Debra L. Beck

CHICAGO —Measuring N-terminal-proB-type natriuretic peptide in the emergency department facilitated diagnosis of acute heart failure, shortened visits, and saved money, according to results of IMPROVE-CHF, a multicenter randomized-controlled trial of the use of NT-proBNP-guided strategy in the management of suspected acute heart failure.

“Our economic analysis found that adding this test to physician judgment reduced the duration of the emergency department visit from an average of 6.3 hours to an average of 5.6 hours,” Dr. Gordon W. Moe reported at the annual scientific sessions of the American Heart Association.

“In addition, it reduced the number of patients rehospitalized within 60 days from 51 to 33 and reduced costs in 2005 U.S. dollars from $5,592 to $4,631 per patient overall, a savings of $961 per patient,” Dr. Moe said.

The IMPROVE-CHF study included 501 patients who presented to seven Canadian emergency departments with dyspnea. NT-proBNP samples were taken in all patients, but in only about half were the treating physicians made aware of the results. In the other half of patients, physicians utilized standard clinical tools to determine a diagnosis.

Patients were followed for 60 days to determine whether knowledge of NT-proBNP values improved the management of patients with suspected acute heart failure in a publicly funded, universal-access health care setting.

Although the amount of time spent in the ED was significantly reduced, the number of ICU admissions, median duration of ICU stay, and the number of patients requiring hospitalization after their ED visit did not differ between the NT-proBNP group and the usual-care group. By 60 days, 23% of patients enrolled had died or were rehospitalized, with no difference between groups.

Discussant Dr. Margaret M. Redford of the Mayo Clinic in Rochester, Minn., noted that the researchers were not clear on whether the cost savings were caused by more efficient treatment of patients or to less use of other diagnostic testing. It was also unclear whether the test was most helpful in making a diagnosis of heart failure or in excluding heart failure.

She also noted that the setting for IMPROVE-CHF—in Canada, where there is a single-payer system and carefully controlled costs—is both a strength and a limitation of the trial. “In this system costs are already carefully controlled, making it a rigorous testing ground for cost-saving measure … but we cannot assume the savings observed in the Canadian system would necessarily be observed in other health care systems.”

CHICAGO —Measuring N-terminal-proB-type natriuretic peptide in the emergency department facilitated diagnosis of acute heart failure, shortened visits, and saved money, according to results of IMPROVE-CHF, a multicenter randomized-controlled trial of the use of NT-proBNP-guided strategy in the management of suspected acute heart failure.

“Our economic analysis found that adding this test to physician judgment reduced the duration of the emergency department visit from an average of 6.3 hours to an average of 5.6 hours,” Dr. Gordon W. Moe reported at the annual scientific sessions of the American Heart Association.

“In addition, it reduced the number of patients rehospitalized within 60 days from 51 to 33 and reduced costs in 2005 U.S. dollars from $5,592 to $4,631 per patient overall, a savings of $961 per patient,” Dr. Moe said.

The IMPROVE-CHF study included 501 patients who presented to seven Canadian emergency departments with dyspnea. NT-proBNP samples were taken in all patients, but in only about half were the treating physicians made aware of the results. In the other half of patients, physicians utilized standard clinical tools to determine a diagnosis.

Patients were followed for 60 days to determine whether knowledge of NT-proBNP values improved the management of patients with suspected acute heart failure in a publicly funded, universal-access health care setting.

Although the amount of time spent in the ED was significantly reduced, the number of ICU admissions, median duration of ICU stay, and the number of patients requiring hospitalization after their ED visit did not differ between the NT-proBNP group and the usual-care group. By 60 days, 23% of patients enrolled had died or were rehospitalized, with no difference between groups.

Discussant Dr. Margaret M. Redford of the Mayo Clinic in Rochester, Minn., noted that the researchers were not clear on whether the cost savings were caused by more efficient treatment of patients or to less use of other diagnostic testing. It was also unclear whether the test was most helpful in making a diagnosis of heart failure or in excluding heart failure.

She also noted that the setting for IMPROVE-CHF—in Canada, where there is a single-payer system and carefully controlled costs—is both a strength and a limitation of the trial. “In this system costs are already carefully controlled, making it a rigorous testing ground for cost-saving measure … but we cannot assume the savings observed in the Canadian system would necessarily be observed in other health care systems.”

CHICAGO —Measuring N-terminal-proB-type natriuretic peptide in the emergency department facilitated diagnosis of acute heart failure, shortened visits, and saved money, according to results of IMPROVE-CHF, a multicenter randomized-controlled trial of the use of NT-proBNP-guided strategy in the management of suspected acute heart failure.

“Our economic analysis found that adding this test to physician judgment reduced the duration of the emergency department visit from an average of 6.3 hours to an average of 5.6 hours,” Dr. Gordon W. Moe reported at the annual scientific sessions of the American Heart Association.

“In addition, it reduced the number of patients rehospitalized within 60 days from 51 to 33 and reduced costs in 2005 U.S. dollars from $5,592 to $4,631 per patient overall, a savings of $961 per patient,” Dr. Moe said.

The IMPROVE-CHF study included 501 patients who presented to seven Canadian emergency departments with dyspnea. NT-proBNP samples were taken in all patients, but in only about half were the treating physicians made aware of the results. In the other half of patients, physicians utilized standard clinical tools to determine a diagnosis.

Patients were followed for 60 days to determine whether knowledge of NT-proBNP values improved the management of patients with suspected acute heart failure in a publicly funded, universal-access health care setting.

Although the amount of time spent in the ED was significantly reduced, the number of ICU admissions, median duration of ICU stay, and the number of patients requiring hospitalization after their ED visit did not differ between the NT-proBNP group and the usual-care group. By 60 days, 23% of patients enrolled had died or were rehospitalized, with no difference between groups.

Discussant Dr. Margaret M. Redford of the Mayo Clinic in Rochester, Minn., noted that the researchers were not clear on whether the cost savings were caused by more efficient treatment of patients or to less use of other diagnostic testing. It was also unclear whether the test was most helpful in making a diagnosis of heart failure or in excluding heart failure.

She also noted that the setting for IMPROVE-CHF—in Canada, where there is a single-payer system and carefully controlled costs—is both a strength and a limitation of the trial. “In this system costs are already carefully controlled, making it a rigorous testing ground for cost-saving measure … but we cannot assume the savings observed in the Canadian system would necessarily be observed in other health care systems.”

WASHINGTON — By angiographic measures, sirolimus-eluting stents outperformed paclitaxel-eluting stents over 9 months in a head-to-head comparison in patients with long coronary lesions, Dr. Seung-Jung Park reported at a symposium sponsored by the Cardiovascular Research Foundation.

“Compared to paclitaxel-eluting stents, sirolimus-eluting stents appear to be more effective in inhibiting neointimal hyperplasia and result in a reduced risk of angiographic restenosis and the need for repeat revascularization in patients with long coronary lesions” in the Percutaneous Treatment of Long Native Coronary Lesions with Drug-Eluting Stents II (LONG-DES II) study, said Dr. Park, who was principal investigator and is chief of interventional cardiology at the Asan Medical Center in Seoul, South Korea.

Despite the favorable results, however, it was noted that longer-term outcomes are needed before making definitive statements regarding the benefits of drug-eluting stents in this lesion subset or which drug-eluting stent is superior. Current guidelines do not extend the use of drug-eluting stents into lesions longer than those seen in the pivotal sirolimus-eluting stent (Cypher) and paclitaxel-eluting stent (Taxus) trials that were used to gain regulatory approval, in which the upper limits were 30 mm in SIRIUS and 28 mm in TAXUS IV.

In a previous, smaller study of patients with long lesions (LONG-DES), the sirolimus-eluting stent was shown to be more effective in reducing angiographic restenosis. The LONG-DES II study sought to compare the efficacy of the two devices in a randomized, controlled fashion. The study included 500 patients with de novo coronary lesions more than 25 mm in length by visual estimation, requiring single or multiple drug-eluting stents, with a planned total stent length of more than 32 mm. Half the patients were treated with sirolimus-eluting stents and the other half with paclitaxel-eluting stents.

Device success neared 100% in both groups. On quantitative coronary angiography, there were no differences in postprocedure acute gain or in diameter residual stenosis. The mean angiographic length of the stented segment was 40.8 mm for sirolimus and 41.1 mm for paclitaxel, a difference that was not statistically significant.

Thirty-day clinical outcomes, including death, myocardial infarction, and target lesion revascularization, also did not differ significantly between groups. One subacute stent thrombosis occurred in the sirolimus-eluting stent arm and none in the paclitaxel arm.

Six-month angiographic follow-up was completed in about 83% of patients and 9-month clinical follow-up was available in all but 6 patients.

The primary end point—the rate of binary angiographic restenosis over 50% at 6 months—was significantly reduced in patients implanted with sirolimus-eluting stents, compared with those receiving paclitaxel-eluting stents. In-segment restenosis was only 3.3% for sirolimus vs. 14.6% for paclitaxel; the in-stent restenosis rates were 2.9% and 11.8%, respectively.

These angiographic differences translated into clinical differences at 9-month follow-up: the incidence of target lesion revascularization was 2.4% for sirolimus, compared with 7.2% for paclitaxel. Target vessel revascularization was undertaken in 3.2% of the sirolimus arm, compared with 7.6% of the paclitaxel arm. Both differences were statistically significant.

In-segment late loss was 0.24 mm for sirolimus, compared with 0.61 mm for paclitaxel. “This is somewhat more late loss than we're used to seeing, even for the sirolimus-eluting stent,” commented Dr. Roxana Mehran of New York-Presbyterian Hospital/Columbia University, New York, in a press conference, although she added that it was still reassuring to see the stents perform well even in more complex lesion morphologies. There were two cases of stent thrombosis recorded by 9 months. Both occurred in the sirolimus-eluting stent arm (0.8%) but did not constitute a statistically significant difference, compared with the paclitaxel arm.

The LONG-DES II study was sponsored by Cordis Corp., which markets the Cypher stent. Additional support was provided by the Cardiovascular Research Foundation in South Korea and the Korean Ministry of Health and Welfare.

WASHINGTON — By angiographic measures, sirolimus-eluting stents outperformed paclitaxel-eluting stents over 9 months in a head-to-head comparison in patients with long coronary lesions, Dr. Seung-Jung Park reported at a symposium sponsored by the Cardiovascular Research Foundation.

“Compared to paclitaxel-eluting stents, sirolimus-eluting stents appear to be more effective in inhibiting neointimal hyperplasia and result in a reduced risk of angiographic restenosis and the need for repeat revascularization in patients with long coronary lesions” in the Percutaneous Treatment of Long Native Coronary Lesions with Drug-Eluting Stents II (LONG-DES II) study, said Dr. Park, who was principal investigator and is chief of interventional cardiology at the Asan Medical Center in Seoul, South Korea.

Despite the favorable results, however, it was noted that longer-term outcomes are needed before making definitive statements regarding the benefits of drug-eluting stents in this lesion subset or which drug-eluting stent is superior. Current guidelines do not extend the use of drug-eluting stents into lesions longer than those seen in the pivotal sirolimus-eluting stent (Cypher) and paclitaxel-eluting stent (Taxus) trials that were used to gain regulatory approval, in which the upper limits were 30 mm in SIRIUS and 28 mm in TAXUS IV.

In a previous, smaller study of patients with long lesions (LONG-DES), the sirolimus-eluting stent was shown to be more effective in reducing angiographic restenosis. The LONG-DES II study sought to compare the efficacy of the two devices in a randomized, controlled fashion. The study included 500 patients with de novo coronary lesions more than 25 mm in length by visual estimation, requiring single or multiple drug-eluting stents, with a planned total stent length of more than 32 mm. Half the patients were treated with sirolimus-eluting stents and the other half with paclitaxel-eluting stents.

Device success neared 100% in both groups. On quantitative coronary angiography, there were no differences in postprocedure acute gain or in diameter residual stenosis. The mean angiographic length of the stented segment was 40.8 mm for sirolimus and 41.1 mm for paclitaxel, a difference that was not statistically significant.

Thirty-day clinical outcomes, including death, myocardial infarction, and target lesion revascularization, also did not differ significantly between groups. One subacute stent thrombosis occurred in the sirolimus-eluting stent arm and none in the paclitaxel arm.

Six-month angiographic follow-up was completed in about 83% of patients and 9-month clinical follow-up was available in all but 6 patients.

The primary end point—the rate of binary angiographic restenosis over 50% at 6 months—was significantly reduced in patients implanted with sirolimus-eluting stents, compared with those receiving paclitaxel-eluting stents. In-segment restenosis was only 3.3% for sirolimus vs. 14.6% for paclitaxel; the in-stent restenosis rates were 2.9% and 11.8%, respectively.

These angiographic differences translated into clinical differences at 9-month follow-up: the incidence of target lesion revascularization was 2.4% for sirolimus, compared with 7.2% for paclitaxel. Target vessel revascularization was undertaken in 3.2% of the sirolimus arm, compared with 7.6% of the paclitaxel arm. Both differences were statistically significant.

In-segment late loss was 0.24 mm for sirolimus, compared with 0.61 mm for paclitaxel. “This is somewhat more late loss than we're used to seeing, even for the sirolimus-eluting stent,” commented Dr. Roxana Mehran of New York-Presbyterian Hospital/Columbia University, New York, in a press conference, although she added that it was still reassuring to see the stents perform well even in more complex lesion morphologies. There were two cases of stent thrombosis recorded by 9 months. Both occurred in the sirolimus-eluting stent arm (0.8%) but did not constitute a statistically significant difference, compared with the paclitaxel arm.

The LONG-DES II study was sponsored by Cordis Corp., which markets the Cypher stent. Additional support was provided by the Cardiovascular Research Foundation in South Korea and the Korean Ministry of Health and Welfare.

WASHINGTON — By angiographic measures, sirolimus-eluting stents outperformed paclitaxel-eluting stents over 9 months in a head-to-head comparison in patients with long coronary lesions, Dr. Seung-Jung Park reported at a symposium sponsored by the Cardiovascular Research Foundation.

“Compared to paclitaxel-eluting stents, sirolimus-eluting stents appear to be more effective in inhibiting neointimal hyperplasia and result in a reduced risk of angiographic restenosis and the need for repeat revascularization in patients with long coronary lesions” in the Percutaneous Treatment of Long Native Coronary Lesions with Drug-Eluting Stents II (LONG-DES II) study, said Dr. Park, who was principal investigator and is chief of interventional cardiology at the Asan Medical Center in Seoul, South Korea.

Despite the favorable results, however, it was noted that longer-term outcomes are needed before making definitive statements regarding the benefits of drug-eluting stents in this lesion subset or which drug-eluting stent is superior. Current guidelines do not extend the use of drug-eluting stents into lesions longer than those seen in the pivotal sirolimus-eluting stent (Cypher) and paclitaxel-eluting stent (Taxus) trials that were used to gain regulatory approval, in which the upper limits were 30 mm in SIRIUS and 28 mm in TAXUS IV.

In a previous, smaller study of patients with long lesions (LONG-DES), the sirolimus-eluting stent was shown to be more effective in reducing angiographic restenosis. The LONG-DES II study sought to compare the efficacy of the two devices in a randomized, controlled fashion. The study included 500 patients with de novo coronary lesions more than 25 mm in length by visual estimation, requiring single or multiple drug-eluting stents, with a planned total stent length of more than 32 mm. Half the patients were treated with sirolimus-eluting stents and the other half with paclitaxel-eluting stents.

Device success neared 100% in both groups. On quantitative coronary angiography, there were no differences in postprocedure acute gain or in diameter residual stenosis. The mean angiographic length of the stented segment was 40.8 mm for sirolimus and 41.1 mm for paclitaxel, a difference that was not statistically significant.

Thirty-day clinical outcomes, including death, myocardial infarction, and target lesion revascularization, also did not differ significantly between groups. One subacute stent thrombosis occurred in the sirolimus-eluting stent arm and none in the paclitaxel arm.

Six-month angiographic follow-up was completed in about 83% of patients and 9-month clinical follow-up was available in all but 6 patients.

The primary end point—the rate of binary angiographic restenosis over 50% at 6 months—was significantly reduced in patients implanted with sirolimus-eluting stents, compared with those receiving paclitaxel-eluting stents. In-segment restenosis was only 3.3% for sirolimus vs. 14.6% for paclitaxel; the in-stent restenosis rates were 2.9% and 11.8%, respectively.

These angiographic differences translated into clinical differences at 9-month follow-up: the incidence of target lesion revascularization was 2.4% for sirolimus, compared with 7.2% for paclitaxel. Target vessel revascularization was undertaken in 3.2% of the sirolimus arm, compared with 7.6% of the paclitaxel arm. Both differences were statistically significant.

In-segment late loss was 0.24 mm for sirolimus, compared with 0.61 mm for paclitaxel. “This is somewhat more late loss than we're used to seeing, even for the sirolimus-eluting stent,” commented Dr. Roxana Mehran of New York-Presbyterian Hospital/Columbia University, New York, in a press conference, although she added that it was still reassuring to see the stents perform well even in more complex lesion morphologies. There were two cases of stent thrombosis recorded by 9 months. Both occurred in the sirolimus-eluting stent arm (0.8%) but did not constitute a statistically significant difference, compared with the paclitaxel arm.

The LONG-DES II study was sponsored by Cordis Corp., which markets the Cypher stent. Additional support was provided by the Cardiovascular Research Foundation in South Korea and the Korean Ministry of Health and Welfare.