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| |  ACP-ASIM: New Surgical Procedures and Emerging Drugs Reducing Burden of Coronary Artery and Cardiovascular Disease By Bonnie Darves NEW ORLEANS, LA -- April 28, 2004 -- Drug-eluting stents and a host of trials on new drugs may soon deliver major benefits in reducing cardiac disease and related mortality rates, according to Robert Bonow, MD, chief of cardiology, Northwestern University, Chicago, Illinois. In his cardiology update here April 23rd at the American College of Physicians - American Society of Internal Medicine Annual Session, Dr. Bonow reviewed treatment-related studies from 2003, and provided summaries of those he considered most important to coronary artery disease (CAD)-related treatment decisions. In a 3-center study of 177 patients with coronary lesions, Park et al found that there may be lower rates of late restenosis when these procedures are used (N Engl J Med. 2003 Apr 17;348(16):1537-1545). The findings of this study also support emerging evidence that drug-eluting stents inhibit restenosis when used with conventional antiplatelet therapy. "The point is that drug-eluting stents are here, and are effective in reducing subsequent in-stent stenosis, but they are expensive," Dr. Bonow said. He cautioned that more time is needed to determine whether long-term benefits are maintained, without treatment-related adverse events. Dr. Bonow discussed findings on the effect of high-density infusion (HDL) treatment with ApoA-I Milano phospholipid complexes (Nissen et al. JAMA. 2003 Nov 5;290(17):2292-2300). The first controlled clinical trial to demonstrate regression of plaque, this study of 123 patients who received weekly infusions over 5 weeks showed that volume of atheroma decreased by as much as 1.53% in some patients. Dr. Bonow noted that although the results appear promising, larger trials are needed to confirm the benefits and address morbidity and mortality endpoints. "The excitement is that there is indeed clinical regression [with ApoA-1], and overall reduction in plaque volume," he said, adding that the study also found a 27% reduction in stroke over time. "Clearly [use of] HDL as treatment is on the horizon." Lipid-lowering with atorvastatin also is showing great promise in preventing coronary and stroke events in hypertensive patients, according to the Anglo-Scandinavian Cardiac Outcomes Trial--Lipid Lowering Arm (ASCOT-LLA), Dr. Bonow said (Lancet. 2003 Apr 5;361(9364):1149-1158). In this study, Sever et al showed that the reduction in major cardiovascular events with atorvastatin was large in patients after acute myocardial infarction (MI), given the short follow-up time of 3.5 years. "Clearly, atorvastatin led to a 36% reduction in the composite endpoint of cardiovascular death and nonfatal MI," Dr. Bonow said, and benefits were also noteworthy in the 27% reduction in fatal and nonfatal stroke, he added. These results suggest that individuals at high risk for coronary events and stroke, who have hypertension and other risk factors, may be candidates for lipid-lowering therapy even if they do not have a markedly elevated cholesterol, he said. In the European Trial on Reduction of Cardiac Events With Perindopril in Stable Coronary Artery Disease (EUROPA), Fox et al studied the efficacy of the angiotensin-converting enzyme (ACE) inhibitor perindopril in reducing death, MI or cardiac arrest in 13,655 patients with stable coronary disease and no heart failure (Lancet. 2003 Sep 6;362(9386):782-8). Their results show that the drug produced a relative risk reduction of 20%, Dr. Bonow said. Based on these findings, physicians should consider treatment with perindopril in concert with other preventive medications in all patients with coronary heart disease, he added. "This is further evidence that patients who have evidence of vascular disease or diabetes should receive an ACE inhibitor or maybe an ARB [angiotensin receptor blocker]," Dr. Bonow said. On the efficacy of ARB therapy on mortality and morbidity in patients with chronic heart failure (CHF), Dr. Bonow discussed the results of the Candesartan in Heart failure: Assessment of Reduction in Mortality and Morbidity (CHARM-Overall) (Lancet. 2003 Sep 6;362(9386):759-766). In this randomized, double blind, controlled parallel trial, Pfeffer et al randomized 7,601 patients to receive the ARB candesartan or placebo, and followed them for 37.7 months. The treatment group experienced lower CV-death rates (but not overall death rates), as well as fewer CHF-related hospital admissions. Dr. Bonow said that although the beneficial effect was not seen uniformly in patients who were already receiving other drugs for CHF, "the CHARM trials indicate that candesartan provides benefit in patients with left ventricular systolic function when used in place of an ACE inhibitor or in combination with an ACE inhibitor."
[Presentation Title: Update in Cardiology.]
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