Clinical effects of physiologic lesion testing in influencing treatment strategy for multi-vessel coronary artery disease

Background

The application of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) in multivessel coronary artery disease (CAD) patients has not been definitively explored. We herein assessed how treatment strategies were decided based on FFR/iFR values in vessels selected clinically. Specifically, we sought to determine whether treatment selection was based on whether the vessel tested was the clinical target stenosis.

Methods

270 consecutive patients with angiographically determined multivessel disease who underwent FFR/iFR testing were included. Patients were classified initially based on their angiographic findings, then re-evaluated from FFR/iFR results (normal or abnormal). Tested lesions were classified into target or non-target lesions based on clinical and non-invasive evaluations.

Results

Abnormal FFR/iFR values were demonstrated in 51.9 % of patients, in whom 51.4 % received coronary stenting (PCI) and 44.3 % had bypass surgery (CABG). With two-vessel CAD patients, medical therapy was preferred when the target lesion was normal (72.6 %), while PCI was preferred when it was abnormal (78.4 %). In non-target lesions, PCI was preferred regardless of FFR/iFR results (78.0 %). With three-vessel CAD patients, CABG was preferred when the target lesion was abnormal (68.5 %), and there was no difference in the selected modality when it was normal. Furthermore, the incidence of tested lesions was higher in the left anterior descending (LAD) compared to other coronary arteries, and two-vessel CAD patients with LAD stenoses were more frequently treated by PCI.

Conclusion

The use of invasive physiologic testing in multivessel CAD patients may alter the preferred treatment strategy, leading to an overall increase in PCI selection.

Assessing Quality in Interventional Practice: Identifying Meaningful and Actionable Metrics

Interventional cardiologists should insist on quality assessment techniques that indisputably reflect the merit of care delivered. Only measurable outcomes and metrics that are modifiable should be identified and collected. An evaluation process should be adopted that genuinely appraises clinical practice, incorporating appropriate benchmarks for comparison.

SCAI Expert Consensus Statement on Management of In-Stent Restenosis and Stent Thrombosis

Stent failure remains the major drawback to the use of coronary stents as a revascularization strategy. Recent advances in imaging have substantially improved our understanding of the mechanisms underlying these occurrences, which have in common numerous clinical risk factors and mechanical elements at the time of stent implantation. In-stent restenosis remains a common clinical problem despite numerous improvements in-stent design and polymer coatings over the past 2 decades. It generates significant health care cost and is associated with an increased risk of death and rehospitalization. Stent thrombosis causes abrupt closure of the stented artery and therefore carries a high risk of myocardial infarction and death. This Society for Cardiovascular Angiography & Interventions (SCAI) Expert Consensus Statement suggests updated practical algorithmic approaches to in-stent restenosis and stent thrombosis. A pragmatic outline of assessment and management of patients presenting with stent failure is presented. A new SCAI classification that is time-sensitive with mechanistic implications of in-stent restenosis is proposed. Emphasis is placed on frequent use of intracoronary imaging and assessment of timing to determine the precise etiology because that information is crucial to guide selection of the best treatment option. SCAI recommends image-guided coronary stenting at the time of initial implantation to minimize the occurrence of stent failure. When in-stent restenosis and stent thrombosis are encountered, imaging should be strongly considered to optimize the subsequent approach.

A Multimedia Strategy to Integrate Introductory Broad-Based Radiation Science Education in US Medical Schools

US physicians in multiple specialties who order or conduct radiological procedures lack formal radiation science education and thus sometimes order procedures of limited benefit or fail to order what is necessary. To this end, a multidisciplinary expert group proposed an introductory broad-based radiation science educational program for US medical schools. Suggested preclinical elements of the curriculum include foundational education on ionizing and nonionizing radiation (eg, definitions, dose metrics, and risk measures) and short- and long-term radiation-related health effects as well as introduction to radiology, radiation therapy, and radiation protection concepts. Recommended clinical elements of the curriculum would impart knowledge and practical experience in radiology, fluoroscopically guided procedures, nuclear medicine, radiation oncology, and identification of patient subgroups requiring special considerations when selecting specific ionizing or nonionizing diagnostic or therapeutic radiation procedures. Critical components of the clinical program would also include educational material and direct experience with patient-centered communication on benefits of, risks of, and shared decision making about ionizing and nonionizing radiation procedures and on health effects and safety requirements for environmental and occupational exposure to ionizing and nonionizing radiation. Overarching is the introduction to evidence-based guidelines for procedures that maximize clinical benefit while limiting unnecessary risk. The content would be further developed, directed, and integrated within the curriculum by local faculties and would address multiple standard elements of the Liaison Committee on Medical Education and Core Entrustable Professional Activities for Entering Residency of the Association of American Medical Colleges.

Shared Decision-Making in Cardiovascular Practice

Clinical decisions are optimally made collaboratively, with patients and clinicians working together to review all available information and treatment options. A comprehensive dialogue that identifies and brings into focus individual patient goals within the context of the evidence base is the ideal approach. Shared decision-making (SDM) is essential to making choices about treatment preferences and characterizes the optimal practice of evidence-based medicine and good patient care. By supporting patient autonomy and engagement, the patient and family become partners in their health care. Decisions surrounding whether or not to proceed with diagnostic and therapeutic procedures after fully discussing appropriate alternatives are best made considering both the evidence base and patient goals. The central feature of SDM is that a clinician and a patient engage in a dialogue to jointly make decisions, with reciprocated sharing of information that both find beneficial to reach the best decision. SDM entails much more than patient education or informed consent: there must be bidirectional transfer of knowledge, discussion of patient preference, and a process of deliberation reaching consensus. Patient decision aids have been shown to improve patient understanding of options and risks, enhance the patient's involvement, and focus their comprehension of treatment preferences. Patient decision aids also may be of value in strengthening the physician-patient relationship. The need to emphasize SDM should be integrated into the quality process at every level to make it meaningful, not an apparently arbitrary obstacle that requires discovery of a shrewd work-around. A more patient-oriented consideration of the benefits of symptom relief and improved quality of life, in addition to survival and freedom from adverse events, could only be beneficial.

Systemic and Coronary Hemodynamic Effects of Tobacco Products on the Cardiovascular System and Potential Pathophysiologic Mechanisms

Tobacco product usage is the single most preventable cause of death in the United States. Smoking promotes atherosclerosis, producing disease in the coronary arteries, the aorta, the carotid and cerebral arteries and the large arteries in the peripheral circulation. The cardiovascular consequences of tobacco products have been the subject of intensive study for several decades. Despite the overwhelming epidemiologic association between smoking and vascular disease, the pathophysiologic mechanisms by which smoking exerts its deleterious effects remain incompletely understood. This review addresses the acute and long-term systemic and coronary hemodynamic effects of tobacco, with an emphasis of the impact on coronary blood flow and pathophysiologic mechanisms.

Rates of revascularization and PCI:CABG ratio: a new indicator predicting in-hospital mortality in acute coronary syndromes

OBJECTIVE

The principal trend in acute coronary syndrome (ACS) is increasing utilization of percutaneous coronary interventions (PCI) and declining coronary artery bypass graft surgery (CABG) utilization. This study was designed to evaluate whether higher PCI:CABG ratios lead to higher in-hospital PCI or CABG mortality.

METHODS

The National Readmission Database for years 2016 was queried for all hospitalized ACS patients who underwent coronary revascularization during their admission. The study population was derived from 355 US hospitals and included 103 021 patients. Hospitals were grouped based on their PCI:CABG ratio into low, intermediate, and high ratio quartiles with a median [interquartile ranges (IQR)] PCI:CABG ratio of 2.9 (2.5-3.2), 5.0 (4.3-5.9) and 8.9 (7.8-10.3), respectively multivariable logistic regression with adjustment for age, demographics and comorbidities were used to identify CABG:PCI ratio related risk for in-hospital CABG and PCI mortality.

RESULTS

Higher PCI:CABG ratios correlated with an increased CABG mortality. There was a median (IQR) mortality of 2.5% (1.6-4.3) in the low ratio quartile; 3.1% (1.9-5.3) in the intermediate quartiles; and 5.3% (3.2-9.1) in the high ratio quartile (P < 0.001). On multivariate analysis, the PCI:CABG ratio was associated with an increased risk for CABG mortality with an adjusted odds ratio of 1.38 (95% CI, 1.14-1.67, P < 0.001) and 2.17 (95% CI, 1.70-2.80, P < 0.001) for hospitals with intermediate and high PCI:CABG ratios, respectively. There was no significant association between PCI:CABG ratio and PCI mortality.

CONCLUSIONS

The programmatic PCI:CABG ratio is a valid indicator of optimal case selection. The PCI:CABG ratio correlates with in-hospital mortality in ACS.

Pathophysiologic Mechanisms of Tobacco Smoke Producing Atherosclerosis

INTRODUCTION

Despite the convincing epidemiologic association between smoking and vascular disease, the pathophysiologic mechanisms by which smoking initiates and contributes to the progression of atherosclerosis remain incompletely understood. A precise dose-dependent correlation has never been demonstrated, suggesting that the biological relationship is complex and influenced by individual genetic and possibly environmental factors. Although endothelial dysfunction and intimal damage appear to be central to atherogenesis, how tobacco products cause this effect has not been established. The purpose of this review is to describe the current state of knowledge of the main pathophysiologic pathways of how tobacco smoking abets atherosclerosis. Constituents of Tobacco Smoke: Tobacco combustion produces a mixture of organic substances. derived from burning organic materials. The predominant gaseous phase constituents include carbon monoxide, acetaldehyde, formaldehyde, acrolein, and other carbonyls, as well as nicotine and tobacco-specific nitrosamines. Potential Pathophysiologic Mechanisms: Smoking-induced changes in coronary vasomotor tone, platelet activation, and endothelial integrity are major components of both the development of atherosclerosis and its clinical presentation. Smoking may initiate and accelerate the progression of atherosclerosis by injuring the vascular intima. Other potential mechanisms include intimal damage and endothelial dysfunction, oxidative stress and injury, thrombosis, lipid abnormalities, and inflammation.

CONCLUSION

Smoking tobacco products contributes measurably to the incidence of acute vascular events and chronic disease. The causative compound, the exact mechanism of injury, and whether the atherogenic effect is modifiable are not known.

Should Interventional Cardiologists Super-Subspecialize?: Moving From Patient Selection to Operator Selection

The field of interventional cardiology has expanded rapidly. As a result, four evolving areas have evolved - peripheral vascular interventions, structural heart interventions, adult congenital heart intervention, and chronic total occlusion. The complexity of these procedures and the number of devices available has grown rapidly. In addition, the professional and public expectations of procedural success and of minimizing case-avoidance have also grown. Specific issues include volume-outcome relationships, maintaining currency and proficiency, accessibility to specialized procedures, and the need to maintain a fundamental level of expertise in acute coronary interventions.

The appropriate use criteria: Improvements for its integration into real world clinical practice

The purpose of this position statement is to suggest ways in which future appropriate use criteria (AUC) for coronary revascularization might be restructured to: (1) incorporate improvement in quality of life and angina relief as primary goals of therapy, (2) integrate the findings of recent trials into quality appraisal, (3) employ the combined information of the coronary angiogram and invasive physiologic measurements together with the results of stress test imaging to assess risk, and (4) recognize the essential role that patient preference plays in making individualized therapeutic decisions. The AUC is a valuable tool within the quality assurance process; it is vital that interventionists ensure that percutaneous coronary intervention case selection is both evidence-based and patient oriented. Appropriate patient selection is an important quality indicator and adherence to evidence-based practice should be one metric in a portfolio of process and outcome indicators that measure quality.

Outcomes of Transcatheter Aortic Valve Replacement With Percutaneous Coronary Intervention versus Surgical Aortic Valve Replacement With Coronary Artery Bypass Grafting

We aimed to compare the outcomes of combined surgical aortic valve replacement (SAVR) with coronary artery bypass grafting (CABG) to concurrent transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) in a large U.S. population sample. The National Inpatient Sample was queried for all patients diagnosed with aortic valve stenosis who underwent SAVR with CABG or TAVR with PCI during the years 2016 to 2017. Study outcomes included all-cause in-hospital mortality, acute stroke, pacemaker insertion, vascular complications, major bleeding, acute kidney injury, sepsis, non-home discharge, length of stay and cost. Outcomes of hospitalization were modeled using logistic regression for binary outcomes and generalized linear models for continuous outcomes. Overall, 31,205 patients were included (TAVR + PCI = 2,185, SAVR + CABG = 29,020). In reference to SAVR + CABG, recipients of TAVR + PCI were older with mean age 82 versus 73 years, effect size (d) = 0.9, had higher proportions of females 47.6% versus 26.6%, d = 0.4 and higher prevalence of congestive heart failure and chronic renal failure. On multivariable analysis, TAVR + PCI was associated with lowers odds for mortality adjusted OR: 0.32 (95% CI: 0.17 to 0.62) p = 0.001, lower odds for acute kidney injury, sepsis, non-home discharge, shorter length of stay and higher odds for vascular complications, need for pacemaker insertion and higher cost. The occurrence of stroke was similar between both groups. In conclusion, results from real-world observational data shows less rates of mortality and periprocedural complications in TAVR + PCI compared to SAVR + CABG.

Overcoming Obstacles in Designing and Sustaining a High-Quality Cardiovascular Procedure Environment

Accurate evaluation of the quality of invasive cardiology procedures requires appraisal of case selection, technical performance, and procedural and clinical outcomes. Regrettably, the medical care delivery system poses a number of obstacles to developing and sustaining a high-quality environment. The purposes of this viewpoint are to summarize the most common impediments, followed to summarize the most common impediments, followed by the optimal ways to design and sustain a quality assurance program to overcome these barriers. A 7-step program to create and implement an effective quality assurance program is outlined.

Cardiovascular Risk Among Patients ≥65 Years of Age with Parkinson's Disease (From the National Inpatient Sample)

In this study, we aimed to investigate the relationship between Parkinson's disease (PD) and vascular disease and risk factors using a nationally representative sample. The National Inpatient Sample was queried for all patients aged ≥65 who were diagnosed with PD during the year 2016. Patients were identified using the International Classification of Diseases-Tenth Revision (ICD-10) diagnosis code: "G20." Each patient diagnosed with PD was frequency-matched to controls at a 1:4 ratio by age and gender. Study outcomes were hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, and stroke. Outcomes were modeled using logistic regression analysis and further validation was obtained using a propensity score-matched analysis. A total of 57,914 patients (weighted: 289,570) with PD were included. Most patients were of Caucasian race (80.8%). Females were 42.4% and the mean age was 79 years, standard error of the mean (0.03). PD correlated with lower odds for hyperlipidemia adjusted odd ratio (a-OR): 0.77 (95% confidence interval [CI]: 0.75 to 0.79) p <0.001, diabetes mellitus a-OR 0.73 (95% CI 0.71 to 0.75) p <0.001, hypertension a-OR 0.68 (95% CI: 0.67 to 0.70) p <0.001, coronary artery disease a-OR 0.64 (95% CI: 0.63 to 0.66) p <0.001 and higher odds for stroke a-OR: 1.27 (95% CI: 1.24 to 1.31) p <0.001. Following propensity score matching, identical findings were found. In conclusion, patients with PD have a distinct cardiovascular profile with higher rates of stroke and lower rates of coronary artery disease and vascular disease risk factors.

Etiology and Determinants of In-Hospital Survival in Patients Resuscitated After Out-of-Hospital Cardiac Arrest in an Urban Medical Center

Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality globally. The goals of this study were to describe common causes of OHCA in an urban US medical center, identify predictive factors for survival, and to assess whether neurological status upon return of spontaneous circulation might be predictive of outcomes: 124 consecutive patients aged 18 years and older with OHCA admitted at Advocate Illinois Masonic Medical Center were studied. All patients resuscitated in the field with return of spontaneous circulation then transferred to the emergency department were included. The Glasgow Coma Score (GCS) was evaluated immediately on hospital arrival. In the total group, 34% (42 of 124) were discharged alive. In patients with coronary artery disease (CAD), 51% (20 of 39) were discharged alive versus 26% (22 of 85) of non-CAD patients (p <0.01). Initial GCS ≥ 9 was highly predictive of survival: 94% (34 of 36) of patients with GCS ≥ 9 survived versus 9% (8 of 88) with GCS ≤ 8 (p <0.0001). Defibrillation in the field was predictive of survival (chi-square = 7.81, p = 0.005). In the CAD group, all 16 patients with GCS ≥ 9 on presentation to the Emergency Department survived whereas all 13 with GCS ≤ 5 died (both p <0.0001). In the non-CAD group, 18 of 20 patients with GCS ≥ 9 survived, whereas only 2 of 52 with GCS ≤ 5 survived (both p <0.0001). Multivariate analysis by logistic regression showed that the strongest predictor of survival in the non-CAD subgroup was GCS (OR 0.27, CI 0.19 to 0.55, p <0.001). In conclusion, the etiology of the OHCA, immediate neurologic status, and defibrillation in the field (suggesting presenting arrhythmia) were predictive of survival. Immediate neurological recovery (GCS ≥ 9) regardless of etiology was a strong predictor of survival to discharge. Additional predictive factors depend on the etiology of the OHCA event. These data suggest that these straightforward factors can be helpful in predicting outcome in patients resuscitated after OHCA.