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News from AHA 2007

November 10, 2007. Summaries by S. Tzeis, G. Andrikopoulos.

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I. Heart failure

The RethinQ study was a prospective, double-blind, randomized clinical trial which evaluated the effect of cardiac resynchronization therapy on patients with narrow QRS (<130 ms), NYHA class III heart failure, ejection fraction <35% and presence of echo-defined mechanical dyssynchrony. At 6 months, CRT was not shown to provide benefit as evidenced by the lack of increase in peak oxygen consumption (primary endpoint), ejection fraction and 6-minute walking distance. The negative findings of the study cast doubt on the expansion of the existing indications of CRT implantation in the subpopulation of heart failure patients with narrow QRS complexes. (epub-November 6, 2007, in print December 13, 2007 - NEJM)

In the CORONA trial, older patients (>60 years) with systolic heart failure (mean ejection fraction 31%) were randomized to either 10 mg of rosuvastatin daily or placebo. After a median follow-up period of 32.8 months, and despite the significant reduction in the LDL and CRP levels in the active treatment group, rosuvastatin was not shown to reduce the primary endpoint of cardiovascular death, nonfatal MI or stroke. (epub-November 5, 2007, in print December 13, 2007 - NEJM).

The AF-CHF study compared rate control versus rhythm control among patients with heart failure (mean LVEF 27%) and atrial fibrillation receiving optimal heart failure therapy and anticoagulation. The trial concluded that both management strategies had a similar influence on total mortality, stroke and worsening heart failure.

The MASCOT trial assessed the impact of overdrive atrial pacing (OAP) in heart failure patients subjected to CRT implantation and demonstrated that OAP was not associated with a difference in the rate of permanent atrial fibrillation at 1 year (primary endpoint), mortality or measured indices of heart failure severity.

II. Interventional cardiology

The TRITON-TIMI 38 trial compared the clopidogrel (300mg loading dose and 75mg daily maintenance dose) versus a novel thienopyridine, prasugrel, (a 60-mg loading dose and a 10-mg daily maintenance dose) in patients with acute coronary syndromes (unstable angina or non-ST-elevation MI in 74% and ST-elevation MI in 26%), subjected to scheduled PCI. After a median duration of therapy of 14.5 months, the primary endpoint of CV death, MI or stroke was significantly lower in the prasugrel group compared with the clopidogrel group, while prasugrel treatment was associated with significantly increased risk of major bleeding, including fatal bleeding. The prespecified analysis of net clinical benefit (composite endpoint of death from any cause, MI, stroke, and TIMI major hemorrhage) favored prasugrel. (epub-November 5, 2007, in print November 15, 2007 - NEJM)

The EVA-AMI study was a non-inferiority trial comparing abciximab versus eptifibatide in 430 STEMI patients undergoing primary PCI and concluded that both GpIIb/IIIa agents resulted in similar rates of myocardial reperfusion as measured by ST-segment resolution at 60 minutes after completion of primary PCI (primary endpoint).

The BRIEF-PCI trial compared the standard 18-hour infusion of eptifibatide versus a brief duration regimen (less than 2 hours) in patients subjected to non-emergent, uncomplicated PCI with stenting and demonstrated that the abbreviation of eptifibatide infusion to less than 2 hours following successful non-emergent coronary stenting reduces major bleeding without an increase in ischemic events.

The analysis of data derived from the National Cardiovascular Data Registry led to the conclusion that the widespread use of drug-eluting stents was associated with a significant increase in the percentage of patients with Class I indication for CABG who are though subjected to PCI.

III. Coronary heart disease

The COURAGE nuclear substudy demonstrated that a significantly higher percentage of patients in the PCI group presented a = 5% ischemia reduction compared to optical medical therapy as assessed by serial rest/stress myocardial perfusion SPECT. Furthermore, the presence of moderate-to-severe pretreatment ischemia or significant posttreatment ischemia reduction was significant predictor of the risk of death or MI.

In the ILLUMINATE trial, the administration of torcetrapid, a cholesteryl ester transfer protein inhibitor, on top of atorvastatin treatment among patients at high cardiovascular risk resulted in increased risk of morbidity and mortality despite the significant increase in HDL-C levels and reduction in LDL-C levels. (epub-November 5, 2007, in print November 22, 2007 - NEJM)

The MASTER-I trial provided evidence that the use of microvolt T-wave alternans is not a significant predictor of life-threatening ventricular tachyarrhythmic events among patients with MADIT-II indication for ICD.

The CORE-64 trial sought to determine the diagnostic accuracy (sensitivity and specificity) of 64-slice multi-detector computed tomography angiography (MDCTA) for detecting significant coronary artery stenosis (>50% luminal stenosis) in patients with suspected CAD in comparison to quantitative coronary angiography (QCA). In patients with Agatson calcium score < 600, MDCTA had a similar diagnostic accuracy in detecting the presence of significant stenosis and identifying those likely to be referred for revascularization when compared to QCA.

IV. Cardiovascular prevention

The POISE trial was a double-blind randomized trial designed to evaluate the effect of perioperative treatment with the beta blocker metoprolol compared with placebo on major cardiovascular events. The treatment with the study drug was continued for 30 days postoperatively. The trial demonstrated a significant reduction in the primary endpoint of CV death, MI or cardiac arrest in the metoprolol group which was though combined with a significant increase in mortality.

V. Anticoagulant therapy

The Couma-Gen study demonstrated that the use of a genotype-guided warfarin dosing regimen was associated with a similar percentage of out of range INRs compared with standard warfarin dosing among patients requiring oral anticoagulation.

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