MD Conference Express AHA 2013 - (Page 29)
Table 1. CATIS Primary and Secondary Endpoints at 14 Days
Odds Ratio
Treatment Control (95% CI)
Death or major disability, %
p Value
33.6
0.98
33.6
Median modified Rankin score 2.0
2.0
Death, %
1.2
1.2
Median time of
hospitalization, days
13.0
1.00
(0.88, 1.14)
0.70
13.0
1.00
(0.57, 1.74)
0.99
0.28
Similarly, there was no significant difference in the
secondary composite outcome of death and major disability
at 3-month post-treatment follow-up (500 vs 502 events;
OR, 0.99; 95% CI, 0.86 to 1.15; p=0.93; Table 2).
Table 2. CATIS Secondary Outcomes at 3-Month Follow-Up
Treatment
Odds Ratio
Control (95% CI)
p Value
Death or major disability, %
25.2
25.3
0.93
Median modified Rankin
score
1.0
1.0
Death, %
3.4
2.7
1.27
(0.88, 1.82)
0.20
Recurrent stroke, %
1.4
2.2
0.65
(0.40, 1.04)
0.07
Vascular events, %
2.4
3.0
0.81
(0.55, 1.19)
0.28
Death or vascular events, %
4.6
4.7
0.98
(0.73, 1.31)
0.88
0.99
(0.86, 1.15)
0.52
Dr. He concluded that, in hypertensive acute ischemic
stroke patients, unless BP is very high (≥220/120 mm Hg),
routine use of antihypertensive treatment to rapidly reduce
BP to 140/90 mm Hg does not reduce morbidity or mortality.
Mitral Valve Repair and Replacement
Yield Similar Outcomes in SMR Study
Written by Mary Mosley
In the Evaluation of Outcomes Following Mitral Valve
Repair/Replacement in Severe Chronic Ischemic Mitral
Regurgitation study [SMR; NCT00807040; Acker M et al.
N Engl J Med 2013], the degree of left ventricular reverse
remodeling at 12 months did not differ in patients who
underwent mitral valve (MV) repair versus MV replacement.
Michael A. Acker, MD, Penn Heart and Vascular Center,
Philadelphia, Pennsylvania, USA, presented the results of
the federally funded (United States, Canada), prospective,
randomized, multicenter study.
Although some may have a preference for MV repair
over replacement in clinical practice, clinical guidelines
from the American Heart Association/American College
of Cardiology and the European Society of Cardiology have
stated that there is a lack of conclusive evidence for the
superiority of either strategy. Retrospective observational
studies indicate that MV repair is associated with
lower perioperative morbidity and mortality while MV
replacement is associated with greater durability [Vassileva
CM et al. Eur J Cardiothorac Surg 2011; Di Salvo TG et al.
J Am Coll Cardiol 2010; Grossi EA et al. J Thorac Cardiovasc
Surg 2001; Gillinov AM et al. J Thorac Cardiovasc Surg 2001].
A total of 251 patients with severe ischemic mitral
regurgitation (IMR) undergoing surgery with or without
coronary revascularization were randomized to MV repair
with annuloplasty ring insertion (n=126) or chordalsparing MV replacement (n=125). The primary endpoint
was the left ventricular end systolic volume index (LVESVI)
on transesophageal echocardiogram (TEE) at 12 months.
In the MV repair group, 11 patients had MV replacement,
while in the MV replacement group, 1 patient had MV repair.
The patients averaged 62 years of age and were mostly male
(62%) and white (78 to 82%).
There was no significant difference in the median
change in LVESVI at 12 months. The rate of recurrent
moderate or severe MR at 12 months-a secondary
endpoint-was significantly higher in the repair group
than in the replacement group (32.6% vs 2.3%; p<0.001). LV
reverse remodeling was seen only in patients undergoing
repair who did not have MR recurrence.
There was no difference in the rate of all-cause mortality
between the repair and replacement groups at 30 days or at
12 months.
The overall incidence of major adverse cardiovascular
and cerebrovascular endpoints at 12 months was also
similar between the two groups (HR, 0.91; 95% CI, 0.58
to 1.42; p=0.68), as was the rate of overall serious adverse
events (202.1 and 189.0 per 100-patient years for repair and
replacement, respectively; p=0.49). There was no difference
in the rates of heart failure, stroke, MV re-operation,
bleeding, localized infection, or rehospitalizations.
Quality-of-life measures were also similar between
groups, with significant improvement seen from baseline in
both the repair and replacement groups as measured by the
Short-Form Health Survey and the Minnesota Living With
Heart Failure questionnaire. The NYHA classification was
significantly improved at 12 months in surviving patients,
with more patients in Classes I and II at 12 months compared
with baseline; the classifications did not differ across groups.
Although this study showed no difference overall
between the two surgical approaches, Dr. Acker stated that
additional follow-up and subgroup analyses may provide
insight about the predictors and clinical impact of MR
recurrence to help optimize therapeutic decision-making
for individual patients.
Official Peer-Reviewed Highlights From the American Heart Association Scientific Sessions 2013
29
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