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Preventive angioplasty can drastically reduce risks of myocardial infarction

 MD-FM Thursday 5 September, 2013




GENERIQUE

Carillon

 

Sarah:

MD-FM, Medical News from around the world with Peter Goodwin



P1

 

PETER:

Hello! And with me is Sarah Maxwell. First, from the annual meeting of the European Society of Cardiology, which took place in Amsterdam this week: For patients with acute ST-segment elevation myocardial infarction, using percutaneous coronary intervention to prevent infarction in arteries not yet occluded, as well as treating the culprit lesions, reduced the risk of fatal and non-fatal myocardial infarction by two-thirds



SARAH:

Yes, and the trial was actually stopped early when it appeared that preventive PCI lead to such a clear benefit. In this study, reported in the New England Journal of Medicine this week, 465 patients with STEMI who were having infarct-artery PCI were randomly assigned to either additional preventive PCI or no further angioplasty. They were deemed eligible if other arteries were more than 50 per cent or more blocked at catherisation. Principal study investigator, David Wald:

 

Wald-1: “We chose a 50 percent cut-off, of course the patients who got into the trial had a range of disease severity, it was a very inclusive trial. There was no age limit, there were very few exclusions, we tried to keep the trial simple and to reflect the sort of patients that we see on a day to day basis. So I think that the results of the trial are clear and can simply be applied to modern day practice.”

 

PETER:

So is this going to change current treatment guidelines for STEMI patients?

 

SARAH:

Well, here’s what Dr. Wald had to say:

 

Wald: “The current guidelines recommend limiting treatment to the infarct artery and doing no more, and they appropriately recommend that because, until now, there’s been a lack of evidence to guide doctors in a different direction. I think the primary trial provides new evidence that can help review those guidelines. It will be of course up to the doctors to look at the evidence and decide for themselves whether it changes their own practice. For me, who used to adopt the guideline approach, it’s changed my practice.” 

 

SARAH:

That was Dr. David Wald, from the Wolfson Institute of Preventive Medicine, in London.



P2

 

PETER:

Antiplatelet therapy was under scrutiny at the ESC: For patients with non-ST-elevation acute coronary syndrome, pre-treatment prior to catheterization with  prasugrel significantly increased the risk of life-threatening bleeding without reducing the risk of major ischemic events.

 

SARAH:

Yes: the ACCOAST trial compared the use of this P2Y-12 receptor antagonist at the time of PCI, or at the time of diagnosis and Professor Gilles Montalescot from Paris, presented the results in Amsterdam:



Montalescot: “This is the first modern study looking at pretreatment for Non-ST elevation ACS, high risk patients, all of them had high risks levels according to troponin and all of them had to go to the cath lab within 24 hours. We were surprised to see that there is absolutely no hint of a benefit of pretreatment. There is not a signal, anywhere, in favor or pretreatment. There is only harm, only bleeding,a two-fold increase in bleeding.”



PETER:

Ok this must have come as a bit of a shock considering that current guidelines recommend that P2Y-12 inhibitors be added as soon as possible before catheterization?

 

SARAH:

Yes, but Professor Montalescot said the recommendations rely on old data from less potent P2Y-12 antagonists that are now out-dated.



Montalescot: “It’s a shift in paradigm. We need to re-appraise what we have learned for pretreatment. This is clearly an important negative study. It is probably the most important negative study I have ever done. It’s going to change practice, it’s going to change guidelines.”



SARAH: Gilles Montalescot, from Hôpital Pitié-Salpêtrière in France.




P3

 

PETER:

Lastly from the ESC: For patients with acute idiopathic pericarditis, Colchicine, mostly used for treating gout, significantly reduced the rate of recurrence when it was added to conventional anti-inflammatory therapy. After a three-month treatment period, only 17 per cent of patients on colchicine developed incessant or recurrent pericarditis, compared with 37.5 per cent of those on placebo.



VIRGULE MUSICALE

 

P4

 

PETER:

Scientists said they were able to predict “with an excellent accuracy” whether lung nodules detected during a first round of screening with low-dose computer tomography would actually turn out to be malignant…

 

SARAH:

Yes, published this week in the New England Journal of Medicine, they reported using predictors such as older age, female gender, family history of lung cancer, emphysema, larger nodule size, location of the nodule in the upper lobe, part-solid nodule type, lower nodule count and spiculation.

 

PETER:

But lung cancers have already been effectively detected using CT-screening haven’t they?

 

SARAH:

Yes. The U.S. National Lung Screening Trial, a randomized study with over 50,000 patients, showed that three rounds of annual CT screenings reduced lung cancer mortality by 20 per cent compared to X-rays. However, as reported in another New England Journal of Medicine paper, experts are still debating how best to interpret initial positive results found using CT scans

 

PETER: Hmm, why so?

 

SARAH:

Well, because while CT scanning enabled them to find more lung cancers at earlier stages, a lot of the results that came out as positive during screening didn’t actually turn out to be cancerous. So experts are still trying to figure out how to improve the early prediction value.

 



VIRGULE MUSICALE



P5

 

PETER:

Treating HIV-infected infants with anti-retrovirals as soon as possible after diagnosis for a limited period of time, and then stopping, gave them better outcomes than lifelong treatment started later on.

 



SARAH:

Yes, new data, published in The Lancet, show that children who had undergone an initial 40 to 96-week-course of anti-retrovirals, starting at an average age of seven weeks, continued to do significantly better after five years than those in whom anti-retroviral treatment was deferred until signs of the illness appeared, the standard of care when the trial was launched in 2005. Lead study author, Mark Cotton:



Cotton: “Almost of third of children in the early therapy arms at the end of the study were still not yet on continuous therapy –they were still doing quite well on antiretrovirals. So it seems like early treatment for a limited period is different to starting it later, once the infection is well established. Under those circumstances, stopping doesn’t have a good track record at all.”



SARAH:

That was Professor Mark Cotton, from South Africa, who cautioned that such approach cannot yet be recommended, because early continuous treatment might just be the best solution overall, and that is not yet known.



Cotton: “One of our limitations is that we didn’t have an early continuous therapy arm. So we don’t think that early limited therapy should go into guidelines yet.”



SARAH:

Professor Cotton said that what these results do highlight is the importance of early treatment in HIV-infected infants, regardless of their CD4 cell count.



BREVE 1 Sur fond musical  

 

PETER:

Finally, in brief:

 

Some fruits may be especially beneficial for lowering diabetic risks. That’s according to a study, published in the British Medical Journal, showing that eating more whole fruits, particularly blueberries, grapes and apples, was associated with a significantly lower risk of type-2 diabetes. On the contrary, fruit juices were associated with a higher risk of diabetes. The authors add that this could be due to juices’ higher glycemic index.



And …

 

BREVE 2

 

A nationwide Hepatitis B immunization program for newborns, launched in 1984 in Taiwan, was extremely successful at lowering the prevalence of chronic virus carriers, the incidence of hepatocellular carcinoma and mortality from fulminant hepatitis. The detailed 30-year outcomes of this program are published this week in JAMA.



That's all from MD-FM for now. Sarah Maxwell and I will be back with more next week, so until then, from me Peter Goodwin, goodbye.

 

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