A-fib
Hazard ratio of rate vs rhythm control in patients with atrial fibrillation (mortality)
What is 1 (no difference~~~actually 0.99-1.34, p =0.08).
No significant difference between groups
-Trend favoured rate control, p=0.08
Subgroup analysis showing higher mortality for
-Rhythm control in elderly
-Rhythm control in CAD
-Rhythm control in CCF
Recommended anticoagulation for all patients, regardless of control
In one study digoxin reduces the rates of hospital admission in patients of heart failure by what percent (within 10%).
What is 6%.
-mortality was unaffected! (34% dig, 35% placebo, p=0.80)
- There were 6 percent fewer hospitalizations overall in that group than in the placebo group, and fewer patients were hospitalized for worsening heart failure (26.8 percent vs. 34.7 percent; risk ratio, 0.72; 95 percent confidence interval, 0.66 to 0.79; P<0.001).
What major disease process is indication for CABG in patients with mutlivessel CAD?
FREEDOM TRIAL 2012 NEJM
-RCT (1900 patients)
PCI V. CABG in Diabetics with mutlivessel disease
-Significant decrease in composite endpoint of Death/MI/Stroke at 5y with CABG (18.7%) V. PCI 26.6%
-Above endpoint more frequent in CABG (42 patients) than CABG (26 patients) at 30 days
-Significant decrease in all cause morality with CABG (10.9%) V. PCI (16.3%) at 5y
-Significant decrease in MI with CABG (6.0%) V. PCI (13.9%)
-Significantly decrease in Stroke with PCI (2.4%) V. CABG (5.2%)
-At 30 days no significant difference in rates of major adverse cardiovascular or cerebrovascular event
-At 1 year significant increase in rates of major adverse cardiovascular and cerebrovascular events with PCI (16.8%) V. 11.8%. Most of this consitutes repeat revascularisation (12.6% V 4.8%
respectively)
-Benefit to CABG demonstrated across all complexities of coronary artery stenosis anatomy as measured by SYNTAX score
-No significant difference between outcomes in subanalysis of paclitaxel V. sacrolimus eluting stents
Overall effect - diabetics requiring revascularisation of >1 lesion >69% stenosis in a major epicardial vessel require CABG
The target rate control for patients with atrial fibrillation.
Lenient Versus Strict Rate Control in Patients With Atrial Fibrillation AFFIRM (NEJM 2010)
Lenient (resting HR<110) vs. strict (resting HR<80; mod. exercise HR<110)
-Lenient rate control non-inferior to strict control (p<0.001)
-Components of outcome similar in 2 groups
-Decreased clinic visits for lenient control
This beta-blocker of choice in patients with chronic heart failure.
What is carvedilol.
COMET RCT. Lancet 2003
Carvedilol superior to metoprolol reducing mortality in NYHA II+ & EF <35%
Significant reduction for carvedilol (vs. metoprolol) for:
-The all-cause mortality was 34% (512 of 1511) for carvedilol and 40% (600 of 1518) for metoprolol (hazard ratio 0.83 [95% CI 0.74-0.93], p=0.0017)
No significant difference in:
-Composite of mortality or all-cause hospitalisation
-Side effects
The treatment of choice of 2 or 3 vessel CAD.
What is CABG
ASCERT TRAIL NEJM 2013
PCI vs. CABG in 2 or 3 vessel disease
-Huge retrospective study (189,793 patients) controlling for confounding
At 1 year
-No significant difference in ACM (RR 0.95)
At 4 years
-All-cause mortality lower for CABG (RR 0.79)
The which Medication was superior for anticoagulation of afib in ARISTOTLE TRIAL.
What is Apixiban.
ARISTOTLE NEJM 2011
Apixaban (vs Warfarin)
-Lower rates of stroke or systemic embolism
-Less bleeding
-Lower mortality
The rate of the primary outcome was 1.27% per year in the apixaban group, as compared with 1.60% per year in the warfarin group (hazard ratio with apixaban, 0.79; 95% confidence interval [CI], 0.66 to 0.95; P<0.001 for noninferiority; P=0.01 for superiority).
The rate of major bleeding was 2.13% per year in the apixaban group, as compared with 3.09% per year in the warfarin group (hazard ratio, 0.69; 95% CI, 0.60 to 0.80; P<0.001), and the rates of death from any cause were 3.52% and 3.94%, respectively (hazard ratio, 0.89; 95% CI, 0.80 to 0.99; P=0.047).
The rate of hemorrhagic stroke was 0.24% per year in the apixaban group, as compared with 0.47% per year in the warfarin group (hazard ratio, 0.51; 95% CI, 0.35 to 0.75; P<0.001).
ICD therapy decreases sudden cardiac death in patients with NYHA class II/III HF by what percent (within 5%).
Extra points for amiodarone reduction.
Amiodarone or an Implantable Cardioverter-Defibrillator for Congestive Heart Failure NEJM
-2521 patients
In patients with NYHA class II or III CHF and LVEF of 35 percent or less, amiodarone has no favorable effect on survival, whereas single-lead, shock-only ICD therapy reduces overall mortality by 23 percent.
Treatment length of DAPT for patients with coronary stents?
Plavix can be stopped at 6 months.
PRODIGY RCT (2012) showed that in patients with stent there was no difference in death, MI, CVA between 6 months of DAPT and 2 years of DAPT. Findings independent of stent type
Agrees with REAL-LATE and EXCELLENT trials
Aspirin continued 24 months