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Comment by Cardiologists posted on LinkedIn’s

European Cardiovascular Medical Devices Group, a subgroup of Cardiovascular Medical Devices Group

on Stenting for Proximal LAD Lesions: In Reference to the Invasive Procedure performed on former President George W. Bush

UPDATED on 8/7/2018

Long-Term Outcomes of Stenting the Proximal LAD

Study Questions:

What are the outcomes of patients undergoing drug-eluting stent (DES) implantation according to lesion location within or outside the proximal left anterior descending (LAD) artery?

Methods:

Among the 8,709 patients enrolled in PROTECT (Patient Related Outcomes With Endeavor Versus Cypher Stenting Trial), a multicenter percutaneous coronary intervention (PCI) trial, the investigators compared the outcomes of 2,534 patients (29.1%; 3,871 lesions [31.5%]) with stents implanted in the proximal LAD with 6,172 patients (70.9%; 8,419 lesions [68.5%]) with stents implanted outside the proximal LAD. For each event, a multivariate model was constructed that examined the effect of several individual baseline clinical and angiographic characteristics, including proximal LAD target lesion, on outcomes (i.e., MACE [major adverse cardiac events], target vessel failure [TVF], and myocardial infarction [MI]).

Results:

At 4-year follow-up, death rates were the same (5.8% vs. 5.8%; p > 0.999), but more MIs occurred in the proximal LAD group (6.2% vs. 4.9%; p = 0.015). The rates of clinically driven TVF (14.8% vs. 13.5%; p = 0.109), MACE (15.0% vs. 13.7%; hazard ratio, 1.1; 95% CI, 0.97-1.31; p = 0.139), and stent thrombosis (2.1% vs. 2.0%; p = 0.800) were similar. DES type had no interaction with MACE or TVF. In multivariate analysis, the proximal LAD was a predictor for MI (p = 0.038), but not for TVF (p = 0.149) or MACE (p = 0.069).

Conclusions:

The authors concluded that proximal LAD location was associated with higher rates of MI during the long-term follow-up, but there were no differences in stent thrombosis, death, TVF, or overall MACE.

Perspective:

This post hoc analysis of a prospective, multicenter study reports no difference in the rates of death, MACE, or TVF at 4 years according to intervention at a proximal LAD or nonproximal LAD lesion. The occurrence of the predefined primary endpoint of stent thrombosis was also not dependent on whether a proximal LAD or nonproximal LAD site was treated. However, of note, stenting of proximal LAD lesions was associated with significantly higher rates of MI compared with stenting of nonproximal LAD lesions. Overall, these findings appear to suggest that proximal LAD lesions may not have additional risk in the contemporary DES era, but the higher risk of MI needs to be studied further. Future studies should compare longer-term clinical outcomes between proximal LAD PCI with DES and minimally invasive left internal mammary artery to LAD.

SOURCE

https://www.acc.org/latest-in-cardiology/journal-scans/2017/03/22/15/11/long-term-outcomes-of-stenting-the-proximal-lad

 

Stenting for Proximal LAD Lesions

Curator: Aviva Lev-Ari, PhD, RN

Michael Reinhardt • First, the media really should not be calling this “stent surgery” its a stent procedure just ask any post-CABG patient… Anyway it really is not possible to determine whether or not is was “unnecessary” without all the relevant patient data; which coronary vessel(s) involved, percent stenosis, etc. Actually I find it interesting that they apparently decided to stent the former president on the basis of a CT Angiogram which is not the standard of care for coronary imaging. I have to assume they performed an additional testing like a CT perfusion analysis and saw a clinically relevant defect and this support the decision to stent. Regarding the post-stent drugs cloplidigrel is not a benign drug but benefits far outweigh the downside of a sub-acute thrombosis which might result in a more serious future event = acute MI.

Rafael Beyar • This was absolutely an indicated procedure and almost all rational physician will treat a young patient with proximal LAD lesions with either a stent or bypass surgery

Dov V Shimon MD • No doubt! Proximal (‘close to origin’) LAD lesions are the leading “Widow makers”. Reestablishing of flow in the artery is saving from cardiac damage and death. Drug eluting stent have 2nd and 3rd generations with very low and acceptable reclosure rates and almost no abrupt closure (thrombosis). True, CTA is a screening test, but it astablishes the need for diagnostic and therapeutic angiogram. We, heart surgeons can provide long-term patency to the LAD using LIMA arterial bypass. The current advantage of stent is the incovenience and pain of surgery. Any responsible physician would opt the procedure even for himself, his relatives , his patients and for definitely for GW Bush.

http://www.linkedin.com/groupItem?view=&gid=3358310&type=member&item=265974376&commentID=157366758&goback=%2Egmr_3358310&report%2Esuccess=8ULbKyXO6NDvmoK7o030UNOYGZKrvdhBhypZ_w8EpQrrQI-BBjkmxwkEOwBjLE28YyDIxcyEO7_TA_giuRN#commentID_157366758

Coronary anatomy and anomalies

On the left an overview of the coronary arteries in the anterior projection.

Coronary anatomy and anomalies

RCA, LAD and Cx in the anterior projection

On the left an overview of the coronary arteries in the lateral projection.

  • Left Main or left coronary artery (LCA)
    • Left anterior descending (LAD)
      • diagonal branches (D1, D2)
      • septal branches
    • Circumflex (Cx)
      • Marginal branches (M1,M2)
  • Right coronary artery
    • Acute marginal branch (AM)
    • AV node branch
    • Posterior descending artery (PDA)

Eur J Cardiothorac Surg. 2004 Apr;25(4):567-71.

Isolated high-grade lesion of the proximal LAD: a stent or off-pump LIMA?

Source

Thoraxcentre, Groningen University Hospital, Groningen, The Netherlands.

Abstract

OBJECTIVES:

The objective of this study was to compare the long-term outcome of patients with an isolated high-grade stenosis of the left anterior descending (LAD) coronary artery randomized to percutaneous transluminal coronary angioplasty with stenting (PCI, stenting) or to off-pump coronary artery bypass grafting (surgery).

METHODS:

Patients with an isolated high-grade stenosis (American College of Cardiology/American Heart Association classification type B2/C) of the proximal LAD were randomly assigned to stenting (n=51) or to surgery (n=51) and were followed for 3-5 years (mean 4 years). Primary composite endpoint was freedom from major adverse cardiac and cerebrovascular events (MACCEs), including cardiac death, myocardial infarction, stroke and repeat target vessel revascularization. Secondary endpoints were angina pectoris status and need for anti-anginal medication at follow-up. Analysis was by intention to treat.

RESULTS:

MACCEs occurred in 27.5% after stenting and 9.8% after surgery (P=0.02; absolute risk reduction 17.7%). Freedom from angina pectoris was 67% after stenting and 85% after surgery (P=0.036). Need for anti-anginal medication was significantly lower after surgery compared to stenting (P=0.002).

CONCLUSION:

Patients with an isolated high-grade lesion of the proximal LAD have a significantly better 4-year clinical outcome after off-pump coronary bypass grafting than after PCI.

Daily Dose

08/12/2013 | 5:48 PM

Was George Bush’s stent surgery really unnecessary?

By Deborah Kotz / Globe Staff

VIEW VIDEO

Ever since President George W. Bush had stent surgery last Tuesday to open a blocked artery, leading physicians who weren’t involved in his care have wondered publically why he had this “unnecessary” procedure. Large clinical trials have demonstrated that stent placement doesn’t extend lives or prevent a future heart attack or stroke in those with stable heart disease.

What’s more, Bush could wind up with complications like a reblockage where the stent was placed or excessive bruising or internal bleeding from the blood thinners that he must take likely for the next year.

Dr Richard Besser, the chief medical correspondent for ABC News, questioned why Bush had an exercise stress test as part of his routine physical exam given that he had no symptoms like chest pain or shortness of breath. The stress test indicated signs of an artery blockage.

“In people who are not having symptoms, the American Heart Association says you should not do a stress test,” Besser said, “since the value of opening that artery is to relieve the symptoms.”

Cleveland Clinic cardiologist Dr. Steve Nissen agreed in his interview with USA Today. Bush, he said, likely “got the classical thing that happens to VIP patients, when they get so-called executive physicals and they get a lot of tests that aren’t indicated. This is American medicine at its worst.”

Two physicians wrote in an Washington Post op-ed column titled “President Bush’s unnecessary surgery” that they worry that the media coverage of Bush’s stent will lead “patients to pressure their own doctors for unwarranted and excessive care.”

But none of these doctors actually treated Bush or examined his medical records, so I’m a little surprised they’re making such firm calls.

Bush, an avid biker who recently completed a 100-kilometer ride, probably shouldn’t have had the exercise stress test if he wasn’t having any heart symptoms. “Routine stress testing used to be done 20 years ago, but isn’t recommended any longer since it doesn’t have any benefit,” said Brigham and Women’s cardiologist Dr. Christopher Cannon.

But Bush’s spokesman insisted the stent was necessary after followup heart imaging via a CT angiogram “confirmed a blockage that required opening.”

Cannon said Bush’s doctors may have seen signs that blood flow wasn’t getting to a significant part of the heart muscle, a condition known as ischemia. Researchers have found that those with moderate to severe ischemia appear to experience a reduction in fatal heart attacks when they have a stent placement along with medical therapy, rather than just taking medications alone. (Larger studies, though, are needed to confirm this finding.)

“If a blockage occurs at the very start of the artery and it’s extensive—95 percent blocked—then chances are it will cause significant ischemia,” Cannon said. While severe ischemia usually causes light-headedness or dizziness during exercise, Bush may have had more moderate ischemia that didn’t cause such symptoms.

It’s impossible to know for certain, he added, without seeing his medical records firsthand.

http://www.boston.com/lifestyle/health/blogs/daily-dose/2013/08/12/was-george-bush-stent-surgery-really-unnecessary/DzklhNCGVlgriNxgpKZtuO/blog.html

President Bush’s unnecessary heart surgery

  • By Vinay Prasad and Adam Cifu, Published: August 9

Vinay Prasad is chief fellow of medical oncology at the National Cancer Institute and the National Institutes of Health. Adam Cifu is a professor of medicine at the University of Chicago.

Former president George W. Bush, widely regarded as a model of physical fitness, received a coronary artery stent on Tuesday. Few facts are known about the case, but what is known suggests the procedure was unnecessary.

Before he underwent his annual physical, Mr. Bush reportedly had no symptoms. Quite the opposite: His exercise tolerance was astonishing for his age, 67. He rode more than 30 miles in the heat on a bike ride for veterans injured in the wars in Iraq and Afghanistan.

If Mr. Bush had visited a general internist practicing sound, evidence-based care, he would not have had cardiac testing. Instead, the doctor would have had conducted age-appropriate cancer screening. For the former president, this would include only colon cancer screening. It no longer would include even prostate-specific antigen testing for cancer. The doctor would have screened for cholesterol, checked for hypertension and made sure the patient was up to date on age-appropriate vaccinations, including those for pneumococcal pneumonia and shingles. Presumably Mr. Bush got these things, and he got the cardiac test as well.What value does a stress test add for an otherwise healthy 67-year-old?No study has shown that this examination improves outcomes. The trials that have been done for so-called routine stress testing examined higher-risk patients. They found that performing stress tests on people at high risk of cardiovascular disease may detect blockages but does not improve symptoms or survival. Routine stress testing does, however, increase the use of procedures such as coronary stenting.Unfortunately, Mr. Bush, like many VIPs, may be paying the price of these in-depth investigations. His stress test revealed an abnormality, prompting another test: a CT angiogram. This study showed a blockage, which was stented open during an invasive procedure. It is worth noting that at least two large randomized trials show that stenting these sorts of lesions does not improve survival. Because Mr. Bush had no symptoms, it is impossible that he felt better after these procedures.

Instead, George W. Bush will have to take two blood thinners, aspirin and Plavix, for at least a month and probably a year. (The amount of time a blood thinner is needed depends on the type of stent placed). While he takes these medications, he will have a higher risk of bleeding complications with no real benefit.

Although this may seem like an issue important only to the former president, consider the following: Although the price of excessive screening of so-called VIPs is usually paid for privately, follow-up tests, only “necessary” because of the initial unnecessary screening test, are usually paid for by Medicare, further stressing our health-care system. The media coverage of interventions like Mr. Bush’s also leads patients to pressure their own doctors for unwarranted and excessive care.

http://www.washingtonpost.com/opinions/president-bushs-unnecessary-heart-surgery/2013/08/09/c91c439c-0041-11e3-9a3e-916de805f65d_story.html

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Reporter: Aviva Lev-Ari, PhD, RN

 

Mark Levin’s business is biotechnology, so it’s no surprise he knew zilch about a tech company called LinkedIn as recently as two years ago. But these days Levin sounds like he can barely do his job without it.

“I’m not the most social media savvy person. I haven’t used a lot of these tools at all,” Levin says, referring to blogs and Twitter. “But I’ll never forget, the first message I got from LinkedIn was an e-mail from what looked like someone called link-a-din. I remember asking myself about Mr. Link-a-din. I was trying to figure out ‘who the hell is this person?’”

Levin, a founding partner of Boston-based Third Rock Ventures and one of the more prominent biotech venture capitalists in the U.S., was a LinkedIn Luddite two years ago. To some extent, he still looks like one: his profile contains no photo, no professional biography, and only tidbits of information posted about his employment history. But appearances can be deceiving. He says he has amassed more than 5,000 connections, and the number keeps growing daily. He says he spends at least a half an hour per day on the site, sifting through more than 100 incoming connection requests a week, and firing off dozens more requests to people he wants to get to know. LinkedIn’s algorithms have gotten to know his tendencies so well, the site is constantly suggesting new people in biotech and pharma companies that he might want to meet. He often does.

Mark Levin of Third Rock Ventures

Levin became so obsessive at one point this year that LinkedIn temporarily shut down his account, until he called the company and assured them he’s a real person using the site for business. Just during a 15-minute phone interview with me on Friday, Levin said he got three new connection requests. One was from an MD that caught his eye immediately.

“About 18 months ago or so, I realized that is an extraordinary way to be in contact with people,” Levin says. “Our biggest challenge is to find great people. We don’t know everybody. And you can find a lot of great people here.”

While many in the tech press mock LinkedIn as an oh-so-boring compiler of mere resumes, it has become the indispensable online hub for networking in life sciences—an industry where relationships make the world go round. LinkedIn has a relatively puny user base of 187 million members around the world, compared to Facebook’s 1 billion, and there’s no question people spend way more time engaging with Mark Zuckerberg’s social network. But it’s also true there’s no question which site matters more to the life sciences. LinkedIn is the singular site for finding people in biotech, whether they are biologists, chemists, toxicologists, admin assistants, business development people, finance pros, or CEOs. There were more than 513,000 people in the LinkedIn database who self-identify as members of the “biotechnology” or “pharmaceutical” industry when I searched on those keywords Friday afternoon.

For journalists like me, this is an everyday reporting tool with almost as much value as Twitter, and possibly more. Even though I only use the basic free version of the site, it’s become an awesome clearinghouse of sources that I call on for help with scoops and analysis. I can slice and dice my network of 2,900 contacts by industry, title, location and more. It’s become a treasure trove of personal e-mails for sources, which I never have to manually update when people leave for new jobs, as they often do. It’s even turned into a place where people read a lot of my stories and the resource where I sometimes find new stories to pursue. In fact, I got the idea for this story by noticing that Levin and I have more than 500 connections in common.

for different reasons, but he raves all the same. Nothing great in biotech can happen without a magical mix of an idea, technology, people, and money.

“Our No. 1 goal in life is to know the best people in the industry who are going to make a difference in our companies,” Levin says. “I don’t remember when it exactly became clear, but it was clear to me that a lot of people were using it to stay in touch. We’ve realized it’s an extraordinary recruiting tool. The more I’ve spent time there, the more aggressive I have gotten.”

Levin isn’t kidding about the emphasis on recruiting at Third Rock, which has a “recruiting partner” in Craig Greaves, a former recruiter at Biogen Idec (NASDAQ: BIIB) and Cubist Pharmaceuticals (NASDAQ: CBST). Levin says all this connecting and re-connecting sometimes leads somewhere fruitful, sometimes not, just like with all other recruiting techniques.

But Levin and his partner at Third Rock aren’t just fiddling around making random contacts, they are being systematic about the connections they form. Once he forms a connection on LinkedIn, he said he sends the new contact a short follow-up note to see what’s new in their lives or careers. He then e-mails his fellow partners to see if any of them know the person. Third Rock uses a premium version of LinkedIn, which has an application that automatically downloads all of Levin’s new contacts into a central database so that all members of the firm can see the person’s profile, Greaves says.

Sometimes an in-person meeting gets scheduled to follow up right away to see if there might be some kind of potential for a match at a Third Rock company. Often Third Rock uses the site for targeted searches, like, say, for an antibody engineer, Greaves says. Other times, it’s just to get acquainted with people who aren’t looking for work now, but might be able to join a startup, consult, or form a valuable partnership with a Third Rock company sometime later, he says.

“We are laying the groundwork and building a network for the long term,” Greaves says.

No doubt, LinkedIn has its potential for misuse just like any other technology, and users need to think about how to use it properly. Back when the site was formed in 2003, people were urged to connect only with people they knew well, because otherwise people might think you were tainted if a shady operator ended up appearing in your network. I think that stigma has largely gone away, because a connection is perceived now as really just like trading business cards, and not an endorsement or recommendation. People have also long worried about whether bosses might be able to use it to spy on their workers, and suspect whether they were getting restless, looking for a new job. I used to leave my entire connections list accessible on the web for anyone who connected with me, until I started connecting with people I don’t really know, and realized some may have ulterior motives that might interfere with my ability to break news.

There are plenty of areas on the site that leave something to be desired. LinkedIn Groups have always struck me as spammy, so I’ve unsubscribed to most of them. The site can be annoying with its constant urges to “update your profile” or “add skills to your profile” or now to “endorse” various people in your network. The whole site appears to be trying really hard to keep people glued to it like Facebook, by constantly updating their status and checking other people’s employment status, which can be annoying and a waste of time.

But the most irritating thing about LinkedIn, to me anyway, is that even though it has achieved critical mass, many C-suite executives and venture capitalists still resist signing up. For example, when I searched on the 40 names of “young and proven” biotech venture capitalists listed in this column two weeks ago, only 24 of the 40 (60 percent) showed up in the LinkedIn database.

I find it baffling that so many senior people in the industry still resist taking advantage of this resource, and have to wonder if they have some better idea on how to network. There’s no getting around the importance of networking. Biotech is a geographically far-flung industry, with hundreds of companies and vendors, who all need to work together in trusting relationships to keep the whole enterprise afloat.

Industry conferences have always been, and still remain, the gold standard way of networking. But those events take time and money, and nobody can do it every day of the week. LinkedIn is becoming the indispensable resource that glues an entire industry together, and helps people make connections between people and ideas and opportunities that would otherwise never be made. While biotech could certainly use a few more groundbreaking advances to make the drug development process more efficient, one of the fastest-growing new tools for the industry is a free resource just a click away on the Web.

Luke Timmerman is the National Biotech Editor of Xconomy. E-mail him at

ltimmerman@xconomy.com 

SOURCE:

 

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