Journal Club. NEWS.

[rsp]

все-таки агрегацию тромбоцитов контролировать надо,
очередное подтверждение: исследование VASP:
http://www.cardiosource.com/pops/imageP ... mgid=19864
http://content.onlinejacc.org/cgi/conte ... 7.12.044v1

[Сергей]

5F гайд vs 7F.
Как получается 8 минут? Научите!

Comparative studies between 5 French guiding catheter and others of larger size using the transfemoral approach
to coronary stenting have not been described. Coronary stent implantation was performed in 90 patients in a
randomized trial. The primary end-point was to compare the incidence of successful uncomplicated stent implantation
per lesion with the 5F and 7F guiding catheters. Patients were excluded for excessive vessel tortuosity
or anticipated need for equipment not fitting through a 5 catheter. Baseline characteristics and the use of direct
stenting did not differ between the two groups. The primary success rate was 97.8% per patient in both groups
and 98% per lesion in the 5 French and 97.9% in the 7 French. Guiding catheter change was necessary in 1
patient in each group to successfully complete the procedure in both groups. The amount of contrast used was 63
± 27.3 mL in the 5 French and 76 ± 25 mL in the 7 French groups (P < 0.05). Vascular complications and blood
transfusions occurred somewhat more frequently in the 7 French group (P = 0.058). The manual compression time
after sheath removal was 5.1 ± 2.0 min and 8.0 ± 4.3 min, respectively, in the 5 and 7 French groups (P < 0.01). In
conclusion, the 5 French guiding catheters showed a similar success rate with coronary stenting when compared
to the 7 French, but the amount of contrast used and manual compression time after sheath removal, as well as the
rate of vascular and bleeding complications, were reduced in the 5 French group. (J Interven Cardiol 2008;21:
50–55)

Полный текст:
http://dump.ru/files/o/o5651726706/

[Сергей]

"Clinical Experience of StarClose Vascular Closure Device in Patients
with First and Recurrent Femoral Punctures"

Стар-клоуз не всем одинаково полезен

"Objective:We present our clinical experience of StarClose in patients undergoing coronary interventions, including
its use in patients after repeated puncture of the same femoral access site.
Background: The StarClose is a novel vascular closure device that deploys a small, flexible, circumferential nitinol
clip onto the femoral artery surface.
Methods: In this study, 103 consecutive patients (24% with repeated punctures) who underwent percutaneous
coronary intervention and received a StarClose were followed up prospectively. The patients were assessed for
vascular complications prior to hospital discharge. Device success, based on time-to-hemostasis, was divided
into (1) immediate success: hemostasis achieved immediately after StarClose deployment without the need for
adjunctive manual compression, (2) partial success: occurrence of minor oozing after StarClose deployment and
hemostasis achieved after <3>3 minutes.
Results: Immediate success, partial success, and device failure rates were 74% (n = 68), 16% (n = 15), and 10%
(n = 9), respectively. There were no major complications attributable to the StarClose device. There were 10
(9.7%) cases of minor complications; all were recurrent wound bleeding requiring manual compression in the
wards. Among these 10 cases of recurrent bleeding, 5 (50%) had initial device success (immediate success, n = 2,
partial success, n = 3) in the catheterization laboratory. The risk for recurrent bleeding was 2.9% after immediate
device success and 20.0% after partial device success.
Conclusion: Our study found no major complications but a 10% failure rate and a 9.7% rate of minor complications.
Close surveillance is important as there is a risk for recurrent bleeding, especially in patients with partial device
success as defined in this report. ( J Interven Cardiol 2008;21:67–73)"

Полный текст:
http://dump.ru/files/o/o632682/

[Сергей]

Body Mass Index and Effectiveness of Reperfusion Strategies: Implications
for the Management of Patients with ST-Elevation Myocardial Infarction

Индекс массы тела, таки влияет на реперфузию!

"Background: Fibrinolytic therapy has maximum dose limit in patients with ST-elevation myocardial infarction
(STEMI). Consequently, obese patients receive lower dose of fibrinolytic per kg body weight compared to lower
weight patients. Whether the relatively lower dose results in lower effectiveness of fibrinolytic agents versus primary
percutaneous coronary interventions (PCI) in patients with higher body mass index (BMI) is not known.
Methods: We analyzed 7,630 STEMI patients receiving primary PCI (46%) or fibrinolysis (54%) <24 hours of
symptom onset from the MITRA PLUS registry. The relative effectiveness of the 2 reperfusion strategies on inhospital
death (adjusted with propensity scores) and bleeding were studied in 3 BMI groups: I-BMI 20–24.9 kg/m2
(n = 2,277), II-BMI 25–29.9 kg/m2 (n = 3,763), and III-BMI &#8805;30 kg/m2 (n = 1,590).
Results: BMI was inversely related to death, shock, stroke, and bleeding in patients treated with either reperfusion
strategy. However, compared with primary PCI, fibrinolysis was associated with higher adjusted death with similar
relative adjusted difference in all 3 groups (group I OR 1.69, 95% CI 1.19–2.44; group II OR 1.89, 95% CI
1.39–2.56; group III OR 1.85, 95% CI 1.08–3.22).
Conclusions: Compared with primary PCI, fibrinolysis was associated with relatively similar higher risk of death
in all 3 BMI groups. Whether the differences in death between fibrinolysis and primary PCI in the high-BMI
categories can be reduced by higher fibrinolytic doses without increasing bleeding risks needs evaluation in future
studies. (J Interven Cardiol 2008;21:8–14)"

Полный текст:
http://dump.ru/files/o/o554309773/

[Сергей]

Management of Multivessel Coronary Disease after ST Elevation
Myocardial Infarction Treated by Primary Angioplasty

Ну и "вечный" спор тупоконечных vs остроконечных

Background: Optimal treatment strategy of patients with ST elevation myocardial infarction (STEMI) and
multivessel coronary artery disease (CAD) undergoing primary angioplasty is still unclear. Percutaneous coronary
intervention (PCI) of non-culprit vessels simultaneously or soon after primary angioplasty is feasible and safe, but
available data failed to consistently show a benefit in long-term clinical outcomes.
Methods:We retrospectively compared in-hospital and long-term outcomes for patients with STEMI and multivessel
CAD treated by primary angioplasty with (Group 1, n=64) or without (Group 2, n=46) early, staged PCI of other
angiographically significant coronary lesions. In-hospital major adverse cardiovascular events (MACE) were
defined as a composite of death, peri-procedural myocardial infarction after staged, elective PCI, stroke, stent
thrombosis, major bleeding, and vascular complications. MACE at follow-up were defined as a composite of death,
stroke, stent thrombosis, any coronary revascularization, and re-hospitalization for acute coronary syndrome.
Results: Group 1 patients underwent staged PCI 5.9 ± 3.5 days after primary angioplasty. The mean length of
follow-up was 13 months (392±236 days). The incidence of in-hospitalMACE was 20.3% in Group 1 and 10.8% in
Group 2 (P=0.186); the incidence of out of hospital MACE was 9.3% in Group 1 and 23.9% in Group 2 (P=0.037).
In Group 1 in-hospital MACE were driven by periprocedural myocardial infarction after the elective procedure,
which occurred in 15.6% of patients.
Conclusions: Our data show that multivessel, staged PCI in STEMI patients is associated with a low incidence
of adverse events at follow-up but with a higher incidence of in-hospital MACE, mainly driven by periprocedural
myocardial infarction during the elective procedure. (J Interven Cardiol 2008;21:1–7)

Полный текст: http://dump.ru/files/o/o7571530388/

[Татьяна Глебовская]

Hyperglycemia and Acute Coronary Syndrome
(A Scientific Statement From the American Heart Association Diabetes Committee of the Council on Nutrition, Physical Activity, and Metabolism )
(Circulation. 2008;117:1610-1619.)

Вопрос вроде и не жизненно важный, но в реальной практике часто возникающий.

Краткая суть - плохо изучено, надо исследовать дальше, это не гайдлайн, но рекомендации:

1.Брать глюкозу у всех больных с подозрением на ОКС
2. У всех больных с ОКС поступивших в ICU - тщательно мониторироватьуровень глюкозы крови и поддерживать в рамках 5 - 7,8 ммоль/л (90-140 мг/дл), вне
зависимости от анамнеза диабета
3. Наиболее эффективно в ICU использовать внутривенное введение инсулина. Конкретные схемы надо ещё разработать. Следует избегать гипогликемии (кот. как известно ассоциирована с плохим прогнозом)
4. Начинать лечение настолько быстро, насколько это возможно.
5.У пациентов, госпитализированы не в ICU можно инсулин вводить подкожно, поддерживая уровень глюкозы менее 10 ммоль/л (180 мг/дл).
6,7 дообследовать и подобрать оптимальное лечение дома и bla-bla-bla

Ссылка на статью
http://circ.ahajournals.org/cgi/reprint ... 107.188629

[AOkhotin]

Нашествие ДЕСов никакой Кураж не остановит

По данным корейцев покрытые стенты ничуть не хуже коронарного шунтирования при многососудистом поражении (ретроспективное исследование):

http://www.incirculation.net/NewsItem/C ... sease.aspx

А по данным норвежцев, многим женщинам инфаркт миокарда идет только на пользу:

http://www.incirculation.net/NewsItem/M ... er-MI.aspx

[Igor Bulatov]

POISE—a randomized controlled trial in more than 8000 patients undergoing noncardiac surgery who were not on beta blockers, randomized to either the beta blocker metoprolol or placebo—at the AHA meeting last year. The results showed that the beta blocker reduced the risk of myocardial infarction (MI) but increased the risk of severe stroke and overall death in patients undergoing noncardiac surgery. It suggested that for every 1000 patients treated, metoprolol would prevent 15 MIs, but there would be an excess of eight deaths and five severe disabling strokes.

Study Highlights

* Included were patients older than 45 years undergoing noncardiac surgery with a length of stay of at least 24 hours with a history of CAD, peripheral artery disease (PAD), heart failure within 3 years or undergoing major vascular surgery, or meeting at least 3 of 7 cardiac risk factor criteria.
* Excluded were those with a heart rate of 50 beats per minute or lower, with second- or third-degree heart block, receiving a beta-blocker or coronary bypass graft surgery within 5 years, or receiving verapamil.
* Patients were randomly assigned to receive either extended-release metoprolol 100 mg (n = 4174) or placebo (n = 4177).
* The first dose was given within 2 to 4 hours before surgery if the patient's heart rate was above 50 beats per minute and systolic BP was above 100 mm Hg.
* The postoperative dose was given within 6 hours of surgery unless the BP or heart rate was low, when the dose was postponed to after 6 hours.
* Oral metoprolol was then given at 200 mg daily for 30 days.
* Those unable to take oral metoprolol were given intravenous metoprolol perioperatively as 15 mg in 25 mL normal saline infused for more than 60 minutes.
* Heart rate and BP were checked at 10, 30, and 60 minutes.
* An electrocardiogram was recorded at 6 to 12 hours, and creatine kinase-MB or troponin levels were measured at the first, second, and 30th postoperative days to exclude MI.
* The prespecified primary outcome was a composite of CV death, nonfatal MI, and nonfatal cardiac arrest at 30 days.
* Secondary outcomes were individual components of the primary outcome and stroke and overall death at 30 days.
* Mean age was 69 years; one third of the participants were women, 43% had CAD, 41% had PAD, 15% had a history of stroke, two thirds had a history of hypertension, and 19% were current smokers.
* Significantly fewer participants in the metoprolol group experienced the primary endpoint (hazard ratio [HR], 0.84; P = .0399).
* There were fewer fatal MIs in the metoprolol group (HR, 0.73; P = .0017).
* There were fewer nonfatal MIs (HR, 0.70; P = .0008) in the metoprolol group.
* There were fewer revascularization procedures and cases of atrial fibrillation in the metoprolol group.
* More patients in the metoprolol group had hypotension or bradycardia.
* More patients in the metoprolol group had a stroke (HR, 2.17; P = .0053), and 49 of 60 strokes were ischemic.
* More patients in the metoprolol group had a fatal stroke (HR, 1.94; P = .0450).
* More patients with a nonfatal stroke in the metoprolol group required help to perform daily activities or were incapacitated.
* Overall mortality was higher for the metoprolol group (HR, 1.33; P = .0317), and sepsis or infection was a more common cause of death in the metoprolol group.
* Median length of hospital stay was similar (8 days) between the 2 groups, as were nights spent in intensive care.
* The results showed that for every 1000 patients with a similar risk profile undergoing noncardiac surgery, extended-release metoprolol would prevent 15 MIs, 3 cardiac revascularization procedures, and 7 new cases of atrial fibrillation.
* However, for every 1000 cases, perioperative metoprolol would result in 8 excess deaths, 5 strokes, 53 cases of clinically important hypotension, and 42 cases of bradycardia.
* The authors suggested that current perioperative guidelines recommending beta-blockers to patients undergoing noncardiac surgery should reconsider their recommendations in light of the significant risks associated with use of perioperative metoprolol.

1. POISE Study Group. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomized controlled trial. Lancet 2008. DOI: 10.1016/S0140-6736(0icon_cool.gif 60601-7. Available at: http://www.thelancet.com.
2. Fleisher LA and Poldermans D. Perioperative beta blockade: where do we go from here? Lancet 2008. DOI: 10.1016/S0140-6736(0icon_cool.gif 60662-5. Available at: http://www.thelancet.com.
3. London MJ. Quo vadis, perioperative beta blockade? Are you "POISE'd" on the brink? Anesth Analg 2008;106:1025-1030.

[AOkhotin]

Исследование из тех, которые влияют на ежедневную практику.
Не очень, впрочем, ясно, что делать с теми, кто уже принимает b-адреноблокаторы.

[Igor Bulatov]

Результаты POISE приведут к пересмотру ACC/AHA 2006 Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Focused Update on Perioperative Beta-Blocker Therapy - 2006.Скорее всего в сторону уменьшения периоперационных доз бетаблокаторов.Полная бетаблокада высокими дозами (как в POISE ) сопровождается выраженной гемодинамической нестабильностью при проведении анестезии и приводит к неоправданно высокому числу случаев ишемии головного мозга при адекватной коронарной перфузии.

http://circ.ahajournals.org/cgi/content ... 13/22/2662

Интересно,что в США проводится более 25 млн анестезий в год.Из них-более 4 млн у пациентов,у которых есть все показания к периоперационной бетаблокаде.Если бы все анестезиологи в США следовали бы гайдлайнс по периоперационному использованию бетаблокаторов,то за 10 лет появилось бы 800 тысяч дополнительных случаев смерти от stroke.K счастью,этого не произошло.Гайдлайнс-не догма.

[AOkhotin]

Немая ишемия хуже, чем перемежающаяся хромота:

http://circ.ahajournals.org/cgi/content ... 17/19/2484

Asymptomatic Peripheral Arterial Disease Is Associated With More Adverse Lower Extremity Characteristics Than Intermittent Claudication.

Conclusions— Persons with PAD who never experience exertional leg symptoms have poorer functional performance, poorer quality of life, and more adverse calf muscle characteristics compared with persons with intermittent claudication and a sedentary, asymptomatic, age-matched group of non-PAD persons.

Исследовали больных с лодыжечно-плечевым индексом менее 0,9. Оказалось, что у тех, кто ни разу не страдал от перемежающейся хромоты, целый ряд показателей был хуже: они меньше проходили при 6-минутном тесте, они ходят медленнее, живут хуже, мышцы голени у них меньше, а удельный вес жира в мышцах голени выше.

Впрочем, можно предположить, что при одинаковом поражении не болит у тех, кто не ходит по каким-то другим причинам.

[rsp]

Американцы заинтересовались импеллой...

FDA clears minimally invasive circulatory-support device for use during cardiac interventions.
Rockville, MD - The FDA has granted marketing clearance to Abiomed's Impella 2.5 cardiac-assist device [1]. The device, which can be implanted percutaneously via the femoral artery into the left ventricle, is used for partial circulatory support for up to six hours.

The pump can deliver up to 2.5 liters of blood per minute from the left ventricle into the ascending aorta, "providing the heart with active support in critical situations," a press release states.

Evidence supporting the device approval comes in part from patients undergoing high-risk PCI in the PROTECT 1 trial.

In PROTECT 1, patients who underwent PCI with circulatory support using the Impella device had twice the expected in-hospital survival and significant improvements in ejection fraction from baseline. According to the press release, there are over 40 peer-reviewed papers about the device. The company is currently conducting two pivotal US studies comparing the Impella 2.5 with its intra-aortic balloon pump, which already has FDA marketing clearance.

Previously approved in Europe, the Impella has been used in over 1500 patients outside the US. Abiomed acquired the Impella 2.5 technology in 2005 when it took over Impella CardioSystems AG.


http://phx.corporate-ir.net/phoenix.zht ... &highlight

[AOkhotin]

Покрытые стенты: маятник пошел обратно?

Drug-Eluting Stents: Is the Tide Turning?
Registry data suggest that DES recipients may fare better than BMS
recipients after all.



The use of drug-eluting stents (DES) in percutaneous coronary intervention
has fallen dramatically in the past 1 to 2 years, following reports of late
stent thrombosis and increased mortality associated with off-label
placement (JW Cardiol May 23 2007). Two new studies of registry data from
the New York State PCI Reporting System explore real-world experience with
DES and bare-metal stents (BMS).

In the first study, 772 patients with ST-segment-elevation MI treated
within 12 hours with BMS were compared with 1154 such patients treated with
DES. Baseline characteristics were similar in the two groups. A
nonsignificant trend toward lower risk-adjusted in-hospital mortality was
seen in DES recipients (1.4%), compared with BMS recipients (2.4%). At 2
years of follow-up, risk-adjusted mortality was significantly lower in DES
recipients (5.0%) than in BMS recipients (8.6%, P=0.007). Subsequent
coronary artery bypass grafting was also performed in significantly fewer
DES recipients (3.0%) than BMS recipients (6.4%, P=0.004). The
target-vessel revascularization (TVR) rate did not differ significantly
between the two groups, nor were significant outcome differences found
between paclitaxel-eluting stent recipients and sirolimus-eluting stent
recipients.

In the second study, investigators compared 11,436 patients who received
BMS before the introduction of DES with 12,926 patients treated during a
similar time period after DES became available (73% of whom received at
least one DES). Follow-up data for about 2 years were analyzed in both
groups. Risk-adjusted in-hospital mortality and 2-year mortality were
similar in the two time periods. The adjusted rates of nonfatal MI and
combined death and MI were significantly lower in the DES era (hazard
ratios, 0.86 and 0.90, respectively). TVR was significantly reduced by 40%
in the DES era. A comparison of DES-era patients who received only BMS with
those who received only DES showed that the BMS-only group had
significantly higher risks for death (HR, 1.50), death and MI (HR, 1.39),
nonfatal MI (HR, 1.34), and TVR (HR, 1.38).

Comment: The former of these two large studies is the first to suggest a
mortality benefit for the off-label use of drug-eluting stents in STEMI.
However, because it is not a randomized, prospective study, the authors'
conclusions -- though reassuring -- cannot be considered definitive. The
latter study also provides evidence of better risk-adjusted outcomes with
DES than with BMS in real-world practice. Notwithstanding the inherent
limitations of observational registry studies, these findings confirm that
DES reduce restenosis without increasing mortality and suggest that the
practice pendulum may have swung too far away from DES.

-- Howard C. Herrmann, MD

Published in Journal Watch Cardiology June 4, 2008 Citation(s):

Hannan EL et al. Drug-eluting versus bare-metal stents in the treatment of
patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol
Intv 2008 Apr 1; 1:129. (Subscription may be required)

Grines CL et al. Should we routinely use drug-eluting stents for acute
myocardial infarction? Let's wait and see. J Am Coll Cardiol Intv 2008 Apr
1; 1:136. (Subscription may be required)

Hannan EL et al. Comparison of coronary artery stenting outcomes in the
eras before and after the introduction of drug-eluting stents. Circulation
2008 Apr 22; 117:2071. (Subscription may be required) (Free)

Mauri L and Normand SLT. Studies of drug-eluting stents: To each his own?
Circulation 2008 Apr 22; 117:2047. (Subscription may be required) (Free)

[Melnichenko]

Мета- анализ: Кесарево и риск диабета 1 типа в детском возрасте

Diabetologia,2008 51: 726-735

Cardwell et al

20 обсервационных исследований по Медлайн, OR -1.23 ( CI-1.15-1.32)
Риск увеличивается при увеличении массы при родах, возраста матери,снижении срока беременности
Исследования в мета- анализе достаточно однороды
Риск сохраняется при учете диабета у матери
Далее подумаю и напишу еще - пока мыслей нет

[Melnichenko]

Основым бросающимся в глаза недостатком исследований, легших в основу мета-анализа, явилось отсутствие данных о ПРИЧИНАХ кесарева сечения
Наиболее вероятное напрашивающееся объяснение - разница в частоте грудного вскармливания ( протективный фактор в отношении СД1) , увы, не работает : с поправкой на грудное вскармливание все равно риск увеличен
Конечно, риск невелик - но версия большей стерильности кесарят выдвигается как основая
Вообще версия "грязь помеха диабету" достаточно активно продвигается ( прямая кореляция между суперчистотой и развитием СД1 ) в кругах эндокринологов уже давно, но как-то всегда звучала маргинально