The American journal of cardiology
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The purpose of this meta-analysis was to compare postprocedural mortality and major adverse cardiovascular and cerebrovascular events between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) for severe aortic stenosis. Seventeen studies (n = 4,659) comparing TAVI (n = 2,267) and SAVR (n = 2,392) were included. End points were baseline logistic European System for Cardiac Operative Risk Evaluation score, all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, transient ischemic attack, and major bleeding events. ⋯ In conclusion, TAVI has similar cardiovascular and all-cause mortality to SAVR at early and long-term follow-up. TAVI is superior to SAVR for major bleeding complications and noninferior to SAVR for postprocedural myocardial infarctions and cerebrovascular events. TAVI is a safe alternative to SAVR in selected high-risk elderly patients with severe aortic stenosis.
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Randomized Controlled Trial Multicenter Study Comparative Study
Incidence and outcome of high on-treatment platelet reactivity in patients with non-ST elevation acute coronary syndromes undergoing percutaneous coronary intervention (from the VIP [VerifyNow and Inhibition of Platelet Reactivity] study).
High residual platelet reactivity (RPR) on clopidogrel treatment has been associated with increased risk for ischemic events during follow-up in patients with acute coronary syndromes. The aim of this study was to assess the incidence, predictors, and clinical consequences of high RPR in a large population of patients with non-ST-segment elevation acute coronary syndromes who underwent percutaneous coronary intervention and stenting. Overall, 833 patients received point-of-care testing of platelet inhibition 30 days after percutaneous coronary intervention. ⋯ The results did not change using the a cut-off value for P2Y₁₂ reaction units of 208. In conclusion, 1/3 of patients with acute coronary syndromes who underwent percutaneous coronary intervention and stenting showed high on-treatment RPR on bedside monitoring. They had a worse prognosis, but the level of platelet inhibition was not independently associated with the incidence of ischemic or bleeding events.
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Limited data are available on comparing the clinical outcomes of coronary artery bypass grafting (CABG) and drug-eluting stent (DES) implantation in patients with reduced left ventricular systolic function in the DES era. From January 2003 to December 2010, 953 patients with reduced left ventricular systolic function, defined as a left ventricular ejection fraction <50%, who had undergone percutaneous coronary intervention with DESs (n = 402) or CABG (n = 551) were enrolled in a retrospective, observational registry. Patients with acute myocardial infarction were excluded. ⋯ However, the rate of major adverse cardiac and cerebrovascular events (35.5% vs 24.1%, adjusted hazard ratio 1.69, 95% confidence interval 1.04 to 2.77, p = 0.036) was higher in the DES group than the CABG group. This was driven by the higher incidence of repeat revascularization in the DES group (11.3% vs 4.3%, adjusted hazard ratio 3.65, 95% confidence interval 1.01 to 10.37, p = 0.018). In conclusion, DES implantation provides comparable long-term clinical outcomes, except for repeat revascularization, to CABG in patients with coronary artery disease and chronic left ventricular systolic dysfunction.
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Randomized Controlled Trial
Effectiveness of spironolactone plus ambrisentan for treatment of pulmonary arterial hypertension (from the [ARIES] study 1 and 2 trials).
In translational models of pulmonary arterial hypertension (PAH), spironolactone improves cardiopulmonary hemodynamics by attenuating the adverse effects of hyperaldosteronism on endothelin type-B receptor function in pulmonary endothelial cells. This observation suggests that coupling spironolactone with inhibition of endothelin type-A receptor-mediated pulmonary vasoconstriction may be a useful treatment strategy for patients with PAH. We examined clinical data from patients randomized to placebo or the selective endothelin type-A receptor antagonist ambrisentan (10 mg/day) and in whom spironolactone use was reported during ARIES-1 and -2, which were randomized, double-blind, placebo-controlled trials assessing the effect of ambrisentan for 12 weeks on clinical outcome in PAH. ⋯ Progressive illness, PAH-associated hospitalizations, or death occurred as an end point for 5.3% of ambrisentan-treated patients; however, no patient treated with ambrisentan + spironolactone reached any of these end points. In conclusion, these pilot data suggest that coupling spironolactone and endothelin type-A receptor antagonism may be clinically beneficial in PAH. Prospective clinical trials are required to further characterize our findings.
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Meta Analysis Comparative Study
Comparison by meta-analysis of percutaneous coronary intervention versus coronary artery bypass grafting in patients with a mean age of ≥70 years.
A paucity of published data evaluating the outcomes of older patients (age ≥70 years) undergoing revascularization for unprotected left main coronary artery disease is available. We performed aggregate data meta-analyses of the clinical outcomes (all-cause mortality, nonfatal myocardial infarction, stroke, repeat revascularization, and major adverse cardiac and cerebrovascular events at 30 days and 12 and 22 months) in studies comparing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with a mean age of ≥70 years and unprotected left main coronary artery disease. A comprehensive, time-unlimited literature search to January 31, 2013 identified 10 studies with a total of 2,386 patients (PCI, n = 909; CABG, n = 1,477). ⋯ These findings were consistent with the findings from a subgroup analysis of patients aged ≥75 years. In conclusion, older patients (age ≥70 years) with unprotected left main coronary artery disease had comparable rates of all-cause mortality, nonfatal myocardial infarction, and major adverse cardiac and cerebrovascular events after PCI or CABG. The patients undergoing PCI had a shorter hospital stay and lower rates of early stroke; however, they experienced higher repeat revascularization rates at longer term follow-up.