Showing papers by "Elliott M. Antman published in 2008"
TL;DR: Elliott M. Antman, MD, FACC, FAHA, Co-Chair*†; Mary Hand, MSPH, RN,FAHA, co-Chair; Paul W. Armstrong,MD, F ACC, FAha‡§; Eric R. Bates, MD; Lakshmi K. Halasyamani, MD¶; Judith S. Lamas,MD; Charles J. Mullany, MB, MS, Facc.
Abstract: Elliott M. Antman, MD, FACC, FAHA, Co-Chair*†; Mary Hand, MSPH, RN, FAHA, Co-Chair; Paul W. Armstrong, MD, FACC, FAHA‡§; Eric R. Bates, MD, FACC, FAHA; Lee A. Green, MD, MPH ; Lakshmi K. Halasyamani, MD¶; Judith S. Hochman, MD, FACC, FAHA**; Harlan M. Krumholz, MD, FACC, FAHA††; Gervasio A. Lamas, MD, FACC**; Charles J. Mullany, MB, MS, FACC; David L. Pearle, MD, FACC, FAHA; Michael A. Sloan, MD, FACC; Sidney C. Smith, Jr, MD, FACC, FAHA§§
1,565 citations
TL;DR: Elliott M. Antman, MD, FACC, FAHA, Chair of the FACC/FAHA Education Committee, presents a state-of-the-art assessment of the state of the science and practice of FACC and FAHA in the field of education and training in the rapidly changing environment.
957 citations
TL;DR: The American College of Cardiology Foundation (ACCF) Task Force on Clinical Expert Consensus Documents (ECDs) as mentioned in this paper developed by the ACCF and other cosponsors are intended to inform practitioners, payers, and other interested parties of the opinion of the ACC and document cosponsors concerning evolving areas of clinical practice and/or technologies that are widely available or new to the practice community.
Abstract: This document has been developed by the American College of Cardiology Foundation (ACCF) Task Force on Clinical Expert Consensus Documents, the American College of Gastroenterology (ACG), and the American Heart Association (AHA). Expert consensus documents (ECDs) are intended to inform practitioners, payers, and other interested parties of the opinion of the ACCF and document cosponsors concerning evolving areas of clinical practice and/or technologies that are widely available or new to the practice community. Topics chosen for coverage by ECDs are so designed because the evidence base, the experience with technology, and/or the clinical practice are not considered sufficiently well developed to be evaluated by the formal American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines process. Often the topic is the subject of ongoing investigation. Thus, the reader should view ECDs as the best attempt of the ACCF and other cosponsors to inform and guide clinical practice in areas where rigorous evidence may not be available or the evidence to date is not widely accepted. When feasible, ECDs include indications or contraindications. Topics covered by ECDs may be addressed subsequently by the ACC/AHA Practice Guidelines Committee as new evidence evolves and is evaluated.
The Task Force on ECDs makes every …
824 citations
TL;DR: Subjects with DM tended to have a greater reduction in ischemic events without an observed increase in TIMI major bleeding and therefore a greater net treatment benefit with prasugrel compared with clopidogrel, demonstrating that the more intensive oral antiplatelet therapy provided with pr asugrel is of particular benefit to patients with DM.
Abstract: Background—Patients with diabetes mellitus (DM) are at high risk for recurrent cardiovascular events after acute coronary syndromes, in part because of increased platelet reactivity. The Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel–Thrombolysis in Myocardial Infarction 38 (TRITON-TIMI 38) showed an overall reduction in ischemic events with more intensive antiplatelet therapy with prasugrel than with clopidogrel but with more bleeding. We compared prasugrel with clopidogrel among subjects with DM in TRITON-TIMI 38. Methods and Results—We classified 13 608 subjects on the basis of preexisting history of DM and further according to insulin use. Prespecified analyses of the primary (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) and key secondary end points, including net clinical benefit (death, nonfatal myocardial infarction, nonfatal stroke, and nonfatal TIMI major bleeding) were compared by use of the log-rank test. We found that 3146 subjects had a preexisting history of DM, including 776 receiving insulin. The primary end point was reduced significantly with prasugrel among subjects without DM (9.2% versus 10.6%; hazard ratio [HR], 0.86; P0.02) and with DM (12.2% versus 17.0%; HR, 0.70; P0.001, Pinteraction0.09). A benefit for prasugrel was observed among DM subjects on insulin (14.3% versus 22.2%; HR, 0.63; P0.009) and those not on insulin (11.5% versus 15.3%; HR, 0.74; P0.009). Myocardial infarction was reduced with prasugrel by 18% among subjects without DM (7.2% versus 8.7%; HR, 0.82; P0.006) and by 40% among subjects with DM (8.2% versus 13.2%; HR, 0.60; P0.001, Pinteraction0.02). Although TIMI major hemorrhage was increased among subjects without DM on prasugrel (1.6% versus 2.4%; HR, 1.43; P0.02), the rates were similar among subjects with DM for clopidogrel and prasugrel (2.6% versus 2.5%; HR, 1.06; P0.81, Pinteraction0.29). Net clinical benefit with prasugrel was greater for subjects with DM (14.6% versus 19.2%; HR, 0.74; P0.001) than for subjects without DM (11.5% versus 12.3%; HR, 0.92; P0.16, Pinteraction0.05). Conclusions—Subjects with DM tended to have a greater reduction in ischemic events without an observed increase in TIMI major bleeding and therefore a greater net treatment benefit with prasugrel compared with clopidogrel. These data demonstrate that the more intensive oral antiplatelet therapy provided with prasugrel is of particular benefit to patients with DM. (Circulation. 2008;118:1626-1636.)
736 citations
TL;DR: Intensive antiplatelet therapy with prasugrel resulted in fewer ischaemic outcomes including stent thrombosis than with standard clopidogrel, and the data affirm the importance of intensive platelet inhibition in patients with intracoronary stents.
447 citations
TL;DR: Both the loading dose and maintenance dose of prasugrel were superior to clopidogrel for the reduction of ischemic events in a TRITON-TIMI 38 analysis, emphasizing the importance of maintaining high levels of inhibition of platelet aggregation via P2Y(12) receptor inhibition during long-term follow-up.
318 citations
TL;DR: In this paper, the authors proposed a general approach to the patient to predict preoperative Cardiac Morbidity using a combination of physical examination and routine laboratory tests and multivariable Indices.
Abstract: TABLE OF CONTENTSPreamble 686Definition of the Problem 688Purpose of These Guidelines 688Methodology and Evidence 689General Approach to the Patient 692History 693Physical Examination and Routine Laboratory Tests 693Multivariable Indices to Predict Preoperative Cardiac Morbidity 694Clinical Assessme
304 citations
TL;DR: The benefits and risks of antiplatelet therapy and NSAID use are summarized in this document as well as recommendations for further study and individual patients' needs are outlined.
219 citations
TL;DR: Prasugrel, a more potent anti-platelet agent, reduced both first and subsequent cardiovascular events compared with clopidogrel in patients with ACS.
Abstract: Aims In the TRITON-TIMI 38 trial, greater platelet inhibition with prasugrel reduced the first occurrence of the primary endpoint (cardiovascular death, MI, or stroke) compared with clopidogrel in patients with an acute coronary syndrome (ACS) undergoing planned percutaneous coronary intervention. We hypothesized that prasugrel would reduce not only first events but also recurrent primary endpoint events and therefore total events compared with clopidogrel.
Methods and results Poisson regression analysis was performed to compare the number of occurrences of the primary endpoint between prasugrel and clopidogrel in TRITON-TIMI 38. Landmark analytic methods were used to evaluate the risk of a recurrent primary endpoint event following an initial non-fatal endpoint event. Among patients with an initial non-fatal event, second events were significantly reduced with prasugrel compared to clopidogrel (10.8 vs. 15.4%, HR 0.65, 95% CI 0.46–0.92; P = 0.016), as was CV death following the non-fatal event (3.7 vs. 7.1%, HR 0.46, 95% CI 0.25–0.82; P = 0.008). Overall there was a reduction of 195 total primary efficacy events with prasugrel vs. clopidogrel (rate ratio 0.79, 95% CI 0.71–0.87; P < 0.001). Recurrent bleeding events occurred infrequently (TIMI major non-CABG bleeds: four with prasugrel and two with clopidogrel). Study drug discontinuation was frequent following the initial major bleeding event (42% of patients discontinued study drug).
Conclusion While standard statistical analytic techniques for clinical trials censor patients who experience a component of the primary composite endpoint, total cardiovascular events remain important to both patients and clinicians. Prasugrel, a more potent anti-platelet agent, reduced both first and subsequent cardiovascular events compared with clopidogrel in patients with ACS.
138 citations
TL;DR: Improvements in access to timely care for patients with STEMI will require a multifaceted approach involving patient education, improvements in the Emergency Medical Services and emergency department components of care, as well as coordinated advocacy efforts to work with payers and policy makers to implement a much-needed health care system redesign.
137 citations
TL;DR: A Markov cost-effectiveness model suggests that providing full coverage for combination therapy to post–myocardial infarction Medicare beneficiaries would save both lives and money from the societal perspective.
Abstract: Background— Effective therapies for the secondary prevention of coronary heart disease–related events are significantly underused, and attempts to improve adherence have often yielded disappointing results. Elimination of patient out-of-pocket costs may be an effective strategy to enhance medication use. We sought to estimate the incremental cost-effectiveness of providing full coverage for aspirin, β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins (combination pharmacotherapy) to individuals enrolled in the Medicare drug benefit program after acute myocardial infarction. Methods and Results— We created a Markov cost-effectiveness model to estimate the incremental cost-effectiveness of providing Medicare beneficiaries with full coverage for combination pharmacotherapy compared with current coverage under the Medicare Part D program. Our analysis was conducted from the societal perspective and considered a lifetime time horizon. In a sensitivity analysis, we...
TL;DR: The American College of Cardiology and American Heart Association have issued a "focused update" of their 2004 guidelines for the management of ST-segment elevation myocardial infarction, and new recommendations on treatment decisions that may be made in the emergency department are presented.
TL;DR: A model to predict 1-year mortality in patients surviving at least 30 days in patients with high-risk NSTE ACS may be quite helpful to healthcare providers in setting expectations and goals with patients after ACS.
Abstract: BACKGROUND
Despite advances in pharmacologic therapy and invasive management strategies for patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS), these patients still suffer substantial morbidity and mortality.
TL;DR: The Post-MI FREEE trial will be the first randomized study to evaluate the impact of reducing cost-sharing for essential cardiac medications in high-risk patients on clinical and economic outcomes.
01 Jan 2008
01 Jan 2008
TL;DR: The results of TRITON–TIMI 38 support the hypothesis that an agent achieving a greater and more consistent level of platelet inhibition (prasugrel) would improve clinical ischemic outcomes compared with standard approved doses of clopidogrel in patients at moderate to high risk with acute coronary syndromes.
Abstract: A primary goal of the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel–Thrombolysis in Myocardial Infarction 38 (TRITON–TIMI 38) was to test the hypothesis that an agent achieving a greater and more consistent level of platelet inhibition (prasugrel) would improve clinical ischemic outcomes compared with standard approved doses of clopidogrel in patients at moderate to high risk with acute coronary syndromes (ACS) who underwent percutaneous coronary intervention (PCI). 1 The results of TRITON–TIMI 38 support this hypothesis, with a highly significant 19% relative reduction favoring prasugrel in the primary composite end point of cardiovascular (CV) death, nonfatal myocardial infarction (MI), and nonfatal stroke, from 12.1% to 9.9%, over a period of up to 15 months of followup. This reduction was observed at the cost of more serious bleeding. 2
TL;DR: Patients previously diagnosed with unstable angina are more properly diagnosed as having non–ST-elevation MI (NSTEMI) on the basis of the detection of elevated levels of cardiac troponins in their blood.
Abstract: Cardiac biomarkers of necrosis provide clinicians with important “messages” from the heart. They are released into the interstitium of the myocardium after loss of the integrity of cardiac myocyte membranes. The pattern of the rise and fall of an individual biomarker (ie, its release kinetics) depends on its intracellular location in the myocyte, molecular weight, and clearance from the interstitium of the myocardium and ultimately the circulation.1 Cardiac biomarkers play an integral role in the clinical diagnosis of myocardial infarction (MI). Referring to the spontaneous occurrence of MI in patients, the World Health Organization required that at least 2 of the following be present to fulfill the criteria for MI: a history of ischemia-type chest discomfort, evolutionary changes on serially obtained ECG tracings, and a rise and fall in serum cardiac markers.2
Article see p 10
See Editorial Circulation . 2008;118:609–611
See Article Circulation . 2008;118:632–638
Several dramatic advances have occurred in the biomarker component of the diagnosis of MI. Analytes with greater specificity for the myocardium were introduced into clinical medicine, with creatine kinase-MB replacing total creatine kinase and subsequently cardiac-specific troponins replacing creatine kinase-MB as the biomarker of choice for diagnosing MI.3 Assay technology improved as clinical chemists moved from enzymatic activity assays for CK to highly specific immunoassays that can detect progressively smaller concentrations of cardiac troponins in the peripheral circulation.4 Although ST-elevation MI (STEMI) is easily identified on the 12-lead ECG, we now recognize that many patients previously diagnosed with unstable angina are more properly diagnosed as having non–ST-elevation MI (NSTEMI) on the basis of the detection of elevated levels of cardiac troponins in their blood.5 Cardiac biomarkers are used as a rough guide to the extent of myocardial necrosis. The higher the peak biomarker level after STEMI, the larger the …
TL;DR: The combination of RI and DM was associated with a particularly high risk of MI and death/MI suggesting that attention to preserving renal function may be of particular benefit for reducing cardiovascular risk in diabetic patients.
TL;DR: Smokers with non-ST-segment elevation acute coronary syndrome are generally younger and have fewer cardiac risk factors and there was little difference in outcomes from 30 days to 1 year for these smokers who quit versus those who did not.
Journal Article•
Journal Article•
TL;DR: TRITON-TIMI 38 randomized 13,608 ACS patients to prasugrel or standard dose clopidogrel, and demonstrated significantly reduced ischemic events with pr asugrel.
Abstract: TRITON-TIMI 38 randomized 13,608 ACS patients to prasugrel or standard dose clopidogrel, and demonstrated significantly reduced ischemic events with prasugrel. Prasugrel has been shown to produce h...
Journal Article•
Journal Article•
TL;DR: In this large group of patients undergoing PCI for ACS, RAA, but not femoral closure devices, were associated with significantly lower rates of instrumented bleeding and transfusion and attenuated the bleeding differences between prasugrel or clopidogrel.
Abstract: Background: Bleeding during acute coronary syndromes (ACS) is associated with worse prognosis. TRITON - TIMI 38 was designed for all patients to have cardiac catheterization, providing an opportunity to evaluate the effects of arterial access site and management on the rates of hemorrhage. Methods: TRITON - TIMI 38 included 13608 patients with ACS; 99% underwent PCI at the time of randomisation. We compared the incidence of non-CABG TIMI major and minor bleeding between three groups: radial artery access (RAA), and femoral artery access with (FAA-CD) and without the use of an arterial closure device (FAA-NC). Results: FAA was used in 12273 (92%) of patients undergoing angiography. FAA-CD was used in 3842 (31%) of FAA. RAA was used in 1120 patients (8%). Compared to FAA, patients with RAA had less prior CAD (MI, PCI or CABG) less frequently received drug-eluting stents and glycoprotein IIb/IIIa inhibitors (GPI). Femoral closure devices were used more often in patients > 90 kg, with a GPI and less frequently in patients chronic kidney disease or prior atherosclerosis (MI, stroke, PAD). TIMI non-CABG major bleeding was non-significantly less frequent with RAA. RAA was associated with a lower rate of TIMI major or minor non-CABG instrumented bleeding (Table, HR 3.09; P=0.004) and blood transfusion (Table; HR 2.05; P=0.002). The rates of spontaneous bleeding were not affected by the site of the arterial access. (Table). FAA-CD had similar bleeding and transfusion rates to FAA-NC. (Table). The previously reported higher rates of bleeding and transfusion with prasugrel were limited to FAA. Conclusions: In this large group of patients undergoing PCI for ACS, RAA, but not femoral closure devices, were associated with significantly lower rates of instrumented bleeding and transfusion and attenuated the bleeding differences between prasugrel or clopidogrel. A strategy of RAA in the presence of intensive antiplatelet therapy warrants further study to reduce bleeding complications.
TL;DR: Is fondaparinux safer than enoxaparin for patients undergoing percutaneous coronary intervention?
Abstract: Is fondaparinux safer than enoxaparin for patients undergoing percutaneous coronary intervention?