Эпизоды
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TICA-CLOP STUDY: Ticagrelor Versus Clopidogrel in Acute Moderate and Moderate-to-Severe Ischemic Stroke, aRandomized Controlled Multi-Center Trial
Randomized Controlled Trial CNS Drugs. 2025Jan;39(1):81-93. doi: 10.1007/s40263-024-01127-7.
Abstract
Background: Many studies evaluated the efficacyand safety of ticagrelor versus clopidogrel in patients with ischemic stroke; none of these trials included North African participants, and all of these trials comprised only participants who experienced transient ischemic attack(TIA) or minor stroke.
Objectives: We compared the efficacy and safety of ticagrelor versus clopidogrel in patients with first-ever noncardioembolic moderate or moderate-to-severe ischemic stroke.
Methods: Our trial involved 900 first-ever noncardioembolic patients with acute ischemic stroke (AIS) who randomlyreceived either loading and maintenance doses of ticagrelor or clopidogrel within the first 24 hour of stroke onset.
Results: We involved 900 patients in the intention-to-treat analysis. A total of 39 (8.7%) patients in ticagrelor armand 62 (13.8%) in clopidogrel arm experienced a new stroke [hazard ratio (HR) 0.46; 95% confidence interval (CI) 0.34-0.83; P value = 0.006]. A total of 57 (12.7%) patients in ticagrelor group and 80 (17.8%) patients in clopidogrelgroup experienced composite of new stroke, myocardial infarction (MI), or death due to vascular insults (HR0.51; 95% CI 0.43-0.82; P value = 0.004). Participants who received ticagrelor experienced less frequent unfavorable outcomes. We found no significant variation between our study's two arms concerning the hemorrhagic and non-hemorrhagic complications.
Conclusion: Patients with noncardioembolic moderate or moderate-to-severe ischemic stroke who received ticagrelor within the first 24 h after ischemic stroke had better clinical outcomes based on recurrent stroke rates and unfavorable modified Rankin Scale (mRS) rates compared with those who received clopidogrel. There were no significant variations between ticagrelor and clopidogrel regarding hemorrhagic and non-hemorrhagic complications.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Examining the Specificity of Smartphone ECG Devices in Decision-Making for ST-Elevation Myocardial Infarction andNon-ST-Elevation Myocardial Infarction
DOI: https://doi.org/10.30701/ijc.1740
Abstract
Background & Objectives: Electrocardiography(ECG) stands as a cornerstone diagnostic tool for assessing cardiac health, particularly in ruling out abnormalities. The integration of smartphone devices presents a promising avenue for expedited detection of cardiac irregularities.This study aims to evaluate the diagnostic efficacy of smartphone ECG devices in subjects admitted to Cardiac Care Units (CCUs) and Cardiac Intensive CareUnits (CICUs).
Methods: A retrospective analysis was conducted on acohort comprising 62 patients presenting with cardiac symptoms. Utilizing smartphone ECG devices as the index, 12-lead ECG tests were administered alongside the Gold Standard ECG machine for comparison among patients in Cardiac Care Units and Cardiac Intensive Care Units. Diagnostic decisions concerning the presence of ST-Elevation Myocardial Infarction (STEMI) or Non-ST-ElevationMyocardial Infarction (NSTEMI) were made by a team of cardiologists following a meticulous review of both sets of ECG reports.
Results: Data analysis was conducted on 56 patients.The smartphone-based ECG device exhibited 100% specificity, 93% sensitivity, 80% Negative Predictive Value, and 100% Positive Predictive Value, yielding an F-score of 0.96 and a Mathew Correlation Coefficient value of 0.86.
This study unequivocally underscores the significantpotential of the Spandan ECG device in accurately identifying a range of cardiac abnormalities, including critical conditions such as ST-Elevation Myocardial Infarction and ischemia. Despite its portable nature, smartphone ECGtechnology demonstrates utility within Critical Care Units for timely monitoring and diagnosis.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Пропущенные эпизоды?
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Metoprolol vs diltiazem for atrial fibrillation with rapid ventricular rate: Systematic review and meta-analysisof adverse events
https://doi.org/10.1016/j.ajem.2024.12.070
Abstract
Background
Intravenous (IV) diltiazem and metoprololare commonly used to achieve rate control for atrial fibrillation with rapid ventricular rate (Afib with RVR), and are both recommended as first-line by current guidelines. While prior studies investigated the efficacy of thesemedications, there is little evidence available regarding the risk of adverse events (AEs) with their use.
Methods
We identified randomized controlled trials(RCT) and observational studies reporting rates of adverse events following administration of Intravenous diltiazem and metoprolol for atrial fibrillation with rapid ventricular rate by searching PubMed, SCOPUS, EMBASE, and CochraneLibrary. Our primary outcome was the incidence of adverse events and specifically hypotension and bradycardia, which were examined individually as secondary outcomes. We performed random-effects meta-analysis to identify ratesof each adverse events. We used moderator analysis and meta-regressions to evaluate risk factors. We used the Cochrane Risk-of-Bias 2 tool and the Newcastle-Ottawa Scale to assess study quality.
Results
We reviewed 13 studies and included 1660 patients, 888 (53 %) treated with metoprolol and 772 (47 %) with diltiazem.Metoprolol was associated with a 26 % lower risk of adverse event (total incidence 10 %) compared to diltiazem (total incidence 19 %), (RR 0.74, 95 % CI 0.56–0.98, p = 0.034) with a prediction interval of 0.50–1.10. Patients with higherinitial heart rates faced higher rates of adverse events (Correlation Coefficient 0.11, 95 % CI 0.03–0.19, p = 0.006). There was no difference with respect to rates of bradycardia (RR 0.44, 95 % CI 0.15–1.30, p = 0.14) or hypotension (RR 0.80, 95 % CI 0.61–1.04, p = 0.10).
Conclusion
Atrial fibrillation with rapid ventricular rate treated with metoprolol had lower rates of adverse event (bradycardiaand/or hypotension) compared to those treated with diltiazem. We found no difference in rates of hypotension or bradycardia when individually assessed. Existing data are limited by small sample sizes, variability in dosing, andlimited representation of important patient subgroups.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Impact of beta-blocker up titration on patientsafter transcatheter edge-to-edge mitral valve repair for secondary mitral regurgitation: The OCEAN-mitral registry
https://doi.org/10.1016/j.ijcard.2024.132595
Abstract
Background
Optimal medical therapy for patients with secondary mitralregurgitation (SMR) undergoing transcatheter edge-to-edge mitral valve repair (M-TEER) remains unclear. This study aimed to investigate the association between beta-blocker up titration and clinical outcomes after mitral transcatheteredge-to-edge repair.
Methods
Using data from the Japanese multicenter registry, weexamined 1474 patients who underwent mitral transcatheter edge-to-edge repair for secondary mitral regurgitation between April 2018 and June 2021. Beta-blocker up titration was defined as an increased dose of beta-blockers 1 month after mitral transcatheter edge-to-edge repair comparedwith that before mitral transcatheter edge-to-edge repair. The 2-year clinical outcomes were compared betweenpatients with and without beta-blocker up titration, utilizing multivariable Cox regression analyses andpropensity score matching (PSM).
Results
Of the 1474 patients who underwent mitral transcatheter edge-to-edge repair, 272 (18.4 %) were receiving increasing doses of beta-blockers at the 1-month follow-up. These patients had lower left ventricular ejection fraction (LVEF)and higher B-type natriuretic peptide levels. Most patients in the beta-blocker up titration group received less than the target dose of beta-blockers. Multivariable Coxregression analyses showed that beta-blocker up titration was significantly associated with a lower risk of all-cause (adjusted hazard ratio [HR]: 0.55; 95 % confidence interval [CI]: 0.36–0.84; P = 0.006) and cardiovascular mortalities (adjusted HR: 0.45, 95 % CI: 0.26–0.79, P = 0.006).Propensity score matching analyses revealed consistent findings. Subgroup analyses revealed a significant interaction between beta-blocker uptitration and leftventricular ejection fraction ≤40 % (interaction P = 0.018).
Conclusions
In patients with secondary mitral regurgitation,beta-blocker uptitration after mitral transcatheter edge-to-edge repair was associated with better clinical outcomes, especially in the group with an left ventricular ejection fraction ≤40 %. Efforts to up titrate guideline-directedmedical therapy after mitral transcatheter edge-to-edge repair for secondary mitral regurgitation may be necessary, even if reaching the target dose proves challenging.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Intravascular imaging-guided percutaneous coronary intervention in patients with acute myocardial infarction and cardiogenic shock
Rev Esp Cardiol (Engl Ed) . 2024 Dec;77(12):995-1007.
Abstract
Introduction and objectives: There are no clinicaldata on the efficacy of intravascular imaging-guided percutaneous coronary intervention (PCI) compared with angiography-guided percutaneous coronaryintervention in patients with acute myocardial infarction (AMI) and cardiogenic shock. The current study sought to evaluate the impact of intravascular imaging-guided percutaneous coronary intervention in patients with acutemyocardial infarction and cardiogenic shock.
Methods: Among a total of 28, 732 patients from thenationwide pooled registry of KAMIR-NIH (November, 2011 to December, 2015) and KAMIR-V (January, 2016 to June, 2020), we selected a total of 1833 patients (6.4%) with acute myocardial infarction and cardiogenic shock who underwent percutaneous coronary intervention of the culprit vessel. The primary endpoint was major adverse cardiovascular events (MACE) at 1 year, a composite of cardiac death, myocardial infarction, repeat revascularization, and definite or probable stent thrombosis.
Results: Among the study population, 375 patients(20.5%) underwent intravascular imaging-guided percutaneous coronary intervention and 1458 patients (79.5%) underwent angiography-guided percutaneouscoronary intervention. Intravascular imaging-guided percutaneous coronary intervention was associated with a significantly lower risk of 1-year major adverse cardiovascular events than angiography-guided percutaneous coronary intervention (19.5% vs 28.2%; HR, 0.59; 95%CI, 0.45-0.77; P<.001), mainly driven by a lowerrisk of cardiac death (13.7% vs 24.0%; adjusted HR, 0.53; 95%CI, 0.39-0.72; P<.001). These results were consistent in propensity score matching (HR, 0.68; 95%CI, 0.46-0.99),inverse probability weighting (HR, 0.61; 95%CI, 0.45-0.83), and Bayesian analysis (Odds ratio, 0.66, 95% credibleinterval, 0.49-0.88).
Conclusions: In acute myocardial infarction patientswith cardiogenic shock, intravascular imaging-guided percutaneous coronary intervention was associated with a lower risk of major adverse cardiovascular events at 1-year than angiography-guided percutaneous coronary intervention, mainly driven by the lower risk of cardiac death.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Global Impact of Optimal Implementation of Guideline-Directed Medical Therapy in Heart Failure
JAMA Cardiol . 2024 Dec 1;9(12):1154-1158. doi: 10.1001/jamacardio.2024.3023.
Abstract
Importance: Guideline-directed medical therapy (GDMT) remains underutilized on a global level, with significant disparities in access to treatment worldwide. The potential global benefits of quadruple therapy on patients with heart failure with reduced ejection fraction (HFrEF) have not yet been estimated.
Objective: To assess the projected population-level benefit of optimal Guideline-directed medical therapy useglobally among patients with heart failure with reduced ejection fraction.
Design, setting, and participants:Estimates for heart failure with reduced ejection fraction prevalence, contraindications to Guideline-directed medical therapy, treatment rates, and the number needed to treat for all-cause mortality at 12 months were derived from previously published sources. Potential lives saved from optimal implementation of quadruple therapy among patients with heart failure with reduced ejection fraction was calculated globally and a sensitivity analysiswas conducted to account for uncertainty in the existing data.
Main outcomes and measures: All-cause mortality.
Results: Of an estimated 28.89million people with heart failure with reduced ejection fraction worldwide, there were 8 2,35 063 (95% CI, 6 296 020-10 762 972) potentially eligible for but not receiving β-blockers, 20, 387 000 (95% CI, 15 867 004-26 184 996)eligible for but not receiving angiotensin receptor-neprilysin inhibitors, 12 223 700 (95% CI, 9 376 895-15 924 973)eligible for but not receiving mineralocorticoid receptor antagonists, and 21 229 170 (95% CI, 16 537 400-27 242 688)eligible for but not receiving sodium glucose cotransporter-2 inhibitors. Optimal implementation of quadruple Guideline-directed medical therapy could potentially prevent 1 188 277 (95% CI, 767 933-1 914 561) deaths over 12 months. A largeproportion of deaths averted were projected in Southeast Asia, Eastern Mediterranean and Africa, and the Western Pacific regions.
Conclusions and relevance: Improvementin use of Guideline-directed medical therapy could result in substantial mortality benefits on a global scale. Significant heterogeneity also exists across regions, which warrants additional study with interventions tailored to country-level differences for optimization of Guideline-directed medicaltherapy worldwide.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Impact of Adherence to Beta-Blockers in Patients With All-Comers ST-Segment Elevation Myocardial Infarction andAccording to Left Ventricular Ejection Fraction at Discharge: Results From the Real-World Registry FAST-STEMI
J Cardiovasc Pharmacol . 2024 Dec 1;84(6):581-589. doi: 10.1097/FJC.0000000000001627.
Abstract
Beta-blockers are a crucial part of post-myocardial infarction (MI) pharmacological therapy. Recent studies haveraised questions about their efficacy in patients without reduced left ventricular ejection fraction (LVEF). This study aims to assess adherence to beta-blockers after discharge for ST-segment elevation myocardial infarction(STEMI) and the impact of adherence on outcomes based on left ventricular ejection fraction at discharge. The retrospective registry FAST-STEMI evaluated real-world adherence to main cardiovascular drugs in patients with ST-segment elevation myocardial infarction between 2012 and 2017 by comparing purchased tablets with expected ones at 1 year through pharmacy registries. Optimal adherence was defined as ≥80%. Primary outcomes included all-cause andcardiovascular death while secondary outcomes were MI, major/minor bleeding events, and ischemic stroke. The study included 4688 patients discharged on beta-blockers. The mean age was 64 ± 12.3 years, 76% were male, and the mean left ventricular ejection fraction was 49.2 ± 8.8%. The mean adherence at 1 year was 87.1%. Optimal adherence was associated with lower all-cause (adjusted hazard ratio, 0.62, 95% confidence interval, 0.41-0.92, P : 0.02) and cardiovascular (adjusted hazards ratio, 0.55, 95% confidence interval, 0.26-0.98, P : 0.043) mortality. In patientswith left ventricular ejection fraction ≤40%, optimal adherence was linked to reduced all-cause and cardiovascular mortality, but this was not found inpatients with either preserved or mildly reduced left ventricular ejection fraction. Predictors of cardiovascular mortality included older age, chronic kidney disease, male gender, and atrial fibrillation. Optimal adherence tobeta-blocker therapy in patients with all-comers ST-segment elevation myocardial infarction reduced all-cause and cardiovascular mortality at 1 year; once stratified by left ventricular ejection fraction, this effect was confirmed only in patients with reduced left ventricular ejection fraction(<40%) at hospital discharge. Impact of adherence to beta-blockers in all-comers ST-segment elevation myocardial infarction patients and according to left ventricular ejection fraction at discharge: results from the real-worldregistry FAST-STEMI.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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A comparison of the effects of ticagrelor and clopidogrel in patients with acute ST-segment elevation myocardialinfarction: a systematic review and meta-analysis of randomized clinical trials
BMC Pharmacol Toxicol. 2024 Dec9;25(1):93. doi: 10.1186/s40360-024-00817-8.
Abstract
Background: Rupture of unstable coronary atherosclerotic plaque leads to acute ST-segment elevation myocardialinfarction (STEMI). Dual anti-platelet therapy is one of the main treatments, and the combination of Aspirin and Clopidogrel is recognized as the standard oralregimen in most cases. Ticagrelor is a new generation of P2Y12 receptor inhibitors. We aimed to compare the effect of Ticagrelor and Clopidogrel in the treatment of patients post- ST-segment elevation myocardial infarction.
Methods: This study investigated PubMed, Scopus, Google Scholar Web of Science, and Embase Cochrane Library clinical trials.gov databases. Heterogeneity between studies was assessed using the I2 index and the Q statistic. The random effects model was used to combinestudies and the Funnel plot and Egger's test were used to assess the publication bias.
Results: Eleven studies were included in this meta-analysis. 5274 patients in the Ticagrelor and 5,295 patients in the Clopidogrel groups were examined. The mean age of the patients was 58.84 years (2.70) and 59.92 years (3.19)in the Ticagrelor and Clopidogrel groups, respectively. Based on the results of the meta-analysis, compared to Clopidogrel, Ticagrelor had decreased the outcomes of mortality, recurrent myocardial infarction, stroke, and MajorAdverse Cardiovascular Events (MACE). However, the post-myocardial infarction bleeding according to Bleeding Academic Research Consortium (BARC) criteria andreperfusion state regarding thrombolysis in myocardial infarction (TIMI) Flow Grading system showed no differences in both groups. However, these effects were not statistically significant.
Conclusions: Ticagrelor decreased thechance of mortality, re-infarction, stroke, and Major Adverse Cardiovascular Events in post- ST-segment elevation myocardial infarction patients compared to clopidogrel. But there was no difference in the chance of major bleedings (BARC ≥ 3) and improvement in thrombolysis in myocardial infarction grade flow between these two drugs. However, none of these findings were statistically significant, and more studies are needed to reach definitive results.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STARUPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.
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Contemporary Use of β-Blockers in Heart Failure Patients With and Without Atrial Fibrillation: A NationwideDatabase Analysis
Clin Pharmacol Ther. 2024 Nov 18. doi: 10.1002/cpt.3496.
Abstract
Evidence of the effectiveness of β-blockers in heart failure (HF) and atrial fibrillation (AF) in a contemporary cohort is controversial. This study investigated the association between the use of β-blockers and prognosis in hospitalized heart failure patients with and without atrial fibrillation in Japan. Patients hospitalized with the first episode of acute heart failure were identified from the National Database of Health Insurance Claims and Specific Health Checkupsof Japan between April 2014 and March 2021. Associations of β-blocker use and prognosis were compared by propensity score matching among the atrial fibrillation or non- atrial fibrillation group. A mixed-effects survival modelwas used, and hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. Among 428,650 patients discharged with Heart Failure in 4,433 hospitals, 175,174 (40.9%) were ≥ 85 years old, 151,873 (35.4%) hadcomplicated atrial fibrillation, and 236 ,457 (55.2%) were β-blocker users. In a matched atrial fibrillation group, β-blocker use was associated with a lower composite outcome of all-cause mortality or HF rehospitalization (HR [95% CI], 0.95 [0.93-0.97]). A similar result was obtained in a matched non- atrial fibrillation group (0.95 [0.94-0.96]). Inaddition, the hazard ratios in patients aged ≥ 85 years and female patients were 1.00 [0.98-1.02] and 1.01 [0.98-1.03]in the atrial fibrillation group and 1.03 [1.01-1.05] and 0.98 [0.97-1.00] in the non- atrial fibrillation group, respectively. The favorable prognostic associations of β-blocker usewere observed regardless of atrial fibrillation in patients across a broad spectrum of heart failure in a superaged society.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of anyscientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on thiswebsite.
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Guideline-directed medical therapy improves cell viability in an iPSC-derived cardiomyocyte hypoxia injury model
https://doi.org/10.1161/circ.150.suppl_1.4147229
Abstract
Introduction: Beta blockers, renin-angiotensin-aldosterone antagonists, and mineralocorticoid antagonists are mainstays of current guideline-directed medical therapy (GDMT) in heart failure with reduced ejection fraction. Theyhave been shown to reduce morbidity and mortality in heart failure patients, reverse remodeling, and improve left ventricular ejection fraction (LVEF) in landmark human clinical trials. Guideline-directed medical therapy has beenhypothesized to interact and have protective effects in bioenergetics in cardiac injury by reducing cardiac workload and energy demand. We have previously used a human induced pluripotent stem cell (iPSC)-derived cardiomyocytes (iCM) injury model to provide an in vitro validation of bioenergetics through measurement of cell viability and proliferation, intracellular measurement of ATP, contractility, and respiratory function. The application of guideline-directed medical therapy in this in vitro model hasnot been previously assessed.
Methods: Highly pure cardiomyocytes were differentiated from a healthy, human monoclonal induced pluripotent stem cell line using CHIR99021 followed by C59 to modulate Wnt pathway activity. Upon spontaneous contractility, cardiomyocytes were replated for purification. Prior to hypoxia exposure, cardiomyocytes were treated with either 5uM metoprolol, 5uM losartan, 5uM spironolactone, or acontrol for 24 hours. To mimic in vivo ischemia, cardiomyocytes are placed in a glucose deprived media (GDM) in a hypoxia inductor chamber with <1% oxygen-containing mixed gas in a 37°C incubator for 18 hours. A second cardiomyocytes group is similarly treated in GDM for 18 hours in a normoxic setting. Cell viability and proliferation was then studied using MTT assay.
Results: The metoprolol, losartan, and spironolactone treatment groups significantly improved cell viability after hypoxic injury when compared to the control treatment groups. Metoprolol treatment had the highest cell viabilityafter hypoxic injury (46%), followed by spironolactone (23%) and losartan (22%), compared to control (13%). In the normoxic group, metoprolol, losartan, and spironolactone treatment showed no significant difference in viabilitycompared to the control group.
Conclusion:iPSC-derived iCMs treated with guideline-directed medical therapy improved cell viability after hypoxic injury. The iPSC hypoxia-injury model appears to be a promising in vitro platform for studying the effects of guideline-directedmedical therapy on cellular bioenergetics.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of anyscientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on thiswebsite.
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Exploring The Risks And Benefits ofUpstream Loading of P2Y12 inhibitors In Acute Coronary Syndrome Patients
https://doi.org/10.1161/circ.150.suppl_1.4139561
Abstract
Background: Acute coronary syndrome (ACS) is theleading cause of heart disease, resulting in over 300,000 deaths annually. The 2014 ACC/AHA guideline recommends a loading dose of a P2Y12 receptor inhibitorprior to PCI with stenting (Class IA).
Objective: This study aims to evaluate therisks and benefits of upstream loading of P2Y12 inhibitors in Acute coronary syndrome patients.
Methodology: We retrospectively analyzed thecharts of all Acute coronary syndrome patients over 18 years old admitted to our community hospital in Michigan from August 2022 to July 2023. Exclusion criteria included patients with type II NSTEMI, hypersensitivity to P2Y12 inhibitors, active bleeding, hemoglobin levels less than 7 g/dl, those already on P2Y12 inhibitors, and pregnant patients.
Results: Out of 518 patients reviewed, 399 were included in the study. Among 285 NSTEMI patients, 89.5% were not loaded with P2Y12 inhibitors in the ED, while 10.5% were. In the loaded group, 3% underwent CABG, 90% required PCI, and 6% received medical treatment. In the non-loadedgroup, 12.5% underwent CABG, one patient had an aortic dissection, and 53.8% and 33.7% required PCI and medical treatment, respectively. Among 114 STEMI patients, 74.5% were not loaded with P2Y12 inhibitors in the ED, while 25.5% were. In the loaded group, 100% required PCI. In the non-loaded group, 8.2% underwent CABG, and 92% requiredPCI.
Conclusion: Our real-world data from a communityhospital indicate that most Acute coronary syndrome patients benefit from P2Y12 loading, with only a minority experiencing adverse effects. To address this, weplan to collaborate with our information technology department to implement reminders for ED physicians to consult with cardiologists about P2Y12 inhibitorloading in Acute coronary syndrome patients.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of anyscientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on thiswebsite.
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Ticagrelor monotherapy the wayforward after Percutaneous Coronary Interventions: An updated meta-analysis
https://doi.org/10.1161/circ.150.suppl_1.4124335
Abstract
Background: With the advent of newer generation drug eluting stents, the chorus for shortening the duration of dual antiplatelet therapy (DAPT) after percutaneous coronary interventions (PCI) is getting louder and louder.Ticagrelor monotherapy after a short course of dual antiplatelet therapy has been studied in a few randomized controlled trials with promising results. Weconducted a systematic review and meta-analysis comparing the ticagrelor monotherapy with dual antiplatelet therapy after short duration dual antiplatelet therapy in patients undergoing percutaneous coronaryinterventions.
Methods: PubMed, Embase and Cochrane databases were searched for Randomized Control Trials comparing ticagrelor monotherapy to dual antiplatelet therapy after percutaneous coronary interventions and reported the outcomes of Major Adverse Cardiac Events including death, myocardial infarction or stroke (MACE); Major AdverseCardiac and Cerebrovascular Events including death, myocardial infarction, stroke, stent thrombosis or target vessel revascularization (MACCE); Major bleeding; Death from any cause; CV death; Stent thrombosis and Target vessel revascularization (TVR). Data were extracted from published reports and quality assessment was performed per Cochrane recommendations. Statistical analysis wasperformed using Review Manager Web (Cochrane Collaboration). Heterogeneity was examined with I2test.
Results: Out of 3208 database results, 5 Randomized Control Trials with 32,393 patients were included; 16,188 (50%) received Ticagrelor monotherapy. Studieshad mean follow-up ranging from 12 months to 24 months. Baseline characteristics are as per Table 1. Safety endpoints of major bleeding (HR 0.50; 95% CI 0.38-0.66; p < 0.0001; I2= 23 %; Figure 1A), was significantly less with ticagrelor monotherapy. Efficacy endpoints of MACE ,MACCE, Death from any cause, CV Death, target vessel revascularization (TVR) and stent thrombosis were not significantly different between ticagrelor and dual antiplatelettherapy (Figure 1 and 2).
Conclusion:Ticagrelor monotherapy reduces major bleeding as compared to continued dual antiplatelet therapy for 12 months after percutaneous coronary interventions.Major ischemic outcomes were similar in both groups. Ticagrelor monotherapy may be the way forward after short duration of dual antiplatelet therapy in patients undergoing percutaneous coronary interventions.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of anyscientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on thiswebsite.
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Position of Beta-blockers in the Treatment of Hypertension Today: An Indian Consensus
J Assoc Physicians India . 2024 Oct;72(10):83-90. doi:10.59556/japi.72.0715.
Abstract
Background: Management of essential hypertension(HTN) remains challenging, with contemporary control being achieved in <1/10 of the cases, especially when aligned with the recently updated guidelines ofAmerican College of Cardiology (ACC) or International Society of Hypertension (ISH). The place and positioning of beta-blockers have been evolving, withrecent focused updates, such as the European Society of Hypertension (ESH) 2023 guidelines, that may hold relevance for the Indian phenotypic traits of prematurecardiovascular disease (CVD), fragile coronary architecture, and/or high resting heart rate. To further develop consensus on the clinical role andrelevance of beta-blockers, including nebivolol, an Indian consensus was evolved with graded recommendations on their clinical role in hypertension,hypertension with additional cardiovascular (CV) risk, or type 2 diabetes mellitus (T2DM).
Methodology: An expert review panel was constituted,comprising interventional and clinical cardiologists as experts, to synthesize the literature for the development of a validated knowledge, attitude, and practice (KAP) survey questionnaire. Research databases, including Cochrane Systematic Reviews, PubMed, and Google Scholar, were accessed for contemporaryinformation and guidelines on beta-blockers updated until Dec 2023. Delphi rounds were conducted to develop graded recommendations based on the strength, quality of evidence, and the agreement among the panelists (n = 9). Consensus was achieved on the graded recommendations, with ≥70% of national panelists in agreement.
Results: Ninety-six percent of respondents opinedthat the new European Society of Hypertension guidelines (2023) help gain confidence in using beta-blockers, which are considered first-line drugs forthe treatment of Hypertension. Beta-blockers, including nebivolol, can be recommended in patients with Hypertension with high resting heart rates,including young hypertensive patients under 40 years of age. For people under 60 years old with Hypertension, regardless of whether they have comorbiddiseases, beta-blockers are the recommended drug choice. Ninety-five percent of respondents opined that nebivolol is the preferred beta-blocker in hypertensivepatients with T2DM, followed by bisoprolol and metoprolol. More than 90% of respondents opined that the three most commonly preferred beta-blockers byexperts in patients with angina were nebivolol, metoprolol, and bisoprolol.
Conclusion: Beta-blockers, including metoprolol and nebivolol, can be considered initial-line therapy for Hypertension management in real-lifesettings in India and nebivolol is preferred because of its two important properties: highest beta-1 selectivity and endothelial-dependent vasodilation.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on thiswebsite.
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Short-Term Dual Antiplatelet TherapyAfter Drug-Eluting Stenting in Patients With Acute Coronary Syndromes. A Systematic Review and Network Meta-Analysis
JAMA Cardiol. Published online October 9, 2024.doi:10.1001/jamacardio.2024.3216
Abstract
Importance : The optimal duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) remains under debate.
Objectives: To analyze the efficacy and safety of dual antiplatelet therapy strategies in patients with acute coronary syndromes using a bayesian network meta-analysis.
Data Sources : MEDLINE, Embase, Cochrane, and LILACS databases were searched from inception to April 8, 2024.
Study Selection : Randomized clinical trials (RCTs) comparing dual antiplatelet therapy duration strategiesin patients with acute coronary syndromes undergoing percutaneous coronary intervention were selected. Short-term strategies (1 month of DAPT followed byP2Y12 inhibitors, 3 months of dual antiplatelet therapy followed by P2Y12 inhibitors, 3 months of DAPT followed by aspirin, and 6 months of dual antiplatelet therapy followed by aspirin) were compared with conventional 12 months of dual antiplatelet therapy.
Data Extraction and Synthesis: This systematic reviewand network meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The risk ratio (RR) with a 95% credible interval (CrI) was calculated within a bayesian random-effects network meta-analysis. Treatments were ranked using surface under the cumulative ranking (SUCRA).
Main Outcomes and Measures : The primary efficacy end point was major adverse cardiac and cerebrovascular events (MACCE); the primary safety end point was major bleeding.
Results: A total of 15 RCTs randomizing 35 ,326 patients (mean [SD] age, 63.1 [11.1] years; 26 ,954 male [76.3%]; 11 ,339 STEMI [32.1%]) withacute coronary syndromes were included. A total of 24, 797 patients (70.2%)received potent P2Y12 inhibitors (ticagrelor or prasugrel). Compared with 12 months of dual antiplatelet therapy, 1 month of dual antiplatelet therapyfollowed by P2Y12 inhibitors reduced major bleeding (RR, 0.47; 95% CrI, 0.26-0.74) with no difference in major adverse cardiac and cerebrovascular events (RR, 1.00; 95% CrI, 0.70-1.41). No significant differences were observed in major adverse cardiac andcerebrovascular events incidence between strategies, although CrIs were wide. SUCRA ranked 1 month of dual antiplatelet therapy followed by P2Y12 inhibitors as the best for reducing major bleeding and 3 months of dual antiplatelet therapy followed by P2Y12 inhibitors as optimal for reducing major adverse cardiac andcerebrovascular events (RR, 0.85; 95% CrI, 0.56-1.21).
Conclusion and Relevance: Results of this systematic review and network meta-analysis reveal that, in patients with acute coronary syndromes undergoing percutaneous coronary intervention with DES, 1 month of dual antiplatelet therapy followed by potent P2Y12 inhibitor monotherapy was associated with a reduction in major bleeding without increasing major adverse cardiac and cerebrovascular events when compared with 12 months of dual antiplatelet therapy. However, anincreased risk of major adverse cardiac and cerebrovascular events cannot be excluded, and 3 months of dual antiplatelet therapy followed by potent P2Y12 inhibitor monotherapy was ranked as the best option to reduce major adverse cardiac and cerebrovascular events. Because most patients receiving P2Y12 inhibitor monotherapy were taking ticagrelor, the safety of stopping aspirin in those taking clopidogrel remains unclear.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of anyscientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on thiswebsite.
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Antihypertensive therapy in patients with arterial hypertension and concomitant diseases in real clinical practice (according to the National Registry of Arterial Hypertension, 2019–2022)
https://doi.org/10.26442/00403660.2024.09.202848
Abstract
Background. Arterial hypertension remains theleading risk factor associated with cardiovascular diseases (CVDs), cerebrovascular disease and chronic kidney disease. About 70% of patients with Arterialhypertension who are on monotherapy cannot achieve blood pressure (BP) targets, and therefore all guidelines for the management of Arterial hypertension haverecently recommended prescribing combination therapy (PCT). In real clinical practice (RCP), there remains significant uncertainty in the effectiveness andrationality of therapy, despite the wide availability of antihypertensive drugs (AHD) and the presence of recommendations for a stepwise approach toprescribing combinations of specific groups of antihypertensive drugs in different clinical situations.
Aim. Analyze the real ongoing antihypertensivetherapy, including the prescribing combination therapy; international nonproprietary names of drugs and their dosages in real clinical practice; compliance of therapy with clinical recommendations; changing trends in the prescribing combination therapy.
Materials and methods. An analysis was carried out ofthe data from the register of Arterial hypertension, the compliance of treatment in different clinical groups of patients and the achievement of BP and low-density lipoprotein cholesterol targets in the sample of 2019–2022 (n=5012). The prescription of antihypertensive drugs and achievement of targets values wereassessed in accordance with current clinical guidelines for the management of Arterial hypertension and hypercholesterolemia. Data from 2010 (n=7782) and 2020 (n=3061) were analyzed to assess the dynamics of prescription of monotherapy and prescribing combination therapy.
Results. The greatest increase in the number of antihypertensive drugs was observed in patients withhypertension in combination with coronary heart disease, heart failure, and atrial fibrillation. In a small group of patients with hypertension withoutother cardiovascular diseases, the recommended combinations of antihypertensive drugs were not prescribed; preference was given to angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and β-Adreno blocker (β-AB). Prescribing combination therapy mainly differed from therecommended combinations by the wider use of drugs from the β-AB group. The prescribing combination therapy of recommended drugs was highest in patients with hypertension and coronary artery disease – more than 90%, hypertension and heart failure in 56.2%, hypertension and atrial fibrillation – 33.3%,hypertension and chronic kidney disease – 19.6%. Achievement of BP and low-density lipoprotein cholesterol targets was insufficient in all analyzed groups. Among the international nonproprietary names of drugs, the mostfrequently prescribed are the following:, metoprolol, bisoprolol, lisinopril, perindopril, losartan, spironolactone, amlodipine, torasemide, indapamide,hypochlorothiazide, moxonidine. The prescribed daily dosages were closer to the initial recommended ones. By 2020, the prescription of PCT with β-AB and a moreuniform prescription of various combinations will come to the fore, while PCT in 2010 is characterized by the presence of one or two leaders combinations.
Conclusion. The described features of prescribing antihypertensive drugs partially reproduce clinical recommendations for the management of Arterialhypertension. Differences in therapy provided in real clinical practice may be associated with an attempt to intensify the treatment of hypertension inpatients with other concomitant CVDs. At the same time, analysis of combinations and dosages of prescribed drugs suggests the presence of wideopportunities for further escalation of therapy. The presented data can provide insight into current patterns of antihypertensive therapy prescription in patients in real clinical practice and lay the foundation for optimizing therapy in different categories hypertensive patients.
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Role of ticagrelor in the peri-thrombolytic phase for patients with ST-segment elevation myocardialinfarction: a comprehensive review
Thromb J . 2024 Oct 11;22(1):90. doi: 10.1186/s12959-024-00658-9
Abstract
Recent years have seen ticagrelor, a potent P2Y12 inhibitor, emerge as a significant advancement in the peri-thrombolytic management of patients with ST-segment elevation myocardial infarction (STEMI), offering a promising alternative to traditional antiplatelet drugs like clopidogrel. This review critically examines the efficacy and safety of ticagrelor during theperi-thrombolytic phase in ST-segment elevation myocardial infarction patients, drawing on evidence from key clinical trials such as TREAT and MIRTOS, as well as other relevant studies. These investigations underscore ticagrelor's superior platelet inhibitioncapabilities, which are crucial for minimizing thrombotic complications post-thrombolysis without increasing bleeding risks. Despite its potential, clopidogrel remains the guideline-recommended choice for such patients, leaving the appropriateness of ticagrelor in this context open to debate. By summarizing the current evidence and identifying gaps in our understanding, this study advocates for targeted research to clarify the long-term benefits and optimal deployment of ticagrelor, highlighting its evolving significance in cardiovascular care.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of anyscientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on thiswebsite.
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Pulmonary Vein Isolation vs Sham Intervention in Symptomatic Atrial Fibrillation: The SHAM-PVI Randomized Clinical Trial
JAMA 2024 Sep 2:e2417921. doi: 10.1001/jama.2024.17921
Abstract
Importance: There are concerns that pulmonary vein isolation for atrial fibrillation may have a profound placebo effect, but no double-blind randomized clinical trials have been conducted.
Objective: To determine whether pulmonary vein isolation is more effective than a sham procedure for improving outcomes in atrial fibrillation.
Design, setting, and participants:Double-blind randomized clinical trial conducted at 2 tertiary centers in the UK between January 2020 and March 2024 among patients with symptomaticparoxysmal or persistent atrial fibrillation. Major exclusion criteria included long-standing persistent atrial fibrillation, prior left atrium ablation, otherarrhythmias requiring ablative therapy, a left atrium of 5.5 cm or larger, and ejection fraction of less than 35%.
Intervention: Participants were randomly assigned to receive pulmonary vein isolation with cryoablation (n = 64) or a sham procedure with phrenic nerve pacing (n = 62).
Main outcomes and measures: The primary end point was atrial fibrillation burden at 6 months, excluding a3-month blanking period. Secondary outcomes included quality-of-life measures, time to events, and safety. Atrial fibrillation burden was measured by an implantable loop recorder.
Results: A total of 126 participants were randomized (mean age, 66.8 years; 89 men [70.63%]; 20.63% with paroxysmal atrial fibrillation). The absolute mean atrial fibrillation burden change from baseline to 6 monthswas 60.31% in the ablation group and 35.0% in the sham group (geometric mean difference, 0.25; 95% CI, 0.15-0.42; P < .001). The estimated difference in theoverall Atrial Fibrillation Effect on Quality of Life score at 6 months, favoring catheter ablation, was 18.39 points (95% CI, 11.48-25.30 points). The Short Form 36general health score also improved substantially more with ablation, with an estimated difference of 9.27 points at 6 months (95% CI, 3.78-14.76 points).
Conclusions and relevance: Pulmonary vein isolation resulted in a statistically significant and clinically important decrease in atrial fibrillation burden at 6 months, with substantial improvements in symptoms and quality of life, compared with a sham procedure.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of anyscientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on thiswebsite.
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2024 European Society of Cardiology Guidelines for Management of Chronic Coronary Syndromes: Key Points
European Heart Journal, ehae177, https://doi.org/10.1093/eurheartj/ehae177
The key points to remember from the 2024European Society of Cardiology (ESC) guidelines for the management of chronic coronary syndromes (CCS) are:
· The term chronic coronary syndromes describesthe clinical presentations of coronary artery disease (CAD) during stable periods, particularly those preceding or following an acute coronary syndrome (ACS). Of note, symptoms of myocardial ischemia due to obstructiveatherosclerotic CAD overlap with those of coronary microvascular disease or vasospasm. Characterization of endotypes is important to guide appropriate medical therapy for angina with nonobstructive coronary arteries(ANOCA)/ischemia with nonobstructive coronary arteries (INOCA) patients.
· Managing individuals with suspected CCS involvesfour steps:
The first step is a general clinical evaluation that focuses on assessing symptoms and signs of chroniccoronary syndromes, differentiating noncardiac causes of chest pain and ruling out acute coronary syndrome. This initial clinical evaluation requires recording a 12-lead resting electrocardiogram, basic blood tests, and inselected individuals, chest X-ray imaging and pulmonary function testing. This evaluation can be done by the general practitioner. The second step is a furthercardiac examination, including echocardiography at rest to rule out left ventricular (LV) dysfunction and valvular heart disease. After that, it is recommended to estimate the clinical likelihood of obstructive CAD to guidedeferral or referral to further noninvasive and invasive testing. The third step involves diagnostictesting to establish the diagnosis of CCS and determine the patient’s risk of future events. The final step includes lifestyle and risk factor modification combined with disease-modifying medications. A combination of antianginal medications is frequently needed, and coronary revascularization is considered if symptoms are refractory to medical treatment or if high-risk CAD is present. If symptoms persist after obstructive CAD is ruled out, coronary microvascular disease and vasospasm should be considered.
· The inclusion of risk factors to classic pretestlikelihood models of obstructive atherosclerotic CAD improves the identification of patients with very low (≤5 %) pretest likelihood of obstructive CAD in whom deferral of diagnostic testing should be considered.
· First-line diagnostic testing of suspected CCSshould be done by noninvasive anatomic or functional imaging. Selection of the initial noninvasive diagnostic test should be based on the pretest likelihoodof obstructive CAD, other patient characteristics that influence the performance of noninvasive tests, and local expertise and availability.
· Coronary computed tomography angiography (CCTA)is preferred to rule out obstructive CAD and detect nonobstructive CAD. Functional imaging is preferred to correlate symptoms to myocardial ischemia, estimate myocardial viability, and guide decisions on coronary revascularization. Positron emission tomography is preferred for absolute myocardial blood flow measurements, but cardiac magnetic resonance perfusion studies may offer an alternative. Selective second-line cardiac imaging with functional testing in patients with abnormal CCTA and CCTA after abnormalfunctional testing may improve patient selection for invasive coronary angiography (ICA).
· Invasive coronary angiography is recommended todiagnose obstructive CAD in individuals with a very high pre- or post-test likelihood of disease, severe symptoms refractory to guideline-directed medical therapy (GDMT), angina at a low level of exercise, and/or high event risk. When ICA is indicated, it is recommended to evaluate the functional severity of ‘intermediate’ stenoses by invasive functional testing (fractional flow reserve, instantaneous wave-free ratioi) before revascularization.
· A single antiplatelet agent, aspirin or clopidogrel, is generally recommended long term in CCS patients withobstructive atherosclerotic CAD. For high-thrombotic-risk CCS patients, long-term therapy with two antithrombotic agents is reasonable, as long asbleeding risk is not high.
· Among CCS patients with normal LV function andno significant left main or proximal left anterior descending lesions, current evidence indicates that myocardial revascularization over GDMT alone does notprolong overall survival.
· Among patients with complex multivessel CADwithout left main CAD, particularly in the presence of diabetes, who are clinically and anatomically suitable for both revascularization modalities, current evidence indicates longer overall survival after coronary artery bypass grafting than percutaneous coronary intervention.
· Lifestyle and risk factor modification combinedwith disease-modifying and antianginal medications are cornerstones in the management of CCS. Furthermore, shared decision making between patients and health care professionals, based on patient-centered care, is paramount in defining the appropriate therapeutic pathway for CCS patients. Patient education is key to improve risk factor control in the long term.
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2024 European Society of Cardiology Guidelines for Management of Elevated BP and Hypertension: Key Points
European Heart Journal, ehae178, https://doi.org/10.1093/eurheartj/ehae178
The key points to remember from the 2024European Society of Cardiology (ESC) guidelines for the management of elevated blood pressure (BP) and hypertension are:
· The most important point is that the targetsystolic BP (SBP) for adults receiving BP medications should be 120-129 mm Hg. One can “opt-out” of this goal for patients who cannot tolerate that level ofBP, patients who have orthostatic symptoms, patients who are over 85 years old or have frailty, or patients with limited life expectancy. For those patients, the goal is as low a pressure toward that goal as can be achieved.
· Blood Pressure is defined as having a continued risk rooted in time of exposure to higher Blood Pressure. For this reason, hypertension is defined as an systolic BP (SBP) >140 mm Hg or diastolic BP (DBP) >90 mm Hg, but a new category of “elevated BP” has been introduced that is an office systolic BP of 120-139 mm Hg or diastolic BP 70-89 mm Hg. This guideline recognizes that risk increases across this scale, rather than starts at a certain level that is defined as “hypertension.” This category of “elevated BP” reminds us of the term “prehypertension” used in JNC-7 (Seventh Report ofthe Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure).
· The guideline focuses on true risk reductionrelated to fatal and nonfatal cardiovascular outcomes. The longstanding tendency of using the surrogate marker of Blood Pressure alone does not supporta Class I indication in this guideline, except for lifestyle and low-risk nondrug interventions.
· Out-of-office BP is recommended for diagnosticpurposes as it can detect white-coat and masked hypertension. Office measurements can be used when out-of-office readings are not obtainable.
· Lifestyle interventions are recommended for 3months. If not fully successful, then drug therapy should be started.
· In pregnant women without contraindications andin consultation with an obstetrician, low- to moderate-intensity exercise can reduce the risk of gestational hypertension and pre-eclampsia and should beconsidered.
· A risk-based approach to hypertension treatmentis recommended, noting that those with diabetes, kidney disease, cardiovascular disease, target organ damage, and diabetes of familial hypercholesterolemia areat increased risk for cardiovascular disease. More time and resources should be devoted to patients at higher overall risk from elevated BP.
· Screening for secondary hypertension is recommended for adults diagnosed with hypertension before the age of 40 years, except for obese young adults for whom screening for sleep apnea should be a first step.
· Self-measurement of BP is recognized to improvepatient empowerment and adherence to treatment.
· It is recognized that the major weakness ofclinical hypertension guidelines is poor implementation. The document includes sections on how to overcome barriers to implementation.
· In patients with atrial fibrillation, manual BPsshould be used, as most automated devices have not been validated for BP measurement in patients with atrial fibrillation.
· The guidelines include sex and gender throughoutthe document. It defines sex as a biological condition of being male or female from conception, based on genes. Gender is a sociocultural dimension of being aman or a woman in a society based on gender roles and norms.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of anyscientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on thiswebsite.
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Transcatheter Valve Repair in Heart Failure with Moderate to Severe Mitral Regurgitation
DOI: 10.1056/NEJMoa2314328
Background
Whether transcatheter mitral-valve repairimproves outcomes in patients with heart failure and functional mitral regurgitation is uncertain.
Methods
We conducted a randomized, controlled trialinvolving patients with heart failure and moderate to severe functional mitral regurgitation from 30 sites in nine countries. The patients were assigned in a1:1 ratio to either transcatheter mitral-valve repair and guideline-recommended medical therapy (device group) or medical therapy alone (control group). Thethree primary end points were the rate of the composite of first or recurrent hospitalization for heart failure or cardiovascular death during 24 months; therate of first or recurrent hospitalization for heart failure during 24 months; and the change from baseline to 12 months in the score on the Kansas CityCardiomyopathy Questionnaire–Overall Summary (KCCQ-OS; scores range from 0 to 100, with higher scores indicating better health status).
Results
A total of 505 patients underwent randomization: 250 were assigned to the device group and 255 to the control group. At 24 months, the rate of first or recurrent hospitalization for heart failure or cardiovascular death was 37.0 events per 100 patient-years in the device group and 58.9 events per 100 patient-years in the control group (rate ratio, 0.64; 95% confidence interval [CI], 0.48 to 0.85; P=0.002). The rate of first or recurrent hospitalization for heart failure was 26.9 events per 100 patient-years in the device group and 46.6 events per 100 patient-years in the control group (rate ratio, 0.59; 95% CI, 0.42to 0.82; P=0.002). The KCCQ-OS score increased by a mean (±SD) of 21.6±26.9 points in the device group and 8.0±24.5 points in the control group (mean difference, 10.9 points; 95% CI, 6.8 to 15.0; P<0.001). Device-specific safety events occurred in 4 patients (1.6%).
Conclusions
Among patients with heart failure with moderate to severe functional mitral regurgitation who received medical therapy, the addition of transcatheter mitral-valve repair led to a lower rate of first or recurrent hospitalization for heart failure or cardiovascular deathand a lower rate of first or recurrent hospitalization for heart failure at 24 months and better health status at 12 months than medical therapy alone.
Disclaimer:
Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of anyscientific information shared by the HCP on the STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on thiswebsite.
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