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Major Cardiovascular Events (major + cardiovascular_event)

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Determinants of Mortality in Patients Undergoing Cardiac Resynchronization Therapy: Baseline Clinical, Echocardiographic, and Angioscintigraphic Evaluation Prior to Resynchronization

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 12 2005
ANTONIO DE SISTI
Background: In dilated cardiomyopathy (DCM) patients (pts) with cardiac resynchronization therapy (CRT) for ventricular dyssynchrony, long-term predictors of mortality and morbidity remain poorly investigated. Method and Results: We reviewed data of 102 pts, 68 ± 10 years, NYHA Class II,IV (14 Class II, 67 Class III, 21 Class IV), who benefited from CRT (69 CRT, 33 CRT-ICD). Fifty-two patients had an ischemic DCM, 36 a previously implanted conventional PM/ICD, 29 a permanent atrial fibrillation, and 19 needed dobutamine in the month preceding implant. QRS duration was 187 ± 35 ms, left ventricular end-diastolic diameter 72 ± 10 mm, mitral regurgitation severity 1.9 ± 0.8, echographic aorto-pulmonary electromechanical delay 61.5 ± 25 ms and septo-lateral left intraventricular delay 86 ± 56 ms, pulmonary artery pressure (PAP) 43 ± 11 mmHg, angioscintigraphic left ventricular ejection fraction (EF) 20 ± 9%, and right ventricular EF 30.5 ± 14%. Over a mean follow-up of 23 ± 20 months, 26 pts died (18 heart failures (HFs), 1 arrhythmic storm, 7 noncardiac deaths). Positive univariate predictors of death from any cause were NYHA Class IV (P < 0.001), and need for dobutamine the month preceding CRT (P < 0.008), while use of ,-blocking agents (P < 0.08) and left ventricular EF (P < 0.09) were negative ones. NYHA Class IV was the only independent predictor at multivariate analysis (P < 0.01). Survival at 24 months was 85% in Class II, 80% in Class III, and 37% in Class IV (II vs III, P = ns; III vs IV, P < 0.001). When using a composite endpoint of death from any cause and unplanned rehospitalization for a major cardiovascular event, there were 48 events (14 HF deaths, 3 noncardiac deaths, 26 HF rehospitalizations, 2 paroxysmal atrial fibrillation, 2 sustained ventricular tachycardia, 1 nonfatal pulmonary embolism). Predictors of death from any cause/unplanned rehospitalization for a major cardiovascular event in the follow-up were NYHA Class IV (P < 0.001), need for dobutamine during the month preceding CRT (P < 0.002), and PAP (<0.02). NYHA Class IV was the only independent predictor at multivariate analysis (P < 0.05). Event-free proportion at 24 months was 70% in Class II, 64% in Class III, and 37% in Class IV (II vs III, P = ns; III vs IV, P < 0.01). When considering determinants of mortality only in NYHA Class IV patients, no variable was significantly correlated to mortality. Need for dobutamine during the last month preceding CRT did not add an adjunctive mortality risk. Conclusion: Baseline NYHA Class IV at implantation appears as the most important determinant of a poor clinical outcome in terms of both mortality and morbidity. No predictive criteria seem available for NYHA Class IV patients, in order to discriminate who will die after CRT and who will not. NYHA Class IV strongly influences the clinical outcome, suggesting that, in future studies planned on mortality and rehospitalization as major endpoints, baseline NYHA Class IV should be separately taken into account. [source]

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PRESCRIBER, Issue 3 2008
Article first published online: 26 FEB 200
Higher risk of CV events in aspirin resistance More than one in four patients may have aspirin resistance, a new metaanalysis shows, and they face a four-to sixfold increased risk of a major cardiovascular event or death compared with aspirin-sensitive patients taking low-dose aspirin (BMJ online: 17 Jan 2008; doi:10. 1136/bmj.39430.529549.BE). The analysis included 20 studies involving a total of 2930 patients with cardiovascular disease. Of these, 28 per cent were defined as having aspirin resistance (according to the various definitions in each study). Compared with aspirin-sensitive patients, the odds ratio of any cardiovascular event or acute coronary syndrome was about 4 and the odds ratio of death was 6. Aspirin-resistant patients did not benefit from other antiplatelet treatment. ADOPT: rosiglitazone fracture risk in women A new analysis of the ADOPT trial (N Engl J Med 2006;355: 2427-43) has found that the risk of fractures during treatment with rosiglitazone (Avandia) is approximately twice as high as with metformin or glibenclamide, but mainly in women (Diabetes Care online: 25 Jan 2008; doi: 10.2337/dc07-2270). The study found a significant difference in risk between the drugs only for women, with a cumulative incidence of 15.1 per cent with rosiglitazone, 7.3 per cent with metformin and 7.7 per cent with glibenclamide after five years. No risk factors were identified although the incidence of fractures was higher among postmenopausal than premenopausal women. New from NICE Infliximab for the treatment of adults with psoriasis. Technology Appraisal Guidance No. 134, Jan 2008 Infliximab (Remicade), a monoclonal antibody against TNF-alpha, should be an option for treating very severe plaque psoriasis in adults, NICE recommends. Using its fast-track single technology appraisal procedure, NICE concluded that infliximab should be considered when standard therapies,methotrexate or ciclosporin (Neoral), or PUVA , have failed or are unsuitable. The criteria for disease severity are defined by the Psoriasis Area Severity Index (PASI) score (,20) and the Dermatology Life Quality Index (DLQI) score (>18). Treatment response is also defined by these measures and infliximab should be continued for longer than 10 weeks only when predefined thresholds are met. Infliximab costs an average of £11 750 annually. In 2006, NICE recommended etanercept (Enbrel) and efalizumab (Raptiva) for patients with severe psoriasis (PASI ,10 and DLQI >10). Commons committee wants tougher targets Most GPs get full QOF points for medicines management even though there is inexplicably large variation in good prescribing practice between PCTs, the Public Accounts Select Committee points out in its latest report, Prescribing Costs in Primary Care. The Committee wants to see tougher QOF targets among several initiatives to reduce prescribing costs. Although most publicity centred on its endorsement of the National Audit Office claim that GPs could save £200 million by prescribing lower-cost drugs, the report contains some more far-reaching proposals. GPs should prescribe generic alternatives within a therapeutic category, so when a brand is not available generically, eg Lipitor, a different drug that is, eg simvastatin, should be used when clinically appropriate. Further, this form of substitution should be rewarded via QOF targets. There should be greater uniformity in the appearance, labelling and packaging of generic and branded equivalents. The Department of Health should consider raising awareness of the value of medicines by printing the cost on packaging, and to reduce the £100 million wasted annually in dumped medicines, it should investigate which drugs aren't used and why patients won't take them. Strategic health authorities should work with the National Prescribing Centre to develop more prescribing indicators with which to measure PCT performance and support PCTs to promulgate best practice. They should also collaborate on promoting joint primary-secondary care formularies and increase the consistency of prescribing, not only between hospital specialists and GPs but also between PCTs. To monitor the influence of the pharmaceutical industry, PCTs should keep a record of gifts and hospitality and publish a register. Questions to ask about mental health treatment The Department of Health has published a booklet designed to raise awareness of medicines management issues affecting people using mental health services and their carers, and professionals in the health and social services. Although one aim of Medicines Management: Everybody's Business is to empower people with mental health problems to ask about their medication, its formal style is better suited to staff who need to improve their person-centred approach to care. It covers what information people should expect and what questions to ask when drug treatment is being considered, what to expect at review and issues to consider when contemplating stopping treatment. Copies can be downloaded at www.dh.gov.uk. Consider statins for all patients with diabetes Treatment with a statin should be considered for all patients with diabetes unless their risk is low, say the authors of a new study (Lancet 2008;371:117-25). Their meta-analysis of 14 randomised trials involving 18 686 people with diabetes and an average follow-up of 4.3 years found that statins reduced vascular events and vascular mortality as much as in nondiabetic populations. The overall benefit was 42 fewer major events per 1000 people treated for five years. This was independent of a history of vascular disease or other baseline characteristics. No evidence for OTC cough medicines There is no evidence that over-the-counter cough medicines for adults and children are effective in relieving acute cough, a new Cochrane review has concluded (Cochrane Database of Systematic Reviews 2008, Issue 1). The review of 17 randomised trials involving 2876 adults and eight involving 616 children reported conflicting findings of uncertain clinical relevance. The trials were heterogeneous and of low quality. Copyright © 2008 Wiley Interface Ltd [source]

Anti,apolipoprotein A-1 IgG predicts major cardiovascular events in patients with rheumatoid arthritis

ARTHRITIS & RHEUMATISM, Issue 9 2010
Nicolas Vuilleumier
Objective To determine whether anti,apolipoprotein A-1 (anti,Apo A-1) IgG are associated with major cardiovascular events in patients with rheumatoid arthritis (RA). Methods We determined anti,Apo A-1 IgG levels and the concentrations of cytokines, oxidized low-density lipoprotein (LDL), and matrix metalloproteinase 1 (MMP-1) MMP-2, MMP-3, and MMP-9 in sera from 133 patients with RA who did not have cardiovascular disease at baseline, all of whom were longitudinally followed up over a median period of 9 years. A major cardiovascular event was defined as a fatal or nonfatal stroke or acute coronary syndrome. The proinflammatory effects of anti,Apo A-1 IgG were assessed on human macrophages in vitro. Results During followup, the overall incidence of major cardiovascular events was 15% (20 of 133 patients). At baseline, anti,Apo A-1 IgG positivity was 17% and was associated with a higher incidence of major cardiovascular events (adjusted hazard ratio 4.2, 95% confidence interval 1.5,12.1). Patients who experienced a subsequent major cardiovascular event had higher circulating levels of anti,Apo A-1 IgG at baseline compared with those who did not have a major cardiovascular event. Receiver operating curve analysis showed that anti,Apo A-1 IgG was the strongest of all tested biomarkers for the prediction of a subsequent major cardiovascular event, with an area under the curve value of 0.73 (P = 0.0008). At the predefined and previously validated cutoff levels, the specificity and sensitivity of anti,Apo A-1 IgG to predict major cardiovascular events were 50% and 90%, respectively. Anti,Apo A-1 IgG positivity was associated with higher median circulating levels of interleukin-8 (IL-8), oxidized LDL, and MMP-9 and higher proMMP-9 activity as assessed by zymography. On human macrophages, anti,Apo A-1 IgG induced a significant dose-dependent increase in IL-8 and MMP-9 levels and proMMP-9 activity. Conclusion Anti,Apo A-1 IgG is an independent predictor of major cardiovascular events in RA, possibly by affecting vulnerability to atherosclerotic plaque. [source]

Plasma matrix metalloproteinase-3 level is an independent prognostic factor in stable coronary artery disease

EUROPEAN JOURNAL OF CLINICAL INVESTIGATION, Issue 9 2005
T. C. Wu
Abstract Background, Recent evidence suggests the important role of matrix metalloproteinases (MMPs) in the progression of atherosclerosis and development of clinical events. We assessed the prognostic value of different plasma MMPs in patients with stable coronary artery disease (CAD). Materials and methods, A total of 165 consecutive nondiabetic patients with angiographically significant CAD (n = 150) or normal coronary angiograms despite exercise-induced myocardial ischemia (cardiac syndrome X, n = 15) and 17 normal subjects were evaluated. In each subject, plasma inflammatory markers including high sensitivity C-reactive protein (hsCRP) and MMP-2, 3 and 9 were measured. In CAD patients, major cardiovascular events including cardiac death, nonfatal myocardial infarction, unscheduled coronary revascularization and hospitalization as a result of unstable angina were prospectively followed up for more than 6 months. Results, Plasma levels of MMPs were significantly higher in CAD patients than in those with cardiac syndrome X and in normal subjects (MMP-2: 914·76 ± 13·20 vs. 830·79 ± 31·95 vs. 783·08 ± 28·40 ng mL,1, P = 0·002; MMP-3: 129·59 ± 4·21 vs. 116·86 ± 8·09 vs. 91·71 ± 9·55 ng mL,1, P = 0·011; MMP-9: 31·42 ± 2·84 vs. 11·40 ± 5·49 vs. 6·71 ± 2·89 ng mL,1, P = 0·006). In CAD patients, there were 48 major cardiovascular events during a mean follow-up period of 17·74 ± 0·85 months. The numbers of diseased vessels (HR = 2·19, 95% CI 1·20,1·02, P = 0·011), plasma hsCRP (HR = 2·21, 95% CI 1·18,4·11, P = 0·013) and MMP-3 level (HR = 2·46, 95% CI = 1·15,5·28, P = 0·021) were associated with the development of cardiovascular events. However, only the plasma MMP-3 level was an independent predictor of the adverse events in CAD patients (HR = 2·47, 95% CI 1·10,5·54, P = 0·028). Conclusions, Plasma MMP levels were increased in CAD patients. Plasma MMP-3 level, rather than hsCRP, was an independent prognostic marker for future cardiovascular events, suggesting its potential role in risk stratification and clinical management of stable CAD. [source]

Meta-analysis: the effects of proton pump inhibitors on cardiovascular events and mortality in patients receiving clopidogrel

ALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 8 2010
C. S. KWOK
Summary Background, Recent studies have suggested an adverse interaction between proton pump inhibitors (PPI) and clopidogrel. Aim, To perform a meta-analysis of cardiovascular outcomes and mortality in patients taking clopidogrel, with and without concomitant PPI. Methods, We searched MEDLINE, EMBASE, Cochrane Controlled Trials Register in October 2009, and checked conference abstracts for randomized and nonrandomized studies that reported the risk of cardiovascular events and mortality with PPI exposure in patients taking clopidogrel. We performed random effects meta-analysis, stratified by study design and assessed heterogeneity using the I2 statistic. Results, Our review included 23 studies covering 93 278 patients. There was substantial heterogeneity in the meta-analyses of major cardiovascular events (19 studies, I2 = 79%) or myocardial infarction (12 studies, I2 = 77%). Analysis of propensity-matched or randomized trial participants showed no associated cardiovascular risk with PPIs, whereas other observational studies generally showed a significant association. Meta-analysis of 13 studies showed no significant association between PPI use and overall mortality (RR 1.09, 95% CI: 0.94,1.26, P = 0.23, I2 = 60%). Conclusion, As there are conflicting and inconsistent data regarding the adverse clopidogrel,PPI interaction, clinicians should focus on potential harm from ulcers/haemorrhage before deciding to omit PPIs in patients taking clopidogrel. [source]

Neopterin induces pro-atherothrombotic phenotype in human coronary endothelial cells

JOURNAL OF THROMBOSIS AND HAEMOSTASIS, Issue 10 2006
P. CIRILLO
Summary.,Background: Inflammation plays a pivotal role in atherothrombosis. Recent data indicate that serum levels of neopterin, a marker of inflammation and immune modulator secreted by monocytes/macrophages, are elevated in patients with acute coronary syndromes and seem to be a prognostic marker for major cardiovascular events. The aim of the present study was to determine whether neopterin might affect the thrombotic and atherosclerotic characteristics of human coronary artery endothelial cells (HCAECs). Methods and results: In HCAECs, neopterin induced TF-mRNA transcription as demonstrated by real time polymerase chain reaction and expression of functionally active tissue factor (TF) as demonstrated by procoagulant activity assay, and of cellular adhesion molecules (CAMs) as demonstrated by FACS analysis, in a dose-dependent fashion. These neopterin effects were prevented by lovastatin, a HMG-CoA reductase inhibitor. Neopterin-induced TF and CAMs expression was mediated by oxygen free radicals through the activation of the transcription factor, nuclear factor-kappa B (NF- ,B), as demonstrated by electrophoretic mobility shift assay and by suppression of CAMs and TF expression by superoxide dismutase and by NF- ,B inhibitor, pyrrolidine-dithio-carbamate ammonium. Conclusions: These data indicate that neopterin exerts direct effects on HCAECs by promoting CAMs and TF expression and support the hypothesis that neopterin, besides representing a marker of inflammation, might be an effector molecule able to induce a pro-atherothrombotic phenotype in cells of the coronary circulation. [source]

Cardiac Resynchronization Therapy in Patients with Mildly Impaired Left Ventricular Function

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 2009
PAUL W.X. FOLEY M.R.C.P.
Aims: We sought to determine the unknown effects of cardiac resynchronization therapy (CRT) in patients with a left ventricular ejection fraction (LVEF) >35%. Because of its technical limitations, echocardiography (Echo) may underestimate LVEF, compared with cardiovascular magnetic resonance (CMR). Methods: Of 157 patients undergoing CRT (New York Heart Association [NYHA] functional class III or IV, QRS , 120 ms), all of whom had a preimplant Echo-LVEF ,35%, 130 had a CMR-LVEF ,35% (Group A, 19.7 ± 7.0%[mean ± standard deviation]) and 27 had a CMR-LVEF >35% (Group B, 43.6 ± 7.7%). All patients underwent a CMR scan at baseline and a clinical evaluation, including a 6-minute walk test and a quality of life questionnaire, at baseline and after CRT. Results: Both groups derived similar improvements in NYHA functional class (A =,1.3, B =,1.2, [mean]), quality of life scores (A =,21.6, B =,33.0; all P < 0.0001 for changes from baseline), and 6-minute walking distance (A = 64.5, B = 70.1 m; P < 0.001 and P < 0.0001, respectively). Symptomatic response rates (increase by ,1 NYHA classes or 25% 6-minute walking distance) were 79% in group A and 92% in group B. Over a maximum follow-up period of 5.9 years for events, patients in group A were at a higher risk of death from any cause, hospitalization for major cardiovascular events (P = 0.0232), or cardiovascular death (P = 0.0411). There were borderline differences in the risk of death from any cause (P = 0.0664) and cardiovascular death or hospitalization for heart failure (P = 0.0526). Conclusions: This observational study suggests that the benefits of CRT extend to patients with a LVEF > 35%. [source]

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PRESCRIBER, Issue 11 2008
Article first published online: 18 JUN 200
New asthma guideline The BTS/SIGN guideline for the management of asthma has been updated. The diagnosis section has been rewritten, there is a new section on difficult asthma and the treatment sections have been updated. A new option at Step 3 (initial add-on therapy) is now the use of a combined budesonide/formoterol inhaler (Symbicort) as a reliever in addition to regular use as a preventer. This reflects evidence from the SMART trials, which showed that an average of one extra puff per day significantly reduced exacerbations and admissions (Br Med J 2007;335:513). Metformin matches insulin in pregnancy Metformin does not worsen perinatal outcomes compared with insulin in gestational diabetes and mothers prefer it, a study from Australia and New Zealand shows (N Engl J Med 2008;358:2003,15). Of the women randomised to metformin treatment, 93 per cent were still taking it at term and 46 had supplemental insulin. The combined incidence of neonatal hypoglycaemia, respiratory distress, need for phototherapy, birth trauma, five-minute Apgar score less than 7 or prematurity was 32 per cent with both treatments. There were no serious adverse events. More women said they would choose the same treatment again for metformin than insulin (77 vs 27 per cent). Same CV protection with antihypertensives There is no difference in protection against major cardiovascular events between different types of antihypertensives in young or older (65 or over) adults, according to the Blood Pressure Lowering Treatment Trialists' Collaboration. Its meta-analysis of 31 trials involving over 190 000 patients (BMJ Online 2008; doi:10.1136/bmj.39548.738 368.BE) found no significant difference by age on blood pressure reduction or risk reduction. Treatment may be chosen according to tolerability and cost as long as effective blood pressure reduction is achieved, the authors conclude. Older people are at greater absolute risk and treatment therefore offers larger reductions in serious vascular events. HPV vaccination starts in September Vaccination against human papilloma virus will be part of the national immunisation programme from the start of the new school year in September. The vaccine, administered as three doses over six months, will initially be offered to girls aged 12,13 (school year 8) to reduce their risk of cervical cancer. A two-year catch-up campaign for all girls up to 18 years old will begin in 2009. MHRA: pancreatitis with exenatide warning The incretin mimetic exenatide (Byetta), licensed for the treatment of type 2 diabetes, may rarely be associated with pancreatitis, warns the MHRA (Drug Safety Update 2008;1:Issue 10). One case has been reported in the UK and 89 in the USA and Germany. The MHRA advises that patients should be warned of the symptoms of pancreatitis (severe abdominal pain, back pain). Treatment should be discontinued if pancreatitis is suspected and the case reported on a yellow card. 2007 prescribing bill Primary-care expenditure on drugs in England in 2007 totalled £8.37 billion, only 2 per cent more than in 2006, according to the latest statistics from the Information Centre (www.ic.nhs.uk). Prescription numbers increased by almost 6 per cent. Prescribing increased in most BNF categories but changed little in musculoskeletal drugs and immunological products and vaccines. Calceos: calcium/ vitamin D3 price match Manufacturer Galen has pledged to continue to price-match its calcium/vitamin D3 supplement Calceos with Adcal-D3 or Calcichew D3 Forte. If the price of either product falls below that of Calceos chewable tablets, Galen will match it within six months. The company says it will honour the pledge until at least 2011. Copyright © 2008 Wiley Interface Ltd [source]

Anti,apolipoprotein A-1 IgG predicts major cardiovascular events in patients with rheumatoid arthritis

Safety and efficacy of carotid stenting in the very elderly,

CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 5 2010
Arthur Grant MD
Abstract Background: Carotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy (CEA) in patients at high risk for complications from surgery. The very elderly (,80-year-old) are one subgroup of patients identified as being at increased risk for carotid surgery. However, there is concern that the very elderly are also at increased risk for complications of CAS. A stroke and death rate of 12% was reported in very elderly patients during the roll-in phase of Carotid Revascularization Endarterectomy versus Stent Trial (CREST). We are reporting on a large clinical series of CAS with independent neurological assessment in the very elderly. Methods: Between 1994 and 2008, a consecutive series of 418 CAS patients (,80-year-old) were treated at four high-volume centers with extensive CAS experience. Independent neurologic assessment was performed after CAS procedures. Thirty-day follow-up information was available in 389 patients. Results: The average age was 83.2 ± 2.8 years. Most patients were male (63.2%), and the target lesion carotid stenosis was asymptomatic in two-thirds (68.2%) of patients. The majority of patients treated with CAS had a history of coronary artery disease (74.4%), hypertension (87.8%), and dyslipidemia (71.1%). One third (30.1%) were diabetic and more than half (56.5%) were current or former smokers. Embolic protection devices (EPD) were used in 78.7% of cases with the CAS procedure being performed before EPD availability being the most common reason for not using them. The overall 30-day incidence of stroke and death was 2.8% (11/389). The cumulative incidence of major cardiovascular events (stroke, death, or myocardial infarction) during that time period was 3.3% (13/389). Conclusions: This large series of CAS with independent neurologic assessment is convincing evidence that the very elderly (,80 years) can safely undergo CAS with stroke and death rates comparable to younger patients. The key to obtaining these excellent results is that CAS be performed by high volume, experienced operators who exercise restraint regarding patient selection. © 2009 Wiley-Liss, Inc. [source]