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A clinical update for you. Did you know this about Breast Cancer?

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CAD Intervention 2023

Title – Diabetes-Related Factors and the Effects of Ticagrelor Plus Aspirin
Subtitle- Leiter L, Bhatt D,et al.
Introduction – Diabetic population is at increased risk of recurrent cardiovascular events. Different strategies to reduce the burden of this increased risk include use of longer-term DAPT with more potent newer drugs like ticagrelor. The THEMIS trial evaluated this aspect using ticagrelor plus aspirin in diabetic population with stable coronary artery disease who did not have MI or stroke earlier. THEMIS-PCI was a predefined subset of the trial of patients who had undergone PCI earlier. Net clinical benefit (summation of benefit and harm) was favorable only in THEMIS-PCI group. This post hoc analysis was done by the investigators to examine if diabetes related factors like duration of diabetes, HbA1C and antihyperglycemic medications at baseline had any bearing on the net clinical benefit of these patients. Efficacy outcome included 3 point MACE (CV death, MI or stroke) and safety outcome was TIMI defined major bleeding.
Summary – Data from THEMIS study showed that the 3 point MACE increased with diabetes duration ( 6.7% for < 5 year and 11.1% for > 20 years of diabetes) and HbA1c ( 6.4% for < 6% and 11.8%> 10% HbA1C). Relative benefits of Ticagrelor plus aspirin were generally consistent across the subgroups. Bleeding rate however did not vary with diabetes duration or HbbA1c and were increased similarly by ticagrelor in all subgroups. The efficacy and safety of ticagrelor plus aspirin did not differ by anti-hyperglycemic therapy at baseline. Use of Ticagrelor produced net clinical benefit only in THEMIS -PCI but not in THEMIS population.
Use of ticagrelor plus aspirin produced generally consistent and favorable net clinical benefit across the diabetes related factors in diabetics who had undergone PCI earlier but not in diabetics with stable angina and no h/o PCI.
Journal link- https://www.jacc.org/doi/10.1016/j.jacc.2021.03.298
Image source https://www.healio.com/~/media/slack-news/stock-images/cardiology/a/aspirin-and-the-heart-adobe-stock.jpg

www.healio.com

Title – Canagliflozin produces sustained blood pressure lowering in patients with diabetes and CKD
Subtitle- Ye N, Jardine M, et al.
Introduction – Managing hypertension in patients with diabetes and CKD is challenging. Patients with diabetes and CKD often need multiple drugs and demonstrate higher incidence of resistant hypertension. While optimal control of blood pressure is crucial in this high risk population, the goal may not be achieved despite use of multiple drugs. Canagliflozin has been shown to reduce blood pressure in patients with diabetes and normal kidney function. This post hoc analysis of CREDENCE trial (which studied effect of canagliflozin on progression of renal damage in patients with diabetes and CKD) was done evaluate the effect of canagliflozin in patients with diabetes and CKD. Effect of canagliflozin on systolic BP across subgroups defined by baseline systolic BP, number of BP lower drug classes and history of resistant hypertension was evaluated along with effect on clinical outcomes across the subgroups.
Summary – Of 4401 participant of the trial, 76.4% had baseline systolic BP > 130 mm of hg while 31.2% had resistant hypertension. Canagliflozin reduced systolic BP by 3.5 mm of hg by week 3 and the effect was maintained over duration of the trial. Similar BP reduction was observed across the subgroups and canagliflozin also reduced need of initiating additional antihypertensive agents. Effect of canagliflozin on renal outcomes was consistent across the blood pressure subgroups.
The analysis showed that in people with diabetes and CKD, canagliflozin lowers systolic BP consistently across the subgroups and the effect is sustained. Canagliflozin can thus be an important adjunct for BP lowering and end-organ protection in these patients.
Journal link- https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.048740
Image source https://images.hindustantimes.com/rf/image_size_630x354/HT/p2/2018/05/17/Pictures/_157a3398-5998-11e8-b87b-3dd7d8bd63e9.jpg

images.hindustantimes.com

Title – ST-Segment Elevation Myocardial Infarction Following Transcatheter Aortic Valve Replacement
Subtitle- Faroux L, Lhermusier T,et al.
Introduction – Coronary artery disease is common in patients undergoing trans-catheter Aortic Valve Replacement (TAVR) and about half of the patients exhibit some degree of coronary artery disease. ACS events after TAVR differ from non-TAVR patients in certain respects with lower incidence of STEMI. However STEMI following TAVR carries a higher risk of mortality and major cardiovascular events. This study was conducted to determine clinical characteristics, management and outcomes of STEMI in patients treated with TAVR. This multicenter study enrolled 118 patients presenting with STEMI at a median of 255 days after TAVR. Procedural features of STEMI after TAVR managemed with primary PCI were compared with all-comer STEMI.
Summary – Median door-to-balloon time was higher in TAVR patients as compared to all-comers (40 min vs 30 min). Procedural time, fluoroscopy time and contrast volume were higher in TAVR patients. PCI failure was more common in patients with previous TAVR (16.5% vs 3.9%). Failure to cannulate coronary ostia occurred in 5 patients with resultant failure to treat culprit lesion. In hospital and late mortality(median 7 months) was higher in TAVR patients at 25.4% and 42.4% as compared to 20.6% and 38.2% in all-comers. The factors influencing higher risk were identified as low GFR (

media.istockphoto.com

Title – Which Patients benefit from intensive blood pressure management?
Subtitle- Bress A, Greene T,et al.
Introduction –
Intensive blood pressure reduction reduces risk of CVD events as demonstrated by the SPRINT study. Intensive blood pressure reduction however comes at cost of increased drug related adverse events which may partially explain the physicians inertia to intensify antihypertensive medications. Besides intensive blood pressure reduction also needs more resources. This secondary analysis of SPRINT trial looked at prediction of magnitude of benefit and adverse events resulting from intensive versus standard blood pressure treatment.
Summary –
In this secondary analysis of SPRINT trial, separate benefit outcomes were first occurrence of 1) CVD composite of AMI or other ACS, stroke, heart failure or CVD death and 2)all-cause mortality. Treatment related adverse effects included hypotension, syncope, bradycardia, electrolyte abnormalities, injurious falls and acute kidney injury. Modified elastic net Cox regression was used to predict absolute risk for each outcome and absolute risk differences on the basis of 36 baseline variables available at the point of care. Over a median follow up of 3.26 years 600 CVD composite events, 363 all-cause deaths and 481 treatment related adverse events were recorded in 8828 patients enrolled in SPRINT trial. Higher baseline CVD risk was associated with greater benefit i.e larger absolute CVD reduction. However, 95% of participants who fell into the highest tertile of predicted benefit also had a high or moderate predicted increase in treatment related adverse event risk. Only few patients were predicted as high benefit and low adverse event risk or low benefit and high adverse event risk. Results for all-cause mortality were also similar.
The analysis showed that participants with higher baseline predicted risk of CVD gained greater benefit from intensive blood pressure treatment although they had higher adverse events as well. The adverse events were mild and self-limiting.
Journal link- https://www.jacc.org/doi/10.1016/j.jacc.2021.02.058
Image source https://www.dicardiology.com/sites/default/files/styles/content_feed_large_new/public/field/image/Blood%20pressure_From%20Welch%20Allyn%20PR%20for%20EcoCuff.jpg?itok=pfc6Ised

www.dicardiology.com

Title – Long term prognosis of late presenters with ST elevation MI
Subtitle- Hoon Cho K, Han X,et al.
Introduction – Approximately 10 to 12% patients present late (> 12 hours) after onset of symptoms of ST elevation MI worldwide. Standard guidelines recommend invasive management of these patients in presence of ongoing ischemia. However the real world data on clinical practice of managing these patients and outcomes is lacking. This analysis of Korean Acute MI registry was done to investigate the real world features of STEMI late presenters and compare them with patients presenting within 12 hours of symptom onset. Five thousand eight hundred and twenty six consecutive patients diagnosed with STEMI during 2011 to 2015 were categorized as late presenters (12 to 48 hours after symptom onset, n = 624) or early presenters (< 12 hours, n= 5202). Co primary outcomes were 180 day and 3 year all-cause mortality.
Summary – Late presenters had remarkably worse outcomes than early presenter with higher 180 day mortality (10.7% vs 6.8%) and 3 year mortality (16.2% vs 10.6%). However presentation > 12 hours of symptom onset was not independently associated with increased mortality. Use of invasive procedures abruptly decreased for patients presenting between 12 to 24 hours and mortality rates increased sharply from first to second 12 hour interval for both 180 day mortality and 3 year mortality.
Data from this nationwide prospective Korean STEMI registry show steep differences in use of invasive procedures and mortality rates for late presenters. These findings call for a multidisciplinary approach for identifying late presenters who can benefit from invasive interventional procedures.
Journal link- https://www.jacc.org/doi/10.1016/j.jacc.2021.02.041
Image source https://myheart.net/wp-content/uploads/2015/04/nstemi.jpg

myheart.net