Journal Scans

Transcatheter Aortic-Valve Replacement for Inoperable Severe Aortic Stenosis

2012-05-25 23:19:00

A total of 358 patients underwent randomization at 21 centers. There was a significant reduction in the 2-year mortality (43.3% vs. 68.0%, p < 0.001) and cardiac mortality (31% vs. 62%, p < 0.001) with TAVR. The rate of stroke was significantly higher after TAVR (13.8% vs. 5.5%, p = 0.01). This included an increased risk of ischemic events in the first 30 days (6.7% vs. 1.7%, p = 0.02) and more hemorrhagic strokes beyond 30 days in the TAVR group (2.2% vs. 0.6%, p = 0.16). TAVR was associated with a significant reduction in risk of rehospitalization at 2 years (32% vs. 72.5%). The benefit of TAVR was attenuated in patients with extensive comorbidities, and there was no advantage of TAVR in patients with a Society of Thoracic Surgeons (STS) score ≥15.

Comparative Outcomes for Patients Who Do and Do Not Undergo Percutaneous Coronary Intervention for Stable Coronary Artery Disease in New York

Hannan EL, Samadashvili Z, Cozzens K, et al. — 2012-05-25 23:11:00

Among the patients with significant CAD, PCI was performed in 89% of all patients. At follow-up of 4 years, patients treated with PCI had significantly lower mortality/MI (16.5% vs. 21.2%; p = 0.003), mortality (10.2% vs. 14.5%; p = 0.02), MI (8.0% vs. 11.3%; p = 0.007), and subsequent revascularization (24.1% vs. 29.1%; p = 0.005). After adjusting for baseline differences, absence of PCI was associated with an increase in the hazard of mortality/MI (hazard ratio [HR],1.49; 95% confidence interval [CI], 1.16-1.93) or mortality (HR,1.46; 95% CI, 1.08-1.97).

Early Developmental Outcome in Children With Hypoplastic Left Heart Syndrome and Related Anomalies: The Single Ventricle Reconstruction Trial

Newburger JW, Sleeper LA, Bellinger DC, et al. — 2012-05-24 16:58:00

A total of 321 patients underwent developmental assessment at age 14.3 ± 1.1 (mean ± standard deviation [SD]) months. Mean PDI (74 ± 19) and MDI (89 ± 18) scores were lower than normative means (p < 0.001). There was no difference in developmental outcome between shunt types. Independent predictors of lower PDI score included clinical center (p = 0.003), birth weight <2.5 kg (p = 0.023), longer Norwood hospitalization (p < 0.001), and more complications between Norwood procedure discharge and age 12 months (p < 0.001). Independent risk factors for lower MDI score included center (p < 0.001), birth weight <2.5 kg (p = 0.04), genetic syndrome/anomalies (p = 0.04), lower maternal education (p = 0.04), longer mechanical ventilation after the Norwood procedure (p < 0.001), and more complications between Norwood discharge and age 12 months (p < 0.001). No relationship was seen between developmental outcome and perfusion type, intraoperative hematocrit or pH management strategies, or cardiac anatomy.

Performance Improvement in Health Care — Seizing the Moment

Blumenthal D. — 2012-05-24 16:48:00

Beyond the “R Word”? Medicine’s New Frugality

Bloche MG. — 2012-05-24 16:44:00

Effect of Continuous Positive Airway Pressure on the Incidence of Hypertension and Cardiovascular Events in Nonsleepy Patients With Obstructive Sleep Apnea: A Randomized Controlled Trial

Barbe F, Duran-Cantolla J, Sanchez-de-la-Torre M, et al. — 2012-05-23 17:29:00

Out of 725 consecutive subjects enrolled, follow-up was complete in 723, in whom there were 68 patients with new hypertension and 28 cardiovascular events in the CPAP group, and 79 patients with new hypertension and 31 cardiovascular events in the control group. This made for a hypertension or cardiovascular event incidence density rate of 9.20 per 100 person-years (95% confidence interval [CI], 7.36-11.04) in the CPAP group and 11.02 per 100 person-years (95% CI, 8.96-13.08) in the control group. The incidence density ratio was 0.83 (95% CI, 0.63-1.1; p = 0.20). For subjects with CPAP adherence >4 hours/night group versus control group, there was a significant reduction in incident hypertension and cardiovascular events with an adjusted incident density ratio of 0.69 (0.50-0.94); p = 0.02.

Aspirin for Preventing the Recurrence of Venous Thromboembolism

2012-05-23 17:18:00

There was no difference between groups for the following: mean age 62 years, >60% male, body mass index, 99% white, index event deep vein thrombosis (DVT) about 60% and pulmonary embolism (PE) 40%, and duration of warfarin treatment (55% 1 year, 35% 6 months). Over a 6-year period, VTE recurred in 28 of the 205 patients who received aspirin and in 43 of the 197 patients who received placebo (6.6% vs. 11.2% per year; hazard ratio, 0.58; 95% confidence interval [CI], 0.36-0.93) (median study period, 24.6 months). During a median treatment period of 23.9 months, 23 patients taking aspirin and 39 taking placebo had a recurrence (5.9% vs. 11.0% per year; hazard ratio, 0.55; 95% CI, 0.33-0.92). One patient in each treatment group had a major bleeding episode. Adverse events were similar in the two groups.

Ranolazine Decreases Mechanosensitivity of the Voltage-Gated Sodium Ion Channel NaV1.5: A Novel Mechanism of Drug Action

Beyder A, Strege PR, Reyes S, et al. — 2012-05-23 16:47:00

In whole cells, bath flow increased peak inward current in both murine ventricular cardiac myocytes (24 ± 8%) and HEK cells heterologously expressing NaV1.5 (18 ± 3%). The flow-induced increases in peak current were blocked by ranolazine. In cell-attached patches from cardiac myocytes and NaV1.5-expressing HEK cells, negative pressure increased NaV peak currents by 27 ± 18% and 18 ± 4% and hyperpolarized voltage dependence of activation by -11 mV and -10 mV, respectively. In HEK cells, negative pressure also increased the window current (250%) and increased late open channel events (250%). Ranolazine decreased pressure-induced shift in the voltage-dependence (IC50 54 μM) and eliminated the pressure-induced increases in window current and late current event numbers. Block of NaV1.5 mechanosensitivity by ranolazine was not due to the known binding site on DIVS6 (F1760). The effect of ranolazine on mechanosensitivity of NaV1.5 was approximated by lidocaine. However, ionized ranolazine and charged lidocaine analog (QX-314) failed to block mechanosensitivity.

Recombinant Tissue Plasminogen Activator for Acute Ischemic Stroke: An Updated Systematic Review and Meta-Analysis

Wardlaw JM, Murray V, Berge E, et al. — 2012-05-23 16:29:00

In up to 12 trials (7,012 patients), rt-PA given within 6 hours of stroke significantly increased the odds of being alive and independent (modified Rankin Scale [mRS], 0-2) at final follow-up (1,611/3,483 [46.3%] vs. 1,434/3,404 [42.1%]; OR, 1.17; 95% CI, 1.06-1.29; p = 0.001), absolute increase of 42 (19-66) per 1,000 people treated, and favorable outcome (mRS, 0-1) absolute increase of 55 (95% CI, 33-77) per 1,000. The benefit of rt-PA was greatest in patients treated within 3 hours (mRS, 0-2; 365/896 [40.7%] vs. 280/883 [31.7%]; 1.53; 1.26-1.86; p < 0.0001), absolute benefit of 90 (46-135) per 1,000 people treated, and mRS 0-1 (283/896 [31.6%] vs. 202/883 [22.9%]; 1.61; 1.30-1.90; p < 0.0001), absolute benefit 87 (46-128) per 1,000 treated. Numbers of deaths within 7 days were increased (250/2,807 [8.9%] vs. 174/2,728 [6.4%]; 1.44; 1.18-1.76; p = 0.0003), but by final follow-up the excess was no longer significant (679/3,548 [19.1%] vs. 640/3,464 [18.5%]; 1.06; 0.94-1.20; p = 0.33). Symptomatic intracranial hemorrhage (272/3,548 [7.7%] vs. 63/3,463 [1.8%]; 3.72; 2.98-4.64; p < 0.0001) accounted for most of the early excess deaths. Patients older than 80 years achieved similar benefit to those ages 80 years or younger, particularly when treated early.

Association Between Treated and Untreated Obstructive Sleep Apnea and Risk of Hypertension

Marin JM, Agusti A, Villar I, et al. — 2012-05-22 15:27:00

During 21,003 person-years of follow-up (median, 12.2 years), 705 cases (37.3%) of incident hypertension were observed. The crude incidence of hypertension per 100 person-years was 2.19 (95% confidence interval [CI], 1.71-2.67) in controls, 3.34 (95% CI, 2.85-3.82) in patients with OSA ineligible for CPAP therapy, 5.84 (95% CI, 4.82- 6.86) in patients with OSA who declined CPAP therapy, 5.12 (95% CI, 3.76-6.47) in patients with OSA nonadherent to CPAP therapy, and 3.06 (95% CI, 2.70-3.41) in patients with OSA and treated with CPAP therapy. Compared with controls, the adjusted HRs for incident hypertension were greater among patients with OSA ineligible for CPAP therapy (1.33; 95% CI, 1.01-1.75), among those who declined CPAP therapy (1.96; 95% CI, 1.44-2.66), and among those nonadherent to CPAP therapy (1.78; 95% CI, 1.23-2.58), whereas the HR was lower in patients with OSA who were treated with CPAP therapy (0.71; 95% CI, 0.53-0.94).

The Growing Power of Some Providers To Win Steep Payment Increases From Insurers Suggests Policy Remedies May Be Needed

Berenson RA, Ginsburg PB, Christianson JB, et al. — 2012-05-22 13:45:00

Although there was an overall trend favoring hospitals across the 12 markets, there is much variation concerning which party—plans or hospitals—was perceived as having the upper hand in negotiations. In most markets, so-called must-have hospitals have long had negotiating leverage over health plans. Studied markets with particularly dominant hospitals include Boston, northern New Jersey, Greenville, and Cleveland. In general, the clout derived from must-have status has increased over the past 3 years. Across all 12 markets, intramarket variations in negotiating leverage were substantial.

Plasma HDL Cholesterol and Risk of Myocardial Infarction: A Mendelian Randomization Study

Voight BF, Peloso GM, Orho-Melander M, et al. — 2012-05-22 13:22:00

Carriers of the LIPG 396Ser allele (2.6% frequency) had higher HDL-C [0.14 mmol/L (5.41 mg/dl) higher, p = 8 × 10^–13], but similar levels of other lipid and nonlipid risk factors for MI compared with noncarriers. This difference in HDL-C is expected to decrease risk of MI by 13% (odds ratio [OR], 0.87; 95% CI, 0.84-0.91). However, the 396Ser allele was not associated with risk of MI (OR, 0.99; 95% CI, 0.88-1.11; p = 0.85). From observational epidemiology, an increase of 1 standard deviation [SD] in HDL-C was associated with reduced risk of MI (OR, 0.62; 95% CI, 0.58-0.66). However, a 1 SD increase in HDL-C due to genetic score was not associated with risk of MI (OR, 0.93; 95% CI, 0.68-1.26; p = 0.63). For LDL-C, the estimate from observational epidemiology (a 1 SD increase in LDL-C associated with OR, 1.54; 95% CI, 1.45-1.63) was concordant with that from genetic score (OR, 2.13; 95% CI, 1.69-2.69; p = 2 × 10^–10).

Multidisciplinary Care of Patients Receiving Cardiac Resynchronization Therapy Is Associated With Improved Clinical Outcomes

Altman RK, Parks KA, Schlett CL, et al. — 2012-05-21 16:51:00

The clinical characteristics between the MC and CC groups at baseline were comparable (age, 68 ±13 vs. 69 ±12; New York Heart Association III, 90 vs. 82%; ischemic cardiomyopathy 55 vs. 64%, p = NS, respectively). The event-free survival was significantly higher in the multidisciplinary versus the CC group (p = 0.0015). A significant reduction in clinical events was noted in the MC group versus the CC group (hazard ratio, 0.62; 95% confidence interval, 0.46-0.83; p = 0.001).

Temporal Trends in Infective Endocarditis in the Context of Prophylaxis Guideline Modifications: Three Successive Population-Based Surveys

Duval X, Delahaye F, Alla F, et al., on behalf of the AEPEI Study Group. — 2012-05-21 15:58:00

Overall, 993 expert-validated IE cases were analyzed (323 in 1991; 331 in 1999; and 339 in 2008). IE incidence remained stable over time (95% confidence intervals given in parentheses): 35 (31-39), 33 (30-37), and 32 (28-35) cases per million in 1991, 1999, and 2008, respectively. Oral streptococci IE incidence did not increase either in the whole patient population (8.1 [6.4-10.1], 6.3 [4.8-8.1], and 6.3 [4.9-8.0] in 1991, 1999, and 2008, respectively) or in patients with pre-existing native valve disease. The increased incidence of Staphylococcus aureus IE (5.2 [3.9-6.8], 6.8 [5.3-8.6], and 8.2 [6.6-10.2]) was not significant in the whole patient population (p = 0.23), but was significant in the subgroup of patients without previously known native valve disease (1.6 [0.9-2.7], 3.7 [2.6-5.1], and 4.1 [3.0-5.6]; p = 0.012).

Off-Pump Coronary Artery Bypass Surgery Is Associated With Worse Arterial and Saphenous Vein Graft Patency and Less Effective Revascularization: Results From the Veterans Affairs Randomized On/Off Bypass (ROOBY) Trial

Hattler B, Messenger JC, Shroyer AL, et al. — 2012-05-21 15:47:00

Off-pump CABG resulted in lower FitzGibbon A patency rates than on-pump CABG for arterial conduits (85.8% vs. 91.4%, p = 0.003) and saphenous vein grafts (SVGs) (72.7 vs. 80.4%, p < 0.001). Fewer off-pump patients were effectively revascularized (50.1% vs. 63.9% on-pump, p < 0.001). Within each major coronary territory, effective revascularization was worse off-pump than on-pump (p values all ≤ 0.001). The 1-year adverse cardiac event rate was 16.4% in patients with ineffective revascularization versus 5.9% in patients with effective revascularization (p < 0.001).