MD Conference Express ACC 2012 - (Page 16)

n C L I N I C A L T R I A L H I G H L I G H T S and shock), but these patients only represent 5% of all presentations with PE. Patients with moderate PE constitute a more prevalent population; however, there are often concerns about major bleeding (which occurs in 6% to 20% of cases) and intracranial hemorrhage (ICH; 2% to 6% of cases) in moderate PE patients when larger doses of t-PA are employed. In addition, practitioners are hesitant to use t-PA when patients are hemodynamically stable and/or receiving concomitant parenteral anticoagulation due to concern that the risks outweigh the benefits. PE is exquisitely sensitive to thrombolysis, as the lungs are the point of convergence of venous circulation; so, a majority of IV-delivered t-PA converges to the clot, making t-PA ideal for the treatment of this population of patients. New data from the Moderate Pulmonary Embolism Treated with Thrombolysis (MOPETT) study, presented by Mohsen Sharifi, MD, A.T. Still University, Mesa, Arizona, USA, suggest that moderate PE patients may be managed with reduced-dose t-PA and modified anticoagulation. MOPETT was a randomized trial of 121 patients (45% men; mean age 59 years). Sixty-one patients received t-PA that was dose-adjusted for weight (for those ≥50 kg, an initial dose of 10 mg t-PA over 1 minute, followed by a 40-mg infusion over 2 hours; for those <50 kg, a total t-PA dose of 0.5 mg/kg, delivered as an initial dose of 10 mg over 1 minute, followed by the remainder as an infusion over 2 hours) in addition to a 20% to 30% reduction in anticoagulant dose (either enoxaparin or heparin), and 60 subjects received anticoagulation alone (standard of care). The coprimary endpoints were pulmonary hypertension (PH) and a composite of PH plus recurrent PE after 28 months of follow-up. The determination of PH was by echocardiography, defined as an estimated pulmonary artery systolic pressure (PASP) >40 mm Hg. Secondary endpoints included in-hospital bleeding, duration of hospitalization, and mortality. Patients were included in this study if they had symptomatic PE plus 2 of the following risk factors for post-PE mortality: chest pain, tachypnea >22 respirations per minute, tachycardia resting heart rate >90 beats per minute, dyspnea, jugular venous pressure >12 cm H20, cough, or oxygen desaturation <90%. Serial changes in PASP from baseline to 28 months by treatment strategy are shown in Table 1. After 28 months, 16% of t-PA patients experienced PH (the first coprimary endpoint) compared with 57% of those who were assigned standard anticoagulation (p<0.001). Patients who were treated with t-PA also had significantly fewer incidences of the second coprimary endpoint, a composite of PH plus recurrent PE at 28 months (16% vs 63%; p<0.001). Secondary events occurred infrequently, in particular mortality, and are shown according to treatment 16 May 2012 assignment in Table 2. No significant in-hospital bleeding occurred with either strategy. Table 1. Serial Changes in PASP from Baseline to 28 Months by Treatment Strategy. t-PA (n=58) Initial PASP (mm Hg) PASP (mm Hg) change within 48 hours PASP at 6 months PASP at 28 months PAH at 28 months* PAH and recurrent PE at 28 months* 50±6 -16±3 31±6 28±5 9 9 Standard of Care (n=56) 51±7 -5±2 49±8 43±6 32 35 p value 0.40 <0.001 <0.001 <0.001 <0.001 <0.001 *PAH=Pulmonary Arterial Hypertension; PASP=Pulmonary Artery Systolic Pressure >40 mm Hg; PE=pulmonary embolism. Table 2. Secondary Events By Treatment Strategy. t-PA (n=61) Recurrent PE (%) Mortality (%) Recurrent PE + mortality (%) Hospital stay, days PE=pulmonary embolism. Standard of Care (n=60) 3 (5) 3 (5) 6 (10) 4.9±0.8 p value 0.077 0.301 0.0489 <0.001 0 1 (1.6) 1 (1.6) 2.2±0.5 The authors concluded that the use of low-dose thrombolysis appeared to be safe and effective in moderate PE to reduce PH, recurrent PE, and hospital stay without an increase in bleeding risk or ICH. However, hard clinical events, such as mortality, clinically evident rightheart failure, and major bleeding events, were infrequent. Larger and long-term studies that test this strategy in representative patients are necessary to ultimately determine whether modified aggressive reperfusion therapy provides more benefit than harm in PE. Pacemaker Therapy In Patients With Neurally Mediated Syncope and Documented Asystole Written by Maria Vinall Michele Brignole, MD, Ospedali del Tigullio, Lavagna, Italy, presented evidence from the International Study on Syncope of Uncertain Etiology 3 Study [ISSUE3; NCT00359203], demonstrating that cardiac pacing therapy is effective for prevention of recurrent syncope in patients with neurally mediated syncope (NMS) and documented asystole. These data contradict previous data from two www.mdconferencexpress.com  http://www.mdconferencexpress.com 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

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