PracticeUpdate: Cardiology | Vol1 - No.2 - 2016

ESC 2016

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Given the level of risk of cardiovascular disease attributed to obstructive sleep apnoea in previous observational studies, wewere surprised not to find a benefit fromCPAP treatment. >5

Any intervention that reduces myocardial infarct size by approximately a thirdmight reasonably be expected to substantially improve long-term outcomes. >6

Findings suggest that lipoprotein apheresis provides significant clinical benefit to patients with refractory angina in the context of raised lipoprotein(a). The outcome represents amuch needed novel treatment option for this therapeutically challenging patient cohort. >8

Direct catheter-based thrombectomy is as effective as bridging thrombolysis in ischaemic stroke

Direct catheter-based thrombectomy is equally effective as thrombolysis in the treatment of acute ischaemic stroke, according to results from the prospective, observational, pilot PRAGUE-16 registry study. P etr Widimsky, MD, of Charles University, Prague, Czech Republic, explained, “If left untreated, acute ischaemic stroke caused by a major artery occlusion results in death PRAGUE-16 included 103 patients who presented within 6 h from the onset of moderate to severe acute ischaemic stroke. Patients had an occluded major cerebral artery but no large ischaemia yet on a CT scan. The attending neurologist decided whether patients received direct catheter-based thrombectomy or bridging thrombolysis + catheter-based thrombectomy based on the clinical picture and CT scan. The intervention was performed within 60 minutes of the CT scan.

for up to half of patients and an additional 40% to 50% are left permanently disabled. In other words, without treatment, only a few patients with major ischaemic stroke survive without severe sequelae.” Functionally independent survival (defined as a modified Rankin Scale score of 0–2) after these major strokes increases to approximately 20% to 30% with thrombolytic treatment in specialised stroke units. The majority of patients, however, still die or remain permanently disabled. In 2015 several randomised trials demonstrated that 45% to 50% of patients can survive and be functionally independent with catheter-based (endovascular) mechanical thrombectomy. If the intervention is performed very early (within 3 h of stroke onset), results are even better – up to 70% of patients may return to normal daily life. Thus, catheter-based mechanical thrombectomy is now recommended for all patients with acute ischaemic stroke caused by a major artery occlusion. Many questions remain, however. Dr Widimsky and col- leagues investigated two of them. First, they set out to deter- mine whether direct (without thrombolysis) cathether-based thrombectomy can achieve comparable results to thrombec- tomy performed after intravenous (“bridging”) thrombolysis. Second, they determined whether catheter-based thrombec- tomy performed in interventional cardiology departments (when no interventional neuroradiology department is available) can achieve results comparable to neuroradiology settings. Dr Widimsky said, “The study aim was to evaluate the feasibility and safety of direct catheter-based thrombectomy performed in close cooperation between cardiologists, neurolo- gists, and radiologists – a true interdisciplinary approach.”

Approximately 73 patients received direct catheter-based thrombectomy and 30, bridging thrombolysis + catheter-based thrombectomy. Good functional outcome (defined as a modi- fied Rankin Scale score of 0–2 after 90 days) was achieved in 41% patients overall with similar results between the two groups. “In our study, 41% of patients who received direct catheter- based thrombectomy had good functional recovery. This compares to 48% of patients given this intervention in seven randomised trials performed in expert neuroradiology units. Our outcomes, however, were significantly better than trials in which patients received medical therapy (intravenous throm- bolysis) alone, of whom only 30% recovered,” Dr Widimsky said. “Our findings suggest that direct catheter-based thrombec- tomy performed in a timely manner may be an alternative to thrombectomy after bridging thrombolysis. Furthermore, in regions with no (or limited) interventional neuroradiology services, modern stroke treatment might be offered via inter- ventional cardiology services in close cooperation with neurolo- gists and radiologists. Both of these preliminary conclusions, however, should be confirmed by larger multicentre studies or large international registries.” 

CPAP is shown to improve wellbeing but not cardiovascular outcomes More than 3 years of nightly treatment with a continuous positive airway pressure (CPAP) machine did not reduce cardiovascular risk more than usual care among patients with cardiovascular disease and obstructive sleep apnoea, reports the Sleep Apnea Cardiovascular Endpoints (SAVE) study. D oug McEvoy, MD, of Flinders University, Adelaide, Australia, explained, “Given the level of risk of cardio- vascular disease attributed to obstructive sleep apnoea in previous observational studies, we were surprised not to find a benefit from CPAP treatment.” apnoea. A total of 2717 individuals were randomised to receive usual care alone or usual care plus CPAP. hypothesised level of effect on cardiovascular outcomes.” Importantly, however, CPAP did improve participant well- being, defined by symptoms of daytime sleepiness, health- related quality of life, mood (particularly depressive symptoms), and attendance at work.

Forty-two percent of patients assigned to CPAP achieved good adherence (an average of 4 or more hours per night). Mean apnoea–hypopnoea index (a measure of obstructive sleep apnoea severity) decreased from 29.0 to 3.7 events per hour when patients used CPAP, indicating good control of their obstructive sleep apnoea. After a mean of 3.7 years for 1341 usual care and 1346 CPAP patients included in the final analysis, however, no dif- ference between groups was observed in the primary outcome, a composite of death from any cardiovascular cause, myocardial infarction or stroke, and hospitalisation for heart failure, acute coronary syndrome, or transient ischaemic attack. Specifically, 17.0% of patients in the CPAP group and 15.4% in usual care experienced a serious cardiovascular event. Dr McEvoy said, “It’s not clear why CPAP treatment did not improve cardiovascular outcomes. It is possible that, even though the average CPAP adherence of approximately 3.3 h per night was as expected, and more than we estimated in our power calculations, it was still insufficient to show the

Dr McEvoy said, “While it is disappointing not to find a reduction in cardiovascular events with CPAP, our results showed that treatment of obstructive sleep apnoea in patients with cardiovascular disease is nevertheless worthwhile. They were much less sleepy and depressed, and their productivity and quality of life was enhanced.” He added, “More research is needed on how to reduce the significant risk of cardiovascular events in people who suffer from sleep apnoea. Given our finding of a possible reduction in cerebrovascular events in patients who were able to use CPAP for more than 4 h per night, and prior studies showing a stronger association between obstructive sleep apnoea and stroke than between obstructive sleep apnoea and coronary artery disease, future trials should consider targeting patients with obstructive sleep apnoea and stroke who can achieve a high level of CPAP compliance.”

The SAVE study recruited sleep apnoea patients with moderate-to- severe disease from 89 clinical centres in seven countries. Participants were predominantly elderly (approxi- mately 61 years), overweight, habitually snoring males, and all had coronary artery or cerebrovascular disease. Participants had to achieve a minimum 3 h of sham-CPAP adherence per night in a 1-week run-in before the study started. Usual care included concomitant cardiovascular risk manage- ment, based on national guidelines, as well as advice on healthy sleep habits and lifestyle changes to minimise obstructive sleep Future trials should consider targeting patients with obstructive sleep apnoea and stroke who can achieve a high level of CPAP compliance.

VOL. 1 • No. 2 • 2016