Vipul Gupta

Optimal medical therapy with or without percutaneous coronary intervention in older patients with stable coronary disease: a pre-specified subset analysis of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive druG Evaluation) trial.

OBJECTIVES Our aim was to access clinical effectiveness of percutaneous coronary intervention (PCI) when added to optimal medical therapy (OMT) in older patients with stable coronary artery disease (CAD). BACKGROUND While older patients with CAD are at increased risk for cardiac events compared with younger patients, it is unclear whether PCI may mitigate this risk more effectively than OMT alone or, alternatively, may be associated with more complications. METHODS We conducted a pre-specified analysis of outcomes in stable CAD patients stratified by age and randomized to PCI+OMT or OMT alone in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive druG Evaluation) trial. RESULTS A total of 1,381 patients (60%) were <65 years of age (mean 56+/-6 years) and 904 patients (40%) were >or=65 years of age (mean 72+/-5 years). Achieved treatment targets for blood pressure, low-density lipoprotein cholesterol, adherence to diet and exercise, and angina-free status did not differ by age or treatment assignment. Among older patients, there was a 2- to 3-fold higher death rate, but similar rates of myocardial infarction, stroke, and major cardiac events compared with younger patients. The addition of PCI to OMT did not improve or worsen clinical outcomes in patients>or=65 years of age during a median 4.6 year follow-up. CONCLUSIONS These data support adherence to American College of Cardiology/American Heart Association clinical practice guidelines that advocate OMT as an appropriate initial management strategy, regardless of age. (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation [COURAGE]; NCT00007657).

Effectiveness of percutaneous coronary intervention in patients with silent myocardial ischemia (post hoc analysis of the COURAGE trial)

Previous studies have suggested that percutaneous coronary intervention (PCI) decreases long-term mortality in patients with silent myocardial ischemia (SMI), but whether PCI specifically decreases mortality when added to intensive medical therapy is unknown. We performed a post hoc analysis of clinical outcomes in patients in the COURAGE trial based on the presence or absence of anginal symptoms at baseline. Asymptomatic patients were classified as having SMI by electrocardiographic ischemia at rest or reversible stress perfusion imaging (exercise-induced or pharmacologic). Study end points included the composite primary end point (death or myocardial infarction [MI]); individual end points of death, MI, and hospitalization for acute coronary syndrome; and need for revascularization. Of 2,280 patients 12% (n = 283) had SMI and 88% were symptomatic (n = 1,997). There were no between-group differences in age, gender, cardiac risk factors, previous MI or revascularization, extent of angiographic disease, or ischemia by electrocardiogram or imaging. Compared to symptomatic patients, those with SMI had fewer subsequent revascularizations (16% vs 27%, p <0.001) regardless of treatment assignment and fewer hospitalizations for acute coronary syndrome (7% vs 12%, p <0.04). No significant differences in outcomes were observed between the 2 treatment groups, although there was a trend toward fewer deaths in the PCI group (n = 7, 5%) compared to the optimal medical therapy (OMT) group (n = 16, 11%, p = 0.12). In conclusion, addition of PCI to OMT did not decrease nonfatal cardiac events in patients with SMI but showed a trend toward fewer deaths. Although underpowered, given similar outcomes in other small studies, these findings suggest the need for an adequately powered trial of revascularization versus OMT in SMI patients.

Acute Coronary Syndromes: Selective vs Early Invasive Strategies

Recommendations in the 2007 update of the American College of Cardiology/American Heart Association guidelines for patients with non–ST‐elevation myocardial infarction (NSTEMI) provide considerable latitude regarding treatment choices and care pathways. Nevertheless, as accumulating evidence leads to increased recommendations for early invasive strategies, more patients are likely to receive care that falls short of recommendations. While tailoring pharmacotherapy to optimize the risk/benefit ratio for individual patients remains essential, it becomes increasingly important that care paradigms be prospectively defined. To facilitate this goal, we examined key differences between the 2002 and 2007 guidelines and explored data underlying changed recommendations for periprocedural pharmacotherapy. Copyright

Papel de un nuevo laboratorio de cateterismo cardiaco en la mejora de la asistencia cardiovascular y sus resultados en pacientes con infarto de miocardio

Cardiovascular disease (CVD) is the leading cause of death in the European Union (EU) and accounts for about 40% of all deaths or approximately 2 million deaths per year. CVD also poses a significant financial burden for EU healthcare systems, which has been estimated to be just unders110 billion (2006). In Spain, CVD represents the number one cause of death, accounting for almost 34% of all mortalities. Within this group, ischemic heart disease is the leading cause of death in men. These sobering statistics clearly emphasize the critical need to better define and enact specific healthcare plans and approaches to mitigate the consequences of acute myocardial infarction (MI), which represents the most severe—yet eminently treatable— expression of CVD through enhanced patient access to specialized tertiary services and life-saving technology. There is an abundance of medical literature to support the important role for the prompt and timely diagnosis and management of patients with acute MI, particularly with the advent of primary percutaneous coronary intervention (PCI) for acute MI and acute coronary syndromes. In this issue of Revista Española de Cardiologı́a, the REGICOR investigators report their single-site clinical experience of outcomes using a longitudinal, comparative analysis before and after the establishment of a cardiac catheterization facility. In this study the REGICOR authors evaluated the impact of opening an on-site diagnostic cardiac catheterization facility on 30-day and 2-year cardiovascular mortality in patients aged 25-74 admitted with acute MI. The authors compared clinical outcomes of MI patients during two temporal periods of observation, one of which (from 1995-1997) was defined as the first, or referent, period, and a later time interval (from 1999-2003) that was defined as the second period, with access to the cardiac catheterization laboratory that opened in 1998. As part of this temporal ‘‘before and after’’ analysis, the authors prospectively evaluated 1,539 consecutive acute MI patients, of which 641 were admitted with acuteMI in the first, pre-catheterization laboratory period and 898 consecutive MI patients who were admitted with acute MI in the second, post-catheterization laboratory period. As noted above, the primary outcome measure for this comparative analysis was 30-day and 2-year cardiovascular mortality. A secondary objective was to compare the effect of the post-MI discharge medication regimen on clinical outcomes in these patients. In light of the continued evolution in the definition of acute MI that has occurred over the past decade (most recently, the new American College of Cardiology [ACC]/American Heart Association [AHA]/European Society of Cardiology [ESC] MI Guidelines) and because of increasingly more sensitive and sophisticated biochemical assays to detect smaller amounts of myocardial necrosis during the study periods, there is not a standardized or uniform definition of MI in this temporal assessment of MI outcomes by the REGICOR Group investigators, as compared with the current MI definition. Moreover, in-person follow-up was not directly ascertained in this study, inasmuch as a telephonic 2-year follow-up was conducted on patients who survived the first 30 days after index MI event. Nevertheless, the authors found— perhaps not surprisingly—that concomitant with the availability of an on-site catheterization laboratory, the number of coronary catheterization and PCI procedures increased. Additionally, timeto-procedure decreased in the second time period, as would be expected with the advent of an on-site, invasive facility. The principal findings of the current study reveal that at 30 days the rate of death or post-infarction angina was lower in the second period, with the initiation of an on-site cardiac catheterization laboratory, and at 2 years of follow-up the all-cause and cardiovascular death rates were likewise lower in the second period, which in part may also be contributed by the increased use of evidence-based medical therapy for these MI patients at hospital discharge. However, just as cardiac catheterization and catheter-based intervention has evolved dramatically over the past 10-20 years, so too has the robustness and intensity of medical therapy and secondary prevention. With mounting (and compelling) scientific evidence derived frommultiple randomized trials, it is clear that physicians have a wider therapeutic armamentarium from which to choose clinically in MI patients, including Rev Esp Cardiol. 2011;64(2):87–88