MD Conference Express ACC 2012 - (Page 17)

randomized trials [Connolly SJ et al. JAMA 2003; Raviele A et al. Eur Heart J 2004] that failed to prove the superiority of cardiac pacing over placebo for the prevention of syncopal recurrences in unselected patients who were affected by NMS. Prof. Brignole believes that the discrepancy between these findings may be explained by the current study’s use of implantable loop recorders (ILRs) to document asystole in patients with NMS before beginning therapy. This was a randomized, controlled, double-blind trial of cardiac pacing in 77 patients with NMS who had asystolic syncope ≥3 seconds or nonsyncopal asystole ≥6 seconds, as established with the use of an ILR. The primary endpoint was time to first syncope recurrence. Subjects with qualifying asystolic events had pacemakers implanted and were randomized 1:1 to either pacemaker on (PM on) or pacemaker off (PM off ) groups. The study was stopped when a total of 27 primary endpoint events, irrespective of study arm, were reached. There were a total of 158 documented endpoints during the ILR screening phase; 56% patients had asystole, 23% had normal sinus rhythm, 10% had tachycardia, and 10% had bradycardia. Baseline characteristics included a mean participant age of 63 years in each group, of which approximately half in each group was female (47% PM on, 59% PM off), and >60% had a prior hospitalization for syncope. Over 80% in the cohort had tilt table testing, with fewer patients in the PM on group having positive results than in the PM off group (42% vs 72%). Diabetes was present in 29% of patients, while 23% had structural heart disease. Overall, patients were characterized by recurrent syncope that began in middle or older age with severe presentations; mean pause, captured by an ILR of 11 seconds; and frequent injuries that were related to absence of warning symptoms. After 24 months, 75% of PM on patients were free from recurrent syncopal episodes compared with 43% of patients who were randomized to PM off (log rank RRR, 57%; p=0.039). Complications were restricted to lead dislodgements (n=5) and 1 incidence of subclavian vein thrombosis. The authors concluded that dual-chamber permanent pacing is effective in reducing recurrence of syncope in patients aged ≥40 years with severe asystolic NMS and suggest that the use of this invasive treatment may be effective for relatively benign NMS. The overall strategy of using an ILR in order to determine suitable patients for pacing likely contributed to the positive findings and explains the discrepancy with the negative results of previous randomized controlled trials. In selected patients, syncope is recurrent, unpredictable, and associated with a high risk of trauma and poor quality of life. It often occurs while engaged in high-risk activity (eg, driving, machine operation, flying, competitive athletics). Prof. Brignole believes that the ILR screening phase is important in determining which patients should receive a pacemaker. Based on prior observations, 18% percent of patients who receive an ILR will be candidates for pacemaker therapy within 1 year, and approximately 40% will be candidates within 4 years. BRIDGE-ACS: Multifaceted Quality Improvement Program Ups the Use of Evidence-Based Care in Brazil Written by Rita Buckley Outcomes from the Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes Trial [BRIDGE-ACS; NCT00958958] show that a simple, multifaceted, educational intervention can lead to significant improvements in the use of evidence-based medications in patients with acute coronary syndromes (ACS). Otavio Berwanger, MD, PhD, Research Institute Hcor-Hospital do Coração, São Paulo, Brazil, presented results from the study. BRIDGE-ACS was a cluster-randomized (concealed allocation) trial that was conducted among 34 clusters (public hospitals) in Brazil. It enrolled a total of 1150 patients with ACS from March through November 2011, with follow-up through January 2012. The primary endpoint was the percentage of eligible patients who received all evidence-based therapies (aspirin, clopidogrel, anticoagulants, and statins) during the first 24 hours [Berwanger O et al. JAMA 2012; Berwanger O et al. Am Heart J 2012]. Secondary endpoints included adherence to all eligible evidence-based therapies during the first 24 hours and the use of aspirin, betablockers, statins, and ACE inhibitors at discharge; a composite evidence-based medicine score; and major cardiovascular (CV) events. CV endpoints, including mortality, CV death, recurrent ischemic events, and bleeding, were also measured as secondary endpoints. Outcomes were reviewed by blinded outcome assessors. The analyses were performed using an intention-to-treat principle. The trial included general public hospitals from major urban areas with an emergency department that treated patients with ACS. Eligible subjects were consecutive patients who met standardized definitions of ACS (STEMI, NSTEMI, and unstable angina) as soon as Continued on page 20 Highlights from the American College of Cardiology 61st Annual Scientific Session 17  http://www.mdconferencexpress.com

Table of Contents for the Digital Edition of MD Conference Express ACC 2012

MD Conference Express ACC 2012
Table of Contents
Treatment of AMI in the Post-Herrick Era
The State of Hypertension Guidelines: 2012
ACRIN PA 4005: Coronary CTA in the ED Identifies Low-Risk Patients and Shortens Length of Stay
One-Year STAMPEDE Trial Results
TAVR Associated with Increased Late Mortality from Paravalvular Regurgitation
The CABG Surgery Off- or On- Pump- Revascularization Study (CORONARY)
The Moderate PE Treated with Thrombolysis Study (MOPETT)
Pacemaker Therapy In Patients With Neurally Mediated Syncope and Documented Asystole
Outcomes from the BRIDGE-ACS Trial
ROMICAT II: More Data Evaluating CT-First for Acute Chest Pain ED Triage
Elective PCI at Community Hospitals With Versus Without On-Site Surgery
Results from the TRA 2P-TIMI 50 Trial
The HOST-ASSURE Randomized Trial
New Monoclonal Antibody to PCSK9 Markedly Lowers LDL-C in Patients on Atorvastatin
Oral Rivaroxaban Alone for Symptomatic PE
Neutral Outcomes But Important Insights From FOCUS-CCTRN
Imaging
STEMI
Acute Coronary Syndrome
Antiplatelet Therapy
New Anti-Diabetes Agents Offer Promise in the Fight Against CVD
The New Hypertrophic Cardiomyopathy Practice Guidelines

MD Conference Express ACC 2012

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