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Frolov AA, Fedotov VD, Frolov IA, Pochinka IG, Protasova NV, Kouzova GN, Mukhin AS, Kuzmichev KV. [Influence of chronic obstructive pulmonary disease on hospital outcomes of percutaneous coronary interventions in patients with acute coronary syndrome]. TERAPEVT ARKH 2024; 96:253-259. [PMID: 38713040 DOI: 10.26442/00403660.2024.03.202638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 03/30/2024] [Indexed: 05/08/2024]
Abstract
AIM To evaluate the impact of chronic obstructive pulmonary disease (COPD) on hospital outcomes of percutaneous coronary interventions (PCI) in patients with acute coronary syndrome (ACS). MATERIALS AND METHODS A cohort prospective study of the COPD effect on mortality and coronary microvascular obstruction (CMVO, no-reflow) development after PCI in ACS was carried out. 626 patients admitted in 2019-2020 were included, 418 (67%) - men, 208 (33%) - women. Median age - 63 [56; 70] years. Myocardial infarction with ST elevation identified in 308 patients (49%), CMVO - in 59 (9%) patients (criteria: blood flow <3 grade according to TIMI flow grade; perfusion <2 points according to Myocardial blush grade; ST segment resolution <70%). 13 (2.1%) patients died. Based on the questionnaire "Chronic Airways Diseases, A Guide for Primary Care Physicians, 2005", 2 groups of patients were identified: 197 (31%) with COPD (≥17 points) and 429 (69%) without COPD (<17 points). Groups were compared on unbalanced data (÷2 Pearson, Fisher exact test). The propensity score was calculated, and a two-way logistic regression analysis was performed. The data were balanced by the Kernel "weighting" method, logistic regression analysis was carried out using "weighting" coefficients. Results as odds ratio (OR) and 95% confidence interval. RESULTS The conducted research allowed us to obtain the following results, depending on the type of analysis: 1) analysis of unbalanced data in patients with COPD: OR death 3.60 (1.16-11.12); p=0.03; OR CMVO 0.65 (0.35-1.22); p=0,18; 2) two-way analysis with propensity score: OR death 3.86 (1.09-13.74); p=0.04; OR CMVO 0.61 (0.31-1.19); p=0.15; 3) regression analysis with "weight" coefficients: OR death 12.49 (2.27-68.84); p=0.004; OR CMVO 0.63 (0.30-1.33); p=0.22. CONCLUSION The presence of COPD in patients with ACS undergoing PCI increases mortality and does not affect the incidence of CMVO.
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Patel KP, Lansky AJ, Kelbæk H, Xu B, van Royen N, Johnson TW, Anderson R, Wijns W, Baumbach A. Long-Term Percutaneous Coronary Intervention Outcomes in Chronic Versus Acute Coronary Syndromes (TARGET All Comers Trial). Am J Cardiol 2024; 217:94-101. [PMID: 38350507 DOI: 10.1016/j.amjcard.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/20/2023] [Accepted: 12/08/2023] [Indexed: 02/15/2024]
Abstract
In the Targeted therapy with a localised abluminal coated, low-dose sirolimus-eluting, biodegreadable polymer coronary stent (TARGET; NCT02520180) All Comers trial the biodegradable polymer (BP) sirolimus-eluting FIREHAWK stent was noninferior to the durable polymer (DP) everolimus-eluting XIENCE stent with respect to target lesion failure (TLF) at 1 and 5 years; however, the long-term safety and efficacy in the setting of acute coronary syndromes (ACS) are not known. We sought to assess the long-term outcomes in ACS versus chronic coronary syndromes (CCS) with BP sirolimus-eluting stent (SES) versus DP everolimus-eluting stent (EES). The TARGET AC study was a multicenter, open-label, noninferiority trial of all comer patients randomly allocated 1:1 to BP SES or DP EES (stratified by ST-elevation myocardial infarction and study site). In this predefined substudy, the outcomes were compared based on clinical presentation (ACS vs CCS) and treatment allocation. A total of 1,653 patients were enrolled (728 with ACS and 922 with CCS), with 94% completing the 5-year follow-up. The baseline characteristics were well-matched between the 2 stent types; however, co-morbidities were more prevalent in the CCS than in the ACS population. TLF (15.5% vs 17.7%, p = 0.24), patient-oriented outcomes (32.0% vs 34.4%, p = 0.31), and stent thrombosis (4.1% vs 3.3%, p = 0.40) were similar between patients with ACS and patients with CCS. In the ACS cohort, the outcomes at 5 years for BP SES versus DP EES were similar for TLF (16.0% vs 14.9%, p = 0.70), ischemia-driven target lesion revascularization (5.6% vs 8.3%, p = 0.17), and definite/probable stent thrombosis (2.7% vs 4.6%, p = 0.18). The same was true for the CCS cohort, with 5-year outcomes for BP SES versus DP EES for TLF (18.0% vs 17.4%, p = 0.82), ischemia-driven target lesion revascularization (6.4% vs 5.0%, p = 0.37), and definite/probable stent thrombosis (3.0% vs 1.8%, p = 0.26). In conclusion, in the TARGET AC trial, 1 in 3 patients had a major adverse event at 5 years, irrespective of CCS or ACS presentation. Long-term, the BP sirolimus-eluting FIREHAWK stent was as safe and effective as the DP everolimus-eluting XIENCE stent across the spectrum of clinical presentations.
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Horn P, Haschemi J, Kelm M. The Role of Gender in Revascularization Strategies for Acute Coronary Syndrome and Multivessel Disease. Am J Cardiol 2024; 217:153-155. [PMID: 38417652 DOI: 10.1016/j.amjcard.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 01/18/2024] [Accepted: 02/10/2024] [Indexed: 03/01/2024]
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Kakar H, Elscot JJ, Scarparo P, Den Dekker WK, Bennett J, Sabaté M, Esposito G, Amat-Santos I, Boersma E, Van Mieghem NM, Diletti R. Immediate or staged complete revascularisation in patients presenting with acute coronary syndrome by number of diseased vessels: a substudy of the BIOVASC randomised trial. EUROINTERVENTION 2024; 20:e479-e486. [PMID: 38629415 PMCID: PMC11017224 DOI: 10.4244/eij-d-23-00762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/20/2023] [Indexed: 04/19/2024]
Abstract
BACKGROUND In patients presenting with acute coronary syndrome (ACS), the number of diseased vessels may affect the efficacy of a complete revascularisation strategy. AIMS The authors sought to evaluate the safety and efficacy of immediate complete revascularisation (ICR) and staged complete revascularisation (SCR) in patients presenting with ACS stratified by the number of diseased vessels. METHODS In this prespecified analysis of the BIOVASC trial, ICR was compared with SCR in patients with two-vessel disease (2VD) or three-vessel disease (3VD). The primary endpoint was a composite of all-cause mortality, myocardial infarction (MI), any unplanned ischaemia-driven revascularisation or cerebrovascular events at 1 year after the index procedure. Comparisons were performed using Cox regression. RESULTS A total of 1,525 patients were enrolled in the BIOVASC trial, of whom 1,177 presented with 2VD and 265 with 3VD. In the 2VD group, 613 patients were assigned to ICR and 564 to SCR. In the 3VD group, 117 patients were assigned to ICR and 148 to SCR. ICR and SCR led to similar results in both the 2VD (hazard ratio [HR] 0.76, 95% confidence interval [CI]: 0.50-1.13; p=0.18) and 3VD groups (HR 0.79, 95% CI: 0.39-1.59; p=0.51) (pinteraction=0.91) in terms of the primary endpoint. ICR was associated with a lower rate of MI in patients with 3VD (HR 0.21, 95% CI: 0.046-0.93; p=0.04) (pinteraction=0.30). CONCLUSIONS ICR might be an option in patients presenting with extensive 3VD and might be associated with a lower rate of myocardial infarction compared with SCR.
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Stähli BE, Stehli J. Timing of revascularisation in acute coronary syndromes with multivessel disease - two sides of the same coin. EUROINTERVENTION 2024; 20:e461-e462. [PMID: 38629419 PMCID: PMC11017221 DOI: 10.4244/eij-e-24-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
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Wang S, Wang Y, Sun S, Li F, Zhao W, Li X, Ye M, Niu Y, Wu X. Free triiodothyronine to free thyroxine ratio as a marker of poor prognosis in euthyroid patients with acute coronary syndrome and diabetes after percutaneous coronary intervention. Front Endocrinol (Lausanne) 2024; 15:1322969. [PMID: 38654927 PMCID: PMC11036861 DOI: 10.3389/fendo.2024.1322969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 03/18/2024] [Indexed: 04/26/2024] Open
Abstract
Objectives In recent years, the free triiodothyronine/free thyroxine (FT3/FT4) ratio, a new comprehensive index for evaluating thyroid function, which could reflect thyroid function more stably and truly than serum thyroid hormone level, has been demonstrated to correlate with the risks of diabetes and cardiovascular disease in euthyroid adults. However, the correlation between thyroid hormone sensitivity and long-term prognosis in euthyroid patients with acute coronary syndrome (ACS) and diabetes after percutaneous coronary intervention (PCI) remains unclear. Methods A total of 1,786 euthyroid patients with ACS who successfully underwent PCI at Beijing Anzhen Hospital from August 2021 to April 2022 were included in our study, which was divided into three groups according to tertiles of thyroid hormone sensitivity index. Cox regression, Kaplan-Meier, and receiver operating characteristic analyses were applied to analyze the associations between the FT3/FT4 ratio with ACS and diabetes after PCI. Results Our analysis indicated that a lower level of FT3/FT4 ratio in euthyroid patients with acute coronary syndrome (ACS) and diabetes after PCI showed significantly higher incidences of major adverse cardiac and cerebrovascular events (MACCE) when compared with a higher level of FT3/FT4 ratio. After adjusting for other covariates, patients with a lower level of FT3/FT4 ratio were negatively associated with the risk of MACCE than those with a higher level of FT3/FT4 ratio (adjusted OR =1.61, 95% CI 1.05-2.47, P = 0.028). In subgroup analyses, individuals were stratified by age, sex, BMI, ACS type, hypertension, and dyslipidemia, showing that there were no significant interactions between the FT3/FT4 ratio and all subgroups for MACCE. In addition, the FT3/FT4 ratio performed better on ROC analyses for cardiac death prediction [area under the curve (AUC), 0.738]. Conclusion A reduced level of FT3/FT4 ratio was a potential marker of poor prognosis in euthyroid patients with ACS and diabetes after PCI.
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Dai C, Liu M, Yang Z, Li Y, Zhou Y, Lu D, Xia Y, Chen A, Li C, Lu H, Dai Y, Ma J, Chen Z, Qian J, Ge J. Real-world performance of indobufen versus aspirin after percutaneous coronary intervention: insights from the ASPIRATION registry. BMC Med 2024; 22:148. [PMID: 38561738 PMCID: PMC10986102 DOI: 10.1186/s12916-024-03374-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 03/27/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Indobufen is widely used in patients with aspirin intolerance in East Asia. The OPTION trial launched by our cardiac center examined the performance of indobufen based dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). However, the vast majority of patients with acute coronary syndrome (ACS) and aspirin intolerance were excluded. We aimed to explore this question in a real-world population. METHODS Patients enrolled in the ASPIRATION registry were grouped according to the DAPT strategy that they received after PCI. The primary endpoints were major adverse cardiovascular and cerebrovascular events (MACCE) and Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding. Propensity score matching (PSM) was adopted for confounder adjustment. RESULTS A total of 7135 patients were reviewed. After one-year follow-up, the indobufen group was associated with the same risk of MACCE versus the aspirin group after PSM (6.5% vs. 6.5%, hazard ratio [HR] = 0.99, 95% confidence interval [CI] = 0.65 to 1.52, P = 0.978). However, BARC type 2, 3, or 5 bleeding was significantly reduced (3.0% vs. 11.9%, HR = 0.24, 95% CI = 0.15 to 0.40, P < 0.001). These results were generally consistent across different subgroups including aspirin intolerance, except that indobufen appeared to increase the risk of MACCE in patients with ACS. CONCLUSIONS Indobufen shared the same risk of MACCE but a lower risk of bleeding after PCI versus aspirin from a real-world perspective. Due to the observational nature of the current analysis, future studies are still warranted to further evaluate the efficacy of indobufen based DAPT, especially in patients with ACS. TRIAL REGISTRATION Chinese Clinical Trial Register ( https://www.chictr.org.cn ); Number: ChiCTR2300067274.
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Uğuz E, Kurtul A, Şen F. Effect of Carvedilol Versus Metoprolol on Contrast-Induced Nephropathy in Patients with Acute Coronary Syndrome Undergoing Percutaneous Intervention Therapy. Angiology 2024; 75:323-330. [PMID: 36647202 DOI: 10.1177/00033197231152572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Carvedilol can inhibit inflammation, vasoconstriction, and oxidative stress, which play important roles in the development and progression of contrast-induced nephropathy (CIN). To the best of our knowledge, no studies have investigated the potential effect of carvedilol on the prevalence of CIN after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). The present study aimed to determine whether carvedilol use is associated with the development of CIN. A total of 319 patients (mean age, 59.2 ± 12.4 years; 77.7% male) with ACS who underwent urgent PCI at our institution between May 2019 and May 2022 were included prospectively. Overall, 100 and 219 patients were assigned to the carvedilol and metoprolol groups, respectively. The prevalence of CIN was significantly lower in the carvedilol group (6.0%) than in the metoprolol group (18.3%; P = .003). Multivariate analysis revealed that carvedilol use (odds ratio [OR] .250, 95% confidence interval [CI] .092-.677, P = .006), amount of contrast agent (OR 1.004, 95% CI 1.000-1.008, P = .031), and admission estimated glomerular filtration rate (OR .978, 95% CI 0.960-.995, P = .014) were independently associated with the development of CIN. The use of carvedilol may be a promising option for the prevention of CIN in patients with ACS undergoing urgent PCI.
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Abdelaziz A, Elsayed H, Atta K, Mechi A, Kadhim H, Aboutaleb AM, Elaraby A, Ellabban MH, Eid M, AboElfarh HE, Ibrahim RA, Zawaneh EA, Ezzat M, Abdelaziz M, Hafez A, Mahmoud A, Ghaith HS, Suppah M. A comprehensive guide on the optimal timing of PCI in the setting of acute coronary syndrome: An updated meta-analysis. Int J Cardiol 2024; 400:131774. [PMID: 38211674 DOI: 10.1016/j.ijcard.2024.131774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 11/19/2023] [Accepted: 01/07/2024] [Indexed: 01/13/2024]
Abstract
BACKGROUND Invasive revascularization is recommended for cohorts of patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndrome (NSTE-ACS). However, the optimal timing of invasive revascularization is still controversial and no defined consensus is established. We aim to give a comprehensive appraisal on the optimal timing of invasive strategy in the heterogenous population of ACS. METHODS Relevant studies were assessed through PubMed, Scopus, Web of science, and Cochrane Library from inception until April 2023. Major adverse cardiovascular events (MACE) and all-cause mortality were our primary outcomes of interest, other secondary outcomes were cardiac death, TVR, MI, repeat revascularization, recurrent ischemia, and major bleeding. The data was pooled as odds ratio (OR) with its 95% confidence interval (CI) in a random effect model using STATA 17 MP. RESULTS A total of 26 studies comprising 21,443 patients were included in the analysis. Early intervention was favor to decrease all-cause mortality (OR = 0.79, 95% CI: 0.64 to 0.98, p = 0.03), when compared to delayed intervention. Subgroup analysis showed that early intervention was significantly associated with all-cause mortality reduction in only NSTE-ACS (OR = 0.83, 95% CI [0.7 to 0.99], p = 0.04). However, there was no significant difference between early and delayed intervention in terms of MACE, cardiac death, TVR, MI, repeat revascularization, recurrent ischemia, and major bleeding. CONCLUSION An early intervention was associated with lower mortality rates compared to delayed intervention in NSTE-ACS with no significant difference in other clinical outcomes. PROSPERO registration: CRD42023415574.
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Bouchlarhem A, Bouyadid S, Bazid Z, Ismaili N, Ouafi NE. Effectiveness of Primary Coronary Intervention for Patients With Delayed ST-Segment Elevation Myocardial Infarction: Insights from Moroccan Cardiology Intensive Care Units. Am J Cardiol 2024; 216:1-8. [PMID: 38181862 DOI: 10.1016/j.amjcard.2023.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 11/25/2023] [Accepted: 12/17/2023] [Indexed: 01/07/2024]
Abstract
The benefits of myocardial revascularization in ST-segment elevation acute coronary syndrome after 12 to 24 hours from symptom onset remain a topic of debate, especially in patients who are stable and asymptomatic. We analyzed the benefit of late revascularization by primary coronary intervention in patients admitted to Moroccan cardiac intensive care units (CICUs) with ST-segment elevation myocardial infarction after 12 hours of symptom onset. We included a total of 406 patients who met the inclusion criteria: 262 patients in the invasive strategy group and 144 patients in the conservative strategy group. A total of 74.6% were men, and 25.4% were women. For the primary outcome, 46 all-cause deaths were observed at 1 year, with 33 patients in the conservative strategy arm and 13 patients in the invasive strategy group, with a significant difference between the 2 groups (p <0.001). For secondary outcomes, there was no difference in readmission for acute coronary syndrome or acute heart failure between the 2 groups (p = 0.277, p = 0.205). For in-CICU cardiogenic shock and ejection fraction <35% at discharge, more events are observed in the conservative strategy, with a significant difference for both (p <0.001). In multivariable analysis, 1-year all-cause mortality was independently associated with revascularization between 12 and 48 hours (hazard ratio [HR] 0.372, 95% confidence interval [CI] 0.182 to 0.762, p = 0.007), ejection fraction <35% at discharge (HR 1.92, 95% CI 1.22 to 2.54, p = 0.04), and cardiogenic shock in-CICU (HR 2.69, 95% CI 1.82 to 3.78, p = 0.005).Although no evidence exists to date on the true benefit of late primary coronary intervention revascularization in patients with ST-segment elevation myocardial infarction, this practice remains common, as indicated by the results of most registries.
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Subkhan M, Heriansyah T, Munirwan H, Purnawarman A, Dimiati H. Association between NT-proBNP level and the number of stents with major advanced cardiovascular events (MACE) in patients with multivessel coronary artery disease treated with percutaneous coronary intervention: A prospective cohort study. NARRA J 2024; 4:e710. [PMID: 38798841 PMCID: PMC11125420 DOI: 10.52225/narra.v4i1.710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/11/2024] [Indexed: 05/29/2024]
Abstract
Complex revascularization strategies, particularly complete revascularization, are controversial in coronary artery disease (CAD), and data supporting routine revascularization in stable CAD is lacking. The importance of percutaneous coronary intervention (PCI) in CAD and N-terminal pro-brain natriuretic peptide (NT-proBNP), which has been studied as a predictor of major advanced cardiovascular events (MACE) in CAD patients, still requires further research. The aim of this study was to determine the association between NT-proBNP levels and the number of stents with MACE incidence in CAD cases. A prospective cohort study was conducted in both types of CAD (acute coronary syndrome (ACS) and chronic coronary syndrome (CCS)). The NT-proBNP levels were measured pre- and post-PCI using fluorescence immunoassay, while MACE was assessed three months post-PCI. The Student t-test was used to compare the levels of NT-proBNP between pre- and post-PCI and between those who had MACE and did not; both in patients treated with single or multiple stenting groups. A total of 32 CAD patients were recruited, consisting of 20 ACS cases and 12 CCS cases. NT-proBNP levels post-PCI increased significantly in both ACS and CCS patients compared to pre-PCI either among those treated with single and multiple stentings. MACE occurred in 4 (12.5%) out of a total of 32 patients, all of which occurred in ACS patients treated with multiple stentings. Those who had MACE had higher post-PCI NT-proBNP levels compared to those who did not have MACE (23,703.50 vs 11,600.17 pg/mL, p=0.013). This study highlights the association between elevated NT-proBNP levels and multiple stenting with the presence of MACE in CAD patients, particularly in ACS cases.
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Ndrepepa G. Percutaneous Coronary Intervention in Nonagenarians Presenting With an Acute Coronary Syndrome. Am J Cardiol 2024; 216:108-109. [PMID: 38428712 DOI: 10.1016/j.amjcard.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/12/2024] [Indexed: 03/03/2024]
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Shao Z, Lu D, Wang Y, Xue D. The effect of coronary stent policies on the risk of percutaneous coronary intervention among acute coronary syndrome patients in Shanghai: Real-world evidence. PLoS One 2024; 19:e0301448. [PMID: 38557900 PMCID: PMC10984406 DOI: 10.1371/journal.pone.0301448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 03/13/2024] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVE This study aimed to analyze the effect of coronary stent policies implemented in Shanghai on the risk of percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS) inpatients based on real-world data. METHODS Two retrospective cohorts of inpatients with a first diagnosis of ACS who had undergone PCI for the first time in the previous year in Shanghai hospitals were examined (one for the postpolicy period and the other for the prepolicy period). χ2 tests were used to compare categorical variables between the two cohorts. Single- and multivariate Cox proportional hazards models were used to compare the risk of major adverse cardiovascular events (MACEs) between the two cohorts. RESULTS A total of 31,760 ACS patients were included in this study. The proportion of ACS inpatients who had at least one bid-winning stent and 3 or more coronary stents implanted for first-time PCI in the postpolicy cohort was higher than that in the prepolicy cohort (86.52% vs. 55.67% and 6.27% vs. 4.39%, respectively; all p values < 0.0001). The single- and multivariate Cox proportional hazards models revealed that the unadjusted and adjusted hazard ratios for MACEs at 1 year after PCI for the postpolicy cohort relative to the prepolicy cohort were 0.869 (P<0.0001) and 0.814 (P = 0.0007), respectively. CONCLUSIONS The implementation of coronary stent policies changed coronary stent utilization but had no significant adverse effects on the risk of PCI among ACS patients in Shanghai in the short term. However, the reasons for changes in the number of coronary stents implanted should be analyzed and addressed in the future.
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Wang J, Li Y, Lei M, Yang Y, Gao H, Wang X, An L, Zhou H, Sun X, Li C, Zhao Z, Xue Z. Effects of dual antiplatelet therapy de-escalation on the prognosis of acute coronary syndrome patients at high risk of ischemia who underwent percutaneous coronary intervention. Chin Med J (Engl) 2024; 137:746-748. [PMID: 38311807 PMCID: PMC10950124 DOI: 10.1097/cm9.0000000000003011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Indexed: 02/06/2024] Open
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Sarma D, Padkins M, Smith R, Bennett CE, Murphy JG, Bell MR, Damluji AA, Anavekar NS, Barsness GW, Jentzer JC. Patients Aged 90 Years and Above With Acute Coronary Syndrome in the Cardiac Intensive Care Unit: Management and Outcomes. Am J Cardiol 2024; 215:19-27. [PMID: 38266797 PMCID: PMC11025344 DOI: 10.1016/j.amjcard.2023.12.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/03/2023] [Accepted: 12/24/2023] [Indexed: 01/26/2024]
Abstract
Limited data exist regarding outcomes after coronary angiography (CAG) and percutaneous coronary intervention (PCI) in patients aged ≥90 years admitted to the cardiac intensive care unit (CICU) with acute coronary syndrome (ACS). We studied sequential CICU patients ≥90 years admitted with ACS from 2007 to 2018. Three therapeutic approaches were defined: (1) No CAG; (2) CAG without PCI (CAG/No PCI); and (3) CAG with PCI (CAG/PCI). In-hospital mortality was evaluated using multivariable logistic regression. All-cause 1-year mortality was evaluated using Kaplan-Meier and multivariable Cox proportional hazards analysis. The study included 239 patients with a median age of 92 (range 90 to 100) years (57% females; 45% ST-elevation myocardial infarction; 8% cardiac arrest; 16% shock). The No CAG group had higher Day 1 Sequential Organ Failure Assessment scores, more co-morbidities, worse kidney function, and fewer ST-elevation myocardial infarctions. In-hospital mortality was 20.8% overall and did not differ between the No CAG (n = 103; 21.4%), CAG/No PCI (n = 47; 21.3%), and CAG/PCI (n = 90; 20.0%) groups, before or after adjustment. Overall 1-year mortality was 52.5% and did not differ between groups before or after adjustment. Median survival was 6.9 months overall and 41.2% of hospital survivors died within 1 year of CICU admission. CICU patients aged ≥90 years with ACS have a substantial burden of illness with high in-hospital and 1-year mortality that was not lower in those who underwent CAG or PCI. These results suggest that careful patient selection for invasive coronary procedures is essential in this vulnerable population.
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Zhu X, Zhang P, Jiang H, Kuang J, Wu L. Using the Super Learner algorithm to predict risk of major adverse cardiovascular events after percutaneous coronary intervention in patients with myocardial infarction. BMC Med Res Methodol 2024; 24:59. [PMID: 38459490 PMCID: PMC10921576 DOI: 10.1186/s12874-024-02179-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/14/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND The primary treatment for patients with myocardial infarction (MI) is percutaneous coronary intervention (PCI). Despite this, the incidence of major adverse cardiovascular events (MACEs) remains a significant concern. Our study seeks to optimize PCI predictive modeling by employing an ensemble learning approach to identify the most effective combination of predictive variables. METHODS AND RESULTS We conducted a retrospective, non-interventional analysis of MI patient data from 2018 to 2021, focusing on those who underwent PCI. Our principal metric was the occurrence of 1-year postoperative MACEs. Variable selection was performed using lasso regression, and predictive models were developed using the Super Learner (SL) algorithm. Model performance was appraised by the area under the receiver operating characteristic curve (AUC) and the average precision (AP) score. Our cohort included 3,880 PCI patients, with 475 (12.2%) experiencing MACEs within one year. The SL model exhibited superior discriminative performance, achieving a validated AUC of 0.982 and an AP of 0.971, which markedly surpassed the traditional logistic regression models (AUC: 0.826, AP: 0.626) in the test cohort. Thirteen variables were significantly associated with the occurrence of 1-year MACEs. CONCLUSION Implementing the Super Learner algorithm has substantially enhanced the predictive accuracy for the risk of MACEs in MI patients. This advancement presents a promising tool for clinicians to craft individualized, data-driven interventions to better patient outcomes.
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Nakamura K, Arai S, Kobayashi K, Nakai S, Sho R, Ishizawa A, Watanabe D, Hirooka S, Ohba E, Mizumoto M, Kuroda Y, Kim C, Uchino H, Shimanuki T, Uchida T. Safe and promising outcomes of in-hospital preoperative rehabilitation for coronary artery bypass grafting after an acute coronary syndrome. BMC Cardiovasc Disord 2024; 24:139. [PMID: 38438846 PMCID: PMC10910820 DOI: 10.1186/s12872-024-03757-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 02/01/2024] [Indexed: 03/06/2024] Open
Abstract
OBJECTIVE In patients with stable hemodynamic status after an acute coronary syndrome (ACS), coronary artery bypass grafting (CABG) after preoperative investigations can provide outcomes comparable to those of emergency surgery. However, no established guidelines exist regarding the preparation period before surgery. We report the results of the use of an inpatient cardiac rehabilitation program followed by CABG after an ACS to improve post-operative outcomes and prognosis after discharge. METHODS From 2005 to 2017, 471 patients underwent either isolated or combined CABG at our institution, and of those, the 393 who received isolated CABG were included in the analysis. Twenty-seven patients (6.9%) were admitted with ACS and underwent preoperative rehabilitation before undergoing CABG, with a subsequent review of surgical morbidity and mortality rates. Propensity score matching yielded a cohort of 26 patients who underwent preoperative rehabilitation (group A) and 26 controls (group B). Preoperative characteristics were similar between groups. RESULTS The completion rate of the rehabilitation program was 96.3%. All programs were conducted with inpatients, with an average length of stay of 23 ± 12 days. All patients completed in-bed exercises, and 85% completed out-of-bed exercises. The 30-day postoperative mortality was 0% in both groups A and B, and the rate of postoperative major adverse cardiac or cerebrovascular events at 12 months did not differ significantly between groups (7.7% vs 3.9%, respectively; p = 1.0). The duration of mechanical ventilation (1.3 ± 0.3 vs 1.5 ± 0.3 days, respectively; p = 0.633), length of intensive care unit stay (4.4 ± 2.1 vs 4.8 ± 2.3 days, respectively; p = 0.584) and length of hospital stay (25 ± 13 vs 22 ± 9 days, respectively; p = 0.378) did not differ significantly between groups. CONCLUSIONS No complications of preoperative rehabilitation were observed, suggesting that it is an acceptable option for patients who experience ACS and undergo CABG. These results are promising in offering more robust designs of future trials.
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Sanetra K, Gerber W, Domaradzki W, Mazur M, Synak M, Kubaszewska M, Kaźmierczak P, Buszman PP, Bochenek A. Use of del Nido cardioplegia in acute coronary syndrome cases with decreased ejection fraction. Perfusion 2024; 39:353-361. [PMID: 36472195 DOI: 10.1177/02676591221144166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND There has been increasing interest in using del Nido cardioplegia in adult cardiac surgery. However, there is limited evidence for its efficacy in patients with acute coronary syndrome and reduced ejection fraction. METHODS This study examined patients with decreased ejection fraction (EF < 40%) who were hospitalized due to acute coronary syndrome and received either del Nido (DN) or cold blood cardioplegia (CB). The patients were matched based on age, gender, myocardial infarction at baseline, and number of conducted surgical procedures. An analysis was conducted on postoperative biomarker release (high-sensitivity troponin T and isoenzyme creatine kinase-MB (CK-MB)), changes in myocardial contractility and perioperative outcomes. RESULTS 62 pairs of patients with similar baseline characteristics were selected. 51.6% of pairs underwent isolated coronary artery bypass grafting, while 48.4% underwent a complex procedure. Postoperative troponin values did not differ significantly at 12 h (median (IQR): 606.7 (381.4-974.8) pg/mL vs. 552 (231.8-1579.5) pg/mL; p = 0.913), nor did CK-MB (median (IQR): 24.3 (12.6-45.5) ng/mL vs. 23.7 (12.3-49.8) ng/mL; p = 0.972). The postoperative EF was similar between groups (median (IQR): 30% (30-35%) vs. 34% (30-38%); p = 0.323). No difference in perioperative mortality, myocardial infarction, stroke, or composite endpoint was noted. In a multivariate analysis, the cardioplegia protocol did not affect biomarker release or changes in ejection fraction. The first stage of acute kidney injury was more frequent in the CB group (28.5% vs. 9.7%, p = 0.033). CONCLUSIONS Both del Nido and cold blood cardioplegia provide adequate cardioprotection in patients with acute coronary syndrome with decreased ejection fraction.
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Elscot JJ, Kakar H, Dekker WKD, Bennett J, Sabaté M, Esposito G, Daemen J, Boersma E, Van Mieghem NM, Diletti R. Complete Revascularization Strategies in Women and Men With Acute Coronary Syndrome and Multivessel Disease. Am J Cardiol 2024; 214:25-32. [PMID: 38163579 DOI: 10.1016/j.amjcard.2023.12.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/05/2023] [Accepted: 12/17/2023] [Indexed: 01/03/2024]
Abstract
This prespecified substudy of the randomized Percutaneous Complete Revascularization Strategies Using Sirolimus Eluting Biodegradable Polymer Coated Stents in Patients Presenting With Acute Coronary Syndromes and Multivessel Disease (BIOVASC) trial aimed to compare immediate complete revascularization (ICR) and staged complete revascularization (SCR) in patients with acute coronary syndrome and multivessel disease, stratified by gender. The primary end point consisted of a composite of all-cause mortality, myocardial infarction, unplanned ischemia-driven revascularization, and cerebrovascular events at 1-year follow-up. The secondary end points included the individual components of the primary composite and major bleedings. We used Cox regression models to relate randomized treatment with study end points. We evaluated the multiplicative and additive interactions between gender and randomized treatment. The BIOVASC trial enrolled 338 women and 1,187 men. Women were older than men (median age 71.6 vs 63.7 years, p <0.001) and had a higher prevalence of chronic obstructive pulmonary disease (10.1% vs 5.6%, p = 0.003), renal insufficiency (7.7% vs 4.4%, p = 0.015), and hypertension (60.4% vs 51.7%, p = 0.005). In women, the composite primary outcome occurred in 7.3% versus 12.9% (hazard ratio 0.53, 95% confidence interval 0.26 to 1.08) in patients randomly allocated to ICR and SCR, respectively, and in men in 7.7% versus 8.4% (hazard ratio 0.89, 95% confidence interval 0.60 to 1.34), with no evidence of a differential effect (interaction pmultiplicative = 0.20, padditive = 0.87). No evidence of heterogeneity between women and men was found when comparing ICR with SCR in terms of the secondary outcomes. In conclusion, no differential treatment effect was found when comparing ICR versus SCR in women or men presenting with acute coronary syndrome and multivessel disease.
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Demir ÖF, Şensoy NÖ, Akpınar E, Demir G. The stress hyperglycemic ratio can predict the no-reflow phenomenon following saphenous vein graft intervention in patients with acute coronary syndrome. Acta Diabetol 2024; 61:333-341. [PMID: 37914926 DOI: 10.1007/s00592-023-02201-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 10/09/2023] [Indexed: 11/03/2023]
Abstract
AIMS The no-reflow phenomenon (NRP) is a common complication of saphenous vein graft (SVG) interventions. The aim of this study was to investigate the effect of the stress hyperglycemia ratio (SHR) on the development of NRP in patients with acute coronary syndrome (ACS) undergoing percutaneous SVG intervention. METHODS The study included 223 patients who presented at our center with ACS, had a history of coronary artery bypass graft and underwent a saphenous graft procedure. The relationship between SHR calculated at the time of presentation from glucose and HbA1c values, and the development of NRP evaluated after the procedure with angiography was determined with univariate and multivariate binary regression analysis. RESULT The study population was separated into two groups as those who developed and did not develop NRP. Mean age was determined to be significantly higher in the group that did not develop NRP compared to the group with NRP (p: 0.004). Angiographically, the thrombus burden was determined to be significantly higher in the group that developed NRP (p < 0.001). Patients were separated into 3 tertiles according to the SHR level (T1, T2, T3), and the rate of NRP development was determined at a significantly higher rate in the T3 group (p < 0.001). CONCLUSIONS This study showed that SHR, a parameter that can be easily calculated noninvasively, is an independent predictor of NRP development in ACS patients undergoing saphenous interventions. In addition, high thrombus burden and predilatation before stenting were also found to be factors that increase the likelihood of developing NRP.
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Daoulah A, Qenawi W, Alshehri A, Jameel Naser M, Elmahrouk Y, Alshehri M, Elmahrouk A, Qutub MA, Alzahrani B, Yousif N, Arafat AA, Almahmeed W, Elganady A, Dahdouh Z, Hersi AS, Jamjoom A, Alama MN, Selim E, Hashmani S, Hassan T, Alqahtani AM, Abohasan A, Ghani MA, Al Nasser FOM, Refaat W, Iskandar M, Haider O, Fathey Hussien A, Ghonim AA, Shawky AM, Abualnaja S, Kazim HM, Abdulhabeeb IAM, Alshali KZ, Aithal J, Altnji I, Amin H, Ibrahim AM, Al Garni T, Elkhereiji AA, Noor HA, Ahmad O, Alzahrani FJ, Alasmari A, Alkaluf A, Elghaysha E, Al Wabisi SO, Algublan AN, Nasim N, Alhamid S, Sait B, Alqahtani AH, Balghith M, Kanbr O, Abozenah M, Lotfi A. Single Versus Dual Antiplatelet Therapy After Coronary Artery Bypass Grafting for Unprotected Left-Main Coronary Disease. Crit Pathw Cardiol 2024; 23:12-16. [PMID: 37948094 DOI: 10.1097/hpc.0000000000000342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
BACKGROUND The use of dual antiplatelet therapy (DAPT) after coronary revascularization for left-main disease is still debated. The study aimed to characterize patients who received dual versus single antiplatelet therapy (SAPT) after coronary artery bypass grafting (CABG) for unprotected left-main disease and compare the outcomes of those patients. RESULTS This multicenter retrospective cohort study included 551 patients who were grouped into 2 groups: patients who received SAPT (n = 150) and those who received DAPT (n = 401). There were no differences in age ( P = 0.451), gender ( P = 0.063), smoking ( P = 0.941), diabetes mellitus ( P = 0.773), history of myocardial infarction ( P = 0.709), chronic kidney disease ( P = 0.615), atrial fibrillation ( P = 0.306), or cerebrovascular accident ( P = 0.550) between patients who received SAPT versus DAPT. DAPTs were more commonly used in patients with acute coronary syndrome [87 (58%) vs. 273 (68.08%); P = 0.027], after off-pump CABG [12 (8%) vs. 73 (18.2%); P = 0.003] and in patients with radial artery grafts [1 (0.67%) vs. 32 (7.98%); P < 0.001]. While SAPTs were more commonly used in patients with low ejection fraction [55 (36.67%) vs. 61 (15.21%); P < 0.001] and in patients with postoperative acute kidney injury [27 (18%) vs. 37 (9.23%); P = 0.004]. The attributed treatment effect of DAPT for follow-up major adverse cerebrovascular and cardiac events was not significantly different from that of SAPT [β, -2.08 (95% confidence interval (CI), -20.8-16.7); P = 0.828]. The attributed treatment effect of DAPT on follow-up all-cause mortality was not significantly different from that of SAPT [β, 4.12 (CI, -11.1-19.32); P = 0.595]. There was no difference in bleeding between groups ( P = 0.666). CONCLUSIONS DAPTs were more commonly used in patients with acute coronary syndrome, after off-pump CABG, and with radial artery grafts. SAPTs were more commonly used in patients with low ejection fraction and acute kidney injury. Patients on DAPT after CABG for left-main disease had comparable major adverse cerebrovascular and cardiac events and survival to patients on SAPT, with no difference in bleeding events.
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Mangieri A, Gitto M. Editorial: Timing of revascularization in acute coronary syndrome with multivessel disease: Do we need to hurry up?? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 60:9-10. [PMID: 37989705 DOI: 10.1016/j.carrev.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 10/31/2023] [Indexed: 11/23/2023]
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Xie F, Yu Z, Xiong Y, Wu Z, Wu Y. Systemic immune-inflammation index and in-stent restenosis in patients with acute coronary syndrome: a single-center retrospective study. Eur J Med Res 2024; 29:145. [PMID: 38409069 PMCID: PMC10895800 DOI: 10.1186/s40001-024-01736-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 02/20/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND In-stent restenosis (ISR) has been shown to be correlated with inflammation. This study aimed to examine the relationship between systemic immune-inflammation index (SII, an innovative inflammatory biomarker) and ISR in acute coronary syndrome (ACS) patients after drug-eluting stent (DES) implantation. METHODS Subjects who were diagnosed with ACS and underwent DES implantation were enrolled retrospectively. All individuals underwent follow-up coronary angiography at six to forty-eight months after percutaneous coronary intervention (PCI). SII was defined as [(platelet count × neutrophil count)/lymphocyte count], and Ln-transformed SII (LnSII) was carried out for our analysis. Multivariate logistic regression analysis was employed to assess the association between LnSII and DES-ISR. RESULTS During a median follow-up period of 12 (11, 20) months, 523 ACS patients who underwent follow-up angiography were included. The incidence of DES-ISR was 11.28%, and patients in the higher LnSII tertile trended to show higher likelihoods of ISR (5.7% vs. 12.1% vs. 16.0%; P = 0.009). Moreover, each unit of increased LnSII was correlated with a 69% increased risk of DES-ISR (OR = 1.69, 95% CI 1.04-2.75). After final adjusting for confounders, a significant higher risk of DES-ISR (OR = 2.52, 95% CI 1.23-5.17) was found in participants in tertile 3 (≥ 6.7), compared with those in tertiles 1-2 (< 6.7). Subgroup analysis showed no significant dependence on age, gender, body mass index, current smoking, hypertension, and diabetes for this positive association (all P for interaction > 0.05). CONCLUSION High levels of SII were independently associated with an increased risk of DES-ISR in ACS patients who underwent PCI. Further prospective cohort studies are still needed to validate our findings.
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Gao XF, Han L, Qian XS, Ge Z, Kong XQ, Lu S, Kan J, Zuo GF, Zhang JJ, Chen SL. [Long-term outcomes of intravascular ultrasound-guided drug-eluting stents implantation in patients with acute coronary syndrome: ULTIMATE ACS subgroup]. ZHONGHUA XIN XUE GUAN BING ZA ZHI 2024; 52:137-143. [PMID: 38326064 DOI: 10.3760/cma.j.cn112148-20231008-00239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Objective: To explore the long-term effects of intravascular ultrasound (IVUS) guidance on patients with acute coronary syndrome (ACS) undergoing drug-eluting stents (DES) implantation. Methods: Data used in this study derived from ULTIMATE trial, which was a prospective, multicenter, randomized study. A total of 1 448 all-comer patients were enrolled between 2014 August and 2017 May. Primary endpoint of this study was target vessel failure (TVF) at 3 years, including cardiac death, target-vessel-related myocardial infarction, and clinically-driven target vessel revascularization. Results: ACS was present in 1 136 (78.5%) patients, and 3-year clinical follow-up was available in 1 423 patients (98.3%). TVF in the ACS group was 9.6% (109/1 136), which was significantly higher than 4.5% (14/312) in the non-ACS group (log-rank P=0.005). There were 109 TVFs in the ACS patients, with 7.6% (43/569) TVFs in the IVUS group and 11.6% (66/567) TVFs in the angiography group (log-rank P=0.019). Moreover, patients with optimal IVUS guidance were associated with a lower risk of 3-year TVF compared to those with suboptimal IVUS results (5.4% (16/296) vs. 9.9% (27/273),log-rank P=0.041). Conclusions: This ULTIMATE-ACS subgroup analysis showed that ACS patients undergoing DES implantation were associated with a higher risk of 3-year TVF. More importantly, the risk of TVF could be significantly decreased through IVUS guidance in patients with ACS, especially in those who had an IVUS-defined optimal procedure.
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Baber U, Jang Y, Oliva A, Cao D, Vogel B, Dangas G, Sartori S, Spirito A, Smith KF, Branca M, Collier T, Pocock S, Valgimigli M, Kim BK, Hong MK, Mehran R. Safety and Efficacy of Ticagrelor Monotherapy in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention: An Individual Patient Data Meta-Analysis of TWILIGHT and TICO Randomized Trials. Circulation 2024; 149:574-584. [PMID: 37870970 DOI: 10.1161/circulationaha.123.067283] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 10/20/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Dual antiplatelet therapy with a potent P2Y12 inhibitor coupled with aspirin for 1 year is the recommended treatment for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). As an alternative, monotherapy with a P2Y12 inhibitor after a short period of dual antiplatelet therapy has emerged as a bleeding reduction strategy. METHODS We pooled individual patient data from randomized trials that included patients with ACS undergoing PCI treated with an initial 3-month course of dual antiplatelet therapy followed by ticagrelor monotherapy versus continued ticagrelor plus aspirin. Patients sustaining a major ischemic or bleeding event in the first 3 months after PCI were excluded from analysis. The primary outcome was Bleeding Academic Research Consortium type 3 or 5 bleeding occurring between 3 and 12 months after index PCI. The key secondary end point was the composite of death, myocardial infarction, or stroke. Hazard ratios and 95% CIs were generated using Cox regression with a one-stage approach in the intention-to-treat population. RESULTS The pooled cohort (n=7529) had a mean age of 62.8 years, 23.2% were female, and 55% presented with biomarker-positive ACS. Between 3 and 12 months, ticagrelor monotherapy significantly reduced Bleeding Academic Research Consortium 3 or 5 bleeding compared with ticagrelor plus aspirin (0.8% versus 2.1%; hazard ratio, 0.37 [95% CI, 0.24-0.56]; P<0.001). Rates of all-cause death, myocardial infarction, or stroke were not significantly different between groups (2.4% versus 2.7%; hazard ratio, 0.91 [95% CI, 0.68-1.21]; P=0.515). Findings were unchanged among patients presenting with biomarker-positive ACS. CONCLUSIONS Among patients with ACS undergoing PCI who have completed a 3-month course of dual antiplatelet therapy, discontinuation of aspirin followed by ticagrelor monotherapy significantly reduced major bleeding without incremental ischemic risk compared with ticagrelor plus aspirin. REGISTRATION URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42023449646.
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