enero, 2018

  • Asociación entre la oclusión del apéndice auricular izquierdo y la readmisión por tromboembolismo en pacientes con fibrilación auricular sometidos a cirugía cardíaca concomitante

    On: 25 enero, 2018
    In: Cardiología Intervencionista, Investigación
    Views: 767
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    Un artículo publicado recientemente en el JAMA (Journal of the American Medical Association) destaca los beneficios de la oclusión quirúrgica del auricular izquierdo para prevenir eventos tromboembólicos en pacientes mayores con fibrilación auricular sometidos a cirugía cardíaca.

    Asociación entre la oclusión del apéndice auricular izquierdo y la readmisión por tromboembolismo en pacientes con fibrilación auricular sometidos a cirugía cardíaca concomitante.

    Friedman DJ, Piccini JP, Wang T, Zheng J, Malaisrie SC, Holmes DR, Suri RM, Mack MJ, Badhwar V, Jacobs JP, Gaca JG, Chow SC, Peterson ED, Brennan JM.

    Key Points
    Question Is surgical left atrial appendage occlusion associated with a reduction in long-term thromboembolic events?

    Findings In this retrospective cohort study of 10 524 Medicare recipients with atrial fibrillation undergoing cardiac surgery, surgical left atrial appendage occlusion, compared with no surgical left atrial appendage occlusion, was significantly associated with lower risk of readmission for thromboembolism at 3 years (unadjusted, 4.2% vs 6.2%; adjusted hazard ratio, 0.67).

    Meaning Surgical left atrial appendage occlusion may be of benefit in preventing thromboembolic events in older patients with atrial fibrillation undergoing cardiac surgery, although randomized trials would be necessary to provide definitive evidence.

     

    https://www.ncbi.nlm.nih.gov/pubmed/29362794

     

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  • Redefiniendo la presión arterial: riesgos y beneficios

    On: 22 enero, 2018
    In: Cardiología Clínica, Investigación
    Views: 878
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    La nueva guía de diagnóstico, prevención, detección, evaluación y manejo en EEUU de hipertensión arterial cambiaría drásticamente el número de pacientes en EEUU considerados como hipertensos y necesitados de medicación. Las nuevas directrices fueron emitidas por la American College of Cardiology (ACC) y la American Heart Association (AHA).

    Los autores de esta revisión, sin embargo, le hacen una crítica, ya que muchos pacientes tendrían además efectos secundarios adversos, por la medicación que deben tomar, que no se compensarían con la disminución del riesgo cardíaco.

     

    Redefining Hypertension — Assessing the New Blood-Pressure Guidelines
    George Bakris, M.D., and Matthew Sorrentino, M.D.

    http://www.nejm.org/doi/full/10.1056/NEJMp1716193?query=featured_home

     

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  • Rivaroxaban con o sin aspirina en enfermedades cardiovasculares estables: lo que dejó el COMPASS Trial

    On: 18 enero, 2018
    In: Cardiología Intervencionista, Investigación
    Views: 815
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    Uno de los highlights de la investigación científica cardiológica en 2017 fue el COMPASS trial presentado por John W. Eikelboom en el New England Journal of Medicine, que demostró que el rivaroxaban con aspirina mejora los resultados en pacientes con enfermedad cardiovascular estable. Dejamos la descripción del abstract del paper y sus autores para más detalles:

    Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease.
    Eikelboom JW, Connolly SJ, Bosch J, Dagenais GR, Hart RG, Shestakovska O, Diaz R, Alings M, Lonn EM, Anand SS, Widimsky P, Hori M, Avezum A, Piegas LS, Branch KRH, Probstfield J, Bhatt DL, Zhu J, Liang Y, Maggioni AP, Lopez-Jaramillo P, O’Donnell M, Kakkar AK, Fox KAA, Parkhomenko AN, Ertl G, Störk S, Keltai M, Ryden L, Pogosova N, Dans AL, Lanas F, Commerford PJ, Torp-Pedersen C, Guzik TJ, Verhamme PB, Vinereanu D, Kim JH, Tonkin AM, Lewis BS, Felix C, Yusoff K, Steg PG, Metsarinne KP, Cook Bruns N, Misselwitz F, Chen E, Leong D, Yusuf S; COMPASS Investigators.

    Abstract
    BACKGROUND:
    We evaluated whether rivaroxaban alone or in combination with aspirin would be more effective than aspirin alone for secondary cardiovascular prevention.

    METHODS:
    In this double-blind trial, we randomly assigned 27,395 participants with stable atherosclerotic vascular disease to receive rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg once daily), rivaroxaban (5 mg twice daily), or aspirin (100 mg once daily). The primary outcome was a composite of cardiovascular death, stroke, or myocardial infarction. The study was stopped for superiority of the rivaroxaban-plus-aspirin group after a mean follow-up of 23 months.

    RESULTS:
    The primary outcome occurred in fewer patients in the rivaroxaban-plus-aspirin group than in the aspirin-alone group (379 patients [4.1%] vs. 496 patients [5.4%]; hazard ratio, 0.76; 95% confidence interval [CI], 0.66 to 0.86; P<0.001; z=-4.126), but major bleeding events occurred in more patients in the rivaroxaban-plus-aspirin group (288 patients [3.1%] vs. 170 patients [1.9%]; hazard ratio, 1.70; 95% CI, 1.40 to 2.05; P<0.001). There was no significant difference in intracranial or fatal bleeding between these two groups. There were 313 deaths (3.4%) in the rivaroxaban-plus-aspirin group as compared with 378 (4.1%) in the aspirin-alone group (hazard ratio, 0.82; 95% CI, 0.71 to 0.96; P=0.01; threshold P value for significance, 0.0025). The primary outcome did not occur in significantly fewer patients in the rivaroxaban-alone group than in the aspirin-alone group, but major bleeding events occurred in more patients in the rivaroxaban-alone group.

    CONCLUSIONS:
    Among patients with stable atherosclerotic vascular disease, those assigned to rivaroxaban (2.5 mg twice daily) plus aspirin had better cardiovascular outcomes and more major bleeding events than those assigned to aspirin alone. Rivaroxaban (5 mg twice daily) alone did not result in better cardiovascular outcomes than aspirin alone and resulted in more major bleeding events. (Funded by Bayer; COMPASS ClinicalTrials.gov number, NCT01776424 .).

    https://www.ncbi.nlm.nih.gov/pubmed/28844192

     

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  • ¿Cuál es el inhibidor ideal para tratar a los pacientes con síndromes coronarios agudos incluyendo infarto con supra ST: clopidogrel, ticagrelos o prasugrel ? ¿Qué nos dice la evidencia clínica? ¿Cuánto tiempo deben tomar esta droga los pacientes y cuáles son los potenciales riesgos?

    On: 9 enero, 2018
    In: Cardiología Intervencionista, Investigación
    Views: 878
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    Dos artículos recientemente publicados tratan de responder estos interrogantes, uno de ellos publicado por el grupo del Centro CECI.

    Estos son los dos artículos:

    1- Wilson SJ , Newby D, Dawson D, Irving J and Berry C Duration of DAPT in acute coronary syndrome Heart. 2017 Apr;103(8):573-580. doi: 10.1136/heartjnl-2016-309871. Epub 2017 Mar 1.
    2- Rodriguez AE, Rodriguez-Granillo AM, Azcarrunz SD, Peralta-Bazan F, Cho MY. Did Prasugrel and Ticagrelor Offer the Same Benefit in Patients with Acute Coronary Syndromes after Percutaneous Coronary Interventions Compared to Clopidogrel? Insights from Randomized Clinical Trials, Registries and Meta-analysis. Curr Pharm Des. 2018 Jan 8. doi: 10.2174/1381612824666180108121834.

    • «Duration of dual antiplatelet therapy in acute coronary syndrome»

    Abstract: Despite a large volume of evidence supporting the use of dual antiplatelet therapy in patients with acute coronary syndrome, there remains major uncertainty regarding the optimal duration of therapy. Clinical trials have varied markedly in the duration of therapy, both across and within trials. Recent systematic reviews and meta-analyses suggest that shorter durations of dual antiplatelet therapy are superior because the avoidance of atherothrombotic events is counterbalanced by the greater risks of excess major bleeding with apparent increases in all-cause mortality with longer durations. These findings did not show significant heterogeneity according to whether patients had stable or unstable coronary heart disease. Moreover, the potential hazards and benefits may differ when applied to the general broad population of patients encountered in everyday clinical practice who have markedly higher bleeding and atherothrombotic event rates. Clinicians lack definitive information regarding the duration of therapy in patients with acute coronary syndrome and risk scores do not appear to be sufficiently robust to address these concerns. We believe that there is a pressing need to undertake a broad inclusive safety trial of shorter durations of therapy in real world populations of patients with acute coronary syndrome. The clinical evidence would further inform future research into strategies for personalised medicine.

    • «Did Prasugrel and Ticagrelor Offer the Same Benefit in Patients with Acute Coronary Syndromes after Percutaneous Coronary Interventions Compared to Clopidogrel? Insights from Randomized Clinical Trials, Registries and Meta-analysis.»

    Abstract: 

    BACKGROUND:
    According to ACC/ AHA guidelines, a minimum of 1 year of dual anti- platelet therapy (DAPT) consisting of aspirin and a platelet ADP-receptor antagonist (P2Y12 inhibitor) is recommended for patients presenting acute coronary syndromes (ACS), regardless of which type of revascularization is performed during the acute event.

    METHODS:
    The purpose of this presentation was to review the present data either from a direct randomized comparison among the three compounds and also large prospective observational registries and meta-analysis were analyzed in detail. With this aim, we performed an extensive large search from PubMed/Medline Journals identifying studies comparing fashion the new P2Y12 inhibitors in patients with ACS including ST elevation myocardial infarction (STEMI)in direct and indirect manner.

    RESULTS:
    Pivotal large randomized clinical trials (RCT) in patients with ACS including STEMI, comparing clopidogrel, a first generation P2Y12 inhibitor against the newer prasugrel and ticagrelor showed major efficacy advantages of the latters although both drugs had more bleeding risk than clopidogrel. Direct comparisons of prasugrel and ticagrelor from large RCT are not yet available, however, several observational registries and meta-analysis reported results from an indirect comparison between both compounds. Major findings and limitations of each of these studies were identified, highlighted and discussed.

    CONCLUSION:
    Prasugrel and ticagrelor are both more effective than clopidogrel to prevent adverse cardiac events in patients with ACS. Compared to ticagrelor, prasugrel appears to be more effective in patients with STEMI , although lack of randomized data didn’t allow to draw definitive conclusions.

    https://www.ncbi.nlm.nih.gov/pubmed/28249994

    https://www.ncbi.nlm.nih.gov/pubmed/29308737

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  • Relaciones de la Industria Farmacéutica y de Dispositivos con los Editores de Revistas Científicas de Alto Impacto

    On: 9 enero, 2018
    In: Investigación
    Views: 742
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    Acaba de salir publicado un estudio sobre las relaciones de la Industria con los Editores y Editores Asociados de las más importantes revistas científicas médicas en sus distintas especialidades de EEUU.
    En ella se analizan los estrechos vínculos financieros que tendrían algunos Editores con la Industria farmacéutica, que serían mucho más frecuentes e importantes que lo deseado y que indudablemente afecta la independencia y transparencia de la información médica publicada en las mismas.
    Los autores identificaron 52 Journals con alto impacto científico en su área y la mayoría de los Editores tenían fuertes relaciones con la Industria farmacéutica y/o de «devices» médicos, algunos de ellos con cifras millonarias.
    Sólo Editores de EEUU fueron seleccionados, ya que los pagos de la Industria están en un registro nacional, no pudiendo los autores conocer el de aquellos de otras nacionalidades ya que la respuesta espontánea dada por los propios involucrados tiene obviamente muchas limitaciones.
    Cuando los autores quisieron corroborar estos datos con los Editores en Jefe de cada Journal solo el 23% respondió a la encuesta.
    La relación de Editores en Jefe/Asociados o aquellos con fuerte decisión en la posible aceptación de trabajos científicos (Deputy Editor) debería ser factor de exclusión de los mismos para actuar como tales y afecta en grado severo la credibilidad de las publicaciones científicas especialmente en Revistas de alto impacto.
    Este excelente artículo publicado en BMJ open habla una vez más de la transparencia Editorial de esta revista inglesa.

    Abstract:

    Objective: To estimate financial payments from industry to US journal editors.

    Design: Retrospective observational study.

    Setting: 52 influential (high impact factor for their specialty) US medical journals from 26 specialties and US Open Payments database, 2014.

    Participants: 713 editors at the associate level and above identified from each journal’s online masthead.

    Main outcome measures: All general payments (eg, personal income) and research related payments from pharmaceutical and medical device manufacturers to eligible physicians in 2014. Percentages of editors receiving payments and the magnitude of such payments were compared across journals and by specialty. Journal websites were also reviewed to determine if conflict of interest policies for editors were readily accessible.

    Results: Of 713 eligible editors, 361 (50.6%) received some (>$0) general payments in 2014, and 139 (19.5%) received research payments. The median general payment was $11 (£8; €9) (interquartile range $0-2923) and the median research payment was $0 ($0-0). The mean general payment was $28 136 (SD $415 045), and the mean research payment was $37 963 (SD $175 239). The highest median general payments were received by journal editors from endocrinology ($7207, $0-85 816), cardiology ($2664, $0-12 912), gastroenterology ($696, $0-20 002), rheumatology ($515, $0-14 280), and urology ($480, $90-669). For high impact general medicine journals, median payments were $0 ($0-14). A review of the 52 journal websites revealed that editor conflict of interest policies were readily accessible (ie, within five minutes) for 17/52 (32.7%) of journals.

    Conclusions: Industry payments to journal editors are common and often large, particularly for certain subspecialties. Journals should consider the potential impact of such payments on public trust in published research.

    http://www.bmj.com/content/359/bmj.j4619

    BMJ 2017;359:j4619

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