Atherosclerotic renal artery stenosis – stents or tablets?

The recent AHA meetings have provided a littany of articles to look at, with the most recent coming in an online first form over at the New England Journal of Medicine. This topic however has been looked at before (ASTRAL and STAR), and now this new trial titled CORAL aims to put the argument to bed once and for all.  Continue reading

Aspiration thrombectomy in acute coronary syndromes

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Aspiration of thrombus makes sense – you present with an acute infarct, there’s plenty of soft thrombus blocking the artery – so you simply suck it out. It has become increasingly popular in the cardiology circle, however the evidence is variable. Some people think if you pull the thrombus out, surely you resolve ST segments earlier and prevent distal embolisation, but others say the device itself can push thrombus further down, not to mention delays time to definitive intervention.

This article from September’s New England Journal of Medicine randomised over 7,000 patients and found that routine thrombus aspiration before PCI, compared with PCI alone, did not reduce 30 day mortality among patients with STEMI. And now there’s this meta-analysis from JACC comparing all patients with acute myocardial infarction which did find a mortality benefit with aspiration (but not with mechanical thrombectomy).

It’s important to note that one of the markers of outcome used here is total ischaemic time – time of symptoms to time of device activation – and you’re going to see more and more of this as the key marker in STEMI, rather than simply door-to-balloon.

Great pair of articles, and there’s a nice editorial in JACC which goes through the data. Read the articles above and then check out the editorial here.

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Doing percutaneous coronary intervention – without a surgical backup

In the early days of percutaneous intervention – stenting and so on – you’d always want to have cardiothoracics around to crack the chest in case of emergency bypass surgery. As the population gets larger, and further away from major centres, more places are doing diagnostic angiography, and some of them are starting to stent. ¬†This month’s NEJM has a look at the safety of doing PCI without surgical backup. Continue reading

A overview on transcatheter aortic valve implantation

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Transcatheter aortic valve replacement, or TAVI, had a lot of publicity over the past few years. Prior to TAVI, when faced with those elderly patients with multiple co-morbidities, who were really very restricted symptomatically from aortic stenosis, there really wasn’t much choice. But with any new advent, people question every complication. So now, the NEJM has got a few different articles looking at the TAVI situation. Continue reading