Site index

  1. Valvular heart disease
    1. Mitral stenosis
    2. Mitral regurgitation
    3. Aortic stenosis
    4. Aortic regurgitation
  2. Congenital heart disease
    1. History and physical examination in congenital heart diseases
    2. ASD
      1. ASD- secundum
      2. ASD-primum
      3. ASD-sinus venosus
      4. ASD-coronary sinus
      5. Lutembacher’s syndrome
    3. Atrioventricular septal defect
    4. Atrioventricular septal defects
    5. Ventricular septal defect
    6. Ventricular septal defect
    7. Ventricular septal defect with pulmonary stenosis
    8. Ventricular septal defect with aortic regurgitation
    9. Left ventricle to right atrium shunt or Gerbode defect
    10. Patent ductus arteriosus
    11. Patent ductus arteriosus
    12. Patent ductus arteriosus in the term infant
    13. Patent ductus arteriosus in the pre-term infant
    14. Aorto-pulmonary window
    15. Cyanosis in the newborn
    16. Transposition of great arteries
    17. Transpositon of great arteries- questions
    18. Double outlet right ventricle – part 1, part 2, part 3, part 4
    19. Tetralogy of Fallot with absent pulmonary valve
    20. Tetralogy of Fallot – part 1, part 2, part 3, part 4
    21. Tetralogy of Fallot
    22. Tetralogy of Fallot- a presentation
    23. Tricupsid atresia
    24. Tricuspid atresia- a presentation
    25. Pulmonary atresia with intact ventricular septum
    26. Partial anomalous pulmonary venous connection
    27. Total anomalous pulmonary venous connection
    28. Corrected transposition of great arteries
    29. Cor triatriatum
    30. Pompe’s disease and the heart
    31. Short topics-
      1. TOF- acquired
      2. Development of interatrial septum
      3. Indications for VSD repair
      4. Cyanosis in ASD and VSD
      5. ASD- genetic causes
      6. Aortic cusp prolapse in VSD
      7. Mechanisms of VSD closure
      8. Persistent truncus arteriosus and single ventricle- hemodynamics
      9. D-TGA pathophysiology
      10. Atrioventricular and ventriculoarterial relations
  3. Arrhythmias
    1. Specific types of VT
    2. Narrow complex tachycardia- how to quickly come to a diagnosis from the ECG?
    3. Short QT syndrome
    4. AV block
    5. Decreased automaticity leading to bradycardia
    6. Ventricular tachyarrhythmias
    7. Ventricular tachycardia
    8. Accelerated idioventricular rhythm
    9. Ventricular premature complexes
    10. Amiodarone induced pulmonary toxicity
    11. SVT with aberrancy- ECG features
    12. AV dissociation to distinguish tachycardias
    13. Cardiac pacemakers
  4. Ischemic heart disease
    1. Approach to myocardial infarction- simplified protocol
    2. ST elevation MI- pathology and clinical features
    3. Sgarbossa criteria
    4. Drugs that affect lipid metabolism
    5. Secondary causes of dyslipidemia
    6. LMCA disease – ECG features
  5. Other topics-
    1. Acute rheumatic fever
    2. Acute rheumatic fever
    3. Second heart sound
    4. Vertebral artery occlusive disease
    5. Carotid artery disease
    6. Rheumatic fever
    7. Cardiac catheterization- analysis of hemodynamic data
    8. Aortic dissection    
    9. Pulmonary embolism
    10. Diastolic dysfunction – mitral Doppler evaluation
    11. Heart failure with normal ejection fraction
    12. Takayasu’s arteritis
  6. Interesting EKGs
    1. Torsades de pointes ECG
    2. Complete heart block ECG
    3. Indeterminate axis ECG
    4. Ectopic atrial rhythm ECG
    5. Hyperkalemia- sine waves ECG
    6. Right ventricular hypertrophy ECG
    7. Dextrocardia ECG
    8. Complete heart block ECG
    9. Digoxin toxicity ECG
    10. Ventricular bigeminy ECG
    11. Hyperkalemia ECG
    12. Atrial flutter ECG
    13. Cardiac tamponade ECG
    14. Atrial tachycardia ECG
    15. Atrioventricular reentrant tachycardia ECG
    16. Acute pericarditis ECG
    17. Arrhythmogenic right ventricular dysplasia ECG
    18. Preexcitation through left lateral pathway ECG
    19. Right ventricular outflow tract ventricular tachycardia ECG
    20. Belhassen’s tachycardia (posterior fascicular ventricular tachycardia)
    21. Arm lead reversal ECG
    22. Alternating bundle branch blocks ECG
  7. Interesting echocardiograms
    1. Mitral stenosis with left atrial clots echo
    2. Bicuspid aortic valve echo
    3. Mitral stenosis echo
    4. PDA with pulmonary artery vegetations echo
    5. Left ventricular endomyocardial fibrosis echo
    6. Severe mitral regurgitation echo
    7. Supravalvular pulmonary stenosis echo
    8. Ventricular septal rupture echo
    9. Right atrial mass echo
    10. Kawasaki disease echo
    11. Tetralogy of Fallot echo
  8. Intersting cardiac catheterization images
    1. Severe coronary artery disease- videos
    2. Coronary sinus venogram
    3. Kissing balloon dilation
    4. Bovine aortic arch
  9. Interesting chest roentgenograms
    1. Supracardiac TAPVC- snowman appearance
    2. Coarctation of aorta- rib notching- chest X-ray
  10. Case studies
    1. A therapeutic dilemma- whether to revascularize or not.
  11. Miscellaneous
    1. Dynamic LVOT obstruction- causes
    2. Grades of clubbing
    3. Random points 1
      2
      3
    4. Basics of hemodynamics
  12. Journal watch
    1. Recent cardiology trials- November 2009
    2. Hospitalizations After Heart Failure Diagnosis: A Community Perspective
    3. A Meta-Analysis of Remote Monitoring of Heart Failure Patients
    4. CASPER registry
    5. TRANSCEND trial
    6. CARDIA study
    7. TRANSFER- AMI trial
    8. STAR trial
    9. TIMIC trial
    10. FAMOUS trial
    11. JACC JULY 07, 2009- original articles
    12. ATHEROMA trial
    13. PHIRST trial
    14. RECORD trial
    15. TIMACS trial
2 Comments

TRILOGY ACS trial

Prasugrel versus Clopidogrel for Acute Coronary Syndromes without Revascularization

 

Background

  • Out of all ACS (UA/NSTEMI) patients, 40 to 60% are managed without revascularization (PCI/CABG).
  • TRITON trial showed that prasugrel had better outcomes compared to clopidogrel in ACS patients undergoing PCI (but major bleeding is increased).

 

Aim

  • To compare the effects of prasugrel and clopidogrel in ACS patients managed without revascularization.

 

Method

  • Inclusion criteria
    • Within 10 days of UA or NSTEMI (UA- 1 mm or more ST depression & cardiac markers negative; NSTEMI- cardiac markers positive, but no ST elevation)

      Plus

    • At least one of the following four enrichment criteria
      • Age more than 60 yrs
      • Diabetes mellitus
      • Prior myocardial infarction
      • Prior PCI or CABG

      (Note- Coronary angiography may or may not have been done before randomization, but if it is planned, it has to be done before randomization. If it is done, at least one lesion of more than 30% should be present or patient must have prior PCI or CABG done.)

  • Exclusion criteria
    • History of TIA or stroke
    • PCI or CABG in last 30 days
    • Renal failure needing dialysis
    • Co-treatment with oral anticoagulants.
  • Plan
    • Multiple centers in 52 countries
    • Double blind double dummy study
    • Patients were classified into two depending on time after first medical contact and whether clopidogrel was already given
      • Less than or equal to 72 hrs and clopidogrel was not given
        • Clopidogrel 300 mg loading followed by 75 mg OD

          Or

        • Prasugrel 30 mg loading followed by 5 or 10 mg OD (5 mg OD if age 75 yrs or more or weight less than 60 kg)
      • More than 72 hrs or less than 72 hrs but patient already exposed to clopidogrel
        • Open label clopidogrel continued before randomization
        • No loading dose- clopidogrel 75 mg OD versus prasugrel 5 or 10 mg OD
    • All patients receive aspirin (strongly advised to keep to 100 mg OD or less).
    • Primary endpoint is a composite of
      • Death from cardiovascular cause
      • Non-fatal MI and
      • Non-fatal stroke
    • Duration
      • Minimum 6 months
      • Maximum 30 months

Results

  • General facts
    • 9326 patients
      • Less than 75 yrs- 7243 patients
      • More than or equal to 75 yrs- 2083 patients
    • Angiogram was performed before randomization in slightly more than 40% cases.
    • Revascularization (PCI/CABG) was done during follow-up in 7.9% in less than 75 year group and median time to revascularization was 113 days.
  • Age less than 75 yrs
    • Median follow-up was 17 months.
    • Primary endpoint-
      • For total time period
        • Prasugrel- 13.9%
        • Clopidogrel- 16%
        • P= 0.21
      • After 12 months, trend to reduced risk with prasugrel (P=0.07 when primary endpoints after 12 months were compared).
      • Thus divergence of Kaplan-Meier curve for primary endpoint was noted after 12 months.
      • Prasugrel provided better results in
        • Smokers
        • Those who underwent angiography before randomization and
        • Those taking PPI.
    • Components of primary endpoint
      • Same in both groups
    • Recurrent ischemic events
      • Lower with prasugrel compared to clopidogrel (P=0.04)
    • Bleeding
      • TIMI major bleeding- same (P=0.27)
      • GUSTO severe/life threatening bleed- same (P=0.87)
      • Intracranial hemorrhage- same (P=0.39)
      • TIMI major or minor bleed- more with prasugrel (P=0.02)
      • GUSTO severe/life threatening or moderate bleed- trend towards increase with prasugrel (P=0.06)
    • New non-benign neoplasms
      • Same (P=0.79)
    • All cause death
      • Same (P=0.4)
  • Overall population
    • Primary outcome
      • Same (P=0.45)
    • Components of primary outcome
      • Same
    • Death from any cause
      • Same (P=0.40)
    • Bleeding
      • TIMI major bleeding- same (P=0.29)
      • GUSTO severe/life threatening bleed- same (P=0.53)
      • Intracranial hemorrhage- same (P=0.42)
      • TIMI major or minor bleed- same (P=0.11)
      • GUSTO severe/life threatening or moderate bleed- same (P=0.10)

Conclusions

  • Prasugrel was not different from clopidogrel in ACS patients followed up for 2.5 years.
  • After 1 year, trend towards benefit with prasugrel was seen in patients of age less than 75 years.
  • Recurrent ischemic events were lower with prasugrel in patients of age less than 75 years.
  • Major bleeds were same with prasugrel and clopidogrel in patients of age less than 75 years.
  • All bleeds were more with prasugrel compared to clopidogrel in patients of age less than 75 years.

Links

For published article in NEJM

http://www.nejm.org/doi/full/10.1056/NEJMoa1205512#t=abstract

For study protocol

http://www.nejm.org/doi/suppl/10.1056/NEJMoa1205512/suppl_file/nejmoa1205512_protocol.pdf

For supplementary appendix

http://www.nejm.org/doi/suppl/10.1056/NEJMoa1205512/suppl_file/nejmoa1205512_appendix.pdf

 

                    

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