Cath Lab Digest - May 2008 - (Page 30)

30 SICP PROFESSIONALS OUT IN FRONT APRIL 2008 continued from previous page and 30 registries (enrolling 174,302 patients) that met our inclusion and exclusion criteria. These studies were combined using a technique known as meta-analysis, which weights each study to calculate an average estimate of safety and efficacy rates across studies. It is important to note that we performed separate analyses of randomized clinical trials and registries. To the best of our knowledge, this is the largest metaanalysis comparing DES and BMS to date. Q A What were the findings of this meta-analysis? The findings were two-fold. First, there did not appear to be an adverse safety signal associated with DES in either the randomized trials or the registries. In fact, we observed reductions in mortality and MI with DES among the registry studies. The reductions that we observed were 20 percent for mortality, and 11 percent for MI. It is important to note that the actual magnitude of the benefit that we observed should not be the take-home message from this analysis, because the comparison between DES and BMS in these studies was not randomized. Second, we found a significant reduction (approximately 50%) in terms of reducing repeat revascularization for DES both in randomized trials and in registry studies. This finding is perhaps equally important to the safety finding, because some have criticized the design of randomized clinical trials of DES as biased in favor of these stents through trial design characteristics such as the implementation of routine angiographic follow up. In our analysis, we found that the effects seen in the randomized trials were parallel to the findings in registries. Q A What was the duration of Plavix® used in these registries? It is likely varied among the different registries, because not all registries actually report the duration of dual anti-platelet therapy. Most registries that were conducted in the early DES era were only using anti-platelet therapy for three to six months, and the later registries may have used it for longer periods. Further, the BMS patients in registries were almost certainly using dual anti-platelet therapy for shorter periods of time. Therefore, I can’t answer that question using our summarylevel analysis that we conducted, but I would estimate that in these trials dual anti-platelet therapy generally was used for one year or less. How do you expect the current guidelines for one year of dual antiplatelet therapy to support the safety of DES? Because of the late-stent thrombosis issue, we tend to keep our patients on anti-platelet therapy longer than with BMS, and that was the spirit of the joint committee guidelines for one year of dual antiplatelet therapy. Unfortunately, there is limited — and conflicting — data addressing the issue of prolonged dual anti-platelet therapy. For example, whereas one publication (Eisenstein et al, JAMA 2007) suggested that continuation of dual anti-platelet therapy might be better, others have suggested that stopping dual anti-platelet therapy at six months does not appear to be associated with higher risk of late-stent thrombosis over long-term follow up. In the absence of a definitive trial, we do not really know the optimal duration of dual anti-platelet therapy, and therefore clinicians have been advised to follow the current guidelines (ACC/AHA/SCAI PCI Practice Guidelines) that state dual anti-platelet therapy be administered for at least 12 months for all DES. Is there any new data coming out on this topic of DES safety? A large randomized trial called the HORIZONS AMI trial, sponsored by the Cardiovascular Research Foundation, will address the issue of DES use in the setting of acute MI, which many clinicians feel puts patients at the highest thrombotic risk. In this study, we prospectively compare DES to BMS in AMI patients. The initial primary endpoint data regarding the efficacy of DES in reducing clinical restenosis will be presented at this year’s Transcatheter Cardiovascular Therapeutics (TCT) meeting, but as far as safety issues are concerned, we need longer-term follow up from this trial. Has the recent DES vs. BMS data affected your practice and/or DES adoption at your institution? Not really. Our group has historically had a lot of experience with DES. We use DES in approximately 80 percent of our cases at Columbia and we systematically collect outcomes on all patients treated with DES in our cath lab. We have seen cases of late-stent thrombosis, but in terms of our overall rate, it is quite low. In light of the initial data from SCAAR and the I truly love my job. Patient contact is probably the most important reason. I enjoy putting patients at ease and making their procedure less stressful. Are you involved with the SICP or other cardiovascular societies? Yes! I am a member of the SICP and President of the Oregon chapter. We affectionately call them “Skippy” meetings. I am also a member of AVIR (Association of Vascular and Interventional Radiographers). Are there websites or texts that you would recommend to other CV labs? Not so much websites, but I would suggest attending any of the Society of Interventional Radiology (SIR)/AVIR conferences. It is very worthwhile. If you could send a message back to yourself at the beginning of your CV lab career, what advice would you give? Get lighter lead; that stuff’s going to destroy your back! Where do you hope to be in your career when it is time to retire? I only have 9 years until retirement and I hope I continue with what I am doing today. Did I mention I love my job? Boating and fishing have also been a lifelong hobby for me. Has anyone in particular been helpful to you in your growth as a cardiovascular professional? Todd Chitwood. He told me many times, “You can do this! You’ve got what it takes.” When we train in our lab, we have set goals. We must meet these goals in order to move on. When I was in training, I had not yet reached my goal of 150 diagnostic case scrubs, but had to scrub in on an intervention. The physician I was scrubbed in with was confident in my skills and encouraged me to proceed. It went great and I’ve never looked back. Where do you think the invasive cardiology field is headed in the future? I believe drug-eluting stents will make their way to IR. I think that we will do less diagnostic cases and more interventions, due to the increased use of cardiac CT and MRI. It won’t surprise me to see standalone labs doing interventions, especially the radial approach. ■ Christopher Kambak can be contacted at CKambak@ohvi.org Q A Do you know a professional who deserves to be featured in Cath Lab Digest? Email Belinda Trollinger, RN, RCIS at: SICPBelinda@aol.com Bern-Rotterdam analyses, we thought that the best way to assess whether there was overall harm or benefit was to conduct rigorous analyses. That was one of the motivations behind the current analysis. Additionally, we have presented data from our MATRIX registry which is registered with the US FDA, and we conducted one of the original meta-analyses of randomized, controlled trials that was published in the New England Journal of Medicine at the same time as the SCAAR registry. Data from this meta-analysis showed that overall rates of death and MI were not higher with DES. Our conclusion was that there did not appear to be adverse safety signals with DES, but DES were efficacious. Plavix is a trademark of Sanofi-Aventis. The HORIZONS AMI Trial is co-funded by Boston Scientific. Q A Q A Sponsored and prepared by Boston Scientific Corporation

Table of Contents Feed for the Digital Edition of Cath Lab Digest - May 2008

Cath Lab Digest - May 2008 The King Faisal Specialist Hospital and Research Centre Cell Therapy in the Cath Lab for Heart Failure: A Look at MyoCell® Therapy and the SEISMIC Trial Performance Improvement Strategies Speed Up Treatment Times in the Management of ST-Elevation Myocardial Infarction (STEMI) Patients Contents Clinical Editor’s Corner Commentary: Performance Improvement Strategies Speed Up Treatment Times in the Management of ST-Elevation Myocardial Infarction (STEMI) Patients Ask the STEMI Expert Comparing Drug-Eluting Stents and Bare-Metal Stents SICP: The Ten-Minute Interview with… Christopher Kambak, RT(R) Cardiac Cath Lab Economics in a Public Hospital of a Developing Country Keeping Your Heart & Vascular Employees: Proven Ideas for an Effective Retention Plan Unspoken Words Ask the Clinical Instructor Society of Invasive Cardiovascular Professionals Meetings Calendar Education Center What Do You Think? Clinical & Industry News Classifieds Advertisers Index

Cath Lab Digest - May 2008

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