confirm the role of DEB in the management of ISR.

Merits of Invasive Strategy in Diabetic Patients With Non‐ST Elevation Acute Coronary Syndrome

An invasive strategy (coronary angiography with intent to perform revascularization) and an ischemia‐guided strategy are 2 commonly used approaches to treat patients with non‐ST elevation acute coronary syndromes (NSTE‐ACSs). These strategies are not mutually exclusive. Patients treated