ESC Congress 2016 - 32

clINIcAl TRIAl HIgHlIgHTs The YEARS algorithm was developed to simplify the decision rule and reduce the need for CTPA. It uses 3 items from the original Wells rule (hemoptysis, signs of deep vein thrombosis, and "PE most likely") in addition to the D-dimer test and a variable threshold for the D-dimer values: ie, 0 YEARS items + D-dimer < 1000 or ≥ 1 YEARS items plus D-dimer < 500 exclude PE, while 0 YEARS items + D-dimer ≥ 1000, or ≥ 1 YEARS items plus D-dimer ≥ 500 indicate the need for a CTPA to confirm a PE [van Es J et al. J Thromb Haemost. 2015]. This prospective cohort study was conducted with 3260 consecutive patients with clinically suspected PE in 12 academic and nonacademic hospitals in The Netherlands. Recurrent venous thromboembolism (VTE) during the 3-month follow-up after negative pulmonary angiography was the primary endpoint (safety). The proportion of patients in whom a CTPA was required was the secondary (efficacy). Patients were mean age 53 years and 62% were women; 88% of patients were treated as outpatients. The overall prevalence of PE in all patients with suspected PE who were screened for the study was 13.2%. Table 1. Events Detected by YEARS Algorithm Group 1 n = 1306 Group 2 n = 352 Group 3 n = 327 Group 4 n = 964 0 0 ≥1 ≥1 D-dimer value < 1000 ≥ 1000 < 500 ≥ 500 CTPA, with or without Without With Without With Nonfatal PE, n 1 2 3 0 Nonfatal DVT, n 1 1 0 4 Events not excluded as COD, n 2 PE 3 PE 0 1 PE Lost to follow-up, n 4 0 0 1 YEARS items, n COD, cause of death; CTPA, computed tomography pulmonary angiography; DVT, deep vein thrombosis; PE, pulmonary embolism. The risk of VTE for patients with suspected acute PE who had either 0 YEARS items and D-dimer < 1000; 0 YEARS items, D-dimer ≥ 1000, and negative CTPA; ≥ 1 YEARS items, D-dimer < 500; or ≥ 1 YEARS items, D-dimer ≥ 500, and negative CTPA (n = 2944; Table 1) was 0.61% (95% CI, 0.36 to 0.96) and the risk of a fatal PE was 0.20% (95% CI, 0.07 to 0.44). For patients managed without CTPA (n = 1629) the risk of VTE was 0.43% and the risk of fatal PE was 0.12%. Patients managed with CTPA (n = 1315) had a 0.84% risk of VTE and a 0.30% risk of fatal 32 October 2016 PE. CTPA was not indicated in 48% of patients using the YEARS algorithm. Compared with the standard algorithm this represents absolute 14% reduction in CTPAs. The strengths of this study include a large sample size, high proportion of patients included in the algorithm, almost complete follow-up, and independently adjudicated endpoints; however, it was limited by the fact that it was not a randomized controlled trial and it did not have a way to ascertain the true incidence of PE in the patients who were not evaluated by a CTPA based on the treatment algorithm. Screening and Aggressive Prevention in Patients With Multisite Artery Disease Fails to Improve Outcomes: The AMERICA Study Written by Toni Rizzo The prevalence and associated risk of asymptomatic multisite artery disease (MSAD) in high-risk patients with coronary artery disease (CAD) are unknown. Systematic identification and aggressive management of MSAD has not been evaluated. The aim of the AMERICA study, presented by Jean-Phillipe Collet, MD, Pitié-Salpêtrière University Hospital, Paris, France, was to demonstrate the superiority of proactive detection and management of asymptomatic MSAD combined with aggressive secondary pharmacologic prevention compared with a conservative strategy based on clinically guided identification of MSAD and standard pharmacologic treatment. The study included 521 patients aged ≥ 18 years with 3-vessel disease for ≤ 6 months or patients aged ≥ 75 years with acute coronary syndrome for < 1 month. The patients were randomized to proactive (n = 263) or conventional (n = 258) management. The proactive strategy included routine screening for asymptomatic atherosclerosis using total-body vascular Doppler ultrasound combined with computed-tomography angiography or magnetic resonance imaging if indicated and ankle brachial index. In addition creatinine clearance, fasting glucose, and low-density lipoprotein cholesterol were measured every 6 months. Patients in the proactive arm also received intensive medical therapy with dual antiplatelet therapy, high-dose statin, ß-blockade, angiotensin converting enzyme inhibition, aldosterone blockade after myocardial infarction (MI) with left ventricular ejection fraction ≤ 40%, smoking cessation therapy, and lifestyle modification. Patients in the conventional strategy arm were tested only if symptomatic and were treated with current standard medical therapy. www.escardio.org/ESCcongressinreview http://www.escardio.org/ESCcongressinreview

Table of Contents for the Digital Edition of ESC Congress 2016