Prakriti Gaba, MD, Cardiology Fellow at Harvard Medical School. In this video, she speaks about the Prevention of Cardiovascular Events and Mortality With Icosapent Ethyl in Patients With Prior Myocardial Infarction.
Outline
Origins:
REDUCE-IT was a double-blind experiment in which 8,179 statin-treated individuals with reduced low-density lipoprotein cholesterol and moderately increased triglycerides were randomly assigned to icosapent ethyl (IPE) or placebo. The primary objective, including death from cardiovascular (CV) causes, was significantly reduced. It was uncertain what effect IPE has on people who had previously had a myocardial infarction (MI).
Goals:
In REDUCE-IT, we wanted to look at the effect of IPE on ischemic events in patients who had previously had a MI.
Methodology:
We conducted post-hoc analysis on patients who had previously experienced MI. CV mortality, MI, stroke, coronary revascularization, or hospitalization for unstable angina were the primary endpoints. The most important secondary outcome was CV death, MI, or stroke.
Outcomes:
A total of 3,693 patients had a previous MI. With IPE vs placebo, the primary endpoint was lowered from 26.1 percent to 20.2 percent; HR: 0.74 (95 percent CI: 0.65-0.85; P = 0.00001). The main secondary endpoint was lowered from 18.0% to 13.3%; HR: 0.71 (95 percent CI: 0.61-0.84; P = 0.00006). There was also a substantial 35% relative risk reduction in total ischemia events (P = 0.0000001), 34% reduction in MI (P = 0.00009), 30% reduction in CV death (P = 0.01), and a 20% reduction in all-cause mortality (P = 0.054), despite a modest rise in atrial fibrillation. Sudden cardiac death and cardiac arrest were also drastically reduced by 40% and 56%, respectively.
Inferences:
Patients in REDUCE-IT with a history of recent MI who were treated with IPE had large and significant relative and absolute risk reductions in ischemic events, including CV mortality. (AMR101 Study to Assess Its Ability to Reduce Cardiovascular Events in High-Risk Patients With Hypertriglyceridemia and Statin Use. The primary goal is to assess the effect of 4 g/day AMR101 on the occurrence of a first major cardiovascular event. NCT01492361; [REDUCE-IT])
Myocardial Infarction
Description
Myocardial Infarction
Prakriti Gaba, MD, Cardiology Fellow at Harvard Medical School. In this video, she speaks about the Prevention of Cardiovascular Events and Mortality With Icosapent Ethyl in Patients With Prior Myocardial Infarction.
Outline
Origins:
REDUCE-IT was a double-blind experiment in which 8,179 statin-treated individuals with reduced low-density lipoprotein cholesterol and moderately increased triglycerides were randomly assigned to icosapent ethyl (IPE) or placebo. The primary objective, including death from cardiovascular (CV) causes, was significantly reduced. It was uncertain what effect IPE has on people who had previously had a myocardial infarction (MI).
Goals:
In REDUCE-IT, we wanted to look at the effect of IPE on ischemic events in patients who had previously had a MI.
Methodology:
We conducted post-hoc analysis on patients who had previously experienced MI. CV mortality, MI, stroke, coronary revascularization, or hospitalization for unstable angina were the primary endpoints. The most important secondary outcome was CV death, MI, or stroke.
Outcomes:
A total of 3,693 patients had a previous MI. With IPE vs placebo, the primary endpoint was lowered from 26.1 percent to 20.2 percent; HR: 0.74 (95 percent CI: 0.65-0.85; P = 0.00001). The main secondary endpoint was lowered from 18.0% to 13.3%; HR: 0.71 (95 percent CI: 0.61-0.84; P = 0.00006). There was also a substantial 35% relative risk reduction in total ischemia events (P = 0.0000001), 34% reduction in MI (P = 0.00009), 30% reduction in CV death (P = 0.01), and a 20% reduction in all-cause mortality (P = 0.054), despite a modest rise in atrial fibrillation. Sudden cardiac death and cardiac arrest were also drastically reduced by 40% and 56%, respectively.
Inferences:
Patients in REDUCE-IT with a history of recent MI who were treated with IPE had large and significant relative and absolute risk reductions in ischemic events, including CV mortality. (AMR101 Study to Assess Its Ability to Reduce Cardiovascular Events in High-Risk Patients With Hypertriglyceridemia and Statin Use. The primary goal is to assess the effect of 4 g/day AMR101 on the occurrence of a first major cardiovascular event. NCT01492361; [REDUCE-IT])
Prakriti Gaba, MD, Cardiology Fellow at Harvard Medical School. In this video, she speaks about the Prevention of Cardiovascular Events and Mortality With Icosapent Ethyl in Patients With Prior Myocardial Infarction.
Outline
Origins:
REDUCE-IT was a double-blind experiment in which 8,179 statin-treated individuals with reduced low-density lipoprotein cholesterol and moderately increased triglycerides were randomly assigned to icosapent ethyl (IPE) or placebo. The primary objective, including death from cardiovascular (CV) causes, was significantly reduced. It was uncertain what effect IPE has on people who had previously had a myocardial infarction (MI).
Goals:
In REDUCE-IT, we wanted to look at the effect of IPE on ischemic events in patients who had previously had a MI.
Methodology:
We conducted post-hoc analysis on patients who had previously experienced MI. CV mortality, MI, stroke, coronary revascularization, or hospitalization for unstable angina were the primary endpoints. The most important secondary outcome was CV death, MI, or stroke.
Outcomes:
A total of 3,693 patients had a previous MI. With IPE vs placebo, the primary endpoint was lowered from 26.1 percent to 20.2 percent; HR: 0.74 (95 percent CI: 0.65-0.85; P = 0.00001). The main secondary endpoint was lowered from 18.0% to 13.3%; HR: 0.71 (95 percent CI: 0.61-0.84; P = 0.00006). There was also a substantial 35% relative risk reduction in total ischemia events (P = 0.0000001), 34% reduction in MI (P = 0.00009), 30% reduction in CV death (P = 0.01), and a 20% reduction in all-cause mortality (P = 0.054), despite a modest rise in atrial fibrillation. Sudden cardiac death and cardiac arrest were also drastically reduced by 40% and 56%, respectively.
Inferences:
Patients in REDUCE-IT with a history of recent MI who were treated with IPE had large and significant relative and absolute risk reductions in ischemic events, including CV mortality. (AMR101 Study to Assess Its Ability to Reduce Cardiovascular Events in High-Risk Patients With Hypertriglyceridemia and Statin Use. The primary goal is to assess the effect of 4 g/day AMR101 on the occurrence of a first major cardiovascular event. NCT01492361; [REDUCE-IT])
Allan S. Jaffe, MD, Professor of Medicine in Cardiology, Professor of Laboratory Medicine in Cardiology, Previous Consultant and Chair of the Division of Clinical Core Laboratory Services, Wayne and Kathryn Preisel Professor for Cardiovascular Disease Research at Mayo Foundation for Medical Education and Research at the Mayo Clinic. In this video, he speaks about Revisiting the definition of perioperative myocardial infarction after coronary artery bypass grafting.
Components required to aid in the diagnosis of CABG-related myocardial infarction.
Allan S. Jaffe, MD, Professor of Medicine in Cardiology, Professor of Laboratory Medicine in Cardiology, Previous Consultant and Chair of the Division of Clinical Core Laboratory Services, Wayne and Kathryn Preisel Professor for Cardiovascular Disease Research at Mayo Foundation for Medical Education and Research at the Mayo Clinic. In this video, he speaks about Revisiting the definition of perioperative myocardial infarction after coronary artery bypass grafting.
Components required to aid in the diagnosis of CABG-related myocardial infarction.
Dr. Jung-Joon Cha is currently works at the Korea University Anam Hospital, Korea University College of Medicine, in the Division of Cardiology, Department of Internal Medicine. Jung-Joon does research in the fields of interventional cardiology, internal medicine, and translational medicine. In this podcast, Dr. Cha discusses Clinical Outcomes in Patients With Delayed Hospitalization for Non–ST-Segment Elevation Myocardial Infarction.
https://www.jacc.org/doi/10.1016/j.jacc.2021.11.019
Abstract-
The frequency of patients presenting with non–ST-segment elevation myocardial infarction (NSTEMI) has decreased recently, although there has been an increase in mortality. Prehospital delay due to patients' reluctance to report their symptoms is a likely explanation for increased mortality.
Objectives
The goal of this study was to see if there was a link between prehospital delay and clinical outcomes in NSTEMI patients.
Methods
The authors looked at 6,544 patients with NSTEMI out of 13,104 patients from the Korea-Acute-Myocardial-Infarction-Registry–National Institutes of Health. Patients were divided into two groups based on the time from symptom to door (StD) (24 or 24 hours). The primary outcome was all-cause death after three years, while the secondary outcome was a three-year composite of all-cause mortality, recurrent MI, and heart failure hospitalization.
Results
In total, 1,827 patients (27.9%) were assigned to the StD time 24 hours group. The StD time 24 hours group had greater all-cause mortality (17.0 percent vs 10.5 percent; P 0.001) and secondary outcome incidence (23.3 percent vs 15.7 percent; P 0.001). Age, sex, atypical chest pain, dyspnea, Q-wave in electrocardiogram, use of emergency medical services, hypertension, diabetes mellitus, chronic kidney disease, left ventricle dysfunction, TIMI (Thrombolysis In Myocardial Infarction) flow, and the GRACE risk score all showed a higher all-cause mortality in the StD time 24 hours group. The elderly, women, nonspecific symptoms such as atypical chest discomfort or dyspnea, diabetes, and no use of emergency medical services were all independent predictors of prehospital delay in the multivariable analysis.
Conclusions
In patients with NSTEMI, prehospital delay is linked to an increased risk of 3-year all-cause mortality. (C110016) (iCReaT Study No.)
Dr. Jung-Joon Cha is currently works at the Korea University Anam Hospital, Korea University College of Medicine, in the Division of Cardiology, Department of Internal Medicine. Jung-Joon does research in the fields of interventional cardiology, internal medicine, and translational medicine. In this video, Dr. Cha discusses Clinical Outcomes in Patients With Delayed Hospitalization for Non–ST-Segment Elevation Myocardial Infarction.
https://www.jacc.org/doi/10.1016/j.jacc.2021.11.019
Abstract-
The frequency of patients presenting with non–ST-segment elevation myocardial infarction (NSTEMI) has decreased recently, although there has been an increase in mortality. Prehospital delay due to patients' reluctance to report their symptoms is a likely explanation for increased mortality.
Objectives
The goal of this study was to see if there was a link between prehospital delay and clinical outcomes in NSTEMI patients.
Methods
The authors looked at 6,544 patients with NSTEMI out of 13,104 patients from the Korea-Acute-Myocardial-Infarction-Registry–National Institutes of Health. Patients were divided into two groups based on the time from symptom to door (StD) (24 or 24 hours). The primary outcome was all-cause death after three years, while the secondary outcome was a three-year composite of all-cause mortality, recurrent MI, and heart failure hospitalization.
Results
In total, 1,827 patients (27.9%) were assigned to the StD time 24 hours group. The StD time 24 hours group had greater all-cause mortality (17.0 percent vs 10.5 percent; P 0.001) and secondary outcome incidence (23.3 percent vs 15.7 percent; P 0.001). Age, sex, atypical chest pain, dyspnea, Q-wave in electrocardiogram, use of emergency medical services, hypertension, diabetes mellitus, chronic kidney disease, left ventricle dysfunction, TIMI (Thrombolysis In Myocardial Infarction) flow, and the GRACE risk score all showed a higher all-cause mortality in the StD time 24 hours group. The elderly, women, nonspecific symptoms such as atypical chest discomfort or dyspnea, diabetes, and no use of emergency medical services were all independent predictors of prehospital delay in the multivariable analysis.
Conclusions
In patients with NSTEMI, prehospital delay is linked to an increased risk of 3-year all-cause mortality. (C110016) (iCReaT Study No.)
Antonio Abbate, MD & Ben Van Tassell, PharmD work at Virginia Commonwealth University. In this podcast Dr. Abbate and Dr. Van Tassell speak on the Interleukin-1 (IL-1) Blockade in Acute Myocardial Infarction (VCU-ART3) (VCU-ART3) trial.
https://clinicaltrials.gov/ct2/show/NCT01950299?recrs=e&cond=Heart&phase=23&lupd_s=01%2F01%2F2019&lupd_e=01%2F03%2F2022&draw=3&rank=590
Abstract-
VCU-ART3 is a randomized double-blind clinical trial in patients with ST-segment elevation myocardial infarction (STEMI) that compares the impact of anakinra high dosage vs. anakinra standard dose vs. placebo on the acute rise and fall of plasma C reactive protein levels over the first 14 days.
Description in detail:
VCU-ART3 is a randomized double-blind clinical trial in patients with ST-segment elevation myocardial infarction (STEMI) that compares the impact of anakinra high dosage vs. anakinra standard dose vs. placebo on the acute rise and fall of plasma C reactive protein levels over the first 14 days.
Antonio Abbate, MD & Ben Van Tassell, PharmD work at Virginia Commonwealth University. In this video Dr. Abbate and Dr. Van Tassell speak on the Interleukin-1 (IL-1) Blockade in Acute Myocardial Infarction (VCU-ART3) (VCU-ART3) trial.
https://clinicaltrials.gov/ct2/show/NCT01950299?recrs=e&cond=Heart&phase=23&lupd_s=01%2F01%2F2019&lupd_e=01%2F03%2F2022&draw=3&rank=590
Abstract-
VCU-ART3 is a randomized double-blind clinical trial in patients with ST-segment elevation myocardial infarction (STEMI) that compares the impact of anakinra high dosage vs. anakinra standard dose vs. placebo on the acute rise and fall of plasma C reactive protein levels over the first 14 days.
Description in detail:
VCU-ART3 is a randomized double-blind clinical trial in patients with ST-segment elevation myocardial infarction (STEMI) that compares the impact of anakinra high dosage vs. anakinra standard dose vs. placebo on the acute rise and fall of plasma C reactive protein levels over the first 14 days.
Dr. Mia Ravn Jacobsen, M.D. is a Corresponding Author at Rigshospitalet, Copenhagen University Hospital - Aalborg University Hospital's Department of Cardiology.
Link to Abstract: https://www.internationaljournalofcardiology.com/article/S0167-5273(21)01192-X/fulltext#%20
Abstract\sBackground
To assess the efficacy and safety of clopidogrel, prasugrel, and ticagrelor in people who have had an ST-segment elevation myocardial infarction (STEMI) and to expand on what has been learned from randomized clinical studies.
Methods
The Eastern Danish Heart Registry was used to identify all consecutive STEMI patients admitted to Copenhagen University Hospital, Rigshospitalet, between 2009 and 2016. Claim medicines and end points were gathered through individual linkage to Danish national registers. Patients alive a week after discharge were included in the study, and they were divided into three groups based on whether they were taking clopidogrel, prasugrel, or ticagrelor. They were then monitored for a year. Multivariate Cox proportional-hazards models were used to analyze the effectiveness end point (a composite of all-cause mortality, recurrent myocardial infarction, and ischemic stroke) and the safety end point (a composite of bleedings resulting to hospitalization).
Results
A total of 5123 patients (clopidogrel [1245], prasugrel [1902], ticagrelor [1976]) were enrolled in the study, with a 95 percent therapy persistency rate. Aspirin was taken at the same time in 95% of the cases. Females made up 24% of the population, while the elderly made up 17%. The efficacy endpoint occurred less frequently for ticagrelor (HR 0.50, 95 percent CI 0.35–0.70) and prasugrel (HR 0.48, 95 percent CI 0.33–0.68) as compared to clopidogrel, with no differences in bleedings requiring hospitalization. Prasugrel and ticagrelor have no differences in comparative effectiveness or safety. Similar results were found in sensitivity analyses using time-dependent drug exposure for the years 2011–2015.
Conclusions
When compared to clopidogrel, ticagrelor and prasugrel were linked with a lower incidence of all-cause mortality, recurrent myocardial infarction, and ischemic stroke in STEMI patients without an increase in bleeding that required hospitalization. There were no differences between prasugrel and ticagrelor.
Dr. Mia Ravn Jacobsen, M.D. is a Corresponding Author at Rigshospitalet, Copenhagen University Hospital - Aalborg University Hospital's Department of Cardiology.
Link to Abstract: https://www.internationaljournalofcardiology.com/article/S0167-5273(21)01192-X/fulltext#%20
Abstract\sBackground
To assess the efficacy and safety of clopidogrel, prasugrel, and ticagrelor in people who have had an ST-segment elevation myocardial infarction (STEMI) and to expand on what has been learned from randomized clinical studies.
Methods
The Eastern Danish Heart Registry was used to identify all consecutive STEMI patients admitted to Copenhagen University Hospital, Rigshospitalet, between 2009 and 2016. Claim medicines and end points were gathered through individual linkage to Danish national registers. Patients alive a week after discharge were included in the study, and they were divided into three groups based on whether they were taking clopidogrel, prasugrel, or ticagrelor. They were then monitored for a year. Multivariate Cox proportional-hazards models were used to analyze the effectiveness end point (a composite of all-cause mortality, recurrent myocardial infarction, and ischemic stroke) and the safety end point (a composite of bleedings resulting to hospitalization).
Results
A total of 5123 patients (clopidogrel [1245], prasugrel [1902], ticagrelor [1976]) were enrolled in the study, with a 95 percent therapy persistency rate. Aspirin was taken at the same time in 95% of the cases. Females made up 24% of the population, while the elderly made up 17%. The efficacy endpoint occurred less frequently for ticagrelor (HR 0.50, 95 percent CI 0.35–0.70) and prasugrel (HR 0.48, 95 percent CI 0.33–0.68) as compared to clopidogrel, with no differences in bleedings requiring hospitalization. Prasugrel and ticagrelor have no differences in comparative effectiveness or safety. Similar results were found in sensitivity analyses using time-dependent drug exposure for the years 2011–2015.
Conclusions
When compared to clopidogrel, ticagrelor and prasugrel were linked with a lower incidence of all-cause mortality, recurrent myocardial infarction, and ischemic stroke in STEMI patients without an increase in bleeding that required hospitalization. There were no differences between prasugrel and ticagrelor.
Jeffrey J. Goldberger, MD, MBA from the University of Miami speaks about the Comparison of Metoprolol versus Carvedilol After Acute Myocardial Infarction.
Link to Article -
https://www.ajconline.org/article/S0002-9149(21)00155-7/fulltext#%20
• Beta-blockers are commonly administered after a heart attack, but no one brand has been recommended.
• In this analysis, metoprolol and carvedilol are compared in a post-MI cohort.
• Carvedilol and metoprolol had comparable overall survival rates in the sample.
• In the ejection fraction 40 percent subgroup, carvedilol outperformed metoprolol in terms of survival.
Summary
Following a myocardial infarction (MI), beta-blockers are commonly prescribed, although no particular beta-blocker is recommended. 4142 patients were discharged on metoprolol and 1487 on carvedilol from the OBTAIN multi-center list of patients with acute MI. The beta-blocker dose was calculated as a percentage of the target daily dose used in randomized clinical trials (metoprolol 200 mg; carvedilol 50 mg). >0 percent -12.5 percent (n=1428), >12.5 percent -25 percent (n=2113), >25 percent -50 percent (n=1392), and >50 percent (n=696) were the beta-blocker dose classes. Three-year survival was calculated using the Kaplan-Meier equation. A multivariable adjustment was used to correct for baseline variations. Carvedilol patients were older (64.4 vs. 63.3 years) and had more comorbidities, including hypertension, diabetes, previous MI, congestive heart failure, lower left ventricular ejection fraction, and a longer period of stay. The mean doses of metoprolol and carvedilol did not vary substantially (37.227.8% and 35.831.0%, respectively). The 3-year survival figures for metoprolol and carvedilol were 88.2% and 83.5 percent, respectively, with an unadjusted HR=0.72 (p0.0001), but HR=1.073 (p=0.43) after multivariable adjustment. In comparison to other dose ranges, patients in the >12.5-25 percent dose range had better survival. In a subgroup of patients with a left ventricular ejection fraction of less than 40%, metoprolol was found to have a worse survival rate than carvedilol (adjusted HR=1.281; 95 percent CI: 1.024-1.602, p=0.03). There were no variations in survival between carvedilol and metoprolol in patients with a left ventricular ejection fraction greater than 40%. Overall survival after acute MI was comparable in patients treated with metoprolol or carvedilol, but carvedilol could be superior in patients with a left ventricular ejection fraction of less than 40%.
Khaled Ziada, MD from the Cleveland Clinic discusses Cangrelor in ST-Elevation Myocardial Infarction to Decrease Infarct Size.
Link to the Clinical Trial-
https://clinicaltrials.gov/ct2/show/NCT03043274?cond=Heart+Attacks&cntry=US&phase=123&draw=2&rank=9
Summary Brief:
This research evaluates variations in the degree of myocardial necrosis observed by cardiac MRI in patients with randomized ST-elevated myocardial infarction who received cangrelor during the percutaneous coronary intervention and contrasts them with patients who did not receive cangrelor randomly.
Description in detail:
Cangrelor is a direct-acting and reversible intravenously administered platelet inhibitor approved as an alternative to percutaneous intervention (PCI) for reducing the risk of periprocedural myocardial infarction, repeat coronary revascularization, and stent thrombosis. Cangrelor is emerging as an important new choice for use in patients undergoing percutaneous intervention who have not been treated with oral platelet inhibitors, as it has a fast onset of action (2 minutes) compared with conventional oral platelet inhibitors.
In addition, several studies have shown that patients undergoing emergent PCI with ST-elevation myocardial infarction (STEMI) do not have adequate platelet inhibition even after a loading dose of conventional oral platelet inhibitors has been given. The clinical meaning of maximum platelet inhibition at the time of PCI, however, is not fully understood.
The primary objective is to characterize the efficacy of intravenous cangrelor immediate platelet inhibition in patients with acute STEMI by determining the degree of infarct size (either enzymatically or by imaging). If the results are positive, this could indicate that in this patient population, immediate platelet inhibition is an important part of treatment.