Long-term survival prospects of patients undergoing percutaneous coronary intervention: Envisioning the future

Implicit and largely intuitive survival predictions guide current clinical decision making after percutaneous coronary intervention (PCI). A model based on nine simple factors known after diagnostic catheterization but prior to PCI provides accurate prediction of five-year survival probability after PCI. Future prediction models and methods incorporating age and gender adjusted risk of death, cause of death (competing risks), and low prevalence but impactful comorbidities automatically implemented in electronic health records have the potential to further inform clinical decision-making and target therapies.

Multisite Investigation of Outcomes With Implementation of CYP2C19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention

OBJECTIVES

This multicenter pragmatic investigation assessed outcomes following clinical implementation of CYP2C19 genotype-guided antiplatelet therapy after percutaneous coronary intervention (PCI).

BACKGROUND

CYP2C19 loss-of-function alleles impair clopidogrel effectiveness after PCI.

METHODS

After clinical genotyping, each institution recommended alternative antiplatelet therapy (prasugrel, ticagrelor) in PCI patients with a loss-of-function allele. Major adverse cardiovascular events (defined as myocardial infarction, stroke, or death) within 12 months of PCI were compared between patients with a loss-of-function allele prescribed clopidogrel versus alternative therapy. Risk was also compared between patients without a loss-of-function allele and loss-of-function allele carriers prescribed alternative therapy. Cox regression was performed, adjusting for group differences with inverse probability of treatment weights.

RESULTS

Among 1,815 patients, 572 (31.5%) had a loss-of-function allele. The risk for major adverse cardiovascular events was significantly higher in patients with a loss-of-function allele prescribed clopidogrel versus alternative therapy (23.4 vs. 8.7 per 100 patient-years; adjusted hazard ratio: 2.26; 95% confidence interval: 1.18 to 4.32; p = 0.013). Similar results were observed among 1,210 patients with acute coronary syndromes at the time of PCI (adjusted hazard ratio: 2.87; 95% confidence interval: 1.35 to 6.09; p = 0.013). There was no difference in major adverse cardiovascular events between patients without a loss-of-function allele and loss-of-function allele carriers prescribed alternative therapy (adjusted hazard ratio: 1.14; 95% confidence interval: 0.69 to 1.88; p = 0.60).

CONCLUSIONS

These data from real-world observations demonstrate a higher risk for cardiovascular events in patients with a CYP2C19 loss-of-function allele if clopidogrel versus alternative therapy is prescribed. A future randomized study of genotype-guided antiplatelet therapy may be of value.

Individualizing dual antiplatelet therapy duration: Prediction tools, genomics, and clinical judgment

Prolonged dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) on average reduces the risk of subsequent myocardial infarction (MI) but increases major bleeds. Individualizing duration of DAPT based on the DAPT trial's net benefit prediction tool would likely optimize outcome beyond population average recommendations. Individualizing agent selection and duration of therapy based on genomic data may further improve outcomes. Clinical judgment remains the most important tool to tailor DAPT duration based on a large array of additional relevant factors not captured by predition rules or genomics.

Precision Medicine at the University of Alabama at Birmingham: Laying the Foundational Processes Through Implementation of Genotype-Guided Antiplatelet Therapy

Precision medicine entails tailoring treatment based on patients' unique characteristics. As drug therapy constitutes the cornerstone of treatment for most chronic diseases, pharmacogenomics (PGx), the study of genetic variation influencing individual response to drugs, is an important component of precision medicine. Over the past decade investigations have identified genes and single-nucleotide polymorphisms (SNPs) and quantified their effect on drug response. Parallel development of point-of-care (POC) genotyping platforms has enabled the interrogation of the genes/SNPs within a timeline conducive to the provision of care. Despite these advances, the pace of integration of genotype-guided drug therapy (GGTx) into practice has faced significant challenges. These include difficulty in identifying SNPs with sufficiently robust evidence to guide clinical decision making, lack of clinician training on how to order and use genotype data, lack of clinical decision support (CDS) to guide treatment, and limited reimbursement. The University of Alabama at Birmingham's (UAB) efforts in precision medicine were initiated to address these challenges and improve the health of the racially diverse patients we treat.

The many radial access learning curves

The radial approach to endovascular procedures has a series of learning curves: diagnostic heart catheterization, low-risk settings and "straightforward" percutaneous coronary intervention, high-risk settings, and complex coronary intervention, and peripheral vascular angiography and intervention. For diagnostic and low-risk interventional procedures, incremental improvements in technical success and safety are observed in the initial 200 procedures for most operators compared to highly experienced operators. Formal didactic training and ongoing support/review from an experienced radial operator(s) may expedite surmounting the series of radial learning curves while maintaining optimal procedural success and safety. Advances in technology and understanding will require the most experienced radial operators to continually embrace their next learning curve.

Unprotected Left Main Disease and Percutaneous Intervention: A Prototype for Precision Medicine

The SYNTAX Score based on angiographic findings is an actionable risk prediction model helping guide treatment for significant unprotected left main disease. Adding the clinical factor based EuroSCORE to SYNTAX improves outcome prediction for percutaneous coronary intervention of unprotected left main disease. Prediction models are an increasingly useful tool permitting cardiologists to optimize patient outcomes through "personalized" or precision medicine.

Radial Access Optimization in the Nascent Post-Adoption Era

Post-procedural upper extremity dysfunction (UED) remains one of the few potential questions about the overall benefits of the transradial approach (TRA) to endovascular procedures compared to femoral (TFA). Data on UED is limited, but the most comprehensive study curiously shows similar incidence of post-procedural UED with TFA as TRA. The effects of trAnsRadial perCUtaneouS coronary intervention on upper extremity function (ARCUS) study will investigate whether patient characteristics influence radial access outcomes such as UED. ARCUS may herald a post-radial-adoption era of more detailed strategies for radial access optimization, typical of a maturing technology.

Risk-guided use of the direct thrombin inhibitor bivalirudin

Mortality and bleeding risks after percutaneous coronary intervention (PCI) can be predicted with bedside models. Bivalirudin reduces access and non-access bleeding by almost half compared to heparin monotherapy and heparin with IIb/IIIa use. In high (>10%) baseline one-year mortality risk PCI patients, bivalirudin reduces mortality by 4% compared to heparin with IIb/IIIa therapy. Increased acute stent thrombosis may be resolved with a 4-hr post-procedure bivalirudin infusion, eliminating bivalirudin's only major drawback except cost.

Insulin-treated diabetes mellitus: An important, actionable risk marker after coronary stenting

Insulin treatment for diabetes is a simple but important risk marker for doubled adjusted death and myocardial infarction rates and tripled stent thrombosis risk after coronary stenting. Insulin treatment does not predict meaningfully increased major bleeding or additional revascularization procedures after drug eluting coronary stent implantation. Third generation P2 Y12 receptor antagonists substantially lower risk of events in diabetics after stenting with insulin treated diabetics having twice the magnitude of benefit of diabetics not needing insulin.

Republished: The association between inflammatory markers, serum lipids and the risk of cardiovascular events in patients with rheumatoid arthritis

OBJECTIVE

To examine the association of serum inflammatory markers (erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)) and serum lipid measures (low-density lipoprotein (LDL)- and high-density lipoprotein (HDL)-cholesterol) with risk of myocardial infarction (MI) and ischaemic stroke (IS) among rheumatoid arthritis (RA) patients.

METHODS

We conducted a retrospective cohort study using 2005-2010 data from a US commercial health plan. Eligible patients had two or more physician diagnoses of RA during a baseline period of at least 180 days with continuous medical and pharmacy coverage. We computed age-adjusted incidence rates of MI and IS, and used spline regression to assess non-linear associations and Cox-regression to quantify the independent association between the laboratory values and the outcomes.

RESULTS

We identified 44 418 eligible RA patients (mean age 49 years; 76% women). CRP>10 mg/L compared with <1 mg/L was associated with increased MI risk (HR 2.12; 95% CI 1.02 to 4.38). ESR>42 mm/h compared with <14 mm/h was associated with increased risk of MI (HR 2.53; 95% CI 1.48 to 4.31) and IS (HR 2.51; 95% CI 1.33 to 4.75) risk. HDL-cholesterol ≥60 mg/dL (1.6 mmol/L) compared with <40 mg/dL (1.0 mmol/L) was associated with reduced MI risk (HR 0.37; 0.21 to 0.66). The association between LDL and MI was not linear; the lowest risk was observed among patients with LDL between 70 mg/L (1.8 mmol/L) and 100 mg/L (2.6 mmol/L). We did not observe a significant association between LDL and IS.

CONCLUSIONS

This study provides evidence supporting the hypothesis that RA-related systemic inflammation plays a role in determining cardiovascular risk and a complex relationship between LDL and cardiovascular risk.

Diabetes is not sufficient justification for IIb/IIIa use in percutaneous coronary intervention

Diabetics, particularly insulin treated, have increased risk of ischemic events and bleeding with percutaneous coronary intervention (PCI). The relative risk of atherothrombotic versus bleeding events is higher in diabetics than non-diabetics. Bivalirudin with provisional IIb/IIIa therapy has less bleeding and lower one-year mortality than routine IIb/IIIa therapy in diabetics undergoing PCI. IIb/IIIa agents should be reserved for provisional and niche applications during PCI.

Renal artery stenting: patient selection post-CORAL

Randomized trials (RCT) show no meaningful improvement in hypertension control with renal artery stenting (RAS) compared to medical therapy alone in patients with largely moderate hypertension and intermediate grade stenoses. Observational studies of patients with severe hypertension and high-grade stenoses on multiple medications report blood pressure improvement after RAS. Angiographic severity of renal artery stenosis has poor correlation with functional measures of flow impairment. Renal frame count may be a useful simple measure of flow impairment, predicting beneficial blood pressure response to RAS. If confirmed in other studies, renal frame count > 30 and a combination of predictive clinical factors may help guide selection of patients for RAS in contemporary practice.

Percutaneous coronary intervention: ever closer to real world silver bullets!?

Bare metal and early drug eluting stents have not meaningfully reduced subsequent rates of death and myocardial infarction compared to balloon angioplasty. Second generation drug eluting stents are associated with meaningful reductions in death and myocardial infarction compared to first generation drug eluting stents.

The association between inflammatory markers, serum lipids and the risk of cardiovascular events in patients with rheumatoid arthritis

OBJECTIVE

To examine the association of serum inflammatory markers (erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)) and serum lipid measures (low-density lipoprotein (LDL)- and high-density lipoprotein (HDL)-cholesterol) with risk of myocardial infarction (MI) and ischaemic stroke (IS) among rheumatoid arthritis (RA) patients.

METHODS

We conducted a retrospective cohort study using 2005-2010 data from a US commercial health plan. Eligible patients had two or more physician diagnoses of RA during a baseline period of at least 180 days with continuous medical and pharmacy coverage. We computed age-adjusted incidence rates of MI and IS, and used spline regression to assess non-linear associations and Cox-regression to quantify the independent association between the laboratory values and the outcomes.

RESULTS

We identified 44 418 eligible RA patients (mean age 49 years; 76% women). CRP>10 mg/L compared with <1 mg/L was associated with increased MI risk (HR 2.12; 95% CI 1.02 to 4.38). ESR>42 mm/h compared with <14 mm/h was associated with increased risk of MI (HR 2.53; 95% CI 1.48 to 4.31) and IS (HR 2.51; 95% CI 1.33 to 4.75) risk. HDL-cholesterol ≥60 mg/dL (1.6 mmol/L) compared with <40 mg/dL (1.0 mmol/L) was associated with reduced MI risk (HR 0.37; 0.21 to 0.66). The association between LDL and MI was not linear; the lowest risk was observed among patients with LDL between 70 mg/L (1.8 mmol/L) and 100 mg/L (2.6 mmol/L). We did not observe a significant association between LDL and IS.

CONCLUSIONS

This study provides evidence supporting the hypothesis that RA-related systemic inflammation plays a role in determining cardiovascular risk and a complex relationship between LDL and cardiovascular risk.

The learning curve for transradial percutaneous coronary intervention among operators in the United States: a study from the National Cardiovascular Data Registry

BACKGROUND

Adoption of transradial percutaneous coronary intervention (TRI) in the United States is low and may be related to challenges learning the technique. We examined the relationships between operator TRI volume and procedural metrics and outcomes.

METHODS AND RESULTS

We used CathPCI Registry data from July 2009 to December 2012 to identify new radial operators, defined by an exclusively femoral percutaneous coronary intervention approach for 6 months after their first percutaneous coronary intervention in the database and ≥15 total TRIs thereafter. Primary outcomes of fluoroscopy time, contrast volume, and procedure success were chosen as markers of technical proficiency. Secondary outcomes included in-hospital mortality, bleeding, and vascular complications. Adjusted outcomes were analyzed by using operator TRI experience as a continuous variable with generalized linear mixed models. Among 54 561 TRI procedures performed at 704 sites, 942 operators performed 1 to 10 procedures, 942 operators performed 11 to 50 procedures, 375 operators performed 51 to 100 procedures, and 148 operators performed 101 to 200 procedures. As radial caseload increased, more TRIs were performed in women, in patients presenting with ST-segment elevation myocardial infarction, and for emergency indications. Decreased fluoroscopy time and contrast use were nonlinearly associated with greater operator TRI experience, with faster reductions observed for newer (<30-50 cases) compared with more experienced (>30-50 cases) operators. Procedure success was high, whereas mortality, bleeding, and vascular complications remained low across TRI volumes.

CONCLUSIONS

As operator TRI volume increases, higher-risk patients are chosen for TRI. Despite this, operator proficiency improves with greater TRI experience, and safety is maintained. The threshold to overcome the learning curve appears to be approximately 30 to 50 cases.