Lowell Satler, MD discusses the AMPLATZER PFO Occluder
The optimal strategy for revascularization in patients with multi-vessel CAD who present with ST-elevation MI (STEMI) has not been defined. The Compare-Acute Investigators randomized 885 patients to a strategy of FFR guided complete revascularization or infarct-related vessel revascularization and demonstrated that the former strategy is associated with a reduction in the composite of death, MI, revascularization and CVA at 12 months.
The non-inferiority of iFR to FFR in terms of MACE has not been studied. The iFR-SWEDHEART Investigators randomized 2037 patients to either iFR or FFR guided PCI and have shown that iFR guided PCI is non-inferior to FFR with respect to the composite of death, MI, or unplanned revascularization.
The impact of evolocumab, a monoclonal antibody directed against PCSK9, upon clinical outcomes is uncertain. The FOURIER study randomized 27,564 patients with atherosclerotic cardiovascular disease and LDL-C levels of 1.8 mmol/L or higher on statin therapy and has shown that evolocumab therapy was associated with not only reductions in LDL-C but also the composite of cardiovascular death, MI, stroke, hospitalization for unstable angina, or coronary revascularization.
Identification of bleeding risk in patients undergoing PCI and requiring DAPT may be challenging. A pooled analysis of individual-patient dataset from eight clinical trials has identified a simple five-item risk score consisting of age, creatinine clearance, haemoglobin, white-blood-cell count and previous spontaneous bleeding for providing a standardized tool for predicting out-of-hospital bleeing whilst on DAPT.
The clinical benefit of pan-arterial revascularization in patients undergoing CABG remains uncertain. A study of eight propensity score-matched studies including 10287 patients comparing 2 versus 3 arterial grafts has indicated that the use of 3 arterial grafts is associated with lowe hazard for late death irrespective of sex, and diabetic status.
Blood pressure control with single agent therapy remains suboptimal. A randomized, placebo-controlled, double blind, crossover trial of a quadpill consisting of a quarter dose of irbesartan, amlodipine, hydrochlorothiazide, and atenolol has demonstrated that such combination is more effective in reducing both office based and 24-hour blood pressure. There were no serious adverse events and all patients reported that the quadpill was easy to swallow.
The superiority of biodegradable polymer drug-eluting stents (BP-DES) over second generation durable polymer DES (DP-DES) is controversial. A meta-analysis of of 16 randomized studies including 19,886 patients has indicated that both types of stents were associated with similar rates of TVR, cardiac death, MI, or stents thrombosis. Landmark analysis also indicated that BP-DES were not associated with a reduction in the risk of very late stent thrombosis.
The utility of routine brain CT and ECG in patients with out of hospital cardiac arrest (OHCA) who achieve return of spontaneous circulation is uncertain. A registry of 200 patients has indicated that 4 ECG findings including narrow QRS complex, atrial fibrillation, prolonged QTc interval and ≥4mm ST-segment depression is highly predictive of the presence or absence of subarachnoid haemorrhage.
Advances in stent technology and antiplatelet therapy has meant a decline in the use of bare metal stents (BMS). A single centre registry of 20,321 patients undergoing PCI over a 10-year period has documented a steady decline in the use of BMS from 2005-2015. Covariables independently associated with the use of BMS were black race, Hispanic ethnicity, cardiogenic shock or acute coronary syndrome, oral anticoagulation, smoking, increasing age, lower haematocrit, and renal impairment.
Nicole Lou Reporter, MedPage Today/CRTonline.org
C Merz, et al.; Circ 2017; 135:1075-92
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D Ryba, et al.; Circ 2017; 135:1056-70
What is your take on IFR as a physiologic test for intermediate lesions?
Equivalent to FFR
Superior to FFR
Inferior to FFR
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