A 60-year-old healthy colleague on no medication with an LDL-C level of 123 mg/dL and High-sensitivity C-reactive protein (hs-CRP) level >2.0 mg/L asked to you whether he should take rosuvastatin 20 mg a day.
Which of the following statements is incorrect regarding JUPITER trial?
Rosuvastatin 20 mg/day significantly decreased the incidence of MI. The JUPITER trial randomized 17,802 men and women without CVD presenting an LDL-C lower than 130 mg/dL, but high levels of hs-CRP, to rosuvastatin, 20 mg daily, or to placebo. Rosuvastatin reduced LDL-C levels by 50% and hs-CRP levels by 37%. The primary endpoint outcome was a composite of MI, stroke, arterial revascularization, hospitalization for UA, or death from CVD. The study was interrupted after 1.9 years at interim analyses because of a significant decrease for primary outcome (HR: 0.56; 95% CI: 0.46 to 0.69). HR for MI was 0.46, 95% CI (0.30 to 0.70), and HR for stroke was 0.52, 95% CI (0.34 to 0.79). In the adverse events section, the physicianreported diabetes was more frequent in the rosuvastatin group (n = 270) than in the placebo group (n = 216, P = 0.01); the difference in the median glycated hemoglobin value was minimal (5.9% versus 5.8%, respectively, P = 0.001).
A 65-year-old man with diabetes presented typical chest pain on exertion in the previous 2 months. Coronary angiography revealed significant complex multivessel coronary disease (SYNTAX score, 34).
What is the expected benefit of a revascularization with CABG versus PCI?
CABG is associated with a reduction of death and of MI, but not of stroke. The future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial randomized 1,900 patients with diabetes and multivessel CAD to a revascularization strategy with (1) CABG or (2) PCI. The primary outcome was defined as death from any cause, nonfatal MI, or nonfatal stroke. The primary outcome rate at 5 years was 26.6% in the PCI group and 18.7% in the CABG group. The benefit of CABG was observed in reduction of death (P = 0.049) and MI (P <0.001) rates, but stroke was more frequent in the CABG group than the PCI group (5.2% versus 2.4%, P = 0.03).
A 41-year-old male smoker was admitted for STEMI and quitted smoking after hospitalization.
Which of the following statements is incorrect regarding smoking cessation?
More than 70% of patients quit smoking after ACS. About 50% to 70% of smokers continue to smoke after an ACS, despite the fact that smokers who quit smoking have a 36% reduction in the risk of mortality and 32% in the risk of recurrent nonfatal MI in comparison with continuing smokers over a mean follow-up of 5 years. Smoking cessation intervention is a major target of secondary prevention of CVD and should be one of the priorities of clinicians providing care to such patients. Given the large benefits of smoking cessation, promotion of smoking cessation is the most effective intervention to reduce morbidity and mortality in smokers with CHD. Unfortunately smoking receives less attention from cardiologists than other CV risk factors, and many smokers with CHD are unable to quit smoking without assistance. Based on a systemic review, several studies found a beneficial effect on smoking cessation rates through a smoking cessation intervention that started in hospital and continued in the ambulatory setting.
Six hours after the start of chest pain, a 55-year-old diabetic man was admitted to the emergency department for anterior STEMI with hemodynamic instability (cold extremities, heart rate of 110 bpm and blood pressure of 85/50 mmHg) and severe reduced LVEF (25% to 30%) estimated by echocardiography.
What is the correct statement regarding the decision to perform an emergent revascularization versus an initial medical stabilization according to the SHOCK trial?
Answers b and d are correct. The leading cause of death in patients hospitalized for acute MI is cardiogenic shock. The SHOCK investigators conducted a randomized trial to evaluate early revascularization in patients with cardiogenic shock. Patients with shock caused by left ventricular failure complicating MI were randomly assigned to emergency revascularization (152 patients) or initial medical stabilization (150 patients). Revascularization was accomplished by either CABG or angioplasty. Intra-aortic balloon counterpulsation was performed in 86% of the patients in both groups. The primary endpoint was mortality from all causes at 30 days. Six-month survival was a secondary endpoint. The mean age of the patients was 66 ± 10 years; 32% were women and 55% were transferred from other hospitals. The median time to the onset of shock was 5.6 hours after infarction, and most infarcts were anterior in location. Ninety-seven percent of the patients assigned to revascularization underwent early coronary angiography, and 87% underwent revascularization; only 2.7% of the patients assigned to medical therapy crossed over to early revascularization without clinical indication. Overall mortality at 30 days (primary endpoint) did not differ significantly between the revascularization and medical therapy groups (46.7% and 56.0%, respectively; difference, – 9.3%; 95% CI for the difference, –20.5% to 1.9%; P = 0.11). However, at 6 months mortality was lower in the revascularization group than in the medical therapy group (50.3% versus 63.1%, P = 0.027).
A 63-year-old man known for chronic kidney disease (CKD) due to longterm uncontrolled hypertension is hospitalized for elective coronary angiography.
Which of the following statements is not correct?
Patients with CKD undergoing cardiac catheterization should receive adequate preparatory hydration. The 2011 ACC/AHA PCI guidelines made recommendations regarding contrast-induced AKI. Contrast-induced AKI is considered one of the most frequent causes of iatrogenic AKI. Risk factors for developing contrast-induced AKI are hypotension, intra-aortic balloon pump, congestive heart failure, CKD, diabetes, age >75 years, anemia, and volume of contrast. The following recommendations are of class I for the prevention of AKI:
However, the administration of Nacetyl-cysteine is not useful for the prevention of contrast-induced AKI and is not recommended based on the results of several randomized controlled trials.
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