Studies Point to New Practices in Heart Care

Through recent research, Duke Heart Center is contributing information about many potentially beneficial changes to common practices in cardiology and cardiovascular surgery.

“We have been fortunate to lead a number of studies that have changed cardiovascular care and clinical outcomes,” says Robert Califf, MD, a cardiologist who directs the Duke Translational Medicine Institute. “Reducing risk of future events, emergency treatment of acute events, and appropriate use of surgical intervention were featured at the American Heart meetings. These advances can only happen when clinicians work together to conduct appropriate clinical trials.”

Lowering Cardiovascular Risks
As a senior author of a study presented Nov. 17 at the American Heart Association (AHA) Scientific Sessions, Califf and his colleagues found that augmenting statins with a cholesterol-blocking drug, ezetimibe, reduced the risk of cardiac death, heart attack, or stroke by 10%. Findings of the highly anticipated, 9-year IMPROVE-IT study (Improved Reduction of Outcomes: Vytorin Efficacy International Trial) were presented by researchers at Duke and Brigham and Women’s Hospital in Boston. The study clarified a long-standing question in cardiac care about whether reducing cholesterol to the lowest levels possible might improve outcomes. Data will be published in 2015.

Speeding up Life-Saving Care
A coordinated emergency response effort modeled after a program that began at Duke Medicine to speed up heart-attack care has now been applied to nearly 24,000 patients in regions across the United States—and it appears to have saved lives. Duke and other national leaders joined the AHA in heading the large, regional demonstration project, which was called Mission: Lifeline STEMI ACCELERATOR.

In the first 18 months of the project, statistically significant improvements in treatment times were achieved for the entire intervention. The percentage of patients who were treated within 90 minutes of first medical contact increased from 54% to 59%, with some regions improving by more than 15%. The mortality rate for patients who received care in the emergency department (ED) within 30 minutes or less was 3.6%; this rate rose to 7% for those who received care 30 to 45 minutes after presenting to the ED, and was 10.8% for those who waited longer than 45 minutes. “The key to success in these types of efforts is getting all these groups working in a coordinated way to provide care quickly,” said Christopher Granger, MD, director of the coronary care unit at Duke University Hospital and senior author of a study (co-led by Duke researchers Dr. James Jollis and Ms. Mayme Roettig) about the Mission: Lifeline effort.

Reducing or Postponing Surgery
With lead author Peter K. Smith, MD, Duke researchers and other colleagues published a study in the New England Journal of Medicine on Dec. 4 that found that both coronary artery bypass graft (CABG) and CABG + mitral valve repair (MVr) patients had significant improvement in left-ventricular end-systolic volume index at 1 year but did not differ in the degree of improvement. There were a significantly increased number of neurologic events in the MVr group, but less residual MR. CABG alone resulted in 70% of the patients having no trace or mild residual MR at 1 year. There were no differences between the groups in terms of mortality, major adverse cardiac and cerebrovascular events, readmissions, or quality of life. Study follow-up will continue for 24 months to learn whether MR improvement lasts and to further judge clinical outcomes for the two groups.

Revascularize All Vessel Blockage in STEMI Patients?
Manesh Patel, MD, a Duke interventional cardiologist, was senior author of a study published in the Nov. 19 issue of the Journal of the American Medical Association that investigated the incidence, extent, and location of obstructive non-infarct-related artery (IRA) disease. The team found that, in patients with ST-segment elevation myocardial infarction (STEMI), 53% had obstructive disease in vessels other than those involved in infarcts. The presence of non-IRA disease was significantly associated with increased 30-day mortality compared to patients without non-IRA disease (3.3% vs. 1.9%). These findings start a conversation about “the appropriateness and timing of non-IRA revascularization in patients with STEMI,” Patel and colleagues wrote.

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