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Okuya Y, Gohil K, Moussa ID. Angiography versus FFR guided complete revascularization versus culprit-only revascularization for patients presenting with STEMI: Network meta-analysis. Catheter Cardiovasc Interv 2022; 100:340-350. [PMID: 35789058 DOI: 10.1002/ccd.30304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/17/2022] [Accepted: 06/05/2022] [Indexed: 11/07/2022]
Abstract
This study aimed to compare the outcomes of different revascularization strategies among patients presenting with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD) undergoing primary percutaneous coronary intervention (PCI). MVD is present in about one-half of patients presenting with STEMI. Despite several randomized controlled trials (RCTs) comparing complete revascularization (CR) and culprit-only revascularization (COR), the optimal PCI strategy for STEMI patients with MVD remains unsettled. Moreover, it is unclear whether angiography-guided CR or fractional flow reserve (FFR)-guided CR is associated with better outcomes. PubMed, Scopus, and Cochrane Library were searched for RCTs comparing CR strategies with COR strategy in patients with STEMI between January 1, 2000 and September 30, 2021 were identified. A frequentist network meta-analyses were performed for three PCI strategies: (1) COR; (2) angiography-guided CR; and (3) FFR-guided CR. Ten RCTs including 7979 patients were included. A strategy of angiography-guided CR or FFR-guided CR was associated with a significantly lower rate of major adverse cardiac events (MACE) and unplanned revascularization compared with COR. Although there were no statistical significant difference between angiography-guided CR and FFR-guided CR, P score analysis showed that angiography-guided CR was ranked as the best strategy for reducing MACE, all-cause mortality, cardiovascular death, recurrent myocardial infarction, and unplanned revascularization. In patients presenting with STEMI and MVD undergoing primary PCI, angiography-guided CR or FFR-guided CR improve outcomes compared with COR. Furthermore, the strategy of angiography-guided CR ranked as the best revascularization strategy in those patients.
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Affiliation(s)
- Yoshiyuki Okuya
- Department of Clinical Sciences, Heart and Vascular Institute, Carle Health, Urbana, Illinois, USA.,Department of Clinical Sciences, Carle Illinois College of Medicine, University of Illinois, Urbana, Illinois, USA
| | - Kavita Gohil
- Department of Clinical Sciences, Stephens Family Clinical Research Institute, Carle Health, Urbana, Illinois, USA
| | - Issam D Moussa
- Department of Clinical Sciences, Heart and Vascular Institute, Carle Health, Urbana, Illinois, USA.,Department of Clinical Sciences, Carle Illinois College of Medicine, University of Illinois, Urbana, Illinois, USA
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Approccio diagnostico e terapeutico al paziente con sindrome coronarica acuta. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2022; 9:2-13. [PMID: 36628068 PMCID: PMC9796604 DOI: 10.33393/grhta.2022.2389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/23/2022] [Indexed: 01/13/2023] Open
Abstract
The current management strategy of acute coronary syndromes aims at symptoms relief as well as at specifically antagonizing each of the different pathogenic components of myocardial ischemia, including the pro-thrombotic state, poor coronary flow and myocardial damage. Different approaches are available, including revascularization procedures and pharmacological interventions. Various anti-anginal, anti-thrombotic and anti-coagulant drugs can be used according to individual features and needs, as well as secondary prevention measures based on statin use and ACE-inhibition. The appropriate use of available measures is crucial to reduce mortality and improve long-term prognosis in patients with acute coronary syndromes.
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Chen WT, Tsai MS, Huang CH, Chang WT, Chen WJ. Protocolized Post-Cardiac Arrest Care with Targeted Temperature Management. ACTA CARDIOLOGICA SINICA 2022; 38:391-399. [PMID: 35673335 PMCID: PMC9121749 DOI: 10.6515/acs.202205_38(3).20211220a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/20/2021] [Indexed: 06/15/2023]
Abstract
Improvements in teamwork and resuscitation science have considerably increased the success rate of cardiopulmonary resuscitation. Cerebral injury, myocardial dysfunction, systemic ischemia and reperfusion response, and precipitating pathology after the return of spontaneous circulation (ROSC) constitute post-cardiac arrest syndrome. Because the entire body is involved in cardiac arrest and the early post-arrest period, protocolized post-arrest care consisting of cardiovascular optimization, ventilation and oxygenation adjustment, coronary revascularization, targeted temperature management (TTM), and control of seizures and blood sugar would benefit survival and neurological outcomes. Emergent coronary angiography is suggested for cardiac arrest survivors suspected of having ST-elevation myocardial infarction, however the superiority of culprit or complete revascularization in patients with multivessel coronary lesions remains undetermined. High-quality TTM should be considered for comatose patients who are successfully resuscitated from cardiac arrest, however the optimal target temperature may depend on the severity of their condition. The optimal timing for making prognostication should be no earlier than 72 h after rewarming in TTM patients, and 72 h following ROSC in non-TTM patients. To predict neurological recovery correctly may need the use of several prognostic tools together, including clinical neurological examinations, brain images, neurological studies and biomarkers.
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Affiliation(s)
| | | | | | | | - Wen-Jone Chen
- Department of Emergency Medicine
- Department of Internal Medicine (Cardiology division), National Taiwan University Medical College and Hospital, Taipei, Taiwan
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Hwang D, Park J, Yang HM, Yang S, Kang J, Han JK, Park KW, Kang HJ, Koo BK, Kim HS. Angiographic complete revascularization versus incomplete revascularization in patients with diabetes mellitus. Cardiovasc Diabetol 2022; 21:56. [PMID: 35439958 PMCID: PMC9019985 DOI: 10.1186/s12933-022-01488-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 03/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background Considering the nature of diabetes mellitus (DM) in coronary artery disease, it is unclear whether complete revascularization is beneficial or not in patients with DM. We investigated the clinical impact of angiographic complete revascularization in patients with DM. Methods A total of 5516 consecutive patients (2003 patients with DM) who underwent coronary stenting with 2nd generation drug-eluting stent were analyzed. Angiographic complete revascularization was defined as a residual SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) score of 0. The patient-oriented composite outcome (POCO, including all-cause death, any myocardial infarction, and any revascularization) and target lesion failure (TLF) at three years were analyzed. Results Complete revascularization was associated with a reduced risk of POCO in DM population [adjusted hazard ratio (HR) 0.70, 95% confidence interval (CI) 0.52–0.93, p = 0.016], but not in non-DM population (adjusted HR 0.90, 95% CI 0.69–1.17, p = 0.423). The risk of TLF was comparable between the complete and incomplete revascularization groups in both DM (adjusted HR 0.75, 95% CI 0.49–1.16, p = 0.195) and non-DM populations (adjusted HR 1.11, 95% CI 0.75–1.63, p = 0.611). The independent predictors of POCO were incomplete revascularization, multivessel disease, left main disease and low ejection fraction in the DM population, and old age, peripheral vessel disease, and low ejection fraction in the non-DM population. Conclusions The clinical benefit of angiographic complete revascularization is more prominent in patients with DM than those without DM after three years of follow-up. Relieving residual disease might be more critical in the DM population than the non-DM population. Trial registration The Grand Drug-Eluting Stent registry NCT03507205. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-022-01488-7.
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Affiliation(s)
- Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Jiesuck Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Han-Mo Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea.
| | - Seokhun Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Jeehoon Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Jung-Kyu Han
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Kyung Woo Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Hyun-Jae Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul, 03080, Republic of Korea
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Bergmark BA, Mathenge N, Merlini PA, Lawrence-Wright MB, Giugliano RP. Acute coronary syndromes. Lancet 2022; 399:1347-1358. [PMID: 35367005 PMCID: PMC8970581 DOI: 10.1016/s0140-6736(21)02391-6] [Citation(s) in RCA: 120] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 12/14/2022]
Abstract
Although substantial progress has been made in the diagnosis and treatment of acute coronary syndromes, cardiovascular disease remains the leading cause of death globally, with nearly half of these deaths due to ischaemic heart disease. The broadening availability of high-sensitivity troponin assays has allowed for rapid rule-out algorithms in patients with suspected non-ST-segment elevated myocardial infarction (NSTEMI). Dual antiplatelet therapy is recommended for 12 months following an acute coronary syndrome in most patients, and additional secondary prevention measures including intensive lipid-lowering therapy (LDL-C <1·4 mmol/L), neurohormonal agents, and lifestyle modification, are crucial. The scientific evidence for diagnosis and management of acute coronary syndromes continues to evolve rapidly, including adapting to the COVID-19 pandemic, which has impacted all aspects of care. This Seminar provides a clinically relevant overview of the pathobiology, diagnosis, and management of acute coronary syndromes, and describes key scientific advances.
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Affiliation(s)
- Brian A Bergmark
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Njambi Mathenge
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Piera A Merlini
- 4th Division of Cardiology, Cardiocenter De Gasperis, ASST GOM Niguarda and Bicocca University, Milan, Italy
| | - Marilyn B Lawrence-Wright
- Division of Cardiology, Department of Medicine, The University of the West Indies at Mona, Kingston, Jamaica
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Don CW, Zwischenberger BA, Kurlansky PA, Rao SV, Sharma G, Lawton JS, Tamis-Holland JE. 2021 ACC/AHA/SCAI Coronary Artery Revascularization Guidelines for Managing the Nonculprit Artery in STEMI. JACC Case Rep 2022; 4:377-384. [PMID: 35693904 PMCID: PMC9175203 DOI: 10.1016/j.jaccas.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/26/2022] [Accepted: 02/15/2022] [Indexed: 11/23/2022]
Abstract
The 2021 Coronary Artery Disease revascularization guidelines of the American College of Cardiology (ACC), the American Heart Association (AHA), and the Society for Cardiovascular Angiography and Interventions (SCAI) provide recommendations for managing nonculprit arteries in ST-segment elevation myocardial infarction (STEMI). Although staged revascularization is preferred, at times same-setting intervention, coronary artery bypass surgery, or medical therapy may be preferable. These cases exemplify clinical scenarios for treating nonculprit arteries in STEMI. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- Jorge Sanz-Sánchez
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele - Milan, Italy
- Cardio Center, Humanitas Research Hospital IRCCS, Rozzano - Milan, Italy
- Interventional Cardiology Unit, La Fe University and Polytechnic Hospital, Valencia, Comunidad Valenciana, Spain
- Centro de Investigación Biomedica en Red (CIBERCV), Madrid, Spain
| | - Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele - Milan, Italy
- Cardio Center, Humanitas Research Hospital IRCCS, Rozzano - Milan, Italy
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Akasaka T, Shiono Y. Nonculprit Lesion PCI in STEMI: How to Decide and When to Perform? JACC Cardiovasc Interv 2022; 15:667-669. [PMID: 35331459 DOI: 10.1016/j.jcin.2022.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/04/2022] [Accepted: 02/11/2022] [Indexed: 11/20/2022]
Affiliation(s)
- Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan.
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
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Elbadawi A, Dang AT, Hamed M, Eid M, Prakash Hiriyur Prakash M, Saleh M, Gad M, Mamas MA, Rahman F, Elgendy IY. FFR- Versus Angiography-Guided Revascularization for Nonculprit Stenosis in STEMI and Multivessel Disease: A Network Meta-Analysis. JACC Cardiovasc Interv 2022; 15:656-666. [PMID: 35331458 DOI: 10.1016/j.jcin.2022.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/02/2021] [Accepted: 01/04/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The aim of this study was to examine the efficacy and safety of fractional flow reserve (FFR)-guided versus angiography-guided approaches for nonculprit stenosis among patients with acute ST-segment elevation myocardial infarction (STEMI) and multivessel disease. BACKGROUND The optimal strategy to guide revascularization of nonculprit stenosis among patients with STEMI and multivessel disease remains uncertain. METHODS Electronic databases were searched for randomized trials evaluating the outcomes of culprit-only revascularization, angiography-guided complete revascularization (CR), or FFR-guided CR. A pairwise meta-analysis comparing CR versus culprit-only revascularization and a network meta-analysis comparing the different revascularization techniques were conducted. The primary outcome was major adverse cardiac events (MACE). RESULTS The analysis included 11 trials with 8,195 patients. CR (ie, angiography-guided or FFR-guided CR) was associated with a lower incidence of MACE (odds ratio [OR]: 0.46; 95% CI: 0.35 to 0.59), cardiovascular mortality (OR: 0.63; 95% CI: 0.41 to 0.98), recurrent myocardial infarction (OR: 0.67; 95% CI: 0.48 to 0.95), and repeat ischemia-driven revascularization (OR: 0.26; 95% CI: 0.19 to 0.35). Network meta-analysis demonstrated that the incidence of MACE was lower with both angiography-guided CR (OR: 0.43; 95% CI: 0.31 to 0.58) and FFR-guided CR (OR: 0.52; 95% CI: 0.35 to 0.78) compared with a culprit-only approach, while there was no difference in risk for MACE between angiography-guided and FFR-guided CR (OR: 0.81; 95% CI: 0.51 to 1.29). CONCLUSIONS Among patients with STEMI and multivessel disease, CR, with angiographic or FFR guidance for nonculprit stenosis, was associated with lower incidence of adverse events compared with culprit-only revascularization. FFR-guided CR was not superior to angiography-guided CR in reducing the incidence of adverse events. Future studies investigating other tools to risk-stratify nonculprit stenoses are encouraged.
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Affiliation(s)
- Ayman Elbadawi
- Division of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Alexander T Dang
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Mohamed Hamed
- Department of Internal Medicine, Florida Atlantic University, Boca Raton, Florida
| | - Mennaallah Eid
- Department of Internal Medicine, Lincoln Medical Center, New York, New York, USA
| | | | - Mohammed Saleh
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Mohamed Gad
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Faisal Rahman
- Division of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Islam Y Elgendy
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar.
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Hu MJ, Tan JS, Jiang WY, Gao XJ, Yang YJ. The optimal percutaneous coronary intervention strategy for patients with ST-segment elevation myocardial infarction and multivessel disease: a pairwise and network meta-analysis. Ther Adv Chronic Dis 2022; 13:20406223221078088. [PMID: 35295615 PMCID: PMC8918769 DOI: 10.1177/20406223221078088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 01/13/2022] [Indexed: 11/16/2022] Open
Abstract
Objective: To investigate the optimal percutaneous coronary intervention (PCI) strategy in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease. Methods: Trials that randomized patients with STEMI and multivessel coronary artery disease to immediate multivessel PCI, staged multivessel PCI, or culprit-only PCI and prospective observational studies that investigated all-cause death were included. Random effect risk ratio (RR) and 95% confidence interval (CI) were calculated. Results: A total of 13 randomized trials with 7627 patients and 21 prospective observational studies with 60311 patients were included. In the pairwise and network meta-analysis based on randomized trials, immediate or staged multivessel PCI was associated with a lower risk of long-term major adverse cardiac events (MACE; RR: 0.58; 95% CI: 0.45 to 0.74) than culprit-only PCI, which was mainly due to lower risks of myocardial infarction (RR: 0.67; 95% CI: 0.51 to 0.88) and revascularization (RR: 0.38; 95% CI: 0.28 to 0.51), without any significant difference in all-cause death (RR: 0.85; 95% CI: 0.69 to 1.04; I2 = 0.0%). However, short-term outcomes were deficient in randomized trials. The results from real-world prospective observational studies suggested that staged multivessel PCI reduced long-term all-cause death (RR: 0.53; 95% CI: 0.39 to 0.71; I2 = 15.6%), whereas immediate multivessel PCI increased short-term all-cause death (RR: 1.58; 95% CI: 1.22 to 2.05; I2 = 43.8%) relative to culprit-only PCI. Conclusion: For patients in randomized trials, multivessel PCI in an immediate or staged procedure was preferred due to improvements in long-term outcomes. As a supplement, the results in real-world patients derived from prospective observational studies suggested that staged multivessel PCI was superior to immediate multivessel PCI. Therefore, staged multivessel PCI may be the optimal PCI strategy for patients with STEMI and multivessel coronary artery disease.
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Affiliation(s)
- Meng-Jin Hu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiang-Shan Tan
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wen-Yang Jiang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Jin Gao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Jin Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
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Demir OM, Little CD, Jabbour R, Rahman H, Sayers M, Ahmed A, Connolly MJ, Kanyal R, MacCarthy P, Wilson SJ, Dalby M, Jain A, Malik I, Rakhit R, Perera D. Impact of COVID-19 pandemic on the management of nonculprit lesions in patients presenting with ST-elevation myocardial infarction: Outcomes from the pan-London heart attack centers. Catheter Cardiovasc Interv 2022; 99:391-396. [PMID: 34967091 PMCID: PMC9015301 DOI: 10.1002/ccd.30056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/21/2021] [Accepted: 12/14/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND The impact of COVID-19 on the diagnosis and management of nonculprit lesions remains unclear. OBJECTIVES This study sought to evaluate the management and outcomes of patients with nonculprit lesions during the COVID-19 pandemic. METHODS We conducted a retrospective observational analysis of consecutive primary percutaneous coronary intervention (PPCI) pathway activations across the heart attack center network in London, UK. Data from the study period in 2020 were compared with prepandemic data in 2019. The primary outcome was the rate of nonculprit lesion percutaneous coronary intervention (PCI) and secondary outcomes included major adverse cardiovascular events. RESULTS A total of 788 patients undergoing PPCI were identified, 209 (60%) in 2020 cohort and 263 (60%) in 2019 cohort had nonculprit lesions (p = .89). There was less functional assessment of the significance of nonculprit lesions in the 2020 cohort compared to 2019 cohort; in 8% 2020 cohort versus 15% 2019 cohort (p = .01). There was no difference in rates of PCI for nonculprit disease in the 2019 and 2020 cohorts (31% vs 30%, p = .11). Patients in 2020 cohort underwent nonculprit lesion PCI sooner than the 2019 cohort (p < .001). At 6 months there was higher rates of unplanned revascularization (4% vs. 2%, p = .05) and repeat myocardial infarction (4% vs. 1%, p = .02) in the 2019 cohort compared to 2020 cohort. CONCLUSION Changes to clinical practice during the COVID-19 pandemic were associated with reduced rates of unplanned revascularization and myocardial infarction at 6-months follow-up, and despite the pandemic, there was no difference in mortality, suggesting that it is not only safe but maybe more efficacious.
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Affiliation(s)
- Ozan M. Demir
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and SciencesKing's College LondonLondonUK
| | - Callum D. Little
- Department of CardiologyRoyal Free London NHS Foundation TrustLondonUK
| | - Richard Jabbour
- Department of CardiologyImperial College Healthcare NHS Foundation TrustLondonUK
| | - Haseeb Rahman
- Department of CardiologyImperial College Healthcare NHS Foundation TrustLondonUK
| | - Max Sayers
- Department of CardiologyBarts Health NHS TrustLondonUK
| | - Asrar Ahmed
- Department of CardiologyRoyal Brompton and Harefield NHS Foundation TrustLondonUK
| | - Michelle J. Connolly
- Department of CardiologySt George's University Hospitals NHS Foundation TrustLondonUK
| | - Ritesh Kanyal
- Department of CardiologyKing's College Hospital NHS Foundation TrustLondonUK
| | - Philip MacCarthy
- Department of CardiologyKing's College Hospital NHS Foundation TrustLondonUK
| | - Simon J. Wilson
- Department of CardiologySt George's University Hospitals NHS Foundation TrustLondonUK
| | - Miles Dalby
- Department of CardiologyRoyal Brompton and Harefield NHS Foundation TrustLondonUK
| | - Ajay Jain
- Department of CardiologyBarts Health NHS TrustLondonUK
| | - Iqbal Malik
- Department of CardiologyImperial College Healthcare NHS Foundation TrustLondonUK
| | - Roby Rakhit
- Department of CardiologyRoyal Free London NHS Foundation TrustLondonUK
| | - Divaka Perera
- NIHR Biomedical Research Centre and British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine and SciencesKing's College LondonLondonUK
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Siddiqui AJ, Omerovic E, Holzmann MJ, Böhm F. Association of coronary angiographic lesions and mortality in patients over 80 years with NSTEMI. Open Heart 2022; 9:openhrt-2021-001811. [PMID: 35101898 PMCID: PMC8804677 DOI: 10.1136/openhrt-2021-001811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 01/09/2022] [Indexed: 01/16/2023] Open
Abstract
Objective Coronary angiography (CA) and percutaneous coronary intervention (PCI) is of great importance during non-ST-segment elevation myocardial infarction (NSTEMI) management. Coronary artery lesions and their association to mortality in elderly patients with NSTEMI was investigated. Methods Patients >80 years of age who underwent CA at index NSTEMI during 2011–2014 were included. Data were collected from the Swedish Coronary Angiography and Angioplasty Registry and Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registries. Coronary lesions were categorised into; one vessel disease (1VD), multi-vessel disease (MVD) and left main disease (LMD) and 0%–49% stenosis grade were considered as controls. Cox regression was used to estimate HRs for all-cause mortality associated with coronary lesions. Survival benefit was determined after PCI and in relation to if revascularisation was complete or incomplete and any complications in the Cath lab was assessed. Results Five thousand seven hundred and seventy patients with history of CA and PCI were included, 10% had normal coronary arteries, 26% had 1VD, 50% MVD and 14% LMD. Mortality was higher in patients with 1VD, MVD and LMD: HR 1.8 (1.3–2.5), HR 2.2 (1.6–3.0) and HR 2.8 (2.1–3.9), respectively. PCI were treated in 84% of 1VD, 73% MVD, and 54% in LMD. Survival was higher with PCI HR 0.85 (0.73–0.99). MVD had lower adjusted mortality HR 0.71 (0.58–0.87) compared with patients with MVD who did not undergo PCI. Complications and mortality were higher in patients with LMD both during CA and PCI, HR 2.9 (1.1–7.6) and HR 4.5 (1.6–12.5). Conclusion Coronary lesions (>50% stenosis) are strong predictors of mortality in elderly patients with NSTEMI. MVD is common and PCI treatment is associated with increased survival.
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Affiliation(s)
- Anwar J Siddiqui
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Emergency and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Felix Böhm
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska Institutet, Stockholm, Sweden
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Foreword. Interv Cardiol 2022; 17:4. [PMID: 35846248 PMCID: PMC9272409 DOI: 10.15420/icr.2022.17.s1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Ozaki Y, Hara H, Onuma Y, Katagiri Y, Amano T, Kobayashi Y, Muramatsu T, Ishii H, Kozuma K, Tanaka N, Matsuo H, Uemura S, Kadota K, Hikichi Y, Tsujita K, Ako J, Nakagawa Y, Morino Y, Hamanaka I, Shiode N, Shite J, Honye J, Matsubara T, Kawai K, Igarashi Y, Okamura A, Ogawa T, Shibata Y, Tsuji T, Yajima J, Iwabuchi K, Komatsu N, Sugano T, Yamaki M, Yamada S, Hirase H, Miyashita Y, Yoshimachi F, Kobayashi M, Aoki J, Oda H, Katahira Y, Ueda K, Nishino M, Nakao K, Michishita I, Ueno T, Inohara T, Kohsaka S, Ismail TF, Serruys PW, Nakamura M, Yokoi H, Ikari Y. CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) update 2022. Cardiovasc Interv Ther 2022; 37:1-34. [PMID: 35018605 PMCID: PMC8789715 DOI: 10.1007/s12928-021-00829-9] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 12/14/2022]
Abstract
Primary Percutaneous Coronary Intervention (PCI) has significantly contributed to reducing the mortality of patients with ST-segment elevation myocardial infarction (STEMI) even in cardiogenic shock and is now the standard of care in most of Japanese institutions. The Task Force on Primary PCI of the Japanese Association of Cardiovascular Interventional and Therapeutics (CVIT) society proposed an expert consensus document for the management of acute myocardial infarction (AMI) focusing on procedural aspects of primary PCI in 2018. Updated guidelines for the management of AMI were published by the European Society of Cardiology (ESC) in 2017 and 2020. Major changes in the guidelines for STEMI patients included: (1) radial access and drug-eluting stents (DES) over bare-metal stents (BMS) were recommended as a Class I indication, (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. In 2020, updated guidelines for Non-ST-Elevation Myocardial Infarction (NSTEMI) patients, the followings were changed: (1) an early invasive strategy within 24 h is recommended in patients with NSTEMI as a Class I indication, (2) complete revascularization in NSTEMI patients without cardiogenic shock is considered as Class IIa recommendation, and (3) in patients with atrial fibrillation following a short period of triple antithrombotic therapy, dual antithrombotic therapy (e.g., DOAC and single oral antiplatelet agent preferably clopidogrel) is recommended, with discontinuation of the antiplatelet agent after 6 to 12 months. Furthermore, an aspirin-free strategy after PCI has been investigated in several trials those have started to show the safety and efficacy. The Task Force on Primary PCI of the CVIT group has now proposed the updated expert consensus document for the management of AMI focusing on procedural aspects of primary PCI in 2022 version.
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Affiliation(s)
- Yukio Ozaki
- Department of Cardiology, Fujita Health University School of Medicine, Aichi, Japan.
| | - Hironori Hara
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Yuki Katagiri
- Department of Cardiology, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Aichi, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takashi Muramatsu
- Department of Cardiology, Fujita Health University School of Medicine, Aichi, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Ken Kozuma
- Department of Cardiology, Teikyo University Hospital, Tokyo, Japan
| | - Nobuhiro Tanaka
- Division of Cardiology, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | | | - Shiro Uemura
- Cardiovascular Medicine, Kawasaki Medical School, Kurashiki, Japan
| | | | | | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Junya Ako
- Department of Cardiology, Kitasato University Hospital, Sagamihara, Japan
| | - Yoshihisa Nakagawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Yoshihiro Morino
- Department of Cardiology, Iwate Medical University Hospital, Morioka, Japan
| | - Ichiro Hamanaka
- Cardiovascular Intervention Center, Rakuwakai Marutamachi Hospital, Kyoto, Japan
| | - Nobuo Shiode
- Division of Cardiology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Junya Shite
- Cardiology Division, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | | | | | | | | | | | - Takayuki Ogawa
- Division of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | | | | | | | | | | | | | | | | | | | | | | | - Masakazu Kobayashi
- Department of Cardiology, Fujita Health University School of Medicine, Aichi, Japan
| | - Jiro Aoki
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | | | | | | | - Masami Nishino
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital, Cardiovascular Center, Kumamoto, Japan
| | | | | | - Taku Inohara
- Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Keio University School of Medicine, Tokyo, Japan
| | - Tevfik F Ismail
- Department of Cardiology, Fujita Health University School of Medicine, Aichi, Japan
- King's College London & Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
- NHLI, Imperial College London, London, UK
| | - Masato Nakamura
- Division of Cardiovascular Medicine, Ohashi Medical Center, Toho University School of Medicine, Tokyo, Japan
| | - Hiroyoshi Yokoi
- Cardiovascular Center, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Yuji Ikari
- Department of Cardiology, Tokai University School of Medicine, Isehara, Japan
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Zhao L, Guo W, Huang W, Wang L, Mo F, Chen X, Li C, Huang S. Comparative Effectiveness of Complete Revascularization Strategies in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease: A Bayesian Network Meta-Analysis. Front Cardiovasc Med 2021; 8:724274. [PMID: 34631826 PMCID: PMC8496298 DOI: 10.3389/fcvm.2021.724274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 08/10/2021] [Indexed: 11/30/2022] Open
Abstract
Whether fractional flow reserve (FFR) should be available for revascularization in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) is controversial. We aimed to compare the efficacy of various complete revascularization (CR) regimens for STEMI patients with MVD. The PubMed and Cochrane Library databases and clinicaltrial.gov were searched for the randomized controlled trials (RCTs) comparing the FFR-guided CR, angiography-guided CR, and culprit-only revascularization (COR) strategies in STEMI patients with MVD. A Bayesian random-effect model was employed to synthesize the evidence in network meta-analysis. We used relative risk (RR) and 95% credible interval (CrI) as measures of effect size. The primary endpoint was the composite outcome of all-cause mortality or myocardial infarction (MI). Twelve RCTs were included. Angiography-guided CR showed a lower event rate of the composite outcome (RR, 0.68; 95%CrI, 0.50–0.87), all-cause mortality (RR, 0.75; 95%CrI, 0.55–0.96), MI (RR, 0.63; 95%CrI, 0.43–0.86), and repeat revascularization (RR, 0.36; 95% CrI, 0.24–0.55) compared with COR. Additionally, angiography-guided CR had a lower risk of primary outcome (RR, 0.64; 95%CrI, 0.38–0.94) and MI (RR, 0.58; 95%CrI, 0.31–0.92) than FFR-guided CR. The difference between the FFR-guided CR and COR in terms of composite outcome, all-cause mortality, and MI was similar. Angiography-guided CR was associated with the highest probability of optimal treatment for the primary outcome (98.5%), followed by FFR-guided CR (1.2%) and COR (0.3%). STEMI patients with MVD benefitted more from angiography-guided CR than from FFR-guided CR. However, only one study compared the effectiveness of FFR-guided and angiography-guided PCI; thus, the comparison between FFR-guided and angiography-guided PCI relied on indirect evidence. Therefore, further studies directly comparing the effectiveness of these two CR strategies are warranted.
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Affiliation(s)
- Lingyue Zhao
- Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Wenqin Guo
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, China
| | - Weichao Huang
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, China
| | - Lili Wang
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, China
| | - Fanrui Mo
- Department of Cardiology, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Xiehui Chen
- Department of Cardiology, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Chaoyang Li
- Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Siquan Huang
- People's Hospital of Longhua District, Shenzhen, China
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66
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Fabris E, Pezzato A, Gregorio C, Barbati G, Falco L, Albani S, Stolfo D, Vitrella G, Rakar S, Perkan A, Sinagra G. STEMI and Multivessel Disease: Medical Therapy Amplifies the Benefit of Complete Myocardial Revascularisation. Heart Lung Circ 2021; 30:1846-1853. [PMID: 34393047 DOI: 10.1016/j.hlc.2021.06.522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 04/13/2021] [Accepted: 06/24/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Patients with ST-elevation myocardial infarction (STEMI) with multivessel disease (MVD) may be treated with different revascularisation strategies. However, the potential predictors of outcomes on top of different revascularisation strategies are poorly studied. This study aimed to evaluate the prognostic impact of two different revascularisation strategies and the potential impact of medical therapy. METHODS Using a propensity score approach, the impact of two treatment strategies was analysed -staged non-culprit revascularisation group vs culprit-lesion-only percutaneous coronary intervention (PCI) group -- on a composite outcome of cardiovascular death (CVD), myocardial infarction, and repeated revascularisation. Moreover, models were further adjusted for medication at discharge. RESULTS Among 1,385 STEMI patients treated with primary PCI, a subgroup of 433 with MVD was analysed. At the median follow-up of 41 (IQR, 21-65) months, after propensity-score adjustment, the multivariable Cox proportional hazard analysis showed that the staged non-culprit revascularisation group was associated with a lower composite endpoint (HR, 0.44; 95% CI, 0.24-0.82; p=0.01), lower CVD (HR, 0.34; 95% CI, 0.14-0.82; p=0.02), and lower all-cause death (HR, 0.46; 95% CI, 0.24-0.86; p=0.02). Use of renin-angiotensin inhibitors was associated with lower CVD (HR, 0.51; 95% CI, 0.27-0.95; p=0.03), and both renin-angiotensin inhibitors (HR, 0.52; 95% CI, 0.32-0.86; p=0.01) and beta blockers (HR, 0.48; 95% CI, 0.29-0.79; p=0.01) were associated with lower all-cause death. CONCLUSIONS In a real-word STEMI population with multivessel disease, staged non-culprit revascularisation was associated with lower cardiovascular mortality compared with a culprit-only PCI strategy. However, both revascularisation and medical therapy played a role in the improvement of mortality outcomes. Medical therapy amplified the benefit of myocardial revascularisation.
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Affiliation(s)
- Enrico Fabris
- Cardiovascular Department, University of Trieste, Trieste, Italy.
| | - Andrea Pezzato
- Cardiovascular Department, University of Trieste, Trieste, Italy
| | - Caterina Gregorio
- Biostatistics Unit, Department of Medical Sciences, University of Trieste, Trieste, Italy
| | - Giulia Barbati
- Biostatistics Unit, Department of Medical Sciences, University of Trieste, Trieste, Italy
| | - Luca Falco
- Cardiovascular Department, University of Trieste, Trieste, Italy
| | - Stefano Albani
- Cardiovascular Department, University of Trieste, Trieste, Italy
| | - Davide Stolfo
- Cardiovascular Department, University of Trieste, Trieste, Italy
| | | | - Serena Rakar
- Cardiovascular Department, University of Trieste, Trieste, Italy
| | - Andrea Perkan
- Cardiovascular Department, University of Trieste, Trieste, Italy
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Jankowski P, Topór-Mądry R, Gąsior M, Cegłowska U, Eysymontt Z, Gierlotka M, Wita K, Legutko J, Dudek D, Sierpiński R, Pinkas J, Kaźmierczak J, Witkowski A, Szumowski Ł. Innovative Managed Care May Be Related to Improved Prognosis for Acute Myocardial Infarction Survivors. Circ Cardiovasc Qual Outcomes 2021; 14:e007800. [PMID: 34380330 DOI: 10.1161/circoutcomes.120.007800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mortality following discharge in myocardial infarction survivors remains high. Therefore, we compared outcomes in myocardial infarction survivors participating and not participating in a novel, nationwide managed care program for myocardial infarction survivors in Poland. METHODS We used public databases. We included all patients hospitalized due to acute myocardial infarction in Poland between October 1, 2017 and December 31, 2018. We excluded from the analysis all patients aged <18 years as well as those who died during hospitalization or within 10 days following discharge from hospital. All patients were prospectively followed. The primary end point was defined as death from any cause. RESULTS The mean follow-up was 324.8±140.5 days (78 034.1 patient-years; 340.0±131.7 days in those who did not die during the observation). Participation in the managed care program was related to higher odds ratio of participating in cardiac rehabilitation (4.67 [95% CI, 4.44-4.88]), consultation with a cardiologist (7.32 [6.83-7.84]), implantable cardioverter-defibrillator (1.40 [1.22-1.61]), and cardiac resynchronization therapy with cardioverter-defibrillator implantation (1.57 [1.22-2.03]) but lower odds of emergency (0.88 [0.79-0.98]) and nonemergency percutaneous coronary intervention (0.88 [0.83-0.93]) and coronary artery bypass grafting (0.82 [0.71-0.94]) during the follow-up. One-year all-cause mortality was 4.4% among the program participants and 6.0% in matched nonparticipants. The end point consisting of all-cause death, myocardial infarction, or stroke occurred in 10.6% and 12.0% (P<0.01) of participants and nonparticipants respectively, whereas all-cause death or hospitalization for cardiovascular reasons in 42.2% and 47.9% (P<0.001) among participants and nonparticipants, respectively. The difference in outcomes between patients participating and not participating in the managed care program could be explained by improved access to cardiac rehabilitation, cardiac care, and cardiac procedures. CONCLUSIONS Managed care following myocardial infarction may be related to improved prognosis as it may facilitate access to cardiac rehabilitation and may provide a higher standard of outpatient cardiac care.
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Affiliation(s)
- Piotr Jankowski
- I Department of Cardiology, Interventional Electrocardiology and Hypertension, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland (P.J.)
| | - Roman Topór-Mądry
- Agency for Health Technology Assessment and Tariff System, Warsaw, Poland (R.T.-M., U.C.)
| | - Mariusz Gąsior
- 3rd Department of Cardiology, Faculty of Medical Sciences in Zabrze (M. Gąsior), Medical University of Silesia, Katowice, Poland
| | - Urszula Cegłowska
- Agency for Health Technology Assessment and Tariff System, Warsaw, Poland (R.T.-M., U.C.)
| | - Zbigniew Eysymontt
- Cardiac Rehabilitation Department, Ślaskie Centrum Rehabilitacji w Ustroniu, Ustron, Poland (Z.E.)
| | - Marek Gierlotka
- Department of Cardiology, University Hospital, Institute of Medical Sciences, University of Opole, Poland (M. Gierlotka)
| | - Krystian Wita
- First Department of Cardiology, School of Medicine in Katowice (K.W.), Medical University of Silesia, Katowice, Poland
| | - Jacek Legutko
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland (J.L.)
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University, Kopernika 17, Krakow, Poland (D.D.)
| | | | - Jarosław Pinkas
- School of Public Health, Centre of Postgraduate Medical Education, Warsaw, Poland (J.P.)
| | - Jarosław Kaźmierczak
- Department of Cardiology, Pomeranian Medical University, Szczecin, Poland (J.K.)
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland (A.W.)
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Kunkel KJ, Lemor A, Mahmood S, Villablanca P, Ramakrishna H. 2021 Update for the Diagnosis and Management of Acute Coronary Syndromes for the Perioperative Clinician. J Cardiothorac Vasc Anesth 2021; 36:2767-2779. [PMID: 34400062 PMCID: PMC8297970 DOI: 10.1053/j.jvca.2021.07.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 02/07/2023]
Abstract
In this review, recent key publications related to acute coronary syndrome (ACS) are summarized and placed into context of contemporary practice. Landmark trials examining vascular access in ST-elevation myocardial infarction, the management of multivessel disease, acute myocardial infarction and cardiac arrest are discussed. An update in pharmacology for ACS provides updates in major trials relating to P2Y12 inhibitor initiation, deescalation, and use in special populations. Additional updates in the use of lipid-lowering agents and adjunctive medications in ACS are reviewed. Finally, cardiac pathology related to coronavirus disease 2019 (COVID-19), as well as the impact of the COVID-19 global pandemic on the care of patients with ACS, is summarized.
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Affiliation(s)
| | - Alejandro Lemor
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Shazil Mahmood
- Division of Internal Medicine, Henry Ford Hospital, Detroit, MI
| | - Pedro Villablanca
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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69
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Affiliation(s)
- Peter Jüni
- From the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Medicine, University of Toronto
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70
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Arnold JH, Bental T, Greenberg G, Vaknin-Assa H, Kornowski R, Perl L. Timing of Nonculprit Percutaneous Coronary Intervention after ST-Elevation Myocardial Infarction. Cardiology 2021; 146:556-565. [PMID: 34284386 DOI: 10.1159/000517295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 05/15/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Complete revascularization of ST-elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) has recently shown to reduce risk of adverse cardiovascular events, including cardiovascular death. Optimal timing of revascularization of nonculprit lesions remains controversial. We aimed to measure cardiac outcomes related to duration between primary percutaneous coronary intervention (pPCI) of the culprit lesion and staged PCI (sPCI) of nonculprit lesions. METHODS From a prospectively collected consecutive registry of 3,002 patients treated for STEMI by pPCI, 1,555 patients with MVD requiring sPCI were identified. Patients were placed into quartiles of duration to sPCI: 0-7 days (Q1), 7-22 days (Q2), 22-42 days (Q3), >42 days (Q4), excluding those who had complete revascularization at the index event. Major adverse cardiac events (MACEs) included all-cause mortality, myocardial infarction, target vessel revascularization, and coronary artery bypass surgery. Cox regression and propensity score matching were performed correcting for confounding factors. RESULTS The average age at presentation was 65.7 ± 11.5 years. 333 were female (21.4%). Mean time between pPCI and sPCI was 28.3 days (±24.8). Rates of MACE were Q1 - 16.5%, Q2 - 21.2%, Q3 - 25.8%, and Q4 - 30.1% (log-rank <0.001). Following regression analysis, sPCI remained an independent risk factor for MACE (hazard ratio [HR] = 1.226 [95% confidence interval {CI}: 1.129-1.331, p < 0.001]). There was no association between the time interval up to sPCI with all-cause death (HR = 1.022 [95% CI: 0.925-1.129, p = 0.671]). CONCLUSIONS Patients with MVD are at increased risk of experiencing MACE after revascularization of nonculprit vessels with increasing time delay between pPCI and sPCI.
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Affiliation(s)
- Joshua H Arnold
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tamir Bental
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gabriel Greenberg
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hana Vaknin-Assa
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leor Perl
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel.,Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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71
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Mol JQ, Belkacemi A, Volleberg RH, Meuwissen M, Protopopov AV, Laanmets P, Krestyaninov OV, Dennert R, Oemrawsingh RM, van Kuijk JP, Arkenbout K, van der Heijden DJ, Rasoul S, Lipsic E, Teerenstra S, Camaro C, Damman P, van Leeuwen MA, van Geuns RJ, van Royen N. Identification of anatomic risk factors for acute coronary events by optical coherence tomography in patients with myocardial infarction and residual nonflow limiting lesions: rationale and design of the PECTUS-obs study. BMJ Open 2021; 11:e048994. [PMID: 34233996 PMCID: PMC8264896 DOI: 10.1136/bmjopen-2021-048994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 06/16/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION In patients with myocardial infarction, the decision to treat a nonculprit lesion is generally based on its physiological significance. However, deferral of revascularisation based on nonischaemic fractional flow reserve (FFR) values in these patients results in less favourable outcomes compared with patients with stable coronary artery disease, potentially caused by vulnerable nonculprit lesions. Intravascular optical coherence tomography (OCT) imaging allows for in vivo morphological assessment of plaque 'vulnerability' and might aid in the detection of FFR-negative lesions at high risk for recurrent events. METHODS AND ANALYSIS The PECTUS-obs study is an international multicentre prospective observational study that aims to relate OCT-derived vulnerable plaque characteristics of nonflow limiting, nonculprit lesions to clinical outcome in patients with myocardial infarction. A total of 438 patients presenting with myocardial infarction (ST-elevation myocardial infarction and non-ST-elevation myocardial infarction) will undergo OCT-imaging of any FFR-negative nonculprit lesion for detection of plaque vulnerability. The primary study endpoint is a composite of major adverse cardiovascular events (all-cause mortality, nonfatal myocardial infarction or unplanned revascularisation) at 2-year follow-up. Secondary endpoints will be the same composite at 1-year and 5-year follow-up, target vessel failure, target vessel revascularisation, target lesion failure and target lesion revascularisation. ETHICS AND DISSEMINATION This study has been approved by the Medical Ethics Committee of the region Arnhem-Nijmegen. The results of this study will be disseminated in a main paper and additional papers with subgroup analyses. TRIAL REGISTRATION NUMBER NCT03857971.
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Affiliation(s)
- Jan-Quinten Mol
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
| | - Anouar Belkacemi
- Department of Cardiology, Isala Hospitals, Zwolle, The Netherlands
| | | | | | - Alexey V Protopopov
- Cardiovascular Center, Regional Clinical Hospital, Krasnoyarsk, Russian Federation
| | - Peep Laanmets
- Department of Cardiology, North Estonia Medical Centre, Tallinn, Estonia
| | - Oleg V Krestyaninov
- Department of Cardiology, Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Robert Dennert
- Department of Cardiology, Dr Horacio E Oduber Hospital, Oranjestad, Aruba
| | - Rohit M Oemrawsingh
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Jan-Peter van Kuijk
- Department of Cardiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Karin Arkenbout
- Department of Cardiology, Tergooi Hospitals, Blaricum, The Netherlands
| | | | - Saman Rasoul
- Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
- Department of Cardiology, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Erik Lipsic
- Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Steven Teerenstra
- Department of Epidemiology, Biostatistics and Health Technology Assessment, Radboudumc, Nijmegen, The Netherlands
| | - Cyril Camaro
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
| | - Peter Damman
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
| | | | | | - Niels van Royen
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
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Ueyama H, Kuno T, Yasumura K, Vengrenyuk Y, Takagi H, Barman N, Suleman J, Banning AS, Boxma-de Klerk BM, Smits PC, Kini A, Sharma SK. Meta-Analysis Comparing Same-Sitting and Staged Percutaneous Coronary Intervention of Non-Culprit Artery for ST-Elevation Myocardial Infarction with Multivessel Coronary Disease. Am J Cardiol 2021; 150:24-31. [PMID: 34011437 DOI: 10.1016/j.amjcard.2021.03.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/24/2021] [Accepted: 03/26/2021] [Indexed: 10/21/2022]
Abstract
Recent trials and meta-analysis have indicated that complete revascularization (CR) of multivessel coronary disease is beneficial in patients with ST-segment elevation myocardial infarction (STEMI) compared to culprit-only intervention. However, the optimal timing of CR remains unclear. We aimed to analyze the optimal timing of CR in patients with STEMI and multivessel disease by performing an updated network meta-analysis using the recent largest randomized controlled trial. PUBMED and EMBASE were searched through October 2020 to identify randomized controlled trials comparing CR and culprit-only revascularization. A random-effect network meta-analysis comparing three arms (same-sitting [during the index procedure] CR versus staged CR versus culprit-only) and 4 arms (same-sitting CR versus staged CR [in-hospital] versus staged CR [out-hospital] versus culprit-only) were performed. Eleven studies with a total of 7,015 patients were included in our analysis. There was no significant difference in major adverse cardiovascular event (MACE) (HR 0.82, 95% CI 0.64-1.05), cardiovascular death (HR 0.69, 95%CI 0.35-1.33), myocardial infarction (HR 0.66, 95%CI 0.37-1.16), and revascularization (HR 1.05, 95%CI 0.70-1.58) between same-sitting CR and staged CR. When staged CR was further divided into staged CR during the hospitalization and after discharge, there was no significant difference in these outcomes between staged CR (in-hospital) and staged CR (out-hospital). In conclusion, in patients with multivessel disease presenting with STEMI, complete revascularization at any timing, including same-sitting, staged in-hospital, and staged out-hospital, may have similar benefits.
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73
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Hu MJ, Li XS, Jin C, Yang YJ. Does multivessel revascularization fit all patients with STEMI and multivessel coronary artery disease? A systematic review and meta-analysis. IJC HEART & VASCULATURE 2021; 35:100813. [PMID: 34169144 PMCID: PMC8209177 DOI: 10.1016/j.ijcha.2021.100813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/06/2021] [Accepted: 05/31/2021] [Indexed: 11/04/2022]
Abstract
Objective We sought to assess the relative merits of different revascularization strategies in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease complicated by cardiogenic shock or chronic total occlusion (CTO). Background Recent randomized trials and meta-analysis have suggested that multivessel percutaneous coronary intervention (PCI) is associated with better outcomes in patients with STEMI and multivessel coronary artery disease, however, patients complicated by cardiogenic shock or CTO were excluded. Methods Studies that compared multivessel PCI (immediate or staged) with culprit-only PCI in patients with STEMI and multivessel coronary artery disease complicated by cardiogenic shock or CTO were included. Random odd ratio (OR) and 95% confidence interval (CI) were conducted. Results Sixteen studies with 8695 patients complicated by cardiogenic shock and eight studies with 2259 patients complicated by CTO were included. In patients complicated by cardiogenic shock, a strategy of CO-PCI was associated with lower risk for short-term renal failure (OR: 0.75; 95% CI: 0.61–0.93; I2 = 0.0%), with no significant difference in MACE, all-cause mortality, re-infarction, revascularization, cardiac death, heart failure, major bleeding, or stroke compared with an immediate MV-PCI strategy. In patients complicated by CTO, a strategy of CO-PCI was associated with higher risk for long-term MACE (OR: 2.06; 95% CI: 1.39–3.06; I2 = 54.0%), all-cause mortality (OR: 2.89; 95% CI: 2.09–4.00; I2 = 0.0%), cardiac death (OR: 3.12; 95% CI: 2.05–4.75; I2 = 16.8%), heart failure (OR: 1.99; 95% CI: 1.22–3.24; I2 = 0.0%), and stroke (OR: 2.80; 95% CI: 1.04–7.53; I2 = 0.0%) compared with a staged MV-PCI strategy, without any difference in re-infarction, revascularization, or major bleeding. Conclusions For patients with STEMI and multivessel coronary artery disease complicated by cardiogenic shock, an immediate multivessel PCI was not advocated due to a higher risk for short-term renal failure, whereas for patients complicated by CTO, a staged multivessel PCI was advocated due to reduced risks for long-term MACE, all-cause mortality, cardiac death, heart failure, and stroke.
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Affiliation(s)
- Meng-Jin Hu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Xiao-Song Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Chen Jin
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Yue-Jin Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
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74
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Paradies V, Waldeyer C, Laforgia P, Clemmensen P, Smits PC. Completeness of revascularisation in acute coronary syndrome patients with multivessel disease. EUROINTERVENTION 2021; 17:193-201. [PMID: 34167938 PMCID: PMC9725070 DOI: 10.4244/eij-d-20-00957] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A significant proportion of patients presenting with acute coronary syndromes (ACS) have multivessel disease (MVD). Despite the abundance of clinical trials in this area, several questions regarding the procedure of complete coronary revascularisation remain unanswered. This state-of-the-art review summarises the latest evidence on complete revascularisation (CR) in this subset of patients and critically appraises clinical decision making based on non-culprit lesion (NCL) assessment. Future areas of research are put into perspective.
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Affiliation(s)
- Valeria Paradies
- Maasstad Ziekenhuis, Maasstadweg 21, 3079 DZ Rotterdam, the Netherlands
| | - Christoph Waldeyer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany,German Center for Cardiovascular Research (DZHK eV.), partner site Hamburg/Kiel/Lübeck, Germany
| | - Pietro Laforgia
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Peter Clemmensen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany,German Center for Cardiovascular Research (DZHK eV.), partner site Hamburg/Kiel/Lübeck, Germany,Faculty of Health Sciences, Department of Regional Health Research, University of Southern Denmark, and Nykoebing Falster Hospital, Odense, Denmark
| | - Pieter C. Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
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75
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Li LF, Qiu M, Liu SY, Zhou HR. Effects of patient characteristics on the efficacy of complete revascularization for treatment of ST-segment elevation myocardial infarction with multivessel disease: A meta-analysis. Medicine (Baltimore) 2021; 100:e26251. [PMID: 34160388 PMCID: PMC8238282 DOI: 10.1097/md.0000000000026251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 05/19/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Several randomized controlled trials (RCTs) have evaluated the efficacy of complete vs culprit-only revascularization for treatment of ST-segment elevation myocardial infarction (STEMI) with multivessel disease. However, the efficacy of complete revascularization vs culprit-only revascularization in some STEMI patient subgroups remains unclear. METHODS We searched PubMed and Embase for related RCTs from the start date of databases to January 3, 2020. The endpoint assessed in this meta-analysis was major adverse cardiac events (MACE). Random-effects meta-analysis was conducted stratified by each of the 5 factors of interest (i.e., sex, age, history of diabetes, ECG infarct location, and the number of arteries with stenosis) to estimate pooled hazard ratio and 95% confidence interval. Random-effects meta-regression was conducted to assess subgroup differences. We examined publication bias by drawing funnel plots and performing Egger test. This meta-analysis is reported according to the PRISMA statement. RESULTS Six RCTs were included for pooled analysis. Compared with culprit-only revascularization, complete revascularization significantly reduced the risk of MACE (hazard ratio 0.48, 95% confidence interval 0.42-0.55; I2 = 0%; P for relative effect < .001). This significant reduction in the risk of MACE exhibited by complete revascularization was observed in most of the subgroups of interest. All of the subgroup effects based on the 5 factors of interest were not statistically significant (Psubgroup ranged from 0.198 to 0.556). Publication bias was not suggested by funnel plots and Egger test. CONCLUSIONS Compared with culprit-only revascularization, complete revascularization significantly reduces the MACE risk in patients with STEMI and multivessel disease, which is independent of sex, age, history of diabetes, ECG infarct location, and the number of arteries with stenosis.
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Affiliation(s)
- Lu-Feng Li
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen
| | - Mei Qiu
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen
| | - Shu-Yan Liu
- Department of Cardiology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Hai-Rong Zhou
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen
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76
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Cerrud-Rodriguez RC, Rashid SMI, Wiley KA, Gonzalez M, Kosmacheva VA, Castillero-Norato I, Rivera C, Villablanca P, Wiley J. Complete Revascularization of Stable STEMI Patients Offers a Significant Benefit if Done During the Index PCI, but Not if It's Done as a Staged Procedure. Int J Gen Med 2021; 14:2239-2248. [PMID: 34113153 PMCID: PMC8184234 DOI: 10.2147/ijgm.s308385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 05/05/2021] [Indexed: 11/23/2022] Open
Abstract
Background Complete revascularization (CR) of hemodynamically stable STEMI improves outcomes when compared to culprit-only PCI. However, the optimal timing for CR (CR during index PCI [iCR] versus staged PCI [sCR]) is unknown. sCR is defined as revascularization of non-culprit lesions not done during the index procedure (mean 31.5±24.6 days after STEMI). Our goal was to determine whether iCR was the superior strategy when compared to sCR. Methods A systematic review of Medline, Cochrane, and Embase was performed for RCTs reporting outcomes of stable STEMI patients who had undergone CR. Only RCTs with a clearly defined timing of CR, for the classification into iCR and sCR, and a follow-up of at least 12 months were included. Seven RCTs comprising 6647 patients (mean age:62.9±1.4 years, male sex:79.4%) met these criteria and were included. Results After a mean follow-up of 25.1±9.4 months, iCR was associated with a significant reduction in cardiovascular mortality (risk ratio [RR] 0.48, 95% confidence interval [CI] 0.26–0.90, p=0.02, relative risk reduction [RRR] 52%) and non-fatal reinfarctions (RR 0.42, 95% CI 0.25–0.70, p=0.001, RRR: 58%). sCR showed a significant reduction in non-fatal reinfarctions only (RR 0.68, 95% CI 0.54–0.85, p=0.0008, RRR: 32%). There was no difference in the safety outcome of contrast-induced nephropathy between groups. Conclusion iCR of stable STEMI patients is associated with a significant reduction in cardiovascular death and a trend towards reduction in all-cause mortality. These benefits are not seen in sCR. Both strategies are associated with a reduction in non-fatal reinfarctions.
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Affiliation(s)
- Roberto C Cerrud-Rodriguez
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Syed Muhammad Ibrahim Rashid
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Karlo A Wiley
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Maday Gonzalez
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Valeriia A Kosmacheva
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Isabella Castillero-Norato
- Facultad de Medicina, Universidad de Panamá, Campus Octavio Méndez Pereira, Panama City, Republic of Panama
| | - Cornelia Rivera
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Pedro Villablanca
- Department of Medicine, Division of Cardiology, Henry Ford Hospital, Detroit, MI, USA
| | - Jose Wiley
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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77
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Ibanez B, Roque D, Price S. The year in cardiovascular medicine 2020: acute coronary syndromes and intensive cardiac care. Eur Heart J 2021; 42:884-895. [PMID: 33388774 DOI: 10.1093/eurheartj/ehaa1090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/07/2020] [Accepted: 12/17/2020] [Indexed: 12/21/2022] Open
Affiliation(s)
- Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,Cardiology Department, IIS-Fundación Jiménez Díaz University Hospital, Madrid, Spain.,CIBERCV, Madrid, Spain
| | - David Roque
- Cardiology Department, Prof. Dr. Fernando Fonseca Hospital, Amadora, Portugal
| | - Susanna Price
- Department of Cardiology and Department of Adult Critical Care, Royal Brompton Hospital, London, UK
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78
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Takahashi K, Serruys PW, Gao C, Ono M, Wang R, Thuijs DJFM, Mack MJ, Curzen N, Mohr FW, Davierwala P, Milojevic M, Wykrzykowska JJ, de Winter RJ, Sharif F, Onuma Y, Head SJ, Kappetein AP, Morice MC, Holmes DR. Ten-Year All-Cause Death According to Completeness of Revascularization in Patients With Three-Vessel Disease or Left Main Coronary Artery Disease: Insights From the SYNTAX Extended Survival Study. Circulation 2021; 144:96-109. [PMID: 34011163 DOI: 10.1161/circulationaha.120.046289] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ten-year all-cause death according to incomplete (IR) versus complete revascularization (CR) has not been fully investigated in patients with 3-vessel disease and left main coronary artery disease undergoing percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). METHODS The SYNTAX Extended Survival study (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]) evaluated vital status up to 10 years in patients who were originally enrolled in the SYNTAX trial. In the present substudy, outcomes of the CABG CR group were compared with the CABG IR, PCI CR, and PCI IR groups. In addition, in the PCI cohort, the residual SYNTAX score (rSS) was used to quantify the extent of IR and to assess its association with fatal late outcome. The rSS of 0 suggests CR, whereas a rSS>0 identifies the degree of IR. RESULTS IR was more frequently observed in patients with PCI versus CABG (56.6% versus 36.8%) and more common in those with 3-vessel disease than left main coronary artery disease in both the PCI arm (58.5% versus 53.8%) and the CABG arm (42.8% versus 27.5%). Patients undergoing PCI with CR had no significant difference in 10-year all-cause death compared with those undergoing CABG (22.2% for PCI with CR versus 24.3% for CABG with IR versus 23.8% for CABG with CR). In contrast, those with PCI and IR had a significantly higher risk of all-cause death at 10 years compared with CABG and CR (33.5% versus 23.7%; adjusted hazard ratio, 1.48 [95% CI, 1.15-1.91]). When patients with PCI were stratified according to the rSS, those with a rSS≤8 had no significant difference in all-cause death at 10 years as the other terciles (22.2% for rSS=0 versus 23.9% for rSS>0-4 versus 28.9% for rSS>4-8), whereas a rSS>8 had a significantly higher risk of 10-year all-cause death than those undergoing PCI with CR (50.1% versus 22.2%; adjusted hazard ratio, 3.40 [95% CI, 2.13-5.43]). CONCLUSIONS IR is common after PCI, and the degree of incompleteness was associated with 10-year mortality. If it is unlikely that complete (or nearly complete; rSS<8) revascularization can be achieved with PCI in patients with 3-vessel disease, CABG should be considered. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00114972. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03417050.
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Affiliation(s)
- Kuniaki Takahashi
- Department of Cardiology, Amsterdam University Medical Center, University of Amsterdam, The Netherlands (K.T., M.O., J.J.W., R.J.d.W.)
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), Ireland (P.W.S., Y.O.)
| | - Chao Gao
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands (C.G., R.W.)
| | - Masafumi Ono
- Department of Cardiology, Amsterdam University Medical Center, University of Amsterdam, The Netherlands (K.T., M.O., J.J.W., R.J.d.W.)
| | - Rutao Wang
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands (C.G., R.W.)
| | - Daniel J F M Thuijs
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands (D.J.F.M.T., M.M., S.J.H., A.P.K.)
| | - Michael J Mack
- Department of Cardiothoracic Surgery, Baylor Scott & White Health, Dallas, TX (M.J.M.)
| | - Nick Curzen
- Department of Cardiology, University Hospital Southampton NHS FT, UK (N.C.)
| | | | - Piroze Davierwala
- University Department of Cardiac Surgery, Heart Centre Leipzig, Germany (F.-W.M., P.D.).,Now with Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Ontario, Canada (P.D.)
| | - Milan Milojevic
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands (D.J.F.M.T., M.M., S.J.H., A.P.K.).,Department of Cardiothoracic Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia (M.M.)
| | - Joanna J Wykrzykowska
- Department of Cardiology, Amsterdam University Medical Center, University of Amsterdam, The Netherlands (K.T., M.O., J.J.W., R.J.d.W.).,Department of Cardiology, University Medical Centre Groningen, University of Groningen, The Netherlands (J.J.W.)
| | - Robbert J de Winter
- Department of Cardiology, Amsterdam University Medical Center, University of Amsterdam, The Netherlands (K.T., M.O., J.J.W., R.J.d.W.)
| | - Faisal Sharif
- CURAM, Cardiovascular Research and Innovation Centre (CVRI), BioInnovate Ireland, Department of Cardiology, Galway University Hospital and National University of Ireland, Ireland (F.S.)
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), Ireland (P.W.S., Y.O.)
| | - Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands (D.J.F.M.T., M.M., S.J.H., A.P.K.)
| | - Arie Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands (D.J.F.M.T., M.M., S.J.H., A.P.K.)
| | - Marie-Claude Morice
- Département of Cardiologie, Hôpital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.)
| | - David R Holmes
- Department of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN (D.R.H.)
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79
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Burgess SN, Juergens CP, Nguyen T, Leung M, Robledo KP, Thomas L, Mussap C, Lo ST, French JK. Diabetes and Incomplete Revascularisation in ST Elevation Myocardial Infarction. Heart Lung Circ 2021; 30:471-480. [DOI: 10.1016/j.hlc.2020.09.928] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 06/18/2020] [Accepted: 09/14/2020] [Indexed: 11/26/2022]
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80
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Werner N, Neumann FJ. Entwicklung kardiovaskuläre Medizin 2020. DER KARDIOLOGE 2021. [PMCID: PMC7944250 DOI: 10.1007/s12181-021-00461-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Auf dem Gebiet der ischämischen Herzerkrankungen war 2020 ein spannendes Jahr. Die COVID-19-Pandemie hat Diagnostik und Therapie der koronaren Herzkrankheit in vielen Bereichen stark beeinflusst. Daneben haben die Ergebnisse der ISCHEMIA-Studie zumindest in Teilen die bisherige Praxis in der Behandlung des stabilen, chronischen Koronarsyndroms (CCS) infrage gestellt. In dieser Studie konnte keine Prognoseverbesserung durch Myokardrevaskularisation bei Patienten mit stabiler Ischämie nachgewiesen werden, wohl aber eine Verbesserung von Lebensqualität und Angina-pectoris-Beschwerden. Darüber hinaus wurden neue europäische Leitlinien zum ACS (akutes Koronarsyndrom) ohne ST-Streckenhebung (NSTE-ACS) vorgestellt. Wichtige Publikationen aus dem Jahr 2020 führen die dort vorgestellten Konzepte weiter. So konnte der Nutzen der frühinvasiven Behandlung beim NSTE-ACS erstmals auch für die ≥ 80-Jährigen nachgewiesen werden. Neuere Analysen bestätigen ferner das Konzept der kompletten Revaskularisation bei ST-Hebungsinfarkt ohne Schock und Mehrgefäßerkrankung. Dieses Konzept wird nun auf das NSTE-ACS übertragen. In der antithrombozytären Therapie stellen aktuelle Studien die antithrombozytäre Vorbehandlung als Teil der frühinvasiven Strategie bei unbekanntem Koronarstatus infrage. Mehrere Studien zeigen den potenziellen Nutzen einer Deeskalation der antithrombozytären Therapie nach NSTE-ACS insbesondere bei älteren Patienten.
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Affiliation(s)
- Nikos Werner
- Herzzentrum Trier, Innere Medizin III – Kardiologie und Intensivmedizin, Krankenhaus der Barmherzigen Brüder Trier, Nordallee 1, 54292 Trier, Deutschland
| | - Franz-Josef Neumann
- Klinik für Kardiologie und Angiologie II, Universitäts-Herzzentrum Freiburg ∙ Bad Krozingen, Südring 15, 79189 Bad Krozingen, Deutschland
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81
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Vetrovec GW. Addressing the issue of “frequent flyers” post‐ PCI. Catheter Cardiovasc Interv 2021. [DOI: 10.1002/ccd.29527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- George W. Vetrovec
- The Pauley Heart Center Virginia Commonwealth University Medical Center, Virginia Commonwealth University Richmond Virginia
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82
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Rathod KS, Spagnolo M, Elliott MK, Beirne AM, Smith EJ, Amersey R, Knight C, Weerackody R, Baumbach A, Mathur A, Jones DA. An Observational Study Assessing Immediate Complete Versus Delayed Complete Revascularisation in Patients with Multi-Vessel Disease Undergoing Primary Percutaneous Coronary Intervention. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2020; 14:1179546820951792. [PMID: 32913394 PMCID: PMC7444144 DOI: 10.1177/1179546820951792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 07/28/2020] [Indexed: 11/16/2022]
Abstract
Background: More than half of the patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) have multi-vessel coronary artery disease. This is associated with worse outcomes compared with single vessel disease. Whilst evidence now exists to support complete revascularisation for bystander disease the optimal timing is still debated. This study aimed to compare clinical outcomes in patients with STEMI and multi-vessel disease who underwent complete revascularisation as inpatients in comparison to patients who had staged PCI as early outpatients. Methods and results: We conducted an observational cohort study consisting of 1522 patients who underwent primary PCI with multi-vessel disease from 2012 to 2019. Exclusions included patients with cardiogenic shock and previous CABG. Patients were split into 2 groups depending on whether they had complete revascularisation performed as inpatients or as staged PCI at later outpatient dates. The primary outcome of this study was major adverse cardiac events (consisting of myocardial infarction, target vessel revascularisation and all-cause mortality). 834 (54.8%) patients underwent complete inpatient revascularisation and 688 patients (45.2%) had outpatient PCI (median 43 days post discharge). Of the inpatient group, 652 patients (78.2%) underwent complete revascularisation during the index procedure whilst 182 (21.8%) patients underwent inpatient bystander PCI in a second procedure. Overall, there were no significant differences between the groups with regards to their baseline or procedural characteristics. Over the follow-up period there was no significant difference in MACE between the cohorts (P = .62), which persisted after multivariate adjustment (HR 1.21 [95% CI 0.72-1.96]). Furthermore, in propensity-matched analysis there was no significant difference in outcome between the groups (HR: 0.86 95% CI: 0.75-1.25). Conclusions: Our study demonstrated that the timing of bystander PCI after STEMI did not appear to have an effect on cardiovascular outcomes. We suggest that patients with multi-vessel disease can potentially be discharged promptly and undergo early outpatient bystander PCI. This could significantly reduce length of stay in hospital.
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Affiliation(s)
- Krishnaraj Sinhji Rathod
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Marco Spagnolo
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Mark K Elliott
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Anne-Marie Beirne
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Elliot J Smith
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Rajiv Amersey
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Charles Knight
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Roshan Weerackody
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Andreas Baumbach
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Anthony Mathur
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Daniel A Jones
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
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83
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Silva CGDSE. Is Complete Revascularization Truly Superior to Culprit-Lesion-Only PCI in Patients Presenting with ST-segment Elevation Myocardial Infarction? Arq Bras Cardiol 2020; 115:238-240. [PMID: 32876191 PMCID: PMC8384295 DOI: 10.36660/abc.20200640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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84
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Albini A, Di Guardo G, Noonan DM, Lombardo M. The SARS-CoV-2 receptor, ACE-2, is expressed on many different cell types: implications for ACE-inhibitor- and angiotensin II receptor blocker-based cardiovascular therapies. Intern Emerg Med 2020; 15:759-766. [PMID: 32430651 PMCID: PMC7236433 DOI: 10.1007/s11739-020-02364-6] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/02/2020] [Indexed: 01/08/2023]
Abstract
SARS-CoV-2 is characterized by a spike protein allowing viral binding to the angiotensin-converting enzyme (ACE)-2, which acts as a viral receptor and is expressed on the surface of several pulmonary and extra-pulmonary cell types, including cardiac, renal, intestinal and endothelial cells. There is evidence that also endothelial cells are infected by SARS-COV-2, with subsequent occurrence of systemic vasculitis, thromboembolism and disseminated intravascular coagulation. Those effects, together with the "cytokine storm" are involved in a worse prognosis. In clinical practice, angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin II receptor blockers (ARBs) are extensively used for the treatment of hypertension and other cardiovascular diseases. In in vivo studies, ACE-Is and ARBs seem to paradoxically increase ACE-2 expression, which could favour SARS-CoV-2 infection of host's cells and tissues. By contrast, in patients treated with ACE-Is and ARBs, ACE-2 shows a downregulation at the mRNA and protein levels in kidney and cardiac tissues. Yet, it has been claimed that both ARBs and ACE-Is could result potentially useful in the clinical course of SARS-CoV-2-infected patients. As detected in China and as the Italian epidemiological situation confirms, the most prevalent comorbidities in deceased patients with COVID-19 are hypertension, diabetes and cardiovascular diseases. Older COVID-19-affected patients with cardiovascular comorbidities exhibit a more severe clinical course and a worse prognosis, with many of them being also treated with ARBs or ACE-Is. Another confounding factor is cigarette smoking, which has been reported to increase ACE-2 expression in both experimental models and humans. Sex also plays a role, with chromosome X harbouring the gene coding for ACE-2, which is one of the possible explanations of why mortality in female patients is lower. Viral entry also depends on TMPRSS2 protease activity, an androgen dependent enzyme. Despite the relevance of experimental animal studies, to comprehensively address the question of the potential hazards or benefits of ACE-Is and ARBs on the clinical course of COVID-19-affected patients treated by these anti-hypertensive drugs, we will need randomized human studies. We claim the need of adequately powered, prospective studies aimed at answering the following questions of paramount importance for cardiovascular, internal and emergency medicine: Do ACE-Is and ARBs exert similar or different effects on infection or disease course? Are such effects dangerous, neutral or even useful in older, COVID-19-affected patients? Do they act on multiple cell types? Since ACE-Is and ARBs have different molecular targets, the clinical course of SARS-CoV-2 infection could be also different in patients treated by one or the other of these two drug classes. At present, insufficient detailed data from trials have been made available.
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Affiliation(s)
- Adriana Albini
- Scientific and Technology Pole, IRCCS MultiMedica, Milan, Italy.
| | - Giovanni Di Guardo
- Faculty of Veterinary Medicine, University of Teramo, 64100, Teramo, Italy
| | - Douglas McClain Noonan
- Scientific and Technology Pole, IRCCS MultiMedica, Milan, Italy
- Department of Biotechnology and Life Sciences, University of Insubria, Varèse, Italy
| | - Michele Lombardo
- Cardiology Unit, San Giuseppe Hospital-MultiMedica, Milan, Italy
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85
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Nishiga M, Wang DW, Han Y, Lewis DB, Wu JC. COVID-19 and cardiovascular disease: from basic mechanisms to clinical perspectives. Nat Rev Cardiol 2020; 17:543-558. [PMID: 32690910 PMCID: PMC7370876 DOI: 10.1038/s41569-020-0413-9] [Citation(s) in RCA: 831] [Impact Index Per Article: 207.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2020] [Indexed: 01/18/2023]
Abstract
Coronavirus disease 2019 (COVID-19), caused by a strain of coronavirus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become a global pandemic that has affected the lives of billions of individuals. Extensive studies have revealed that SARS-CoV-2 shares many biological features with SARS-CoV, the zoonotic virus that caused the 2002 outbreak of severe acute respiratory syndrome, including the system of cell entry, which is triggered by binding of the viral spike protein to angiotensin-converting enzyme 2. Clinical studies have also reported an association between COVID-19 and cardiovascular disease. Pre-existing cardiovascular disease seems to be linked with worse outcomes and increased risk of death in patients with COVID-19, whereas COVID-19 itself can also induce myocardial injury, arrhythmia, acute coronary syndrome and venous thromboembolism. Potential drug-disease interactions affecting patients with COVID-19 and comorbid cardiovascular diseases are also becoming a serious concern. In this Review, we summarize the current understanding of COVID-19 from basic mechanisms to clinical perspectives, focusing on the interaction between COVID-19 and the cardiovascular system. By combining our knowledge of the biological features of the virus with clinical findings, we can improve our understanding of the potential mechanisms underlying COVID-19, paving the way towards the development of preventative and therapeutic solutions.
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Affiliation(s)
- Masataka Nishiga
- Stanford Cardiovascular Institute, Stanford, CA, USA. .,Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, China
| | - Yaling Han
- Cardiovascular Research Institute, Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - David B Lewis
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph C Wu
- Stanford Cardiovascular Institute, Stanford, CA, USA. .,Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA. .,Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
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86
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Gershlick AH, Banning AS. Complete revascularisation in the STEMI patient: is it worth the effort? EUROINTERVENTION 2020; 16:195-199. [PMID: 32597764 DOI: 10.4244/eijv16i3a34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Anthony H Gershlick
- University of Leicester, University Hospitals of Leicester, NIHR Leicester Biomedical Research Centre, Leicester, United Kingdom
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87
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Figini F, Chen SL, Sheiban I. ST-elevation Myocardial Infarction and Multivessel Coronary Artery Disease – A Critical Review of Current Practice, Evidence and Meta-analyses. Heart Int 2020; 14:80-85. [DOI: 10.17925/hi.2020.14.2.80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/11/2020] [Indexed: 01/09/2023] Open
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