This document summarizes the results of a post-hoc analysis of the TWILIGHT trial to evaluate the safety and efficacy of ticagrelor monotherapy versus ticagrelor plus aspirin in patients who underwent complex percutaneous coronary intervention (PCI). The analysis found that in patients who underwent complex PCI, ticagrelor monotherapy was associated with a lower risk of clinically relevant bleeding compared to ticagrelor plus aspirin, without increasing the risk of ischemic events. Specifically, ticagrelor monotherapy resulted in a 46% lower risk of BARC type 3 or higher bleeding. There were no significant differences in rates of death, myocardial infarction, or stroke between the two treatment groups in either complex or non-
Coronary CTO is characterized by heavy atherosclerotic plaque burden within the artery, resulting in complete (or nearly complete) occlusion of the vessel. Although the duration of the occlusion is difficult to determine on clinical grounds, a total occlusion must be present for at least 3 months to be considered a true CTO. Patients with CTO typically have collateralization of the distal vessel on coronary angiography, but these collaterals may not provide sufficient blood flow to the myocardial bed, resulting in ischemia and anginal symptoms. CTO is clinically distinct from acute coronary occlusion, which occurs in the setting of ST-segment–elevation myocardial infarction, or subacute coronary occlusion, discovered with delayed presentation after ST-segment–elevation myocardial infarction. Clinical features and treatment considerations of these entities differ considerably from CTO.
Among patients who have a clinical indication for coronary angiography, the incidence of CTO has been reported to be as high as 15% to 30%. Patients with CTO are referred for angiography because of anginal symptoms or significant ischemia on noninvasive ischemia testing. Patients who are symptomatic will have stable exertional angina resulting from a limitation of collateral vessel flow to meet myocardial oxygen demand with stress. Of patients referred for PCI in clinical trials of CTO PCI, only 10% to 15% of patients are asymptomatic. It is likewise uncommon for patients with CTO to present with an acute coronary syndrome caused by the CTO itself.
Coronary CTO is characterized by heavy atherosclerotic plaque burden within the artery, resulting in complete (or nearly complete) occlusion of the vessel. Although the duration of the occlusion is difficult to determine on clinical grounds, a total occlusion must be present for at least 3 months to be considered a true CTO. Patients with CTO typically have collateralization of the distal vessel on coronary angiography, but these collaterals may not provide sufficient blood flow to the myocardial bed, resulting in ischemia and anginal symptoms. CTO is clinically distinct from acute coronary occlusion, which occurs in the setting of ST-segment–elevation myocardial infarction, or subacute coronary occlusion, discovered with delayed presentation after ST-segment–elevation myocardial infarction. Clinical features and treatment considerations of these entities differ considerably from CTO.
Among patients who have a clinical indication for coronary angiography, the incidence of CTO has been reported to be as high as 15% to 30%. Patients with CTO are referred for angiography because of anginal symptoms or significant ischemia on noninvasive ischemia testing. Patients who are symptomatic will have stable exertional angina resulting from a limitation of collateral vessel flow to meet myocardial oxygen demand with stress. Of patients referred for PCI in clinical trials of CTO PCI, only 10% to 15% of patients are asymptomatic. It is likewise uncommon for patients with CTO to present with an acute coronary syndrome caused by the CTO itself.
#flozins
🫀DAPA 🆚placebo in HFpEF
Now we have a positive trial!
⬇️18% in CV☠️ death or
worsening HF among LVEF>40%
⬇️ 21%heart failure
💥Results same for LVEF> 60% 🆚LVEF<60%
Optimize guide catheter support
Fabrice Leroy, Lille, France
11th Experts Live CTO
The annual Euro CTO meeting
September 13th –14th, 2019 - Berlin, Germany
COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
#flozins
🫀DAPA 🆚placebo in HFpEF
Now we have a positive trial!
⬇️18% in CV☠️ death or
worsening HF among LVEF>40%
⬇️ 21%heart failure
💥Results same for LVEF> 60% 🆚LVEF<60%
Optimize guide catheter support
Fabrice Leroy, Lille, France
11th Experts Live CTO
The annual Euro CTO meeting
September 13th –14th, 2019 - Berlin, Germany
COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
This trial describes the use of Aspirin or Clopidogrel as a monotherapy after percutaneous coronary intervention in myocardial infarction patients. Though the guidelines have not said anything strictly but trials have shown Clopidogrel to be better than Aspirin.
Impact of access site on bleeding and ischemic events in patients with non-ST-segment elevation myocardial infarction treated with prasugrel at the time of percutaneous coronary intervention or as pretreatment at the time of diagnosis: the ACCOAST access substudy
Reestenosis, Síndrome coronario agudo. Rol actual de los nuevos antiplaquetarios en el síndrome coronario agudo. Congreso SOLACI Chile 2011.Dr. Ramón Corbalán. Encuentre más presentaciones en la página www.solaci.org/
Novedades en el manejo del paciente con FA: actualización tras AHA 2016
22/11/2016 19:30h Casa del Corazón, Madrid
http://manejofa.secardiologia.es
#manejoFA
Seguimiento de pacientes con FA y SCA tras intervención coronaria percutánea. Evidencia con ACOD
Dr. Marcelo Sanmartín Fernández, Hospital Universitario Ramón y Cajal (Madrid)
XXVII Reunión anual de la sección de Hemodinámica y Cardiología Intervencionista
16 y 17 de junio de 2016 León
http://secardiologia.es/xxvii-reunion-anual-de-la-seccion-de-hemodinamica-y-cardiologia-intervencionista
Novedades en farmacología en intervencionismo
Antonio Fernández Ortiz (Hosp. Clínico San Carlos. Madrid)
Vitamin D is an important prohormone for optimal intestinal calcium absorption for mineralization of bone. Because the vitamin D receptor is present in multiple tissues, there has been interest in evaluating other potential functions of vitamin D, particularly, in cardiovascular diseases (CVD). Cross-sectional studies have reported that vitamin D deficiency is associated with increased risk of CVD, including hypertension, heart failure, and ischemic heart disease. Initial prospective studies have also demonstrated that vitamin D deficiency increases the risk of developing incident hypertension or sudden cardiac death in individuals with preexisting CVD. Very few prospective clinical studies have been conducted to examine the effect of vitamin D supplementation on cardiovascular outcomes. The mechanism for how vitamin D may improve CVD outcomes remains obscure; however, potential hypotheses include the downregulation of the renin-angiotensin-aldosterone system, direct effects on the heart, and vasculature or improvement of glycemic control. This review will examine the epidemiologic and clinical evidence for vitamin D deficiency as a cardiovascular risk factor and explore potential mechanisms for the cardioprotective effect of vitamin D.
How to deal with CALCIFIED CORONARY ARTERY LESIONS .Coronary artery calcification (CAC) is highly prevalent in patients with coronary heart disease (CHD) and is associated with major adverse cardiovascular events. There are two recognized type of CAC—intimal and medial calcification, and each of them have specific risk factors. Several theories about the mechanism of vascular calcification have been put forward, and we currently believe that vascular calcification is an active, regulated process. CAC can usually be found in patients with severe CHD, and this asymptomatic phenomenon make early diagnosis of CAC important. Coronary computed tomographic angiography is the main noninvasive tool to detect calcified lesions. Measurement of coronary artery calcification by scoring is a reasonable metric for cardiovascular risk assessment in asymptomatic adults at intermediate risk. To date, effective medical treatment of CAC has not been identified. Several strategies of percutaneous coronary intervention have been applied to CHD patients with CAC, but with unsatisfactory results. Prognosis of CAC is still a major problem of CHD patients. Thus, more details about the mechanisms of CAC need to be elucidated in order to improve the understanding and treatment of CAC.
Hypertension is a common medical and social problem leading to cardiovascular diseases worldwide. Antihypertensive drugs are clinically applied to decrease the morbidity and mortality induced by hypertension itself and its complications. The 2014 hypertension guideline of the Eighth Joint National Committee (JNC8) for hypertension therapy in the United States has made several significant changes with respect to the clinical management of hypertension and the initiative medications, as compared with the previous guidelines. In addition to the instructions that pharmacologic treatment should be initiated when blood pressure (BP) is 150/90 mmHg or higher in adults over 60 years, 140/90 mmHg in adults younger than 60 years, or 140/90 mmHg or higher (regardless of age) in patients with hypertension and diabetes, a thiazide-type diuretic, calcium (Ca2+) channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB) should be considered to start an initial antihypertensive medication in non-black population. In black population with or without diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. Thus, CCB has become one of the most important initial agents for antihypertensive monotherapy. Furthermore, since CCBs have been proved not to increase the risk of coronary events and stroke,CCBs appear to be a favorable choice for monotherapy as well as for combination with other agent classes in the treatment of hypertension and may provide specific benefits beyond BP lowering.Nowadays, dihydropyridine (DHP) CCBs are one group of most frequently prescribed antihypertensive medications in China and other Eastern Asian countries.
Among patients with or at high risk of CVD, use of an FDC strategy for blood pressure, cholesterol, and platelet control vs usual care resulted in significantly improved medication adherence.Polypill therapy significantly improved adherence, SBP and LDL-cholesterol in high risk patients compared with usual care, especially among those who were under-treated at baseline.
A transesophageal echocardiogram (TEE) uses echocardiography to assess the structure and function of the heart. During the procedure, a transducer (like a microphone) sends out ultrasonic sound waves. When the transducer is placed at certain locations and angles, the ultrasonic sound waves move through the skin and other body tissues to the heart tissues, where the waves bounce or "echo" off of the heart structures. The transducer picks up the reflected waves and sends them to a computer. The computer displays the echoes as images of the heart walls and valves.
A traditional echocardiogram is done by putting the transducer on the surface of the chest. This is called a transthoracic echocardiogram. A transesophageal echocardiogram is done by inserting a probe with a transducer down the esophagus. This provides a clearer image of the heart because the sound waves do not have to pass through skin, muscle, or bone tissue. The TEE probe is much closer to the heart since the esophagus and heart are right next to each other.
Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
Francesca Gottschalk from the OECD’s Centre for Educational Research and Innovation presents at the Ask an Expert Webinar: How can education support child empowerment?
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
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Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
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Biological screening of herbal drugs: Introduction and Need for
Phyto-Pharmacological Screening, New Strategies for evaluating
Natural Products, In vitro evaluation techniques for Antioxidants, Antimicrobial and Anticancer drugs. In vivo evaluation techniques
for Anti-inflammatory, Antiulcer, Anticancer, Wound healing, Antidiabetic, Hepatoprotective, Cardio protective, Diuretics and
Antifertility, Toxicity studies as per OECD guidelines
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
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BÀI TẬP BỔ TRỢ TIẾNG ANH GLOBAL SUCCESS LỚP 3 - CẢ NĂM (CÓ FILE NGHE VÀ ĐÁP Á...
Twilight complex study
1. Dr Awadhesh Kr Sharma, DM,FACC,FSCAI
Assistant Professor
LPS Institute of Cardiology,
GSVM Medical College, Kanpur, UP,INDIA
E-mail: awakush@gmail.com
2.
3.
4.
5. Post-hoc analysis of the TWILIGHT trial
To evaluate the safety and efficacy of a regimen of
ticagrelor monotherapy versus ticagrelor plus aspirin,
in patients who initially completed 3 months
of DAPT after complex PCI.
6. • Patients who undergo complex PCI are at high risk of ischemic events 1,2. This risk is higher with increments
in PCI complexity and may be reduced by extending DAPT 3.
• On the other hand (regardless of PCI complexity) extension of DAPT duration is associated with increased
risk for major bleeding, which is in turn associated with increased morbidity, mortality and healthcare cost 4.
• A strategy of withdrawing aspirin and maintaining P2Y12 inhibitor monotherapy after a brief period of DAPT
has emerged a potential bleeding reduction strategy 5. In particular, the TWILIGHT study showed that
monotherapy with the potent P2Y12-receptor inhibitor ticagrelor after 3 months of DAPT was associated with a
lower incidence of clinically relevant bleeding, without increasing the risk of ischemic events compared to
continuing DAPT 6.
• Whether such an approach mitigates bleeding complications, without increasing ischemic risk in patients who
undergo complex PCI is unknown.
1. Giustino et al. J Am Coll Cardiol 2016;68:1851-1864.
2. Genereux et al. Int J Cardiol 2018;268:61-67.
3. Serruys et al. Eur Heart J 2019;40:2595-2604.
4. Baber et al. JACC Cardiovasc Interv 2016;9:1349-57.
5.Capodanno et al. Nature Reviews Cardiology 2018;15:480-496. 6. Mehran et al. N
Engl J Med 2019;381:2032-2042.
7. 3 M 15 M 18 M
Ticagrelor + Placebo
• Randomized, double-blind placebo-controlled trial in 187 sites and 11 countries.
• High-risk PCI patients treated with ticagrelor plus aspirin for 3 months.
• Event-free and adherent patients were randomized to aspirin versus placebo and continued
ticagrelor for an additional 12 months.
Enrolled PCI Pts
(N = 9006)
Ticagrelor + Aspirin Standard of Care
Enrolled Complex
PCI (N = 2956)
Randomized
Complex PCI
2620
Standard of Care
Randomization Period
12 Months
Observation Period
3 Months
Dangas et al, JACC 2020
Post Enrollment Period
3 Months
8. Clinical criteria
Age ≥65 years
Female gender
Troponin positive ACS
Established vascular disease (previous MI,
documented PAD or CAD/PAD revascularization)
DM treated with medications or insulin
CKD (eGFR <60ml/min/1.73m2 or CrCl <60ml/min)
Angiographic criteria
Multivessel CAD
Target lesion requiring total stent length >30mm
Thrombotic target lesion
Bifurcation lesion(s) with Medina X,1,1 classification
requiring ≥2 stents
Left main (≥50%) or proximal LAD (≥70%) lesions
Calcified target lesion(s) requiring atherectomy
Patients Must meet at least 1 clinical AND 1 angiographic criterion
Key Exclusions: STEMI; Salvage PCI; need for chronic oral anticoagulation; planned
repeat coronary revascularization
9. Dangas et al, JACC 2020
Target Population
Randomized TWILIGHT participants undergoing complex PCI, as defined below.
Complex PCI included PCI with at least 1 of the following characteristics:
• 3 vessels treated
• ≥3 lesions treated
• total stent length >60 mm
• bifurcation with 2 stents implanted
• use of any atherectomy device
• left main as target vessel
• venous or arterial bypass graft as target lesion
• chronic total occlusion of target lesion
Endpoints
Primary: BARC 2, 3 or 5 bleeding between 0 - 12 months after randomization
Secondary: All-cause death, non-fatal MI or stroke between 0 - 12 months after randomization
Defined a major
bleeding event as
Bleeding Academic
Research Consortium
(BARC) type 3b or
higher.
BARC bleeding types
range from 0 (no
bleeding) to 5 (fatal
bleeding);
Type 3b indicates overt
bleeding leading to a
decrease in hemoglobin
level of at least 5 mg per
deciliter, cardiac
tamponade, surgical
intervention, or
intravenous treatment
with vasoactive drugs.
10. Dangas et al, JACC 2020
Statistical Analysis
• Analyses were performed in the intention-to-treat population for bleeding endpoints and in the per-
protocol population for ischemic endpoints.
• The cumulative incidence of the primary and secondary endpoints was estimated by Kaplan–Meier
methods.
• Hazard ratios (HR) and 95% confidence intervals were generated with Cox proportional-hazards models.
• The consistency of the treatment effects of ticagrelor monotherapy versus ticagrelor plus aspirin between
the complex and non-complex PCI subgroups was evaluated with formal interaction testing.
22. 0.01 1 100
Ticagrelor
plus placebo
Ticagrelor
plusaspirin
3 vessels treated 7/101 6/112
≥3 lesions treated 17/359 15/333
>60 mm total stent length 22/609 25/595
Use of atherectomy device 2/119 12/120
Bifurcation with 2 stents
implanted
4/123 5/126
CTO as target lesion 3/220 9/218
Venous or arterial graft as
target lesion
11/76 9/83
Left main as target lesion 8/165 11/184
Overall 43/1,152 56/1,159
HR (95% CI)
1.29 (0.43-3.83)
1.06 (0.53-2.12)
0.87 (0.49-1.53)
0.16 (0.04-0.73)
0.83 (0.22-3.08)
0.33 (0.09-1.22)
1.35 (0.56-3.26)
0.80 (0.32-1.99)
0.77 (0.52-1.15)
100.1
23. Dangas et al, JACC 2020
Ticagrelor
plus placebo
Ticagrelor
plus aspirin
1 Complex PCI criterion 22/694 34/715
2 Complex PCI criteria 13/252 11/224
≥3 Complex PCI criteria 8/138 11/146
Overall 43/1,084 56/1,085
HR (95% CI)
0.67 (0.39-1.15)
1.05 (0.47-2.35)
0.76 (0.31-1.90)
0.77 (0.52-1.15)
0.01 0.1
Ticagrelor plus placebo better
1 10
Ticagrelor plus aspirin better
100
Death, MI or Stroke
24. Dangas et al, JACC 2020
• As a post-hoc analysis, randomization was not stratified by complex PCI status and we did not account for
multiplicity thereby increasing the chance for a type 1 error.
• The complex PCI and the non-complex PCI groups were not individually powered to draw definite conclusions
on the effect of a regimen of ticagrelor monotherapy on the bleeding and ischemic endpoints. However, the
magnitude and direction of the effect were largely consistent with the overall trial findings.
• These results are not generalizable to all patients who undergo PCI due to the inclusion and exclusion criteria
applied in the TWILIGHT trial.
• The observed treatment effects are applicable only to patients who tolerated an initial 3 months of DAPT with
ticagrelor plus aspirin without any major adverse events. Whether the ticagrelor monotherapy findings are
generalizable to a regimen of clopidogrel or prasugrel monotherapy remains unknown.
25. Dangas et al, JACC 2020
• Among patients who underwent complex PCI as defined by a combination of high-
risk angiographic and procedural features, a regimen of ticagrelor monotherapy
(after an initial 3 months of DAPT with ticagrelor plus aspirin) was associated with
significantly lower clinically-relevant bleeding without increasing the risk of
ischemic events compared to continuing the DAPT.
• This effect was consistent across the individual components of the complex PCI
definition.
26. It doesn’t matter who you are, if you have a vision and are determined to achieve that vision
through the constant acquisition of knowledge, you will certainly realize your goals.
-Dr. APJ Abdul Kalam