Drug-eluting stents versus bare-metal stents for acute coronary syndrome

Long-term cardiovascular outcomes of biodegradable polymer drug eluting stents in patients with diabetes versus non-diabetes mellitus: a meta-analysis

BACKGROUND

Today, diabetes mellitus (DM) has become a worldwide concern. DM is a major risk factor for the development of cardiovascular diseases (CVD). Eligible patients with CVD are treated invasively by percutaneous coronary intervention (PCI) whereby a stent is implanted inside the coronary vessel with the particular lesion to allow sufficient blood flow. Newer scientific research have shown that even though associated with a lower rate of re-stenosis, first-generation drug eluting stents (DES) were associated with a higher rate of late stent thrombosis. Recently, newer stents, namely biodegradable polymer DES (BP-DES) have been developed to overcome the safety issues of earlier generation DES. In this analysis we aimed to systematically compare the long term (≥ 12 months) adverse cardiovascular outcomes observed in DM versus non-DM patients who were implanted with BP-DES.

METHODS

Cochrane central, MEDLINE (Subset PubMed), EMBASE, Web of Science, http://www.

CLINICALTRIALS

gov and Google scholar were searched for relevant publications involving BP-DES in patients with DM versus non-DM and their associated adverse cardiovascular outcomes. The mean follow-up time period ranged from 12 to 120 months. Data analysis was carried out with the latest version of the RevMan software (version 5.4). Based on the Mantel-Haenszel test, risk ratios (RR) with 95% confidence intervals (CI) were calculated and used to represent the results following analysis.

RESULTS

Seven (7) studies with a total number of 10,246 participants were included in this analysis. Stents which were implanted during PCI were BP-DES. Participants were enrolled from the year 2006 to 2013. Our current results showed that in patients who were implanted with BP-DES, the risks of major adverse cardiac events (RR: 1.30, 95% CI: 1.18-1.43; P = 0.00001), myocardial infarction (RR: 1.48, 95% CI: 1.14-1.93; P = 0.003), all-cause mortality (RR: 1.70, 95% CI: 1.29-2.23; P = 0.0002), cardiac death (RR: 1.93, 95% CI: 1.28-2.93; P = 0.002), target vessel revascularization (RR: 1.35, 95% CI: 1.03-1.77; P = 0.03), target lesion revascularization (RR: 1.28, 95% CI: 1.07-1.54; P = 0.007) and target lesion failure (RR: 1.79, 95% CI: 1.52-2.12; P = 0.00001) were significantly higher in the DM group. Definite and probable stent thrombosis (RR: 1.80, 95% CI: 1.28-2.55; P = 0.0009) were also significantly higher in the DM group.

CONCLUSIONS

Diabetes mellitus was an independent risk factor associated with long term adverse cardiovascular outcomes following PCI with BP-DES.

Trends in antiplatelet strategies 12-months following coronary stent placement in anticoagulated patients

BACKGROUND

Antithrombotic guidelines for patients undergoing percutaneous coronary interventions (PCIs) and also requiring anticoagulant medications are evolving. This study describes changes to antithrombotic therapy and associated outcomes 12-months following PCI in patients requiring ongoing anticoagulation therapy.

METHODS

Records of patients identified from queries of electronic medical records were manually reviewed to verify changes to antithrombotic therapy from discharge to 12-months and at 12-months following PCI, and episodes of major bleeding, clinically relevant non-major bleeding (CRNMB), major adverse cardiovascular or neurological events (MACNE), and all-cause mortality outcomes during an additional 6-months follow-up.

RESULTS

Patients (n = 120) receiving anticoagulation therapy at 12-months post PCI were classified into the following groups according to antiplatelet therapy status: no antiplatelet therapy (n = 16), single antiplatelet therapy (SAPT) (n = 85), and dual antiplatelet therapy (DAPT) (n = 19). Between 12- and 18-months following PCI there were 2 major bleeds, 7 CRNMB, 6 MACNE, 2 venous thromboembolisms, and 5 deaths. All but one bleeding episode occurred in the SAPT group. The odds of remaining on DAPT at 12-months were higher in patients who had PCI for acute coronary syndrome (odds ratio [OR] 2.91, 95% confidence interval [CI] 0.96, 8.77), and in those experiencing MACNE in the 12-months following PCI (OR 1.95, 95% CI 0.67, 5.66), but these associations were not statistically significant.

CONCLUSION

Most anticoagulated patients were continued on antiplatelet therapy 12-months post PCI. Bleeding was numerically more common in anticoagulated patients continuing SAPT therapy beyond 12 months. There was significant variability in antithrombotic prescribing patterns 12-months post PCI suggesting a potential opportunity for standardizing care in this patient population.

Clinical results of everolimus-eluting stents and sirolimus-eluting stents in patients undergoing percutaneous coronary intervention

Background

It has been pronounced that everolimus-eluting stent (EES) had lower charge of goal-lesion revascularization and stent thrombosis as compared with sirolimus-eluting stents (SES).The goal of this observation was to compare the efficacy and protection of EES with SES in primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI).

Methods

In this retrospective study, a total of 404 patients with coronary artery stenosis who underwent angioplasty of one or more coronary arteries were included in the study. Of these, 202 were treated with SES and the others with EES. The data were collected by a questionnaire through which the annual incidence of coronary stent complications including the occurrence of stent thrombosis (confirmed by re-angiography), the occurrence of acute coronary syndrome leading to hospitalization, the occurrence of vascular myocardial infarction related to the stenting vessel, the need for re-angiography and angioplasty and finally the incidence of cardiac mortality were evaluated.

Results

This study showed that the odds ratio of EES thrombosis to SES stent in the unadjusted model is 1.01 (0.06-16.34) and in the adjusted model for confounding variables was equal to 0.80 (0.04-13.35) which in both models, these values were not statistically significant.

Conclusion

The findings of the present study indicate that there is no statistically significant difference between the outcomes in the two groups treated with SES and EES release stents.

Predicting Cardiovascular Stent Complications Using Self-Reporting Biosensors for Noninvasive Detection of Disease

Self-reporting implantable medical devices are the future of cardiovascular healthcare. Cardiovascular complications such as blocked arteries that lead to the majority of heart attacks and strokes are frequently treated with inert metal stents that reopen affected vessels. Stents frequently re-block after deployment due to a wound response called in-stent restenosis (ISR). Herein, an implantable miniaturized sensor and telemetry system are developed that can detect this process, discern the different cell types associated with ISR, distinguish sub plaque components as demonstrated with ex vivo samples, and differentiate blood from blood clot, all on a silicon substrate making it suitable for integration onto a vascular stent. This work shows that microfabricated sensors can provide clinically relevant information in settings closer to physiological conditions than previous work with cultured cells.

Drug-Eluting Stents: Their Preventative/Prophylactic Role Against Gemcitabine Induced Acute Coronary Syndrome

Acute coronary syndrome (ACS), a subdivision of ischemic cardiac disease, is the sudden occlusion of coronary vessels that results in decreased blood supply to heart muscles and possible infarction. Though some of the etiologies are hypertension, hyperlipidemia, diabetes mellitus, and tobacco; certain types of chemotherapies play a major role. Percutaneous coronary intervention (PCI) has shown lifesaving results via drug-eluting stent (DES) deployment into occluded vessels. In this study, DES utilization among patients receiving chemotherapy will be assessed to observe if it provides any prevention against ACS.

Articles were systematically screened in three databases such as PubMed, PubMed Central (PMC), and Medical Literature Analysis and Retrieval System Online (MEDLINE) using keywords and Medical Subject Heading (MeSH) terms for applicable articles. Additionally, a few relevant articles from the Cochrane Library, Molecular Diversity Preservation International (MDPI), and The New England Journal of Medicine were also used. Inclusion/exclusion criteria were applied post article screening via title and abstracts. Quality appraisal check was done using the Scale for the Assessment of Narrative Review Articles (SANRA) checklist, A Measurement Tool to Assess Systematic Reviews (AMSTAR) checklist, Cochrane bias assessment tool, and Joanna Briggs Institute (JBI) checklist. Ten related studies were strictly reviewed. DES did not appear to play a preventable role against ACS during chemotherapy as no study was found assessing DES prophylactically and its efficacy in cancer patients.

Future clinical trials on DES prophylactic use might be beneficial to evaluate if ACS adversities of chemotherapy can be prevented. This review is of significant benefit as cardiovascular adversities would not impede chemotherapy efficacy as cardiac adversities would not be part of the equation.

Effects of National Hospital Accreditation in Acute Coronary Syndrome on In-Hospital Mortality and Clinical Outcomes

Background

Acute coronary syndrome (ACS) is a life-threatening medical condition that accounts for an annual expenditure of more than $300 billion in the United States. Hospital accreditation has been shown to improve patient and hospital outcomes for various conditions.

Objectives

This study aimed to determine the benefits of hospital accreditation in patients with ACS.

Methods

This nationwide population-based cohort study used Taiwan's National Health Insurance Research Database from 1997 to 2011 (n = 249,354). Multivariable logistic regression was used to analyze the risk of in-hospital events among those treated in accredited and non-accredited hospitals, and to compare outcomes in hospitals before and after accreditation. The effect of accreditation on these events was also stratified by accreditation grade.

Results

A total of 823 hospitals were included, of which 2.4% were medical centers, 13.7% were regional hospitals, and 83.8% were district hospitals. The in-hospital mortality [odds ratio (OR), 0.82; 95% confidence interval (CI), 0.79-0.85; p < 0.001] and recurrent acute myocardial infarction (AMI) admission (OR, 0.81; 95% CI, 0.71-0.93; p = 0.003) rates were significantly lower in the after-accreditation group than in the before-accreditation group. There was a substantial and marked decrease in the in-hospital mortality rate after accreditation in 2008.

Conclusions

This cohort study demonstrated that ACS accreditation was associated with better in-hospital mortality and recurrent AMI admission rates in ACS patients.

Triglyceride to high-density lipoprotein cholesterol ratio as a risk factor of repeat revascularization among patients with acute coronary syndrome after first-time percutaneous coronary intervention

BACKGROUND

It is clinically important to identify high-risk patients with acute coronary syndrome (ACS) who may require repeat revascularization. This retrospective study identified risk factors for repeat revascularization among ACS patients after first-time successful percutaneous coronary interventions (PCIs). The predictive value of the triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio for repeat revascularization was also evaluated.

METHODS

We enrolled consecutive ACS patients who had coronary angiography performed during the period from 6 to 12 months after a first-time successful PCI. The primary outcome of the study was to identify the risk factors of repeat revascularization. The subjects were stratified based on repeat PCI events. After comparing various clinical characteristics, univariate and multivariate Cox proportional hazard model analyses were adopted to evaluate the effects of risk factors on repeat revascularization.

RESULTS

The patients (n=271) were divided into the event (+) group (n=101) and the event (-) group (n=170). In the event (+) group, target lesion revascularization (TLR) accounted for 20.79% and target vessel revascularization (TVR) accounted for 50.49% of the patients. In contrast, 52.47% of the patients required de novo vessel revascularization (DVR). After adjustment for confounding factors, the TG/HDL-C ratio [hazard ratio (HR) =1.206, 95% confidence interval (CI): 1.016-1.431, P=0.032 for each higher TG/HDL-C ratio unit] and the Gensini score (HR =1.012, 95% CI: 1.005-1.018, P<0.001 for each higher Gensini score unit) were independent risk factors for a repeat PCI. Subgroup analyses showed that higher TG/HDL-C ratios were associated with a significantly higher risk of repeat PCIs in the male, hypertensive, and diabetes mellitus subgroups.

CONCLUSIONS

The TG/HDL-C ratio and Gensini score could serve as risk factors for repeat revascularization in ACS patients after a first-time successful PCI.

The Future of Cardiovascular Stents: Bioresorbable and Integrated Biosensor Technology

Cardiovascular disease is the greatest cause of death worldwide. Atherosclerosis is the underlying pathology responsible for two thirds of these deaths. It is the age-dependent process of "furring of the arteries." In many scenarios the disease is caused by poor diet, high blood pressure, and genetic risk factors, and is exacerbated by obesity, diabetes, and sedentary lifestyle. Current pharmacological anti-atherosclerotic modalities still fail to control the disease and improvements in clinical interventions are urgently required. Blocked atherosclerotic arteries are routinely treated in hospitals with an expandable metal stent. However, stented vessels are often silently re-blocked by developing "in-stent restenosis," a wound response, in which the vessel's lumen renarrows by excess proliferation of vascular smooth muscle cells, termed hyperplasia. Herein, the current stent technology and the future of biosensing devices to overcome in-stent restenosis are reviewed. Second, with advances in nanofabrication, new sensing methods and how researchers are investigating ways to integrate biosensors within stents are highlighted. The future of implantable medical devices in the context of the emerging "Internet of Things" and how this will significantly influence future biosensor technology for future generations are also discussed.

Strategies to prevent stricture after esophageal endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) has been widely applied as a less invasive and more effective method for treating early esophageal cancers such as squamous cell carcinoma and dysplasia of Barrett's esophagus. However, post-ESD esophageal stricture often occurs if patients suffer circumferential mucosal defects of more than three-quarters of the circumference of the esophagus, which makes it difficult for patients to swallow and greatly reduces their quality of life. Moreover, there is currently no standard method to treat post-ESD esophageal stricture, even though it is extraordinarily important to prevent its formation. In recent years, several strategies to prevent esophageal stricture have emerged. These strategies can be classified into pharmacological, mechanical, tissue engineering, and other novel strategies, with each strategy having its own strengths and weaknesses. Although the pharmacological prophylaxis and mechanical strategies are relatively mature, they still have their drawbacks like high time-consumption, the occurrence of re-stricture, and significant side effects. Tissue engineering strategies and other novel strategies have shown promising preliminary results, but more clinical trials are needed. In this review, we discuss these strategies, with a particular focus on tissue engineering strategies and other novel strategies. It is hoped that this discussion will aid in finding more effective and safer strategies to prevent esophageal stricture.

Prothrombin complex concentrate versus placebo, no intervention, or other interventions in critically bleeding patients associated with oral anticoagulant administration: a protocol for a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis

BACKGROUND

Acute critical bleeding is one of the most feared complications during treatment with oral anticoagulating agents. As more patients undergo treatment with anticoagulating agents, critically bleeding episodes in patients with vitamin K antagonists, thrombin inhibitor, or factor Xa inhibitor-inducted coagulopathy will be encountered frequently by physicians. Hence, an effective treatment capable of reversing the iatrogenic coagulopathy in the acute setting is needed. In randomised clinical trials and observational studies, prothrombin complex concentrate has been reported to be superior to other acute interventions, and many guidelines recommend prothrombin complex concentrate in treatment of critically bleeding patients. The aim of this systematic review is to synthesise the evidence of the effects of prothrombin complex concentrate compared with placebo, no intervention, or other treatment options in critically bleeding patients treated with oral anticoagulants.

METHODS/DESIGN

A comprehensive search for relevant published literature will be undertaken in Cochrane Central Register of Controlled Trials, MEDLINE, Embase, WHO International Clinical Trials Registry Platform, Science Citation Index, regulatory databases, and trial registers. We will include randomised clinical trials comparing prothrombin complex concentrate versus placebo, no intervention, or other interventions in critically bleeding patients with oral anticoagulant-induced coagulopathy. Data extraction and risk of bias assessment will be handled by two independent review authors. Meta-analysis will be performed as recommended by Cochrane Handbook for Systematic Reviews of Interventions, bias will be assessed with domains, and trial sequential analysis will be conducted to control random errors. Certainty will be assessed by GRADE.

DISCUSSION

As critical bleeding in patients treated with oral anticoagulants is an increasing problem, an up-to-date systematic review evaluating the benefits and harms of prothrombin complex concentrate is urgently needed. It is the hope that this review will be able to guide best practice in treatment and clinical research of these critically bleeding patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018084371.

Association of Decreased Docosahexaenoic Acid Level After Statin Therapy and Low Eicosapentaenoic Acid Level with In-Stent Restenosis in Patients with Acute Coronary Syndrome

Aim: It is speculated that statin therapy modulates the synthesis of polyunsaturated fatty acids (PUFA), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). However, the data available on the effects of statin therapy on the serum levels of PUFA and the subsequent impact on in-stent restenosis (ISR) in patients with acute coronary syndrome (ACS) are limited.

Methods: A total of 120 ACS patients who received emergent coronary stent implantation, follow-up coronary angiography to evaluate ISR, and new statin therapy were enrolled. We measured the serum levels of the PUFA and lipids at the onset of ACS and at the follow-up coronary angiography.

Results: The follow-up coronary angiography revealed 38 ISR cases. New statin therapy significantly reduced the serum levels of DHA and low-density lipoprotein cholesterol (LDL-C), while it did not affect EPA level. Single regression analysis revealed that a decreased serum level of LDL-C was associated with decreased DHA level. The multiple logistic regression analysis revealed that the decreased DHA level after statin therapy and low serum level of EPA on admission were determinants of prevalence of ISR.

Conclusion: Statin therapy decreased the serum level of DHA with a parallel reduction in LDL-C level in patients with ACS. Decreased DHA level after statin therapy and low EPA level on admission are risk factors for ISR, indicating that in patients with ACS, decreased serum levels of DHA may be a residual target for the prevention of ISR.

Drug-eluting stents versus bare-metal stents for acute coronary syndrome

BACKGROUND

Approximately 3.7 million people died from acute coronary syndrome worldwide in 2012. Acute coronary syndrome, also known as myocardial infarction or unstable angina pectoris, is caused by a sudden blockage of the blood supplied to the heart muscle. Percutaneous coronary intervention is often used for acute coronary syndrome, but previous systematic reviews on the effects of drug-eluting stents compared with bare-metal stents have shown conflicting results with regard to myocardial infarction; have not fully taken account of the risk of random and systematic errors; and have not included all relevant randomised clinical trials.

OBJECTIVES

To assess the benefits and harms of drug-eluting stents versus bare-metal stents in people with acute coronary syndrome.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, SCI-EXPANDED, and BIOSIS from their inception to January 2017. We also searched two clinical trials registers, the European Medicines Agency and the US Food and Drug Administration databases, and pharmaceutical company websites. In addition, we searched the reference lists of review articles and relevant trials.

SELECTION CRITERIA

Randomised clinical trials assessing the effects of drug-eluting stents versus bare-metal stents for acute coronary syndrome. We included trials irrespective of publication type, status, date, or language.

DATA COLLECTION AND ANALYSIS

We followed our published protocol and the methodological recommendations of Cochrane. Two review authors independently extracted data. We assessed the risks of systematic error by bias domains. We conducted Trial Sequential Analyses to control the risks of random errors. Our primary outcomes were all-cause mortality, major cardiovascular events, serious adverse events, and quality of life. Our secondary outcomes were angina, cardiovascular mortality, and myocardial infarction. Our primary assessment time point was at maximum follow-up. We assessed the quality of the evidence by the GRADE approach.

MAIN RESULTS

We included 25 trials randomising a total of 12,503 participants. All trials were at high risk of bias, and the quality of evidence according to GRADE was low to very low. We included 22 trials where the participants presented with ST-elevation myocardial infarction, 1 trial where participants presented with non-ST-elevation myocardial infarction, and 2 trials where participants presented with a mix of acute coronary syndromes.Meta-analyses at maximum follow-up showed no evidence of a difference when comparing drug-eluting stents with bare-metal stents on the risk of all-cause mortality or major cardiovascular events. The absolute risk of death was 6.97% in the drug-eluting stents group compared with 7.74% in the bare-metal stents group based on the risk ratio (RR) of 0.90 (95% confidence interval (CI) 0.78 to 1.03, 11,250 participants, 21 trials/22 comparisons, low-quality evidence). The absolute risk of a major cardiovascular event was 6.36% in the drug-eluting stents group compared with 6.63% in the bare-metal stents group based on the RR of 0.96 (95% CI 0.83 to 1.11, 10,939 participants, 19 trials/20 comparisons, very low-quality evidence). The results of Trial Sequential Analysis showed that we did not have sufficient information to confirm or reject our anticipated risk ratio reduction of 10% on either all-cause mortality or major cardiovascular events at maximum follow-up.Meta-analyses at maximum follow-up showed evidence of a benefit when comparing drug-eluting stents with bare-metal stents on the risk of a serious adverse event. The absolute risk of a serious adverse event was 18.04% in the drug-eluting stents group compared with 23.01% in the bare-metal stents group based on the RR of 0.80 (95% CI 0.74 to 0.86, 11,724 participants, 22 trials/23 comparisons, low-quality evidence), and Trial Sequential Analysis confirmed this result. When assessing each specific type of adverse event included in the serious adverse event outcome separately, the majority of the events were target vessel revascularisation. When target vessel revascularisation was analysed separately, meta-analysis showed evidence of a benefit of drug-eluting stents, and Trial Sequential Analysis confirmed this result.Meta-analyses at maximum follow-up showed no evidence of a difference when comparing drug-eluting stents with bare-metal stents on the risk of cardiovascular mortality (RR 0.91, 95% CI 0.76 to 1.09, 9248 participants, 14 trials/15 comparisons, very low-quality evidence) or myocardial infarction (RR 0.98, 95% CI 0.82 to 1.18, 10,217 participants, 18 trials/19 comparisons, very low-quality evidence). The results of the Trial Sequential Analysis showed that we had insufficient information to confirm or reject our anticipated risk ratio reduction of 10% on cardiovascular mortality and myocardial infarction.No trials reported results on quality of life or angina.

AUTHORS' CONCLUSIONS

The current evidence suggests that drug-eluting stents may lead to fewer serious adverse events compared with bare-metal stents without increasing the risk of all-cause mortality or major cardiovascular events. However, our Trial Sequential Analysis showed that there currently was not enough information to assess a risk ratio reduction of 10% for all-cause mortality, major cardiovascular events, cardiovascular mortality, or myocardial infarction, and there were no data on quality of life or angina. The evidence in this review was of low to very low quality, and the true result may depart substantially from the results presented in this review.More randomised clinical trials with low risk of bias and low risks of random errors are needed if the benefits and harms of drug-eluting stents for acute coronary syndrome are to be assessed properly. More data are needed on the outcomes all-cause mortality, major cardiovascular events, quality of life, and angina to reduce the risk of random error.