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VO L . 6 , N O. 2 T he Leading Inde p endent Ne wspaper for the Cardiologist F E B R UA RY 2 0 0 8
INSIDE
New Data Drive
Guideline Changes
V IVIAN E. L EE /E LSEVIER G LOBAL M EDICAL N EWS
For PCI and STEMI
Rapid reperfusion is ultimate STEMI goal.
A Shocking BY ROBERT FINN The STEMI updates, for ex-
Omission San Francisco Bureau ample, reiterate that the overar-
Few physicians talk about ching goal of treatment remains
T
ICD shutoff at end of life. he pace of research in car- rapid reperfusion. But they state
diology is proceeding so that, with the exception of as-
PAGE 19 rapidly that important pirin, NSAIDs and cyclooxyge-
The ENHANCE results were “disappointing, but not surprising” changes have just been issued to nase-2 inhibitors should be dis-
because of the study’s design, according to Dr. Michael Davidson. two guidelines initially promul- continued immediately. And
Marrow Victory gated in the not-so-distant past. β-blockers should not be admin-
Bone marrow cells improved Announced in December, the istered to patients in certain high-
W
hen results from the failed to slow atherosclerotic pro- each included significant recom- This dual antiplatelet therapy is
controversial study gression any better than an iden- mendations for practice changes. See Guideline page 8
that assessed ezetim- tical dosage of simvastatin alone,
ibe’s ability to slow atheroscle- Dr. Christie M. Ballantyne, pro-
rotic progression when added to
a high-dose statin regimen were
fessor of medicine at Baylor Col-
lege of Medicine, Houston, and Calcium Supplements Up
reported via a press release on chief of the section of athero-
Jan. 14, cardiologists split on sclerosis and vascular medicine Contrasting MI Risk in Older Women
whether the findings signaled a told CARDIOLOGY NEWS. “One ex- Positions
flawed study or a flawed drug. planation is that there are differ- Cardiologists push the FDA BY DAMIAN MCNAMARA cause so many women are pre-
The results were “disappoint- ences in the drug effects [be- Miami Bureau scribed calcium supplements,”
to reconsider its black box
ing, but not surprising because I tween ezetimibe and statins] that Dr. Rita F. Redberg said in an in-
warning on contrast agents.
had a lot of concern that this
was not the right patient popula-
tion and not the right methodol-
go beyond their reduction of
LDL. Another is that the trial
had technical issues.”
PAGE 28 C alcium supplementation sig-
nificantly increased the risk
of a myocardial infarction among
terview. “I would not recom-
mend calcium supplementation
based on this finding. This raises
ogy,” Dr. Michael Davidson, pro- See Ezetimibe page 20 healthy, postmenopausal women, enough concern. With any sup-
fessor of medicine and director of compared with placebo, in a sec- plement, you have to show evi-
preventive cardiology at the Uni- VITAL SIGNS ondary analysis of an osteoporo- dence of benefit without risk,”
versity of Chicago, told CARDI- sis study. said Dr. Redberg, who was not
OLOGY NEWS. Physicians should consider this involved in the study.
National Health Expenditures
But other experts tied the increased cardiovascular risk The HDL/LDL cholesterol ra-
study’s negative result to limita- As Percentage of Gross Domestic Product against other clinical benefits of tios improved among the 732
tions of ezetimibe itself. 15.8% 15.9% 15.9% 16.0% calcium supplementation in old- women who took daily calcium
“It appears that this method for er women until confirmatory supplementation, compared with
13.8%
lowering LDL cholesterol is not 12.3% studies can be completed, the au- the 739 participants who took
beneficial,” commented Dr. thors suggested. placebo. This suggests that a dif-
Steven Nissen, chairman of the 9.1% “It is an important finding be- See Supplements page 6
department of cardiovascular 7.2%
medicine at the Cleveland Clinic. CARDIOLOGY NEWS Presorted Standard
U.S. Postage
“I was always worried that LDL 5635 Fishers Lane, Suite 6000 PAID
E LSEVIER G LOBAL M EDICAL N EWS
Anticoagulation for DES a Priority shock, or who are at risk for heart failure
or shock,” said Dr. Antman of Harvard Highlights of the
Guideline from page 1 Medical School, Boston. “There is infor-
mation about facilitated PCI indicating PCI Update
so important that physicians should take The focused update strategy was devel- that a strategy of a full-dose fibrinolytic
into account the possibility that the patient
may later need medical procedures that
would require that antiplatelet therapy be
oped by ACC/AHA Task Force on Prac-
tice Guidelines as a way to speed up the
often years-long process of developing
followed by immediate routine PCI is not
recommended anymore.”
On the other hand, “It’s not unreason-
I mportant aspects of the PCI fo-
cused update include:
씰 After implantation of a DES, dual
discontinued. Bare-metal stents or balloon comprehensive new guidelines on the ba- able to use a strategy of preparatory phar- antiplatelet therapy comprising clopi-
angioplasty with provisional stent im- sis of full literature reviews. Twice a year macological regimen other than a full- dogrel and aspirin is required for at
plantation should be considered for those or more experts are polled, and if there is dose fibrinolytic and routine immediate least 1 year and possibly longer.
patients. a consensus that data from late-breaking PCI in certain situations where the patient 씰 If the patient is likely to face addi-
The STEMI update was a joint effort of clinical trials warrant an update, one can is at risk, PCI cannot be performed with- tional surgery requiring interruption
the American College of Cardiology and be prepared relatively quickly. (See side- in 90 minutes, and bleeding risk is low.” of dual antiplatelet therapy, a bare-
the American Heart Association and ap- bars for update highlights.) Dr. Antman said that he has not heard metal stent (BMS) or balloon angio-
peared in the Jan. 15, 2008 issues of Circu- According to Dr. Elliott M. Antman, any significant criticisms of the new STE- plasty with provisional stent implan-
lation and the Journal of the American Col- cochair of the STEMI update committee MI guidelines, and that most will not be tation should be considered instead
lege of Cardiology. The PCI update was a and chair of the 2004 writing committee, difficult to implement. “Physicians un- of a DES.
joint effort of the ACC, the AHA, and the new research suggests several important derstand the importance of responding to 씰 Between 24 hours and 28 days af-
Society for Cardiovascular Angiography changes in the management of this most evidence,” he said. “These are strategies ter a heart attack, PCI is not recom-
and Interventions (SCAI) and appeared in critical type of heart attack. Among at least that are a matter of just organizing sys- mended in patients with one- or
Circulation, the Journal of the American 15 guideline modifications or additions, he tems of care for patients with STEMI. We two-vessel disease and a totally oc-
College of Cardiology, and Catheteriza- highlighted several in an interview. would hope that physicians would meet as cluded coronary artery if they are
tion and Cardiovascular Interventions. The “We indicate that physicians should not a team in their local hospitals and local sys- not hemodynamically and electrical-
updates are available online at www.amer- routinely administer intravenous β-block- tems and consider how they are going to ly stable and have no ongoing or eas-
icanheart.org and www.acc.org. ers acutely to patients with heart failure or approach the STEMI patients in the future ily provoked chest pain.
with this new information in mind.” 씰 On the other hand, physicians
The recommendation for prehospital might consider PCI for those pa-
Highlights of STEMI Focused Update 12-lead ECG may be one of the most
challenging to implement, since many
tients or patients who respond favor-
ably to initial fibrinolysis treatment