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Borovac JA. Unlocking the Gates of ISCHEMIA: Moving Toward Personalized Angina Management for Chronic Coronary Syndrome. J Am Coll Cardiol 2024; 83:1367-1369. [PMID: 38599712 DOI: 10.1016/j.jacc.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 04/12/2024]
Affiliation(s)
- Josip Andelo Borovac
- Division of Interventional Cardiology, University Hospital of Split, Split, Croatia; Department of Pathophysiology, University Hospital of Split, Split, Croatia; University Department of Health Studies, University of Split, Split, Croatia.
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Skowrońska A, Sinnadurai S, Teisseyre P, Gryka P, Doryńska A, Dzierwa M, Gąsior M, Grabowski M, Kamiński K, Kasprzak JD, Kubica J, Lesiak M, Szafran B, Wójcik M, Pinkas J, Sierpiński R, Gellert R, Jankowski P. First-year follow-up costs of myocardial infarction management in Poland from the payer's perspective. Kardiol Pol 2024; 82:183-191. [PMID: 38348614 DOI: 10.33963/v.phj.99006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Myocardial infarction (MI) remains a major burden for healthcare systems. Therefore, we intended to analyze the determinants of cost management of patients hospitalized for MI in Poland. METHODS Data on patients hospitalized and discharged with the diagnosis of acute MI were derived from the public payer claims database. Adult patients, reported between October 1, 2017 and December 31, 2019, were included. Costs of hospitalization for acute MI and cumulative one-year follow-up were analyzed. RESULTS The median (IQR) of the total direct cost was €3804.7 (2674.1-5712.7) per patient and 29% (€1113.6 [380.5-2490.4]) of these were costs related to the use of post-hospitalization healthcare resources. The median cost of cardiovascular disease management was €3624.7 (2582.1-5258.5), and 26% of this sum were follow-up costs. The analysis of the total cost for individual years showed a slight increase in median costs in subsequent years: €3450.7 (2407.8-5205.2) in 2017, €3753.8 (2642.6-5681.9) in 2018, and €3944.9 (2794.8-5844.4) in 2019. Male sex, heart failure, atrial fibrillation, diabetes, kidney disease, chronic obstructive pulmonary disease, and history of stroke in addition to hospitalization in a department other than cardiology or internal disease were independently related to the cost of MI patient management. CONCLUSIONS The high cost of management of MI patients was independently related to sex, heart failure, atrial fibrillation, diabetes, kidney disease, chronic obstructive pulmonary disease, and history of stroke as well as hospitalization in other than cardiology or internal disease department.
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Affiliation(s)
- Anna Skowrońska
- Agency for Health Technology Assessment and Tariff System, Warszawa, Poland
| | - Siamala Sinnadurai
- Department of Epidemiology and Health Promotion, School of Public Health, Centre of Postgraduate Medical Education, Warszawa, Poland.
- Department of Population Medicine and Lifestyle Diseases Prevention, Medical University of Bialystok, Białystok, Poland.
| | - Paweł Teisseyre
- Agency for Health Technology Assessment and Tariff System, Warszawa, Poland
- Institute of Computer Science, Polish Academy of Sciences, Warszawa, Poland
- Faculty of Mathematics and Information Science, Warsaw University of Technology, Warszawa, Poland
| | - Patrycja Gryka
- Agency for Health Technology Assessment and Tariff System, Warszawa, Poland
| | - Agnieszka Doryńska
- Agency for Health Technology Assessment and Tariff System, Warszawa, Poland
| | - Magdalena Dzierwa
- Agency for Health Technology Assessment and Tariff System, Warszawa, Poland
| | - Mariusz Gąsior
- 3rd Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Marcin Grabowski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Karol Kamiński
- Department of Population Medicine and Lifestyle Diseases Prevention, Medical University of Bialystok, Białystok, Poland
| | | | - Jacek Kubica
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Maciej Lesiak
- Department of Cardiology, Faculty of Medicine II, Poznan University of Medical Sciences, Poznań, Poland
| | - Bartosz Szafran
- Cardiology Outpatient Pro Corde, Wroclaw and Cardiology Department, County Hospital Wroclaw, Wrocław, Poland
| | - Mariusz Wójcik
- Clinical Department of Cardiology with the Acute Coronary Syndromes Subdivision, Clinical Provincial Hospital No. 2 in Rzeszow, Rzeszów, Poland
| | - Jarosław Pinkas
- School of Public Health, Centre of Postgraduate Medical Education, Warszawa, Poland
| | | | - Ryszard Gellert
- Department of Nephrology and Internal Medicine, Centre of Postgraduate Medical Education, Warszawa, Poland
| | - Piotr Jankowski
- Department of Epidemiology and Health Promotion, School of Public Health, Centre of Postgraduate Medical Education, Warszawa, Poland
- Department of Internal Medicine and Geriatric Cardiology, Centre of Postgraduate Medical Education, Warszawa, Poland
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Rao SJ, Iqbal SB, Kanwal AS, Aronow WS, Naidu SS. Multi-modality management of hypertrophic cardiomyopathy. Hosp Pract (1995) 2023; 51:2-11. [PMID: 36598161 DOI: 10.1080/21548331.2022.2162297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Hypertrophic cardiomyopathy (HCM) is an autosomal dominant inherited condition defined by left ventricular wall thickness greater than 15 mm in the absence of other conditions that could explain that degree of hypertrophy. Obstructive HCM associated with left ventricular outflow tract obstruction is defined by an intraventricular systolic pressure gradient greater than or equal to 30 mm Hg. Over the past couple of decades, there has been an expansion of both invasive and pharmacotherapeutic options for patients with HCM, with recent guidelines calling for a melody of invasive and non-invasive treatment strategies. There are several invasive therapies including proven therapies such as alcohol septal ablation and septal myectomy. Novel invasive therapies such as MitraClip, radiofrequency septal ablation and SESAME procedure have more recently been promoted. Pharmacological therapy has also dramatically evolved and includes conventional medications such as beta-blockers, calcium channel blockers, and disopyramide. Mavacamten, a novel cardiac myosin inhibitor, may significantly change management. Other myosin inhibitors and modulators are also being developed and tested in large clinical trials. Given significant phenotypical variability in patients with HCM, clinical management can be challenging, and often requires an individualized approach with a combination of invasive and non-invasive options.
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Affiliation(s)
- Shiavax J Rao
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, USA
| | - Shaikh B Iqbal
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, USA
| | - Arjun S Kanwal
- Department of Cardiology, Westchester Medical Center, Valhalla, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and Department of Medicine, New York Medical College, Valhalla, USA
| | - Srihari S Naidu
- Hypertrophic Cardiomyopathy Center, Cardiac Catheterization Laboratory, Department of Cardiology, Westchester Medical Center and Department of Medicine, New York Medical College, Valhalla, USA
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Elbadawi A, Elgendy IY, Kumfa P. Invasive Management for Non-ST-Segment-Elevation Myocardial Infarction and Chronic Kidney Disease: Does One Size Fit All? J Am Heart Assoc 2022; 11:e026390. [PMID: 35713279 PMCID: PMC9238646 DOI: 10.1161/jaha.122.026390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ayman Elbadawi
- Section of CardiologyBaylor College of MedicineHoustonTX
- Division of CardiologyUniversity of Texas Southwestern Medical CenterDallasTX
| | - Islam Y. Elgendy
- Division of Cardiovascular MedicineGill Heart Institute, University of KentuckyLexingtonKY
| | - Paul Kumfa
- Division of CardiologyUniversity of Texas Medical BranchGalvestonTX
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Majmundar M, Ibarra G, Kumar A, Doshi R, Shah P, Mehran R, Reed GW, Puri R, Kapadia SR, Bangalore S, Kalra A. Invasive Versus Medical Management in Patients With Chronic Kidney Disease and Non-ST-Segment-Elevation Myocardial Infarction. J Am Heart Assoc 2022; 11:e025205. [PMID: 35713283 PMCID: PMC9238658 DOI: 10.1161/jaha.121.025205] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 04/04/2022] [Indexed: 02/02/2023]
Abstract
Background The role of invasive management compared with medical management in patients with non-ST-segment-elevation myocardial infarction (NSTEMI) and advanced chronic kidney disease (CKD) is uncertain, given the increased risk of procedural complications in patients with CKD. We aimed to compare clinical outcomes of invasive management with medical management in patients with NSTEMI-CKD. Methods and Results We identified NSTEMI and CKD stages 3, 4, 5, and end-stage renal disease admissions using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes from the Nationwide Readmission Database 2016 to 2018. Patients were stratified into invasive and medical management. Primary outcome was mortality (in-hospital and 6 months after discharge). Secondary outcomes were in-hospital postprocedural complications (acute kidney injury requiring dialysis, major bleeding) and postdischarge 6-month safety and major adverse cardiovascular events. Out of 141 052 patients with NSTEMI-CKD, 85 875 (60.9%) were treated with invasive management, whereas 55 177 (39.1%) patients were managed medically. In propensity-score matched cohorts, invasive strategy was associated with lower in-hospital (CKD 3: odds ratio [OR], 0.47 [95% CI, 0.43-0.51]; P<0.001; CKD 4: OR, 0.79 [95% CI, 0.69-0.89]; P<0.001; CKD 5: OR, 0.72 [95% CI, 0.49-1.06]; P=0.096; end-stage renal disease: OR, 0.51 [95% CI, 0.46-0.56]; P<0.001) and 6-month mortality. Invasive management was associated with higher in-hospital postprocedural complications but no difference in postdischarge safety outcomes. Invasive management was associated with a lower hazard of major adverse cardiovascular events at 6 months in all CKD groups compared with medical management. Conclusions Invasive management was associated with lower mortality and major adverse cardiovascular events but minimal increased in-hospital complications in patients with NSTEMI-CKD compared with medical management, suggesting patients with NSTEMI-CKD should be offered invasive management.
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Affiliation(s)
- Monil Majmundar
- Department of CardiologyMaimonides Medical Center, BrooklynNew YorkNY
| | - Gabriel Ibarra
- Department of Internal MedicineBrown UniversityProvidenceRI
| | - Ashish Kumar
- Department of Internal MedicineCleveland Clinic Akron GeneralAkronOH
| | - Rajkumar Doshi
- Division of CardiologySt. Joseph’s University Medical CenterPatersonNJ
| | - Palak Shah
- Department of Internal MedicineNew York Medical College/Metropolitan HospitalNew YorkNY
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Grant W. Reed
- Department of Cardiovascular MedicineHeart, Vascular, and Thoracic Institute, Cleveland ClinicClevelandOH
| | - Rishi Puri
- Department of Cardiovascular MedicineHeart, Vascular, and Thoracic Institute, Cleveland ClinicClevelandOH
| | - Samir R. Kapadia
- Department of Cardiovascular MedicineHeart, Vascular, and Thoracic Institute, Cleveland ClinicClevelandOH
| | | | - Ankur Kalra
- Division of Cardiovascular MedicineKrannert Cardiovascular Research CenterIndiana University School of MedicineIndianapolisIN
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Nunez‐Mir GC, Walter JA, Grayson KL, Johnson DM. Assessing drivers of localized invasive spread to inform large-scale management of a highly damaging insect pest. Ecol Appl 2022; 32:e2538. [PMID: 35044021 PMCID: PMC9286796 DOI: 10.1002/eap.2538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/17/2021] [Accepted: 09/15/2021] [Indexed: 05/19/2023]
Abstract
Studies of biological invasions at the macroscale or across multiple scales can provide important insights for management, particularly when localized information about invasion dynamics or environmental contexts is unavailable. In this study, we performed a macroscale analysis of the roles of invasion drivers on the local scale dynamics of a high-profile pest, Lymantria dispar dispar L., with the purpose of improving the prioritization of vulnerable areas for treatment. Specifically, we assessed the relative effects of various anthropogenic and environmental variables on the establishment rate of 8010 quadrats at a localized scale (5 × 5 km) across the entire L. dispar transition zone (the area encompassing the leading population edge, currently from Minnesota to North Carolina). We calculated the number of years from first detection of L. dispar in a quadrat to the year when probability of establishment of L. dispar was greater than 99% (i.e., waiting time to establishment after first detection). To assess the effects of environmental and anthropogenic variables on each quadrat's waiting time to establishment, we performed linear mixed-effects regression models for the full transition zone and three subregions within the zone. Seasonal temperatures were found to be the primary drivers of local establishment rates. Winter temperatures had the strongest effects, especially in the northern parts of the transition zone. Furthermore, the effects of some factors on waiting times to establishment varied across subregions. Our findings contribute to identifying especially vulnerable areas to further L. dispar spread and informing region-specific criteria by invasion managers for the prioritization of areas for treatment.
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Affiliation(s)
- Gabriela C. Nunez‐Mir
- Department of BiologyVirginia Commonwealth UniversityRichmondVirginiaUSA
- Department of Biological SciencesUniversity of Illinois at ChicagoChicagoIllinoisUSA
| | - Jonathan A. Walter
- Department of Environmental SciencesUniversity of VirginiaCharlottesvilleVirginiaUSA
| | | | - Derek M. Johnson
- Department of BiologyVirginia Commonwealth UniversityRichmondVirginiaUSA
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Haller‐Bull V, Bode M. Modeling herbivore functional responses causing boom-bust dynamics following predator removal. Ecol Evol 2021; 11:2209-2220. [PMID: 33717449 PMCID: PMC7920789 DOI: 10.1002/ece3.7185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 11/10/2020] [Accepted: 12/16/2020] [Indexed: 11/07/2022] Open
Abstract
Native biodiversity is threatened by invasive species in many terrestrial and marine systems, and conservation managers have demonstrated successes by responding with eradication or control programs. Although invasive species are often the direct cause of threat to native species, ecosystems can react in unexpected ways to their removal or reduction. Here, we use theoretical models to predict boom-bust dynamics, where the removal of predatory or competitive pressure from a native herbivore results in oscillatory population dynamics (boom-bust), which can endanger the native species' population in the short term. We simulate control activities, applied to multiple theoretical three-species Lotka-Volterra ecosystem models consisting of vegetation, a native herbivore, and an invasive predator. Based on these communities, we then develop a predictive tool that-based on relative parameter values-predicts whether control efforts directed at the invasive predator will lead to herbivore release followed by a crash. Further, by investigating the different functional responses, we show that model structure, as well as model parameters, are important determinants of conservation outcomes. Finally, control strategies that can mitigate these negative consequences are identified. Managers working in similar data-poor ecosystems can use the predictive tool to assess the probability that their system will exhibit boom-bust dynamics, without knowing exact community parameter values.
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Affiliation(s)
- Vanessa Haller‐Bull
- School of Mathematical SciencesQueensland University of TechnologyBrisbaneQldAustralia
- ACEMS, Australian Research Council Centre of Excellence for Mathematical and Statistical FrontiersBrisbaneQldAustralia
- AIMS@JCUAustralian Institute of Marine ScienceTownsvilleQldAustralia
| | - Michael Bode
- School of Mathematical SciencesQueensland University of TechnologyBrisbaneQldAustralia
- ACEMS, Australian Research Council Centre of Excellence for Mathematical and Statistical FrontiersBrisbaneQldAustralia
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Kunniardy P, Koshy AN, Meehan G, Murphy AC, Ramchand J, Clark DJ, Farouque O, Yudi MB. Invasive versus Conservative Management in Patients ≥85 years presenting with Non-ST Elevation Myocardial Infarction. Intern Med J 2021; 52:1167-1173. [PMID: 33647172 DOI: 10.1111/imj.15258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/12/2021] [Accepted: 02/23/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Guidelines recommend early coronary angiography (CA) in patients with non-ST-elevation myocardial infarction (NSTEMI), irrespective of age. However, elderly patients are less likely to be treated according to these guidelines due to their perceived high risk and medical comorbidities. Whether an invasive strategy is associated with improved survival in patients aged ≥85 years remains uncertain due to their exclusion from randomised trials. METHODS Consecutive patients aged ≥85 years presenting to a tertiary centre with NSTEMI between 2008-18 were included in this retrospective cohort study. Patients were stratified based on whether they underwent invasive management with CA with a view to revascularisation versus conservative management. The primary outcome was long-term mortality. RESULTS Of 7,591 patients with NSTEMI, 1052 patients ≥85years were included. 99(9.4%) patients underwent CA. Those undergoing CA were more likely to be younger, male, live independently, without mobility or cognitive issues (all p<0.01). Overall, 495(47%) patients died during a mean follow-up of 1.3±1 year. On Cox regression, after adjusting for age, pre-morbid functional status, cognition and cardiovascular risk factors, invasive management was the strongest predictor for survival (HR 0.47; 95%CI 0.26-0.85; p=0.01). Invasive management was associated with a trend to increased risk of in-hospital bleeding (6.1% vs 2.6%, p=0.054) with no significant difference in stroke (2.0% vs 3.8%, p=0.37). CONCLUSION In patients aged ≥85 years who presented with NSTEMI, invasive management was associated with improved survival without significant differences in bleeding or stroke. A randomised controlled study assessing the efficacy and safety of invasive management in very elderly patients with NSTEMI is warranted. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Phelia Kunniardy
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Georgie Meehan
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Alexandra C Murphy
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jay Ramchand
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Heart and Vascular Institute, Cleveland Clinic Miller Family Heart and Vascular Institute, Cleveland, Ohio, USA
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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Chen PF, Tang L, Pei JY, Yi JL, Xing ZH, Fang ZF, Zhou SH, Hu XQ. Prognostic value of admission electrocardiographic findings in non-ST-segment elevation myocardial infarction. Clin Cardiol 2020; 43:574-580. [PMID: 32125713 PMCID: PMC7299002 DOI: 10.1002/clc.23349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/24/2020] [Accepted: 02/14/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Admission electrocardiographic (ECG) findings of non-ST-segment elevation myocardial infarction (NSTEMI) include transient ST-segment elevation (TSTE), ST-segment depression (STD), T-wave inversion (TWI), and no ischemic changes (NIC). HYPOTHESIS This study aimed to assess the prognostic value of qualitative ECG findings at presentation and to clarify the influence of invasive treatment on the prognostic value of admission ECG findings. METHODS We analyzed the Acute Coronary Syndrome Quality Improvement in Kerala (ACS QUIK) study post hoc. NSTEMI patients were included and classified into four groups per ECG findings. Study endpoints were in-hospital and 30-day mortality rates and major adverse events (MAE). We performed multivariate logistic regression, adjusting for covariates in the Global Registry of Acute Coronary Events risk model, with subset analyses of patients treated with or without invasive management. RESULTS STD patients had significantly higher in-hospital and 30-day mortality rates/MAE than TWI patients, which had lower in-hospital mortality rate/MAE than the NIC group. TSTE patients had intermediate outcomes. In multivariate logistic regression using the TWI group as the reference, STD and NIC remained independently associated with worse outcomes. Subset analysis showed prognostic value of admission ECG in non-invasively managed but not in invasively managed patients. CONCLUSIONS STD was associated with adverse outcomes, TWI with benign prognoses. NIC should not be taken to indicate low risk. Qualitative analysis of admission ECG is suitable for rapid risk stratification of NSTMI patients at presentation. However, it may not be predictive of short-term outcomes of NSTEMI patients after invasive management.
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Affiliation(s)
- Peng-Fei Chen
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Liang Tang
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Jun-Yu Pei
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Jun-Lin Yi
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Zhen-Hua Xing
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Zhen-Fei Fang
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Sheng-Hua Zhou
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Xin-Qun Hu
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, China
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Abstract
The FRISC II study addressed two key questions in the management of acute coronary syndromes: is it beneficial to extend low-molecular-weight heparin (LMWH) therapy with dalteparin beyond the initial period of acute treatment; and, is a strategy of early invasive therapy, including angioplasty and surgical revascularization, preferable to a more conservative strategy? The study focused on patients with unstable coronary artery disease (UCAD), that is, angina and non-ST-segment-elevation myocardial infarction (MI). Patients were allocated in a randomized, factorial study design to either an invasive or a conservative management strategy. Within each of these groups, patients were further randomized to receive either 3 months of extended treatment with dalteparin or placebo, following at least 5 days' treatment with open-label dalteparin. After 1 year, patient survival and MI-free survival were significantly higher in the invasive therapy group than in the noninvasive group. Patients who received extended dalteparin treatment had a significantly reduced probability of death or MI after 1 month (relative risk reduction 47%; p = 0.002), a benefit still evident after 60 days, but after 3 months there was no longer any significant clinical advantage compared with placebo. There was, however, a significant reduction in the combined incidence of death, MI, or revascularization at 3 months in the extended dalteparin treatment group (relative risk reduction 13%; p = 0.031). The benefits of extended dalteparin treatment were particularly marked in patients with elevated troponin-T or ST-segment depression. A subgroup analysis of conservatively managed patients who underwent revascularization in the first 45 days revealed that the probability of death or MI at 1 year was significantly lower among patients who received extended dalteparin treatment (relative risk reduction 35%; p = 0.02). Extended dalteparin treatment is, however, associated with a small increase in bleeding risk. In conclusion, early invasive therapy (following combined treatment with aspirin and dalteparin) is recommended in a majority of patients with UCAD. Furthermore, extended dalteparin treatment for up to 45 days is efficacious and well tolerated, and therefore provides a useful "bridge" to revascularization when early revascularization is not immediately available.
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Affiliation(s)
- F Kontny
- Department of Cardiology, The Heart and Lung Centre, Ullevål University Hospital, Oslo, Norway
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