EFFECTS OF ADVANCING AGE ON THE EFFICACY AND SIDE-EFFECTS OF ANTIARRHYTHMIC DRUGS IN POSTMYOCARDIAL INFARCTION PATIENTS WITH VENTRICULAR ARRHYTHMIAS
attack trial experience; Geriatrics & Gerontology; suppression; therapy
Objective: To determine the effect of age on the response to anti-arrhythmic drugs. Design: Randomized controlled trial comparing particular drugs. Setting: Multi-institutional (The Cardiac Arrhythmia Suppression Trial, CAST). Participants: 2,371 patients, age <80, with ventricular arrhythmias after a recent myocardial infarction. Subjects classified by age as less-than-or-equal-to 55, 56-65, and 66-79 years. Intervention: Upwardly titrated doses of encainide, flecainide or moricizine. After identification of a tolerated and effective dose of one of the drugs, participants were randomized to that drug and dose versus its placebo for up to 10 months. Main Outcome Measures: Efficacy of drug (suppression of ventricular premature depolarizations and/or non-sustained ventricular tachycardia), side effects and mortality. Results: Older patients had more previous MIs, congestive heart failure (CHF), hypertension, NSVT, repolarization abnormalities, digitalis use, and diuretic use. They had less pathologic Q-waves or electrocardiographic injury pattern, and their left ventricular ejection fraction (LVEF) was lower. First dose VPD suppression with the first drug averaged 53% and is not associated with age (P = 0.29). Adverse events including death are more frequent in older patients taking study drugs (P < 0.001). This trend is consistent in all three study drugs and at varying LVEFs. History of prior MI, low LVEF, VPD (in log scale), and digitalis therapy also correlates with adverse events (all P < 0.05). Following adjustment for these factors, older age is an independent predictor of adverse events (relative risk 1.30 per decade of age, P < 0.001). Conclusions: Older age increases the susceptibility to adverse cardiac events from a class of relatively toxic antiarrhythmic agents.
Akiyama T; Pawitan Y; Campbell W B; Papa L; Barker A H; Rubbert P; Friedman L; Keller M; Josephson R A
Journal of the American Geriatrics Society
1992
1992-07
Journal Article or Conference Abstract Publication
<a href="http://doi.org/10.1111/j.1532-5415.1992.tb01957.x" target="_blank" rel="noreferrer noopener">10.1111/j.1532-5415.1992.tb01957.x</a>
Coronary stenting in the elderly: Longitudinal results in a wide spectrum of patients treated with a new and more practical approach
Elderly; Cardiovascular System & Cardiology; follow-up; angioplasty; anticoagulation; multicenter; implantation; angiography; antiplatelet therapy; artery stents; balloon; intracoronary ultrasound; intravascular ultrasound guidance; palmaz-schatz stents; stents
One hundred-twelve intracoronary stents (83 Palmaz-Schatz, 25 biliary, and 4 Gianturco-Roubin) were placed in 87 (51.7% male) patients aged greater than or equal to 70 years (70-93; mean 76.1) during a 1-year period. Ail stents were deployed using high-pressure inflation (mean 17.4 +/- 2 atm) without intravascular ultrasound. All patients received antiplatelet therapy with aspirin and ticlopidine. Seven patients additionally received warfarin at the physician's discretion, No patient was excluded from analysis regardless of presentation (40% acute myocardial infarction and 12.6% bailout) or complication. There were four deaths and two target vessel reinterventions in-hospital. One reintervention (a bailout) developed a non-Q-wave myocardial infarction. Bleeding, vascular complications, and length of stay were all greater for the warfarin group. The event-free survival rate was 83,9%, at an average of 8.6 months follow-up. A wide range of elderly patients can thus undergo stenting without intravascular ultrasound, usually without warfarin, yielding results comparable to those with more standard therapy in select populations. (C) 1998 Wiley-Liss, Inc.
Bage M D; Bauman W B; Gupta R; Berkovitz K E; Ormond A P; Grigera F; Josephson R A
Catheterization and Cardiovascular Diagnosis
1998
1998-08
Journal Article or Conference Abstract Publication
<a href="http://doi.org/10.1002/(sici)1097-0304(199808)44:4%3C397::aid-ccd6%3E3.0.co;2-%23" target="_blank" rel="noreferrer noopener">10.1002/(sici)1097-0304(199808)44:4%3C397::aid-ccd6%3E3.0.co;2-%23</a>
Prediction of cardiac death in patients with a very low ejection fraction after myocardial infarction: a Cardiac Arrhythmia Suppression Trial (CAST) study.
*Stroke Volume; Blood Pressure; Heart Arrest/mortality; Heart Rate; Humans; Left/*mortality/physiopathology; Multicenter Studies as Topic; Myocardial Infarction/drug therapy/*mortality/physiopathology; Prognosis; Proportional Hazards Models; Randomized Controlled Trials as Topic; Risk Factors; Thrombolytic Therapy; Ventricular Dysfunction
The Cardiac Arrhythmia Suppression Trial (CAST) database was analyzed with a Cox proportional hazards regression model to predict the mortality of patients with very poor left ventricular systolic function (ejection fraction \textless or = .20). Predictors of total death or cardiac arrest were (relative risk), QRS duration (1.10/10 msec increase), coronary artery bypass grafting (0.38), basal heart rate (1.26/10 min-1 increase), diastolic blood pressure (0.79/10 mm Hg increase), diabetes mellitus (1.59), EF (0.94/1 U increase), and ease of suppression (the ability to suppress ambient ventricular ectopy on the lowest dose of the first randomly chosen CAST drug) (0.64). Predictors of arrhythmic death or arrhythmic cardiac arrest included thrombolysis (0.44), coronary artery bypass grafting (0.38), diuretic use (1.71), heart rate (1.21/10 min-1 increase), calcium channel blocker use (1.69), and QRS duration (1.10/10 msec increase). Thus easily measurable clinical and laboratory variables help predict prognosis in this clinically important subgroup. The pathophysiologic basis for and the clinical implications of the ease of ventricular arrhythmia suppression correlating with prognosis requires further study.
Josephson R A; Chahine R A; Morganroth J; Anderson J; Waldo A; Hallstrom A
American heart journal
1995
1995-10
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1016/0002-8703(95)90064-0" target="_blank" rel="noreferrer noopener">10.1016/0002-8703(95)90064-0</a>
Administration of a glycoprotein IIb/IIIa receptor blocker with a thienopyridine derivative does not increase the risk of thrombocytopenia
Aspirin; clopidogrel; coronary stent placement; Environmental Sciences & Ecology; implantation; population; therapy; ticlopidine; trial; Zoology
The combination of aspirin, a thienopyridine derivative, and a glycoprotein IIb/IIIa receptor inhibitor has become standard therapy for patients undergoing percutaneous coronary intervention (PCI). Recent studies have shown an increased incidence of thrombocytopenia in those patients receiving a high loading dose of clopidogrel (thienopyridine) with abciximab (IIIb/IIIa receptor inhibitor) prior to coronary intervention. We reviewed the records of 504 patients who underwent PCI at a large tertiary care hospital and noted an incidence of thrombocytopenia of 4.8%, comparable to published historical controls who received abciximab without clopidogrel. In patients undergoing PCI, there was no difference in thrombocytopenia or bleeding complications between patients receiving a high or a low dose of a thienopyridine. We conclude that a high loading dose of a thienopyridine derivative prior to PCI may be administered safely and efficaciously in the setting of concomitant administration of abciximab without an undue risk of thrombocytopenia.
Silver K H; Newman I; Rohr S M; Johnson J; Josephson R A
Ohio Journal of Science
2005
2005-09
Journal Article
n/a