The high-dose clopidogrel group showed a decreased incidence of MI, in-stent thrombosis, and death. This benefit confirms the importance of achieving early and adequate antiplatelet therapy. However, the study authors noted a higher percentage of major bleeding and minor bleeding, although the increase was not statistically significant (2.8% vs. 3.5%, P=0.379, and 7.4% vs. 8.2%, P=0.699, respectively).
Bottom line: High-dose clopidogrel before and within the first 15 days after PCI decreases the risk of MI, in-stent thrombosis, and death, with no statistical increase in bleeding complications. Long-range studies beyond the two-month interval might be beneficial.
Citation: Lemesle G, Delhaye C, Sudre A, et al. Impact of high loading and maintenance dose of clopidogrel within the first 15 days after percutaneous coronary intervention on patient outcome. Am Heart J. 2008;10:1-8.
B-Type Natriuretic Peptide (BNP) Identifies Patients Developing Sepsis-Induced Myocardial Depression
Clinical question: Can plasma BNP be used as a marker to identify patients at risk for sepsis-induced depression of myocardial function?
Background: Previous studies have established BNP levels are increased in patients with septic shock but have not examined the relationship between plasma BNP concentration and left ventricular (LV) systolic dysfunction.
Study design: Prospective cohort.
Setting: Academic medical center.
Synopsis: The authors divided 93 prospectively selected ICU patients with severe sepsis into two groups: one with normal left ventricular (LV) function and a group with LV systolic dysfunction. Comparison of the plasma BNP concentrations between these two groups demonstrated a significant positive correlation between the BNP level and the degree of LV systolic dysfunction, suggesting BNP is a reasonable marker for identification of septic patients with sepsis-induced myocardial depression.
Further, the study’s results suggest BNP measurements early in the course of septic shock might be useful prognostic indicators. However, it is unclear to what extent the knowledge gained from such measurements would alter care management, or how BNP compares to echocardiography in terms of diagnostic and prognostic utility. Thus, these results might not be adequate to justify the routine measurement of BNP in patients with severe sepsis.
Bottom line: Elevated BNP in septic patients is associated with the presence or risk of sepsis-induced myocardial depression, and might be a negative prognostic indicator.
Citation: Post F, Weilemann LS, Messow CM, Sinning C, Munzel T. B-type natriuretic peptide as a marker for sepsis-induced myocardial depression in intensive care patients. Crit Care Med. 2008;36:3030–3037.
High Risk of Death with Thrombolytic Use in Low-Risk Pulmonary Embolism (PE)
Clinical question: Is there an advantage to thrombolytic therapy in the treatment of acute PE versus treatment with unfractionated or low-molecular-weight (LMW) heparin?
Background: Given the high mortality linked to PE, consistent indications for thrombolytic therapy in acute PE are needed. An assessment of the prevalence of thrombolytic therapy and mortality, as compared with standard anticoagulation, has been described inconsistently.
Study design: Retrospective cohort study.
Setting: 186 acute-care hospitals in Pennsylvania.
Synopsis: Using a database of ICD-9 codes, 15,116 patients were reviewed. Logistic regression was used to evaluate the association between thrombolytic therapy and 30-day mortality. Poisson regression was used to evaluate the association between thrombolytic therapy and in-hospital mortality. For those receiving thrombolysis and considered unlikely candidates for the therapy based on documentation at presentation (low predicted probability), the in-hospital mortality and overall 30-day mortality rate were higher when compared with those who did not receive thrombolysis. An exception to this was a group of patients with high predicted probability of receiving thrombolysis. In this group, thrombolysis was not associated with increased risk. Limitations to the study include lack of assessment of right ventricular function, changes in condition after presentation, lack of long-term outcomes, and lack of exact cause of death.