Cardiovascular Journal of Africa: Vol 27 No 6 (November/December 2016)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 6, November/December 2016

AFRICA

395

disease. The finding was that PET scanning was superior to both

CCTA and SPECT.

Plasma apheresis was used in patients with uncontrolled

angina receiving maximally tolerated medical therapy. Apheresis

improved myocardial perfusion and increased exercise tolerance,

as assessed by the six-minute walk test.

The 15-year follow up of the FRISC-II study was reported;

it had compared an early invasive strategy in NSTEMI to an

initial non-invasive strategy.

Patients who participated are now

80 years old on average. The overall mortality rate has been 40%.

Sixty per cent of patients initially treated without intervention

have subsequently undergone revascularisation. The frequency

of unplanned revascularisation followed a parallel trajectory in

the two groups after three to four years. CV death or MI was

‘postponed’ by three to four years in the intervention group,

which also experienced a substantial reduction in the frequency

of rehospitalisation. These benefits were seen in those patients

who were troponin positive at the time of enrollment. By

contrast, the 10-year follow up of the ICTUS study again found

no benefit from early intervention, with the incidence of MI

driven by peri-procedural events.

A Japanese trial, which had compared

ad hoc

to deferred PCI

in patients with stable CAD, reported its five-year outcomes.

There were no differences in incidence of death or MI. Deferred

cases fared better when heart failure was present, but the

deferred group also had a higher incidence of stroke.

Widimsky presented a small trial (1 230 patients) from

the Czech Republic that looked at one-month outcomes in

STEMI patients who received either prasugrel or ticagrelor

(PRAGUE-18 study). No differences were discernible at seven

and 30 days. Due to financial constraints, many patients had to

switch to clopidogrel after discharge, frustrating the assessment

of effect at a later time point.

NORSTENT included 9 013 patients receiving their first

coronary stent [either bare-metal (BMS) or newer drug-eluting

stents (DES)] between 2008 and 2011.

Seventy-one per cent of

cases were treated for ACS. Eighty-four per cent of procedures

were performed by the radial route. Forty per cent of patients

had multi-vessel disease. An average of 1.7 stents was implanted

per patient. Dual antiplatelet therapy (DAPT) was given for nine

months in both groups.

Median follow up was for five years. There were no

differences in outcome between the two types of stent. Repeat

revascularisation was 3.3% less with DES. Stent thrombosis

occurred in 0.8% with DES and 1.2% in BMS patients. Quality

of life was no different between the two groups.

In the LEADERS FREE trial, patients over 75 years of age

at high risk of bleeding received either a BioFreedom

polymer-

free drug-coated stent or Gazelle

BMS and DAPT for only one

month. Their average age was 81 years, 63% had multi-vessel

disease and one-third had atrial fibrillation (AF). Sixty per cent

of procedures were performed via the radial artery. At one year

the event rate was 14 versus 11% in favour of the BioFreedom

stent, the difference being driven by the incidence of MI. There

was a 49% reduction in target-vessel revascularisation and no

increase in rate of bleeding.

A 10-year follow up of the SIRTAX trial showed an increase

in non-CV mortality rate between five and 10 years and a

constant rate of MI, but a fall-off in the incidence of target lesion

revascularisation and stent thrombosis with no difference between

paclitaxel- and sirolimus-eluting stents. The use of DAPT, aspirin

and statin treatment was observed to be declining.

A five-year follow up of the trial comparing Biolimus

(biodegradable polymer) to sirolimus-eluting stents showed some

crossover of benefit in favour of Biolimus

with regard to rates of

death, MI, stent thrombosis and target-vessel revascularisation.

A two-year follow up of the ABSORB

stent (bio-absorbable

vascular scaffold) study found four instances of very late

stent thrombosis. Optical coherence tomography showed that

undersizing of the stent and discontinuities in stent structure

might have been the cause.

TheDOCTORS study comparedoptical coherence tomography-

guided to angiography-guided intervention in localised single-vessel

disease. Fractional flow reserve (FFR) results were moderately

improved when using optical coherence tomography.

The BBK II trial compared TAP stenting with Culotte

stenting in bifurcation lesions, demonstrating that the Culotte

technique yielded better results in the side branch. Commentators

cautioned against use of the Culotte technique by those who are

not experts.

Jang, from Harvard Medical School, reported on an optical

coherence tomography-guided study in Chinese patients with

ACS, which identified plaque erosion as the underlying cause

in 30%. These patients were treated with aspirin and ticagrelor

without stenting. He showed that thrombus volume was

diminished at one month.

A sub-study of the DAPT trial evaluated whether OMT

(using ACE-I/ARB, beta-blockade, statin, thienopyridine and

aspirin when indicated by guidelines) influenced the outcome

of prolonging DAPT. The benefit of DAPT was shown to be

consistent, whether or not patients were receiving OMT.

The ITALIC trial two-year result showed no difference

between six months and 24 months of DAPT (predominantly

using clopidogrel). However, there was a trend towards increased

events in patients with prior MI who received only six months

of DAPT.

A study of an ‘as-treated’ subgroup of the FREEDOM

trial compared coronary artery bypass grafting (CABG) to

percutaneous coronary intervention (PCI) in patients with

diabetes and multi-vessel CAD, both with and without chronic

kidney disease. CABG was associated with a lower incidence of

death and MI but with an increase in the risk of stroke.

The STITCH trial evaluated the benefit of CABG in patients

with left ventricular systolic dysfunction (LVSD). CABG

benefited patients in all age groups. CV mortality was the most

frequent cause of death at all ages. Non-cardiac causes of death

were more frequent in the elderly.

BASKET-SAVAGE compared BMS to DES in saphenous

vein graft stenting with the option of using a filter wire and/

or GPIIb/IIIa inhibitors. DES were associated with an 80%

reduction in MACE (12 vs 30%) driven by non-fatal MI

and target-vessel revascularisation. There was no difference in

mortality rate. The contribution of the filter wire and GPIIb/IIIa

inhibition used in 67% of cases could not be determined.

Heart failure

The 2016 heart failure guideline discusses means to prevent

or delay the onset of symptomatic heart failure. Predominant

among these are treatment of hypertension, statins for those with