coronary disease
DISEASE INTERVENTION COMPARISON RESULTS
N Engl J Med. 2018 Jun 13. doi: 10.1056/NEJMoa1800389. [Epub ahead of print] Randomized Controlled Trial, Multicenter Study
IN atherosclerosis, cardiovascular disease, coronary disease, primary prevention, high risk patients The Use of
Mediterranean diet supplemented with extra-virgin olive oil, or with mixed nuts
As Prevention, Primary
Is better Than
simple advice to reduce dietary fat
To reduce cardiovascular events (myocardial infarction, stroke, or cardiovascular death): medit. diet plus olive oil 3.8% VS medit. diet plus nuts 3.4% VS control group 4.4%
Am J Cardiol. 2013 Jun 15;111(12):1701-7 Diagnostic
IN coronary disease, acute coronary syndrome, myocardial infarction, older patients The Use of
high-sensitive cardiac troponin, increased cutoff at 40-50 ng/L in older patients and renal failure
As Diagnostic Tool
Is better Than
standard cutoff at 14 ng/L
To better diagnose acute coronary syndrome: sensitivity 87% and specificity 87% at 50 ng/Lfor older patients
J Am Coll Cardiol. 2002 Oct 16;40(8):1408-13 Cohorts
IN atherosclerosis, coronary disease, ischemic stroke The Use of
chronic infections, sropositivity to helicobacter pylori, clamidia pneumoniae, citomegalovirus
As Prognostic Item
Is useless Than
-
To predict risk for cardiovascular disease
J Am Coll Cardiol. 2005 Nov 15;46(10):1855-62. Epub 2005 Oct 24 Meta-Analysis
IN atherosclerosis, coronary disease, ischemic stroke, high or normal cholesterol The Use of
statins
As Treatment, Chronic
Is equal Than
interventions to primarily lower LDL cholesterol, if equal reduction
To The regression lines for non-statin and statin trials were similar and consistent with a one-to-one relationship between LDL-cholesterol lowering and coronary disease and stroke reduction.
Lancet. 2005 Oct 8;366(9493):1267-78. Epub 2005 Sep 27 Meta-Analysis
IN atherosclerosis, coronary disease, ischemic stroke, high or normal cholesterol The Use of
statins
As Treatment, Chronic
Is better Than
placebo
To reduce coronary and all-cause mortality (RRR 12%), and reduce major vascular events (vascular death, infarction, revascularization or stroke): RRR 21%.
Arch Intern Med. 2007 Jun 11;167(11):1122-9 Cohorts
IN atherosclerosis, coronary disease, ischemic stroke, peripheral arterial disease The Use of
chronic kidney disease measures (anemia, microalbuminuria, and GFR of <60 mL/min)
As Etiologic risk factor
Is useful Than
added to classical vascular risk factors
To idependently predict the risk of cardiovascular disease: OR about 1.30 for each one of the 3 measures, OR 1.98 for chronic kidney disease.
BMJ. 2002 Jan 12;324(7329):71-86 Meta-Analysis
IN atherosclerosis, coronary disease, ischemic stroke, peripheral arterial disease The Use of
antiplatelet drugs, aspirin, low-dose (75-150 mg/d), adenosine diphosphate (ADP) receptor inhibitors, clopidogrel
As Treatment, Chronic
Is better Than
placebo
To reduce recurrence of ischemic coronary and cerebral events, with absolute reductions of 3 to 4%, depending on specific conditions
Ann Intern Med. 2009 Mar 17;150(6):405-10 Systematic Review
IN atherosclerosis, coronary disease, stroke, ischemic, cardiovascular death The Use of
aspirin
As Prevention, Primary
Is better Than
placebo
To reduce cardiovascular events (myocardial infarction in men and strokes in women) but not cardiovascular death or overall mortality. Aspirin use increases serious bleeding events.
Lancet. 2009 May 30;373(9678):1849-60 Meta-Analysis
IN atherosclerosis, coronary disease, stroke, ischemic, cardiovascular death The Use of
aspirin
As Prevention, Primary
Is better Than
placebo
To reduce, both as primary or secondary prevention, serious cardiovascular events but increasing major bleeding. Benefit for primary prevention was limited: 0.51% events aspirin VS 0.57% placebo, 0.10% major bleedings aspirin VS 0.07% placebo
Lancet. 1996 Nov 16;348(9038):1329-39 Randomized Controlled Trial, Multicenter Study
IN atherosclerosis, coronary disease, stroke, ischemic, peripheral arterial disease, or multiple risk factors The Use of
antiplatelet drugs, P2Y12 inhibitors, clopidogrel (75 mg/d)
As Treatment, Chronic
Is better Than
antiplatelet drugs, aspirin (325 mg/d)
To marginally reduce ischemic events (stroke, myocardial infarction or vascular death): 5.32% per year clopidogrel VS 5.83% per year aspirin, ARR 0.51% x year. Adverse effects was similar, i.e. intracraneal (0.33-0.47%) & GI bleeding (0.52-0.72%)
N Engl J Med. 2006 Apr 20;354(16):1706-17. Epub 2006 Mar 12 Randomized Controlled Trial, Multicenter Study
IN atherosclerosis, coronary disease, stroke, ischemic, peripheral arterial disease, or multiple risk factors The Use of
combined antiplatelet drugs, P2Y12 inhibitors, clopidogrel (75 mg/d) added to low-dose aspirin
As Treatment, Chronic
Is equal Than
antiplatelet drugs, low-dose aspirin (75 to 160 mg/d) alone
To reduce, at 2 years, cardiovascular events (myocardial infarction, stroke, or cardiovascular death): 6.8% clopidogrel plus aspirin VS 7.3% aspirin alone. Bleeding was not significantly different. Combined treatment worse for non-symptomatic patients
N Engl J Med. 2007 Oct 11;357(15):1477-86 Randomized Controlled Trial, Multicenter Study
IN atherosclerosis, hypercholesterolemic adults and NOT coronary disease The Use of
statins, pravastatin
As Prevention, Primary
Is better Than
placebo
To reduce death from cronory heart disease, at 5 years of treatment and 10 years after: 11.8% for the entire 15 years period with statin VS 15.5% placebo
Lancet. 2002 Jul 6;360(9326):7-22 Randomized Controlled Trial, Multicenter Study
IN atherosclerosis, normo-cholesterol adults with coronary disease, other occlusive arterial disease, or diabetes The Use of
statins, simvastatin, for 5 years
As -
Is better Than
placebo
To reduce coronary death rate (5.7% intv. / 6.9% cont.) and all-cause mortality (12.9% intv. / 14.7% cont.). Reduce major vascular events after the first year.
Eur Heart J. 2011 Mar;32(5):637-45 Diagnostic
IN coronary disease The Use of
coronary multidetector computed tomography
As Diagnostic Tool
Is worse Than
coronary angiography
To detect significant coronary stenosis: sensib 100%, spec 85%, positive predict value 81%, negative predict value 100%. It detected all patients with atherosclerosis but misclassified some as severe stenosis
JAMA. 2006 Jul 26;296(4):403-11 Diagnostic
IN coronary disease The Use of
coronary multidetector computed tomography
As Diagnostic Tool
Is worse Than
coronary angiography
To diagnose coronary stenosis of more than 50%: in patient-based analysis, 98% sensitivity for detecting at least 1 stenosis, 54% specificity, 50% positive predictive value, 99% negative predictive value. So, too much false positives.
Eur Heart J. 2007 Oct;28(20):2485-90 Diagnostic
IN coronary disease The Use of
coronary multidetector computed tomography
As Diagnostic Tool
Is better Than
exercise electrocardiography, with coronary angiography as gold standard
To diagnose significant coronary disease: 91% sensitivity and 83% specificity of scan VS 73% sensitivity and 31% specificity of exercise ECG.
Ann Intern Med. 2000 Jun 6;132(11):862-70. Cohorts
IN coronary disease The Use of
stress test, treadmill exercise testing, in elderly persons
As Diagnostic Tool
Is equal Than
treadmill exercise testing, in younger persons
To predict overall survival and cardiac event-free survival. Workload achieved was the main exercise testing variable that was predictive of death.
J Am Coll Cardiol. 2010 Mar 9;55(10):1017-28 Cohorts
IN coronary disease The Use of
cardiac computed tomography angiography , and also, in addition, left ventricle ejection fraction
As Prognostic Item
Is useful Than
no comparison here
To predict increased risk of all-cause mortality or nonfatal myocardial infarction at 1.5 years: HR 3 when sever coronary disease detected.
Circulation. 2012 Jun 12;125(23):2873-91. Epub 2012 May 14 Meta-Analysis
IN coronary disease The Use of
drug-eluting stents, specially using everolimus, sirolimus and zotarolimus, but not those using paclitaxel
As Treatment, Acute
Is better Than
bare-metal stents
To reduce long-term need for revascularization and reduce myocardial infarction (RR 0.50), with no increase in the risk of any long-term safety outcomes, including stent thrombosis
Am J Med. 2009 Apr;122(4):356-65 Meta-Analysis
IN coronary disease The Use of
calcium channel blockers
As Treatment, Chronic
Is better Than
placebo, or mixed comparison placebo plus others treatments
To reduce angina and stroke, but not to reduce mortality (either all-cause or cardiovascular) nor to reduce myocardial infarction
Eur Heart J. 2005 Oct;26(20):2148-53. Epub 2005 Jun 23 Randomized Controlled Trial
IN coronary disease The Use of
coronary artery bypass surgery
As Treatment, Chronic
Is equal Than
percutaneous coronary angioplasty
To improve long-term survival: overall mortality was similar after 13 years. Time to first re-intervention was significantly shorter in angioplasty, but frequency of re-intervention was comparable (about 70%) and also symptomatic angina or dyspnoea.
Ann Intern Med. 2007 Nov 20;147(10):703-16 Systematic Review
IN coronary disease The Use of
coronary artery bypass surgery
As Treatment, Chronic
Is equal Than
percutaneous coronary intervention (angioplasty with/out stent)
To modify mortality at 10 years. Strokes were more common after CABG(1.2% CABG vs. 0.6% PCI) and repeated revascularization was more common after PCI (at 5 years 46.1% balloon angioplasty, 40.1% PCI with stents, and 9.8% CABG).
N Engl J Med. 2007 Mar 8;356(10):1030-9 Meta-Analysis
IN coronary disease The Use of
drug-eluting stents, sirolimus
As Treatment, Chronic
Is equal Than
bare-metal stents
To reduce the overall risk of death, myocardial infarction and stent thrombosis.
Lancet. 2007 Sep 15;370(9591):937-48 Meta-Analysis
IN coronary disease The Use of
drug-eluting stents, sirolimus, paclitaxel
As Treatment, Chronic
Is equal Than
bare-metal stents
To reduce the risk of death and myocardial infarction
N Engl J Med. 2007 Mar 8;356(10):998-1008 Meta-Analysis
IN coronary disease The Use of
drug-eluting stents, sirolimus, paclitaxel
As Treatment, Chronic
Is worse Than
bare-metal stents
To reduce stent thrombosis at 4 years (1.2 to 1.3% drug-eluting VS 0.6 to 0.9% bare-metal) Rates of death or myocardial infarction did not differ.
JAMA. 1999 Dec 1;282(21):2058-67 Meta-Analysis
IN coronary disease The Use of
vitamin K antagonists, added to aspirin, but not alone
As Treatment, Chronic
Is better Than
aspirin alone
To prevent myocardial infarction or stroke (risk reduction not given), but based in few studies (3 studies, 480 patients) and increasing bleeding risk by about 2 fold.
Am Heart J. 1999;137(6):1137-1144 Diagnostic
IN coronary disease, acute coronary syndrome The Use of
troponin T
As Diagnostic Tool
Is better Than
creatine kinase-MB (CK-MB)
To equally diagnosing acute myocardial infeartion in the first 24 h, but much better predicting death or major cardiac complications
Circulation. 2003 Feb 25;107(7):966-72 Randomized Controlled Trial
IN coronary disease, acute coronary syndrome The Use of
P2Y12 inhibitors, clopidogrel, added to aspirin, combined anti-platelet therapy
As Treatment, Acute
Is better Than
aspirin alone
To reduce ischemic events (cardiovascular death, myocardial infarction, or stroke) at 30 days (4.3% in intv. VS 5.4% in ctrl.) and at 12 months (5.2% in intv. VS 6.3% in ctrl.) No significant excess in life-threatening bleeds (but yes for total bleeds)
N Engl J Med. 2007 Nov 15;vol(issue):pag [Epub ahead of print Nov 4] Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome The Use of
P2Y12 inhibitors, prasugrel, added to aspirin, combined anti-platelet drugs
As Treatment, Acute
Is better Than
clopidogrel, added to aspirin, combined anti-platelet therapy
To reduce recurrence of myocardial infarction (7.4% for prasugrel VS 9.7% for clopidogrel) and a derived combined end-point of cardiovascular death and major events.
N Engl J Med. 2009 Sep 10;361(11):1045-57 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome The Use of
P2Y12 inhibitors, ticagrelor, added to aspirin, combined anti-platelet therapy
As Treatment, Acute
Is better Than
clopidogrel, added to aspirin, combined anti-platelet drugs
To reduce at 12 months cardiovascular events (death from vascular causes, myocardial infarction, or stroke): 10% ticagrelor VS 12% clopidogrel. Ticagrelor increased minor bleedings but not major haemorrhages.
N Engl J Med. 2011 Aug 25;365(8):699-708. [Epub 2011 Jul 24] Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome The Use of
anticoagulants, oral factor Xa inhibitors, apixaban, 5 mg twice daily
As Treatment, Chronic
Is worse Than
placebo
To improve results at 8 months: it increase in major bleeding events (1.3% apixaban VS 0.5% placebo) and did not reduced cardiovascular events (7.5% apixaban VS 7.9% placebo)
N Engl J Med. 2012 Jan 5;366(1):9-19. Epub 2011 Nov 13 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome The Use of
anticoagulants, oral factor Xa inhibitors, rivaroxaban, 2.5 or 5 mg twice daily, in addition to double antiplatelet treatment
As Treatment, Chronic
Is better Than
placebo
To reduce at 13 months cardiovascular events (cardiovascular death, myocardial infartion , stroke): 8.9% rivaroxaban VS 10.7% placebo. However, it increases major bleedings: 2.1% rivaroxaban VS 0.6% placebo
J Am Coll Cardiol. 2018 May 01;71(17):1869-1877 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome The Use of
selecting the PY212 antiplatelet (clopidogrel, prasugrel, or ticagrelor) on the basis of a patient,s genetics, genotyping of ABCB1, CYP2C19*2, and CYP2C19*17
As Treatment, Chronic
Is better Than
selecting P2Y12 antiplatelet on clinical characteristics alone
To reduce at 1 year a composite endpoint of cardiovascular death and the first occurrence of nonfatal myocardial infarction, nonfatal stroke, and major bleeding: 16% pharmacogenomic VS 26% usual care
N Engl J Med. 2014 Dec 4;371(23):2155-66 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, after percutaneous coronary intervention, drug eluting stents The Use of
dual antiplatelet therapy (aspirin + P2Y12 inhibitor (clopidogrel or prasugrel)) for 30 months
As Treatment, Chronic
Is worse Than
dual antiplatelet therapy (aspirin + thienopyridine) for 12 months only
To improve all-cause mortality (2.0% 30 months VS 1.5% 12 months), even if it reduced cardiovascular events (4.3% 30 months VS 5.9% 12 months). Extended treatment increased major bleedings (2.5% vs 1.6%) but that did not explain the mortality difference
N Engl J Med. 2015 May 07;372(19):1791-800 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, after percutaneous coronary intervention, drug eluting stents The Use of
mantaining dual antiplatelet after 1 year with ticagrelor (90 mg twice daily or 60 mg twice daily) plus low-dose aspirin
As Treatment, Chronic
Is better Than
placebo plus low-dose aspirin
To reduce cardiovascular events (8% both doses ticagrelor VS 9% aspirin alone) but increasing major bleeding (2.5% ticagrelor VS 1% aspirin alone)
J Am Coll Cardiol. 2015 Mar 24;65(11):1092-102 Meta-Analysis
IN coronary disease, acute coronary syndrome, after percutaneous coronary intervention, drug eluting stents The Use of
short- (≤6 months) dual antiplatelet therapy
As Treatment, Chronic
Is better Than
long-term (1 year) dual antiplatelet therapy
To reduce bleeding (HR 0.66) while achieving similar rates of cardiac events (cardiac death, myocardial infarction, or definite/probable stent thrombosis: HR 1.11)
BMJ. 2015 Apr 16;350:h1618 Meta-Analysis
IN coronary disease, acute coronary syndrome, after percutaneous coronary intervention, drug eluting stents The Use of
short term course of dual antiplatelet therapy
As Treatment, Chronic
Is better Than
12 month dual antiplatelet therapy
To reduce major bleeding (OR 0.58) with no significant differences in ischaemic or thrombotic outcomes. Extended VS 12 month Tt yielded a reduction of ischemic events (OR 0.33 to 0.53) but more major bleeding (OR 1.66) and more all-cause deaths (OR 1.30)
N Engl J Med. 2017 Oct 19;377(16):1513-1524 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, after percutaneous coronary intervention, drug eluting stents, atrial fibrillation The Use of
dual treatment with dabigatran 110 mg twice daily plus an a P2Y12inhibitor (clopidogrel or ticagrelor) antiplatelet
As Treatment, Chronic
Is better Than
triple therapy with dose-adjusted vitamin K antagonist plus dual antiplatelet
To reduce at 14 months major or clinically relevant bleeding events (15% dabigatran 110mg VS 27% triple therapy) with no increase of cardiovascular events (13.7% dual-therapy VS 13.4% triple-therapy)
Lancet. 2013 Mar 30;381(9872):1107-15 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, after percutaneous coronary intervention, drug eluting stents, atrial fibrillation The Use of
dual treatment with INR adjusted warfarin plus clopidogrel
As Treatment, Chronic
Is better Than
triple therapy with dose-adjusted vitamin K antagonist plus dual antiplatelet (aspirin + clopidogrel)
To reduce at 1 year any bleeding event (19% dual Tt VS 44% triple Tt) with no increase in the rate of thrombotic events
N Engl J Med. 2016 Dec 22;375(25):2423-2434 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, after percutaneous coronary intervention, drug eluting stents, atrial fibrillation The Use of
low-dose rivaroxaban (15 mg /d) plus an P2Y12 inhibitor antiplatelet for 12 months OR very-low-dose rivaroxaban (2.5 mg twice daily) plus dual antiplatelet for 1, 6, or 12 months
As Treatment, Chronic
Is better Than
dose-adjusted vitamin K antagonist plus dual antiplatelet for 1, 6, or 12 months
To reduce clinically significant bleeding (17% rivaroxaban 15 + 1 antiplatelet, 18% rivaroxaban 2.5 + 2 antiplatelets, and 26.7% antivitamin K + 2 antiplatelets) while having similar rates of cardiovascular events (6.5%, 5.6% and 6% respectively)
N Engl J Med. 2004 Apr 8;350(15):1495-504 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, high or normal cholesterol The Use of
high dose statins, atorvastatin 80 mg/d
As Treatment, Chronic
Is better Than
standard dose statins, standard lipid lowering, pravastatin 40 mg/d
To reduce cardiovascular events (composite of death from any cause, myocardial infarction, hospitalization for unstable angina, revascularization and stroke): 22,4% at 2 years in intv. VS 26,3% in ctrl.
J Am Coll Cardiol. 2010 May 11;55(19):2096-106 Cohorts
IN coronary disease, acute coronary syndrome, myocardial infarction The Use of
copeptin, added to troponin
As Diagnostic Tool
Is better Than
troponin
To more accurately diagnose an acute coronary syndrome (c-statistics 0.93 copeptin + troponin VS 0.84 troponin alone) and to rule out coronary syndrome in the first 3 hours: 92% negative predictive value with copeptin + troponin
Cochrane Database Syst Rev. 2011;1:CD007038 Systematic Review, Cochrane Review
IN coronary disease, acute coronary syndrome, myocardial infarction The Use of
pentasacharide analogues, fondaparinux
As Treatment, Acute
Is better Than
low molecular weight heparins (LMWH), enoxaparin
To reduce the risk of all-cause mortality at 90 to 180 days (RR 0.89) while reducing minor bleeding
Ann Intern Med. 2005 Aug 16;143(4):241-50 Meta-Analysis
IN coronary disease, acute coronary syndrome, myocardial infarction The Use of
vitamin K antagonists, warfarin, added to aspirin
As Treatment, Chronic
Is better Than
aspirin alone, NOT compared to aspirin plus clopidrogel
To decrease the annual rate of myocardial infarction (0.022 vs. 0.041) and ischemic stroke (0.004 vs. 0.008) but not to reduce mortality. Major bleeding increased (0.015 vs. 0.006)
Eur Heart J. 2011 Jun;32(11):1379-89 Diagnostic
IN coronary disease, acute coronary syndrome, myocardial infarction, older patients The Use of
high-sensitive cardiac troponin assays
As Diagnostic Tool
Is better Than
standard cardiac troponin assay
To diagnose acute myocardial infarction: AUC 0.95 sensitive troponine VS 0.90 standard troponine. Best cut-offs in elderly patients differed clearly from younguer patients. Mild elevations are commont in non-infarctus elderly (20% patients)
Eur Heart J. 2013 Sep 11. [Epub ahead of print] Meta-Analysis
IN coronary disease, acute coronary syndrome, myocardial infarction, ST-segment elevation The Use of
intracoronary bone marrow cell therapy
As Treatment, Acute
Is better Than
placebo or no cell therapy
To improve (at a time not well defined) left ventricle ejection fraction (LVEF) : 2.5% mean increase, 5.3% when LVEF was < 40%
N Engl J Med. 1998 Nov 5;339(19):1349-57 Randomized Controlled Trial
IN coronary disease, acute coronary syndrome, myocardial infarction, unstable angina, normal cholesterol The Use of
statins, pravastatin 40 mg/d
As Prevention, Secondary
Is better Than
placebo
To reduce - at 6 years - overall mortality (11.0% in pravastatin vs 14.1% in placebo) and cardiovascular mortality (7.3% in pravastatin vs 9.6% in placebo)
JAMA. 2006 Apr 5;295(13):1519-30. Epub 2006 Mar 14 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, ST-segment elevation The Use of
pentasacharide analogues, fondaparinux (2.5 mg/d) for 8 days
As Treatment, Acute
Is better Than
unfractionated heparin for 2 days, or placebo
To reduce at 30 days bad outcome (death or reinfarction): 9.7% fondaparinux VS 11.2% controls. No difference in bleeding.
Lancet. 2000 Jul 1;356(9223):9-16 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, unstable angina The Use of
routine invasive strategy (angiography and revascularization), first 10 days
As Treatment, Acute
Is better Than
non invasive startegy
To reduce, 1 year later, death (2.2% invasive VS 3.2% conservative) and reinfarction (9% invasive VS 12% conservative)
N Engl J Med. 2001 Aug 16;345(7):494-502 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, without ST elevation The Use of
adenosine diphosphate (ADP) receptor inhibitors, clopidogrel, added to aspirin, combined anti-platelet therapy
As Treatment, Acute
Is better Than
aspirin alone
To reduce, at 1 year, ischemic events (cardiovascular death, myocardial infarction or stroke): 9.3% in intv VS 11.4% in ctrl. Increase major bleeds (3.7% in intv. VS 2.7% in ctrl.)
J Am Coll Cardiol. 2010 Mar 2;55(9):858-64 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, without ST elevation The Use of
early invasive strategy of coronary angiography and revascularization when feasible
As Treatment, Acute
Is equal Than
conservative strategy: coronary angiography and revascularization only if recurrent ischemia or on provocative testing
To modify at 5 years cumulative death or MI rates (22.3% early VS 18.1% conservative), or mortality.
JAMA. 2001 Nov 21; 286 (19):2405-12 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, without ST elevation The Use of
early invasive strategy of coronary angiography between 4 and 48 hours and revascularization when feasible
As Treatment, Acute
Is better Than
Conservative strategy: coronary angiography and revascularization only if recurrent ischemia at rest or on provocative testing
To reduce composite end point of death, MI, or rehospitalization for acute coronary syndrome at 6 months: 15.3% in intv. VS 25% in ctrl.
N Engl J Med. 2005 Sep 15;353(11):1095-104 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, without ST elevation The Use of
early invasive strategy of coronary angiography revascularization when feasible
As Treatment, Acute
Is equal Than
conservative strategy: coronary angiography and revascularization only if recurrent ischemia or on provocative testing
To reduce at 1 year a composite enpoint of death, nonfatal myocardial infarction, or rehospitalization for anginal symptoms: 22.7% in early invasive VS 21.2% with conservative strategy. Early invasive strategy associated more AMI but less rehospitalisations
Lancet. 2002 Jan 19;359(9302):189-98 Meta-Analysis
IN coronary disease, acute coronary syndrome, without ST elevation The Use of
glycoprotein IIb/IIIa inhibitors, anti-platelet
As Treatment, Acute
Is better Than
placebo
To reduce at 30 days death or myocardial infarction (10.8% in intv. VS 11.8% in ctrl.). Increase major bleeds (2,4% in intv. VS 1,4% in ctrl)
N Engl J Med. 2006 Apr 6;354(14):1464-76. Epub 2006 Mar 14 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, without ST elevation The Use of
pentasacharide analogues, fondaparinux (2.5 mg/d SC) for 6 days
As Treatment, Acute
Is equal Than
low molecular weight heparin (LMWH), enoxaparin 1 mg/Kg/12h
To reduce at 30 days bad outcome (death, reinfarction, or refractory ischemia): 8.0% fondaparinux VS 8.6% enoxaparin. Fondaparinux had fewer major haemorrhages: 3.1% VS 5.0% enoxaparin
JAMA. 2008 Jul 2;300(1):71-80 Meta-Analysis
IN coronary disease, acute coronary syndrome, without ST elevation, biomarkers positive The Use of
early invasive strategy of coronary angiography revascularization when feasible
As Treatment, Acute
Is better Than
conservative strategy
To reduce death, myocardial infarction or readmission: 21% early invasive strategy VS 25.5% conservative.
Lancet. 2006 Sep 16;368(9540):998-1004 Randomized Controlled Trial, Multicenter Study
IN coronary disease, acute coronary syndrome, without ST-segment elevation The Use of
early invasive strategy with coronary angiography and, if appropriate, revascularisation within 7 days
As Treatment, Acute
Is better Than
conservative strategy: non-invasive primarily medical strategy
To reduce at 5 years death or myocardial infarction: 19.9% invasive strategy VS 24.5% conservative strategy.
Ann Intern Med. 2008 Feb 5;148(3):186-96 Systematic Review
IN coronary disease, acute coronary syndrome, without ST-segment elevation The Use of
routine invasive strategy (angiography and revascularization)
As Treatment, Acute
Is equal Than
conservative strategy (ischaemia- or symptom-driven angiography)
To reduce mortality (RR 0.90, 0.80 to 1.14) or re-infarction (RR 0.86, 0.68 to 1.08)
Eur Heart J. 2012 Jan;33(1):51-60 Randomized Controlled Trial
IN coronary disease, acute coronary syndrome, without ST-segment elevation, women The Use of
routine invasive strategy (angiography and revascularization)
As Treatment, Acute
Is worse Than
conservative strategy (ischaemia- or symptom-driven angiography)
To routine invasive strategy increased death at 1 year in women (8.8% VS 1.1% in the RCT and OR 1.51 in the meta-analysis) and did NOT modify MI and stroke rates. Results in men are not always extapolable to women
JAMA. 2007 Jul 18;298(3):299-308 Cohorts
IN coronary disease, atherosclerosis The Use of
nonfasting triglycerides
As Etiologic risk factor
Is useful Than
no comparison here
To predict risk of developping coronary disease, myocardial infarction and death.
Ann Intern Med. 2010 May 18;152(10):630-9 Cohorts
IN coronary disease, chest pain The Use of
coronary multidetector computed tomography, computed tomography coronary angiography
As Diagnostic Tool
Is better Than
stress testing
To screen for coronary disease, specially in patients at intermediate pre-test probability (+ results indicated 93% need for coronary angiography and negative results indicated no need for further testing (1% + cases).
N Engl J Med. 1997 Dec 4;337(23):1648-53 Cohorts
IN coronary disease, chest pain, acute coronary syndrome The Use of
troponin I, troponin T
As Diagnostic Tool
Is better Than
CPK and ECG alone
To identify early patients at risk to develop myocardial infartion or death from cardiac causes: For the 34 total events (20 deaths, 14 infarctions), troponin I was positive in 32 and negative in 2. Troponin T was positive in 27 and negative in 7.
Lancet. 2012 Feb 4;379(9814):453-60 Diagnostic
IN coronary disease, chest pain, high risk patients The Use of
magnetic resonance imaging (MRI) of the heart, with adenosine stress
As Diagnostic Tool
Is better Than
single-photon emission computed tomography (SPECT), with adenosine stress, perfusion scintigraphy
To diagnose significant coronary disease (gold standard : coronary angiography) : IRM sensitivity 86%, specificity 83% ; SPECT sensitivity 66%, specificity 82%
Heart. 2010 Dec;96(24):1973-9 Diagnostic
IN coronary disease, chest pain, low to intermediate risk patients The Use of
coronary multidetector computed tomography, 64-slice CT coronary angiography
As Diagnostic Tool
Is better Than
exercise ECG testing (invasive coronariography as reference test)
To accurately diagnose significant coronary disease: sensitivity 100%, specificity 98.7%, positive and negative predictive values 92.9% and 100%, at the patient level (as opposed to analysis by coronary segment)
Health Technol Assess. 2008 May;12(17):iii-iv, ix-143 Systematic Review
IN coronary disease, clinically suspected The Use of
coronary multidetector computed tomography, 64-slice or higher
As Diagnostic Tool
Is worse Than
invasive coronary angiography
To diagnose suspected coronary disease: high negative predictive value 95 - 100%, less good positive predictive value, less detailed info. Useful to avoid unnecessary invasive angiography.
J Am Coll Cardiol. 2008 Jan 1;51(1):37-45 Meta-Analysis
IN coronary disease, elderly patients The Use of
statins
As Prevention, Secondary
Is better Than
placebo
To reduce overall mortlity (15.6% statins VS 18.7% placebo, NNT 28), cardiac mortality, myocardial infarction and stroke
Eur Heart J. 2006 May;27(10):1230-7. Epub 2006 Apr 18 Cohorts
IN coronary disease, heart failure, stroke, cardiovascular death, risk in general population The Use of
brain natriuretic peptide (BNP), plasma N-terminal pro-A-type and pro-B-type natriuretic peptides (BNP)
As Prognostic Item
Is useful Than
no comparison here
To predict risk of death from cardiovascular causes: adjusted risk was 1.35-fold for each SD increment in multivariate analysis
J Am Coll Cardiol. 2007 Oct 9;50(15):1469-75 Diagnostic
IN coronary disease, intermediate and low risk symptomatic patients The Use of
coronary multidetector computed tomography
As Diagnostic Tool
Is useful Than
coronary angiography as gold standard
To diagnose significant coronary disease: see below pre and post-test probabilities of coronary disease for each strata of high, intermediate and low risk.
Eur Heart J. 2007 Dec;28(24):3034-41 Diagnostic
IN coronary disease, intermediate pre-test probability patients The Use of
16 and 64-slice coronary multidetector computed tomography
As Diagnostic Tool
Is worse Than
coronary angiography as gold standard
To diagnose significant coronary disease: sensitivity 99%, specificity 75%, NPV 99%, PPV ?
N Engl J Med. 2011 May 5;364(18):1718-27. Epub 2011 Apr 4 Randomized Controlled Trial, Multicenter Study
IN coronary disease, left main coronary artery stenosis The Use of
coronary artery bypass surgery
As Treatment, Acute
Is equal Than
percutaneous stent implantation, sirolimus-eluting
To modify major cardiovascular events (death, infarction or stroke) at 2 years: 4.4% stent VS 4.7% surgery. Ischemia-driven target-vessel revascularization was more frequent in stent patients, however (9% VS 4%)
N Engl J Med. 2011 Apr 28;364(17):1607-16. Epub 2011 Apr 4 Randomized Controlled Trial, Multicenter Study
IN coronary disease, left ventricular dysfunction The Use of
coronary artery bypass surgery
As Treatment, Acute
Is equal Than
medical treatment alone
To modify mortality from any cause: 36% bypass VS 41% medical Tt (P=0.12). Bypass surgery reduced death from adjudicated cardiovascular cause and hospitalizations
N Engl J Med. 2011 Apr 28;364(17):1617-25. Epub 2011 Apr 4. Randomized Controlled Trial, Multicenter Study
IN coronary disease, left ventricular dysfunction, ischemic but viable myocardium The Use of
coronary artery bypass surgery
As Treatment, Acute
Is equal Than
medical treatment alone
To modify mortality (no frequency figures given in abstract)
N Engl J Med. 1999 Aug 26;341(9):650-8 Cohorts
IN coronary disease, lifestyle and habits The Use of
exercise regular, enfermedad coronaria
As Prevention, ejercicio físico
Is Than
To
Lancet. 2009 Apr 4;373(9670):1190-7 Meta-Analysis
IN coronary disease, multivessel disease The Use of
coronary artery bypass surgery
As Treatment, Acute
Is equal Than
percutaneous coronary intervention (angioplasty with/out stent)
To reduce long-term (6 years) mortality (15% bypass VS 16% PCI). Bypass may reduce mortality in patients with diabetes or aged > 65 years
N Engl J Med. 2005 May 26;352(21):2174-83 Cohorts
IN coronary disease, multivessel disease (2 or 3 vessels) The Use of
coronary artery bypass surgery
As Treatment, Chronic
Is better Than
percutaneous stent implantation
To reduce death and revascularization at 3 years: rates?
Circulation. 2010 Sep 7;122(10):949-57 Randomized Controlled Trial
IN coronary disease, multivessel disease, stable angina The Use of
coronary artery bypass surgery
As Treatment, Chronic
Is better Than
percutaneous coronary intervention or medical treatment alone or
To reduce at 10 years: myocardial infarction (10% CABG VS 13% PCI VS 21% medical) and need for further revascularization, but there wer no significant difference in overall mortality (75% CABG or PCI, 69% medical Tt, p NS)
Heart. 2009 Mar;95(3):198-202 Systematic Review
IN coronary disease, myocardial infarction The Use of
rutine oxygen
As Treatment, Acute
Is worse Than
room air
To improve mortality or clinical outcomes: the only one study found that high-flow O2 had non-sifnificant increased risk of death and higher enzyme levels
Eur Heart J. 2007 Dec;28(24):3012-9 Meta-Analysis
IN coronary disease, myocardial infarction The Use of
further reduction of resting heart rate using beta blockers (or calcium channel blockers)
As Treatment, Chronic
Is better Than
less important reduction of resting herat rate
To reduce cardiac mortality: each 10 b.p.m. reduction estimated to reduce the relative risk of cardiac death by 30%
J Am Coll Cardiol. 2014 Nov 18-25;64(20):2071-82 Randomized Controlled Trial, Multicenter Study
IN coronary disease, myocardial infarction The Use of
polypill, fixed-dose combinations of drugs
As Treatment, Chronic
Is better Than
same drugs given separately
To improve medication adherence : 51% polypill VS 41% drugs separately
Ann Intern Med. 1998 Nov 1;129(9):681-9 Randomized Controlled Trial
IN coronary disease, myocardial infarction The Use of
statins
As Treatment, Chronic
Is Than
To
N Engl J Med. 2002 Sep 26;347(13):969-74 Randomized Controlled Trial, Multicenter Study
IN coronary disease, myocardial infarction The Use of
vitamin K antagonists, warfarin, added to aspirin or alone
As Treatment, Chronic
Is better Than
aspirin alone
To reduce cardiovascular events (death, MI or ischemic stroke), rates per year: 3.5% warfarin plus aspirin VS 4.2% warfarin VS 5% aspirin.
N Engl J Med. 1999 Aug 26;341(9):625-34 Randomized Controlled Trial
IN coronary disease, myocardial infarction, cardiogenic shock The Use of
early invasive strategy, early revascularization, angioplasty or surgical
As Treatment, Acute
Is better Than
conservative strategy: initial medical stabilization and selective late revascularization
To reduce mortality at 6 months: 50% with urgent revascularization vs. 63% conttrols
JAMA. 2006 Jun 7;295(21):2511-5 Randomized Controlled Trial, Multicenter Study
IN coronary disease, myocardial infarction, cardiogenic shock The Use of
early invasive strategy, early revascularization, angioplasty or surgical
As Treatment, Acute
Is better Than
conservative strategy: initial medical stabilization and selective late revascularization
To to improve patient long term survival: at 6 years, overall survival rates were 32.8% in early revasc and 19.6% in initial medical Tt
N Engl J Med. 2003 Nov 13;349(20):1893-906 Randomized Controlled Trial, Multicenter Study
IN coronary disease, myocardial infarction, heart failure, chronic, systolic The Use of
angiotensin II receptor blockers, valsartan, alone or combined with ACE inhibitors
As Treatment, Chronic
Is equal Than
angiotensin converting enzyme (ACE) inhibitors, captopril
To modify overall mortality (about 9.97% per year in valsartan, 9.75% per year in captopril and 9.63% per year with combined treatment) Combining valsartan + captopril did not increased survival but it did adverse events
PLoS Med. 2009 Apr 21;6(4):e1000057 Cohorts
IN coronary disease, myocardial infarction, non-Q, unrecognized The Use of
delayed-enhancement cardiac magnetic resonance
As Diagnostic Tool
Is better Than
ECG and cardiac enzymes
To diagnose recent non-Q myocardial infarction: 27% of patients suspected of ischemic heart disease. Unrecognized non-Q infarction carries a hight mortality: 26% at 2.2 years.
N Engl J Med. 2005 Mar 24;352(12):1179-89 Randomized Controlled Trial, Multicenter Study
IN coronary disease, myocardial infarction, ST-segment elevation The Use of
antiplatelet drugs, adenosine diphosphate (ADP) receptor inhibitors, clopidogrel (300-mg loading dose, 75 mg/d after) added to fibrinolysis plus aspirin plus heparin
As Treatment, Acute
Is better Than
standard antithrombotic Tt with fibrinolysis + aspirin + heparin alone (+ placebo)
To reduce at 30 days vascular events (cardiovascular death, recurrent infarction, revascularization because recurrent ischemia): 11,6% with clopidogrel VS 14,6% standard Tt, Major bleeding and intracranial hemorrhage similar in the two groups.
Lancet. 2005 Nov 5;366(9497):1607-21 Randomized Controlled Trial, Multicenter Study
IN coronary disease, myocardial infarction, ST-segment elevation The Use of
antiplatelet drugs, adenosine diphosphate (ADP) receptor inhibitors, clopidogrel (75 mg/d) added to standard Tt (aspirin 100%, fibrinolysis 50%, anticoagulant 75%)
As Treatment, Acute
Is better Than
aspirin alone and standard antithrombotic Tt
To To reduce at 30 days vascular events (death, recurrent infarction, stroke): 9,2% with clopidogrel VS 10,1% aspirin alone.
Lancet. 2005 Nov 5;366(9497):1622-32 Randomized Controlled Trial, Multicenter Study
IN coronary disease, myocardial infarction, ST-segment elevation The Use of
early intravenous beta-blockers (metoprolol, up to 15 mg IV then 200 mg oral daily
As Treatment, Acute
Is equal Than
placebo
To reduce at 30 days death (7.7% VS 7.8%) or death, reinfarction, or cardiac arrest combined (9.4% with metoprolol VS 9.9% with placebo).
Circulation. 2010 Apr 6;121(13):1484-91 Randomized Controlled Trial, Multicenter Study
IN coronary disease, myocardial infarction, ST-segment elevation The Use of
early treatment with primary percutaneous coronary intervention, angioplasty
As Treatment, Acute
Is better Than
early primary fibrinolysis
To reduce at 8 years reinfarction (13% angioplasty VS 18.5% fibrinolysis ) and mortality (27% angioplasty VS 33% fibrinolysis )
JAMA. 2007 Nov 28;298(20):2399-405 Randomized Controlled Trial, Multicenter Study
IN coronary disease, myocardial infarction, ST-segment elevation The Use of
glucose-insulin-potassium infusion
As Treatment, Acute
Is equal Than
no this treatment
To improve death or heart failure: 6.2% in the GIK group VS 5.5% in the control group, p non significant.
Am J Cardiol. 2005 Oct 15;96(8):1053-8. Epub 2005 Aug 24 Randomized Controlled Trial
IN coronary disease, myocardial infarction, ST-segment elevation The Use of
glucose-insulin-potassium infusion
As Treatment, Acute
Is better Than
usual care (thrombolysis with streptokinase) alone
To reduce at 1 month major adverse cardiac events (death, reinfarction, serious arrhythmias and severe heart failure): 10% with gluc-insulin-K vs 32.5% without.
JAMA. 2005 Jan 26;293(4):437-46 Randomized Controlled Trial, Multicenter Study
IN coronary disease, myocardial infarction, ST-segment elevation The Use of
glucose-insulin-potassium infusion
As Treatment, Acute
Is equal Than
usual care alone
To reduce mortality, cardiogenic shock or reinfarction at 30 days
Eur Heart J. 2004 Dec;25(24):2187-94 Randomized Controlled Trial
IN coronary disease, myocardial infarction, ST-segment elevation The Use of
late (2 - 15 days after MI) routine percutaneous revascularization
As Treatment, Acute
Is equal Than
medical treatment alone, if patient stable
To reduce cardivascular events (composite of cardiac death, non-fatal MI, or ventricular tachyarrhythmia) at 3 years: 7.3% revascularization VS 8.7% controls
N Engl J Med. 2006 Apr 6;354(14):1477-88. Epub 2006 Mar 14 Randomized Controlled Trial, Multicenter Study
IN coronary disease, myocardial infarction, ST-segment elevation The Use of
low molecular weight heparins (LMWH), enoxaparin, for at least 2 days
As Treatment, Acute
Is better Than
unfractionated heparin (UFH), for the same time
To reduce, at 30 days, death or recurrent infarction: 9.9% enoxaparin VS 12% unfractionated heparin. Major bleeding were a little more frequent with enoxaparin (2.1%) than with UFH (1.4%)
Circulation. 2005 Dec 20;112(25):3855-67. Epub 2005 Dec 12 Meta-Analysis
IN coronary disease, myocardial infarction, ST-segment elevation The Use of
low molecular weight heparins (LMWH), for 4 to 8 days
As Treatment, Acute
Is better Than
placebo or unfractionated heparin (UFH)
To reduce, at 7 days, the risk of reinfarction (1.6% LMWH VS 2.2% placebo, NNT 167) and reduce death (7.8% LMWH VS 8.7% placebo, NNT 111)
Circulation. 2005 Dec 20;112(25):3846-54. Epub 2005 Nov 15 Randomized Controlled Trial, Multicenter Study
IN coronary disease, myocardial infarction, ST-segment elevation The Use of
low molecular weight heparins (LMWH), for 4 to 8 days
As Treatment, Acute
Is better Than
unfractionated heparin (UFH)
To reduce, at 30 days, cardiovascular death or recurrent myocardial infarction (6.9% with LMWH versus 11.5% with UFH)
JAMA. 2005 Jan 26;293(4):427-35 Randomized Controlled Trial, Multicenter Study
IN coronary disease, myocardial infarction, ST-segment elevation The Use of
low molecular weight heparins (LMWH), reviparin, for 7 days
As Treatment, Acute
Is better Than
placebo, added to usual medical care
To reduce cardivascular events (composite of death, reinfarction or stroke) at 30 days: 11,8% LMWH VS 13,6% controls; with reductions of 1,5% in mortality and 0,3% in reinfartion, non significant for stroke, 0,1% increase of severe bleeding.
Eur Heart J. 2011 Jan;32(1):51-60 Randomized Controlled Trial
IN coronary disease, myocardial infarction, ST-segment elevation, elder patients The Use of
primary percutaneous coronary intervention
As Treatment, Acute
Is equal Than
fibrinolysis
To significantly reduce cardiovascular events (all-cause mortality, re-infarction, or disabling stroke) at 30 days: 19% pPCI VS. 25% fibrinolysis. A pooled analysis with other 2 trials showed, however, a significant reduction of cardiovascular events
J Am Coll Cardiol. 2007 Jan 30;49(4):422-30 Meta-Analysis
IN coronary disease, myocardial infarction, ST-segment elevation, failed thrombolysis The Use of
rescue emergency angioplasty after failed thrombolytic therapy
As Treatment, Acute
Is better Than
repeated thrombolysis or conservative treatment
To reduce heart failure (RR 0.73) and reinfarction (RR 0.58), but associated with increased risk of stroke (RR 4.98)
N Engl J Med. 2005 Dec 29;353(26):2758-68 Randomized Controlled Trial, Multicenter Study
IN coronary disease, myocardial infarction, ST-segment elevation, failed thrombolysis The Use of
rescue emergency angioplasty after failed thrombolytic therapy
As Treatment, Acute
Is better Than
repeated thrombolysis or conservative treatment
To reduce, at 6 months, cardiovascular events (composite of death, reinfarction, stroke, or severe heart failure): 15.4% with rescue angioplasty VS 31.3% with repeated thrombolysis and 29.1% with conservative treatment
N Engl J Med. 2006 Dec 7;355(23):2395-407 Randomized Controlled Trial, Multicenter Study
IN coronary disease, myocardial infarction, total occlusion of the infarct-related artery The Use of
routine (3 to 28 days) invasive strategy, percutaneous coronary stenting
As Treatment, Acute
Is equal Than
optimal medical therapy and percutaneous intervention only if needed
To reduce, at 4 year, death or myocardial reinfarction: 17.2% invasive group VS 15.6% medical therapy
Lancet. 2005 Sep 10;366(9489):914-20 Randomized Controlled Trial, Multicenter Study
IN coronary disease, myocardial infarction, without ST-segment elevation The Use of
routine invasive strategy (angiography and revascularization)
As Treatment, Acute
Is better Than
conservative strategy (ischaemia- or symptom-driven angiography)
To reduce at 5 years: death or non-fatal myocardial infarction (16.6% in invasive VS 20% in conservative strategy). A trend to reduce death but not significant.
Am J Med. 2005 May;118(5):465-74 Meta-Analysis
IN coronary disease, myocardial infarction, without ST-segment elevation, unstable angina The Use of
routine invasive strategy
As Treatment, Acute
Is better Than
conservative strategy
To reduce rates of fatal or nonfatal re-infarction and hospital readmission, but not all-cause mortality.
N Engl J Med. 2017 10 05;377(14):1319-1330 Randomized Controlled Trial, Multicenter Study
IN coronary disease, stable The Use of
anticoagulants, oral factor Xa inhibitors, rivaroxaban (2.5 mg twice daily) plus aspirin (100 mg once daily)
As Treatment, Chronic
Is better Than
rivaroxaban (5 mg twice daily) alone, or aspirin (100 mg once daily) alone
To reduce cardiovascular events (death, stroke or MI): 4.1% riva+aspirine VS 5.4% aspirine. But increased major bleeding: 3.1% VS 1.9%. Riva 5 mg/d alone did not better than aspirin and had more bleeding.
N Engl J Med. 2011 Dec 1;365(22):2078-87. Epub 2011 Nov 15 Clinical Trial (non-controlled, non-randomized)
IN coronary disease, stable The Use of
high dose statins, atorvastatin 80 mg daily, or rosuvastatin 40 mg daily
As Treatment, Chronic
Is useful Than
no comparison done
To induced regression of atherome plaques (decrease percent atheroma volume (by about 1%) and total atheroma volume) measured by serial intravascular ultrasonography at 4.5 years
N Engl J Med. 1999 Jul 8;341(2):70-6 Randomized Controlled Trial
IN coronary disease, stable The Use of
high dose statins, atorvastatin 80 mg/d
As Treatment, Chronic
Is better Than
routine angioplasty, without statins
To reduce cardiovascular events (composite of coronary fatal and nonfatal events and stroke) at 18 months: 13.4% statin VS 20.9% angioplasty (mostly worsening angor)
N Engl J Med. 2007 Apr 12;356(15):1503-16. Epub 2007 Mar 26 Randomized Controlled Trial, Multicenter Study
IN coronary disease, stable The Use of
routine invasive strategy (angiography and revascularization)
As Treatment, Chronic
Is equal Than
optimal medical therapy alone
To reduce all-cause mortality or myocardial infarction, at 4.6 years: 19% routine PCI vs. 18.5% medical Tt alone. No difference in stroke or hospitalizations neither.
Lancet. 1992 Dec 12;340(8833):1421-5 Randomized Controlled Trial, Multicenter Study
IN coronary disease, stable angina The Use of
aspirin, low dose (75 mg/d)
As Treatment, Chronic
Is better Than
placebo
To reduce major cardiovascular events (34% relative reduction)
JAMA. 1999 May 26;281(20):1927-36 Meta-Analysis
IN coronary disease, stable angina The Use of
beta blockers
As Treatment, Chronic
Is better Than
calcium channel blockers
To reduce number of angina episodes (OR 0.31). But no significant differences in rates of death or myocardial infarction.
JAMA. 2003 Mar 5;289(9):1117-23 Randomized Controlled Trial, Multicenter Study
IN coronary disease, stable angina, elderly patients The Use of
routine invasive strategy (angiography and revascularization)
As Treatment, Chronic
Is equal Than
optimal medical therapy alone
To modify 1-year mortality (11% invasive VS 8% medical, p NS) or modify death + nonfatal infarction (17% invasive VS 20% medical). Invasive approach had increased events early months, and medical management had more cardiac events after 6 months.
Circulation. 2007 Mar 6;115(9):1082-9 Randomized Controlled Trial, Multicenter Study
IN coronary disease, stable angina, multvessel disease The Use of
coronary artery bypass graft (CABG)
As Treatment, Chronic
Is better Than
naked percutaneous coronary intervention (PCI), or medical therapy alone
To reduce, at 5 years, myocardial infarction, or refractory angina requiring revascularization (21% CABG VS 33% PCI VS 36% medical). No differences in overall mortality between the 3 goups
N Engl J Med. 2005 Apr 7;352(14):1425-35 Randomized Controlled Trial
IN coronary disease, stable, normal cholesterol The Use of
high dose statins, atorvastatin 80 mg/d
As Treatment, Chronic
Is better Than
standard dose statins, atorvastatin 10 mg/d
To reduce cardiovascular events (cardiac death or arrest, AMI or stroke) at 5 years: 8,7% with 80mg/d VS 10,9% with 10mg/d, an ARR of 0,44% year
Circulation. 2014 Apr 15;129(15):1577-85 Cohorts
IN coronary disease, stable, atrial fibrillation The Use of
anticoagulation alone, vitamin K antagonists
As Treatment, Chronic
Is equal Than
bi-therapy combining anticoagulant (vitamin K antagonist) + an antiplatelet
To modify at 3 years the risk of myocardial infarction, cardiac death or thromboembolism, while the risk of bleeding was higher with bi-therapy (HR 1.5)
N Engl J Med. 2009 Jun 11;360(24):2503-15. Epub 2009 Jun 7 Randomized Controlled Trial, Multicenter Study
IN coronary disease, stable, diabetes mellitus, type 2 The Use of
systematic prompt revascularization, either by percutaneous coronary intervention (PCI) or coronary-artery bypass grafting (CABG)
As Treatment, Chronic
Is equal Than
intensified medical therapy alone
To reduce at 5 years major cardiovascular events (77.2% revascularization VS 75.9% medical Tt). A reduction in cardiovascular events was observed with CABG in tri-troncular patients (22% revascularization VS 30% medical Tt)
Lancet. 2003 Sep 6;362(9386):782-8 Randomized Controlled Trial, Multicenter Study
IN coronary disease, stable, normal left ventricular function, most patients previous myocardial infarction and revascularization The Use of
angiotensin converting enzyme (ACE) inhibitors, perindopril 8 mg/d, added to standard treatment
As Treatment, Chronic
Is better Than
placebo
To reduce cardiac events (cardiovascular death, myocardial infarction, or cardiac arrest): 8% perindopril VS 10% placebo
N Engl J Med. 2004 Nov 11;351(20):2058-68 Randomized Controlled Trial, Multicenter Study
IN coronary disease, stable, normal left ventricular function, most patients previous revascularization The Use of
angiotensin converting enzyme (ACE) inhibitors, trandolapril (4 mg/d), added to standard treatment
As Treatment, Chronic
Is equal Than
placebo
To reduce cardiac events (death from cardiovascular causes, myocardial infarction, or coronary revascularization): 21.9% in trandolapil VS 22.5% in placebo - at 5 years (so, aprox. 4.4% per year event rate)
Lancet. 2008 Sep 6;372(9641):807-16 Randomized Controlled Trial, Multicenter Study
IN coronary disease, stable, reduced left ventricular function The Use of
ivabradine, added to beta-blockers
As Treatment, Chronic
Is equal Than
placebo
To reduce a composite outcome (cardiovascular deah, myocardial infarction or worsening heart failure) at 20 months. It improved a secondary endpoint (myocardial infarction) but not main endpoint, in one subgroup analysis (patients with heart rate > 70 bpm)
N Engl J Med. 2009 Mar 5;360(10):961-72 Randomized Controlled Trial, Multicenter Study
IN coronary disease, three-vessel disease, or left main coronary artery disease The Use of
coronary artery bypass surgery
As Treatment, Acute
Is better Than
percutaneous coronary intervention
To reduce at 12 months major cardiovascular events (12.4% surgery VS 17.8% percutaneous), mainly reducing the need for rvascularization (5.9% surgery VS 13.5% percutaneous). But more strokes with surgery: 2.2% VS 0.6% percutaneous.
N Engl J Med. 2011 Mar 17;364(11):1016-26 Randomized Controlled Trial, Multicenter Study
IN coronary disease, three-vessel or left main coronary artery disease The Use of
coronary artery bypass surgery
As Treatment, Acute
Is better Than
percutaneous coronary intervention with drug-eluting stents
To modestly improve symptoms of angina (difference in score: 1.7 points) and increase number of patients free from angina at 12 months: 76% surgery VS 71% PCI
N Engl J Med. 2000 Oct 19;343(16):1139-47 Cohorts
IN coronary disease, unstable angina The Use of
troponin, C reactive protein (CRP)
As Prognostic Item
Is Than
To
Lancet. 2000 Jun 3;355(9219):1936-42 Meta-Analysis
IN coronary disease, unstable angina The Use of
heparin, low molecular weight, unfractionated
As Treatment, Acute
Is Than
To
N Engl J Med. 1997 Aug 14;337(7):447-52 Clinical Trial, Randomized Controlled Trial
IN coronary disease, unstable angina The Use of
heparin, low molecular weight, unfractionated
As Treatment, Acute
Is Than
To
J Am Coll Cardiol. 1995 Aug;26(2):313-8 Clinical Trial, Randomized Controlled Trial.
IN coronary disease, unstable angina The Use of
low molecular weight heparin (LMWH), added to aspirin
As Treatment, Acute
Is better Than
aspirin alone, or aspirin plus unfractionated heparin
To reduce recurrent angina and myocardial infarction, but not death
N Engl J Med. 1999 Dec 16;341(25):1882-90 Randomized Controlled Trial
IN coronary disease, ventricular arrhythmia, sudden death The Use of
implantable cardioverter defibrillator
As Treatment, Chronic
Is better Than
antiarrhythmic drugs or no treatment
To reduce the risk of sudden death.
Eur Heart J. 2013 Jun 4. [Epub ahead of print] Cohorts
IN dementia, alzheimer, coronary disease, acute coronary syndrome, myocardial infarction, older patients The Use of
cholinesterase inhibitors
As Treatment, Chronic
Is better Than
no cholinesterase inhibitors
To reduce the risk of myocardial infarction (HR 0.62) and death (HR 0.64). Patients taking the highest doses recommended had the lowest risk of MI or death
JAMA. 2009 Apr 15;301(15):1547-55 Randomized Controlled Trial, Diagnostic
IN diabetes mellitus, type 2, asymptomatic for coronary disease The Use of
routine screening for coronary artery disease, adenosine-stress radionuclide myocardial perfusion imaging
As Diagnostic Tool
Is equal Than
non screening
To reduce cardiac death or nonfatal myocardial infarction at 5 years: 2.7% screened patients VS 3% non-screened.
J Am Coll Cardiol. 2005 Aug 2;46(3):425-31 Randomized Controlled Trial, Multicenter Study
IN heart failure, acute, coronary disease, myocardial infarction The Use of
aldosterone blockers, eplerone, 25 mg/day initiated 3 to 14 days after AMI
As Treatment, Chronic
Is better Than
placebo
To reduce at 30 days all-cause mortality (3.2% with eplerone VS 4.6% with placebo), reduce cardiovascular mortality and reduce hospitalizations.
Ann Intern Med. 2004 Nov 2;141(9):693-704 Meta-Analysis
IN heart failure, chronic, systolic, coronary disease, acute myocardial infarction The Use of
angiotensin II receptor blockers, added to or replacing angiotensin converting enzyme (ACE) inhibitors
As Treatment, Chronic
Is equal Than
angiotensin converting enzyme (ACE) inhibitors alone
To modify all-cause mortality or heart failure hospitalization.
Arch Intern Med. 2007 Jan 22;167(2):117-24 Meta-Analysis
IN heart valve disease, mechanical heart valve, atrial fibrillation, coronary disease The Use of
aspirin, added to vitamin K antagonists, warfarin
As Treatment, Chronic
Is better Than
vitamin K antagonists, warfarin, alone
To reduce arterial thromboembolism, but only in patients with mechanical heart valve (OR 0.27) and not for coronary disease or atrial fibrillation. There was not differences in all-cause mortality and major bleeding was higher (OR 1.43)
J Am Coll Cardiol. 2008 Dec 16;52(25):2156-62 Cohorts
IN lifestyle and habits, mind-body relations, stress, coronary disease, cardiovascular death The Use of
psychological distress
As Etiologic risk factor
Is useful Than
no comparison here
To identify patients with higher risk of cardiovascular events (HR 1.54 if psych distress) Most of the increased risk was explained by behavior: those patients had more cigarrette smoking, alcohol intake, less activity.
Am J Cardiol. 2008 Sep 15;102(6):689-92 Cohorts
IN metabolic syndrome, coronary disease, overall mortality The Use of
number of metabolic Sd factors: central obesity, hypertension, high-density lipoprotein cholesterol, triglycerides, impaired glucose metabolism
As Etiologic risk factor
Is useful Than
no comparison
To predict the risk of cardivascular and all-cause death
Arch Intern Med. 1999 Oct 25;159(19):2273-8 Randomized Controlled Trial
IN mind-body relations, coronary disease, acute coronary syndrome The Use of
remote intercessory prayer, praying for others
As Treatment, Acute
Is better Than
no praying, usual care group
To reduce a particular score of the hospital course of patients. No influence observed in mortality or length of stay in ICU or in hospital.
Lancet. 2005 Jul 16-22;366(9481):211-7 Randomized Controlled Trial
IN mind-body relations, coronary disease, percutaneous coronary intervention, elective The Use of
remote intercessory prayer, praying for others, MIT therapy: music, imagery and touching
As Treatment, Acute
Is equal Than
none of those treatments
To reduce mortality, major adverse effects of coronary intervention or readmission to hospital at 6 months
J Am Coll Cardiol. 2007 Feb 27;49(8):863-71 Randomized Controlled Trial, Diagnostic
IN pain, chest, acute, ruling out coronary disease The Use of
coronary multidetector computed tomography
As Diagnostic Tool
Is better Than
standard diagnostic evaluation of low-risk acute chest pain
To exclude or identify coronary disease as the source of chest pain: scan alone immediately did it in 75% of patients and reduced time to diagnosis.
Circulation. 2006 Nov 21;114(21):2251-60. Epub 2006 Oct 30 Diagnostic
IN pain, chest, acute, ruling out coronary disease The Use of
coronary multidetector computed tomography, added to clinical estimate
As Diagnostic Tool
Is better Than
clinical estimate only
To accurately rule out an acute coronary syndrome if not significant coronary stenosis found (negative predictive value, 100%).