Pulmonary vein isolation beats AV node ablation for drug-refractory AF in HF patients

Pulmonary vein isolation beats AV node ablation for drug-refractory AF in HF patients

23 October 2008

MedWire News: Pulmonary vein isolation is superior to atrioventricular (AV) node ablation with biventricular pacing for the treatment of drug-refractory atrial fibrillation (AF) in patients with heart failure (HF), conclude researchers. continuing story..

Unfortunately, one requires a surgical procedure whereas the other is mainly a percutaneous procedure. Would it be cost effective? How about the surgical risks involved in patients who may not be hemodynamically stable to start of with? The jury is out there.

More on pulmonary vein isolation
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HYVET: Hypertension in the very elderly trial

HYVET showed that indapamide SR* ±perindopril treatment significantly reduced total mortality by 21% (P=0.019) and stroke mortality by 39% (P=0.046).


Furthermore, in patients receiving indapamide SR there were also relative risk reductions of 30% in stroke (P=0.055), of 64% in heart failure (P<0.001) and 34% in all cardiovascular events (P<0.001).

This means that one death would be avoided for every 40 patients treated with indapamide SR ±perindopril therapy for 2 years.

www.hyvet.com

Doubts on the benefits of aspirin

Aspirin Does Not Prevent Heart Attacks in High-Risk Patients

DUNDEE, United Kingdom -- October 17, 2008 -- Taking regular aspirin and antioxidant supplements does not prevent heart attacks in high-risk groups with diabetes and asymptomatic arterial disease, according to a study published today in the online issue of the BMJ.

Although there is considerable evidence showing no protective benefit of aspirin in high-risk patients without heart disease, guidelines are inconsistent and aspirin is commonly prescribed for the primary prevention of heart disease in patients with diabetes and with peripheral arterial disease.

Jill Belch, University of Dundee, Dundee, United Kingdom, and colleagues investigated whether aspirin and antioxidants given together or separately can reduce heart attacks and death in patients with diabetes and arterial disease.

The study included 1,276 patients aged over 40 years with diabetes and evidence of artery disease. Patients were randomised to receive either aspirin or placebo, an antioxidant or placebo, aspirin and antioxidant, or double placebo. Patients were followed over 8 years.

Overall, the researchers found no benefit from either aspirin or antioxidant treatment in the prevention of heart attacks or death. Patients in the aspirin groups had 116 primary events compared with 117 in the placebo group. No significant difference in events was seen between the antioxidant group and the placebo group.

The authors concluded by voicing their concern at the widespread prescribing of aspirin despite the lack of evidence to support its use in the primary prevention of heart attacks and death in people with diabetes and in view of its possible side effects.

In an accompanying editorial, William Hiatt, Colorado Prevention Center, Denver, Colorado, said: "These findings show that unlike statins and drugs for reducing hypertension, which have a benefit in all risk groups including those with and without heart disease, only patients with a history of clinical or symptomatic heart disease or stroke disease benefit from taking aspirin."

SOURCE: University of Dundee

However, the latest American Diabetes Association recommendations continue to advocate aspirin.

Antiplatelet Agents
● Use aspirin therapy (75–162 mg/day)as a secondary prevention strategy in diabetic individuals with a history of CVD. (A)
● Use aspirin therapy (75–162 mg/day)as a primary prevention strategy in those with type 1 or type 2 diabetes at increased cardiovascular risk, including those who are 40 years of age or who have additional risk factors (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria). (A)

Download the ADA 2008 recommendations on the treatment of diabetes. here.

Warfarin Warning: Shortfalls in Anticoagulation for AF Up Risks of ICH and Embolic Stroke

If the Americans are having problems maintaining INR targets with warfarin, I shudder to think what our data would be. (thesis project anyone??) Only 19% were in therapeutic range all the time according to this american study.

Walker AM, Bennett D. Epidemiology and outcomes in patients with atrial fibrillation in the United States. Heart Rhythm. 2008;5:1365-1372. doi:10.1016/j.hrthm.2008.07.014.

More confusion on Drug Eluting Stents

When drug eluting stents (DES) was first introduced, it was touted to make bare metal stents (BMS) a thing of the past. These DES stents are to solve the problem of early restenosis that plaqued the BMS.

Unfortunately as more data surface, DES is losing its edge with high events of late stent thrombosis and increased mortality in some populations. Duration of antiplatelet therapy is now prolonged and some doctors are even contemplating lifelong therapy with antiplatelets. Reading study after study only causes more confusion, with advocates on either side of the fence.

Many cardiologists do not give satisfactory answers as there is obviously none. The choice of using DES or BMS on most occasions is settled due to financial constraints rather than clinical benefits.

In Malaysia, DES remains extremely costly and out of reach for many average Malaysians. Even worse, some patients are denied even BMS due to financial reasons despite strong clinical indications. Even antiplatelet therapy with clopidogrel is unaffordable.

As of now, the haze is only getting thicker.

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