Month: May 2014

Colchicine for Recurrent Pericarditis

In a new trial (Lancet March 30, 2014), colchicine, was found to be safe and beneficial adjunct to nonsteroidal anti-inflammatory drugs, even in patients with multiple recurrences.  Previous trials have demonstrated the efficacy and safety of colchicine as an adjunct to conventional treatment in patients with acute pericarditis or first recurrences.

To assess whether colchicine’s effectiveness extends to multiple recurrences, investigators in Italy conducted the multicenter, double-blind, CORP-2 trial. They randomly assigned 240 patients with ≥ 2 recurrences of pericarditis to receive placebo or 0.5 mg colchicine (twice daily in patients heavier than 70 kg; once daily in those ≤70 kg) for 6 months. All participants also received nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids.                                                 During a mean follow-up of 20 months, the rate of pericarditis recurrence was about half as high in the colchicine group as in the placebo group (21.6% vs. 42.5%; P<0.001), and the rate of remission at 1 week of treatment was significantly higher in the colchicine group (83.3% vs. 59.2%). Rates of adverse events and drug discontinuation were low and similar in both groups.

These findings suppot the evidence that colchicine is a safe and effective adjunct to NSAIDs for the treatment of pericarditis.

Source:

Imazio M et al. for the ICAP Investigators. A randomized trial of colchicine for acute pericarditis. N Engl J Med 2013 Sep 1; [e-pub].                                                                                                                                                                     

Imazio M et al. Efficacy and safety of colchicine for treatment of multiple recurrences of pericarditis (CORP-2): A multicentre, double-blind, placebo-controlled, randomised trial. Lancet 2014 Mar 30; [e-pub].

 

β blockers for Heart Failure: Which One Should You Use?

β blockers are a cornerstone of the medical management of heart failure. The long term use of certain β blockers in patients with heart failure reduces hospital admissions and improves symptoms, quality of life, and survival. However, it is still unclear whether this is a class effect or whether one β blocker is superior to another.    

Three landmark placebo-controlled trials of nearly 9000 patients with heart failure demonstrated the efficacy of carvedilol, long acting metoprolol succinate, and bisoprolol in reducing mortality and hospital admission in patients with heart failure. However, large trials of nebivolol and bucindolol found no reductions in all-cause mortality compared with placebo, despite benefits in cardiovascular morbidity or mortality (1).

A systematic review and meta-analysis of 8 randomized, controlled, direct-comparison trials involving 4,563 patients with systolic heart failure receiving atenolol, bisoprolol, metoprolol, nebivolol, or carvedilol.  In this analysis, carvedilol, as compared against atenolol, bisoprolol, metoprolol and nebivolol in randomized direct comparison trials, significantly reduced all-cause mortality in systolic HF patients (2).

A more recent meta-analysis analyzed the results of 21 randomized trials (focusing on atenolol, bisoprolol, bucindolol, carvedilol, metoprolol, and nebivolol) comparing β blockers with other β blockers or other treatments in patients with heart failure and reduced ejection fraction (3). The primary endpoint was all cause death at the longest available follow-up, assessed with odds ratios and Bayesian random effect 95% credible intervals, with independent extraction by observers.   As expected, in the overall analysis, β blockers provided credible mortality benefits in comparison with placebo or standard treatment after a median of 12 months (odds ratio 0.69, 0.56 to 0.80). However, no obvious differences were found when comparing the different β blockers head to head for the risk of death, sudden cardiac death, death due to pump failure, or drug discontinuation. Accordingly, improvements in left ventricular ejection fraction were also similar irrespective of the individual study drug.

CONCLUSION: The benefits of β blockers in patients with heart failure with reduced ejection fraction seem to be mainly due to a class effect, as no statistical evidence from current trials supports the superiority of any single agent over the others. Therefore, β blockers reduce mortality but do not differ from each other.  

Effect of ACE Inhibitors and ARBs on Cardiovascular Outcomes in Diabetes

A recent meta-analysis, published in JAMA Intern Med on March 31, 2014, analyzed the effect of ACE inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) on all-cause mortality, cardiovascular (CV) deaths, and major CV events in patients with diabetes mellitus (DM). The authors of this study included randomized clinical trials reporting the effects of ACEI and ARB regimens for DM on all-cause mortality, CV deaths, and major CV events with an observation period of at least 12 months.

The major results of 35 trials involving more than 50,000 patients showed that ACEIs reduced all-cause mortality, CV mortality, and major CV events in patients with DM.

By contrast, ARBs did not reduce all-cause mortality, CV mortality, or major CV events. Neither ACEIs nor ARBs were associated with a decrease in the risk for stroke in patients with DM. This study suggests that ACEIs vs ARBs be used as first-line therapy in patients with diabetes.  Primary end points were all-cause mortality and death from CV causes. Secondary end points were the effects of ACEIs and ARBs on major CV events.

Twenty-three of 35 identified trials compared ACEIs with placebo or active drugs (32,827 patients) and 13 compared ARBs with no therapy (controls) (23 867 patients). When compared with controls (placebo/active treatment), ACEIs significantly reduced the risk of all-cause mortality by 13%, CV deaths by 17%, and major CV events by 14%, including myocardial infarction by 21% and heart failure by 19%.

Treatment with ARBs did not significantly affect all-cause mortality, CV death rate, and major CV events with the exception of heart failure.

Both ACEIs and ARBs were not associated with a decrease in the risk for stroke in patients with DM. Meta-regression analysis showed that the ACEI treatment effect on all-cause mortality and CV death did not vary significantly with the starting baseline blood pressure and proteinuria of the trial participants and the type of ACEI and DM.

The authors concluded that angiotensin-converting enzyme inhibitors reduced all-cause mortality, CV mortality, and major CV events in patients with DM, whereas ARBs had no benefits on these outcomes. Thus, ACEIs should be considered as first-line therapy to limit excess mortality and morbidity in this population.

Source:

Cheng J, Zhang W, Zhang X, et al. Effect of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers on All-Cause Mortality, Cardiovascular Deaths, and Cardiovascular Events in Patients With Diabetes Mellitus: A Meta-Analysis JAMA Intern Med 2014 Mar 31;[EPub Ahead of Print].

FDA: Does Not Recommend Using Aspirin for Primary Prevention of Heart Attack or Stroke

Aspirin should not be used to prevent a first heart attack or stroke in patients with no history of cardiovascular disease, according to the U.S. Food and Drug Administration (FDA).

In a statement released on May 5, 2014, the FDA said that its review of available data does not support the use of aspirin for primary prevention of a heart attack or stroke. Furthermore, the FDA pointed out that aspirin use is associated with “serious risks,” including increased risk of bleeding in the stomach and brain.

As for secondary prevention for people with cardiovascular disease or those who have had a previous heart attack or stroke, the available evidence continues to support aspirin use.  In patients who have had a cardiovascular event, the known benefits of aspirin for secondary prevention outweigh the risk of bleeding.

This development highlights the importance of patients having one-on-one discussions with their health care providers regarding the best treatment options for their individual circumstances.

Subscribe to Our Newsletter

Lorem ipsum dolor amet consetetur sadipscing elitr diam nonumy eirmod tempor invidunt ut.
© All rights reserved.
Powered by YOOtheme.