LATEST IN CORONORY HEART DISEASE

CORONARY HEART DISEASE
The POISE trial published in 2008 raised important concerns about the use of beta blockers in patients undergoing noncardiac surgery. A subsequent meta-analysis of 33 randomized trials of beta blocker therapy evaluated outcomes in over 12,000 patients, of whom over 8000 were from POISE . Beta blocker therapy was not associated with a significant reduction in the risk of either all-cause or cardiovascular mortality.Patients with heterozygous familial hypercholesterolemia have a poor prognosis and aggressive lipid lowering therapy is indicated in most. Although the combination of ezetimibe plus simvastatin lowers low density lipoprotein cholesterol to a greater extent than monotherapy with simvastatin and has been shown to be safe , one study of adolescents with heterozygous FH did not demonstrate that the combination improved arterial intima-media thickness to a greater degree than a similar dose of simvastatin monotherapy during up to 53 weeks of therapy .Statins have many (pleiotropic) effects which may be both clinically important and independent of their well established low density lipoprotein cholesterol lowering ability. In a trial of 60 patients with dyslipidemia, who were randomly assigned to high dose simvastatin or a combination of ezetimibe with lower doze simvastatin, both groups had similar 35 to 40 percent reductions in LDL-C and serum CRP. However, a significant improvement in flow-mediated dilatation was only seen in the high-dose simvastatin group .While no randomized trial data are available to compare open surgery with endovascular repair of the thoracic aorta (TEVAR), recent observational studies and one meta-analysis support equivalent or better outcomes with the latter .Evidence suggests that the oral antiplatelet agent prasugrel will be an important addition to the long term management of patients who have sustained an acute non-ST elevation myocardial infarction. Compared to clopidogrel, death rates after a first ischemic event and recurrent events are less with prasugrel .The issue of whether the use of clopidogrel within five days of coronary artery bypass surgery increase the risk of important perioperative bleeding has been controversial. Recent publications do not definitively answer this question.Free wall rupture after acute myocardial infarction has a poor prognosis. One study suggests that the incidence of this complication has fallen over the past forty years from about four to two percent and that the associated mortality has also fallen . A progressive increase in the use of reperfusion therapies and medical therapies such as beta blockers, angiotensin-converting enzyme inhibitors and aspirin, as well as better control of blood pressure with each subsequent decade were also noted.The JUPITER trial, a randomized trial of rosuvastatin therapy in healthy men (aged 50 and older) and women (aged 60 and older) with an LDL-C level below 130 mg/dL (3.4 mmol/L) and a C-reactive protein (CRP) level of at least 2.0 mg/L, found a large reduction in the primary composite cardiovascular endpoint (hazard ratio 0.56) . The magnitude of this reduction was greater than might have been expected from prior trials and may have been overestimated when the trial was stopped early for benefit. Although some have interpreted this trial as showing particular benefit in patients with an elevated CRP level, the design did not allow evaluation of whether a similar relative benefit might have been seen in patients with lower CRP levels or whether measuring CRP added information beyond standard risk calculation. In primary prevention, we suggest first calculating a patient's baseline risk for cardiovascular events and then treating with statin therapy in patients for whom a 20 to 30 percent relative reduction in events would translate into an absolute risk reduction large enough to be of value to the patients.In a study of 13,636 patients prescribed clopidogrel following acute myocardial infarction, investigators identified 734 cases readmitted with myocardial infarction and 2057 controls. On multivariate analysis, current use of proton pump inhibitors (PPI) was associated with a significantly increased risk of reinfarction . This finding was observed in other preliminary clinical studies. In addition reports of decreased effectiveness of clopidogrel in inhibiting platelet function in the presence of PPI have been observed . Based upon these findings, we no longer recommend PPI therapy for all patients on clopidogrel and aspirin.