- Email: [email protected]
Journal Scan
Journal Scan myocardial infarction (MI). However, little is known about medication use among patients with coronary artery disease who undergo percutaneous coronary intervention (PCI). Objective: This study was conducted to examine the patterns of use of medical therapy among patients who undergo PCI; and to examine the determinants of medical therapy in these patients. Methods: The Routine versus Selective Exercise Treadmill Testing after Angioplasty (ROSETTA) registry is a prospective multicentre study examining the use of functional testing after PCI. The medication use was examined among 787 patients who were enrolled in the ROSETTA registry at 13 clinical centres in five countries. Results: Most patients were men (mean age 61± 11 years, 76% male) who underwent single vessel PCI (85%) with stent implantation (58%). At admission, discharge and six months, rates of acetylsalicylic acid use were 77%, 96% and 93%, respectively (discharge versus six months, p<0.0001). Rates of use of other oral antiplatelet agents were 11%,59% and 2% (p=0.02). For individual anti-ischemic medications, rates of use were as follows: beta-blockers 49%, 58% and 59% (p<0.0001); calcium antagonists 34%, 43% and 42% (p<0.0001), and nitrates 42%, 56% and 43% (p<0.0001). Rates of use of combination anti-ischemic medications were as follows: triple therapy 7%, 9% and 9% (p<0.0001); double therapy 34%,47% and 38% (p<0.0001); monotherapy 36%,36% and 41% (p<0.0001); and no anti-ischemic therapy 23%,8% and 12% (p<0.0001). Rates of use of angiotensin-converting enzyme inhibitors were 25%,33% and 32% (p<0.0001), and rates of use of lipid lowering agents were 41%,52% and 61% (p<0.0001).
315 by Pfeffer et al has compared the effects of angiotensins receptor blocker - VALSARTAN, ACE inhibitor, Captopril and combination of both in high risk patients of myocardial infarction with clinical and radiological evidence of heart failure, evidence of left ventricular systolic dysfunction or both. It was a multicentric, double blind randomized trial in which 14,808 patients were enrolled in a 1:1:1 ratio to receive valsartan alone (titrated to 160mg BD), or Captopril alone (titrated to 50mg tds) or the combination of captopril (titrated to 50mg tds) and valsartan (titrated to 80mg BD) beginning 12 hrs to 10 days after acute myocardial infarction. The primary end point of the study was death from any cause during a median follow up of 24.7 months. The mortality was 19.9%, 19.5% and 19.3% in valsartan group, captopril group and valsartan + captopril group respectively. The results thus reflected that both valsartan and captopril were equally effective in terms of overall mortality. The rate of secondary end point of death from cardiovascular causes, recurrent myocardial infarction or hospitalization for heart failure was also similar in the three groups.
Conclusions: This study has shown that though the trials and guidelines statements have favourably affected the rates of use of acetylsalicylic acid and other antiplatelet agents after PCI, however, in spite of patients undergoing a successful revascularization procedure, most physicians do not reduce the use of anti-ischemic medical therapy.
Analysis of adverse events revealed that they were less common with mono therapy than with combination therapy. Hypotension and renal dysfunction were more common in valsartan group while cough, rash and taste disturbances were common in captopril group. The study also revealed another issue that use of combination of angiotensin receptor blocker (valsartan) and ACE inhibitor (captopril) did not improve overall survival despite the theoretical more complete blockade of rennin-angiotensin system as was reported in some earlier studies. It, rather resulted in an increased rate of adverse events. The authors conclude that valsartan is as effective as captopril in reducing rate of death and other adverse cardiovascular outcomes among patients who had had a myocardial infarction and can be considered as an effective alternative. However they have correctly stated that “the choice between these alternative treatments will depend on cumulative clinical experience, tolerabillity, safety, convenience and cost”.
Contributed by:
Contributed by:
Maj KS Brar Graded Specialist(Medicine), Military Hospital, Alwar.
Brig SR Mehta VSM*, Lt Col S Johri+ * Consultant & Head, +Associate Professor, Department of Medicine, Armed Forces Medical College, Pune-40.
Pfeffer MA, Mc Murray JJV, Valazquez EJ et al. Valsarton, Captopril a both in Myocardial Infarction complicated by heart failure, left ventricular dysfunction or both. N Engl J Med 2003;349:1893-1906. Angiotensin converting enzymes (ACE) inhibitors have been shown to reduce mortality, overall risk of death as well as risk of major non fatal cardiovascular events and morbidity after myocardial infarction specially in those who have left ventricular dysfunction or clinical evidence of heart failure. However, there is a subgroup of patients in whom heart failure worsens despite optimal medical therapy. Experimental observation has shown that ACE inhibitors block only 13% of total production of angiotensin II in human heart due to ACE independent pathways (e.g. Chymase, cathepsin and Kellikrein) which convert angiotensin I to angiotensin II. These observations provided rationale for development of angiotensin receptor antagonists which block deleterious effects of angiotensin II more completely by directly blocking the angiotensin type I receptors. Moreover, it was proposed that concurrent treatment with ACE inhibitors and angiotensin receptor blockade might provide more effective strategy. The present study VALIANT(Valsartan in Acute Myocardial Infarction trial) reported MJAFI, Vol. 60, No. 3, 2004
Oktay K, Arkan B, Rosenwaks R, Rucinsky J. A technique for transplantation of ovarian cortical strips to forearm. Fertil Steril 2003;80:193-8. Recent advances in cancer treatment including aggressive chemotherapy, radiotherapy and bone marrow transplantation have resulted in a significant increase in cure rates. However, such treatment protocols often cause infertility and premature ovarian failure. Successful transplantation of frozen-banked ovarian tissue, as well as orthotopic ovarian transplantations have been described in literature. But some consider intra-abdominal placement of ovarian tissue less desirable than the placement in arm where the tissue is easily accessible, especially when the tissue is of malignancy. The authors had selected two cases for transplantation of ovarian cortical strips. The first patient was to under go radiotherapy for CA Cx and other one had bilateral salpingo-opherectomy for recurrent ovarian cysts. After the removal of ovary, the thin slices of ovarian cortical tissue were prepared, frozen or preserved in media and later transplanted under the forearm. Both the patients were menopausal immediately after oopherectomy. The first patient
315 by Pfeffer et al has compared the effects of angiotensins receptor blocker - VALSARTAN, ACE inhibitor, Captopril and combination of both in high risk patients of myocardial infarction with clinical and radiological evidence of heart failure, evidence of left ventricular systolic dysfunction or both. It was a multicentric, double blind randomized trial in which 14,808 patients were enrolled in a 1:1:1 ratio to receive valsartan alone (titrated to 160mg BD), or Captopril alone (titrated to 50mg tds) or the combination of captopril (titrated to 50mg tds) and valsartan (titrated to 80mg BD) beginning 12 hrs to 10 days after acute myocardial infarction. The primary end point of the study was death from any cause during a median follow up of 24.7 months. The mortality was 19.9%, 19.5% and 19.3% in valsartan group, captopril group and valsartan + captopril group respectively. The results thus reflected that both valsartan and captopril were equally effective in terms of overall mortality. The rate of secondary end point of death from cardiovascular causes, recurrent myocardial infarction or hospitalization for heart failure was also similar in the three groups.
Conclusions: This study has shown that though the trials and guidelines statements have favourably affected the rates of use of acetylsalicylic acid and other antiplatelet agents after PCI, however, in spite of patients undergoing a successful revascularization procedure, most physicians do not reduce the use of anti-ischemic medical therapy.
Analysis of adverse events revealed that they were less common with mono therapy than with combination therapy. Hypotension and renal dysfunction were more common in valsartan group while cough, rash and taste disturbances were common in captopril group. The study also revealed another issue that use of combination of angiotensin receptor blocker (valsartan) and ACE inhibitor (captopril) did not improve overall survival despite the theoretical more complete blockade of rennin-angiotensin system as was reported in some earlier studies. It, rather resulted in an increased rate of adverse events. The authors conclude that valsartan is as effective as captopril in reducing rate of death and other adverse cardiovascular outcomes among patients who had had a myocardial infarction and can be considered as an effective alternative. However they have correctly stated that “the choice between these alternative treatments will depend on cumulative clinical experience, tolerabillity, safety, convenience and cost”.
Contributed by:
Contributed by:
Maj KS Brar Graded Specialist(Medicine), Military Hospital, Alwar.
Brig SR Mehta VSM*, Lt Col S Johri+ * Consultant & Head, +Associate Professor, Department of Medicine, Armed Forces Medical College, Pune-40.
Pfeffer MA, Mc Murray JJV, Valazquez EJ et al. Valsarton, Captopril a both in Myocardial Infarction complicated by heart failure, left ventricular dysfunction or both. N Engl J Med 2003;349:1893-1906. Angiotensin converting enzymes (ACE) inhibitors have been shown to reduce mortality, overall risk of death as well as risk of major non fatal cardiovascular events and morbidity after myocardial infarction specially in those who have left ventricular dysfunction or clinical evidence of heart failure. However, there is a subgroup of patients in whom heart failure worsens despite optimal medical therapy. Experimental observation has shown that ACE inhibitors block only 13% of total production of angiotensin II in human heart due to ACE independent pathways (e.g. Chymase, cathepsin and Kellikrein) which convert angiotensin I to angiotensin II. These observations provided rationale for development of angiotensin receptor antagonists which block deleterious effects of angiotensin II more completely by directly blocking the angiotensin type I receptors. Moreover, it was proposed that concurrent treatment with ACE inhibitors and angiotensin receptor blockade might provide more effective strategy. The present study VALIANT(Valsartan in Acute Myocardial Infarction trial) reported MJAFI, Vol. 60, No. 3, 2004
Oktay K, Arkan B, Rosenwaks R, Rucinsky J. A technique for transplantation of ovarian cortical strips to forearm. Fertil Steril 2003;80:193-8. Recent advances in cancer treatment including aggressive chemotherapy, radiotherapy and bone marrow transplantation have resulted in a significant increase in cure rates. However, such treatment protocols often cause infertility and premature ovarian failure. Successful transplantation of frozen-banked ovarian tissue, as well as orthotopic ovarian transplantations have been described in literature. But some consider intra-abdominal placement of ovarian tissue less desirable than the placement in arm where the tissue is easily accessible, especially when the tissue is of malignancy. The authors had selected two cases for transplantation of ovarian cortical strips. The first patient was to under go radiotherapy for CA Cx and other one had bilateral salpingo-opherectomy for recurrent ovarian cysts. After the removal of ovary, the thin slices of ovarian cortical tissue were prepared, frozen or preserved in media and later transplanted under the forearm. Both the patients were menopausal immediately after oopherectomy. The first patient