Como es un articulo muy interesante, mando el pdf del JACC sobre la estratificacion de pacientes del MADIT II, con las caracteristicas de pacientes en quienes es mas beneficioso el implante de CDI dentro del perfil MADIT II.
http://jmrubioc.googlepages.com/MADITII_EStratificacionclinica_JACC0.pdf
miércoles, 11 de junio de 2008
Articulo Revision Coronary CT
La Dra Sanchez-Borque nos manda este articulo de revision del Heart de este mes sobre TAC coronario, con informacion sobre historia, tecnologia básica, aplicaciones...
http://heart.bmj.com/cgi/content/full/94/6/781
http://heart.bmj.com/cgi/content/full/94/6/781
martes, 10 de junio de 2008
Aliskiren y valsartan
Aliskiren Combined with Losartan in Type 2 Diabetes and Nephropathy
Hans-Henrik Parving, M.D., D.M.Sc., Frederik Persson, M.D., Julia B. Lewis, M.D., Edmund J. Lewis, M.D., and Norman K. Hollenberg, M.D., Ph.D., for the AVOID Study Investigators*
Background Diabetic nephropathy is the leading cause of end-stage renal disease in developed countries. We evaluated the renoprotective effects of dual blockade of the renin−angiotensin−aldosterone system by adding treatment with aliskiren, an oral direct renin inhibitor, to treatment with the maximal recommended dose of losartan (100 mg daily) and optimal antihypertensive therapy in patients who had hypertension
and type 2 diabetes with nephropathy.
Methods We enrolled 599 patients in this multinational, randomized, double-blind study. After a 3-month, open-label, run-in period during which patients received 100 mg of losartan daily, patients were randomly assigned to receive 6 months of treatment with aliskiren (150 mg daily for 3 months, followed by an increase in dosage to 300 mg daily for another 3 months) or placebo, in addition to losartan. The primary outcome was a reduction in the ratio of albumin to creatinine, as measured in an earlymorning urine sample, at 6 months.
Results The baseline characteristics of the two groups were similar. Treatment with 300 mg of aliskiren daily, as compared with placebo, reduced the mean urinary albumin-tocreatinine ratio by 20% (95% confidence interval, 9 to 30; P<0.001), with a reduction of 50% or more in 24.7% of the patients who received aliskiren as compared with 12.5% of those who received placebo (P<0.001). A small difference in blood pressure was seen between the treatment groups by the end of the study period (systolic, 2 mm Hg lower [P = 0.07] and diastolic, 1 mm Hg lower [P = 0.08] in the aliskiren group). The total numbers of adverse and serious adverse events were similar in the groups.
Conclusions Aliskiren may have renoprotective effects that are independent of its bloodpressure−lowering effect in patients with hypertension, type 2 diabetes, and nephropathywho are receiving the recommended renoprotective treatment.
Comentario Dra Ana Pastor
COMENTARIOS:
-La proteinuria persistente es el final de la nefropatía diabética, un estado que se caracteriza por el aumento progresivo de la TA, una disminución del filtrado glomerular, y un riesgo elevado de acontecimientos adversos cardiovasculares.
- Este estudio a doble ciego muestra una reducción de albuminuria en grupo control vs placebo, que sigue siendo significativa tras ajustarse a TAS en cada grupo. Es decir, que la reducción de la proteinuria es independiente al efecto antihipertensivo del fármaco y del losartán.
-En este estudio no se incluyeron pacientes con K mayor de 5.1 ni pacientes con filtardo glomerular <30ml/min. Por lo que el efecto sobre el potasio sérico y en pacientes con función renal deprimida no ha sido estudiado.
Hans-Henrik Parving, M.D., D.M.Sc., Frederik Persson, M.D., Julia B. Lewis, M.D., Edmund J. Lewis, M.D., and Norman K. Hollenberg, M.D., Ph.D., for the AVOID Study Investigators*
Background Diabetic nephropathy is the leading cause of end-stage renal disease in developed countries. We evaluated the renoprotective effects of dual blockade of the renin−angiotensin−aldosterone system by adding treatment with aliskiren, an oral direct renin inhibitor, to treatment with the maximal recommended dose of losartan (100 mg daily) and optimal antihypertensive therapy in patients who had hypertension
and type 2 diabetes with nephropathy.
Methods We enrolled 599 patients in this multinational, randomized, double-blind study. After a 3-month, open-label, run-in period during which patients received 100 mg of losartan daily, patients were randomly assigned to receive 6 months of treatment with aliskiren (150 mg daily for 3 months, followed by an increase in dosage to 300 mg daily for another 3 months) or placebo, in addition to losartan. The primary outcome was a reduction in the ratio of albumin to creatinine, as measured in an earlymorning urine sample, at 6 months.
Results The baseline characteristics of the two groups were similar. Treatment with 300 mg of aliskiren daily, as compared with placebo, reduced the mean urinary albumin-tocreatinine ratio by 20% (95% confidence interval, 9 to 30; P<0.001), with a reduction of 50% or more in 24.7% of the patients who received aliskiren as compared with 12.5% of those who received placebo (P<0.001). A small difference in blood pressure was seen between the treatment groups by the end of the study period (systolic, 2 mm Hg lower [P = 0.07] and diastolic, 1 mm Hg lower [P = 0.08] in the aliskiren group). The total numbers of adverse and serious adverse events were similar in the groups.
Conclusions Aliskiren may have renoprotective effects that are independent of its bloodpressure−lowering effect in patients with hypertension, type 2 diabetes, and nephropathywho are receiving the recommended renoprotective treatment.
Comentario Dra Ana Pastor
COMENTARIOS:
-La proteinuria persistente es el final de la nefropatía diabética, un estado que se caracteriza por el aumento progresivo de la TA, una disminución del filtrado glomerular, y un riesgo elevado de acontecimientos adversos cardiovasculares.
- Este estudio a doble ciego muestra una reducción de albuminuria en grupo control vs placebo, que sigue siendo significativa tras ajustarse a TAS en cada grupo. Es decir, que la reducción de la proteinuria es independiente al efecto antihipertensivo del fármaco y del losartán.
-En este estudio no se incluyeron pacientes con K mayor de 5.1 ni pacientes con filtardo glomerular <30ml/min. Por lo que el efecto sobre el potasio sérico y en pacientes con función renal deprimida no ha sido estudiado.
Articulo Clopidogrel JACC Junio 08
Volume 51, Issue 23, June 10, 2008
CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY
Long-Term Outcomes by Clopidogrel Duration and Stent Type in a Diabetic Population With De Novo Coronary Artery Lesions
Somjot S. Brar, MD*,*, John Kim, MD, Simerjeet K. Brar, BS, Ray Zadegan, MD, Michael Ree, BS, In-Lu A. Liu, MS, Prakash Mansukhani, MD, Vicken Aharonian, MD, Ric Hyett, BS and Albert Yuh-Jer Shen, MDObjectives: The purpose of this study was to determine whether long-term clinical outcomes differed between bare-metal stents (BMS) and drug-eluting stents (DES) by duration of clopidogrel use among diabetic patients.
Background: There is concern that DES are associated with late adverse events such as death and myocardial infarction (MI) secondary to stent thrombosis. However, data on outcomes in diabetic patients remain limited.
Methods: We identified 749 patients with diabetes mellitus who underwent stent implantation with either BMS (n = 251) or DES (n = 498) from October 2002 to December 2004. We performed survival analysis on the full cohort and on those event-free from death, MI, or repeat revascularization at 6 months (n = 671).
Results: By clopidogrel duration, the event rate for death or MI was 3.2% in the >9-month group, 9.4% in the 6- to 9-month group, and 16.5% in the <6-month>9-month group, 4.3% in the 6- to 9-month group, and 10.0% in the <6-month group, p < 0.001. When taking BMS clopidogrel non-users as a referent in the multivariate analysis, the hazard ratio (95% confidence interval [CI]) for death and nonfatal MI for DES clopidogrel users, DES clopidogrel nonusers, and BMS clopidogrel users were: HR 0.22 (95% CI 0.08 to 0.62, p = 0.005), HR 0.39 (95% CI 0.13 to 1.13, p = 0.08), and HR 0.25 (95% CI 0.08 to 0.81, p = 0.02), respectively.
Conclusions: Longer duration of clopidogrel use was associated with a lower incidence of death or MI in both the BMS and DES groups. Among clopidogrel nonusers, the incidence of death/MI or death did not differ by stent type.
COMENTARIOS de Dr Piñero:
- Estamos hablando de pacientes diabéticos, en donde más indicados están los DES (por la alta tasa de reestenosis que presentan estos pacientes)
- Cuánto mayor tiempo se use Clopidogrel parece que menor es la tasa de IAM/muerte TANTO para DES como BMS. PERO ¿por qué recomendaban tanto tiempo el clopidogrel a los paciente con BMS? (¿por ser SCA?, si es así habría que dar de todas todas 1 año de clopidogrel independeientemente del tipo del Stent, si no me equivoco)
- Aunque no se encuentran diferencias estadísticamente significativas de IAM/Mortalidad entre los pacientes que no toman clopidogrel, independientemente del tipo de Stent, sí que parece que existe un efecto favorable de los DES (a pesar de no tomar Clopidogrel; HR 0.39 (95% CI 0.13 to 1.13, p = 0.08)).
Esto podría ser importante y a discutir, porque en principio en todos los pacientes que no van a poder tomar clopidogrel ni se plantea el poner un DES- Se trata de un estudio observacional, no es un ensayo clínico, por lo que hay que tener cuidado con la interpretación de los resultados.
CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY
Long-Term Outcomes by Clopidogrel Duration and Stent Type in a Diabetic Population With De Novo Coronary Artery Lesions
Somjot S. Brar, MD*,*, John Kim, MD, Simerjeet K. Brar, BS, Ray Zadegan, MD, Michael Ree, BS, In-Lu A. Liu, MS, Prakash Mansukhani, MD, Vicken Aharonian, MD, Ric Hyett, BS and Albert Yuh-Jer Shen, MDObjectives: The purpose of this study was to determine whether long-term clinical outcomes differed between bare-metal stents (BMS) and drug-eluting stents (DES) by duration of clopidogrel use among diabetic patients.
Background: There is concern that DES are associated with late adverse events such as death and myocardial infarction (MI) secondary to stent thrombosis. However, data on outcomes in diabetic patients remain limited.
Methods: We identified 749 patients with diabetes mellitus who underwent stent implantation with either BMS (n = 251) or DES (n = 498) from October 2002 to December 2004. We performed survival analysis on the full cohort and on those event-free from death, MI, or repeat revascularization at 6 months (n = 671).
Results: By clopidogrel duration, the event rate for death or MI was 3.2% in the >9-month group, 9.4% in the 6- to 9-month group, and 16.5% in the <6-month>9-month group, 4.3% in the 6- to 9-month group, and 10.0% in the <6-month group, p < 0.001. When taking BMS clopidogrel non-users as a referent in the multivariate analysis, the hazard ratio (95% confidence interval [CI]) for death and nonfatal MI for DES clopidogrel users, DES clopidogrel nonusers, and BMS clopidogrel users were: HR 0.22 (95% CI 0.08 to 0.62, p = 0.005), HR 0.39 (95% CI 0.13 to 1.13, p = 0.08), and HR 0.25 (95% CI 0.08 to 0.81, p = 0.02), respectively.
Conclusions: Longer duration of clopidogrel use was associated with a lower incidence of death or MI in both the BMS and DES groups. Among clopidogrel nonusers, the incidence of death/MI or death did not differ by stent type.
COMENTARIOS de Dr Piñero:
- Estamos hablando de pacientes diabéticos, en donde más indicados están los DES (por la alta tasa de reestenosis que presentan estos pacientes)
- Cuánto mayor tiempo se use Clopidogrel parece que menor es la tasa de IAM/muerte TANTO para DES como BMS. PERO ¿por qué recomendaban tanto tiempo el clopidogrel a los paciente con BMS? (¿por ser SCA?, si es así habría que dar de todas todas 1 año de clopidogrel independeientemente del tipo del Stent, si no me equivoco)
- Aunque no se encuentran diferencias estadísticamente significativas de IAM/Mortalidad entre los pacientes que no toman clopidogrel, independientemente del tipo de Stent, sí que parece que existe un efecto favorable de los DES (a pesar de no tomar Clopidogrel; HR 0.39 (95% CI 0.13 to 1.13, p = 0.08)).
Esto podría ser importante y a discutir, porque en principio en todos los pacientes que no van a poder tomar clopidogrel ni se plantea el poner un DES- Se trata de un estudio observacional, no es un ensayo clínico, por lo que hay que tener cuidado con la interpretación de los resultados.
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