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Source: Alabed S, Providência R and Chico TJA. Cochrane corner: .....

Source: Alabed S, Providência R and Chico TJA. Cochrane corner: .....


. Drug

Adenosine

CCA (Verapamil or Diltiazem)

Recommended by guidelines

1st line drug

2nd line drug

Safety in situations

Poor LV function, concomitant beta-blocker use,  broad complex tachycardia and in children

Stable patients, asthmatics, previous unpleasant experience with adenosine, people with frequent relapses on adenosine, in people with frequent atrial or ventricular ectopics at risk of an early recurrence of the arrhythmia

Cost

Expensive

Cheaper

How administered

6 mg and followed this up with another dose of 12 mg if SVT was not terminated with the first dose.

Verapamil : 5 mg boluses or infusion over up to 5 min. Diltiazem : slow intravenous infusion at a rate of 2.5 mg/min, to a maximum dose of 50 mg.

Effectiveness

No significant difference found

In this study

Abbreviations- LV- left ventricular, SVT- supraventricular tachycardia

Conclusion:  

Since both adenosine and verapamil have similar reversion rates and are readily available and simple to administer, patient preference and treatment costs may be some of the only crucial differences deserving consideration and may suggest revision of guidelines.

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Aspirin is being taken by millions of people all over the world  with the hope that it wi.....

Aspirin is being taken by millions of people all over the world  with the hope that it wi.....


1.   Dai Y, Ge J. Clinical use of aspirin in treatment and prevention of cardiovascular disease. Thrombosis. 2012;2012:245037.

2.   Cadavid AP. Aspirin: The mechanism of action revisited in the context of pregnancy complications. Front Immunol. 2017 Mar 15;8:261.

3.   Using aspirin for the primary prevention of cardiovascular disease [Internet]. Available at: https://www.uspreventiveservicestaskforce.org/Home/GetFileByID/768. Accessed on Oct 2,2018.

4.   Gaziano JM, Brotons C, Coppolecchia R, Cricelli C, Darius H, Gorelick PB, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): A randomized, double-blind, placebo-controlled trial.Lancet. 2018 Sep 22;392(10152):1036–46.

5.   ASCEND Study Collaborative Group. Effects of aspirin for primary prevention in persons with diabetes mellitus. N Engl J Med. 2018 Aug 26.

McNeil JJ, Nelson MR, Woods RL, Lockery JE, Wolfe R, Reid CM, et al. Effect of aspirin on all-cause mortality in the healthy elderly. N Engl J Med. 2018 Sep 16.

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In ASPREE (Aspirin in Reducing Events in the Elderly) trial, 19,114 participants were randomly.....

In ASPREE (Aspirin in Reducing Events in the Elderly) trial, 19,114 participants were randomly.....


In ASCEND study, among 15,480 participants with diabetes but no evident cardiovascular disease.....

In ASCEND study, among 15,480 participants with diabetes but no evident cardiovascular disease.....


A randomized, double-blind, placebo-controlled and multicentre study aimed to address the role.....

A randomized, double-blind, placebo-controlled and multicentre study aimed to address the role.....


GLOBAL LEADERS is the largest trial (randomized and open-label superiority at 130 sites in 18 .....

GLOBAL LEADERS is the largest trial (randomized and open-label superiority at 130 sites in 18 .....


Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis (POET) Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis (POET)

https://doi.org/10.1056/NEJMoa1808312, accessed on Sept 10, 2018.

Key Points:

In a randomized trial, switching to oral antibiotics after at least 10 days of intravenous (IV) treatment was not inferior to continued IV antibiotics in patients with endocarditis on the left side of the heart who were in stable condition.

Study Protocol:

This was a randomized, noninferiority, multicenter trial of 400 adults in stable condition who had a good response to at least 10 days of IV antibiotic therapy, and were able to take oral medication. These patients had endocarditis on the left side of the heart caused by Streptococcus, Enterococcus faecalis, Staphylococcus aureus, or coagulase-negative Staphylococci and who were being treated with IV antibiotics. They were assigned to continue IV treatment (199 patients) or to switch to oral antibiotic treatment (201 patients). In all patients, antibiotic treatment was administered intravenously for at least 10 days. If feasible, patients in the orally treated group were discharged to outpatient treatment. Oral antibiotics with good bioavailability (various combinations of moxifloxacin, amoxicillin, clindamycin, rifampicin, dicloxacillin, fusidic acid, and linezolid) were used.

27% had an infected prosthetic valve, and 38% had undergone valve surgery. Median time from diagnosis to randomization was 17 days. After randomization, the intravenously treated group received 19 additional days of inpatient treatment, while the orally treated group was discharged after a median of 3 days and received a total of 17 additional days of treatment.

 

Fig-1 Kaplan–Meier Plot of the Probability of the Primary Composite Outcome.

The primary outcome was a composite of all-cause mortality, unplanned cardiac surgery, embolic events, or relapse of bacteremia with the primary pathogen, from the time of randomization until 6 months after antibiotic treatment was completed.

Study Results: During 6-month follow-up, a composite endpoint of all-cause mortality, unplanned cardiac surgery, clinically evident embolic events, or relapse of bacteremia with the primary pathogen occurred in 12% of the intravenously treated group and 9% of the orally treated group, indicating noninferiority.

Conclusions: Thus, in patients with endocarditis on the left side of the heart caused by Streptococcus, E. faecalis, S. aureus, or coagulase-negative Staphylococci, who were in clinically stable condition and who had had an adequate response to initial treatment, a shift from initial IV to oral antibiotic treatment was noninferior to continued IV antibiotic treatment.

Comments:

In contrast to the current guidelines which advocates 4 to 6 weeks of IV antibiotic therapy, this randomized controlled trial from Denmark prompts us to tread a new path on the antibiotic management of endocarditis.

Patients in the orally treated group were shifted from IV to oral treatment at an average of about day 17, that is, during half the treatment period. This may be of great financial and psychological benefit to patients in our country.

It should be noted that although the results seemed consistent across prespecified subgroups, including the subgroups defined according to type of valve affected (native valve or prosthetic valve) and according to type of treatment (surgery during the disease course or conservative treatment) and according to the four different bacterial types, the trial was not powered to assess the primary outcome in any of the prespecified subgroups, in particular the various empirically defined oral antibiotic regimens.

Also, to keep in mind is that in such a lethal infection such as this, selection of the appropriate patients and oral regimens will require profound experience and expertise, as well as the assurance of adherence.

The study shows that for clinically stable, afebrile patients with no evidence of marked inflammation via the inflammatory markers and a negative transesophageal echocardiogram, without antibiotic resistance and who can be seen 2 or 3 times a week in the outpatient a little more than 2 weeks of hospitalization could be replaced by orally treated regimen at home.

Thus, partial duration oral treatment could be an option in carefully selected patients.

Suggested readings:

  1. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC guidelines for the management of infective endocarditis: the Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015;36:3075-3128.
  2. Heldman AW, Hartert TV, Ray SC, et al. Oral antibiotic treatment of right-sided staphylococcal endocarditis in injection drug users: prospective randomized comparison with parenteral therapy. Am J Med 1996;101:68-76
  3. Iversen K, Høst N, Bruun NE, et al. Partial oral treatment of endocarditis. Am Heart J 2013;165:116-122
  4. Al-Omari A, Cameron DW, Lee C, Corrales-Medina VF. Oral antibiotic therapy for the treatment of infective endocarditis: a systematic review. BMC Infect Dis 2014;14:140-140.
  5. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation 2015;132:1435-1486.

 

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Cardio Currents

Aspirin for primary prevention: What do AS.....

Cardio Currents

Aspirin for primary prevention: What do AS.....


                                                                                                                                               -Dr Akshay Mehta

A randomized study assessed the cardiovascular events in diabetes (ASCEND) in 15,480 patients (> age 40) with type 2 diabetes (> 90%) but without heart disease. Patients were randomized to aspirin 100 mg or matching placebo and were followed for a mean of 7.4 years.

Majority of the trial participants (80%) were with low or moderate vascular risk score based on age, sex, smoking, systolic blood pressure, body mass index, diabetes duration, HbA1c, assignment to aspirin versus placebo and assignment to omega-3 versus placebo. The baseline 5-year risk of serious vascular events (including transient ischemic attack) without aspirin were thus defined as  <5%, 5-10%, ≥10%. Furthermore, majority of the trial participants (75%) were on statins and 60% were hypertensives.

There was a relative risk reduction in major adverse events (mostly non-fatal) by about 12%, but an increase in major (non-fatal and non-intra cranial) bleeds by 29%.

A Study to Assess the Efficacy and Safety of Enteric-Coated Acetylsalicylic Acid in Patients at Moderate Risk of Cardiovascular Disease (ARRIVE) randomized 12,546 patients (men > 55 years and women > 60 years) to receive aspirin 100 mg or placebo at 501 study sites in 7 countries. The median follow-up was 60 months. The eligible patients had an average cardiovascular risk, deemed to be moderate on the basis of the number of specific risk factors (cholesterol, blood pressure, family history of early CAD). The patients at high risk of gastrointestinal bleeding or other bleeding or diabetes were excluded.

The primary efficacy endpoint was a composite outcome of time to first occurrence of cardiovascular death, myocardial infarction, unstable angina, stroke, or transient ischemic attack. The safety endpoints were hemorrhagic events and incidence of other adverse events.

In the intention-to-treat analysis, acetylsalicylic acid (ASA) did not reduce events. In the per protocol analysis, myocardial infarction rates were significantly reduced, with a 19% relative reduction in the composite primary endpoint. Further, ASA doubled the rate of GI bleeding in relative terms but by only 0.5% in absolute terms.

Summarizing both the trials, from the observed rate of cardiac events (one third of what was expected), one can say that the cohorts were a low to moderate risk group which could be due to a better lifestyle and concomitant statin use.

There was neither a mortality benefit nor fatal bleeding with low dose aspirin, although other events were reduced at the cost of non- fatal bleeds.

A recent patient level analysis of primary prevention ASA trials revealed a relationship between aspirin dose and body weight. Low aspirin doses (75-100 mg) were effective only in patients weighing less than 70 kg  and had no benefit in the 80% men and nearly 50% of all women weighing 70 kg or more (about 154 lbs).  However, this was a post hoc analysis.

Back in the year 2016, recommendation from USPSTF (United States Preventive Services Task Force) was to initiate low-dose aspirin in adults (aged 50-59 years) who have a 10% or greater 10-year CVD risk, are not at increased bleeding risk, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years.

Hence, the decision about low dose (or higher dose in obese people) aspirin use for primary prevention remains an individualized one after a thorough discussion with the patient taking cognizance of the risk of events versus the risk of (mainly GI) bleeding.

Take home message: In patients at low to moderate risk there was a little benefit and little harm hence more importance should be laid on lifestyle changes like diet, exercise, smoking, central obesity and statin therapy if indicated.

Suggested readings :

1. ASCEND Study Collaborative Group. Effects of aspirin for primary prevention in persons with diabetes mellitus. NEJM. Published online August 26, 2018.

2. Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): A randomized, double-blind, placebo-controlled trial. Lancet. Published online August 26, 2018.

3. Rothwell PM, Cook NR, Gaziano JM, et al. Effects of aspirin on risks of vascular events and cancer according to bodyweight and dose: Analysis of individual patient data from randomized trials. Lancet 2018;392:387–99.

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Introduction: Patients with Takotsubo syndrome (TTS) have a .....

Introduction: Patients with Takotsubo syndrome (TTS) have a .....


Key Points:

  1. The aim of the study was to analyze the frequ.....

    Key Points:

    1. The aim of the study was to analyze the frequ.....