Further information: Evaluation of Patients for Noncardiac Surgery (see p2487) from Cardiovascular Medicine, 3rd Edn*

ESC Clinical Practice Guidelines for Pre-operative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-Cardiac Surgery (2009) (ESC website accessed 08/28/09)   Full text

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Further information: Infective Endocarditis (see p443) from Cardiovascular Medicine, 3rd Edn*

ESC Clinical Practice Guidelines on Prevention, Diagnosis and Treatment of Infective Endocarditis (2009) (ESC website accessed 08/28/09)   Full text

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Further information: Pulmonary Arterial Hypertension (see p2203) from Cardiovascular Medicine, 3rd Edn*ESC Clinical Practice Guidelines on Diagnosis and Treatment of Pulmonary Hypertension (2009) (Eur Heart J; doi:10.1093/eurheartj/ehp297)   Full text

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Further information: Aortic Valve Disease (see p381), Mitral Valve Diseases (see p397), and Echocardiographic Assessment of Valvular Heart Disease (see p487) from Cardiovascular Medicine, 3rd Edn*

Acute valvular regurgitation is sometimes difficult to diagnose and information on the medical management of patients is limited because there are no randomized, clinical trials to provide guidance. Although acute regurgitation can occur in any valve – i.e. aortic, mitral, pulmonic, or tricuspid – it has greater clinical impact and is more common in valves of the left side of the heart. The mitral and aortic valves are the subject of a recent article by Stout and Verrier [1].

When the acute aortic regurgitation is severe, medical therapy is often insufficient, and therefore, a patient presenting with severe acute valvular regurgitation often has a surgical emergency. It is critical that an immediate and correct diagnosis be made, although it is not uncommon for acute valvular regurgitation to be misdiagnosed as chronic. The majority of patients with severe acute aortic or mitral valve regurgitation present with symptoms of shock, such as weakness, dizziness, an altered mental state, dyspnea and hemodynamic instability. However, there are differences in acute aortic and mitral valve regurgitation that must be detected, and patients with chronic aortic or mitral valve regurgitation may present with symptoms similar to acute regurgitation. Therefore, physical examination needs to be enhanced by other diagnostic testing, especially emergent echocardiography with Doppler, in order to reach a correct diagnosis.

[1] Stout DK, Verrier ED. Acute valvular regurgitation. Circulation 2009;119:3232-3241

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Further information: Medical Treatment of Unstable Angina, Acute Non–ST-Elevation Myocardial Infarction, and Coronary Artery Spasm (see p937) and Percutaneous Coronary Intervention for Unstable Coronary Artery Disease (see p1005) from Cardiovascular Medicine, 3rd Edn*

In 2007, Eisenstein et al published “Clopidogrel Use and Long-Term Clinical Outcomes after Drug-Eluting Stent Implantation,” [1] in which the authors concluded that the use of clopidogrel reduced the risk of death or myocardial infarction (MI) in patients who had undergone percutaneous coronary intervention (PCI) and received a drug-eluting stent (DES). In addition to other studies on the use of antiplatelet therapy after PCI, the results of CURRENT-OASIS 7 should be available for presentation at the Scientific Sessions of the American Heart Association slated for November 14-17, 2009, and may define optimum dosing regimens for the use of clopidogrel. However, the use of clopidogrel in combination with a proton pump inhibitor has come under scrutiny, and at the Scientific Sessions of the American Heart Association held November 10–14, 2008, two studies [2,3] reported reduced effectiveness of clopidogrel when used in conjunction with a proton pump inhibitor. More recently, Ho et al [4] conducted a retrospective cohort study of 8205 acute coronary syndromes (ACS) patients after their discharge from 127 VA hospitals who were taking clopidogrel with or without a proton-pump inhibitor (PPI). Main outcome measures were all-cause mortality and/or rehospitalization for ACS. Of the 8205 total patients studied after discharge who were on clopidogrel, 5244 were also prescribed PPI while 2961 patients were not.

Death or hospitalization for ACS occurred in 1561 patients taking clopidogrel with PPI and in 615 patients taking only clopidogrel. Similar statistics from the paper showing adverse results when clopidogrel and PPI were used together were the result of multivariable analyses and a nested case-control study. In May 2009, the European Medicines Agency (EMEA) published an article titled, “Public statement on possible interaction between clopidogrel and proton pump inhibitors” [5]. The statement was written to reinforce the concerns as reported in studies, such as the aforementioned JAMA paper, suggesting the possibility of significant interactions that might occur between the combined use of clopidogrel and PPI that rendered clopidogrel less effective and placed patients at increased risk of thrombotic events, including MI. The resulting controversy seems to suggest that additional studies need to be conducted on the interaction between the combined use of clopidogrel and PPI in patients being treated for ACS

[1] Eisenstein EL, Anstrom KJ, Kong DF, et al. Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation. JAMA 2007;297:159-168
[2] Aubert RE, Epstein RS, Teagarden JR, et al. Proton pump prohibitors effect on clopidogrel effectiveness: The medco outcomes study. Circulation 2008; 118(suppl 1):3998a
[3] Dunn SP, Macauley TE, Brennan DM, et al. Baseline proton pump inhibitor use is associated with increased cardiovascular events with and without use of clopidogrel in the CREDO trial. Circulation 2008; 118(suppl 1):3999a
[4] Ho M, Maddox TM, Wang L, et al. Risk of adverse outcomes associated with concomitant use of clopidogrel and proton pump inhibitors following acute coronary syndrome. JAMA 2009;301:937-944
[5] Wathion N. European Medicines Agency. Public statement on possible interaction between clopidogrel and proton pump inhibitors. EMEA/328956/2009. May 2009 London

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Further information: Percutaneous Coronary Intervention for Acute Myocardial Infarction (see p1021) and Drug-Eluting Coronary Stents (see p1031) from Cardiovascular Medicine, 3rd Edn*

The authors of the current study [1] compared by meta-analyses the use of drug-eluting stents (DES) with bare metal stents (BMS) in randomized controlled trials (RCT), where controls were in place, and in observational or “real world” studies, where DES were used “off-label”.

A total of 22 RCTs with enrollment of 9470 patients and 34 observational studies that included data from 182,901 patients were analyzed. The primary end points for the analyses were all-cause death, myocardial infarction (MI), and target vessel revascularization (TVR). For RCTs, all studies that met the inclusion/exclusion criteria were included, as was the case for observational studies. However, there were studies within the observational group that, because of their nature, required separate analyses.

After the systematic reviews and meta-analyses of DES vs. BMS were completed, the authors determined that in RCTs, there was no detectable difference in death or MI in either off-label or on-label use, but treatment with DES was associated with a 55% reduction in the need to revascularize the target lesion. In observational studies, nonrandomized use of DES resulted in a 22% reduction in all-cause mortality and a 13% reduction in MI, as well as a 55% reduction in TVR. Thus, the data indicate that use of DES are safe in both on-label use and off-label use and that the DES appear to reduce the need to revascularize the target lesion at a later date.

[1] Kirtane AJ, Gupta A, Iyengar S, et al. Safety and efficacy of drug-eluting and bare-metal stents: comprehensive meta-analysis of randomized trials and observational studies. Circulation 2009;119:3198-3206

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Further information: Coronary Artery Bypass Surgery and Percutaneous Coronary Revascularization: Impact on Morbidity and Mortality in Patients with Coronary Artery Disease (see p1073) from Cardiovascular Medicine, 3rd Edn*

This article reports the result of the authors’ intent to pool data for analysis of the effect of patient characteristics on the outcome of randomized trials conducted to compare coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) in patients with multivessel coronary artery disease (CAD) [1]. Ten trials were selected, thus making data on 7812 patients available. The trials were all conducted prior to the use of drug-eluting stents, and of the ten, six of the trials used balloon angioplasty and four used bare-metal stents.

The analysis of data indicated that patient characteristics having the most significant effect on outcome were diabetes and the age of patient. The median follow-up was 5.9 years, and in patients with diabetes who were 65 years of age or older, the pooled data showed that mortality was lower in patients receiving CABG, but treatment effect did not prove to be altered by other patient characteristics, including the number of diseased vessels. Therefore, since long-term mortality proved to be similar with either CABG or PCI, except in diabetic patients and patients older than 65 years of age, the choice of treatment should be influenced by patient preference.

[1] Hlatky MA, Boothroyd DB, Bravata DM, et al. Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: A collaborative analysis of individual patient data from ten randomized trials.
Lancet 2009; 373:1190-97

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