Endovascular Management of Massive and Submassive Acute Pulmonary Embolism: Current Trends in Risk Stratification and Catheter-Directed Therapies.

PURPOSE OF REVIEW: Acute pulmonary embolism (PE) is a common condition associated with high morbidity and mortality. Prior studies have evaluated the role of systemic fibrinolysis and catheter-directed therapy (CDT) in the management of PE. In this review, we examine current data on risk stratification and the appropriate allocation of systemic fibrinolysis and CDT in acute PE patients with elevated risk of adverse outcomes. RECENT FINDINGS: Classification of pulmonary embolism is based on risk of adverse events, and relies on clinical parameters, imaging findings, and biomarkers. The synthesis of this data permits appropriate risk stratification of acute PE patients, and is the foundation upon which treatment decisions are made. While systemic thrombolytics remain the frontline therapy for hemodynamically unstable PE patients, studies have suggested that CDT has a significant promise as the primary modality for treating hemodynamically stable patients at increased risk for clinical decompensation and as an alternative therapy for hemodynamically unstable patients who may not tolerate systemic thrombolytics. The appropriate use of CDT in patients with acute PE is dependent on accurate risk stratification. CDT offers the potential to reduce excessive bleeding while maintaining the efficacy of systemic thrombolytics, but will require data from larger randomized trials to support its use prior to widespread adoption as the frontline therapy for PE in patients at elevated risk of adverse outcomes.

Vorapaxar in patients with coronary artery bypass grafting: Findings from the TRA 2°P-TIMI 50 trial.

BACKGROUND: Vorapaxar is a first-in-class protease-activated receptor-1 antagonist indicated for the reduction of cardiovascular death, myocardial infarction, and stroke in stable patients with prior atherothrombosis, who have not had a prior stroke or transient ischemic attack. The aims of this study were to investigate: 1) the role of vorapaxar in patients with severe coronary artery disease treated previously with coronary artery bypass grafting (CABG); and 2) safety in patients undergoing CABG while receiving vorapaxar. METHODS: TRA 2°P-TIMI 50 was a randomized, double-blinded, placebo-controlled trial of vorapaxar in 26,449 stable patients with prior atherothrombosis followed for a median of 30 months. We 1) investigated the efficacy of vorapaxar among patients with a history of CABG prior to randomization ( n=2942); and 2) assessed the safety among 367 patients who underwent a new CABG during the trial. RESULTS: Patients with a prior CABG were at higher risk for cardiovascular death, myocardial infarction, or stroke at three years compared with patients without a prior CABG (13.7% vs. 7.8%, p<0.001). Among patients with a prior CABG, vorapaxar significantly reduced the risk of cardiovascular death, myocardial infarction, or stroke (11.9% vs. 15.6%, hazard ratio 0.71, 95% confidence interval 0.58-0.88, p=0.001; number-needed-to-treat = 27). In patients undergoing CABG while receiving vorapaxar, the rate of Thrombolysis in Myocardial Infarction CABG major bleeding was 6.3% vs. 4.1% with placebo (hazard ratio 1.53, 95% confidence interval 0.58-4.01, p=0.39). CONCLUSIONS: In patients with a prior CABG, vorapaxar significantly reduced the risk of recurrent major cardiovascular events. In patients undergoing CABG while receiving vorapaxar, bleeding risk appeared similar to that seen in the overall trial population.

The relationships between sugar-sweetened beverage intake and cardiometabolic markers in young children.

BACKGROUND: The consumption of sugar-sweetened beverages has been implicated as a major contributor to the development of obesity and cardiometabolic disease. OBJECTIVE: To evaluate the relationships between sugar-sweetened beverage intake and cardiometabolic markers in young children. DESIGN: A cross-sectional analysis of the National Health and Nutrition Examination Survey data collected by the National Center for Health Statistics. PARTICIPANTS: A total of 4,880 individuals aged 3 to 11 years from nationally representative samples of US children participating in the National Health and Nutrition Examination Survey during 1999-2004 were studied. MAIN OUTCOME MEASURES: Concentrations of total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglyceride, and C-reactive protein as well as waist circumference and body mass index percentile for age-sex. STATISTICAL ANALYSES PERFORMED: Multivariate linear regression analyses were performed to determine independent associations between each outcome variable and the number of serving equivalents of sugar-sweetened beverages consumed after adjusting for age, sex, race, poverty status, physical activity, and energy intake. RESULTS: Increased sugar-sweetened beverage intake was independently associated with increased C-reactive protein concentrations (P=0.003), increased waist circumference (P=0.04), and decreased high-density lipoprotein cholesterol concentrations (P<0.001). Subgroup analyses demonstrated differences in the association of sugar-sweetened beverage intake with metabolic markers and anthropometric measurements among age ranges, sex, and racial/ethnic groups. CONCLUSIONS: In this cross-sectional analysis of children's dietary data, sugar-sweetened beverage intake was independently associated with alterations in lipid profiles, increased markers of inflammation, and increased waist circumference in children. Prospective studies are needed, but awareness of these trends is essential in combating the growing metabolic and cardiovascular disease burden in the pediatric population.