Trends in management and outcome of patients with non-ST elevation acute coronary syndromes and peripheral arterial disease

Ischemic cardio-cerebrovascular disease and all-cause mortality in Chinese elderly patients: a propensity-score matching study

BACKGROUND

Ischemic cardio-cerebrovascular disease is the leading cause of mortality worldwide. However, studies focusing on elderly and very elderly patients are scarce. Hence, our study aimed to characterize and investigate the long-term prognostic implications of ischemic cardio-cerebrovascular diseases in elderly Chinese patients.

METHODS

This retrospective cohort study included 1026 patients aged ≥ 65 years who were categorized into the mono ischemic cardio-cerebrovascular disease (MICCD) (either coronary artery disease or ischemic stroke/transient ischemic attack) (n = 912) and the comorbidity of ischemic cardio-cerebrovascular disease (CICCD) (diagnosed with both coronary artery disease and ischemic stroke/transient ischemic attack at admission) (n = 114). The primary outcome was all-cause death. The mortality risk was evaluated using the Cox proportional hazards risk model with multiple adjustments by conventional and propensity-score-based approaches.

RESULTS

Of the 2494 consecutive elderly patients admitted to the hospital, 1026 (median age 83 years [interquartile range]: 76.5-86.4; 94.4% men) met the inclusion criteria. Patients with CICCD consisted mostly of very elderly (79.2% vs. 66.1%, P < 0.001) individuals with a higher burden of comorbidities. Over a median follow-up of 10.4 years, 398 (38.8%) all-cause deaths were identified. Compared with the MICCD group, the CICCD group exhibited a higher adjusted hazard ratio (HR) (95% confidential interval, CI) of 1.71 (1.32-2.39) for long-term mortality after adjusting for potential confounders. The sensitivity analysis results remained robust. After inverse probability of treatment weighting (IPTW) modeling, the CICCD group displayed an even worse mortality risk (IPTW-adjusted HR: 2.07; 95% CI 1.47-2.90). In addition, anemia (adjusted HR: 1.48; 95% CI 1.16-1.89) and malnutrition (adjusted HR: 1.43; 95% CI 1.15-1.78) are also independent risk factors for all-cause mortality among elderly and very elderly patients.

CONCLUSIONS

Our results thus suggest that elderly patients with ischemic cardio-cerebrovascular disease and anemia or malnutrition may have higher mortality, which may be predicted upon admission. These findings, however, warrant further investigation.

Temporal trends in characteristics and outcomes after myocardial infarction in patients with and without peripheral artery disease - A Nationwide, register-based follow-up study

AIM

Patients with peripheral artery disease (PAD) represent a high-risk population with increased morbidity and mortality. We aimed to examine trends in myocardial infarction (MI), PAD and adverse clinical outcomes from years 2000 to 2019.

METHODS

This nationwide Danish-based registry study included all patients with MI from years 2000-2019. Patients with PAD were compared to patients without PAD. Temporal changes in PAD prevalence over time was examined using the Cochrane-Armitage trend test, and Cox regression was used to test for between-group significance in all care and outcome measures.

RESULTS

A total of 196,635 patients experienced an MI within the study time frame; the prevalence of PAD over time showed a slight increase (p < 0.01). Patients with MI and a concurrent PAD diagnosis elicited a heavier burden of comorbidities. The primary MACE endpoint showed significant decreases in both patients with and without PAD (p < 0.01); the decrease was more marked in patients without a concurrent PAD diagnosis (p < 0.01) alongside with 1-year all-cause mortality (p < 0.01). There was a slight increase in initiation of preventive pharmacotherapy with a prominent increase in initiation of P2Y12-inhibitors post discharge in patients without PAD in comparison to patients with PAD, and the same pattern applied for lipid lowering agents (p < 0.01). Also, there was an increase in revascularization in patients with MI but more markedly in patients without coexisting PAD.

CONCLUSIONS

Despite significant decreases in MACE and mortality and significant increases in guideline-recommended care and revascularization over time for MI patients both with and without PAD, improvement in all these measures was less prominent in patients with MI and concomitant PAD.

Identifying a Clinical Risk Triage Score for Adult Emergency Department

Emergency triage is crucial for the treatment and prognosis of emergency patients, but its validity needs further improvement. The purpose of this study was to identify a risk score for adult triage. We conducted a regression analysis of physiological and biochemical data from 1,522 adult patients. A 60-point triage scoring model included temperature, pulse, systolic blood pressure, oxygen saturation, consciousness, dyspnea, admission mode, syncope history, chest pain or chest tightness, complexion, hematochezia or hematemesis, hemoptysis, white blood count, creatinine, bicarbonate, platelets, and creatine kinase. The area under curve in predicting ICU admission was 0.929 (95% CI [0.913-0.944]) for the derivation cohort and 0.911 (95% CI [0.884-0.938]) for the validation cohort. Four categories: critical level (≥13 points), severe level (6-12 points), urgency level (1-5 points), and sub-acute level (0 points) were divided, which significantly distinguished the severity of emergency patients.

Association between cholesterol efflux capacity and peripheral artery disease in coronary heart disease patients with and without type 2 diabetes: from the CORDIOPREV study

Background

Peripheral artery disease (PAD) is recognized as a significant predictor of mortality and adverse cardiovascular outcomes in patients with coronary heart disease (CHD). In fact, coexisting PAD and CHD is strongly associated with a greater coronary event recurrence compared with either one of them alone. High-density lipoprotein (HDL)-mediated cholesterol efflux capacity (CEC) is found to be inversely associated with an increased risk of incident CHD. However, this association is not established in patients with PAD in the context of secondary prevention. In this sense, our main aim was to evaluate the association between CEC and PAD in patients with CHD and whether the concurrent presence of PAD and T2DM influences this association.

Methods

CHD patients (n = 1002) from the CORDIOPREV study were classified according to the presence or absence of PAD (ankle-brachial index, ABI ≤ 0.9 and ABI > 0.9 and < 1.4, respectively) and T2DM status. CEC was quantified by incubation of cholesterol-loaded THP-1 cells with the participants' apoB-depleted plasma was performed.

Results

The presence of PAD determined low CEC in non-T2DM and newly-diagnosed T2DM patients. Coexisting PAD and newly-diagnosed T2DM provided and additive effect providing an impaired CEC compared to non-T2DM patients with PAD. In established T2DM patients, the presence of PAD did not determine differences in CEC, compared to those without PAD, which may be restored by glucose-lowering treatment.

Conclusions

Our findings suggest an inverse relationship between CEC and PAD in CHD patients. These results support the importance of identifying underlying mechanisms of PAD, in the context of secondary prevention, that provide potential therapeutic targets, that is the case of CEC, and establishing strategies to prevent or reduce the high risk of cardiovascular events of these patients.

Trial registrationhttps://clinicaltrials.gov/ct2/show/NCT00924937. Unique Identifier: NCT00924937

Independent Impact of Peripheral Artery Disease on Percutaneous Coronary Intervention

Background

Peripheral artery disease (PAD) is a known risk factor for adverse outcomes in patients undergoing percutaneous coronary intervention. However, in some studies PAD is not an independent risk factor. We sought to examine the independent impact of PAD on a large prospective percutaneous coronary intervention registry.

Methods and Results

From our single‐center prospective percutaneous coronary intervention registry, we have retrospectively analyzed 25 690 patients (years 2004–2018). We examined the influence of PAD on short‐ and long‐term outcomes using both regression and propensity‐matched analyses. Patients with documented PAD (n=1610, 6.3% of total) were older (66.7±10.8 versus 65.4±12.1, P<0.01), had higher rates of diabetes mellitus (69.3% versus 46.3%, P<0.01), hypertension (92.1% versus 76.1%, P<0.01) and renal failure (38.3% versus 18.2%, P<0.01). There were no differences in the rates of stable versus acute presentations, but less were treated with Prasugrel and Ticagrelor (3.3% versus 8.0% and 7.9% versus 11.9%, respectively, P<0.001 for both). Both 30‐day and 3‐year rates of all‐cause death and major adverse cardiac events were higher for patients with PAD versus control (4.9% versus 2.1% and 7.3% versus 3.3% death and major adverse cardiac events at 30 days, respectively; 43.4% versus 29.0% and 55.0% versus 37.8%, respectively at 3 years, P<0.001 for all). Following multivariate analysis, the presence of PAD was associated with a higher risk of both death (hazard ratio [HR], 1.66; CI 1.52–1.83; P<0.001) and major adverse cardiac events (HR, 1.51; CI, 1.40–1.64; P<0.001).

Conclusions

PAD constitutes an independent risk factor for adverse outcomes in patients undergoing percutaneous coronary intervention. Further studies are needed to ascertain which effective therapies may mitigate this risk.

Antithrombotic strategies for patients with coronary and lower extremity peripheral artery diseases: a narrative review

INTRODUCTION

Patients with coexisting coronary artery disease (CAD) and peripheral artery disease (PAD) present a very high rate of cardiovascular (CV) morbidity and mortality. Several studies have demonstrated that different regimens of antithrombotic therapies may reduce adverse CV events in patients with CAD or PAD. However, data on optimal antithrombotic combination to use in these very high-risk patients are scarce and conflicting.

AREAS COVERED

This paper reviews current data on antithrombotic therapies tested in CAD patients with concomitant lower extremity PAD.

EXPERT OPINION

The antithrombotic response in lower extremity PAD patients varies based on the atherosclerotic burden. For patients with isolated stable PAD may be sufficient a less potent P2Y12 inhibitor as clopidogrel, whereas patients with lower extremity PAD and documented CAD benefit from a more intense and prolonged antithrombotic treatment.

Temporal Trends in Invasive Management and In-Hospital Mortality of Patients With Non-ST Elevation Acute Coronary Syndromes and Chronic Kidney Disease

We analyzed data from 4 nationwide prospective registries of consecutive patients with acute coronary syndromes (ACS) admitted to the Italian Intensive Cardiac Care Unit network between 2005 and 2014. Out of 26 315 patients with ACS enrolled, 13 073 (49.7%) presented a diagnosis of non-ST elevation (NSTE)-ACS and had creatinine levels available at hospital admission: 1207 (9.2%) had severe chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] <30), 3803 (29.1%) mild to moderate CKD (eGFR 31-59), and 8063 (61.7%) no CKD (eGFR > 60 mL/min/1.73 m²). Patients with severe CKD had worse clinical characteristics compared with those with mild-moderate or no kidney dysfunction, including all the key predictors of mortality (P < .0001) which became worse over time (all P < .0001). Over the decade of observation, a significant increase in percutaneous coronary intervention rates was observed in patients without CKD (P for trend = .0001), but not in those with any level of CKD. After corrections for significant mortality predictors, severe CKD (odds ratio, OR: 5.49; 95% CI: 3.24-9.29; P < .0001) and mild-moderate CKD (OR: 2.33; 95% CI: 1.52-3.59; P < .0001) remained strongly associated with higher in-hospital mortality. The clinical characteristics of patients with NSTE-ACS and CKD remain challenging and their mortality rate is still higher compared with patients without CKD.

Rivaroxaban in patients with ischaemic chronic cardiomyopathy and obstructive peripheral arterial disease: rationale for treatment and results

Patients with overt clinical atherosclerosis (ATS) or with previous peripheral vascular events have a high risk of ischaemic complications. A careful control of cardiovascular (CV) risk factors has been shown to improve prognosis, likely driven by a decrease progression of ATS. Prevention of occlusive complications is, on the other hand, based on antithrombotic therapy. So far, this therapeutic goal has been pursued through antiplatelet therapy with aspirin and P2Y12 receptor inhibitors. Anticoagulant therapy with full-dose vitamin K inhibitors, although effective in some arterial conditions, is burdened by high bleeding risk, and by low long-term compliance. In the COMPASS study, the association of aspirin with the factor Xa inhibitor, rivaroxaban, in a dose of one-fourth of the dose used in atrial fibrillation, decreased by more than 20% the incidence of CV events in patients with multi-district ATS. The positive effect was also observed as far as major peripheral complications, the like of critical limb ischaemia or limb amputations. This positive preventive effect was in addition to the effect of other preventive measures, such as the use of statins, ACE inhibitors, and aspirin itself. As compared to the aspirin-only treatment, the association with low-dose rivaroxaban had a significantly higher bleeding risk, which should be carefully considered when evaluating the individual risk/benefit ratio of the combined treatment.

Fifteen-Year Trends of Cardiogenic Shock and Mortality in Patients with Diabetes and Acute Coronary Syndromes

PURPOSE

Our study was intended to examine time trends of management and mortality of acute coronary syndrome patients with associated diabetes mellitus.

METHODS

We analyzed data from 5 nationwide registries established between 2001 and 2014, including consecutive acute coronary syndrome patients admitted to the Italian Intensive Cardiac Care Units.

RESULTS

Of 28,225 participants, 8521 (30.2%) had diabetes: as compared with patients without diabetes, they were older and had significantly higher rates of prior myocardial infarction and comorbidities (all P < .0001). Prevalence of diabetes and comorbidities increased over time (P for trend < .0001). Cardiogenic shock rates were higher in patients with diabetes, as compared with those without diabetes (7.8% vs 2.8%, P < .0001), and decreased significantly over time only in patients without diabetes (P = .007). Revascularization rates increased over time in patients both with and without diabetes (both P for trend < .0001), although with persistingly lower rates in patients with diabetes. All-cause in-hospital mortality was higher in patients with diabetes (5.4 vs 2.5%, respectively, P < .0001) and decreased more consistently in patients without diabetes (P for trend = .007 and < .0001, respectively). At multivariable analysis, diabetes remains an independent predictor of both cardiogenic shock (odds ratio 2.03; 95% confidence interval, 1.77-2.32; P < .0001) and mortality (odds ratio 1.95; 95% confidence interval, 1.69-2.26; P < .0001).

CONCLUSIONS

Despite significant mortality reductions observed over 15 years in acute coronary syndromes, patients with diabetes continue to show threefold higher rates of cardiogenic shock and lower revascularization rates as compared with patients without diabetes. These findings may explain the persistingly higher mortality of patients with diabetes and acute coronary syndromes.

Access site complications following Impella-supported high-risk percutaneous coronary interventions

Mechanical circulatory support (MCS) devices are increasingly used to provide hemodynamic stability for patients with severe coronary artery disease, comorbidities, and/or impaired hemodynamics during high-risk percutaneous coronary interventions (PCI). Vascular access site complications, particularly those due to the use of large-bore sheaths, may limit outcomes in these patients. The aim of this study was to investigate the incidence and predictors of vascular complications in protected high-risk PCIs. Therefore, we included patients undergoing high-risk PCI with an Impella device from January 2016 to August 2018. Vascular complications were graded according to ‘Valve Academic Research Consortium-2’, a definition routinely used in transcatheter valve implantation procedures. In total, 61 patients (mean age 72 ± 11 years, 79% male, SYNTAX score 33 ± 7) were included, and angiographic- and fluoroscopic-guided vascular access was used for Impella implantation in all patients. Major vascular complications occurred in 5 male patients (8%). All major vascular complications were treated conservatively without the need for surgical intervention, and only one patient received a transfusion of three erythrocyte concentrates. Regression analysis revealed that patients with peripheral arterial disease of the lower extremities are at higher risk of major vascular complications. In conclusion, the utilization of Impella using a standardized protocol for angiographic- and fluoroscopic-guided vascular access was associated with a low rate of vascular complications.