Impact of stent diameter on outcomes following percutaneous coronary intervention with second‐generation drug‐eluting stents: Results from a large single‐center registry

Clinical implication of ticagrelor monotherapy in patients with small vessel coronary artery disease: results from the TICO randomized trial

Background

The aim of this study was to evaluate the efficacy and safety of ticagrelor monotherapy in patients with small vessel disease compared with ticagrelor-based DAPT within the Ticagrelor Monotherapy after 3 Months in the Patients Treated with New Generation Sirolimus Eluting Stent for Acute Coronary Syndrome (TICO) trial population.

Methods

Reference vessel diameter ≤2.5 mm was considered as small vessel disease. We conducted a comparison of the incidence of target lesion failure (TLF) and Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding. TLF was defined as a composite of cardiac death, target lesion myocardial infarction, stent thrombosis, and target lesion revascularization.

Results

652 patients among 3,056 TICO population (21.3%) had small vessel disease. Patients with small vessel disease showed a higher rate of TLF compared to those without small vessel disease (2.9% vs. 1.0%, log-rank p < 0.001). The presence of small vessel disease emerged as an independent predictor for 1-year TLF (HR 2.84, 95% CI 1.54-5.25), while it did not show a significant association with bleeding complications. The 12-month TLF rate was 1.6% for ticagrelor monotherapy after 3-month DAPT, and 4.2% for ticagrelor-based 12-month DAPT (p = 0.059) in patients with small vessel disease (HR 0.38, 95% CI 0.14-1.04, p for interaction = 0.261). The incidence of BARC type 3 or 5 bleeding rate 2.5% for ticagrelor monotherapy after 3-month DAPT, and 5.6% for ticagrelor-based 12-month DAPT (p = 0.052) in patients with small vessel disease (HR 0.44, 95% CI 0.19-1.01, p for interaction = 0.322). In the 3-month landmark analysis, ticagrelor monotherapy significantly reduced BARC type 3 or 5 bleeding in patients with small vessel disease (HR 0.09, 95% CI 0.01-0.69, log-rank p = 0.005) while demonstrating a similar incidence of TLF compared to ticagrelor based 12-month DAPT during the 3-12 months period.

Conclusions

There are no significant interactions between the antiplatelet strategy regarding the 12-month incidence of ischemic and bleeding complications. Ticagrelor monotherapy demonstrated a reduction in bleeding complications after a 3-month period of DAPT without increasing the rate of TLF, when compared to ticagrelor-based 12-month DAPT, specifically in patients with small vessel disease. Clinical Trial Registration: www.ClinicalTrials.gov, identifier, NCT02494895.

Predictive significance and diagnostic accuracy of plasma fibrinogen levels for coronary stenting outcomes

Objective: The advancement in percutaneous transluminal coronary angioplasty (PTCA) has led to it becoming the predominant mode of revascularization. Post PTCA adverse events in the form of stent thrombosis, recurrent ischemia, unplanned revascularization, recurrent hospitalization etc. result in morbidity as well as mortality. Biomarkers predicting such outcomes can be useful in initiating more aggressive medical therapy and greater modification of risk factors. This study was undertaken to study the predictive significance of periprocedural plasma fibrinogen levels for coronary stenting outcomes. Methods: 80 patients diagnosed as either chronic stable angina (CSA), unstable angina (UA), Non ST Elevation Myocardial Infarction (NSTEMI) or late presentation ST Elevation Myocardial Infarction (STEMI) undergoing planned PTCA were included in study. Patients were evaluated for clinical history, electrocardiogram (ECG), two dimensional echocardiography (2D-echo) and cardiac biomarkers (Creatinine Phorphokinase-MB isomer (CK-MB) and Troponin I). Serum fibrinogen level was measured 24 hours prior to PTCA along with routine pre-operative investigations; and also 24 hours after coronary stenting. Patients were followed for six months. Outcome measure was taken to be freedom from cardiac related adverse events, including rehospitalisation, unplanned repeat revascularization, definite stent thrombosis, transient ischemic attack, stroke and all-cause mortality. Results:  Fibrinogen level ≥393 mg/dL, 24 hours prior to percutaneous transluminal coronary angioplasty, was associated with higher major adverse cardiac and cerebrovascular events (MACCE) rates (60%) as compared to those with fibrinogen level &lt;393 mg/dL (3.6%).  Fibrinogen level ≥427 mg/dL 24 hours after percutaneous transluminal coronary angioplasty, was associated with higher major adverse cardiac and cerebrovascular events rates (65%) as compared to those with fibrinogen level &lt;427 mg/dL (6.7%). Conclusion: The current study demonstrates that higher baseline and post procedural fibrinogen, is an independent predictor of 6 months major adverse cardiac and cerebrovascular events after elective percutaneous coronary intervention. Key words:  Coronary stent outcomes, major adverse cardiac and cerebrovascular events, plasma fibrinogen, stent diameter

Complement use of Chinese herbal medicine after percutaneous coronary intervention: a prospective observational study

BACKGROUND

Chinese herbal medicine is widely used as a complement or alternative treatment in coronary artery disease (CAD) patients after percutaneous coronary intervention (PCI) in China. We compared the incidence of the major adverse cardiovascular event (MACE) of CAD patients with or without the complement use of Chinese herbal medicine after PCI.

METHODS

In this prospective, observational study that was conducted from September 2016 to August 2019 in Fuwai Hospital (China), we followed up consecutive patients who received PCI treatment for two years. MACE was defined as the composite all-cause mortality, revascularization, and myocardial infarction (MI) and was compared between those using (integrative medicine group) or those not using Chinese herbal medicine as an additional treatment to standard Western medicine, with unadjusted (Kaplan-Meier curves) and risk-adjusted (multivariable Cox regression) analyses.

RESULTS

A total of 5942 patients after PCI were enrolled in this study, and 5453 patients were included in the final analysis (4189 [76.8%] male; mean age: 61.9 ± 9.9% years). During the follow-ups, 2932 (53.8%) patients used only Western medicine while 2521(46.2%) patients had used Chinese herbal medicine as an additional treatment to standard Western medicine. Patients in the integrative medicine group (IM group) were older than the Western medicine group (WM group), had more females and less previous MI. The incidence of MACE was 15.3% (449/2932) in WM group and 11.54% (291/2521) in IM group. Cox regression analysis showed that cumulative incidence of MACE was 27% lower in patients of the IM group than those in WM group (hazard ratio = 0.73; 95% CI: 0.63-0.85; P < 0.0001).

CONCLUSIONS

For CAD patients after PCI treatment, complement use of Chinese herbal medicine is associated with a lower 2-year MACE incidence. Randomized prospective studies are warranted to provide higher levels of benefit evidence in these patients.

Determinant of repeat revascularization within 5 years of Percutaneous Coronary Intervention at a tertiary care hospital, Karachi: A matched case-control study

Objective

To determine factors associated with repeat revascularization among adults aged 25 years and above within 5 years of first Percutaneous Coronary Intervention (PCI) at a tertiary care hospital.

Methods

A matched case-control study was conducted through a hospital records review. A total of 90 cases with repeat revascularization and 180 controls without repeat revascularization were included. Data was analyzed using Multiple Conditional Logistic Regression.

Results

The mean age was similar in cases and controls (60.05 ± 10.01 vs 62.20 ± 10.43 years) and sex (male: 77.8% vs. 76.1%). History of being an ever-smoker (40% vs. 25%), overweight (36.3% vs. 30.6%), and poor glycemic control (23.3% vs. 12.2%) were more among the cases than controls. However, obesity (53.7% vs. 44.3%) and pre-diabetes (16.1% vs. 7.8%) were more in controls compared to cases.

Upon matching on the time of index PCI, the adjusted odds of ever smokers among patients with repeat revascularization was 2.47 times the odds of ever smokers among patients who did not undergo revascularization. Increasing stent diameter by 1 mm was found to reduce the risk of repeat revascularization by 51%.

Conclusions

Smoking cessation and appropriate selection of stent diameter in patients undergoing revascularization can reduce the risk of repeat revascularization in the future.

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Study assessed determinants of repeat revascularization after initial PCI from a large tertiary care hospital in Karachi.

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Ever smokers undergoing index PCI have 2.47 times increased risk of repeat revascularization.

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1 mm increase in stent diameter reduces 51% risk of repeat revascularization.

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Association between smoking and repeat revascularization may be a severe problem than estimated due to the reporting bias.

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More effective and well-tolerated strategies are needed for smoking cessation and sustain abstinence.

Applied pharmacology in percutaneous coronary intervention: You can't fight mother nature

Differential outcomes based on target vessel diameter persist in the era of second generation drug eluting stents. These differences are mainly driven by need for target vessel revascularization without appreciable differences in hard atherosclerotic cardiovascular disease outcomes that is, mortality and myocardial infarction. Future non mechanistic treatment options based on patient characteristics maybe needed.

1-Year Outcomes with COMBO Stents in Small-Vessel Coronary Disease: Subgroup Analysis From the COMBO Collaboration

BACKGROUND

Small vessel diameter is associated with higher risk of target lesion revascularization (TLR) after percutaneous coronary intervention (PCI). The COMBO sirolimus-eluting biodegradable-polymer stent has a proprietary anti-CD34 antibody layer to enhance homogeneous endothelialization, which may be advantageous in treating small vessels.

OBJECTIVE

We examined for differences in 1-year clinical outcomes after PCI by maximum implanted stent diameter from the COMBO collaboration.

METHODS

The COMBO collaboration (n = 3614) is a patient-level pooled dataset of patients undergoing PCI with COMBO stents in the MASCOT and REMEDEE multicenter registries. Stent diameter was available in 3590 (99.3%) patients. We compared patients receiving COMBO stents <3 mm versus ≥3 mm. The primary endpoint was 1-year target lesion failure (TLF), composite of cardiac death, target vessel-myocardial infarction (TV-MI) or clinically driven TLR. Secondary outcomes included stent thrombosis (ST). Adjusted outcomes were assessed using Cox regression methods.

RESULTS

The study included 792 (22%) patients with small stents <3 mm and 2798 (78%) patients with large stents ≥3 mm. Small stent patients included more women with lower body mass index and higher prevalence of diabetes but similar prevalence of acute coronary syndrome. Risk of 1-year TLF was similar in small and large stent groups (4.4% vs. 3.8%, HR 1.12, 95% CI 0.74-1.72, p = 0.58). There were no differences in the rates of cardiac death (1.7% vs. 1.5%, p = 0.74), TV-MI (1.4% vs. 1.2%, p = 0.58) or TLR (2.7% vs. 2.1%, p = 0.31). Definite or probable ST occurred in 1.3% of the small stent and 0.7% of the large stent PCI patients, p = 0.14, HR 2.13, 95% CI 0.93-5.00, p = 0.07.

CONCLUSIONS

One-year ischemic outcomes after COMBO PCI were similar irrespective of stent diameter in this all-comers international cohort.