Showing papers by "William E. Boden published in 2001"

Suture closure of the femoral arteriotomy following invasive cardiac procedures: a detailed analysis of efficacy, complications, and the impact of early ambulation in 1,200 consecutive, unselected cases.

Abstract: The purpose of this study was to assess the efficacy and safety of using a percutaneous suture device to close femoral arteriotomies following invasive cardiac procedures. All patients presenting for invasive cardiac procedures performed from the femoral artery were considered for suture closure. Patients were carefully assessed for access site complications, oozing, and the impact of suture closure on the safety of early ambulation. Clinical follow-up at 3-6 months was performed to assess for late complications. Femoral artery suture closures were performed in 1,200 consecutive cases in 1,097 patients. In 12.8% of cases, the patients ambulated within 1 hr. The success rate was 91.2% and the complication rate was 3.4%. Complications included the development of a hematoma (2.1%), the need for vascular surgery (0.6%), retroperitoneal hemorrhage (0.3%), blood transfusion (0.7%), local infection (0.5%), and pseudoaneurysm formation (0.1%). Factors found to be independently predictive of procedural failure were an age > 70 years, an ACT > 300 sec, left femoral artery access, and the performance of primary angioplasty. Follow-up at 3-6 months revealed no major hemorrhagic complications. We conclude that percutaneous suture closure effectively achieves femoral artery hemostasis in patients undergoing invasive cardiac procedures. The technique permits early ambulation and is associated with a relatively low incidence of complication.

Interpreting new treatment guidelines for non-ST-segment elevation acute coronary syndromes.

Abstract: The American College of Cardiology/American Heart Association Task Force on Practice Guidelines has published recommendations on the diagnosis and treatment of patients with known or suspected unstable angina and non-ST-segment elevation myocardial infarction. The acute ischemia pathway presented in these guidelines encompasses both an early invasive strategy and an early conservative strategy. There are now 4 randomized, controlled trials that have compared the routine early invasive strategy with the selective-invasive or ischemia-guided strategy (Thrombolysis in Myocardial Infarction [TIMI] IIIB, Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital [VANQWISH], Fragmin and Fast Revascularization During Instability in Coronary Artery Disease [FRISC] II, and Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy [TACTICS]-TIMI 18). The most relevant of these studies to current clinical practice are the FRISC II and TACTICS-TIMI 18 studies. The data from these studies indicate that ST-segment depression or elevated levels of troponin or the MB isoenzyme of creatinine kinase are markers of increased risk and that such patients would benefit from early revascularization. However, the data further suggest that aggressive antiplatelet, antithrombin, and anti-ischemic therapies are also important. Although FRISC II and TACTICS-TIMI 18 support an early invasive approach in most patients (ie, intermediate- and high-risk patients) with non-ST-segment elevation acute coronary syndromes (ACS), all 4 trials support a more conservative approach in those without electrocardiographic changes or enzyme elevations, notably the use of intensive antiplatelet, antithrombotic, and anti-ischemic therapy combined with careful clinical assessment and provocative testing. Patients then undergo catheterization and revascularization only if spontaneous angina occurs or if there is electrocardiographic, enzymatic, or other objective evidence of stress-induced myocardial ischemia. We conclude that tailoring the early initial therapy in hospital to the level of risk is essential to optimizing efficacy and clinical outcomes in this challenging, but common group of ACS patients.

Roundtable discussion: therapeutic challenges and deficiencies.

Abstract: ROUNDTABLE DISCUSSION Jeffrey J. Popma, MD (Boston, Massachusetts): Let’s consider the situation of a 70-year-old man who is admitted with unstable angina caused by restenosis in a vein graft to the left anterior descending artery (Table 1). The graft was treated with atherectomy and -radiation therapy with strontium 90. Preliminary data from 2 trials have been presented showing that radiation is as effective as radiation in preventing restenosis. These trials are Sr Treatment of Angiographic Restenosis (START)1 and Intimal Hyperplasia Inhibition with Beta In-stent (INHIBIT).2 The full reports are expected soon. What about further management of this patient? Do you treat the elderly the same as you do young patients? Donald B. Hunninghake, MD (Minneapolis, Minnesota): A person who has a clinical event should be treated, regardless of age. Improving quality of life and preventing recurrent events are the primary goals of therapy. Prolonging life is secondary. This patient has diabetes along with coronary artery disease, and in such patients, the levels of low-density lipoprotein cholesterol (LDL-C) should be 100 mg/dL. Personally, I would place this patient on a high dose of a statin (eg, atorvastatin 80 mg), with a target of 60 mg/dL. Data also suggest that it would be prudent to consider adding niacin to reduce triglycerides beyond that obtained with a statin, as well as to increase the level of high-density lipoprotein cholesterol (HDL-C). We recently published data showing that niacin can be given to patients with diabetes without deterioration in carbohydrate tolerance.3 A fibrate could also be considered to decrease levels of triglycerides. The patient also needs to be advised to lose weight. William E. Boden, MD (Hartford, Connecticut): I agree with Dr. Hunninghake. This patient has similar HDL-C and LDL-C levels as the Veterans Affairs High-Density Lipoprotein Intervention Trial Study Group (VA-HIT) population.4 The results of that study suggest that even a relatively small increase in HDL-C may have clinical benefit. Andrew P. Selwyn, MD (Boston, Massachusetts): Coexisting diabetes and hypertension are strong reasons for prescribing angiotensin-converting enzyme (ACE) inhibitors for their antihypertensive and renoprotective effects. But to address a broader issue, this patient has the original coronary artery disease plus the different pathologies associated with bypass surgeries and stenting. Whenever I see a patient like this in the clinic, the first thought that comes to mind is that of decades of missed opportunities. Roger S. Blumenthal, MD (Baltimore, Maryland): It seems to me that this case study demonstrates why this educational program was begun. This person has been exposed to numerous surgeons and cardiologists and yet is still undertreated. The cost of aggressive risk-factor management would have been less than the surgeries and other interventions this patient has ended up receiving. Dr. Boden: The Clinical Outcome Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial5 is designed to test a new management paradigm involving aggressive risk-factor modification plus aggressively treating the culprit lesion. The risk-factor modification addresses many of the issues discussed here. Lifestyle modification will include smoking cessation, the American Heart Association (AHA) Step II diet, and moderate physical exercise 3 to 4 times per week. Target levels will be 60 From the Department of Medicine, Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts, USA; University of Minnesota School of Medicine, Minneapolis, Minnesota, USA; Department of Preventive Cardiology, St. Francis Hospital, Roslyn, New York, USA; Division of Cardiology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; and University of Connecticut School of Medicine, Division of Cardiology, Hartford Hospital, Hartford, Connecticut, USA. Address for reprints: Jeffrey J. Popma, MD, Interventional Cardiology, Brigham and Women’s Hospital, 75 Francis Street, L-2 Catheterization Laboratory, Boston, Massachusetts 02115. E-mail: jpopma@ partners.org TABLE 1 Case History: 70-Year-Old Man with Unstable Angina