Colchicine in Patients with Chronic Coronary Disease.

BACKGROUND: Evidence from a recent trial has shown that the antiinflammatory effects of colchicine reduce the risk of cardiovascular events in patients with recent myocardial infarction, but evidence of such a risk reduction in patients with chronic coronary disease is limited. METHODS: In a randomized, controlled, double-blind trial, we assigned patients with chronic coronary disease to receive 0.5 mg of colchicine once daily or matching placebo. The primary end point was a composite of cardiovascular death, spontaneous (nonprocedural) myocardial infarction, ischemic stroke, or ischemia-driven coronary revascularization. The key secondary end point was a composite of cardiovascular death, spontaneous myocardial infarction, or ischemic stroke. RESULTS: A total of 5522 patients underwent randomization; 2762 were assigned to the colchicine group and 2760 to the placebo group. The median duration of follow-up was 28.6 months. A primary end-point event occurred in 187 patients (6.8%) in the colchicine group and in 264 patients (9.6%) in the placebo group (incidence, 2.5 vs. 3.6 events per 100 person-years; hazard ratio, 0.69; 95% confidence interval [CI], 0.57 to 0.83; P<0.001). A key secondary end-point event occurred in 115 patients (4.2%) in the colchicine group and in 157 patients (5.7%) in the placebo group (incidence, 1.5 vs. 2.1 events per 100 person-years; hazard ratio, 0.72; 95% CI, 0.57 to 0.92; P = 0.007). The incidence rates of spontaneous myocardial infarction or ischemia-driven coronary revascularization (composite end point), cardiovascular death or spontaneous myocardial infarction (composite end point), ischemia-driven coronary revascularization, and spontaneous myocardial infarction were also significantly lower with colchicine than with placebo. The incidence of death from noncardiovascular causes was higher in the colchicine group than in the placebo group (incidence, 0.7 vs. 0.5 events per 100 person-years; hazard ratio, 1.51; 95% CI, 0.99 to 2.31). CONCLUSIONS: In a randomized trial involving patients with chronic coronary disease, the risk of cardiovascular events was significantly lower among those who received 0.5 mg of colchicine once daily than among those who received placebo. (Funded by the National Health Medical Research Council of Australia and others; LoDoCo2 Australian New Zealand Clinical Trials Registry number, ACTRN12614000093684.).

Comparison of Safety and Efficacy of Unfractionated Heparin Versus Bivalirudin in Patients Undergoing Percutaneous Coronary Intervention.

BACKGROUND: Anti-platelet and anti-coagulant adjunctive therapies are associated with a clinically significant increased risk of major bleeding. We retrospectively assessed in-hospital major adverse clinical events (MACE) and major bleeding in patients undergoing percutaneous coronary intervention (PCI) who received either unfractionated heparin (UFH) or bivalirudin. METHOD: Consecutive patients undergoing PCI for acute coronary syndrome (ACS) at Fremantle Hospital from August 2008 to December 2013 were identified. Patients received dual antiplatelet therapy (DAPT), with either UFH (50-100IU/kg) or bivalirudin (bolus 0.75mg/kg and infusion 1.75mg/kg/hr). Adjunctive glycoprotein IIb/IIIa (GPIIbIIIa) antagonist use was at the operator's discretion. In-hospital events were identified from case notes and PCI database review. RESULTS: Of 3371 patients identified, 1740 received UFH and 1631 received bivalirudin. The two groups were similar with respect to age, 62.5 SD 12.1 yrs vs. 62.8 SD 12.2 yrs, (p=0.575) female gender, 24% vs. 26% (p=0.10), current smokers, 66% vs. 70% (p=0.53), diabetes, 25% vs. 26% (p=0.62) and the use of DAPT (p=ns). Presentation with ST-segment-elevation myocardial infarction (STEMI) was significantly higher in the UFH group (28% vs. 19%, p<0.001). The use of transfemoral arterial access was similar (93% UFH vs. 92% bivalirudin) (p=0.41). More patients received GPIIb/IIIa antagonist in the UFH group (30% vs. 3%; p <0.001). There was no difference in pre-discharge acute stent thrombosis (<24hours) occurring in 1.0% with UFH vs. 0.5% with bivalirudin (p=0.20). The equipoise on the outcomes of stent thrombosis persisted after multivariate adjustment for difference in rates of STEMI. In-hospital BARC Type 1-3 major bleeding occurred in 3.7% in the UFH group vs. 2.9% in the bivalirudin group (p=0.20). CONCLUSION: Unfractionated heparin compared with bivalirudin was not associated with a higher incidence of in-hospital MACE or major bleeding in a cohort with overall high rates of transfemoral access, despite significantly higher use of GPIIb/IIIa antagonists in the UFH group.

Optimising pharmacotherapy for secondary prevention of non-invasively managed acute coronary syndrome.

About half of all patients who experience an acute coronary syndrome (ACS) in Australia have their conditions managed non-invasively - that is, they do not undergo coronary angiography and revascularisation in hospital. ACS patients whose conditions are managed non-invasively may not receive the same level of evidence-based care as those who receive coronary revascularisation. This article reviews the optimal pharmacological management of ACS managed non-invasively. There is strong evidence to support the prescription of dual antiplatelet therapy (DAPT; aspirin with a P2Y12 inhibitor). DAPT should continue for 12 months after an ACS, then aspirin should be continued indefinitely. Anticoagulation with warfarin or a novel oral anticoagulant may be needed if atrial fibrillation occurs; the combination with DAPT increases the risk of bleeding. Unless contraindicated, high-intensity statin therapy should be prescribed for all post-ACS patients irrespective of their cholesterol level. Non-statin lipid therapy has not been shown to improve outcomes. Use of ß-adrenergic blockers is recommended in most guidelines, but the clinical trials to support this recommendation were performed more than 30 years ago, and routine long-term use may not be relevant to modern treatment, except when there is cardiac failure or left ventricular dysfunction. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are also widely recommended, but the evidence for benefit is stronger when there is left ventricular dysfunction. Calcium-channel blockers, nitrates, antiarrhythmic drugs, digoxin and diuretics do not improve outcomes in post-ACS patients.

Right and left heart catheterization via an antecubital fossa vein and the radial artery--a prospective study.

Right heart catheterization has been described via the arm but previous reports have been retrospective, performed for limited indications, and may not give an accurate assessment of the success rate or safety of this technique. We sought to prospectively examine the feasibility and safety of left and right heart catheterization entirely via the arm using the radial artery and an antecubital fossa vein for a broad range of indications. Fifty-eight consecutive procedures were included. Transradial arterial access was successful in 57 patients (98%), right heart catheterization via the antecubital fossa vein was successful in 54 patients (93%) and bilateral catheterization from the arm was achieved in 53 patients (91%). Standard diagnostic catheterization was the most frequent procedure (59%), although thermodilution (6.9%), percutaneous coronary intervention (33%), and coronary sinus sampling (16%) were also performed in selected cases. Compared to a historical cohort of patients undergoing right and left heart catheterization via femoral access, mean procedural time (38 vs 47 minutes; P=.03) and screening time (8.1 vs 11.2 minutes; P<.001) were significantly reduced. There was 1 venous forearm hematoma that was managed conservatively. Right and left heart catheterization can be performed routinely via the arm in a broad range of patients and is associated with reduced procedural and fluoroscopy time as compared to femoral access. This approach can be considered for all patients in whom right and left heart catheterization is planned.

The resting status of the coronary microcirculation is a predictor of microcirculatory function following elective PCI for stable angina.

BACKGROUND/OBJECTIVES: We performed a prospective study to investigate markers of percutaneous coronary intervention (PCI) related microvascular injury. METHODS: Consecutive patients undergoing PCI for stable angina were studied. The index of microvascular resistance (IMR) was measured using a temperature and pressure sensing guidewire (TPSG) before and after single vessel PCI. Basal transit-time (TmnBase), that reflected non-hyperemic blood flow was also measured. Fasting bloods were taken to measure blood sugar, HbA1c and lipids. Asymmetric dimethylarginine (ADMA) was also measured as a marker of systemic endothelial function. RESULTS: 55 patients were included in the study. Mean age was 59.9 ± 11.2, 74.1% male. There was no significant difference in IMR post PCI compared with pre PCI values (IMR pre PCI = 16.96 [11.5,25.38] vs. IMR post PCI 14.2 [10.37,26.25] p = 0.96). IMR post PCI was higher in diabetic (DM) patients compared with non-diabetics [IMR post DM = 22.72 (13.35,42.91) vs. no DM = 13.9 (10.18,21.45), p = 0.02]. Fasting blood sugar, HbA1c and IMR pre PCI were correlated with post PCI IMR. IMR pre PCI, HbA1C and fasting glucose were higher in patients who developed PCI related microvascular dysfunction. The strongest independent predictor of post PCI IMR was the pre PCI IMR. CONCLUSION: The baseline status of the microcirculation is an important determinant of post PCI microvascular function. Diabetics appear to have higher post PCI IMR.