Heart stents and cvd news

Stent Thrombosis the Deadliest of DES Complications
Here's the first two paragraphs
Early stent thrombosis may be the deadliest among the ischemic and hemorrhagic events that can occur after getting a drug-eluting stent (DES), the ADAPT-DES study suggests.
All-cause mortality at 2 years was most common in patients with stent thrombosis (27.2% versus 2.7% for those with no events, hazard ratio [HR] 11.37, 95% CI 7.61-16.98), Sorin J. Brener, MD, of New York Methodist Hospital in New York City, and colleagues found.

Vulnerable Plaque "Hype-othesis" This is one powerful article by Larry Husten, published February 24, 2016.  Here are some of what it says, the Nissen referred to is Steven Nissen M.D. of the Cleveland Clinic
' "The problem isn't because of the deficiencies of any one technology, said Nissen. Instead, there's "something wrong with the whole notion." The problem is that the "exact characteristics of vulnerable plaque remain uncertain" and that vulnerability "is diffuse and global, not local."
"Even if we knew what to look for, we would have to scan every branch of every vessel," said Nissen. But the available evidence now suggests that the type of lesions once thought to be highly specific for heart attacks are, in fact, everywhere, and ruptured plaques are ubiquitous.
This is why stenting individual coronary lesions doesn't improve outcomes, he argued. By contrast, systemic therapies, like statins and antiplatelets, can improve outcomes.
Nissen proposed a simple explanation for why there has been so much attention paid to vulnerable plaque: "there are a lot of people looking for reasons to put a stent in a patient." '

The 2007 COURAGE study
This is a quote from the conclusions:
As an initial management strategy in patients with stable coronary artery disease,
PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy.


Still true today, May 2015, Patients Often Misinformed about PCI Pros and Cons
And as of November 2015 Courage at 15: Still no edge for stenting

There is no informed consent in hospitals, that's the sum of this article.  Doctors don't have to describe the risks when they suggest a procedure.

ICD deaths may be higher than realized.  Sudden Death in Patients With Cardiac Implantable Electronic Devices.  That consent form you signed before your cardiac procedure is a license to them to implant an ICD, you have no choice.  Yeah, the doctors will assure you it was necessary.
JAMA Intern Med. 2015 Aug;175(8):1342-50. doi: 10.1001/jamainternmed.2015.2641.

Stress Tests may not be useful in many situations  2016 article

Here is a study that basically says this device won't make things worse Diamondback 360® Micro Crown OAS  It's described as a sander for severely calcified lesions, used before stenting.

February 2015 From the CREDO-Kyoto study.   At 5 years, patients with and without diabetes who had three-vessel and/or left main disease had better rates of cardiac death, MI and coronary revascularization after CABG compared with PCI.

Update

2017 You need to know which contrast agent is being used if you have an MRI.  Here is a quote from this news story   "Sammy Almashat, MD, MPH, a research associate for the consumer group Public Citizen, argued that if they knew the evidence regarding the differences between the two classes of contrast agents, "virtually all patients" would choose the macrocyclics. He, like Brent and Vaughan, argued for adopting the the European Medicines Agency's approach. That agency suspended certain GBCAs in July."


2017 Another article emphasizing that coronary CTA is much more meaningful for diagnosing occlusive coronary stenosis.

2017 Changing management of suspected angina and CAD  The article speaks of increased emphasis on coronary CTA

The stress test is becoming obsolete.  Here is an article about it The Death of Stress Test and the Rise of the Coronary CT Angiogram

Removed news about bioresorbable stents.  They have proved to be a bust.

DAPT risk calculator
DAPT score may help determine which patients benefit from extended use.  2017 article

No Lives Saved With Extended Plavix Use accurate as of November 2015
Here's a complication of PCI, chances are the doctor proposing the procedure won't mention it to you. During PCI, myocardial injury on a microvascular level is a frequent occurrence, and it begins a cascade of biochemical processes that culminate in an inflammatory and thrombotic environment. 

and another threat if you have DES stents neoatherosclerosis-may-cause-late-failure-in-des

Post PCI you may develop atrial fibrillation.  Rarely, but sometimes after PCI a person can have a devastating stroke.

Optical Coherence Tomography -  OCT definition according to this description the images of 10X better than with IVUS.  Using it may reduce unnecessary stenting.

Here is a database to check for drug interactions, statins and some heart drugs can make muscle injury from statins more probable. Medscape Drug Interaction Checker

FFR and IVUS may not really provide patient benefit.  Here's the quote:
This is from http://www.medpagetoday.com/Cardiology/Strokes/46554


Modalities Might Not Enhance Survival After PCI
Using fractional flow reserve (FFR) or intravascular ultrasound to guide percutaneous coronary intervention (PCI) didn't result in longer survival, a registry study suggested.
On the basis of the FAME and FAME 2 trials, the use of FFR to guide PCI has been incorporated into practice guidelines, but neither trial was powered for effects on mortality.
To look at potential effects on survival, Pascal Meier, MD, of University College London Hospital, and colleagues analyzed data from the pan-London PCI registry, which includes patients who underwent PCI at one of the eight primary PCI centers in the London area. The analysis -- reported online in JAMA Internal Medicine -- included 41,688 patients who underwent an elective or urgent procedure from January 2004 through July 2011 (after excluding those with ST-segment elevation myocardial infarction [STEMI]).
Overall, 6.6% of the procedures involved FFR guidance, 4.4% involved intravascular ultrasound guidance, and the rest were done with angiography alone.
All-cause mortality was tracked for a median of 3.3 years. The use of FFR was not associated with the risk of dying (HR 0.88, 95% CI 0.67-1.16) and intravascular ultrasound was associated with increase in the mortality risk (HR 1.39, 95% CI 1.09-1.78). In a propensity-matched analysis, however, intravascular ultrasound was no longer associated with increased mortality (HR 1.33, 95% CI 0.85-2.09).
The average number of stents implanted -- a secondary outcome -- was lower in the FFR group (1.1) compared with the intravascular ultrasound group (1.6) and the angiography group (1.7). In-hospital mortality also was lower in the FFR group compared with angiography alone (0.2% versus 0.5%, P=0.03), "but this was a secondary endpoint and was based on few events," the authors noted.
"These data are in line with results from previous randomized trials suggesting that FFR-guided PCI may have a stent-sparing effect, but this did not translate into a survival benefit," they wrote.
"It is perhaps too optimistic to expect a survival advantage from the use of a purely diagnostic procedure," they added. "This is particularly true in patients with stable coronary artery disease, for whom PCI has never demonstrated a clear survival benefit."














Radial Access 1st Choice for PCI, ESC Says


Radial access should be the initial choice for percutaneous coronary intervention (PCI), saving femoral access for bailout, according to a consensus document from the European Society of Cardiology (ESC).
The radial approach leads to less bleeding and improved survival, especially in ST-elevation myocardial infarction (STEMI) patients, according to Martial Harmon, MD, of the University of Caen in Normandy, France, and co-authors.
However, it is still necessary for interventional cardiologists to maintain proficiency in the femoral approach, "which is indispensable in a variety of procedures, like intra-aortic counter pulsation and complex structural heart disease procedures ... as well as when radial access fails," they wrote online inEuroIntervention....  The article continues on medpage.
Your cardiologist may talk a good game, have given public lectures on using radial access but that doesn't mean he or she practices what she preaches.  Ask your cardiologist if this is the way he intends to proceed.


Here's a commentary about why the phrase "unstable angina" will no longer be used.
unstable-angina-we-hardly-knew-ye September 5, 2012 NSTEMI replaces the phrase unstable angina
Here's a quote: patients with acute chest pain, no ST-segment elevation, and a discernable rise in hs cardiac troponin have NSTEMI. Patients with acute chest pain, no ST-segment elevation, and no rise in their hs cardiac troponin level must have a noncardiac cause for their pain. 

August 28, 2012
Guidewire technology improves heart patient care 
My comment: Don't think because you are at a large medical center in which this technology is available that it will be used on you. Be sure to ask.


NIH article about stress tests   It explains the Bruce protocol.

Stress Echo in Asymptomatic Revascularized Patients Not Useful : Cardiology News
Here's the first paragraph:
Routine exercise stress echocardiography may not be warranted in asymptomatic patients after coronary revascularization because even though it may identify those at high risk, this does not improve patient outcomes, according to a report published online May 14, 2012 in Archives of Internal Medicine. 

Newer Lipid Markers Useless for CVD Risk Prediction : Cardiology News
Here's the summary from the article:
Major Finding: Replacing total and HDL cholesterol measures with any other "emerging" lipid markers did not improve CVD risk prediction, and adding such markers to conventional methods of risk assessment improved prediction only slightly.



Plavix generic since mid May 2012

April 27 2012
Alternative Dosing Regimens Work Around Statin Myalgia : Cardiology News
A warning from the article "It must be emphasized, however, that none of the alternative dosing regimens have proved to reduce cardiovascular events. The issue hasn’t been studied."
another quote from the article "Alternate-day dosing as an answer for statin-intolerant patients only can be carried out effectively with rosuvastatin or atorvastatin, drugs with half-lives markedly longer than the other statins. " 


March 2012
Questions to Ask Your Interventional Cardiologist About Angioplasty and Stents My mistake was to ask no questions. With hindsight the questions are obvious, but I failed to ask them.  The questions are:
Do I have a life-threatening blockage?
How will I know if I have a life-threatening blockage?
What will happen if I dont undergo angioplasty and stenting? 
Would medication alone work just as well for me?
What should I do if I have more questions? 
Click on the link for discussions for these five questions.
 
February 23, 2012
Behavioral intervention helped increase physical activity after PCI
If you encourage patients to improve their physical activity, many more will exercise and benefit from the activity.  Patients in the intervention group suffered from less depression after 12 months compared to the control group.  Two thirds of the people chose walking as their form of exercise.

 Ties between companies and cardiac societies

Before getting a stent find out what medications will be prescribed for you afterwards. If you can't afford the medications, you had better have a serious conversation with the people who are suggesting a stent would be a good remedy for your problems.

FDA medical devices database  This is where to get information on the stent you will have inserted or the one you are stuck with.

More research needed to evaluate role of vitamin D in reducing CVD
Vitamin D may protect against stroke, cognitive impairment
This study did not measure blood levels of Vitamin D. It relied on a food frequency questionnaire of 26,309 people.

Drug-eluting stent use linked to lower mortality, repeat revascularization rates in elderly patients
In a study of more than 400,000 patients aged at least 65 years, drug-eluting stent use declined in patients aged 85 years and older, although drug-eluting stents were associated with lower adverse event rates compared with bare metal stents, according to study results.

Continuous dose of nitroglycerin increases severity of heart attacks, study shows

April 4, 2012
A link between atherosclerosis and autoimmunity
The long arm of the dendritic cell: A link between atherosclerosis and autoimmunity

Late stent thrombosis is a condition that can kill you, years after a DES stent is inserted.

An interesting blog The Skeptical Cardiologist

Definitions (work in progress)

AE adverse event
ACS acute coronary syndrome
ASA aspirin
BORG scale of perceived exertion
DCB drug coated balloon
FFR fractional flow reserve
ICD implantable cardioverter-defibrillator
ISA Incomplete stent apposition or stent malapposition is the lack of contact between stent struts and the underlying arterial wall.
MACE major adverse cardiac event
MET Metabolic Equivalent for Task
MR mitral regurgitation
OCT Optical Coherence Tomography
NOAC New Oral Anticoagulant
PAH pulmonary arterial hypertension Pulmonary hypertension is a type of high blood pressure that affects the arteries in the lungs and the right side of the heart.
TLR target lesion revascularization
stenticide killed by your stent
CTA coronary computed tomography angiogram, a useful description is on the Cleveland Clinic Site. 
PAC Premature atrial contraction
PCI percutaneous coronary intervention
PCB paclitaxel coated balloon
PICVA Percutaneous In-Situ Coronary Venous Arterialization  This definition is from medhelp.org
     "the way is works is to use the coronary vein that runs alongside the artery to bypass the blockage"
RCT Randomized Control Trial
PVC premature ventricular contraction
VCI vascular cognitive impairment VCI is defined by evidence of clinical stroke or subclinical vascular brain injury and cognitive impairment affecting at least 1 cognitive domain.  definition taken from the article Risk Assessment and Management of Vascular Cognitive Impairment
DAPT dual antiplatelet therapy
thienopyridine One of a group of compounds, including ticlopidine and clopidogrel, which prevent platelet aggregation (definition from Drugs.com)

Autobiographical Notes

I tried Crestor for two months.  I developed a severe pain in the achilles tendon of my right leg.  I switched back to simvastatin.

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