Интересные ссылки

[Yariko]

Сообщение от GIZA

В 2010 г опубликовано FDA дополнение к рекомендации 2009 г по применению Клопидогреля совместно с Омепразолом.
[Ссылки доступны только зарегистрированным пользователям ]
Что изменилось за последующие годы?
Changes in Practice Patterns of Clopidogrel in Combination with Proton Pump Inhibitors after an FDA Safety Communication
[Ссылки доступны только зарегистрированным пользователям ]
To conclude, this analysis highlights two important facts:
1) the FDA Safety Communication resulted in a reduction in the total number of patients undergoing clopidogrel-PPI combination therapy and 2) although a decrease in the proportion of patients receiving a combination with a CYP2C19 inhibitor PPI, omeprazole remained one of the PPIs most prescribed with clopidogrel. These findings are surprising considering the multitude of FDA communications, drug label changes, and clinical studies discouraging the use of such combination.

и что? Вы считаете FDA истиной в последней инстанции? Его решение не всегда базируется на доказательной базе. В том же 2010 году был опубликован консенсус экспертов с совершенно противоположным мнением. Данные обсервационных исследований противоречивы, фармакодинамические тоже, а единственное рандомизированное исследование не продемонстрировало, что риск сердечно-сосудистых событий возрастал, поэтому the evidence remains weak for diminish antiplatelet activity associated with PPIs and thienopyridine coprescription [Ссылки доступны только зарегистрированным пользователям ]

[angio]

Уважаемые коллеги. В начале февраля на базе РК НПК состоялся саммит по гибридным подходам к лечению патологии аорты, клапанных пороков и МФА.

К сожалению, сам я там не присутствовал. Однако полная программа конференции выложена в свободном доступе и представляет довольно интересный материал.

[Ссылки доступны только зарегистрированным пользователям ] - трансляция 1 февраля
[Ссылки доступны только зарегистрированным пользователям ] - трансляция 2 февраля

[Yariko]

А я давно об этом говорила. Одна из причин плачевных результатов HERS и WHO связана с применение конского конъюгированного эстрогена
[Ссылки доступны только зарегистрированным пользователям ]

Importance Little is known about the comparative cardiovascular safety of oral hormone therapy products, which impedes women from making informed safety decisions about hormone therapy to treat menopausal symptoms.

Objective To compare the relative clinical cardiovascular safety of 2 commonly used oral estrogen drugs—conjugated equine estrogens (CEEs) and estradiol.

Design, Setting, and Participants Population-based, case-control study from January 1, 2003, to December 31, 2009, comparing cardiovascular event risk associated with current CEEs and estradiol use in a large health maintenance organization in which the preferred formulary estrogen changed from CEEs to estradiol during the course of data collection. Participants were 384 postmenopausal women aged 30 to 79 years using oral hormone therapy.

Main Outcomes and Measures Incident venous thrombosis was the primary clinical outcome, and incident myocardial infarction and ischemic stroke were secondary outcomes. As validation, an intermediate clotting phenotype, the endogenous thrombin potential–based normalized activated protein C sensitivity ratio, was measured in plasma of controls.

Results We studied 68 venous thrombosis, 67 myocardial infarction, and 48 ischemic stroke cases, with 201 matched controls; all participants were current users of oral CEEs or estradiol. In adjusted analyses, current oral CEEs use compared with current oral estradiol use was associated with an increased venous thrombosis risk (odds ratio, 2.08; 95% CI, 1.02-4.27; P = .045) and an increased myocardial infarction risk that did not reach statistical significance (odds ratio, 1.87; 95% CI, 0.91-3.84; P = .09) and was not associated with ischemic stroke risk (odds ratio, 1.13; 95% CI, 0.55-2.31; P = .74). Among 140 controls, CEEs users compared with estradiol users had higher endogenous thrombin potential–based normalized activated protein C sensitivity ratios (P < .001), indicating a stronger clotting propensity.

Conclusions and Relevance In an observational study of oral hormone therapy users, CEEs use was associated with a higher risk of incident venous thrombosis and possibly myocardial infarction than estradiol use. This risk differential was supported by biologic data. These findings need replication and suggest that various oral estrogen drugs may be associated with different levels of cardiovascular risk.

[angio]

Statin-Taking Patients With LDL-C of 70–100 mg/dL at Decreased Risk of MACE

The investigators, led by Dr Morton Leibowitz (Clalit Research Institute, Clalit Health Services, Tel Aviv, Israel), note that these results "do not provide support for a blanket principle that lower LDL-C is better for all patients in secondary prevention."

When asked whether any of the findings surprised him, Leibowitz told heartwire from Medscape via email that "we were very pleased with the robustness of the findings. Below 100 mg/dL made a difference; below 70 mg/dL did not." And the number-one takeaway message? "Don't accept 'lower is better' for all patients."

As reported by heartwire ,American College of Cardiology/American Heart Association guidelines released in 2013 moved away from targeting specific LDL levels because of a lack of scientific evidence. But this action continues to be debated.
On the other hand, the ESC 2012 guidelines recommend targeting to an LDL-C level of <70 mg/DL.

For the current study, the researchers sought to examine whether this "lower-is-better" strategy really is advantageous in a real-world, community setting. They assessed records from 2009 through 2013 for 31,619 patients enrolled in Israel's Clalit Health Services who were between the ages of 30 and 84 years (mean age 67.3 years; 73% men) and who were at least 80% adherent to their treatment with statins, based on prescription fulfillment.

"Index LDL-C was defined as the first achieved serum LDL-C measure after at least 1 year of statin treatment, grouped as low (<70.0 mg/dL), moderate (70.01–100.0 mg/dL), or high (100.1–130.0 mg/dL)," explain the investigators. There were 9086, 16,782, and 5751 patients in each of the groups, respectively.

The primary outcome was MACE, which included a composite of acute MI, unstable angina, angioplasty or bypass surgery, stroke, or all-cause mortality.

At a mean of 1.6 years of follow-up, 9035 of the patients had a MACE (6.7 per 1000 persons per year). The moderate LDL-C group had significantly fewer MACE (27.4%) vs both the low LDL-C group (29.5%) and the high LDL-C group (30.6%; both comparisons P<0.001).

The adjusted hazard ratio (HR) for MACE was a nonsignificant 1.02 for the low vs moderate LDL-C groups (95% CI 0.97–1.07, P=0.54). However, the adjusted HR was significantly lower in the moderate vs high LDL-C groups, at 0.89 (95% CI 0.84–0.94).

In further analyses, the investigators expanded their examination to 54,884 patients—all of whom had >50% treatment adherence. In this cohort, the low LDL-C group had a higher risk of MACE vs the moderate group (HR 1.06, 95% CI 1.02–1.10), whereas the moderate group had a lower risk vs the high LDL-C group (HR 0.87, 95% CI 0.84–0.91, both comparisons P=0.001).

Leibowitz added that the key clinical question when the investigators undertook this study was: if a patient has stable CAD, is taking statins, and has achieved a reasonable reduction in LDL-C, "how compelling is it to push below 70 mg/dL? Given the advent of new expensive medications that lower LDL cholesterol but have not yet demonstrated impact on events, how critical is the achieved LDL level?"

After seeing the results, he noted that the take-home message for clinicians is to "look at each patient critically when deciding to add secondary lipid-lowering medications."

Expounding on this, Ascher et al write in their editor's note that targeting an LDL-C level of less than 100 mg/dL instead of a level of less than 70 mg/dL may "help to minimize adverse effects that are more common with higher statin doses needed for lower LDL targets while maximizing benefits."

"The findings . . . also support consideration of absolute LDL-C levels instead of relative LDL-C percentage reductions in gauging an adequate response to statin therapy and raise questions about the practice of statin dosing by intensity."

[Yariko]

Comparison of ACC/AHA and ESC Guideline Recommendations Following Trial Evidence for Statin Usein Primary Prevention of Cardiovascular Disease
Results From the Population-Based Rotterdam Study

IMPORTANCE The American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) guidelines both recommend lipid-lowering treatment for primary prevention based on global risk for cardiovascular disease (CVD). However, randomized clinical trials (RCTs) for statin use have included participants with specific risk-factor profiles.
OBJECTIVE To evaluate the overlap between the ACC/AHA and ESC guideline recommendations and available evidence from RCTs for statin use in primary prevention of CVD.
DESIGN, SETTING, AND PARTICIPANTS We calculated the 10-year risk for hard atherosclerotic CVD (ASCVD) following the ACC/AHA guideline, 10-year risk of CVD mortality following the ESC guideline, and we determined eligibility for each of 10 major RCTs for primary prevention of CVD. Conducted from July 2014 to August 2015, this study included 7279 individuals free of CVD, aged 45 to 75 years, examined between 1997 and 2008 for the Rotterdam Study, a prospective population-based cohort.
MAIN OUTCOMES AND MEASURES Proportions of individuals qualifying for lipid-lowering treatment per guidelines, proportions of individuals eligible for any of the 10 RCTs, overlap between these groups, and corresponding ASCVD incidence rates.
RESULTS Of the 7279 individuals included in the study, 58.2%were women (n = 4238) and had a mean (SD) age of 61.1 (6.9) years. The ACC/AHA guidelines would recommend statin initiation in 4284 participants (58.9%), while the ESC guidelines would in 2399 participants (33.0%) (overlapping by 95.8% with ACC/AHA). A total of 3857 participants (53.0%) met eligibility criteria for at least 1 RCT. Recommendations from both guidelines and trial evidence overlapped for 1546 participants (21.2%), who were at high risk for ASCVD (21.5 per 1000 person-years). A further 1703 participants (23.4%) would be recommended for statins by the guidelines in the absence of direct trial evidence, while 1176 (16.2%) would have been eligible for at least 1 trial without being recommended statin treatment by any guideline. Finally, 1719 participants (23.6%) would not be recommended a statin, nor would qualify for any of the trials. These individuals had low incidence of ASCVD (3.3 per 1000 person-years).
CONCLUSIONS AND RELEVANCE Based on this European population study, ACC/AHA and ESC prevention guidelines often did not align at the individual level. However, for one-fifth of the general population, guidelines on both sides of the Atlantic recommend statin initiation, with trial data supporting the efficacy. There should be no controversy about providing optimal
preventive medication to these individuals.

JAMA Cardiol. doi:10.1001/jamacardio.2016.1577

[Yariko]

Вышли новые [Ссылки доступны только зарегистрированным пользователям ] ЧАВО по дислипидемии обновлено соотвественно.

[Dr.Vad]

Cardiovascular Safety of Celecoxib, Naproxen, or Ibuprofen for Arthritis
[Ссылки доступны только зарегистрированным пользователям ]

[angio]

The study looked at a cohort from the National Inpatient Sample, 33,343 patients who were admitted to the hospital for takotsubo syndrome from 2003 to 2011; of these, 210 patients were active marijuana users, as indicated by patient history or a positive urine drug screening test.

The marijuana users formed a distinct subgroup of takotsubo patients. A total of 64% of the marijuana users were women and 36% were men, whereas 92% of the nonusers were women and 8% were men.

Compared with patients who did not use marijuana, active users were younger and had a lower prevalence of hypertension (38% vs 62%), type 2 diabetes (2.4% vs 17.6%), and hyperlipidemia (15.7% vs 52.4%; all P<0.001).

However, the active users were also more likely to have psychiatric illness or abuse substances. Specifically, they were more likely to have a history of depression (32.9% vs 14.5%), anxiety disorder (28.4% vs 16.2%), or psychosis (11.9% vs 3.8%), and they were more likely to smoke (73.3% vs 28.6%) or abuse alcohol (13.3% vs 2.8%) or cocaine or amphetamines (11.9% vs 0.3%; all P<0.001).

In multivariable binary regression analysis adjusted for known risk factors for takotsubo, marijuana use was an independent predictor of takotsubo (odds ratio 1.99, 95% CI 1.72–2.32; P<0.0001).].

Patients who used marijuana were less likely to die during hospitalization (0% vs 1%, P=NS) and less likely to have a major adverse cardiac event (23% vs 32%, P=0.008).

Но мне больше понравилось как высказался один из исследователей:

"We need to understand more about the potential association between marijuana use and cardiovascular adverse events and continue to investigate the mechanisms that might explain it"

References:
Singh A, Agrawal S, Fegley M, et al. Marijuana (cannabis) use is an independent predictor of stress cardiomyopathy in younger men.. American Heart Association 2016 Scientific Sessions; November 13, 2016; New Orleans, LA. Abstract S4054

[Dr.Vad]

что будет, если дозу новых антикоагулянтов слегка передозоровать или недодозировать при ФП? - повышается смертность на 90% в первом и риск госпитализаций на 25% во втором случае, подробнее

J Am Coll Cardiol. 2016 Dec 20;68(24):2597-2604.
Off-Label Dosing of Non-Vitamin K Antagonist Oral Anticoagulants and Adverse Outcomes: The ORBIT-AF II Registry.
Steinberg BA и соавт. [Ссылки доступны только зарегистрированным пользователям ]

[GIZA]

The Medical Letter® on Drugs and Therapeutics
December 5, 2016
In Brief

PPIs and Torsades de Pointes

The Arizona Center for Education and Research on Therapeutics (AZCERT) has recently added the proton pump inhibitors (PPIs) omeprazole (Prilosec, and others), esomeprazole (Nexium, and others), lansoprazole (Prevacid, and others), and pantoprazole (Protonix, and generics) to its lists of Drugs with Conditional Risk of Torsades de Pointes (TdP) and Drugs to Avoid in Patients with Congenital Long QT Syndrome.
PPIs do not directly cause prolongation of the QT interval, but they have been associated with hypomagnesemia, which is often accompanied by hypocalcemia and hypokalemia and can result in cardiac repolarization disturbances such as QT interval prolongation. Reports have described cases of QT interval prolongation and TdP associated with severe PPI-induced hypomagnesemia. TdP has also been reported in patients taking a PPI concomitantly with drugs that directly prolong the QT interval. The newer PPIs dexlansoprazole (Dexilant) and rabeprazole (Aciphex, and generics) have not been linked to QT interval prolongation or TdP to date, but they can cause hypomagnesemia.
Serum magnesium levels should be monitored periodically in patients taking a PPI for an extended period of time (>2 weeks). If possible, extended PPI therapy should be avoided in patients who require treatment with drugs that carry a known risk of TdP and in those with long QT syndrome. If extended PPI therapy must be used with a drug that prolongs the QT interval, close monitoring of magnesium levels and the QT interval is recommended.

[GIZA]

Новое ACC/AHA/HRS официальное руководство по синкопе.
2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope
[Ссылки доступны только зарегистрированным пользователям ]
Слайд руководства
[Ссылки доступны только зарегистрированным пользователям ]

[GIZA]

2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease
Краткий обзор
[Ссылки доступны только зарегистрированным пользователям ]
В формате PDF
[Ссылки доступны только зарегистрированным пользователям ]

[GIZA]

Опубликована вторая часть целенаправленного обновления руководства по сердечной недостаточности
2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure
[Ссылки доступны только зарегистрированным пользователям ]

[Korzun]

Сообщение от GIZA

Опубликована вторая часть целенаправленного обновления руководства по сердечной недостаточности
2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure
[Ссылки доступны только зарегистрированным пользователям ]

Любопытно, что при анемии и ХСН рекомендуют в/в железо при ферритине меньше 100:
In patients with NYHA class II and III HF and iron
deficiency (ferritin <100 ng/mL or 100 to 300 ng/mL
if transferrin saturation is <20%), intravenous iron
replacement might be reasonable to improve
functional status and QoL.
Правда градация IIb, но доказанность B-R.

А вот эритропоэтином при ХСН лучше не баловаться:
In patients with HF and anemia, erythropoietinstimulating
agents should not be used to improve
morbidity and mortality

[Dr.Vad]

ета цифра с учетом коррекции на хр. воспаление и повышенный с-реактивный белок у большинства таких пациентов, поетому и железо внутрь у них недавно не оказалось таким еффективным как в/в:
JAMA. 2017 May 16;317(19):1958-1966.
Effect of Oral Iron Repletion on Exercise Capacity in Patients With Heart Failure With Reduced Ejection Fraction and Iron Deficiency: The IRONOUT HF Randomized Clinical Trial.
[Ссылки доступны только зарегистрированным пользователям ]