CLINICAL
NEWS JOURNAL WRAP
Negative Statin
News May Be
Associated
with Early
Discontinuation,
CVD Mortality
Negative statin-related news stories
may be associated with early statin
discontinuation, and consequently may
increase the risk of myocardial infarction and cardiovascular disease mortality, according to a study published Dec.
1 in European Heart Journal.
The study looked at 674,900
Danish individuals ages 40 or older
who were using statins from 1995
to 2010. The authors identified
1,931 statin-related news stories
from Jan. 1995 and onwards in Danish newspapers, magazines, radio,
television, websites, and news agencies and assessed the effect on statin
discontinuation.
Results showed that individuals on
statins increased from <1% in 1995
to 11% in 2010, however, early statin
discontinuation increased from 6% in
1995 to 18% in 2010.
“We found that exposure to
negative news stories about statins
was linked to stopping statins early
and expl ained 2% of all heart attacks and 1% of all deaths from cardiovascular disease associated with
early discontinuation of statins,”
said Børge Nordestgaard, MD,
DMSc, chief physician at Copenhagen University Hospital in Denmark
and a co-author of the study.
“Although we cannot say for sure
that statin-related negative news
stories cause the early discontinuation
of statins, our findings suggest that
this is likely. And although this type
of association research cannot prove
causality, our data suggest that early
discontinuation of statins leads to
unnecessary heart attacks and deaths
from cardiovascular disease,” he adds.
The authors conclude that, moving
forward, their findings “suggest a
need for protocols aimed at increasing early adherence to stain therapy.”
Nielsen SF and Nordestgaard BG. EHJ.
2015;doi:10.1093/eurheartj/ehv641.
18
CardioSource WorldNews
Predicting Risk
in Pediatric and
Congenital Cardiac
Catheterization
In a recent paper published in Circulation, researchers developed and
validated a model to predict the occurrence of major adverse events after
cardiac catheterization for congenital
heart disease.
The researchers, led by Natalie
Jayaram, MD, MSB, aimed to apply
aspects of prior risk-standardization
methodology to develop a risk-standardization tool for the NCDR Improving Pediatric and Adult Congenital Treatment (IMPACT) Registry®.
The primary outcome was the
occurrence of a major adverse event:
cardiac arrest, tamponade, embolic
stroke or thrombus, device embolization, new requirement for dialysis,
event requiring extracorporeal membrane oxygenation, event requiring
left ventricular assist device unplanned cardiac or vascular surgery,
or subsequent cardiac catheterization. Death was only included in a
secondary analysis.
The study cohort included 19,608
cardiac catheterization procedures
performed at 58 U.S. centers between Jan. 2011, and March 2013. A
major cardiac adverse event occurred
in 378 (1.9%) patients. Cardiac
arrest was the most frequent, occurring in 158 (0.8%) procedures.
Neonates and infants were more
likely to experience an adverse event
compared with older children and
adults. Additionally, patients with
single-ventricle physiology and renal
insufficiency were more likely to
experience an adverse event compared with those that had a chronic
lung disease or genetic/congenital
condition. Patients requiring inotropic support before the case were
significantly more likely to experience an adverse event compared with
patients without inotropic needs.
The final model included eight
variables: age, single-ventricular
anatomy, renal insufficiency, procedure-type risk category, low systemic
arterial saturation, low mixed venous
saturation, elevated systemic ventricular end-diastolic pressure, and
elevated main pulmonary artery
systolic mean or pressure. The model
had good discrimination.
The authors write that “risk standardization will be of critical importance to institutions participating in
IMPACT, allowing them to compare
their outcomes with outcomes from
other U.S. centers after adjusting for
important patient characteristics, thus
identifying areas for improvement.
Ultimately, this could allow improved
care in the setting of catheterization
for congenital heart disease.”
Jayaram N, Beekman RH, Benson L, et al.
Circulation.2015;132:1863-70.
Which Stents Are
Safest in Surgery?
The safety of surgery in patients with
a coronary stent may depend on the
type of stent they have, according to a
study published Dec. 8 in Circulation:
Cardiovascular Quality and Outcomes.
Newer generation drug-eluting stents
(DES) and bare metal stents (BMS)
showed similar safety and were safer
than older generation DES.
A significant number of patients
receive coronary stents and then
need surgery. Risks during surgery
include ischemic and bleeding events.
The study authors, led by Francesco Saia, MD, examined patients
who had undergone PCI and stenting from the multicenter Registro
regionale AngiopLastiche dell’EmiliaRomana (REAL) Registry. A total of
13,128 patients underwent 17,226
surgical procedures. The cumulative
incidence of any surgery at 30 days,
6 months, 1 year, and 5 years was
3.6%, 9.4%, 14.3%, and 40.0%, respectively. At 30 days, 6 months and
1 year, the cumulative incidence of
noncardiac surgery was 1.3%, 5.1%,
and 9.1% and of cardiac surgery was
0.8%, 2.1%, and 2.6%, respectively.
The majority of the procedures were
noncardiac and about one-third were
done on an urgent basis.
BMS was more common in
patients who underwent surgery less
than 1 year from PCI, possibly reflecting the preference for BMS in patients
with planned surgery.
After 30 days post-surgery, 754
(4.4%) patients died, 438 (2.5%) ex-
perienced cardiac death, 256 (1.5%)
experienced nonfatal myocardial infarction (MI), and a serious bleeding
event (SBE) occurred in 1,099 (6.4%)
patients. Bleeding was fatal in 115
cases (10.5% of all SBE). Thrombotic
risk was independently associated
with periprocedural cardiac death/
MI, whereas surgical risk and bleeding risk were not. Stent thrombosis
risk was not independently associated with periprocedural SBE, but
operative risk category was a significant predictor of and bleeding risk
category was strongly related to SBE.
About 18% of the procedures had a
high cardiac risk and 25% had a high
bleeding risk.
There was an increased risk of
ischemic events with older DES. BMS
and newer DES were not significantly
different between 6 and 12 months
and over 12 months after PCI, but
newer DES appeared somewhat safer
between 0 and 180 days. Finally, the
researchers evaluated the overall effect of surgery and timing of surgery
with respect to PCI over cardiovascular mortality during follow-up and
found that surgery was associated
with an increased risk, which was
strongly influenced from the time
span between PCI and surgery.
According to the authors, the “study
confirms that careful cardiovascular
risk stratification, including assessment
of intrinsic surgical cardiac risk, bleeding risk, and thrombotic risk associated
with the stent, may be helpful in predicting the risk of periprocedu ral event
and should always be adopted.”
In a Journal Scan on ACC.org,
Prashant Vaishnava, MD, writes,
“Though limited by its retrospective
design, this is an important study,
which establishes that the incidence
of noncardiac surgery after PCI may
be higher than has traditionally
been reported. The authors re-focus
perioperative risk management to
an integrated approach that includes
consideration of ischemic risk,
thrombotic risk, and bleeding risk.
As the authors opine and as is accepted, there is a “need for dedicated pharmacological strategies aimed
at minimizing both ischemic and
bleeding risk in patients with coronary stents undergoing surgery.” ■
Saia F, Belotti LMB, Guastaroba
P, et al. Circ Cardiovasc Qual Outcomes. 2015;doi:10.1161/CIRCOUTCOMES.115.002155.
January 2016