Outcomes after percutaneous coronary intervention (PCI) in patients with prior coronary artery bypass grafting (cabg)

Background

In patients with prior CABG requiring subsequent PCI there is uncertainty whether bypass grafts or native coronary arteries should be targeted.

Methods

We analysed data from 2,764 patients with prior CABG in the Melbourne Interventional Group registry (2005–2018), divided into two groups: those undergoing PCI to a native vessel (n=1,928) and those with PCI to a graft vessel (n=836).

Results

Patients with a graft vessel PCI were older, had more high-risk clinical characteristics (prior MI, heart failure, ejection fraction <50%, renal impairment, peripheral and cerebrovascular disease), and high-risk procedural features (ACC/AHA types B2/C lesions). However, patients in the native vessel group were more likely to have PCI to a chronic total occlusion. The majority of graft PCI were to saphenous vein grafts (84%), with 10% to radial and 6% to LIMA/RIMA grafts. Distal embolic protection devices were used in 30% of graft PCI. Patients with graft PCI had higher rates of no reflow (6.3% vs. 1.5%; p<0.001), coronary perforation (p=0.016) and inpatient stent thrombosis (p=0.028). However, 30-day mortality and major adverse cardiovascular and cerebrovascular events (MACCE) were similar. Unadjusted long-term mortality (median follow up 4.8 years) was higher in patients who had undergone a graft PCI (44% vs. 32%, p<0.001), but following Cox proportional hazards modelling, PCI vessel type was not a predictor of long-term mortality (HR 1.13; 95% CI 0.96–1.33, p=0.14).

Conclusions

Early clinical outcomes and risk-adjusted long-term mortality are similar for patients with prior CABG undergoing PCI to a native vessel or a bypass graft.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): The Alfred Hospital

Sex differences in pre-hospital analgesia and outcomes in patients presenting with acute coronary syndromes

Background

Opioid analgesia remains the mainstay of pain management in acute coronary syndromes (ACS). Significant sex differences persist in ACS presentation, management and outcomes, but the impact of sex-differences on pre-hospital pain management of ACS with opioids is unknown. There is increasing awareness of the importance of pre-hospital factors in ACS, as well as emerging concerns with opioid use impairing the gastrointestinal absorption of oral P2Y12 inhibitors.

Purpose

This study examined if sex-differences in pre-hospital pain scores, opioid administration and clinical outcomes exist in ACS patients.

Methods

Patients presenting with ACS via ambulance (2014–2018) that underwent percutaneous coronary intervention (PCI) were prospectively collected via the Victorian Cardiac Outcomes Registry (VCOR), the Melbourne Interventional Group (MIG), and linked to the Ambulance Victoria database. The primary outcome was 30-day major adverse cardiac events (MACE). Secondary outcomes were descriptive analyses of pre-hospital pain score, intravenous morphine equivalent analgesic dosing, plus predictors of MACE and Thrombolysis In Myocardial Infarction (TIMI) 0–1 flow pre-PCI using logistic regression.

Results

10,547 patients were included (female: 2,775 [26.3%]). Opioids were administered to 1,585 (57%) females and 5,068 (65%) males (p<0.001). Adjusted 30-day MACE was similar between opioid groups in both sexes (female: OR 1.21, CI 0.82–1.79, p=0.34; male: OR 0.89, 0.68–1.16, p=0.40). Median pain score at presentation was 6 (IQR 4,8) for both sexes. Median opioid dose was 2.5 mg (IQR 0,10) in females and 5 mg (IQR 0,10) in males (p<0.001), with similar pain relief achieved. Adjusted rates of TIMI 0–1 pre-PCI were higher in patients administered opioids (female: OR 2.83, CI 2.14–3.56, p<0.001; male: OR 2.95, CI 2.49–3.49, p<0.001).

Conclusions

Female patients undergoing PCI received less opioid analgesia, but no sex-differences in pre-hospital pain scores were seen. Opioid administration was associated with impaired antegrade flow in the culprit artery in both sexes, but not short-term MACE. Randomised trials evaluating the clinical implications of opioid administration in ACS with sex subgroup analyses are needed to guide clinical practice.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Melbourne Interventional GroupVictorian Cardiac Outcomes Registry

Trends in intra-aortic balloon pump use in cardiogenic shock in the post-SHOCK II trial era

Background

Myocardial infarction complicated by cardiogenic shock (MI-CS) has a poor prognosis, even with early revascularisation. Previously, intra-aortic balloon pump (IABP) use was thought to improve outcomes, but the SHOCK-II trial in 2012 found no survival benefit.

Purpose

This study aimed to determine the trends in IABP use in patients with MI-CS undergoing percutaneous intervention (PCI) over time and characteristics associated with use.

Methods

Between 2005–2018, patients presenting with MI-CS that underwent percutaneous coronary intervention (PCI) at a hospital participating in the Melbourne Interventional Group Registry were included. The primary outcome was the trend in IABP use over time. Secondary outcomes included mortality, 30-day MACCE (major adverse cardiovascular and cerebrovascular events) and predictors of outcome, determined via logistic regression.

Results

Of the 1,110 patients identified, IABP was used in 478 (43%). IABP was used more in patients with left main and left anterior descending culprit lesions (62% vs. 46%), lower ejection fraction (<35%; 18% vs. 11%), and pre-procedural inotrope use (81% vs. 73%), all p<0.05. IABP use was associated with higher inpatient bleeding (18% vs. 13%) and 30-day MACCE (58% vs. 51%), both p<0.05. The rate of MI-CS increased over time, but after 2012 there was a decline in IABP use (Figure 1). IABP use was a predictor of 30-day MACCE (OR 1.6, 95% CI 1.18–2.29, p=0.003). However, IABP was not associated with in-hospital, 30-day or long-term mortality (45% vs. 47%, p=0.44; 46% vs. 50%, p=0.25; 60% vs. 62%, p=0.39).

Conclusions

Consistent with the SHOCK II trial, IABP use is not associated with reduced short- or long-term mortality, but in this study was associated with increased short-term adverse events. IABP use is declining, but is still used in sicker patients with greater myocardium at risk, given limited alternatives.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Melbourne interventional group

Lignocaine versus opioids in coronary intervention: assessing antiplatelet activity and ticagrelor levels (LOCAL) study

Background

Opioid analgesia impairs the bioavailability and antiplatelet effect of oral P2Y12 inhibitors prompting investigation of mitigation strategies including identifying alternative analgesic agents.

Purpose

To assess the impact of intravenous fentanyl and lignocaine on the bioavailability and antiplatelet effect of ticagrelor in patients with unstable angina and non-ST elevation myocardial infarction, as well as their procedural analgesic efficacy and safety.

Methods

The LOCAL trial was a prospective, single centre, double-blind, randomized, controlled trial where intravenous lignocaine was the experimental analgesic agent assessed in this trial compared to intravenous fentanyl as procedural analgesia during coronary angiography and percutaneous coronary intervention. Patients with an indication for dual antiplatelet therapy and no contraindication were given 180mg of ticagrelor orally as integral tablets with 250 mL of tap water at the end of the case. Blood was sampled at time 0, 0.5, 1, 2 and 4 hours post administration of ticagrelor for pharmacokinetic and comprehensive pharmacodynamic analysis.

Results

Seventy patients undergoing coronary angiography with an indication for ticagrelor loading were included in the pharmacokinetic and pharmacodynamic analysis. Plasma ticagrelor levels at 2 h post loading dose were significantly lower in the fentanyl compared to lignocaine treatment arm (476 vs. 792 ng/mL, p=0.02, see figure 1). The area under the plasma-time curves for ticagrelor (987 vs. 2189 ng.h/mL, p=0.001) and its active metabolite (173 vs. 394 ng.h/mL, p<0.001) were both significantly lower in the fentanyl arm. Platelet reactivity assessed by the VerifyNow assay was higher at all time points after baseline in the fentanyl compared to lignocaine arm. The VASP flow cytometry assay demonstrated higher platelet reactivity at 2 hours in the fentanyl group (40% vs. 22% platelet reactivity index, p=0.001). The Multiplate Analyzer demonstrated higher platelet reactivity in the fentanyl arm at 60 minutes (43 vs. 26 area under the curve units, p=0.001) as did expression of activated platelet GpIIb/IIIa receptor (2829 vs. 1426 geometric mean fluorescence intensity (GMFI), p=0.006) and P-selectin (439 vs. 211 GMFI, p=0.001). High on-treatment platelet reactivity (HPR) was significantly higher in the fentanyl arm at 60 min using the MPA (41% vs. 9%, p=0.002) and 120 min using the VFN (30% vs. 3%, p=0.003) and VASP (37% vs. 6%, p=0.002) assays (see figure 2). Both drugs were well tolerated with a high level of patient satisfaction (fentanyl 94% vs. lignocaine 97%, p=0.56).

Conclusion(s)

Unlike fentanyl, lignocaine does not impair the bioavailability or delay the antiplatelet effect of ticagrelor. Both drugs were well tolerated and effective with a high level of patient satisfaction for procedural analgesia. Systemic pain medication during PCI should be reconsidered and if performed, lignocaine is a beneficial alternative to fentanyl.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): TBA Figure 1. Ticagrelor and AM pharmacokineticsFigure 2. Ticagrelor pharmacodynamics

A mixed methods pilot and feasibility open trial of internet-delivered cognitive behaviour therapy (iCanADAPT Advanced) for people with advanced cancer with depression and/or anxiety

PURPOSE

Evaluate the feasibility, acceptability and potential efficacy of a form of online therapy for clinical depression and/or anxiety in people living with advanced cancer.

METHODS

A single-arm open trial of a six-lesson clinician-supervised, internet-delivered cognitive behavioural therapy (iCBT) transdiagnostic intervention (iCanADAPT Advanced) was undertaken. Qualitative (semi-structured telephone interview conducted at 3-months) and quantitative data (questionnaires collected at pre-, post-, and 3-month follow-up) were analysed.

RESULTS

27 participants partook (26 women, 56% breast cancer, mean age 56yo; average number of mental health diagnoses 1.8, with majority (81%) meeting criteria for generalised anxiety disorder). Feasibility - Unanticipated numbers (48%) of participants had physical health deterioration (cancer progression or death). iCBT had high adherence overall (completion rates: 37% did 6 lessons; 70% did 4 lessons) but adherence was higher for those whose cancer remained stable (completion rates: 43% did 6 lessons; 85% did 4 lessons). Acceptability - the intervention was acceptable to the majority of participants, with high treatment satisfaction. Advisory data was achieved regarding future versions. Potential efficacy - regardless of physical health status, participants who completed the iCBT showed a significant decrease over time in anxiety and depression symptoms.

CONCLUSIONS

Online therapies may be useful in assisting those living with advanced cancer dealing with clinical depression and anxiety disorders. The specific modality of clinician supervised iCBT has significant potential to be a suitable modality of online therapy.

PREIMPLANTATION GENETIC TESTING: Non-invasive prenatal testing for aneuploidy, copy-number variants and single-gene disorders

The discovery of cell-free fetal DNA (cffDNA) in maternal plasma has enabled a paradigm shift in prenatal testing, allowing for safer, earlier detection of genetic conditions of the fetus. Non-invasive prenatal testing (NIPT) for fetal aneuploidies has provided an alternative, highly efficient approach to first-trimester aneuploidy screening, and since its inception has been rapidly adopted worldwide. Due to the genome-wide nature of some NIPT protocols, the commercial sector has widened the scope of cell-free DNA (cfDNA) screening to include sex chromosome aneuploidies, rare autosomal trisomies and sub-microscopic copy-number variants. These developments may be marketed as 'expanded NIPT' or 'NIPT Plus' and bring with them a plethora of ethical and practical considerations. Concurrently, cfDNA tests for single-gene disorders, termed non-invasive prenatal diagnosis (NIPD), have been developed for an increasing array of conditions but are less widely available. Despite the fact that all these tests utilise the same biomarker, cfDNA, there is considerable variation in key parameters such as sensitivity, specificity and positive predictive value depending on what the test is for. The distinction between diagnostics and screening has become blurred, and there is a clear need for the education of physicians and patients regarding the technical capabilities and limitations of these different forms of testing. Furthermore, there is a requirement for consistent guidelines that apply across health sectors, both public and commercial, to ensure that tests are validated and robust and that careful and appropriate pre-test and post-test counselling is provided by professionals who understand the tests offered.

Efficacy and safety of a sodium-glucose co-transporter-2 inhibitor versus placebo as an add-on therapy for people with type 2 diabetes inadequately treated with metformin and a dipeptidyl peptidase-4 inhibitor: a systematic review and meta-analysis of randomised controlled trials

AIMS

To conduct a systematic review and meta-analysis to assess the efficacy, safety and tolerability of sodium-glucose co-transporter-2 inhibitors vs placebo as add-on therapy after metformin and dipeptidyl peptidase-4 inhibitor dual therapy in type 2 diabetes.

METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO registration number: CRD42018099398). A search was conducted via PubMed, www.clinicaltrials.gov and Cochrane Central Register of Controlled Trials of relevant randomised controlled trials up until 14 August 2020 that compared sodium-glucose co-transporter-2 inhibitors vs placebo as add-on therapy after metformin and dipeptidyl peptidase-4 inhibitor therapy. A random-effects model was used.

RESULTS

Six randomised controlled trials (1661 participants) met the inclusion criteria. Compared with placebo, sodium-glucose co-transporter-2 inhibitor treatment, as add-on to metformin and dipeptidyl peptidase-4 inhibitor therapy, was associated with a significant reduction in HbA_1c level [mean difference -8 mmol/mol, 95% CI -10, -6 (-0.7%, 95% CI -0.9, -0.6); P < 0.00001], in fasting plasma glucose level [mean difference -1.70 mmol/l, 95% CI -1.91, -1.49; P < 0.00001], in weight (mean difference -1.76 kg, 95% CI -2.04, -1.48; P < 0.00001) and in blood pressure (systolic blood pressure: mean difference -3.6 mmHg, 95% CI -4.8, -2.4; P < 0.00001; diastolic blood pressure: mean difference -1.5 mmHg; 95% CI -2.4, -0.6; P = 0.002). Genital mycotic infections (odds ratio 7.37, 95% CI 3.06, 17.76; P < 0.00001) were more common with sodium-glucose co-transporter-2 inhibitors, but there was no significant statistical difference in urinary tract infections (odds ratio 1.16, 95% CI 0.63, 2.13; P = 0.64), in hypoglycaemia (odds ratio 1.36, 95% CI 0.61, 3.04; P = 0.45), or in discontinuation rates due to adverse events (odds ratio 1.52, 95% CI 0.78, 2.97; P = 0.22) between the two groups.

CONCLUSIONS

In comparison with placebo, add-on therapy with a sodium-glucose co-transporter-2 inhibitor is significantly more efficacious in lowering HbA_1c , fasting plasma glucose and weight in people with type 2 diabetes following inadequate glycaemic control with metformin and a dipeptidyl peptidase-4 inhibitor. The rate of discontinuation due to adverse events was similar despite higher risk of genital mycotic infections.

Rationally derived inhibitors of hepatitis C virus (HCV) p7 channel activity reveal prospect for bimodal antiviral therapy

Since the 1960s, a single class of agent has been licensed targeting virus-encoded ion channels, or 'viroporins', contrasting the success of channel blocking drugs in other areas of medicine. Although resistance arose to these prototypic adamantane inhibitors of the influenza A virus (IAV) M2 proton channel, a growing number of clinically and economically important viruses are now recognised to encode essential viroporins providing potential targets for modern drug discovery. We describe the first rationally designed viroporin inhibitor with a comprehensive structure-activity relationship (SAR). This step-change in understanding not only revealed a second biological function for the p7 viroporin from hepatitis C virus (HCV) during virus entry, but also enabled the synthesis of a labelled tool compound that retained biological activity. Hence, p7 inhibitors (p7i) represent a unique class of HCV antiviral targeting both the spread and establishment of infection, as well as a precedent for future viroporin-targeted drug discovery.

What factors influence organisational readiness for change? Implementation of the Australian clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients (ADAPT CP)

AIMS

Translation of evidence-based psycho-oncology interventions into routine care can significantly improve patient outcomes, yet effective implementation remains challenging due to numerous real-world barriers. A key factor that may influence implementation is organisational readiness for change. This mixed method study sought to identify factors associated with organisational readiness for implementing the Australian clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients (ADAPT CP).

METHODS

We collected data from multidisciplinary staff across six Australian cancer services who were preparing to implement the ADAPT CP. Services were categorised as having 'high' versus 'mid-range' organisational readiness based on a median split on the Organizational Readiness for Implementing Change (ORIC) questionnaire (score range = 12-60). Qualitative data from the semi-structured interviews based on the Promoting Action Research in Health Services (PARiHS) framework were analysed thematically and compared for services with high- versus mid-range organisational readiness.

RESULTS

Three services with high- (mean ORIC range, 52.25-56.88), and three with mid-range (range, 38.75-46.39) organisational readiness scores were identified. Staff at services reporting higher readiness described a more collaborative and proactive service culture, strong communication processes and greater role flexibility. They also reported greater confidence in overcoming anticipated barriers and clearer strategies for addressing issues.

CONCLUSIONS

Levels of organisational readiness were related to distinct qualitative themes. Targeting these issues in services where readiness is mid-range or low prior to full-scale roll-out may improve staff levels of confidence and efficacy in implementing psycho-oncology-focused interventions.

PROgesterone Therapy for Endometrial Cancer Prevention in Obese Women (PROTEC) Trial: A Feasibility Study

Obesity is the major etiologic driver for endometrial cancer. The levonorgestrel intrauterine system (LNG-IUS) reduces the risk of endometrial cancer and its precursor, atypical hyperplasia. We assessed feasibility and uptake of the LNG-IUS for primary prevention of endometrial cancer in high-risk women and its impact on endometrial tissue biomarkers. Women with class-III obesity [body mass index (BMI) > 40 kg/m²] and histologically normal endometrium were invited to participate in a clinical trial of the LNG-IUS for endometrial protection. Recruitment, successful LNG-IUS insertion, and adherence to trial procedures were recorded. We measured impact of the LNG-IUS on circulating biomarkers of endometrial cancer risk, endometrial proliferation (Ki-67, pAKT, PTEN), endometrial hormone receptor status [estrogen receptor and progesterone receptor (PR)], mental wellbeing, and menstrual function. At 6 months, women chose to keep their LNG-IUS or have it removed. In total, 103 women were approached, 54 were offered a participant information sheet, 35 agreed to participate, and 25 received a LNG-IUS. Their median age and BMI were 54 years [interquartile range (IQR) 52-57] and 47 kg/m² (IQR 44-51), respectively. Three women (3/35, 9%) were ineligible due to atypical hyperplasia/endometrial cancer on their baseline biopsy. The LNG-IUS was well tolerated and had a positive overall effect on bleeding patterns and mental wellbeing. The LNG-IUS was associated with endometrial morphologic change, reduced Ki-67, and PR expression, but circulating biomarkers of endometrial cancer risk were unchanged. All but one woman (96%) kept her LNG-IUS. The LNG-IUS appears to be acceptable to some women with class-III obesity for primary prevention of endometrial cancer, which could provide a strategy for a prevention trial.Prevention Relevance: Novel strategies are urgently needed to prevent the rise in endometrial cancer diagnoses predicted by escalating obesity rates. Here, we show that women with class III obesity are willing to engage in risk reduction with a levonorgestrel intrauterine system, which could provide a strategy for an endometrial cancer prevention trial.

Post-tuberculosis lung health: perspectives from the First International Symposium

ALTHOUGH CURABLE, TB frequently leaves the individual with chronic physical and psycho-social impairment, but these consequences have been largely neglected. The 1^st International Post-Tuberculosis Symposium (Stellenbosch, South Africa) was held to discuss priorities and gaps in addressing this issue. A barrier to progress has been the varied terminology and nomenclature, so the Delphi process was used to achieve consensus on definitions. Lack of sufficient evidence hampered definitive recommendations in most domains, including prevention and treatment of post-TB lung disease (PTLD), but the discussions clarified the research needed. A consensus was reached on a toolkit for future PTLD measurement and on PTLD patterns to be considered. The importance of extra-pulmonary consequences and progressive impairment throughout the life-course was identified, including TB recurrence and increased mortality. Patient advocates emphasised the need to address the psychological and social impacts post TB and called for clinical guidance. More generally, there is an urgent need for increased awareness and research into post-TB complications.

Small molecule AZD4635 inhibitor of A2AR signaling rescues immune cell function including CD103+ dendritic cells enhancing anti-tumor immunity

Accumulation of extracellular adenosine within the microenvironment is a strategy exploited by tumors to escape detection by the immune system. Adenosine signaling through the adenosine 2A receptor (A_2AR) on immune cells elicits a range of immunosuppressive effects which promote tumor growth and limit the efficacy of immune checkpoint inhibitors. Preclinical data with A_2AR inhibitors have demonstrated tumor regressions in mouse models by rescuing T cell function; however, the mechanism and role on other immune cells has not been fully elucidated.