Research priorities to address polypharmacy in older adults with cancer

Polypharmacy poses a significant public health problem that disproportionately affects older adults (≥65 years) since this population represents the largest consumers of medications. Clinicians caring for older adults with cancer must rely on evidence to understand polypharmacy and its implications, not only to communicate with patients and other healthcare providers, but also because of the significant interplay between polypharmacy, cancer, cancer-related treatment, and clinical outcomes. Interest in polypharmacy is rising because of its prevalence, the origins and facilitating factors behind it, and the direct and indirect clinical outcomes associated with it. The growing body of publications focused on polypharmacy in older adults with cancer demonstrates that this is a significant area of research; however, limited evidence exists to guide medication use (e.g., prescribing, administration) in this population. Currently, research priorities aimed at polypharmacy in the field of geriatric oncology lack clarity. We identified current gaps in the literature in order to establish research priorities for polypharmacy in older adults with cancer. The five research priorities—Polypharmacy Methodology and Definitions, Suboptimal Medication Use, Comorbidities and Geriatric Syndromes, Underrepresented Groups, and Polypharmacy Interventions—highlight critical areas for future research to improve outcomes for older adults with cancer.     

Role of Antiischemic Agents in the Management of Non‐ST Elevation Acute Coronary Syndrome (NSTE‐ACS)

Non‐ST elevation acute coronary syndrome (NSTE‐ACS) is the commonest acute presentation of coronary artery disease (CAD). Mortality and morbidity of the condition has improved substantially over the last few decades as a result of the cumulative effect of multiple interventions acting via different mechanisms. Despite a significant increase in the rate of coronary intervention, medical therapy continues to retain a central role in the treatment of NSTE‐ACS particularly in frail patients where revascularization is inappropriate or when it is incomplete. Several antiischemic agents have been used in the treatment of the condition. Beta blockers are often the first‐line choice with calcium channel blockers and nitrates being used as an alternative when beta blockers are contraindicated, or as an addition to achieve optimal symptom control. Newer agents, such as nicorandil, ivabradine, and ranolazine have also been used in refractory cases. Although most of these agents have been extensively studied in large randomized controlled trials in patients with stable CAD or ST elevation acute coronary syndrome (STE‐ACS), the evidence supporting their use in NSTE‐ACS is less clear cut. In this article, we review various drugs available for controlling ischemia and the latest evidence in support of their use in NSTE‐ACS.     

Effect of completeness of revascularization on clinical outcome in patients with multivessel disease presenting with unstable angina who undergo percutaneous coronary intervention

We evaluated the current short- and medium-term outcomes of complete revascularization, compared to culprit lesion percutaneous coronary intervention (PCI), in patients with multivessel coronary disease presenting with unstable angina. One hundred fifty-one patients with multivessel coronary disease presented to a tertiary cardiothoracic center with unstable angina/non-ST elevation myocardial infarction (UA/NSTEMI) between January 2000 and September 2001. In group A (n=71), the intended strategy was complete revascularization by multivessel PCI. In group B (n=80), culprit lesion PCI was intended despite the presence of other lesions amenable to PCI (B1) or due to confounding anatomical factors (B2). Clinical variables and endpoints were collected from patient notes, a dedicated database and telephone follow-up, and included recurrent stable and unstable angina, need for repeat PCI or elective coronary artery bypass graft, incidence of non-fatal myocardial infarction (MI) and death. Baseline characteristics were similar in each group. Procedural success was achieved in over 95% of cases in both groups with high stent implantation rates (>96%). There was no observed difference in mortality or incidence of MI between the groups. Compared to group A, more patients in group B1 had residual angina [22.8% (13/57) versus 9.9% (7/71); p=0.041] and required further PCI [17.5% (10/57) versus 7.0% (5/71); p=0.045]. There was a non-significant trend toward fewer readmissions for UA and less long-term antianginal medication in group A [38.0% (27/71) versus 52.6% (30/57); p=0.043]. Complete and culprit lesion revascularization by PCI are safe methods of treating patients with multivessel coronary disease presenting with UA/NSTEMI. Reductions in residual angina, repeat PCI and need for antianginal therapies suggest that complete revascularization should be the strategy of choice when possible.     

Sirolimus-eluting stents for the treatment of atherosclerotic ostial lesions

BACKGROUND: Ostial atherosclerotic lesions are distinct from other lesion sites in terms of outcomes following percutaneous interventions. Despite aggressive lesion modification strategies, long-term outcome is hampered by restenosis. Various stent designs have failed to show significant improvement in target lesion revascularization (TLR) rates. The present study evaluates the clinical outcomes following sirolimus-eluting stent implantation for ostial lesions. MATERIALS AND METHODS: The sirolimus-eluting stent (SES) was the device of choice at our institute for all coronary interventions from April 2002 to March 2003. This study population is comprised of 50 patients who received drug-eluting stents for atherosclerotic ostial lesions during this period. Sixty-eight percent of the patients were male and 24 patients (48%) had a history of previous revascularization. Indication for intervention were as follows: acute myocardial infarction, 7 patients (14%), stable angina, 23 patients (46%), unstable angina, 20 patients (40%). Angioplasty and stent implantations were done according to the standard protocol. All patients were prospectively followed up for major adverse cardiac events. The event-free survival was 90% at one year. There were 5 (10%) target vessel revascularization, 3 (6%) myocardial infarctions and 1 (2%) death during a mean follow-up of 414.5 +/- 54.5 days. TLR was required in 4 (8%) patients. CONCLUSIONS: SES implantation is feasible in ostial locations and is associated with low subsequent revascularization.     

'Cold hand, ischemic heart': treatment by stenting of the left subclavian artery

A 59-year-old man presented with worsening angina and a cold, painful left hand, eight years after coronary artery bypass surgery. Coronary angiography showed extensive coronary atherosclerosis with blocked vein grafts to his left circumflex and right coronary arteries. There was a severe narrowing in the left subclavian artery before the origin of the left internal mammary artery (LIMA) which appeared patent. PTCA and stent implantation to the left subclavian artery stenosis restored normal flow to the left hand and the LIMA with abolition of his ischemic hand symptoms and marked improvement of his angina.     

The whole nine yards: multiple cardiac surgical and percutaneous interventions in a patient during 30 years of care

A 38-year-old man underwent coronary artery bypass graft surgery for angina pectoris following myocardial infarction. During the following 28 years, he required two repeat coronary artery bypass graft surgical procedures, nine percutaneous coronary interventions and 17 coronary angiograms. His treatment included saphenous vein, left internal mammary artery and gastroepiploic artery grafting, percutaneous transluminal coronary angioplasty and intragraft thrombolytic therapy, directional coronary atherectomy, cutting balloon angioplasty, intracoronary stenting with bare-metal and drug-eluting stents, treatment for in-stent restenosis, stenting of the left main and circumflex coronary arteries and saphenous vein graft as well as intracoronary pressure wire diagnostics. In addition to his statin therapy, antiplatelets and angiotensin-converting enzyme inhibitors, he also underwent biventricular automatic implantable cardioverter-defibrillator implantation and atrioventricular node radiofrequency ablation for his impaired left ventricular function, ventricular tachycardia and rapid atrial fibrillation. The present unusual case represents almost 'the whole nine yards' of treatment that has become available to patients with coronary artery disease during the past 30 years of technological development.     

Ventriculo-atrial shunt causing tricuspid endocarditis: its percutaneous removal

A 21-year-old patient developed tricuspid endocarditis with the distal sections of two redundant ventriculo-atrial shunts remaining in the right atrium. We report their percutaneous removal using a Dotter basket.     

First degree atrioventricular block associated with right atrial myxoma

First degree atrioventricular block occurred in a 68 year old man with a large right atrial myxoma. This conduction abnormality resolved within three months of successful surgical removal of the tumour. It is suggested that mechanical compression by the myxoma on either the underlying conduction tissue or the interventricular septum is likely to have caused this phenomenon.