Warfarin plus Aspirin After Aortic Valve Prosthesis Placement?
An observational study suggests that the combination reduces mortality, at the cost of increased bleeding, when used in the 3 months after surgery.Patients receiving an aortic bioprosthesis have a low overall risk for thromboembolism, but controversy surrounds whether they benefit from anticoagulation in the first months after surgery. To address this issue, researchers used the Society of Thoracic Surgeons Adult Cardiac Surgery Database to compare the effectiveness of the early use of aspirin alone, aspirin plus warfarin, and warfarin alone.
A collaborative meta-analysis suggests that the effect is real but smaller than previously thought.In a recent meta-analysis of published cohort studies, job strain was associated with about a 40% increase in risk for coronary heart disease. However, these studies are susceptible to publication bias and limited by methodological idiosyncrasies. To minimize these shortcomings, investigators conducted a participant-level meta-analysis of 13 published and unpublished European studies including 197,473 individuals (mean age, 42; 49% women). The same validated model was used in all of the studies to assess baseline job strain.
The Latest and Greatest in Anticoagulation — Still Not a Good Idea After ACS
The newer oral anticoagulants are associated with increased rates of major bleeding that offset their antithrombotic benefit.The burgeoning use of new oral anticoagulants (e.g., dabigatran, rivaroxaban, apixaban) has rekindled interest in whether these agents, combined with standard antiplatelet therapy, could reduce thrombotic events after acute coronary syndromes (ACS). To synthesize the current evidence base, researchers performed a meta-analysis of seven trials in which 31,286 ACS patients were randomized to placebo or a new oral anticoagulant, either an anti-Xa or direct thrombin inhibitor. All patients also received antiplatelet therapy, and most received dual antiplatelet therapy with aspirin and a thienopyridine.
Reducing Co-pays for Cardiovascular Meds: More Bang for the Buck?
Cutting co-payments for statins and clopidogrel was associated with improvements in adherence and resource utilization but no change in overall spending.In a recent randomized trial, provision of evidence-based drug therapy after myocardial infarction at no cost to the patients, while failing to show benefit with regard to the primary composite endpoint, was associated with improvement in both adherence and vascular events (JW Cardiol Nov 14 2011). Now, the same research group has studied the effects of reducing co-payments for statins and clopidogrel on adherence, resource utilization, and events in 2830 employees of a large company as compared with 49,801 employees of companies that did not change their co-payment policies. Pharmacy and medical services claims data from 1 year before through 1 year after the change in co-payment policy were included in the analysis.
Do Patients' Stroke and Bleeding Risks Affect Apixaban's Advantage over Warfarin?
In an ARISTOTLE subanalysis, apixaban maintained its edge across the range of risk scores in patients with atrial fibrillation, but stronger confirmation is needed.
In the manufacturer-sponsored ARISTOTLE trial, apixaban outperformed warfarin for prevention of stroke or systemic embolism in 18,201 patients with atrial fibrillation (JW Cardiol Aug 29 2011). In a secondary analysis of the ARISTOTLE data, investigators have analyzed whether the results differed according to patients' scores on CHADS2 (available online), CHA2DS2VASc (available online), and HAS-BLED (available online), models commonly used to predict risks for stroke and bleeding.
Results of the RELAX-AHF trial are grounds for cautious optimism.
Persistently high hospitalization rates for acute heart failure (HF) have not given rise to effective new treatment strategies — although certainly not for lack of effort (JW Cardiol Jul 6 2011, Nov 14 2007, and Apr 4 2007). Serelaxin, a recombinant vasoactive peptide, was recently the subject of an intriguing phase II study (JW Cardiol Apr 1 2009). Now, the RELAX-AHF investigators present results of a manufacturer-sponsored, double-blinded study in 1161 patients with acute HF (mean age, 72; 55% with at least moderate left ventricular systolic dysfunction). All participants had dyspnea, radiographic pulmonary edema, elevated N-terminal-pro–B-type natriuretic peptide levels, and mild or moderate renal dysfunction. Exclusion criteria included systolic blood pressure 125 mm Hg, intravenous HF medications (aside from diuretics or nitrates), mechanical support, and recent acute coronary syndrome. Patients were randomized to continuous infusion of serelaxin (30 µg/kg/day) or placebo for 48 hours.
Both are reasonable long-term options.
Durability of the early benefits of endovascular repair compared with open repair of abdominal aortic aneurysm (AAA) remains hard to pin down (JW Cardiol May 19 2010). Now, researchers from 42 Veterans Affairs medical centers present long-term follow-up data (up to 9 years; mean, 5.2) from the OVER trial involving 881 patients with AAA (mean age, 70) who were candidates for both endovascular and open repair and were randomly assigned to one or the other (JW Cardiol Dec 9 2009).
Functional Capacity in Heart Failure: Which Test, and for What Purpose?
As a prognostic tool, the 6-minute walk test was as good as cardiopulmonary exercise testing, but neither added much to clinical and demographic markers.
An Encouraging Trial of a Mesh-Covered Stent in Primary Percutaneous Coronary Intervention
Compared with other devices, a bare-metal stent with a mesh covering to trap potentially embolic material was associated with a higher rate of ST-segment resolution.
In three separate phase II trials, a proprotein convertase subtilisin/kexin type 9 protease inhibitor achieves significant reductions in LDL levels compared with placebo or ezetimibe.
Statin therapy, which reduces both low-density lipoprotein cholesterol (LDL-C) levels and cardiovascular risk, is unsuccessful in many patients because of poor response, intolerance, allergy, or a combination of the three. Nonstatin agents also lower LDL-C levels; to date, however, few data support their effectiveness at improving clinical outcomes. Attention is now focused on investigational, fully human, monoclonal antibodies directed against proprotein convertase subtilisin/kexin type 9 (PCSK9), which impairs the liver's ability to remove LDL-C from the blood. In three manufacturer-sponsored phase II studies of a subcutaneously administered PCSK9 inhibitor, AMG 145, investigators assessed the potential of this approach in different patient cohorts with or at risk for cardiovascular disease.