Thursday, 1 February 2018
Monday, 15 January 2018
Tuesday, 9 January 2018
Wednesday, 3 January 2018
The most-read stories of Cardiology in 2017
The most-read stories on TCTMD this year included some surprises—among them the utility of supplemental oxygen during suspected MI and the disparate timing of hypertension onset according to race and sex. More easily predicted contenders include the COMPASS trial of rivaroxaban in ACS, Absorb’s risks and subsequent market withdrawal, the much-discussed ORBITA trial, and the setbacks faced by the Lotus valve.
Don’t waste time with oxygen. Focus instead on getting patients to the cath lab as quickly as possible, says one expert.
On the same day that ABSORB III 2-year data were being presented at ACC 2017, the agency raised concerns.
Full results for the trial were already slated to be released at an upcoming meeting, but the “magnitude of the effect” warranted an announcement, the sponsor said.
The intriguing study, which hints at a placebo effect of PCI, left physicians debating the merits of revascularization in stable coronary artery disease.
African-Americans and males have a greater risk of transitioning from ideal to elevated blood pressure in childhood and early adulthood.
The issue is related to the device’s locking mechanism, and is similar to the problem that plagued the next-generation Lotus Edge device in 2016.
The single-center study has economic and clinical implications for a strategy already in use in some parts of the world.
In a blow to interventionalists, the results did not show a benefit of the procedure over medical therapy alone. But hope remains.
The study is a “piece in a mosaic,” one researcher says, and comes after a number of other analyses challenged ticagrelor’s supremacy.
The results, which run counter to current guidelines and appropriate use criteria, will change practice, several experts agree.
Beyond the Breaking News
Outside of the daily news, several feature stories and blog posts also proved popular in 2017. These include:
Conference Organizers, Physicians Wary as Direct Industry Sponsorship Winds Down in Europe
How Low Can You Go? Concerns Over Aggressive LDL Lowering Eased as PCSK9 Evidence Mounts
My Takeaways From ACC 2017: Even With a Sea Change, the Tide Takes Its Time
Living or Leaving: Does Palliative Care Deserve a Place at the TAVR Table?
The Numbers Game: Door-to-Balloon or First Medical Contact? STEMI Care Still Needs Work Nationwide
Thursday, 28 December 2017
MRI scan safe for most people with older pacemakers, defibrillators
Reuters Health) - There’s good news for people with pacemakers and the doctors who treat them.
A new study reinforces earlier work suggesting that MRI scans are safe for patients with older devices, even if the MRI is focusing on the chest area.
Until now, the sensitive electronics of older pacemakers and implantable defibrillators were thought to be vulnerable to disruption when subjected to the magnetic fields and radio waves that allow magnetic resonance imaging, or MRI, to see into the body.
The new study in The New England Journal of Medicine “confirms that pretty much anybody who has a pacemaker or implanted defibrillator can, with very few restrictions, safely get an MRI scan if they need it,” as long as the devices are properly adjusted before the scan and safeguards are in place, coauthor Dr. Henry Halperin, professor of medicine, radiology and biomedical engineering at Johns Hopkins University in Baltimore, told Reuters Health in a telephone interview.
To prevent problems, the researchers reprogrammed the devices to adopt a standard heart rhythm for people whose hearts won’t beat on their own and disabled functions that might cause the pacemaker to fire improperly if the MRI produced erratic signals in the heart. After the MRI, the devices were returned to their original settings.
Only newer devices designated as “MRI-conditional” have been considered safe by the U.S. Food and Drug Administration. The vast majority in use - about 6 million worldwide - do not have that designation. A 2005 analysis estimated that at least half of those patients will someday need an MRI.
The U.S. Centers for Medicare and Medicaid Services (CMS), which administers the Medicare insurance program for the elderly and disabled, will only pay for MRI scans in patients with “MRI-conditional” devices, coauthor Dr. Saman Nazarian, of the University of Pennsylvania Perelman School of Medicine, told Reuters Health in an email.
Given the results of the new study and an earlier one published in February, which also showed the older devices to be safe, “it’s hard to understand the position” of the CMS, said Nazarian, a cardiac electrophysiologist.
In that February study, a separate team of researchers reported in The New England Journal that no serious problems were seen in 1,318 patients with a pacemaker or implantable defibrillator who received an MRI. But in those cases, the chest area wasn’t scanned by the MRI.
In the new tests by the Nazarian-Halperin team, about 200 of the 1,509 pacemaker and defibrillator patients had their chest scanned with a 1.5 Tesla MRI. Neither the chest scans nor the scans done elsewhere in the body produced significant problems, said Dr. Halperin.
Nine of the devices were disrupted but reset themselves to a backup mode. In all but one case, the effect was temporary. There was one instance where the device had to be replaced, but it had a low battery and could not be properly reprogrammed.
Thus, a nearly-dead battery is probably one of the few reasons not to have an MRI, Dr. Halperin said. “Pacemakers do funny things when the battery is low.”
In five instances, doctors halted the MRI exam. In one case, the heart rate fell to under 40 beats per minute. In another, the patient’s heartbeat became too rapid. In the remaining three, the doctors decided that an MRI probably wouldn’t produce a useful image anyway.
Dr. Halperin said pacemakers and defibrillators cleared by the FDA since the 2000s are much better protected from the magnetic and radio waves of an MRI. “And we program them to avoid most any problems that might happen.”
Dr. Nazarian said he would advise patients that even if they have a device that’s not specifically rated for MRI safety, “Many centers across the U.S. are capable of performing safe imaging despite your device.”
Optimal Medical Therapy With or Without Stenting For Coronary Chronic Total Occlusion - DECISION-CTO
The DECISION-CTO trial showed that routine CTO-PCI + OMT is not superior to OMT alone in reducing cardiovascular outcomes among patients with at least one CTO.
Description:
The goal of the trial was to assess the safety and efficacy of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) compared with optimal medical therapy (OMT) among patients with at least one CTO.
Study Design
Patients were randomized to CTO-PCI + OMT (n = 417) or OMT (n = 398). The trial had to be stopped early due to slow enrollment. In the PCI arm, revascularization for all significant non-CTO lesions within a vessel diameter of ≥2.5 mm for patients with multivessel coronary artery disease was recommended. PCI had to be completed within 30 days of randomization. All patients were prescribed guideline-derived OMT.
- Total number of enrollees: 834
- Duration of follow-up: 5 months
- Mean patient age: 62.5 years
- Percentage female: 18%
Inclusion criteria:
- Silent ischemia, stable angina, or acute coronary syndrome
- De novo CTO located in a proximal to mid epicardial coronary artery with a reference diameter of ≥2.5 mm
- CTO was defined as a coronary artery obstruction with TIMI flow grade 0 of at least 3 months’ duration based on patient history.
Exclusion criteria:
- CTO located in the distal coronary artery, three different vessels CTOs in any location. two proximal CTOs in a separate coronary artery, left main segment, in-stent restenosis, or graft vessel
- Left ventricular ejection fraction (LVEF) <30%
- Severe comorbidity
Other salient features:
- Previous PCI: 17%, chronic kidney disease: 1.4%
- Mean LVEF: 57%
- Stable angina presentation: 73%
- Multivessel disease: 73%
- Location of CTO: LAD 43%, RCA 46%
- J-CTO score: 2.3
- CTO PCI success: 91%, retrograde approach 24%
- Statin use at 1 year: 92%
Principal Findings:
The primary endpoint for CTO-PCI + OMT vs. OMT, major adverse cardiac events (MACE) at 3 years (all-cause mortality, MI, stroke, repeat revascularization), was 20.6% vs. 19.6%, p for noninferiority 0.008.
Secondary outcomes for CTO-PCI + OMT vs. OMT:
- MACE at 5 years: 26.3% vs. 25.1%, p = 0.67
- MACE at 5 years on per-protocol analysis: 25.0% vs. 29.0%, p = 0.3
- Cardiovascular mortality at 5 years: 1.9% vs. 3.6%, p = 0.22
- Spontaneous MI at 5 years: 1.8% vs. 1.8%, p = 0.93
- Repeat revascularization at 5 years: 14.0% vs. 11.8%, p = 0.38
- Quality of life measures, including Seattle Angina Questionnaire for angina was similar
Interpretation:
The results of this trial indicate that routine CTO-PCI + OMT is not superior to OMT alone in reducing cardiovascular outcomes among patients with at least one CTO. Although negative, this is a landmark trial for the field of CTO PCI. It is one of the first to systematically compare the two therapies. EXPLORE was another CTO-PCI trial recently published that focused on patients with STEMI undergoing primary PCI with a coexistent CTO and showed no improvement in LV function with CTO-PCI. Further analyses will be important to see if there are certain scenarios (e.g., high ischemic burden) where CTO-PCI might be beneficial. It is interesting to note that with contemporary expertise and techniques, the success for CTO-PCI is >90%.
A plea for green earth
The plant is the producer of the food chain. It provides food, shelter, and medicine. A dense green patch touches all. Rapid industrialization is the hologram of civilization but at the cost of deforestation? pollution and has forced a lot of species to the extinction. I, you and everyone else understands the role of plants in our life irrespective of the level of education. People all the level shares effort to makes this earth looks green. Government plans afforestation, people far from city plant trees and people in densely populated industrialized cities put shrubs in pots as a plea for a green city. This original photograph is a snap of my terrace garden. My flat is located on the top floor of a four-storeyed building the capital city of Odisha. It is one of the evening in rainy season. A with a lot of clouds in the sky. It is a very rapidly expanding the city. I am in this flat for last 2years.My only daughter, wife, and parents to spend some time every morning and afternoon to look after this bonsai forest. My daughter enjoys fresh roses. I like tomato, brinjal and green chili. The impact of season change is quite apparent. In summer, these plants need more water, grow taller and look healthy. In the winter, the plants appear constipating in growth, do not much flower and look boring. I spare some time in the late evening after hospital time.Like anyone else ,I am also busy otherwise :earning ,spending and browsing a smart phone . The terrace view shows crows are enjoying the city life perching on the sky touching iron rods from upcoming innumerable skyscrapers. The complex issues of industrialization and the good living condition is deeply connected.
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