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Newsletters December 2010 - Jefferson Cardiology Happenings

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Risks of Combining Coumadin with Anti-Platelet Therapy

Many patients with atrial fibrillation taking Coumadin may be given anti-platelet therapy for arterial disease or after stent placement. A Danish published registry evaluated 119,000 patients who survived a first hospitalization for atrial fibrillation. Nearly 83,000 were discharged on Coumadin, aspirin, Plavix or a combination. When analysis was adjusted for age, sex and other medical therapy, it was found that the risk of fatal or serious non fatal bleeding was 3.7 times greater in those taking aspirin, Coumadin and Plavix compared to Coumadin alone. This risk was 3.1 times greater in those on Coumadin plus Plavix and 1.7 times greater in those on aspirin and Plavix and 1.8 times greater in those on aspirin plus Coumadin. Compared to Coumadin, the combination of Coumadin plus Plavix or Coumadin aspirin and Plavix did not reduce the incidence of stroke.

These findings demonstrate the increased risk of serious and fatal hemorrhage with combining Coumadin plus antiplatelet therapy. Combining Coumadin with aspirin and Plavix is particularly risky. The thought can be raised that patients on chronic Coumadin at risk for stroke should preferentially receive bare metal stents as these stents require a shorter period of triple antiplatelet therapy.

Comparative Effectiveness of Therapy for Coronary Disease

A Brazilian study was recently published comparing outcomes of patients with multivessel coronary artery disease with patients randomized to coronary bypass surgery, coronary interventions including stents with balloon angioplasty and thirdly, with medical therapy. People were watched over 11 years and outcomes were evaluated for death, heart attacks and severe angina requiring either coronary bypass or coronary angioplasty with stents when possible. This is the longest follow up period on record.

Overall the best results were seen with coronary bypass surgery as 33% of bypass patients, 42% of angioplasty patients and 59% of medically treated pa-tients developed at least one outcome. The lowest cardiac mortality was seen in the surgery group at 11% compared to 14% with angioplasty and 21% with medical therapy. Overall mortality was similar in all 3 groups. Only 7% of bypass patients required repeat cardiac procedures compared to 40% of the angioplasty and medical treatment groups. Non-fatal heart attacks occurred in 10% of the bypass pa-tients but 13% in angioplasty group and 21% of the medically treated group. About 60% of the bypass and angioplasty groups were free of angina compared to 40% of the medically treated patients. A nonsignificant incidence of stroke was seen in the surgical group.

This information is of interest given the long-term follow-up. Yet, the duration of the study could suggest that study patients may not have had drug eluding stents, current antiplatelet therapy for stents and optimal medical therapy for medically treated patients. To better identify therapy for patients with multivessel coronary disease, future studies may need to stratify patients according to symptoms and information demonstrating the degree to which blood flow is reduced to live heart muscle.

Improved CPR Results

In 2005, Arizona launched an education program including training 30,000 people and a media campaign to instruct in compression only CPR including chest compression but no mouth to mouth resuscitation. Subsequently, survival was tracked comparing conventional bystander CPR to compression only CPR. Post out of hospital cardiac arrest, 5% survived to dis-charge from the hospital who had no CPR compared with 8% for conventional CPR and 13% for compression CPR. Survival without brain damage occurred in 13% treated with hands on CPR and 8% with conventional CPR. Overall survival im-proved from 4% in 2005 to 10% in 2009. Current American Heart Association guidelines now recommend compression only CPR for untrained bystanders.

Male Hormone for Women with Heart Failure

Some heart failure patients may have low levels of male hormone, androgen. Such patients may have reduced functional status related to bone and muscular function. Small studies have demonstrated benefit of testosterone given to male heart failure patients. Now a study has been done giving low dose testosterone to 36 post menopausal women, average age 68, with significantly weakened heart muscle and marked limitation of physical activity. The treatment group received testosterone patches applied to their skin and these were compared with a control group without male hormone therapy.

Results demonstrated that at 6 months, those women with heart failure given testosterone were able to walk fur-ther, had better leg strength without any changes in heart function. There was also better sensitivity to insulin. These findings are preliminary but may offer future benefits if these results are confirmed by ongoing and future studies.

Dabigatran Update

Dabigatran, a newly released drug, may serve many of the roles of Coumadin and will require no monitoring blood tests. Results may be similar to Coumadin or better when the Coumadin monitoring studies demonstrate suboptimal effectiveness. Dabigatran will be much more expensive than Coumadin and cannot be given to patients with reduced kidney filtration, heart valve disease, liver disease, or recent stroke. Time will tell what role this drug will have.

Staff News

We would like to extend a very Happy Birthday to our clinical manager, Brian Cooper, aka, Coumadin King!
Happy Holidays

We at JCA would like to wish everyone and their families a happy and safe holiday season and a prosperous New Year!

A publication of Jefferson Cardiology Association
Alan D. Bramowitz, M.D. | Michael S. Nathanson, M.D. | Gennady Geskin, M.D.

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