ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization: a report by the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular Computed Tomography

Likelihood of coronary angiography among First Nations patients with acute myocardial infarction

BACKGROUND

Morbidity due to cardiovascular disease is high among First Nations people. The extent to which this may be related to the likelihood of coronary angiography is unclear. We examined the likelihood of coronary angiography after acute myocardial infarction (MI) among First Nations and non-First Nations patients.

METHODS

Our study included adults with incident acute MI between 1997 and 2008 in Alberta. We determined the likelihood of angiography among First Nations and non-First Nations patients, adjusted for important confounders, using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database.

RESULTS

Of the 46,764 people with acute MI, 1043 (2.2%) were First Nations. First Nations patients were less likely to receive angiography within 1 day after acute MI (adjusted odds ratio [OR] 0.73, 95% confidence interval [CI] 0.62-0.87). Among First Nations and non-First Nations patients who underwent angiography (64.9%), there was no difference in the likelihood of percutaneous coronary intervention (PCI) (adjusted hazard ratio [HR] 0.92, 95% CI 0.83-1.02) or coronary artery bypass grafting (CABG) (adjusted HR 1.03, 95% CI 0.85-1.25). First Nations people had worse survival if they received medical management alone (adjusted HR 1.38, 95% CI 1.07-1.77) or if they underwent PCI (adjusted HR 1.38, 95% CI 1.06-1.80), whereas survival was similar among First Nations and non-First Nations patients who received CABG.

INTERPRETATION

First Nations people were less likely to undergo angiography after acute MI and experienced worse long-term survival compared with non-First Nations people. Efforts to improve access to angiography for First Nations people may improve outcomes.

IMPLEMENTATION OF EVIDENCE-BASED CLINICAL-AND-MORPHOLOGICAL APPROPRIATE USE CRITERIA FOR CORONARY REVASCULARIZATION IN PATIENTS WITH ACUTE CORONARY SYNDROME IN RUSSIA

Aim. To study possibility of using the evidence-based clinical-andmorphological appropriate use criteria for percutaneous coronary interventions (PCIs) for expert evaluation of high-technology procedures implementation in patients with acute coronary syndrome (ACS) in Russia.

Materials and methods. The appropriateness of performed PCI was assessed in patients with ACS, underwent coronary revascularization. The potential need in PCI was determined in ACS patients refused from coronary revascularization. Assessment was performed with the help of ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate Use Criteria for Coronary Revascularization Focused Update (ACCF 2012). Data from 65,912 ACS patients, containing in Russian ACS Registry (2010–2011) were examined.

Results. ACCF 2012 criteria allow to assess the clinical appropriateness of PCI in 79.2% of patients underwent coronary revascularization and to determine the potential need in PCI in 80.6% of patients, refrained from coronary revascularization. Among ACS patients underwent PCI (n=9147), intervention was appropriate in 68.9% of cases. Inappropriate PCI was revealed in 4.6% of cases. Among patients refrained from PCI (n=56765), coronary revascularization was potentially appropriate in 57.9% of cases.

Conclusion. ACCF 2012 clinical-and-morphological criteria allow to judge on appropriateness of performed PCI and to evaluate the potential need in PCI among the most part of Russian ACS patients. In present study coronary revascularization was appropriate in the majority of ACS patients. It was shown possible to use the evidence-based clinical-andmorphological criteria for expert evaluation of high-technology procedures implementation in Russian ACS patients.

A Schiff base-derived copper (II) complex is a potent inducer of apoptosis in colon cancer cells by activating the intrinsic pathway

Metal-based drugs with extensive clinical applications hold great promise for the development of cancer chemotherapeutic agents. In the last few decades, Schiff bases and their complexes have become well known for their extensive biological potential. In the present study, we examined the antiproliferative effect of a copper (II) complex on HT-29 colon cancer cells. The Cu(BrHAP)2 Schiff base compound demonstrated a potent antiproliferative effect in HT-29 cells, with an IC50 value of 2.87  μg/ml after 72 h of treatment. HT-29 cells treated with Cu (II) complexes underwent apoptosis death, as exhibited by a progressive elevation in the proportion of the G1 cell population. At a concentration of 6.25  μg/ml, the Cu(BrHAP)2 compound caused significant elevation in ROS production following perturbation of mitochondrial membrane potential and cytochrome c release, as assessed by the measurement of fluorescence intensity in stained cells. Furthermore, the activation of caspases 3/7 and 9 was part of the Cu (II) complex-induced apoptosis, which confirmed the involvement of mitochondrial-mediated apoptosis. Meanwhile, there was no significant activation of caspase-8. Taken together, these results imply that the Cu(BrHAP)2 compound is a potential candidate for further in vivo and clinical colon cancer studies to develop novel chemotherapeutic agents derived from metal-based agents.

Determinants of invasive treatment in lower extremity peripheral arterial disease

OBJECTIVE

Since it is unknown what factors are weighed in a clinician's decision to refer patients with symptomatic lower extremity peripheral arterial disease (PAD) for invasive treatment, we examined the relationship between health status, lesion location, and site variations and invasive treatment referral ≤1 year following diagnosis in patients with PAD.

METHODS

This was a prospective observational cohort study on ambulatory patients that presented themselves at two vascular surgery outpatient clinics. A total of 970 patients with new symptoms of PAD or with an exacerbation of existing PAD symptoms that required clinical evaluation and treatment (Rutherford Grade I) were eligible, 884 consented and were included between March 2006 and November 2010. We report on 505 patients in the current study. Prior to patients' initial PAD evaluation, the Short Form-12, Physical Component Scale (PCS) was administered to measure health status. Anatomical lesion location (proximal vs distal) was derived from duplex ultrasounds. PCS scores, lesion location, and site were evaluated as determinants of receiving invasive (endovascular, surgery) vs noninvasive treatment ≤1 year following diagnosis in Poisson regression analyses, adjusting for demographics, ankle-brachial index, and risk factors.

RESULTS

Invasive treatment as a first-choice was offered to 167 (33%) patients. While an association between poorer health status and invasive therapy was found in unadjusted analyses (relative risk [RR], 0.98; 95% confidence interval [CI], 0.97-1.00; P = .011), proximal lesion location (RR, 3.66; 95% CI, 2.70-4.96; P < .0001) and site (RR, 1.69; 95% CI, 1.11-2.58; P = .014) were independent predictors of invasive treatment referral in the final model.

CONCLUSIONS

One-third of patients were treated invasively following PAD diagnosis. Patients' health status was considered in providers' decision to refer patients for invasive treatment, but having a proximal lesion was the strongest predictor. This study also found some important first indications of site variations in offering invasive treatment among patients with PAD. Future work is needed to further document these variations in care.

Mitochondrial tRNA variants in Chinese subjects with coronary heart disease

BACKGROUND

Coronary heart disease is the leading cause of death worldwide. Mitochondrial genetic determinants for the development of this disorder remain less explored.

METHODS AND RESULTS

We performed a clinical and genetic evaluation and mutational screening of 22 mitochondrial tRNA genes in a cohort of 80 genetically unrelated Han Chinese subjects and 125 members of 4 families with coronary heart disease and 512 Chinese control subjects. This analysis identified 16 nucleotide changes among 9 tRNA genes. Of these, the T5592C mutation creates a highly conservative base pairing (5G-68C) on the acceptor stem of tRNA(Gln), whereas the G15927A mutation destabilizes a highly conserved base pairing (28C-42G) in the anticodon stem of tRNA(Thr). However, the other tRNA variants were polymorphisms. The pedigrees of BJH24 carrying the T5592C mutation, BJH15, and BJH45 harboring the G15927A mutation exhibited maternal transmission of coronary heart disease. Sequence analysis of their mitochondrial genomes revealed the presence of T5592C or G15927A mutation but the absence of other functionally significant mutations in all matrilineal relatives of these families.

CONCLUSIONS

Our previous observations showed that altered structures of tRNAs by these mtDNA mutations caused mitochondrial dysfunction. These may be the first evidence that mtDNA mutations increase the risk of coronary heart disease. Our findings may provide new insights into the pathophysiology of this disorder.

Co-existence of carotid artery disease, renal artery stenosis, and lower extremity peripheral arterial disease in patients with coronary artery disease

In atherosclerosis, carotid artery stenosis (CAS), renal artery stenosis (RAS), lower extremity peripheral arterial disease (PAD), and coronary artery disease (CAD) are common pathologic lesions; their interrelationship is, however, unclear. We studied concomitant multiple atherosclerotic lesions in patients with CAD to understand their prevalence and relations. A cross-sectional analysis was performed on data from consecutive patients who underwent nonemergent coronary angiography. Simultaneous carotid and renal artery Doppler studies and ankle-brachial systolic pressure measurements were reviewed to diagnose concomitant lesions and their severity. The study included 1,734 patients (aged 71 ± 9 years; 70% men), with prevalences of CAS, RAS, lower extremity PAD, and CAD of 6%, 7%, 13%, and 72%, respectively. In patients with CAD (n = 1,253), the prevalences of CAS, RAS, and lower extremity PAD were 7%, 9%, and 16%, respectively; 24% CAD patients had ≥1 additional atherosclerotic lesion. Significant interactions among the prevalences of these lesions were found. In addition, the extent of CAD and the prevalences of CAS, RAS, and lower extremity PAD were significantly correlated. Multivariate analysis supported these relationships. In conclusion, the prevalences of CAS, RAS, lower extremity PAD, and CAD were strongly interrelated in the study population; CAD severity was related to that of other atherosclerotic lesions. Additional systematic screening of other concomitant atherosclerotic lesions is recommended, especially in CAD patients having multivessel disease, left main disease, and/or already diagnosed with other concomitant atherosclerotic lesions.

Patient and hospital characteristics associated with inappropriate percutaneous coronary interventions

OBJECTIVES

This study sought to examine whether rates of inappropriate percutaneous coronary intervention (PCI) differ by demographic characteristics and insurance status.

BACKGROUND

Prior studies have found that blacks, women, and those who have public or no health insurance are less likely to undergo PCI. Whether this reflects potential overuse in whites, men, and privately insured patients, in addition to underuse in disadvantaged populations, is unknown.

METHODS

Within the National Cardiovascular Data Registry CathPCI Registry, we identified 221,254 nonacute PCIs performed between July 2009 and March 2011. The appropriateness of PCI was determined using the Appropriate Use Criteria for coronary revascularization. Multivariable hierarchical regression was used to evaluate the association between patient demographics and insurance status and inappropriate PCI, as defined by the Appropriate Use Criteria.

RESULTS

Of 211,254 nonacute PCIs, 25,749 (12.2%) were classified as inappropriate. After multivariable adjustment, men (adjusted odd ratio [OR]: 1.08 [95% CI: 1.05 to 1.11]; p < 0.001) and whites (adjusted OR: 1.09 [95% CI: 1.05 to 1.14]; p < 0.001) were more likely to undergo an inappropriate PCI in comparison with women and nonwhites. Compared with privately insured patients, those who had Medicare (adjusted OR: 0.85 [95% CI: 0.83 to 0.88]), other public insurance (adjusted OR: 0.78 [95% CI: 0.73 to 0.83]), and no insurance (adjusted OR: 0.56 [95% CI: 0.50 to 0.61]) were less likely to undergo an inappropriate PCI (p < 0.001). In addition, compared with urban hospitals, those admitted at rural hospitals were less likely to undergo inappropriate PCI, whereas those at suburban hospitals were more likely.

CONCLUSIONS

For nonacute indications, PCIs categorized as inappropriate were more commonly performed in men, whites, and those who had private insurance. Higher rates of PCI in these patient populations may, in part, be due to procedural overuse.

Early Atherosclerosis in HIV Infected Subjects on Suppressive Antiretroviral Treatment: Role of Osteoprotegerin

Cardiovascular disease is increased in HIV-infected patients. Cytokines such as osteoprotegerin are implicated in atherosclerosis. The aim of our study was to evaluate the role of osteoprotegerin in the development and progression of atherosclerosis in HIV infected subjects on suppressive antiretroviral treatment. We enrolled 76 patients; 35 HIV infected men on suppressive Highly Active Antiretroviral Therapy with Framingham score <10%; 21 HIV negative individuals matched for age, gender, and Framingham score, and 20 subjects with Framingham score >10% as control groups. HIV positive subjects underwent echocardiography, electrocardiography, and heart multidetector computed tomography, whereas in HIV negative subjects, tomography was only performed in case of any abnormalities either in echocardiography or electrocardiography. In HIV positive patients, computed tomography showed stenosis in 51.4% of the subjects. Osteoprotegerin plasma levels were higher in HIV-infected patients than those in healthy controls but lower than in HIV negative subjects with Framingham score >10%. Higher osteoprotegerin plasma levels were found in HIV positive patients with grade I stenosis than in patients with grade II/III stenosis. In conclusion, in HIV infected subjects with Framingham score <10%, osteoprotegerin plasma concentrations are associated with atherosclerosis, in particular at the early stage of the process.

Analysis Of Medicare Advantage HMOs compared with traditional Medicare shows lower use of many services during 2003-09

Enrollment in Medicare Advantage, the managed care program for Medicare beneficiaries, has grown rapidly, from 4.6 million enrollees in 2003 to 12.8 million by 2012, or 27 percent of all current Medicare beneficiaries. We analyzed utilization patterns of enrollees in Medicare Advantage health maintenance organization (HMO) plans compared to matched samples of people in traditional Medicare during 2003-09, to ascertain whether the HMO enrollees demonstrated different levels of use of services, which can be a hallmark of more integrated care. We found that utilization rates in some major categories, including emergency departments and ambulatory surgery or procedures, generally were 20-30 percent lower in Medicare Advantage HMOs in all years. Medicare Advantage HMO enrollees initially had lower rates of ambulatory visits and hospitalizations, although these rates converged by 2008; they also received about 10 percent fewer hip or knee replacements. In contrast, HMO enrollees underwent more coronary bypass surgery than patients in traditional Medicare. These findings suggest that overall, Medicare Advantage HMO enrollees might use fewer services and be experiencing more appropriate use of services than enrollees in traditional Medicare.

Advanced cardiovascular stent coated with nanofiber

Nanofiber was explored as a stent surface coating substance for the treatment of coronary artery diseases (CAD). Nanofibers loaded with nanoparticles containing β-estradiol were developed and exploited to prevent stent-induced restenosis through regulation of the reactive oxygen species (ROS). Eudragit S-100 (ES), a versatile polymer, was used as a nanoparticle (NP) base, and the mixtures of hexafluoro-2-propanol (HFIP), PLGA and PLA at varying ratios were used as a nanofiber base. β-Estradiol was used as a primary compound to alleviate the ROS activity at the subcellular level. Nile-Red was used as a visual marker. Stent was coated with nanofibers produced by electrospinning technique comprising the two-step process. Eudragit nanoparticles (ES-NP) as well as 4 modified types of NP-W (ES-NP were dispersed in H2O, which was mixed with HFIP (1:1 (v/v) and then subsequently added with 15% PLGA), NP-HW (ES-NP were dispersed in H2O, which was mixed with HFIP (1:1 (v/v)) already containing 15% PLGA), NP-CHA (ES-NP with a chitosan layer were added in H2O, which was mixed with HFIP (1:1 (v/v)) containing 15% PLGA), and NP-CHB (ES-NP with a chitosan layer were added in H2O, which was mixed with HFIP (1:1 (v/v)) containing the mixture of PLGA and PLA at a ratio of 4:1) were developed, and their properties, such as the loading capacity of β-estradiol, the release profiles of β-estradiol, cell cytotoxicity and antioxidant responses to ROS, were characterized and compared. Among composite nanofibers loaded with nanoparticles, NP-CHB had the maximal yield and drug-loading amount of 66.5 ± 3.7% and 147.9 ± 10.1 μg, respectively. The nanofibers of NP-CHB coated on metallic mandrel offered the most sustained release profile of β-estradiol. In the confocal microscopy study, NP-W exhibited a low fluorescent intensity of Nile-Red as compared with NP-HW, indicating that the stability of nanoparticles decreased, as the percentage volume of the organic solvent increased. Nanofibers incorporated with β-estradiol yielded a high endothelial proliferation rate, which was about 3-fold greater than the control (without β-estradiol). The cells treated with the enhanced level of H2O2 (>1 mM: as ROS source) were mostly nonviable (81.1 ± 12.4%, p < 0.01), indicating that ROS induce cell apoptosis and trigger the rupture of atheroma thin layer in a concentration dependent manner. Nanofibers containing β-estradiol (0.5 mM) lowered cellular cytotoxicity from 25.2 ± 4.9% to 8.1 ± 1.4% in the presence of 600 μM H2O2, and from 86.8 ± 8.4% to 59.4 ± 8.7% in the presence of 1.0 mM H2O2, suggesting that β-estradiol efficiently protected hPCECs from ROS induced cytotoxicity. The level of NO production in hPCECs in the presence of β-estradiol after 6 days of incubation was much greater than that of the control without β-estradiol. In summary, nanofibers loaded with nanoparticles containing β-estradiol could be used as a suitable platform for the surface coating of a cardiovascular stent, achieving enhanced endothelialization at the implanted sites of blood vessels.

Appropriateness of percutaneous coronary intervention: a review

The appropriateness of coronary revascularization for various clinical scenarios has been reviewed formally by several specialty and subspecialty societies resulting in the formulation of scored appropriateness criteria. The goal of the appropriateness criteria is to guide physician decision-making and future research as well as to label coronary revascularization more clearly for patients and payors in regards to its expected benefits in certain situations. The appropriateness criteria were formulated from a standardized process and are intended to be updated at regular intervals as new data further elucidates the clinical roles of revascularization. Since its last iteration in early 2012, several studies have been published that may further expand scenarios or impact the appropriateness of revascularization in already-established scenarios. The differentiation of appropriateness with particular forms of revascularization has been reserved for specific clinical scenarios where revascularization is generally considered necessary and appropriate. The goals of this review are 1) to highlight aspects of the methodology and development of the coronary revascularization appropriateness criteria, and 2) to focus on the role established specifically for percutaneous coronary intervention within the criteria. Important data published in 2012 that further evaluates the role of percutaneous coronary intervention will also be reviewed with a focus on its potential impact on future iterations of the appropriateness criteria.