Thomas J. Helton

Incremental effect of clopidogrel on important outcomes in patients with cardiovascular disease: a meta-analysis of randomized trials.

ObjectivesTo quantify the impact of clopidogrel plus aspirin on the individual outcomes of death, myocardial infarction, or stroke in patients with established cardiovascular disease, or in patients with multiple risk factors for vascular disease.BackgroundRandomized trials have demonstrated a reduction in composite outcomes when clopidogrel is added to aspirin therapy in patients with coronary artery disease; however, the magnitude of benefit on individual outcomes is unknown.MethodsWe conducted a meta-analysis on randomized, controlled trials that compared aspirin plus clopidogrel with aspirin plus placebo for the treatment of coronary artery disease.ResultsThis analysis included five randomized trials (CURE, CREDO, CLARITY, COMMIT, and CHARISMA) in 79 624 patients. The incidence of all-cause mortality was 6.3% in the aspirin plus clopidogrel group versus 6.7% in the aspirin group (odds ratio [OR] 0.94; 95% CI 0.89, 0.99; p = 0.026). The incidence of myocardial infarction was 2.7% and 3.3% (OR 0.82; 95% CI 0.75, 0.89; p < 0.0001), and stroke was 1.2% and 1.4% (OR 0.82; 95% CI 0.73, 0.93; p = 0.002). Similarly, the incidence of major bleeding was 1.6% and 1.3% (OR 1.26; 95% CI 1.11, 1.41; p < 0.0001), and fatal bleeding was 0.28% and 0.27% (OR 1.04; 95% CI 0.76, 1.43; p = 0.79).ConclusionThe addition of clopidogrel to aspirin results in a small reduction in all-cause mortality in patients with ST-elevation myocardial infarction and a modest reduction in myocardial infarction and stroke in patients with cardiovascular disease. The overall incidence of major bleeding however is increased, although there is no excess of fatal bleeds or hemorrhagic strokes.

The effect of drug-eluting stents on intermediate angiographic and clinical outcomes in diabetic patients: Insights from randomized clinical trials

OBJECTIVE Implantation of drug-eluting stents has emerged as the predominant percutaneous revascularization strategy in diabetic patients, despite limited outcomes data. Accordingly, our aim was to conduct a meta-analysis to assess the benefit and safety profile of drug-eluting stents in diabetic patients. METHODS We included randomized trials comparing either the paclitaxel- or sirolimus-eluting stent with a bare-metal stent or with each other in diabetic patients during a follow-up of at least 6 months. RESULTS A total of 16 studies were identified, which included 2951 diabetic patients who were followed up for 6 to 12 months. Target lesion revascularization was less frequently performed in patients who received drug-eluting stents compared with bare-metal stents (risk ratio [RR] 0.35, 95% CI 0.27-0.46, P < .0001). Similar reductions were noted in the incidence of major adverse cardiovascular events (RR 0.42, 95% CI 0.31-0.56, P < .0001), in-segment restenosis (RR 0.31, 95% CI 0.25-0.40, P < .0001), and non-Q-wave myocardial infarction (RR 0.57, 95% CI 0.32-0.99, P = .046). Event rates were similar for Q-wave myocardial infarction (RR 0.72, 95% CI 0.25-2.07, P = .54), death (RR 0.64, 95% CI 0.32-1.28, P = .20), and stent thrombosis (RR 0.41, 95% CI 0.13-1.27, P = .12). CONCLUSIONS In conclusion, diabetic patients who receive drug-eluting stents have a significantly lower incidence of target lesion revascularization, in-segment restenosis and myocardial infarction at 6 to 12 months, compared with bare-metal stents. The rates of mortality and stent thrombosis are similar.

Clinical trial experience with transcatheter aortic valve insertion

Surgical aortic valve replacement has long been considered the standard of care for patients with severe symptomatic aortic stenosis, however, an aging population with increasing complex comorbidities now represents a growing population of patients that is often considered inoperable for a traditional surgical approach. Transcatheter aortic valve implantation is a developing technology that offers an alternative treatment modality for these very high risk patients. This manuscript will review the currently available clinical trial data with transcatheter aortic valve implantation and offer perspective as to the future of this novel technology.

The optimal treatment of carotid atherosclerosis: a 2008 update and literature review.

Abstract Carotid and cerebrovascular disease have major public health implications given the associated morbidity and mortality. However, the best treatment for this disease is uncertain. Carotid endarterectomy has proven useful in primary and secondary prevention of strokes for patients with significant internal carotid artery stenoses. Many patients are considered at high risk for such surgical procedures and therefore have relatively few treatment options. Carotid stenting is currently being investigated as an alternative therapeutic intervention for these patients. This article reviews the literature pertaining to carotid intervention and its current status in 2008.

Outcomes of cardiac catheterization and percutaneous coronary intervention for in‐hospital ventricular tachycardia or fibrillation cardiac arrest

Objective: This study examined outcomes of patients with sudden cardiac death attributable to primary ventricular tachycardia (VT) or ventricular fibrillation (VF) that underwent cardiac catheterization with or without percutaneous coronary intervention (PCI). Background: The decision to perform cardiac catheterization and PCI in resuscitated patients with sudden cardiac death remains controversial. Prior data suggest a potential benefit from percutaneous revascularization. Methods: All patients with an in‐hospital pulseless VT or VF cardiac arrest from August 2002 to February 2008 who underwent cardiac catheterization were included. Retrospective chart review was performed to obtain clinical, neurologic, and angiographic data. Primary endpoints were all‐cause mortality and neurologic outcome. Results: Two thousand and thirty‐four patients had in‐hospital cardiac arrest, of these 116 had pulseless VT or VF and were resuscitated and 93 (80%) underwent coronary angiography. The median time to follow‐up was 1.3 years (IQR: 0.5–2.9 years). Obstructive coronary artery disease (CAD) was observed in 74 (79%) individuals, of whom 37 underwent PCI. Thirty‐five patients with obstructive CAD (47%) died compared to 41% with nonobstructive CAD. In unadjusted and multivariable adjusted analysis PCI was not associated with lower mortality (adjusted hazard ratio: 1.54, 95% CI, 0.79–3.02, P = 0.20). No significant differences were noted in neurologic status at discharge (P = 0.49). Conclusion: In this study, an aggressive revascularization strategy with PCI did not confer a survival advantage nor was it associated with improved neurologic outcomes. There was no suggestion of harm with PCI and further studies are necessary to identify potential subgroups that may benefit from revascularization.

Don’t Turn Your Head!

A 67-year-old healthy man presented for evaluation of vertigo. The patient had had intermittent vertiginous symptoms and near syncope with extreme head turning for 1 year. Previous workup included a carotid ultrasound that revealed <29% bilateral stenosis. Transcranial Doppler revealed low flow in the left vertebral artery with high velocities in the right vertebral artery; however, there was no evidence of velocity shift in the basilar artery with head turning. The patient continued to have debilitating symptoms despite conservative therapy for cervicogenic vertigo. Cerebral angiogram with head turning to the left demonstrated a normal right vertebral …

COMPLETE HEART BLOCK ASSOCIATED WITH DENGUE HEMORRHAGIC FEVER

Dengue is the most prevalent viral disease transmitted by mosquitoes, producing clinical illness in 96 million cases annually. It is not uncommon for cardiovascular system to be affected with mosquito-borne dengue virus. Clinical manifestations of cardiac complications have a spectrum from self-

Antithrombotic Therapy in Carotid and Peripheral Intervention

Peripheral arterial disease is a spectrum of disease processes involving the non-coronary arterial system that is primarily the result of atherothrombosis. Although the field of peripheral intervention is older than coronary intervention, the evolution of this field has lagged behind that of its coronary counterpart. Adjunctive therapies demonstrated to be beneficial in the realm of percutaneous coronary interventions (PCI) have not been as systematically assessed within the peripheral arena. Nevertheless, current opinion rests with the belief that adjunctive antiplatelet and antithrombotic agents improve outcomes for patients undergoing peripheral interventional procedures. Future studies will foster a better understanding of the idiosyncrasies related to peripheral interventions and the optimal utilization of currently available and developing antithrombotic agents in order to further advance this field.