Rationale and design of the Randomized Evaluation of patients with Stable angina Comparing Utilization of noninvasive Examinations (RESCUE) trial

RESCUE is a phase III, randomized, controlled, multicenter, comparative efficacy study, designed to compare two diagnostic imaging/treatment paradigms that use coronary computed tomography angiography (CCTA) or single photon emission computed tomography myocardial perfusion imaging (SPECT MPI) for assisting in the diagnosis of ischemic heart disease in patients with stable angina symptoms, and guiding subsequent treatment. The study is based on the hypothesis that CCTA as a diagnostic tool is associated with no increase in cardiac risk, decreased cost, and reduced radiation exposure compared with SPECT MPI. The RESCUE trial was funded by the Agency for Healthcare Research and Quality (AHRQ) and the American College of Radiology Imaging Network (ACRIN) Fund for Imaging Innovation, began in 2011, and completed in 2014.

Balloon Versus Computed Tomography Sizing of the Aortic Annulus for Transcatheter Aortic Valve Replacement and the Impact of Left Ventricular Outflow Tract Calcification and Morphology on Sizing

OBJECTIVES

To evaluate the role of balloon annular sizing in transcatheter aortic valve replacement (TAVR).

BACKGROUND

Multidetector cardiac computed tomography (MDCT) is the gold standard for aortic annular sizing in TAVR. Balloon sizing is increasingly used in patients with borderline annular size and severe calcification. A comparison between these two techniques is needed.

METHODS

We retrospectively compared baseline characteristics and 30-day outcomes of patients undergoing balloon-expandable TAVR using annular MDCT or balloon sizing. Paravalvular leak (PVL) rates were compared adjusting for access site, valve generation, size, and valve calcification.

RESULTS

A total of 205 patients underwent TAVR with MDCT (n = 110) or balloon sizing (n = 95). Balloon-sized patients were older (83 years vs 81 years; P=.03), had more valve calcification (60.2% vs 30.9%; P<.001), and underwent more minimalist TAVR (61.1% vs 40%; P=.03). Although we found no difference between balloon and MDCT sizing in rates of acute renal failure (3.2% vs 0.9%; P=.34), annular rupture (1.1% vs 1.8%; P>.99), ≥ mild PVL by angiography (40% vs 35.5%; P=.57), or 30-day transthoracic echocardiography (40.7% vs 29.3%; P=.78), balloon-sized patients had a higher aortic regurgitation index (≥25) of 74.4% vs 54.1% (P=.01). Thirty-day rates of ≥ moderate PVL were 7.0% with balloon and 5.7% with MDCT sizing (P=.34). Balloon sizing recommended a different valve size in 34.0% of patients who underwent both methods (n = 50). A different recommendation occurred more often in patients with moderate/severe annular calcification (50.0% vs 33.3%; P=.01) and non-tubular left ventricular outflow tracts (LVOTs) (70.6% vs 30.3%; P=.01).

CONCLUSION

Balloon sizing can be a complement to MDCT for annular sizing in TAVR, especially in patients with moderate/severe annular calcification, borderline annular size, and non-tubular LVOT.

Revascularization in patients with diabetes: PCI or CABG or none at all

Patients with diabetes have a high incidence of coronary artery disease, with particularly high rates of acute coronary syndromes and mortality. Revascularization by coronary artery bypass grafting was found to be effective in reducing angina and mortality in patients with extensive coronary artery disease over 30 years ago. Percutaneous coronary intervention, particularly with drug-eluting stents, has more recently been demonstrated to reduce recurrent angina and improve quality of life in diabetic patients with less extensive coronary artery disease. Most recently, coronary artery bypass grafting has been shown to be superior to percutaneous coronary intervention in improving mortality in patients with diabetes and three-vessel coronary artery disease who are not at high surgical risk. The role of coronary artery bypass grafting vs. percutaneous coronary intervention in patients who have less extensive coronary artery disease and/or higher surgical risk has not been fully elucidated. Newer treatment strategies, such as percutaneous coronary intervention with second-generation drug-eluting stents, use of fractional flow reserve guidance, or hybrid revascularization combining minimally invasive coronary artery bypass grafting with percutaneous coronary intervention, may result in further improvements in outcomes in patients with diabetes and coronary artery disease.

Plasma stromal cell-derived factor 1α/CXCL12 level predicts long-term adverse cardiovascular outcomes in patients with coronary artery disease

OBJECTIVE

Stromal derived factor-1α/CXCL12 is a chemoattractant responsible for homing of progenitor cells to ischemic tissues. We aimed to investigate the association of plasma CXCL12 with long-term cardiovascular outcomes in patients with coronary artery disease (CAD).

METHODS

785 patients aged: 63 ± 12 undergoing coronary angiography were independently enrolled into discovery (N = 186) and replication (N = 599) cohorts. Baseline levels of plasma CXCL12 were measured using Quantikine CXCL12 ELISA assay (R&D systems). Patients were followed for cardiovascular death and/or myocardial infarction (MI) for a mean of 2.6 yrs. Cox proportional hazard was used to determine independent predictors of cardiovascular death/MI.

RESULTS

The incidence of cardiovascular death/MI was 13% (N = 99). High CXCL12 level based on best discriminatory threshold derived from the ROC analysis predicted risk of cardiovascular death/MI (HR = 4.81, p = 1 × 10(-6)) independent of traditional risk factors in the pooled cohort. Addition of CXCL12 to a baseline model was associated with a significant improvement in c-statistic (AUC: 0.67-0.73, p = 0.03). Addition of CXCL12 was associated with correct risk reclassification of 40% of events and 10.5% of non-events. Similarly for the outcome of cardiovascular death, the addition of the CXCL12 to the baseline model was associated with correct reclassification of 20.7% of events and 9% of non-events. These results were replicated in two independent cohorts.

CONCLUSION

Plasma CXCL12 level is a strong independent predictor of adverse cardiovascular outcomes in patients with CAD and improves risk reclassification.