Journal Wrap

The hottest research from various peer-reviewed journals.

Triple Vascular Screening Significantly Reduced Overall Mortality in Older Men

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Overall mortality was reduced by 7 percent among a large population of men aged 65 to 74 years who received combined triple screening for abdominal aortic aneurysm (AAA), peripheral artery disease (PAD) and hypertension and subsequent intervention, compared with no screening, according to the VIVA randomized trial. The results were presented by Jes S. Lindholt, DMSci, PhD, at ESC Congress 2017 and simultaneously published in The Lancet. Read More >>>

In VIVA, conducted in Denmark, abdominal ultrasound was used to screen for AAA and Doppler-based ankle brachial index for PAD. The screening intervention was attended by 75 percent of the 50,168 invited men. AAA was identified in 3.3 percent (n = 619) of participants, 49.6 percent of whom had repair within five years. PAD was diagnosed in 11 percent (n = 2,073) of participants and 4 percent had repair for intermittent claudication within five years. Men with AAA or PAD received a nurse-driven consultation for initiation of preventive treatment, including 75 mg aspirin, 40 mg statin, and instructions on diet, smoking cessation and exercise. Possible hypertension was found in 10 percent (n = 1,963).

"The probability for cost effectiveness of screening was estimated at 98 percent for life year gained."

For the primary outcome of all-cause mortality, at five years, significantly more men in the intervention group had survived compared with controls (hazard ratio [HR], 0.93; p = 0.012). The number needed to screen was 169. No significant difference between the groups was reported for the secondary outcomes of cause-specific mortality, cardiovascular disease-related hospital admission, diabetes, intracerebral hemorrhage, renal failure, cancer, 30-day postoperative mortality, cost-effectiveness and quality of life.

The probability for cost effectiveness of screening was estimated at 98 percent for life year gained and 99 percent for quality-adjusted life years. The investigators concluded this screening appears to be an effective and cost-effective prevention strategy and recommended that health policy makers should implement triple vascular screening for men aged 65 to 74 years.

Lindholt JS, Sogaard S. Lancet 2017;Aug 28:[Epub ahead of print].

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CNS Infarction Risk Not Reduced With Cerebral Embolic Protection During SAVR

Cerebral embolic protection devices did not significantly reduce the risk of central nervous system (CNS) infarction at seven days after surgical aortic valve replacement (SAVR) compared with a standard aortic cannula, according to results of a study by Michael J. Mack, MD, FACC, et al., published in the Journal of the American Medical Association.

A total of 383 patients were randomized immediately after sternotomy to suction-based extraction (n = 118), intra-aortic filtration (n = 133) or in the control group to standard aortic perfusion cannula (n = 132). Within the control group, the first 12 patients served as controls for the intra-aortic filtration group only and the other 120 were controls for both device groups. Read More >>>

The patients were assessed at baseline and postoperative days one, three, seven, 30 and 90. The primary endpoint was freedom from clinical or radiographic CNS infarction at seven days after SAVR. The NIH stroke scale (NIHSS) at days one, three and seven was used for serial neurological assessment and reporting of ischemic stroke during hospitalization.

Three patients randomized to intra-aortic filtration and two to suction-based extraction did not receive the designated device. Embolic debris was captured in 99 percent of patients in the intra-aortic filtration group and in 75 percent in the suction-based extraction group.

No significant difference was observed in freedom from CNS infarction at postoperative day seven between the suction-based extraction and control groups (32.0 vs. 33.3 percent) or the intra-aortic filtration and control groups (25.6 vs. 32.4 percent). The rate of clinically apparent stroke in the suction-based extraction group vs. controls was 5.1 vs. 5.8 percent and in the intra-aortic filtration group vs. controls was 8.3 percent vs. 6.1 percent.

The composite endpoint was reached by 21.4 percent in the suction-based extraction group and 24.2 percent of controls and by 33.3 percent in the intra-aortic filtration group vs. 23.7 percent of controls. The incidence of delirium over time was significantly greater in the treatment than control groups. Decline in overall cognitive scores was greater in patients with clinically apparent stroke.

In this study, cerebral embolic protection devices did not significantly reduce the risk of CNS infarction compared with a standard aortic cannula at seven days after SAVR. “Potential benefits for reduction in delirium, cognition, and symptomatic stroke merit larger trials with longer follow-up,” write the investigators.

Mack MJ, Acker MA, Gelijns AC, et al. JAMA 2017;318:536-47.

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Adverse Events Observed With BVS vs. EES

Bioresorbable vascular scaffolds (BVS) were associated with increased rates of composite device-oriented and patient-oriented adverse events at the two-year follow-up compared with everolimus-eluting stents (EES), according to a study published in The Lancet.

In this systematic review and meta-analysis, Ziad A. Ali, MD, et al., identified seven randomized trials in which patients were randomly assigned to Absorb BVS (n = 3,216) or metallic EES (n = 2,332) and followed for two years. The primary efficacy outcome was the device-oriented composite endpoint – cardiac mortality, target vessel myocardial infarction or ischemia-driven target lesion revascularization – and the primary safety outcome measure was definite or probable device thrombosis. Read More >>>

Two-year relative risks of the device-oriented composite endpoint were significantly higher with BVS than with EES. These differences were driven by increased target vessel myocardial infarction and ischemia-driven target lesion revascularization with BVS. Two-year relative risks of the patient-oriented composite endpoint were also higher with BVS than with EES, driven by increased rates of myocardial infarction with BVS. Device thrombosis occurred more commonly with BVS than with EES over the two years.

Ali ZA, Serruys PW, Kimura T, et al. Lancet 2017;390:760-72.

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Mortality Similar for Blacks and Whites After PCI in Veterans Affairs Study

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Race was not independently associated with one-year mortality among black and white patients treated with PCI in Veterans Affairs (VA) hospitals, according to a study published in JAMA Cardiology.

Taisei Kobayashi, MD, et al., used data from the VA Clinical Assessment, Reporting and Tracking System for Cardiac Catheterization Laboratories, which includes data from the electronic health record, along with several data sources for vital status, to compare outcomes in black and white patients who underwent PCI between October 2007 and September 2013 in 63 VA hospitals. Read More >>>

They analyzed outcomes from January 2016 to April 2017 in 42,391 patients; 13.3 percent of the cohort was black. Most patients were male (98.4 percent) with a mean age of 65 years. Black patients tended to be younger, have lower socioeconomic status and live in urban areas, and have a higher burden of comorbidities and to be initially seen in the cardiac catheterization laboratory.

For the primary outcome of one-year mortality, in the unadjusted analysis, black patients compared with white patients had higher rates (7.1 vs. 5.9 percent; p < 0.001). They also had higher rates of the secondary outcomes of 30-day acute kidney injury (20.8 vs. 13.8 percent; p < 0.001), 30-day blood transfusion (3.4 vs. 2.7 percent; p < 0.01) and one-year readmission rates for myocardial infarction (3.3 vs. 2.7 percent; p = 0.01) compared with white patients.

However, in the analysis adjusted for demographics, comorbidities and procedural characteristics, there were no differences between black and white patients for one-year mortality. Except for a higher rate of adjusted 30-day acute kidney injury (odds ratio, 1.22), there was no difference in secondary outcomes between the unadjusted and adjusted analyses.

The study also found that black patients were less likely to receive a drug-eluting stent or to be prescribed beta-blockers, compared with white patients.

“This study represents the largest modern analysis to date of the influence of race on cardiovascular outcomes among U.S. veterans,” the study authors write. “A strength of the study is the ability to adjust for a wide range of confounders through the merging of clinical registry data with administrative claims.”

Kobayashi T, Glorioso TJ, Armstrong EJ, et al. JAMA Cardiol;July 19:[Epub ahead of print].

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Differential Impacts of Coronary Stent Type and Duration of DAPT

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The type of stent partially influences the risk of adverse cardiovascular events when different dual antiplatelet therapy (DAPT) durations are prescribed, according to a study published in the European Heart Journal. However, when not considering duration of DAPT, durable and biodegradable polymer stents along with bioresorbable scaffolds (BRS) have a similar rate of major adverse cardiovascular events (MACE) defined as death, myocardial infarction and target vessel revascularization.

Using a network meta-analysis of 64 randomized controlled trials and 102,735 patients, Fabrizio D’Ascenzo, MD, et al., compared the different types of drug-eluting stents (DES) and durations of DAPT. The primary endpoint was MACE and the secondary endpoints were definite stent thrombosis and the individual MACE components. Read More >>>

The arms of interest were stents with DAPT duration <12 months, stents with DAPT duration of 12 months and stents with DAPT >12 months; there were 150 arms of interest. The results focused on the comparison among BRS, polymer biodegradable stents and second-generation DES – everolimus-eluting stent (EES) and zotarolimus-eluting stent (ZES) – with different DAPT durations.

"Despite the large amount of data evaluated in our analysis, its results should be interpreted carefully and in light of some important considerations." Fabrizio D’Ascenzo, MD, et al.

After a median follow-up of 20 months, the rates of MACE were similar across the different arms of interest. Of note, there was a lower incidence of myocardial infarction with EES and ZES for a DAPT duration >12 months vs. all other groups. Also, there was a higher rate of stent thrombosis with a BRS compared with EES and ZES, regardless of the DAPT duration. A higher risk for major bleeding was seen for a DAPT duration >12 months vs. a shorter duration.

No differences were observed for target lesion revascularization, target vessel revascularization and death among the different combinations of stent and DAPT duration.

“Despite the large amount of data evaluated in our analysis, its results should be interpreted carefully and in light of some important considerations,” the authors write. “Half of the patients included were admitted for acute coronary syndrome (ACS): while for selected patients with stable coronary artery disease a shortened DAPT could represent a safe choice, in patients with ACS a shortened DAPT may lead to a higher rate of adverse events.”

D’Ascenzo F, Iannaccone M, Saint-Hilary G, et al. Eur Heart J;Aug 11:[Epub ahead of print].

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Clinical Topics: Acute Coronary Syndromes, Dyslipidemia, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Nonstatins, Novel Agents, Statins, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine, Diet, Hypertension

Keywords: ACC Publications, Cardiology Interventions, Absorbable Implants, Acute Coronary Syndrome, Acute Kidney Injury, Aged, American Medical Association, Ankle Brachial Index, Aortic Aneurysm, Abdominal, Aortic Valve, Aspirin, Blood Transfusion, Catheters, Cardiac Catheterization, Cerebral Hemorrhage, Cognition, Comorbidity, Control Groups, Coronary Artery Disease, Cost-Benefit Analysis, Delirium, Diabetes Mellitus, Diet, Drug-Eluting Stents, Electronic Health Records, Embolic Protection Devices, Health Policy, Hospitalization, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Incidence, Infarction, Intermittent Claudication, Intracranial Embolism, Myocardial Infarction, Neoplasms, Odds Ratio, omega-Chloroacetophenone, Outcome Assessment (Health Care), Patient Readmission, Peripheral Arterial Disease, Polymers, Quality of Life, Quality-Adjusted Life Years, Registries, Renal Insufficiency, Research Personnel, Risk, Sirolimus, Smoking Cessation, Sternotomy, Stroke, Suction, Thrombosis, Veterans

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