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Navarese E.P.,Nicolaus Copernicus University | Gurbel P.A.,Center for Thrombosis Research | Andreotti F.,Catholic University | Tantry U.,Center for Thrombosis Research | And 9 more authors.
Annals of Internal Medicine | Year: 2013

Background: The optimal timing of coronary intervention in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACSs) is a matter of debate. Conflicting results among published studies partly relate to different risk profiles of the studied populations. Purpose: To do the most comprehensive meta-analysis of current evidence on early versus delayed invasive treatment in NSTE-ACS. Data Sources: MEDLINE, PubMed Central, and Google Scholar databases; conference proceedings; ClinicalTrials.gov registry; and Current Controlled Trials registry through May 2012. Study Selection: Available randomized, controlled trials (RCTs) and observational studies comparing early versus delayed intervention in the NSTE-ACS population. Data Extraction: Data were extracted for populations, interventions, outcomes, and risk of bias. All-cause mortality was the prespecified primary end point. The longest follow-up available in each study was chosen. The odds ratio with 95% CI was the effect measure. Data Synthesis: Seven RCTs (5370 patients) and 4 observational studies (77 499 patients) were included. Early intervention was less than 20 hours after hospitalization or randomization for RCTs and 24 hours or less for observational studies. Meta-analysis of the RCTs was inconclusive for a survival benefit associated with the early invasive strategy (odds ratio, 0.83 [95% CI, 0.64 to 1.09]; P = 0.180); a similar result emerged from the observational studies. With early versus late intervention, the odds ratios in the RCTs were 1.15 (CI, 0.65 to 2.01; P = 0.63) and 0.76 (CI, 0.56 to 1.04; P = 0.090) for myocardial infarction and major bleeding during follow-up, respectively. Limitation: Current evidence from RCTs is limited by the small overall sample size, low numbers of events in some trials, and heterogeneity in the timing of intervention and in patient risk profiles. Conclusion: At present, there is insufficient evidence either in favor of or against an early invasive approach in the NSTE-ACS population. A more definitive RCT is warranted to guide clinical practice. Primary Funding Source: None. © 2013 American College of Physicians. Source


Schneider M.P.,Friedrich - Alexander - University, Erlangen - Nuremberg | Hua T.A.,Novartis | Bohm M.,Saarland University | Wachtell K.,The Heart Center | And 2 more authors.
Journal of the American College of Cardiology | Year: 2010

Objectives: The authors reviewed published clinical trial data on the effects of renin-angiotensin system (RAS) inhibition for the prevention of atrial fibrillation (AF), aiming to define when RAS inhibition is most effective. Background: Individual studies examining the effects of RAS inhibition on AF prevention have reported controversial results. Methods: All published randomized controlled trials reporting the effects of treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in the primary or secondary prevention of AF were included. Results: A total of 23 randomized controlled trials with 87,048 patients were analyzed. In primary prevention, 6 trials in hypertension, 2 trials in myocardial infarction, and 3 trials in heart failure were included (some being post-hoc analyses of randomized controlled trials). In secondary prevention, 8 trials after cardioversion and 4 trials assessing the medical prevention of recurrence were included. Overall, RAS inhibition reduced the odds ratio for AF by 33% (p < 0.00001), but there was substantial heterogeneity among trials. In primary prevention, RAS inhibition was effective in patients with heart failure and those with hypertension and left ventricular hypertrophy but not in post-myocardial infarction patients overall. In secondary prevention, RAS inhibition was often administered in addition to antiarrhythmic drugs, including amiodarone, further reducing the odds for AF recurrence after cardioversion by 45% (p = 0.01) and in patients on medical therapy by 63% (p < 0.00001). Conclusions: This analysis supports the concept of RAS inhibition as an emerging treatment for the primary and secondary prevention of AF but acknowledges the fact that some of the primary prevention trials were post-hoc analyses. Further areas of uncertainty include potential differences among specific RAS inhibitors and possible interactions or synergistic effects with antiarrhythmic drugs. © 2010 American College of Cardiology Foundation. Source


New-onset atrial fibrillation (AF) is reported to increase the risk of death in myocardial infarction (MI) patients. However, previous studies have reported conflicting results and no data exist to explain the underlying cause of higher death rates in these patients. All patients with first acute MI between 1997 and 2009 in Denmark, without prior AF, were identified from Danish nationwide administrative registers. The impact of new-onset AF on all-cause mortality, cardiovascular death, fatal/nonfatal stroke, fatal/nonfatal re-infarction and noncardiovascular death, were analyzed by multiple time-dependent Cox models and additionally in propensity score matched analysis. In 89 703 patients with an average follow-up of 5.0 ± 3.5 years event rates were higher in patients developing AF (n=10 708) versus those staying in sinus-rhythm (n=78 992): all-cause mortality 173.9 versus 69.4 per 1000 person-years, cardiovascular death 137.2 versus 50.0 per 1000 person-years, fatal/nonfatal stroke 19.6/19.9 versus 6.2/5.6 per 1000 person-years, fatal/nonfatal re-infarction 29.0/60.7 versus 14.2/37.9 per 1000 person-years. In time-dependent multiple Cox analyses, new-onset AF remained predictive of increased all-cause mortality (HR: 1.9 [95% CI: 1.8 to 2.0]), cardiovascular death (HR: 2.1 [2.0 to 2.2]), fatal/nonfatal stroke (HR: 2.3 [2.1 to 2.6]/HR: 2.5 [2.2 to 2.7]), fatal/nonfatal re-infarction (HR: 1.7 [1.6 to 1.8]/HR: 1.8 [1.7 to 1.9]), and non- cardiovascular death (HR: 1.4 [1.3 to 1.5]) all P<0.001). Propensity-score matched analyses yielded nearly identical results (all P<0.001). New-onset AF after first-time MI is associated with increased mortality, which is largely explained by more cardiovascular deaths. Focus on the prognostic impact of post-infarct AF is warranted. Source


Galantowicz M.,The Heart Center
Seminars in Thoracic and Cardiovascular Surgery: Pediatric Cardiac Surgery Annual | Year: 2013

There are many reasons to consider using the Hybrid Stage 1 procedure as the initial palliation for hypoplastic left heart syndrome. It allows all options for treatment, including a delayed traditional approach, as well as a platform to evolve our overall approach to this challenging heart defect. © 2013 Elsevier Inc. Source


OBJECTIVE: To describe a case of continued aspirin use for primary prevention of a cardiovascular event in a patient post-aspirin-induced upper gastrointestinal (GI) bleed and evaluate published evidence to determine whether reinitiating aspirin therapy for this patient was appropriate. CASE SUMMARY: A 65-year-old man had been taking chronic low-dose (81 mg/day) aspirin therapy since 2002 for primary prevention of a cardiovascular event. He developed an upper GI bleed with lowered hemoglobin (9 mg/dL) and hematocrit (26.3%) after concomitantly taking 2 doses of naproxen (220 mg each). An objective causality assessment with the Naranjo probability scale revealed a probable adverse reaction of an upper GI bleed associated with concomitant naproxen and aspirin use. No further naproxen was taken. Aspirin was discontinued and pantoprazole was started, with resolution of the bleeding. Aspirin was restarted 2.5 months after pantoprazole was initiated, and no further bleeding occurred. DISCUSSION: Upper GI bleeds associated with aspirin therapy are well described in the literature. The management of cardiovascular event prophylaxis after a GI bleed is often controversial; consensus in regard to the optimal method of management does not exist. We evaluated GI protection strategies for patients with a history of aspirin-induced GI bleeding requiring cardiovascular prophylaxis. We found that the benefit of aspirin for the primary prevention of cardiovascular events needs to be carefully balanced with the risks associated with its use. The current literature supports that the best approach to prevent recurrent aspirininduced GI bleeding is to administer a proton pump inhibitor with aspirin therapy. CONCLUSIONS: The benefit of aspirin for primary prevention of cardiovascular events needs to be carefully balanced with the risks associated with its use. Based on the current literature, the best approach to preventing recurrent aspirininduced GI bleeds is to administer a proton pump inhibitor concomitantly with aspirin therapy. © 1967-2013 Harvey Whitney Books Co. All rights reserved. Source

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