Perindopril Beneficial for Stable Coronary Artery Disease

Speaker: Maarten L. Simoons, MD, Professor of Medicine, Thoraxcenter, Erasmus Medical Center, University Hospital, Rotterdam, The Netherlands

According to a subgroup analysis of patients in the European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease (EUROPA), perindopril (Aceon tablet, Solvay) 8 mg daily, when added to standard therapy, helped to prevent cardiac events. The benefits pertained to all stable patients with coronary artery disease, including those who had had revascularization surgery and no previous myocardial infarction (MI).

Initially, the EUROPA trial had indicated that an angiotensin-converting enzyme (ACE)-inhibitor with a high affinity for tissue, significantly decreased the composite risk of major cardiac events by 20% in patients with stable CAD without apparent heart failure. Examples of major cardiac events included cardiovascular death, MI, and resuscitated cardiac arrest.

Approximately 55% of the 12,218 patients (6,709 patients) in the EUROPA trial had undergone revascularization. Approximately equal numbers of patients had had a percutaneous coronary intervention (PCI) (3,122 patients) or coronary artery bypass graft (CABG) surgery (3,136 patients). It was noted that 3,047 patients had not experienced a previous MI.

Of the total group of patients who had undergone revascularization, 3,340 had received perindopril and 3,369 had received placebo. Baseline characteristics and demographics were comparable in the two groups. Overall, the incidence of the composite endpoint of major cardiac events was 6.6% with perindopril and 8% with placebo, for a significant risk reduction of 17.3% favoring perindopril (P = .036).

The incidence of MI alone was 4.6% for the perindopril patients and 5.9% with placebo, for a significant risk reduction of 23% favoring perindopril (P = .015).

In the 3,047 patients who had undergone revascularization who had no history of MI, the incidence of MI was 3.8% with canadian perindopril and 5.5% with placebo, for a significant risk reduction of 31.7% favoring perindopril (P = .026).

Bivalirudin Monotherapy Improves Outcomes in Acute Coronary Syndrome Patients Undergoing Early Cardiac Catheterization

Speaker: Gregg W. Stone, MD, Professor of Medicine and Director of Cardiovascular Research and Education, Cardiovascular Research Foundation, Columbia University Medical Center, and Lenox Hill Hospital, New York, New York

A randomized study was conducted to compare the effectiveness of bivalirudin (Angiomax, The Medicines Company), a direct thrombin inhibitor, with heparin, an indirect thrombin inhibitor, plus a glycoprotein IIb/IIIa inhibitor, or bivalirudin alone in patients with acute coronary syndrome (ACS). Bival-irudin alone was found to be as effective as more complicated dual regimens and resulted in the most positive net clinical outcomes with less bleeding and ischemia.

The Acute Catheterization and t/rgent intervention Triage Strategy (ACUITY) trial was designed to test several combinations of drug therapies in patients at moderate-to-high risk for ACS. Typical drug therapy consists of aspirin, clopidogrel bisulfate (Plavix, Bristol-Myers Squibb/sanofi aventis), hep-arin, and a glycoprotein IIb/IIIa inhibitor. All of these drugs interfere in the blood-clotting process in the coronary artery. Even though together they achieve better efficacy, the combination may compromise safety in the process. discount drugs canda

The ACUITY study enrolled more than 13,800 patients who underwent cardiac catheterization within 72 hours, followed by percutaneous coronary intervention (PCI) or surgical revascularization when necessary. The patients received one of three treatments:

  • heparin, either unfractionated conventional, or a low-molecular-weight heparin, enoxaparin (Lovenox, sanofi aventis) plus a glycoprotein IIb/IIIa inhibitor
  • bivalirudin plus a glycoprotein IIb/IIIa inhibitor
  • bivalirudin alone

One month after treatment, the investigators measured the net clinical benefit, which balanced the risks of ACS itself against the major bleeding risks of anticlotting therapy. At this point, the comparison of ischemic events met the predefined criteria for non-inferiority between bivalirudin plus a glyco-protein IIb/IIIa inhibitor or bivalirudin alone and heparin plus a glycoprotein IIb/IIIa inhibitor.

Patients in the bivalirudin monotherapy arm had the most positive outcomes, with rates of major bleeding significantly lower than those in the control arm who received a glyco-protein IIb/IIIa inhibitor.

With bivalirudin plus a glycoprotein IIb/IIIa inhibitor, the endpoints also demonstrated non-inferiority, with no significant increase in either ischemic or bleeding complications, compared with heparin plus a glycoprotein IIb/IIIa inhibitor. Although bivalirudin plus a glycoprotein IIb/IIIa inhibitor is an acceptable substitute for heparins plus a glycoprotein IIb/IIIa inhibitor, no ischemic benefit resulted from this combination.