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CVD Critical Pathways Group 2005 Teleconferences

2. Faculty. Gregg C. Fonarow, MD Eliot Corday Professor of Medicine and Cardiovascular Science Director, Ahmanson-UCLA Cardiomyopathy Center UCLA Division of Cardiology UCLA Medical Center Los Angeles, California. The Network for Continuing Medical Education requires that CME faculty disclose, duri

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CVD Critical Pathways Group 2005 Teleconferences

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    1. CVD Critical Pathways Group 2005 Teleconferences

    2. 2 Faculty

    3. The Network for Continuing Medical Education requires that CME faculty disclose, during the planning of an activity, the existence of any personal financial or other relationships they or their spouses/partners have with the commercial supporter of the activity or with the manufacturer of any commercial product or service discussed in the activity. Disclosure Statement

    4. Gregg C. Fonarow, MD, has served as a consultant to and has received research support from GlaxoSmithKline, Pfizer Inc., and Scios Inc. He has also received honoraria from Merck & Co., Inc. Charles V. Pollack, Jr., MA, MD, FACEP, representing the team from Pennsylvania Hospital has served as a consultant to Millennium Pharmaceuticals Inc. and Schering-Plough Corporation, has received honoraria from Aventis Pharmaceuticals Inc., Bristol-Myers Squibb Company, Millennium Pharmaceuticals Inc., Sanofi-Synthelabo Inc., and Schering-Plough Corporation, and research support from Aventis Pharmaceuticals Inc. Faculty Disclosure Statement

    5. 5 Polling Question #1 Did you attend the 2005 American Heart Association Scientific Sessions? Yes, I attended the entire duration of the conference Yes, I attended part of the conference No, I did not attend

    6. Update on the 2005 AHA Scientific Sessions

    7. 7 Update on the 2005 AHA Scientific Sessions FIELD (Fenofibrate Intervention and Event Lowering in Diabetes) IDEAL (Incremental Decrease in Endpoints Through Aggressive Lipid Lowering) SURVIVE (Survival of Patients with Acute Heart Failure in Need of Intravenous Inotropic Support) REVIVE-2 (Randomized Evaluations of Levosimendan) More Lessons from CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines) New PCI Guidelines (Excerpts from New PCI Guidelines (review of oral antiplatelet recommendations)

    8. 8 FIELD: Design

    9. 9 FIELD: Primary Endpoint The primary composite endpoint of CHD death or nonfatal MI was not significantly lower in the fenofibrate group compared to the placebo group.

    10. 10 FIELD: Primary Endpoint CHD death was not significantly different between treatment groups Nonfatal MI was significantly lower in the fenofibrate group compared with the placebo group

    11. 11 FIELD: Secondary Endpoint The secondary composite endpoint of total CV events was significantly lower in the fenofibrate group compared to the placebo group (% of treatment arm)

    12. 12 FIELD: Secondary Endpoint CV Mortality, Total Mortality, and Stroke were not significantly different between the fenofibrate and placebo groups

    13. 13 FIELD: Secondary Endpoint Percentage of coronary revascularization and all revascularization were significantly lower in the fenofibrate group compared to placebo

    14. 14 IDEAL Trial: Study Design

    15. 15 IDEAL Trial: Primary Endpoint The primary composite endpoint of major coronary event occurred in 9.3% of the atorvastatin group and 10.4% of the simvastatin group.

    16. 16 IDEAL Trial: Primary Endpoint (cont) Among the components of the primary endpoint, there was no difference in CHD death or cardiac arrest with resuscitation, but nonfatal MI occurred less frequently in the atorvastatin group.

    17. 17 IDEAL Trial: Secondary Endpoints Major cardiovascular events, defined as any primary event plus stroke, occurred less often in the atorvastatin group. Any cardiovascular event, defined as major CV event plus hospitalization for CHF and peripheral artery disease, also occurred less often in the atorvastatin group.

    18. 18 IDEAL Trial: Serious Adverse Events There was no difference in the frequency of serious adverse events, but adverse events resulting in permanent drug discontinuation was more frequent in the atorvastatin group.

    19. 19 IDEAL Trial: Serious Adverse Events (cont) Liver enzyme elevation occurred more frequently in the atorvastatin group, as did myalgia.

    20. 20 REVIVE 2 Design

    21. 21 REVIVE-2: Approximate Time-dependent Rates of “Moderate or Marked" Improvement in Patient Global Assessment

    22. 22 Adverse Events in REVIVE-2

    23. 23 REVIVE-2: Secondary Endpoint

    24. 24 SURVIVE-W: Design

    25. 25 SURVIVE-W: Primary Endpoint There was no significant difference in the primary endpoint of all-cause mortality between the levosimendan and dobutamine groups

    26. 26 SURVIVE-W: Secondary Endpoint There was no difference in all-cause mortality between treatment groups at 31 days

    27. 27 SURVIVE-W: Post-hoc Analysis In a post-hoc analysis, all-cause mortality at 5 days was not significantly different between treatment groups

    28. 28 Patterns and Impact of Aspirin Dosing in NSTEMI: Results from the CRUSADE Initiative 22,618 patients with NSTEMI Patients were from 369 hospitals in the CRUSADE program Evaluated between 5/03 and 9/04 Analysis included acute (<24 hours) and discharge aspirin doses in relation to concomitant clopidogrel use and other clinical predictors

    29. 29 Patterns and Impact of Aspirin Dosing in NSTEMI: Results from the CRUSADE Initiative ASA at discharge with concomitant clopidogrel (n=12,635) 37.6% (n=4745) received 81 mg ASA 58.5% (n=7397) received 325 mg of ASA Patients who were discharged from a cardiology inpatient service (n=11,587) 37.5% (n=4350) received 81 mg ASA 58.5% (n=6780) received 325 mg ASA

    30. 30 Patterns and Impact of Aspirin Dosing in NSTEMI: Results from the CRUSADE Initiative ASA at discharge without concomitant clopidogrel (n=4772) 44.0% (n=2101) received 81 mg ASA 51.2% (n=2445) received 325 mg of ASA CONCLUSION: The majority of patients with NSTEMI are still being treated with 325 mg ASA at discharge, both with and without concomitant clopidogrel despite recent studies that have demonstrated a better safety profile with low-dose ASA. Further quality improvement interventions are needed

    31. 31 ACC/AHA/SCAI 2005 Guideline Update for PCI Oral Antiplatelet Adjunctive Therapies Patients already taking daily chronic ASA therapy should take 75 mg to 325 mg ASA before the PCI procedure is performed

    32. 32 ACC/AHA/SCAI 2005 Guideline Update for PCI Oral Antiplatelet Adjunctive Therapies After the PCI procedure, in patients with neither ASA resistance, allergy, nor increased risk of bleeding, ASA 325 mg daily should be given for at least 1 month after bare-metal stent implantation, 3 months after sirolimus-eluting stent implantation, and 6 months after paclitaxel-eluting stent implantation, after which daily chronic ASA use should be continued indefinitely at a dose of 75 to 162 mg.

    33. 33 ACC/AHA/SCAI 2005 Guideline Update for PCI Oral Antiplatelet Adjunctive Therapies A loading dose of clopidogrel should be administered before PCI is performed

    34. 34 ACC/AHA/SCAI 2005 Guideline Update for PCI Oral Antiplatelet Adjunctive Therapies In patients who have undergone PCI, clopidogrel 75 mg daily should be given for at least 1 month after bare-metal stent implantation (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks), 3 months after sirolimus stent implantation, and 6 months after paclitaxel stent implantation, and ideally up to 12 months in patients who are not at high risk of bleeding.

    35. 35 ACC/AHA/SCAI 2005 Guideline Update for PCI Oral Antiplatelet Adjunctive Therapies If clopidogrel is given at the time of procedure, supplementation with GP IIb/IIIa receptor antagonists can be beneficial to facilitate earlier platelet inhibition than with clopidogrel alone.

    36. 36 ACC/AHA/SCAI 2005 Guideline Update for PCI Oral Antiplatelet Adjunctive Therapies When a loading dose of clopidogrel is administered, a regimen of greater than 300 mg is reasonable to achieve higher levels of antiplatelet activity more rapidly, but the efficacy and safety compared with a 300-mg loading dose are less established.

    37. Featured Institution Pennsylvania Hospital Philadelphia, Pennsylvania

    38. 38 Polling Question #2 1) We are currently on the same item 2) We have since moved to the next checkbox on the checklist 3) We have progressed by more than one item on the checklist ACS pathways are up-to-date and regularly followed

    39. 39 Progress Checklist: Immediate Goals

    40. 40 Progress Checklist: Short-term Goals/Activities

    41. 41 Progress Checklist: Long-term Goals/Activities

    42. 42 Question-and-Answer Session

    43. 43 Concluding Remarks

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