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Lee OH, Kim Y, Son NH, Cho DK, Kim JS, Kim BK, Choi D, Hong MK, Jeong MH, Jang Y. Safety and Efficacy of Contemporary Drug-Eluting Stents in Patients With ST-Segment Elevation Myocardial Infarction and a High Ischemic Risk. Front Cardiovasc Med 2022; 9:880351. [PMID: 35677690 PMCID: PMC9167955 DOI: 10.3389/fcvm.2022.880351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background In patients with ST-elevation myocardial infarction (STEMI) with a high risk of ischemic events, the safety and efficacy of drug-eluting stent (DES) are unclear. Methods Based on the nationwide, multicenter, prospective registry, we selected 1,592 patients who underwent primary percutaneous coronary intervention (PCI) with everolimus-(EES) and zotarolimus-eluting stent (ZES) for STEMI with a high risk of an ischemic event. The occurrence of target lesion failure (TLF) for 3 years, defined as the composite of cardiac death, target vessel myocardial infarction (TV-MI), and ischemia-driven target lesion revascularization (ID-TLR), was evaluated. Results The prevalence of high ischemic risk features was observed in 43.4% (2,744/6,325) of overall patients with STEMI. Among them, a total of 1,078 and 514 patients were treated with EES and ZES, respectively. At 3 years, the risk of TLF was not significantly different between the two groups (p = 0.93). In addition, the incidence of cardiac death, TV-MI, ID-TLR, and definite/probable stent thrombosis (ST) were also not different between the two groups. Moreover, elderly patients (age > 75 years) and PCI for the left main disease were identified as independent predictors of TLF. Conclusion Implantation of EES or ZES provided comparable clinical outcomes in STEMI patients and high ischemic risks.
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Affiliation(s)
- Oh-Hyun Lee
- Yonsei University College of Medicine Cardiovascular Center, Yongin Severance Hospital, Yongin-si, South Korea
| | - Yongcheol Kim
- Yonsei University College of Medicine Cardiovascular Center, Yongin Severance Hospital, Yongin-si, South Korea
| | - Nak-Hoon Son
- Data Science Team (Biostatistician), Center for Digital Health, Yongin Severance Hospital, Yongin-si, South Korea
- Department of Statistics, Keimyung University, Daegu, South Korea
| | - Deok-Kyu Cho
- Yonsei University College of Medicine Cardiovascular Center, Yongin Severance Hospital, Yongin-si, South Korea
| | - Jung-Sun Kim
- Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, South Korea
| | - Byeong-Keuk Kim
- Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, South Korea
| | - Donghoon Choi
- Yonsei University College of Medicine Cardiovascular Center, Yongin Severance Hospital, Yongin-si, South Korea
| | - Myeong-Ki Hong
- Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, South Korea
| | - Myung Ho Jeong
- Chonnam National University Hospital and Medical School, Gwangju, South Korea
- *Correspondence: Myung Ho Jeong,
| | - Yangsoo Jang
- Department of Cardiology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam-si, South Korea
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Chandrasekhar J, Sartori S, Aquino MB, Baber U, Hájek P, Atzev B, Hudec M, Ong TK, Mates M, Borisov B, Warda HM, den Heijer P, Wojcik J, Iniguez A, Coufal Z, Khashaba A, Schee A, Munawar M, Gerber RT, Yan BP, Tejedor P, Kala P, Liew HB, Lee M, Kalkman DN, Dangas GD, de Winter RJ, Colombo A, Mehran R. Comparison of One-Year Outcomes in Patients >75 Versus ≤75 Years With Coronary Artery Disease Treated With COMBO Stents (From The MASCOT Registry). Am J Cardiol 2020; 127:1-8. [PMID: 32418717 DOI: 10.1016/j.amjcard.2020.04.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/07/2020] [Accepted: 04/13/2020] [Indexed: 12/20/2022]
Abstract
Older patients who undergo coronary interventions are at greater risk of ischemic events and less likely to tolerate prolonged dual antiplatelet therapy (DAPT) due to bleeding risk. The COMBO biodegradable polymer sirolimus-eluting stent promotes rapid endothelialization through endothelial progenitor cell capture technology which may be advantageous in elderly patients. We compared 1-year clinical outcomes and DAPT cessation events in patients >75 versus ≤75 years from the MASCOT registry. MASCOT was a prospective, multicenter cohort study of all-comers undergoing attempted COMBO stenting. The primary endpoint was 1-year target lesion failure (TLF), composite of cardiac death, myocardial infarction (MI) not clearly attributed to a nontarget vessel or clinically driven target lesion revascularization. Bleeding was adjudicated using the Bleeding Academic Research Consortium criteria. Adjusted outcomes were analyzed using Cox regression methods. The study included 18% (n = 479) patients >75 years and 72% (n = 2,135) patients ≤75 years. One-year TLF occurred in 4.6% patients >75 years versus 3.1% patients ≤75years of age, p = 0.10; adj hazard ratio 1.36, 95% confidence intervals 0.77 to 2.38, p = 0.29. There were no significant differences in cardiac death (1.7% vs 1.3%, p = 0.55), MI (2.1% vs 1.2%, p = 0.14), target lesion revascularization (1.7% vs 1.4%, p = 0.60) and definite stent thrombosis (0.8% vs 0.4%, p = 0.19). Major Bleeding Academic Research Consortium 3,5 bleeding (3.1% vs 1.5%, p = 0.01) and DAPT cessation rates (32.4% vs 23.0%, p <0.001) were significantly higher in elderly patients. In conclusion, elderly patients >75 years treated with COMBO stents had similar TLF but significantly greater incidence of bleeding than younger patients and DAPT cessation in one-third of patients over 1 year.
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Affiliation(s)
- Jaya Chandrasekhar
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA; Amsterdam UMC, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Samantha Sartori
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Melissa B Aquino
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Usman Baber
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Petr Hájek
- Motol University Hospital, Prague, Czech Republic
| | | | | | | | - Martin Mates
- Nemocnice na Homolce - Kardiologie, Prague, Czech Republic
| | | | - Hazem M Warda
- Alhyatt Cardiovascular Center and Tanta University Hospital, Alexandria, Egypt
| | | | - Jaroslaw Wojcik
- Hospital of Invasive Cardiology IKARDIA, Lublin/Nałęczów, Poland
| | | | - Zdeněk Coufal
- T. Bata Regional Hospital Zlin, Zlin, Czech Republic
| | | | - Alexandr Schee
- Karlovarská krajská nemocnice a.s., Karlovy Vary, Czech Republic
| | | | | | - Bryan P Yan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | | | - Petr Kala
- University Hospital Brno, Brno, Czech Republic
| | | | - Michael Lee
- Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Deborah N Kalkman
- Amsterdam UMC, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - George D Dangas
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Robbert J de Winter
- Amsterdam UMC, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | | | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA.
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Esmonde S, Sharma D, Peace A. Antiplatelet agents in uncertain clinical scenarios-a bleeding nightmare. Cardiovasc Diagn Ther 2018; 8:647-662. [PMID: 30498688 PMCID: PMC6232352 DOI: 10.21037/cdt.2018.06.09] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 06/28/2018] [Indexed: 12/14/2022]
Abstract
Despite over 40 years since the first percutaneous coronary intervention (PCI) was performed, the optimal dual antiplatelet therapy (DAPT) regime poses a significant challenge for clinicians, especially in certain scenarios. DAPT is the standard of care in PCI following an acute coronary syndrome (ACS) or for elective patients with obstructive coronary artery disease (CAD). There remains significant uncertainty regarding DAPT in patients at high risk of bleeding, such as the elderly and patients requiring anticoagulation. More and more clinicians are faced with a dilemma of weighing risks and benefits from the increasing list of potent, new antiplatelet agents and direct oral anticoagulants (DOACs) in a growing, aging population. Historically, most studies failed to recognize bleeding risk, instead focusing on ischemic risk. In recent years however, bleeding has been recognized as a very significant driver of morbidity and mortality in patients undergoing PCI. There is a paucity of data in this cohort leading to divergent and sometimes conflicting recommendations, largely based on expert consensus of opinion. In the current review, we critically evaluate the available evidence in these uncertain scenarios.
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Affiliation(s)
- Sean Esmonde
- Department of Cardiology, Altnagelvin Area Hospital, Western Health and Social Care Trust, Derry/Londonderry, Northern Ireland, UK
| | - Divyesh Sharma
- Department of Cardiology, Altnagelvin Area Hospital, Western Health and Social Care Trust, Derry/Londonderry, Northern Ireland, UK
| | - Aaron Peace
- Department of Cardiology, Altnagelvin Area Hospital, Western Health and Social Care Trust, Derry/Londonderry, Northern Ireland, UK
- Northern Ireland Centre for Stratified Medicine, Ulster University, C-TRIC, Derry/Londonderry, Northern Ireland, UK
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Discretionary decisions and disparities in receiving drug-eluting stents under a universal healthcare system: A population-based study. PLoS One 2017; 12:e0179127. [PMID: 28594876 PMCID: PMC5464647 DOI: 10.1371/journal.pone.0179127] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 05/24/2017] [Indexed: 11/19/2022] Open
Abstract
Objectives One of the main objectives behind the expansion of insurance coverage is to eliminate disparities in health and healthcare. However, researchers have not yet fully elucidated the reasons for disparities in the use of high-cost treatments among patients of different occupations. Furthermore, it remains unknown whether discretionary decisions made at the hospital level have an impact on the administration of high-cost interventions in a universal healthcare system. This study investigated the adoption of drug-eluting stents (DES) versus bare metal-stents (BMS) among patients in different occupations and income levels, with the aim of gauging the degree to which the inclination of health providers toward treatment options could affect treatment choices at the patient-level within a universal healthcare system. Design and participants We adopted a cross-sectional observational study design using hierarchical modeling in conjunction with the population-based National Health Insurance database of Taiwan. Patients who received either a BMS or a DES between 2007 and 2010 were included in the study. Results During the period of study, 42,124 patients received a BMS (65.3%) and 22,376 received DES (34.7%). Patients who were physicians or the family members of physicians were far more likely to receive DES (OR: 3.18, CI: 2.38–4.23) than were patients who were neither physicians nor in other high-status jobs (employers, other medical professions, or public service). Similarly, patients in the top 5% income bracket had a higher probability of receiving a DES (OR: 2.23, CI: 2.06–2.47, p < .001), than were patients in the lowest income bracket. After controlling for patient-level factors, the inclination of hospitals (proportion of DES>50% or between 25% and 50%) was shown to be strongly associated with the selection of DESs (OR: 3.64 CI: 3.24–4.09 and OR: 2.16, CI: 2.01–2.33, respectively). Conclusions Even under the universal healthcare system in Taiwan, socioeconomic disparities in the use of high-cost services remain widespread. Differences in the care received by patients of lower socioeconomic status may be due to the discretionary decisions of healthcare providers.
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Lee MS, Shlofmitz E, Lluri G, Shlofmitz RA. Outcomes in Elderly Patients With Severely Calcified Coronary Lesions Undergoing Orbital Atherectomy. J Interv Cardiol 2017; 30:134-138. [PMID: 28116818 DOI: 10.1111/joic.12362] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES We evaluated the clinical outcomes of elderly patients who underwent orbital atherectomy for the treatment of severe coronary artery calcification (CAC) prior to stenting. BACKGROUND Percutaneous coronary intervention (PCI) of severe CAC is associated with worse clinical outcomes including death, myocardial infarction (MI), and target vessel revascularization (TVR). The elderly represents a high-risk group of patients, often have more comorbid conditions, and have worse outcomes after PCI compared to younger patients. Clinical trials and a large multicenter registry have demonstrated the safety and efficacy of orbital atherectomy for the treatment of severe CAC. Clinical outcomes of elderly patients who undergo orbital atherectomy are unknown. METHODS Of the 458 patients, 229 were ≥75 years old (elderly) and 229 were <75 years old (younger). The primary endpoint was rate of 30-day major adverse cardiac and cerebrovascular events (MACCE), comprised of cardiac death, MI, TVR, and stroke. RESULTS The primary endpoint was similar in the elderly and younger groups (2.2% vs. 2.2%, P = 1), as were the individual endpoints of death (2.2% vs. 0.4%, P = 0.1), MI (0.9% vs. 1.3%, P = 0.65), TVR (0% vs. 0%, P = 1), and stroke (0% vs. 0.4%, P = 0.32). The rates of angiographic complications and stent thrombosis were similarly low in both groups. CONCLUSIONS The elderly represented a sizeable number of patients who underwent orbital atherectomy. It is a safe and effective treatment strategy for elderly patients with severe CAC as the clinical outcomes were similar to their younger counterparts. A randomized trial should further clarify the role of orbital atherectomy in these patients.
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Comparison among patients≥75 years having percutaneous coronary angioplasty using drug-eluting stents versus bare metal stents. Am J Cardiol 2015; 115:1179-84. [PMID: 25770974 DOI: 10.1016/j.amjcard.2015.01.557] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 01/29/2015] [Accepted: 01/29/2015] [Indexed: 11/20/2022]
Abstract
Limited data are available on long-term efficacy and safety of drug-eluting stents (DES) in elderly patients who underwent PCI. A total of 635 consecutive patients aged ≥75 years who underwent PCI were enrolled at 2 European centers. Of these, 170 patients received at least 1 DES, whereas 465 patients received bare metal stent (BMS) only. Primary end point was the incidence of net adverse clinical events (NACE), defined as the occurrence of ischemic events or bleeding events, and was compared at a median follow-up of 31.2 months. Clinical follow-up information was available in 593 patients (93.4%). The duration of dual antiplatelet therapy was 12.3±5.1 months in the DES group and 3.8±7.4 months in the BMS group. The Kaplan-Meier estimate of NACE at 5 years was significantly lower in DES-treated patients (40.5%) than in BMS-treated patients (55.7%; p=0.009). This benefit was driven by a significant reduction in myocardial infarction (8.6% vs 16.6%; p=0.038) and target vessel revascularization rates (7.9% vs 21.9%; p=0.003) in the DES group, with no significant increase in the incidence of bleeding events (13.8% vs 12.2%; p=0.882). These results were confirmed at propensity score-adjusted Cox proportional hazard analysis. In conclusion, in patients≥75 years, the use of DES compared with BMS seems to reduce myocardial infarction and repeat revascularization rates at long-term follow-up, without an increase in bleeding despite longer duration of dual antiplatelet therapy. This net clinical benefit, resulting from persistent efficacy and safety over time, may support the use of DES as a reasonable option in patients≥75 years.
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