This document provides an overview and update on gender differences in the treatment of acute coronary syndrome (ACS) and percutaneous coronary intervention (PCI). Some key points summarized:
1) Women have historically experienced later referrals for treatment of ACS, resulting in more advanced coronary artery disease and worse outcomes. However, outcomes after PCI have improved over time for both men and women.
2) Women continue to be underrepresented in clinical trials of PCI due to barriers like later presentation and higher risk profiles making them ineligible.
3) While early data showed gender was an independent predictor of mortality after PCI, more recent studies have found no differences in death or re-intervention rates between men and women after adjusting for
1) Women with coronary artery disease often experience delays in diagnosis and treatment compared to men. They are less likely to receive timely reperfusion therapy and invasive procedures.
2) Outcomes following procedures like PCI are generally similar for men and women now if treated aggressively and according to guidelines. However, women still face higher risks of vascular complications.
3) Presentation of acute coronary syndromes can differ between men and women. Women tend to be older with more comorbidities but may have less obstructive coronary disease. Outcomes improve when treatment is administered irrespective of gender according to clinical condition.
The LANCELOT-ACS trial investigated the safety and tolerability of the PAR-1 inhibitor atopaxar in 603 patients with acute coronary syndrome. The trial found that atopaxar achieved potent platelet inhibition through PAR-1 without significantly increasing bleeding risk compared to placebo. There were favorable trends for reduced major cardiac events but dose-dependent increases in liver enzymes and QTc interval prolongation at higher doses. Further studies are still needed to fully establish the safety and efficacy of atopaxar.
What is the place of CT coronary angiography in ED chest pain?kellyam18
CT coronary angiography is a relatively new modality for identifying coronary artery disease. What is its place in ED chest pain assessment. See the evidence -and the evidence gaps- and judge for yourself where it might fit!
1) The PLATO trial compared ticagrelor to clopidogrel for prevention of cardiovascular events in patients with acute coronary syndromes. It involved over 18,000 patients across 43 countries.
2) The primary endpoint was a composite of death from vascular causes, myocardial infarction, or stroke. At 12 months, this occurred in 9.8% of ticagrelor patients compared to 11.7% of clopidogrel patients, showing ticagrelor was more effective at reducing cardiovascular events.
3) The primary safety endpoint of major bleeding at 12 months occurred in 11.6% of ticagrelor patients and 11.2% of clopidogrel patients, showing no significant
- Early initiation of high-intensity statin therapy in acute coronary syndrome patients significantly reduces mortality and morbidity rates compared to later initiation or lower-intensity statins. Clinical trials found a 16-36% reduction in major coronary events with early high-dose statin use.
- Guidelines recommend high-intensity statins like atorvastatin 80mg or simvastatin 80mg for acute coronary syndrome patients, though risks like side effects must be considered. Long-term statin therapy is also generally advised after acute coronary syndrome.
1) A study evaluated 161 patients presenting to the emergency department with chest pain using cardiac MRI to detect acute coronary syndrome (ACS). MRI had higher sensitivity and specificity for detecting ACS compared to electrocardiogram, troponin levels, and clinical risk scores.
2) MRI detected regional wall motion abnormalities in 89% of patients with ischemic heart disease and was 99% specific. Delayed hyperenhancement detected ischemia in 67% of patients and was also 99% specific.
3) Quantitative analysis of wall thickening by MRI also effectively diagnosed ACS, non-ST elevation MI, and ischemic heart disease, with areas under the receiver operating characteristic curves of 0.82 to 0.90.
The document summarizes several primary prevention trials of statins:
1) The WOSCOPS trial found that pravastatin reduced coronary heart disease events and mortality in men aged 45-64 with moderate hypercholesterolemia.
2) The MEGA trial showed that pravastatin reduced cardiovascular events in Japanese patients with hypercholesterolemia and lower baseline risks compared to Western trials.
3) The AFCAPS/TexCAPS trial found that lovastatin reduced first acute major coronary events in patients without clinically evident cardiovascular disease but with average cholesterol levels.
1) Women with coronary artery disease often experience delays in diagnosis and treatment compared to men. They are less likely to receive timely reperfusion therapy and invasive procedures.
2) Outcomes following procedures like PCI are generally similar for men and women now if treated aggressively and according to guidelines. However, women still face higher risks of vascular complications.
3) Presentation of acute coronary syndromes can differ between men and women. Women tend to be older with more comorbidities but may have less obstructive coronary disease. Outcomes improve when treatment is administered irrespective of gender according to clinical condition.
The LANCELOT-ACS trial investigated the safety and tolerability of the PAR-1 inhibitor atopaxar in 603 patients with acute coronary syndrome. The trial found that atopaxar achieved potent platelet inhibition through PAR-1 without significantly increasing bleeding risk compared to placebo. There were favorable trends for reduced major cardiac events but dose-dependent increases in liver enzymes and QTc interval prolongation at higher doses. Further studies are still needed to fully establish the safety and efficacy of atopaxar.
What is the place of CT coronary angiography in ED chest pain?kellyam18
CT coronary angiography is a relatively new modality for identifying coronary artery disease. What is its place in ED chest pain assessment. See the evidence -and the evidence gaps- and judge for yourself where it might fit!
1) The PLATO trial compared ticagrelor to clopidogrel for prevention of cardiovascular events in patients with acute coronary syndromes. It involved over 18,000 patients across 43 countries.
2) The primary endpoint was a composite of death from vascular causes, myocardial infarction, or stroke. At 12 months, this occurred in 9.8% of ticagrelor patients compared to 11.7% of clopidogrel patients, showing ticagrelor was more effective at reducing cardiovascular events.
3) The primary safety endpoint of major bleeding at 12 months occurred in 11.6% of ticagrelor patients and 11.2% of clopidogrel patients, showing no significant
- Early initiation of high-intensity statin therapy in acute coronary syndrome patients significantly reduces mortality and morbidity rates compared to later initiation or lower-intensity statins. Clinical trials found a 16-36% reduction in major coronary events with early high-dose statin use.
- Guidelines recommend high-intensity statins like atorvastatin 80mg or simvastatin 80mg for acute coronary syndrome patients, though risks like side effects must be considered. Long-term statin therapy is also generally advised after acute coronary syndrome.
1) A study evaluated 161 patients presenting to the emergency department with chest pain using cardiac MRI to detect acute coronary syndrome (ACS). MRI had higher sensitivity and specificity for detecting ACS compared to electrocardiogram, troponin levels, and clinical risk scores.
2) MRI detected regional wall motion abnormalities in 89% of patients with ischemic heart disease and was 99% specific. Delayed hyperenhancement detected ischemia in 67% of patients and was also 99% specific.
3) Quantitative analysis of wall thickening by MRI also effectively diagnosed ACS, non-ST elevation MI, and ischemic heart disease, with areas under the receiver operating characteristic curves of 0.82 to 0.90.
The document summarizes several primary prevention trials of statins:
1) The WOSCOPS trial found that pravastatin reduced coronary heart disease events and mortality in men aged 45-64 with moderate hypercholesterolemia.
2) The MEGA trial showed that pravastatin reduced cardiovascular events in Japanese patients with hypercholesterolemia and lower baseline risks compared to Western trials.
3) The AFCAPS/TexCAPS trial found that lovastatin reduced first acute major coronary events in patients without clinically evident cardiovascular disease but with average cholesterol levels.
MRI can effectively evaluate patients presenting to the emergency department with possible acute coronary syndrome. In a study of 161 such patients, MRI had higher sensitivity and specificity than electrocardiography, troponin levels, or clinical risk scores for detecting acute coronary syndrome, non-ST elevation myocardial infarction, and ischemic heart disease. Regional wall motion abnormalities detected by MRI had 89% sensitivity and 99% specificity for detecting ischemic heart disease compared to 67% sensitivity and 99% specificity for detecting ischemic heart disease using delayed hyperenhancement. MRI provides accurate information to guide patient management in the emergency department.
MRI was able to detect acute coronary syndrome (ACS) in patients presenting to the emergency department with chest pain with higher sensitivity and specificity than other tests like ECG, troponin levels, and TIMI risk score. In a study of 161 patients, MRI showed 84% sensitivity and 85% specificity for detecting ACS compared to 28% sensitivity for ECG. MRI also detected non-ST elevation myocardial infarction with 100% sensitivity compared to 30% for ECG. MRI provides a safe, noninvasive tool for evaluating chest pain in the emergency department and can effectively triage patients.
The document summarizes the results of a clinical trial studying the effects of blood pressure lowering treatment on secondary stroke prevention. The trial involved over 6,000 patients with a history of cerebrovascular disease across 10 countries. It found that treatment with perindopril (an ACE inhibitor) plus indapamide lowered blood pressure more than single drug therapy or placebo and reduced the risk of fatal or non-fatal stroke by 28%. Combination therapy also reduced major vascular events by 26% and was well-tolerated with few side effects. The results indicate that blood pressure lowering provides significant benefits for secondary stroke prevention, regardless of baseline blood pressure or medical history.
PLATO (Platelet Inhibition and Patient Outcomes)theheart.org
The PLATO trial compared the antiplatelet drug ticagrelor to clopidogrel in 18,624 ACS patients over 1 year. The primary outcome was a composite of death from vascular causes, heart attack, or stroke. Ticagrelor was superior to clopidogrel in reducing the primary outcome (9.8% vs 11.7%) and death from any cause (10.2% vs 12.3%). Major bleeding did not differ significantly between the drugs, though ticagrelor increased major non-CABG bleeding. Experts commented that ticagrelor showed clear benefits over clopidogrel and could become the new standard of care.
1) The IMPROVE-IT trial investigated whether adding ezetimibe to simvastatin therapy provides additional cardiovascular benefit compared to simvastatin monotherapy in 18,144 high-risk patients who had an acute coronary syndrome.
2) At a median follow-up of 6 years, combination ezetimibe/simvastatin therapy resulted in a statistically significant 9% relative risk reduction in major cardiovascular events compared to simvastatin alone.
3) Combination therapy also significantly reduced the risk of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke by 10% compared to simvastatin monotherapy.
1) The IMPROVE-IT trial investigated whether adding ezetimibe to simvastatin therapy provides additional cardiovascular benefit compared to simvastatin monotherapy in 18,144 high-risk patients who recently had an acute coronary syndrome.
2) Patients receiving ezetimibe/simvastatin had a lower rate of major cardiovascular events (32.7% vs 34.7%) over a median follow-up of 6 years, demonstrating the additional clinical benefit of further lowering LDL-C with ezetimibe.
3) Ezetimibe/simvastatin also reduced the rate of the composite endpoint of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke compared to
This document summarizes a study from the NCDR registry comparing outcomes in patients undergoing primary PCI for STEMI who were anticoagulated with bivalirudin versus heparin. The study found that while in-hospital mortality was lower in the bivalirudin group, the composite endpoint of death, MI or stroke at 30 days was not significantly different between the two groups. Registry data from the UK and Sweden also showed no significant differences in mortality or stent thrombosis rates between bivalirudin and heparin in primary PCI patients.
This document summarizes guidelines for cholesterol treatment and clinical trials evaluating lipid targets. It discusses the ATP III guidelines, major trials after ATP III including TNT, JUPITER, ACCORD-LIPID, and AIM-HIGH. It then reviews the 2013 ACC/AHA cholesterol treatment guidelines, including the 4 groups that benefit from statins, ASCVD risk assessment, and future directions. Clinical cases are used to illustrate guideline recommendations for statin treatment based on a patient's risk factors.
Ticagrelor is a reversible P2Y12 inhibitor that was developed to overcome limitations of clopidogrel such as variable metabolism and slow onset of action. The PLATO trial found ticagrelor to be superior to clopidogrel in reducing cardiovascular events in ACS patients with no increase in major bleeding. The PEGASUS trial found ticagrelor reduced cardiovascular events in stable patients with prior MI compared to placebo on aspirin. However, the EUCLID trial found ticagrelor was no better than clopidogrel in reducing events in PAD patients and increased dyspnea. The TREAT trial is investigating ticagrelor vs clopidogrel after fibrinolytic therapy in STE
This document discusses the benefits of high-dose statin therapy for patients with acute coronary syndrome (ACS). It summarizes several studies that found high-dose statin therapy started very early (within 24 hours) for ACS patients was associated with reduced mortality. One study of over 10,000 ACS patients found very early statin therapy reduced 7-day and 30-day mortality. Another study found high-dose atorvastatin improved coronary flow and ST segment resolution in STEMI patients compared to low-dose atorvastatin. The document also notes that statin therapy duration is important, with one study finding risk of further cardiovascular events was lower the longer patients continued high-dose atorvastatin therapy.
Statin use is associated with a small increased risk of developing diabetes. However, the cardiovascular benefits of statin therapy still outweigh the diabetes risk. Several studies have found that statin use leads to a 9-13% increased risk of diabetes, but the absolute increased risk is low. The number of patients needed to treat with statins to prevent a cardiovascular event is lower than the number needed to harm in terms of diabetes risk. Therefore, clinical practice for statin therapy for reducing cardiovascular risk should not change.
Dr ranjith mp.statins for primary prevention of coronary heart disease drranjithmp
The West of Scotland Coronary Prevention Study (WOSCOPS) investigated the effects of pravastatin treatment in men aged 45-64 with hypercholesterolemia but no history of heart disease. The study found that pravastatin reduced coronary events by 31% and cardiovascular deaths by 32% compared to placebo after 5 years. Pravastatin treatment also lowered LDL cholesterol by 26% and led to a 37% reduction in coronary interventions. The results demonstrated that statin treatment can significantly reduce cardiovascular risks even in primary prevention patients without known heart disease.
This document provides biographical information about Dr. Wei-Chun Huang, including his academic and professional qualifications. It lists his positions, including serving as the director of the Department of Critical Care Medicine at Kaohsiung Veterans General Hospital, as well as his affiliations with professional organizations in Taiwan and internationally. The document also thanks the ICU departments from 14 hospitals across Taiwan for their participation in a conference.
The document summarizes the results of the CABANA Pilot Study, which compared catheter ablation to antiarrhythmic drug therapy for atrial fibrillation. The study found that ablation was more effective than drugs at preventing recurrent symptomatic atrial fibrillation over 12 months of follow-up. However, the pilot study had some limitations due to its small sample size and short follow-up duration. It established the feasibility of conducting a larger pivotal trial to determine long-term outcomes of ablation versus drug therapy for atrial fibrillation.
The document summarizes the results of the CABANA Pilot Study, which compared catheter ablation to antiarrhythmic drug therapy for atrial fibrillation. The study found that ablation was more effective than drugs at preventing recurrent symptomatic atrial fibrillation over 12 months of follow-up. However, the pilot study had some limitations due to its small sample size and short follow-up duration. It established the feasibility of conducting a larger pivotal trial to determine long-term outcomes of ablation versus drug therapy for atrial fibrillation.
The document summarizes a study that compared the effects of aggressive atorvastatin therapy (80 mg) versus conventional simvastatin therapy (40 mg) on markers of inflammation in patients with familial hypercholesterolemia. The study found that atorvastatin reduced levels of hs-CRP and other inflammatory markers to a greater extent than simvastatin after 2 years. Patients with the largest reductions in hs-CRP also showed greater reductions in carotid intima-media thickness. However, about one-third of patients in both treatment groups experienced increases in hs-CRP levels. The study suggests more aggressive statin therapy may be more effective at reducing atherosclerosis by its anti-inflammatory effects.
1) Complete revascularization (CR), defined as treating all significant coronary stenoses, is associated with lower mortality compared to incomplete revascularization (IR) based on observational studies and randomized trials. IR is more common after percutaneous coronary intervention (PCI) than coronary artery bypass grafting (CABG).
2) For stable coronary artery disease (SCAD), CR is recommended when feasible, while for acute coronary syndromes (ACS) and ST-segment elevation myocardial infarction (STEMI), treating the culprit lesion only is usually recommended initially, with staged revascularization of non-culprit lesions if needed.
3) Randomized trials of preventive PCI of non-culprit lesions in STEMI
1) Several early trials evaluated lipid lowering drugs such as mevastatin and lovastatin, which were isolated from fungi and shown to inhibit HMG CoA reductase. However, mevastatin was not marketed due to toxicity in dogs. Lovastatin was first marketed as Mevacor in 1987.
2) Large primary prevention trials such as WOSCOPS, AFCAPS/TexCAPS, CARDS and JUPITER demonstrated significant reductions in cardiovascular events with statin therapy compared to placebo in various populations with and without known heart disease.
3) Secondary prevention trials in patients with stable CAD such as 4S, CARE, LIPID and TNT showed that statin therapy reduces
Icosapent ethyl (IPE), a highly purified ethyl ester of eicosapentaenoic acid (EPA), was evaluated for its effect on coronary atherosclerotic plaque progression in patients with elevated triglycerides on statin therapy. In a randomized controlled trial of 80 patients, IPE 4g/day resulted in significant regression of low attenuation plaque volume compared to placebo after 18 months. IPE also reduced total, non-calcified, fibrofatty and fibrous plaque volumes but not calcified plaque volume. No significant differences in lipid levels were observed between groups.
The document discusses the lack of consensus around treating asymptomatic carotid artery disease. While surgery reduces the risk of stroke, the absolute benefit is small given the already low risk with medical management alone. More recent data favors a purely medical approach for most asymptomatic patients. The evidence for invasive treatments like carotid endarterectomy (CEA) or stenting is considered weak, with no clear benefits shown for subgroups like women, those over 75, or different degrees of stenosis. Treating asymptomatic disease at a population level may lead to many unnecessary interventions that provide little benefit given evolving medical therapies.
CT coronary angiography in ED chest pain patientskellyam18
CTCA shows promise in reducing length of stay and costs for ED chest pain patients, but more research is needed. While CTCA is highly sensitive for detecting CAD, it may overestimate lesion severity and has radiation risks. Current evidence does not clearly support CTCA as a routine test for ED chest pain patients without known CAD who have normal ECG and biomarkers. CTCA may be useful in select subgroups, but how to define these subgroups is unclear.
MRI can effectively evaluate patients presenting to the emergency department with possible acute coronary syndrome. In a study of 161 such patients, MRI had higher sensitivity and specificity than electrocardiography, troponin levels, or clinical risk scores for detecting acute coronary syndrome, non-ST elevation myocardial infarction, and ischemic heart disease. Regional wall motion abnormalities detected by MRI had 89% sensitivity and 99% specificity for detecting ischemic heart disease compared to 67% sensitivity and 99% specificity for detecting ischemic heart disease using delayed hyperenhancement. MRI provides accurate information to guide patient management in the emergency department.
MRI was able to detect acute coronary syndrome (ACS) in patients presenting to the emergency department with chest pain with higher sensitivity and specificity than other tests like ECG, troponin levels, and TIMI risk score. In a study of 161 patients, MRI showed 84% sensitivity and 85% specificity for detecting ACS compared to 28% sensitivity for ECG. MRI also detected non-ST elevation myocardial infarction with 100% sensitivity compared to 30% for ECG. MRI provides a safe, noninvasive tool for evaluating chest pain in the emergency department and can effectively triage patients.
The document summarizes the results of a clinical trial studying the effects of blood pressure lowering treatment on secondary stroke prevention. The trial involved over 6,000 patients with a history of cerebrovascular disease across 10 countries. It found that treatment with perindopril (an ACE inhibitor) plus indapamide lowered blood pressure more than single drug therapy or placebo and reduced the risk of fatal or non-fatal stroke by 28%. Combination therapy also reduced major vascular events by 26% and was well-tolerated with few side effects. The results indicate that blood pressure lowering provides significant benefits for secondary stroke prevention, regardless of baseline blood pressure or medical history.
PLATO (Platelet Inhibition and Patient Outcomes)theheart.org
The PLATO trial compared the antiplatelet drug ticagrelor to clopidogrel in 18,624 ACS patients over 1 year. The primary outcome was a composite of death from vascular causes, heart attack, or stroke. Ticagrelor was superior to clopidogrel in reducing the primary outcome (9.8% vs 11.7%) and death from any cause (10.2% vs 12.3%). Major bleeding did not differ significantly between the drugs, though ticagrelor increased major non-CABG bleeding. Experts commented that ticagrelor showed clear benefits over clopidogrel and could become the new standard of care.
1) The IMPROVE-IT trial investigated whether adding ezetimibe to simvastatin therapy provides additional cardiovascular benefit compared to simvastatin monotherapy in 18,144 high-risk patients who had an acute coronary syndrome.
2) At a median follow-up of 6 years, combination ezetimibe/simvastatin therapy resulted in a statistically significant 9% relative risk reduction in major cardiovascular events compared to simvastatin alone.
3) Combination therapy also significantly reduced the risk of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke by 10% compared to simvastatin monotherapy.
1) The IMPROVE-IT trial investigated whether adding ezetimibe to simvastatin therapy provides additional cardiovascular benefit compared to simvastatin monotherapy in 18,144 high-risk patients who recently had an acute coronary syndrome.
2) Patients receiving ezetimibe/simvastatin had a lower rate of major cardiovascular events (32.7% vs 34.7%) over a median follow-up of 6 years, demonstrating the additional clinical benefit of further lowering LDL-C with ezetimibe.
3) Ezetimibe/simvastatin also reduced the rate of the composite endpoint of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke compared to
This document summarizes a study from the NCDR registry comparing outcomes in patients undergoing primary PCI for STEMI who were anticoagulated with bivalirudin versus heparin. The study found that while in-hospital mortality was lower in the bivalirudin group, the composite endpoint of death, MI or stroke at 30 days was not significantly different between the two groups. Registry data from the UK and Sweden also showed no significant differences in mortality or stent thrombosis rates between bivalirudin and heparin in primary PCI patients.
This document summarizes guidelines for cholesterol treatment and clinical trials evaluating lipid targets. It discusses the ATP III guidelines, major trials after ATP III including TNT, JUPITER, ACCORD-LIPID, and AIM-HIGH. It then reviews the 2013 ACC/AHA cholesterol treatment guidelines, including the 4 groups that benefit from statins, ASCVD risk assessment, and future directions. Clinical cases are used to illustrate guideline recommendations for statin treatment based on a patient's risk factors.
Ticagrelor is a reversible P2Y12 inhibitor that was developed to overcome limitations of clopidogrel such as variable metabolism and slow onset of action. The PLATO trial found ticagrelor to be superior to clopidogrel in reducing cardiovascular events in ACS patients with no increase in major bleeding. The PEGASUS trial found ticagrelor reduced cardiovascular events in stable patients with prior MI compared to placebo on aspirin. However, the EUCLID trial found ticagrelor was no better than clopidogrel in reducing events in PAD patients and increased dyspnea. The TREAT trial is investigating ticagrelor vs clopidogrel after fibrinolytic therapy in STE
This document discusses the benefits of high-dose statin therapy for patients with acute coronary syndrome (ACS). It summarizes several studies that found high-dose statin therapy started very early (within 24 hours) for ACS patients was associated with reduced mortality. One study of over 10,000 ACS patients found very early statin therapy reduced 7-day and 30-day mortality. Another study found high-dose atorvastatin improved coronary flow and ST segment resolution in STEMI patients compared to low-dose atorvastatin. The document also notes that statin therapy duration is important, with one study finding risk of further cardiovascular events was lower the longer patients continued high-dose atorvastatin therapy.
Statin use is associated with a small increased risk of developing diabetes. However, the cardiovascular benefits of statin therapy still outweigh the diabetes risk. Several studies have found that statin use leads to a 9-13% increased risk of diabetes, but the absolute increased risk is low. The number of patients needed to treat with statins to prevent a cardiovascular event is lower than the number needed to harm in terms of diabetes risk. Therefore, clinical practice for statin therapy for reducing cardiovascular risk should not change.
Dr ranjith mp.statins for primary prevention of coronary heart disease drranjithmp
The West of Scotland Coronary Prevention Study (WOSCOPS) investigated the effects of pravastatin treatment in men aged 45-64 with hypercholesterolemia but no history of heart disease. The study found that pravastatin reduced coronary events by 31% and cardiovascular deaths by 32% compared to placebo after 5 years. Pravastatin treatment also lowered LDL cholesterol by 26% and led to a 37% reduction in coronary interventions. The results demonstrated that statin treatment can significantly reduce cardiovascular risks even in primary prevention patients without known heart disease.
This document provides biographical information about Dr. Wei-Chun Huang, including his academic and professional qualifications. It lists his positions, including serving as the director of the Department of Critical Care Medicine at Kaohsiung Veterans General Hospital, as well as his affiliations with professional organizations in Taiwan and internationally. The document also thanks the ICU departments from 14 hospitals across Taiwan for their participation in a conference.
The document summarizes the results of the CABANA Pilot Study, which compared catheter ablation to antiarrhythmic drug therapy for atrial fibrillation. The study found that ablation was more effective than drugs at preventing recurrent symptomatic atrial fibrillation over 12 months of follow-up. However, the pilot study had some limitations due to its small sample size and short follow-up duration. It established the feasibility of conducting a larger pivotal trial to determine long-term outcomes of ablation versus drug therapy for atrial fibrillation.
The document summarizes the results of the CABANA Pilot Study, which compared catheter ablation to antiarrhythmic drug therapy for atrial fibrillation. The study found that ablation was more effective than drugs at preventing recurrent symptomatic atrial fibrillation over 12 months of follow-up. However, the pilot study had some limitations due to its small sample size and short follow-up duration. It established the feasibility of conducting a larger pivotal trial to determine long-term outcomes of ablation versus drug therapy for atrial fibrillation.
The document summarizes a study that compared the effects of aggressive atorvastatin therapy (80 mg) versus conventional simvastatin therapy (40 mg) on markers of inflammation in patients with familial hypercholesterolemia. The study found that atorvastatin reduced levels of hs-CRP and other inflammatory markers to a greater extent than simvastatin after 2 years. Patients with the largest reductions in hs-CRP also showed greater reductions in carotid intima-media thickness. However, about one-third of patients in both treatment groups experienced increases in hs-CRP levels. The study suggests more aggressive statin therapy may be more effective at reducing atherosclerosis by its anti-inflammatory effects.
1) Complete revascularization (CR), defined as treating all significant coronary stenoses, is associated with lower mortality compared to incomplete revascularization (IR) based on observational studies and randomized trials. IR is more common after percutaneous coronary intervention (PCI) than coronary artery bypass grafting (CABG).
2) For stable coronary artery disease (SCAD), CR is recommended when feasible, while for acute coronary syndromes (ACS) and ST-segment elevation myocardial infarction (STEMI), treating the culprit lesion only is usually recommended initially, with staged revascularization of non-culprit lesions if needed.
3) Randomized trials of preventive PCI of non-culprit lesions in STEMI
1) Several early trials evaluated lipid lowering drugs such as mevastatin and lovastatin, which were isolated from fungi and shown to inhibit HMG CoA reductase. However, mevastatin was not marketed due to toxicity in dogs. Lovastatin was first marketed as Mevacor in 1987.
2) Large primary prevention trials such as WOSCOPS, AFCAPS/TexCAPS, CARDS and JUPITER demonstrated significant reductions in cardiovascular events with statin therapy compared to placebo in various populations with and without known heart disease.
3) Secondary prevention trials in patients with stable CAD such as 4S, CARE, LIPID and TNT showed that statin therapy reduces
Icosapent ethyl (IPE), a highly purified ethyl ester of eicosapentaenoic acid (EPA), was evaluated for its effect on coronary atherosclerotic plaque progression in patients with elevated triglycerides on statin therapy. In a randomized controlled trial of 80 patients, IPE 4g/day resulted in significant regression of low attenuation plaque volume compared to placebo after 18 months. IPE also reduced total, non-calcified, fibrofatty and fibrous plaque volumes but not calcified plaque volume. No significant differences in lipid levels were observed between groups.
The document discusses the lack of consensus around treating asymptomatic carotid artery disease. While surgery reduces the risk of stroke, the absolute benefit is small given the already low risk with medical management alone. More recent data favors a purely medical approach for most asymptomatic patients. The evidence for invasive treatments like carotid endarterectomy (CEA) or stenting is considered weak, with no clear benefits shown for subgroups like women, those over 75, or different degrees of stenosis. Treating asymptomatic disease at a population level may lead to many unnecessary interventions that provide little benefit given evolving medical therapies.
CT coronary angiography in ED chest pain patientskellyam18
CTCA shows promise in reducing length of stay and costs for ED chest pain patients, but more research is needed. While CTCA is highly sensitive for detecting CAD, it may overestimate lesion severity and has radiation risks. Current evidence does not clearly support CTCA as a routine test for ED chest pain patients without known CAD who have normal ECG and biomarkers. CTCA may be useful in select subgroups, but how to define these subgroups is unclear.
The SAFE-PCI for Women Trial was a prospective, randomized trial comparing radial versus femoral approaches for percutaneous coronary intervention (PCI) in women. 1787 women undergoing cardiac catheterization or PCI were randomized to radial or femoral access. The trial was terminated early due to lower than expected event rates. In the subgroup of women undergoing PCI (n=345 radial, n=346 femoral), there was no significant difference in the primary efficacy endpoint of bleeding or vascular complications between radial and femoral access. However, radial access was associated with a higher rate of needing conversion to femoral access. Overall, the results suggest an initial radial access strategy may be preferred for some women undergoing cardiac procedures.
An Update on Carotid Artery PTAS:Contemporary Results, Trends, and Challenges...MedicineAndFamily
This document summarizes an update on carotid artery stenting (CAS). It discusses the rationale for CAS, guidelines for patient selection, results from clinical trials comparing CAS to carotid endarterectomy (CEA). Contemporary data shows similar perioperative risks for CAS and CEA. Embolic protection devices are recommended for CAS to prevent stroke from debris. Proper credentialing and facility requirements are important for CAS programs.
This document provides guidance on starting a successful transradial cardiac catheterization program. It discusses how the author started their program during fellowship by attending courses and enrolling patients in clinical trials. It highlights advantages of transradial access such as reduced access complications, earlier ambulation, and improved patient comfort. The document also reviews data demonstrating reduced bleeding and improved outcomes with transradial compared to transfemoral access. Overall, it presents a case for transradial access and provides tips for establishing a successful transradial program.
This document discusses indications and techniques for carotid artery stenting (CAS). It notes that symptomatic stenosis over 70% on non-invasive imaging or over 50% on catheter angiography are indications for revascularization. Asymptomatic stenosis over 70% may also be treated if life expectancy is over 5 years and stenosis is over 80%. The technique involves pre- and post-dilation of stents with the use of protection devices to prevent embolic strokes. Results depend on the operator's experience and complications include strokes, hypotension, and restenosis. Larger trials found CAS and CEA to have similar outcomes, with CAS preferred for younger patients, though CEA is preferred in certain high risk cases.
This document provides guidelines for managing abnormal Pap smears, cervical dysplasia, and cervical cancer. It discusses evaluating Pap test results using the Bethesda system and determining appropriate follow up. It also outlines treatment options for cervical dysplasia like cryotherapy, LEEP, and cone biopsy. For invasive cervical cancer, it describes staging and evaluating and treating the disease in consultation with a gynecologic oncologist.
Ponencia realizada por la Dra. Antonia Sambola Ayala, Hospital Universitari Vall d'Hebron, Barcelona, en el CardioTV titulado 'Riesgo CV en la mujer', celebrado el 21 de septiembre de 2022.
This document summarizes a study that analyzed Medicare claims data to compare rates of carotid stent placement (CSS) versus carotid endarterectomy (CE) among white and black patients from 2005-2006. The study found no evidence of racial differences in receiving CSS in the initial period of Medicare coverage. A logistic regression model controlling for patient and hospital characteristics found black patients had similar odds of receiving CSS compared to whites. Additional models found no significant interaction between patient race and geographic variability in CSS utilization rates.
- A 65-year-old female presented to the emergency room with sudden onset of chest pain, pressure, nausea, vomiting, shortness of breath, and lightheadedness.
- Her medical history included hypertension, diabetes, and hyperlipidemia. Diagnostic tests found elevated cardiac enzymes and EKG changes consistent with a heart attack.
- She was started on medications and transferred for further treatment, where imaging found apical ballooning syndrome, also known as stress-induced cardiomyopathy or "broken heart syndrome". This occurs when emotional or physical stress causes transient left ventricular dysfunction mimicking a heart attack.
This document provides biographical information about Dr. Niraj Sharma in 3 paragraphs. It states that he is an electrophysiologist at CardioVascular Group/Gwinnett Medical Group. It notes that he is board certified in internal medicine, cardiovascular diseases, and electrophysiology. It indicates that his special interests include treating patients with abnormal heart rhythms and ablation of arrhythmias such as atrial fibrillation. It also provides details about his medical education and training.
What to choose in stable CAD- Medical therapy only or PCI or CABG?cardiositeindia
This document summarizes guidelines for determining the appropriateness of coronary revascularization via percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for stable coronary artery disease (CAD) based on symptoms, risk level determined by noninvasive testing, medical therapy, and coronary anatomy. Key factors that determine appropriateness include angina class, extent of ischemia on stress testing, use of optimal medical management, and severity and location of coronary lesions. PCI or CABG is generally considered appropriate for high-risk patients or those with significant symptoms despite medical therapy.
This document summarizes advances in the management of breast cancer over the last 30 years. It discusses trends towards increased use of breast-conserving surgery rather than total mastectomy, as randomized trials have shown equivalent survival outcomes. Sentinel lymph node biopsy has largely replaced axillary lymph node dissection for nodal staging due to lower morbidity. While bilateral mastectomy rates have increased, studies find local recurrence rates remain low with breast-conserving surgery and radiation. Overall, management of breast cancer has shifted to less invasive surgical options due to long-term data demonstrating equivalent survival.
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2. While screening can detect cancer early, it also risks overdiagnosing biologically unimportant cancers and subjects men to potential harms of treatment without clear benefits due to their age.
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Acs ami update-win program - scai 2010
1. ACS & AMI Update
WIN Program - SCAI 2010
Kimberly A. Skelding MD FSCAI FACC FAHA
Associate Interventional Cardiology
Geisinger Health System
Danville, Pennsylvania
2. Disclosure Information
ACS & AMI Update
WIN Program - SCAI 2010
Kimberly A. Skelding. MD, FSCAI, FAHA, FACC
Nothing to Disclose
3. Gender Differences in Treatment
• Late referrals
- more advanced CAD
- more urgent/emergent procedures
- longer DTB times in STEMI cases
• Lower rates of IMA grafts in women even after
adjustment for age, extent of disease and urgent
surgery
• Similar benefits from GP IIb/IIIa agents and stents
• Improved PCI mortality over time in both men and
women
ClinCardiol 2007;30:491-5
4. Percutaneous Coronary Intervention
• Only 33% of PCI are performed in women annually
• Delayed treatment with PCI in women is common
– Often >24 hours after presentation
• Women continue to be underrepresented in clinical
trials of percutaneous coronary intervention
– They don’t meet inclusion criteria!!!
• Get there late
• More risk factors: older, worse renal function
• Sicker on presentation
Blomkalns AL et al. J Am Coll Cardiol 2005;45:832-37, Lee et al. JAMA.
2001;286:708-713, Harris DJ et al. N Engl J Med 2000;343(7):475-480, Simon V. Science 2005;308(5728):1517.
5. Outcomes following PCI
• Early data (1978-81) reported gender
was independently predictive of
mortality
• Later data (1985-6), corrected for risk
factors, decreased but did not remove
the gender gap
• More recent data suggests no
difference in death, MI, and emergent
CABG but continued increased risk of
morbidity, particularly bleeding
Cowley MJ et al. Circulation 1985;71(1):90-7, Kelsey SF. Circulation 1993;87(3):720-7, Argulian E et al. Am J
Cardiol 2006;96:48-53, Abbott JD et al. Am J Cardiol 2007;99:626-631, Thompson CA et al Catheter Cardiovasc
Interv 2006;67(1):25-31, Blomkalns AL et al. J Am Coll Cardiol 2005;45:832-37, Lansky AJ et al. Circulation
2005;111:940-953
6. Outcomes following PCI
• Contemporary subacute or late thrombosis rates
are similar between genders, 1.3% vs 1.2%, p=NS
• Women are 61% more likely to present with in-
stent restenosis following drug eluting stents,
particularly diffuse in-stent restenosis
– Harder to treat
– Worse prognosis
• 1.9x more women will return to the ER within 30
days of their intervention even after
successful interventions
Abbott JD et al. Am J Cardiol 2007;99:626-631, Trabattoni D et al. Ital Heart J 2005;6:138-142, Hubbard BL et al.
Am J Cardiol 2007;99:197-201.
7. Differences Between Men and Women
Undergoing PTCA
Clinical
Observations Anatomy Explanation
↑ unstable angina Less MV disease Spasm
Lower hemoglobin
↑ angina at f/u Similar rates of Higher heart rate
incomplete revasc. Higher BP
Fewer repeat PTCAs Similar restenosis rates Gender bias
↑ CHF Better EF Diastolic dysfunction
8. Women Have Higher Rate of
Vascular Complications After PCI
Circ 2005;III;940-953
10. Radial Approach is still Associated
with More Bleeding in Women
• 1348 ACS patients pretreated with ASA,
clopidogrel → radial PCI using 70 u/kg uFH and
abciximab
(EASY trial of early discharge)
Women Men p value
Sheath size – 5F 57% 44% 0.0003
– 6F 43% 55%
Hb drop 1.7% 0.4% 0.059
Hematoma 22% 5.8% 0.001
Final ACT (sec) 322 308 0.003
AHJ 2009; 157:740
11. Gender Differences in Response
to Anticoagulants
• Among drug applications submitted to FDA
between 1994 and 2000, 20% had gender
differences in pharmacokinetics
- gender differences in gastric emptying
- more hepatic cytochrome CYP3A in women
- more dietary supplements taken by women
- more accumulation in fat
- less renal excretion
• Nine fold increase in HIT in women compared
to men (Blood 2006;108:2937-410)
12.
13. Bivalirudin Reduces (but does not eliminate)
PCI Related Bleeding Differences
Between Men and Women
(p<0.001)
UFH+GPIIb/IIIa
Bivalirudin
(Non-CABG) Major Bleeding %
14.00%
11.80%
12.00%
10.00% (p<0.0001)
8.00% 6.30%
6.00% 4.90%
4.00% 2.50%
2.00%
0.00%
(n=1401) (n=3779) Lancet 2007;369:;907
Women Men AJC 2009;103:1197
15. Dilemma
• Women have atypical symptoms → physicians need high
level of suspicion and aggressive diagnostic testing,
however . . . . .
• Women have higher rates of normal coronaries at the time
of cath
• How can one avoid overutilization of cath, but at the same
time avoid misdiagnosis in women?
– Noninvasive testing
– Determine pre-test probability of CAD
– CT angiography (avoid radiation exposure in younger
women)
16. Gender differences in CAD significance
after diagnostic cath for ACS
P<0.0001
90
Women
ACS % with Significant CAD
80 Men
70
60
50
40
30
20
10
0
Black Hispanic N. Amer. Asian Caucasian
N= 23,382 8,708 1,596 3,725 412,918
% 50.2 39.1 37.6 39.4 38
Female
Circ 2008;117:1792
ACC/NCDR database
17. Differences in ACS Management
• CURE trial data: 4,836 women and 7,726 men
with ACS
– Women older, more diabetes, more
hypertension and hyperlipidemia.
– Men more smoking, MI history, PAD and CVA.
• Women had fewer invasive procedures with
ACS, 47.6% vs 60.5%, p=0.0001, regardless of
risk
• No difference in CV death, MI or CVA if they
presented with ACS.
• Women more likely to develop refractory angina
and be re-hospitalized, (16.6% vs 13.9%,
p=0.0001) after their first episode of ACS
Anand SS et al J Am Coll Cardiol 2005
18. Treatment of Women with
Acute Coronary Syndrome
• Less likely to have an ECG done within 10 minutes of
presentation
• Less likely to be cared for by a cardiologist during their
inpatient admission
• Less likely to acutely be given appropriate pharmacotherapy
such as heparin, aspirin, statins, ACE-I
LESS OFTEN RECEIVE GUIDELINE RECOMMENDED
THERAPY BUT WOULD SIGNIFICANTLY BENEFIT FROM
AN EARLY AGGRESSIVE INVASIVE STRATEGY
Blomkalns AL et al. J Am Coll Cardiol 2005;45:832-37, Lansky AJ et al. Circulation
2005;111:940-953, Braunwald E et al. J Am Coll Cardiol 2002;40:1366-1374
19. Outcome Following Treatment of
Acute Coronary Syndrome
• Young women, <55 years old, have >2 times the risk of
having a dissection or artery occlusion during their procedure
• All women have increased bleeding and vascular access site
complications, those <55 years old have >5 times the risk
compared to men
• Following PCI, women with ACS have a 37% higher risk of
death, MI or rehospitalization than men with ACS
• Women <65 years old are at 46% higher risk of death, MI or
rehospitalization
Glaser R et al. Am J Cardiol 2006;98:1446-1450, Abbott JD et al. Am J Cardiol
2007;99:626-631, Chauhan MS et al. Am J Cardiol 2005;95:101-104, Argulian E et al
Am J Cardiol 2006;98:48-53, Lansky AJ et al. Circulation 2005;111:940-953,
Anand SS et al. J Am Coll Cardiol 2005;46:1845-51.
20.
21. Meta-Analysis of Invasive vs
Conservative Rx for ACS
• Eight trials (3075 women and 7075 men)
• Women older, more comorbidites, but more likely to have insignificant (<50%)
CAD at cath (24 vs 8% p<0.001)
JAMA 2008;300:71
22. Conclusions of ACS Meta-Analysis
• Men - Both high and low risk benefit from invasive
strategy
• Women - High risk ACS women benefit from
invasive approach
- Low risk women may be treated
conservatively (but invasive approach
not harmful)
JAMA 2008;300:71
23. Gender Differences in
Atherosclerosis
• Plaque erosion as the
etiology of coronary
thrombosis and AMI
A B
occurs at a higher frequency
in women than in men
• In an autopsy study of 291
patients who died of AMI and
had coronary thrombosis,
C
the prevalence of plaque D
erosions was 37%
in women and 18% in men
Arbustini. Heart. 1999;82:269-272.
24. Gender Differences in AMI Management Persist:
Get with the Guidelines Database 2001-2006
Measure/Treatment Men (n=47 556) Women (n=30 698) P value
Early medical therapy
Aspirin within <24 h 93.3 91.0 <0.0001
β-Blockers within <24 h 87.2 84.7 <0.0001
Invasive procedures
Cardiac catheterization 56.2 45.6 <0.0001
PCI 52.3 36.1 <0.0001
CABG 9.2 5.4 <0.0001
Revascularization 60.2 40.9 <0.0001
Any reperfusion therapy* 73.0 56.3 <0.0001
Primary PCI 61.1 47.3 <0.0001
Fibrinolytic Therapy 6.2 5.1
Fibrinolytic therapy + PCI 5.8 3.9
Timeliness of reperfusion*
DTN time median (25th-75th) min 39.0 47.0 <0.0001
DTB time median (25th – 75th) min 95.0 103.0 <0.0001
Circ 2008;118:2803
*STEMI subpopulation (28.2% women, 35.1% men, p<0.0001)
25. Mechanism of MI May be Different
in Women
• Spontaneous coronary dissection: women > men
• Takotsubo (high circulating levels of
catecholamines): women > men
• Spasm (migranes, Raynauds): women > men
• Non-STEMI: women > men (subendocardial
ischemia due to LVH, microvascular disease,
endothelial dysfunction)
26. Treatment of Acute Myocardial Infarction
• Women have longer door-to-balloon times
• Women are less likely to undergo invasive
evaluation on the index admission regardless
of age
• Contemporary in-hospital and late mortality
rates are similar across genders when
treated in randomized controlled trials ~
treated irrespective of gender
Zahn R et al. Heart 2005;91(8):1041-6, Lansky AJ et al. Circulation 2005;111:940-953, Antman EM et al.
Circulation. 2008 Jan 15;117(2):296-329, Reynolds HR et al. Arch Intern Med 2007;
167:2054-2060, Milcent C et al. Circulation 2007;115:833-839.
27. AMI in Women:
Later Presentation and Delay in Treatment
- CADILLAC Primary PCI Trial-
P
Men Women Value
N 1520 562 -
Chest pain to ER (hrs) 2.6 ± 2.5 3.0 ± 2.6 < 0.001
ER to procedure (hrs) 1.9 ± 2.2 2.1 ± 2.3 < 0.001
Stent use 57% 57% NS
Abciximab use 54% 51% NS
28. Outcomes Following 1st Myocardial
Infarction
• 38% of women will die within one year versus 25%
of men
• Within 6 years 35% of women will have another MI
vs 18% of men
• More than twice as many women will be disabled
with heart failure within 6 years of their first MI
• Women are 55% less likely to participate in cardiac
rehabilitation
• Women experience more depressive symptoms
following AMI, particularly those <60 years old
Rosamond W et al. Circulation 2008;117:e25-146. Witt BJ et al. J Am Coll Cardiol 2004;44:988-
996, Mallik S et al Arch Inern Med 2006;166:876-883.
29. Primary PCI is Superior to Lytics in Women
Meta-Analysis - 23 Randomized Trials (PCAT-2)
16 Lytic
14.4
14 Primary PCI
30-Day Mortality
12
9.6
10 8.5
7.7
8 7.1
6 5.3 4.9
3.5
4
2
0
≤ 2 hrs > 2 hrs ≤ 2 hrs > 2 hrs
Women Men
31. CAD in Women: Conclusions
• The risk factor profile in women presenting with ACS
and AMI is distinctive compared to men. Women are
older, have more HTN, DM, but less extensive CAD
and better preserved LVEF.
• Despite having less extensive CAD, prognosis is
worse than in men
• Symptoms may be atypical – even in the midst of
AMI! Have a high level of suspicion
• In ACS and AMI women benefit from early invasive
strategy and enoxaparin therapy.
32. Treat With Parity
• Use clinical judgement
• Be an advocate for women in your
institution
• Look at your own local data
• Improve outcomes, improve your
practice, improve enrollment in clinical
trials
Editor's Notes
Atherosclerotic plaque morphology differs in women and men. Acute coronary thrombosis results from 2 different types of plaque morphologies: plaque rupture and plaque erosion. Arbustini et al evaluated the prevalence of plaque erosion as a substrate for coronary thrombosis through a pathological study in patients with acute MI not treated with thrombolysis or coronary interventional procedures. This figure shows plaque erosion in 4 sections; the thrombus outlines the profile of the plaque, and there is no evidence of continuity between thrombus and plaque core. 34 Acute coronary thrombi were found in 291 hearts (98%); in 74 cases (25%) 40/107 women (37.4%) and 34/184 men (18.5%; P =.0004) the plaque substrate for thrombosis was erosion. 34 Plaque erosion is an important substrate for coronary thrombosis in patients who die of acute MI, and its prevalence is significantly higher in women than in men. 34 34. Arbustini E, Dal Bello B, Morbini P, et al. Plaque erosion is a major substrate for coronary thrombosis in acute myocardial infarction. Heart . 1999;82:269-272.