Tilak Pasala

Effect of early statin therapy on risk of atrial fibrillation after coronary artery bypass grafting with or without concomitant valve surgery.

Statins decrease postoperative atrial fibrillation (AF) if given before cardiac surgery. However, whether early administration of statins after surgery decreases the risk of postoperative AF is unknown. The association of early reinstitution of postoperative statin therapy within 48 hours to the occurrence of postoperative AF was studied in propensity-adjusted analyses of 200 consecutive patients in sinus rhythm who had undergone coronary artery bypass grafting with or without valve surgery. Postoperative AF occurred in 36 patients (18%). Of 52 patients who received a statin early after surgery, 4 (7.7%) developed AF compared to 32 (28%) of 148 patients who did not (p = 0.043). In the propensity-adjusted analyses, early postoperative statin treatment was associated with a significantly lower occurrence of AF (odds ratio 0.39, 95% confidence interval 0.15 to 0.99), irrespective of concomitant β-blocker therapy. The length of stay was shorter for the patients who received early postoperative statins (median 6.1 days, interquartile range 4 to 7, vs 7.8 days, interquartile range 5 to 8; p = 0.0031). In conclusion, of preoperative statin users undergoing coronary artery bypass grafting with or without valve surgery, early postoperative reinstitution of statins was associated with a lower occurrence of postoperative AF and a shorter length of stay. Early postoperative statin therapy might be a feasible and safe method of reducing postoperative AF.

Clinical and economic studies of eptifibatide in coronary stenting

Platelet adhesion and aggregation at the site of coronary stenting can have catastrophic clinical and economic consequences. Therefore, effective platelet inhibition is vital during and after percutaneous coronary intervention. Eptifibatide is an intravenous antiplatelet agent that blocks the final common pathway of platelet aggregation and thrombus formation by binding to glycoprotein IIb/IIIa receptors on the surface of platelets. In clinical studies, eptifibatide was associated with a significant reduction of mortality, myocardial infarction, or target vessel revascularization in patients with acute coronary syndrome undergoing percutaneous coronary intervention. However, recent trials conducted in the era of dual antiplatelet therapy and newer anticoagulants failed to demonstrate similar results. The previously seen favorable benefit of eptifibatide was mainly offset by the increased risk of bleeding. Current American College of Cardiology/American Heart Association guidelines recommend its use as an adjunct in high-risk patients who are undergoing percutaneous coronary intervention with traditional anticoagulants (heparin or enoxaparin), who are not otherwise at high risk of bleeding. In patients receiving bivalirudin (a newer safer anticoagulant), routine use of eptifibatide is discouraged except in select situations (eg, angiographic complications). Although older pharmacoeconomic studies favor eptifibatide, in the current era of P2Y12 inhibitors and newer safer anticoagulants, the increased costs associated with bleeding make the routine use of eptifibatide an economically nonviable option. The cost-effectiveness of eptifibatide with the use of strategies that decrease the bleeding risk (eg, transradial access) is unknown. This review provides an overview of key clinical and economic studies of eptifibatide well into the current era of potent antiplatelet agents, novel safer anticoagulants, and contemporary percutaneous coronary intervention.

Comparison of approaches for stroke prophylaxis in patients with non-valvular atrial fibrillation: Network meta-analyses of randomized controlled trials

Background Multiple novel oral anticoagulants and left atrial appendage closure devices (WATCHMAN) have been tested against dose-adjusted vitamin K antagonists in randomized controlled trials for stroke prophylaxis in non-valvular atrial fibrillation. No direct comparisons of these strategies are available from randomized controlled trials. We conducted the current analyses by combining efficacy and safety characteristics of all FDA approved stroke prophylaxis treatment strategies for patients with non-valvular atrial fibrillation. Materials and Methods We searched SCOPUS from 1945 till October 2015 for randomized controlled trials comparing these strategies and reporting efficacy and safety outcomes. Six randomized controlled trials were identified and included in the final analyses and review. We followed PRISMA guidelines for network meta-analyses while reporting the current analyses. We collected data on ischemic stroke, major bleeding, and the composite primary safety endpoint as defined by various randomized controlled trials. Network meta-analyses were conducted using consistency and inconsistency models for efficacy and safety outcomes. Surface under the cumulative ranking curve were then utilized to cluster rank these treatments for safety and efficacy. Results Six randomized controlled trials with 59,627 patients comparing six treatment strategies were eligible for the analyses. All prophylaxis strategies had comparable rates of ischemic stroke. Apixaban was associated with the least number of primary safety endpoint events as compared with all other treatments. In the cluster analyses assessing safety and efficacy, apixaban, edoxaban and dabigatran ranked best followed by vitamin K antagonists and rivaroxaban, whereas the WATCHMAN left atrial appendage closure device ranked last. Conclusions Dose-adjusted vitamin K antagonists, novel oral anticoagulants, and the WATCHMAN left atrial appendage closure devices are equally efficacious for ischemic stroke prevention but these treatments have different safety profiles. More randomized controlled trials are needed to directly compare these strategies.

Transradial access mitigates bleeding benefit offered by bivalirudin over heparin in patients undergoing percutaneous coronary intervention: Insights from meta-analysis of randomized and observational studies

OBJECTIVE Recent randomized control trials (RCTs) showed conflicting efficacy and safety between bivalirudin and heparin during percutaneous coronary intervention (PCI). We aimed to perform an updated meta-analysis, including real-world and trial data to examine the factors affecting their risk-benefit ratio. METHODS We searched Medline, the Cochrane library, and meeting abstracts for studies comparing bivalirudin versus heparin during PCI. Random-effect meta-analyses for MACE (major adverse cardiovascular events), stent thrombosis (ST) and major bleeding were performed. p-Value <0.05 was considered statistically significant. RESULTS Meta-analysis of 20 RCTs and 31 observation studies (n=165,835) showed that bivalirudin and heparin were similar in the risk of MACE in RCTs (OR 1.05, 95% CI 0.97-1.13) and observational studies (OR 0.94, 95% 0.81-1.10). Major bleeding was lower with bivalirudin in both RCTs (OR 0.60, 95% CI 0.51-0.70) and observational studies (OR 0.56, 95% CI 0.47-0.68). However, in the metaregression analysis, every 10% increase of transradial access decreased the bleeding benefit of bivalirudin by 4.9% (p=0.046, adjusted for GPI and heparin loading dose). ST with bivalirudin was higher with ST-segment elevation myocardial infarction (STEMI) in RCTs (OR 1.51, 95% CI 1.15-1.99) but not in observational studies (p=0.65). CONCLUSIONS In this large meta-analysis, bivalirudin is associated with a lower risk of bleeding compared to heparin in both RCTs and observational studies, however, transradial PCI mitigated most of this bleeding benefit. Heparin should be the preferred agent in transradial PCI given its lower cost and comparable outcomes.

Aspirin Resistance Predicts Adverse Cardiovascular Events in Patients with Symptomatic Peripheral Artery Disease

Antiplatelet therapy reduces the risk of myocardial infarction, stroke, and vascular death in patients who have symptomatic peripheral artery disease. However, a subset of patients who take aspirin continues to have recurrent cardiovascular events. There are few data on cardiovascular outcomes in patients with peripheral artery disease who manifest aspirin resistance. Patients with peripheral artery disease on long-term aspirin therapy (≥4 wk) were tested for aspirin responsiveness by means of the VerifyNow Aspirin Assay. The mean follow-up duration was 22.6 ± 8.3 months. The primary endpoint was a composite of death, myocardial infarction, or ischemic stroke. Secondary endpoints were the incidence of vascular interventions (surgical or percutaneous), or of amputation or gangrene caused by vascular disease. Of the 120 patients enrolled in the study, 31 (25.8%) were aspirin-resistant and 89 (74.2%) were aspirin-responsive. The primary endpoint occurred in 10 (32.3%) patients in the aspirin-resistant group and in 13 (14.6%) patients in the aspirin-responsive group (hazard ratio=2.48; 95% confidence interval, 1.08-5.66; P=0.03). There was no significant difference in the secondary outcome of revascularization or tissue loss. By multivariate analysis, aspirin resistance and history of chronic kidney disease were the only independent predictors of long-term adverse cardiovascular events. Aspirin resistance is highly prevalent in patients with symptomatic peripheral artery disease and is an independent predictor of adverse cardiovascular risk. Whether intervening in these patients with additional antiplatelet therapies would improve outcomes needs to be explored.

Fusion Imaging for Paravalvular Leak Closure

Paravalvular leak (PVL) is a well-recognized complication after heart valve surgery and transcatheter valve replacement [1, 2]. Historically, repeat open-heart surgery has been the mainstay of treatment for paravalvular leaks [1]. However, recent advances in transcatheter therapies have made percutaneous closure of PVLs a less invasive and safe alternative, especially in those at high risk for repeat surgery. Percutaneous repair of PVLs can be associated with considerable complexity and is advised to be performed at experienced centers [3]. These procedures are heavily reliant on various imaging modalities for pre-procedural planning and intraprocedural guidance. Traditionally, these procedures were guided by 2-dimensional (2D) echocardiographic and fluoroscopic guidance to project complex 3D anatomy. Understandably, this posed challenges for acquiring spatial information that is needed to perform these procedures effectively and safely. The advent of echocardiography and computed tomography angiography (CTA) into 3D and 4D visualization and post-processing technology has allowed a more comprehensive understanding of the anatomy and better intraprocedural guidance. However, individual modalities like fluoroscopy and echocardiography provide different information of the anatomy and are presented separately. It can be challenging for operators to piece together these parallel information simultaneously. The integration of CTA with fluoroscopy (CTA-fluoroscopy fusion) and echocardiography with fluoroscopy (echo-fluoroscopy fusion) in the catheterization laboratory allows operators to overcome many of the challenges posed when these imaging modalities are used individually. Merging relevant information from different imaging modalities on to a composite image, commonly referred to as fusion imaging, has been shown to improve efficacy and safety and reduce the requirement of radiation, contrast, and procedural time [4]. More importantly, fusion imaging provides more accurate intraprocedural guidance when approaching PVL closure.

CENTRAL INDICES OF AORTIC STIFFNESS PREDICT SEVERITY AND BURDEN OF CORONARY ARTERY DISEASE BEYOND TRADITIONAL RISK MODELS

Atherosclerotic cardiovascular disease (ASCVD) risk prediction model includes risk factors such as age, sex, race, cholesterol, and systolic blood pressure (BP). However, routinely used peripheral BP differs from central (ascending aorta) BP with age. Hence traditional models may not accurately

Transcatheter Aortic Valve Replacement for All-comers With Severe Aortic Stenosis: Could It Become a Reality?

Transcatheter aortic valve replacement (TAVR) has progressed at a rapid pace driven by the Heart Valve Team approach and a rigorous commitment to evidence-based medicine. Rapid advances in technology have propelled TAVR to the forefront of treatment options. TAVR has progressed from a procedure performed in hybrid operating rooms under general anesthesia to a cathlab procedure performed under monitored anesthesia, thus reducing hospital stay and in some cases allowing ‘‘same-day’’ discharge. The indications for TAVR have been broadened, supported by hard evidence. Currently, TAVR is indicated for prohibitive, high and intermediate surgical risk patients. However, can TAVR become the therapy of choice for all patients in the near future? To answer this question, we need to explore some of the resolved issues and future challenges (Figure 1) that could make this technology a formidable force in the treatment of aortic stenosis (AS).

Fusion Imaging for Structural Heart Disease Interventions

Purpose of ReviewAccurate procedural guidance is necessary for structural heart disease (SHD) interventions to reduce procedural times and improve results. Fluoroscopy remains the foundation imaging modality for guidance of transcatheter therapy. However, fluoroscopy has limitations in that it only provides 2D projections of complex 3D anatomy. Fusion technology has the capability to project cardiac imaging, including echocardiography and computed tomography (CT), onto fluoroscopy for a more complete representation of the anatomy to help guide SHD interventions. This in turn allows for a more effective workflow that may improve safety and efficacy while decreasing procedural times, radiation exposure, and contrast dosage. This review focuses on the use of fusion imaging for SHD interventions.Recent FindingsRecent studies support the feasibility of fusion imaging for a variety of SHD interventions. The impact of fusion imaging on operator confidence, procedural success rates, and outcome measures, such as procedure time and radiation exposure, are currently being evaluated.SummaryThe use of echocardiography-fluoroscopy and computed tomography angiography (CTA)-fluoroscopy fusion imaging has been established for a multitude of SHD interventions. While fusion imaging has the potential to improve SHD interventions, data is mainly limited to observational studies. Therefore, future studies are needed to evaluate if fusion imaging leads to an improvement in procedural success and a reduction in procedural time, radiation exposure, and contrast dose.

Revisiting Femoral vs. Radial access—do vascular closure devices level the playing field?

Previous large randomized multicenter trials have shown superiority of radial to femoral access in reducing major bleeding, vascular complications, and in some cohorts, mortality Vascular closure devices improve time to hemostasis and ambulation, as well as patient comfort, but have not been shown to reduce major complications or mortality consistently in the high level evidence base. The combination of optimal femoral access and closure with a vascular closure device has the potential to narrow the gap between the radial and femoral approaches in high risk patients, but unfortunately this study was too limited to confirm either non‐inferiority or equivalence