Clinical outcomes in patients with stable coronary artery disease with vs. without a history of myocardial revascularization

Possibilities of dispensary observation in reducing mortality from coronary heart disease

Dispensary observation of patients with coronary artery disease can significantly reduce the likelihood of cardiovascular complications onset. Active outpatient monitoring allows to correct the main risk factors for cardiovascular complications, to estimate the risk of unfavorable cardiovascular events onset and to identificate patients who will get benefit of coronary revascularization. The introduction of a comprehensive assessment of cardiovascular risk and the development of remote monitoring technologies will improve the long-term results of outpatient follow-up of patients with coronary artery disease at high cardiovascular risk.

Cross-comparative metabolomics reveal sex-age specific metabolic fingerprints and metabolic interactions in acute myocardial infarction

The elucidation of metabolic perturbations and gender-age-specific metabolic characteristics associated with acute myocardial infarction (AMI) is essential for clinical risk stratification and disease management. A comprehensive cross-comparative metabolomics analysis was performed on the sera from 445 healthy controls, 347 AMI patients without cardiovascular disease (CVD), 79 AMI with CVD (AMICVD) patients including 27 deaths. Machine-learning-based integrated biomarker profiling and global network analysis were used to create a multi-biomarker for distinguishing the different AMI outcomes. The changes of most metabolites were dependent on AMI, but gender and age also give additional contributions to the changes of histidine, malonate, O-acetyl-glycoprotein and trimethylamine N-oxide. The altered metabolic pathways included gut dysbiosis, increased amino acid metabolism, glucose metabolism and ketone metabolism, and inactivation of tricarboxylic acid cycle. Enhanced histidine metabolism and microbiota dysbiosis may be one of the key factors during the developing of AMI into AMICVD. For the differential diagnosis of AMI events, three sets of specific multi-biomarkers provided relatively high accuracy with the areas under the curve more than 0.8 and hazard ratio more than 1 in the discovery set, and the results were reproduced and confirmed by the validation set. First use of cross-comparative metabolomics and machine-learning-based integrated biomarker analysis gives great capability to discriminate the different AMI outcomes. Also, the multi-biomarkers seem to be a valid and accurate auxiliary diagnosis biomarker in addition to standard stratification based on clinical parameters.

The prospective randomized trial of the optimal evaluation of cardiac symptoms and revascularization: Rationale and design of the PRECISE trial

BACKGROUND

Clinicians vary widely in their preferred diagnostic approach to patients with non-acute chest pain. Such variation exposes patients to potentially avoidable risks, as well as inefficient care with increased costs and unresolved patient concerns.

METHODS

The Prospective Randomized Trial of the Optimal Evaluation of Cardiac Symptoms and Revascularization (PRECISE) trial (NCT03702244) compares an investigational "precision" diagnostic strategy to a usual care diagnostic strategy in participants with stable chest pain and suspected coronary artery disease (CAD).

RESULTS

PRECISE randomized 2103 participants with stable chest pain and a clinical recommendation for testing for suspected CAD at 68 outpatient international sites. The investigational precision evaluation strategy started with a pre-test risk assessment using the PROMISE Minimal Risk Tool. Those at lowest risk were assigned to deferred testing (no immediate testing), and the remainder received coronary computed tomographic angiography (cCTA) with selective fractional flow reserve (FFR_CT) for any stenosis meeting a threshold of ≥30% and <90%. For participants randomized to usual care, the clinical care team selected the initial noninvasive or invasive test (diagnostic angiography) according to customary practice. The use of cCTA as the initial diagnostic strategy was proscribed by protocol for the usual care strategy. The primary endpoint is time to a composite of major adverse cardiac events (MACE: all-cause death or non-fatal myocardial infarction) or invasive cardiac catheterization without obstructive CAD at 1 year. Secondary endpoints include health care costs and quality of life.

CONCLUSIONS

PRECISE will determine whether a precision approach comprising a strategically deployed combination of risk-based deferred testing and cCTA with selective FFR_CT improves the clinical outcomes and efficiency of the diagnostic evaluation of stable chest pain over usual care.

Long-Term Prognostic Role of Computed Tomography Coronary Angiography for Stable Angina

Purpose of review

Chest pain is a common presentation, and there are a wide variety of ways in which it can be investigated and treated. There is growing interest in whether the way we reach a diagnosis of angina can affect the long-term prognosis. In addition to its unparalleled negative predictive value, computed tomography coronary angiography (CCTA) gives anatomical information on the extent and severity of coronary artery disease. This article discusses recent research into the ability of CCTA to predict and improve long-term prognosis for patients with stable angina.

Recent findings

Results from retrospective studies, randomised controlled trials and meta-analyses all suggest that initial investigation with computed tomography coronary angiography confers a prognostic benefit. In addition, the most recent studies have shown that the assessment of plaque burden and plaque constituents is predictive of long-term outcomes.

Summary

Management of stable chest pain should be guided by a CCTA-based approach. Future research should focus on whether incorporating plaque analysis strategies into clinical practice confers additional benefit.

Prognostic significance of previous myocardial infarction and previous revascularization in patients undergoing SPECT MPI

BACKGROUND

Accurate risk stratification in patients with known coronary artery disease (CAD) is critical for patient management. Prior myocardial infarction (MI) or revascularization without MI are often equated as known CAD. We compared the prognostic significance of prior MI and previous revascularization in patients undergoing single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI).

METHODS

Consecutive patients undergoing SPECT MPI at Cedars-Sinai Medical Center between 1992 and 2012 were included. Medical history, including history of MI or revascularization, was collected prospectively. Association with all-cause mortality was assessed with multivariable Cox analysis, adjusted for patient demographics, medical history, medications, and SPECT MPI results.

RESULTS

In total, 50,121 patients were identified including 7428 (14.8%) with a history of previous MI and 3608 (7.2%) with a history of revascularization without prior MI. During a median follow-up of 8.0 years, 19,696 (39.3%) patients died including 4467 (60.1%) with a history of MI and 1880 (52.1%) with a history of revascularization. Prior MI (adjusted HR 1.12, p=0.001) and prior revascularization without MI (adjusted HR 1.15, p<0.001) were independently associated with increased all-cause mortality. Previous MI (adjusted HR 1.27, p<0.001) and previous revascularization without MI (adjusted HR 1.21, p<0.001) were significantly associated with increased all-cause mortality only in patients without ischemia.

CONCLUSIONS

In this large cohort of patients undergoing SPECT MPI, previous MI and previous revascularization without MI were independent predictors of all-cause mortality, with no significant difference in associated risk. History of CAD may be particularly important for risk stratification in patients without ischemia.

Adherence to guideline recommendations for coronary angiography in a poor South-East Asian setting: Impact on short- and medium-term clinical outcomes

In South-East Asian populations and particularly in Indonesia, access to coronary angiography (CAG) is limited. We aimed to assess the adherence for undergoing CAG for indicated patients, according to the guideline recommendations. We then examined whether this adherence would have an impact on patients' short- and medium-term mortality and morbidity. We consecutively enrolled 474 patients with acute and stable coronary artery disease who had indication for CAG at Makassar Cardiac Center, Indonesia from February 2013 to December 2014. We found that adherence to CAG recommendation in poor South-East Asian setting is low. Of 474 recommended patients, only 273 (57.6%) underwent the procedure. Factors for not undergoing CAG were: older age, female gender, low educational and socio-economic status, and insurance type. While reasons for patients refusing CAG and subsequent intervention included fear, symptoms reduction, and lack of trust concerning the procedure benefit. During follow-up (median 19 (IQR 6-39.3) months), 155 (32.7%) patients died, and 259 (54.6%) experienced at least one adverse event. Adherence to CAG recommendation was associated with a significantly lower short- and medium-term mortality, independent of revascularization and other potential confounders. In sub-group analysis, adhered patients "with revascularization" had significantly better outcomes compared to the "non-revascularization" and "not adhere" groups.

Predictors of medium-term mortality in patients hospitalised with coronary artery disease in a resource-limited South-East Asian setting

Objective

To measure medium-term outcomes and determine the predictors of mortality in patients with coronary artery disease (CAD) both during and after hospitalisation in a resource-limited South-East Asian setting.

Methods

From February 2013 to December 2014, we conducted a prospective observational cohort study of 477 patients admitted to Makassar Cardiac Center, Indonesia, with acute coronary syndrome and stable CAD. We actively obtained data on clinical outcomes and after-discharge management until April 2017. Multivariable Cox proportional hazard analysis was performed to examine predictors for our primary outcome, all-cause mortality.

Results

From hospital admission, patients were followed over a median of 18 (IQR 6-36) months; in total 154 (32.3%) patients died. More patients with acute myocardial infarction died in the hospital compared with patients with unstable and stable angina (p=0.002). Over the total follow-up, there was a difference in mortality between non-ST-segment elevation myocardial infarction (n=41, 48.2%), ST-segment elevation myocardial infarction (n=65, 30.8%), unstable angina (n=18, 26.5%) and stable coronary artery disease (n=30, 26.5%) groups (p=0.007). The independent predictors of all-cause mortality were hyperglycaemia on admission (HR 1.55 (95% CI 1.12 to 2.14), p=0.008), heart failure/Killip class ≥2 (HR 2.50 (95% CI 1.76 to 3.56), p<0.001), estimated glomerular filtration rate <60 mL/min (HR 1.77 (95% CI 1.26 to 2.50), p=0.001), no revascularisation (percutaneous coronary intervention/coronary artery bypass grafting) (HR 2.38 (95% CI 1.31 to 4.33), p=0.005) and poor adherence to after-discharge medications (HR 10.28 (95% CI 5.52 to 19.16), p<0.001). Poor medication adherence predicted postdischarge mortality and did so irrespective of underlying CAD diagnosis (p interaction=0.88).

Conclusions

Patients with CAD in a poor South-East Asian setting experience high in-hospital and medium-term mortality. The initial severity of the disease, lack of access to guidelines-recommended therapy and poor adherence to after-discharge medications are the main drivers for excess mortality. Improved access to early and late hospital care and patient education should be prioritised for better survival.

Characteristics and the average 30-day and 6-month clinical outcomes of patients hospitalised with coronary artery disease in a poor South-East Asian setting: the first cohort from Makassar Cardiac Center, Indonesia

OBJECTIVE

To provide a detailed description of characteristics at hospital admission and clinical outcomes at 30-day and 6-month follow-up in patients hospitalised with coronary artery disease (CAD) in a poor South-East Asian setting.

DESIGN

Prospective observational cohort study.

SETTING

From February 2013 to December 2014, in Makassar Cardiac Center, Indonesia.

PARTICIPANTS

477 patients with CAD (acute coronary syndrome and stable CAD).

OUTCOME MEASURES

All-cause mortality and major adverse cardiovascular events (MACE).

RESULTS

Out of 477 patients with CAD, the proportion of young age (<60 years) was 53.9% and 72.7% were male. At admission, 44.2% of patients were diagnosed with ST-segment elevation myocardial infarction (STEMI), 38.6% with diagnosis or signs of heart failure and 75.1% had previous hypertension. Out of 211 patients with STEMI, only 4.7% had been treated with primary percutaneous coronary intervention (PCI) and 6.2% received thrombolysis. The time lapse from symptom onset to hospital admission was 26.8 (IQR 10.0-48.0) hours, and 19.1% of all patients had undergone either PCI or coronary artery bypass graft. The survival rate at 6 months was 78.9%. The rates of all-cause mortality at 30 days and 6 months were 13.4% and 7.3%, respectively; the rate of composite MACE at 30 days was 26.2% and 18.0% at 6 months.

CONCLUSIONS

Patients with CAD from a poor South-East Asian setting present themselves with predominantly unstable conditions of premature CAD. These patients show relatively severe illness, have significant time delay from symptom onset to admission or intervention, and most do not receive the guidelines-recommended treatment. Awareness of symptoms, prompt initial management of acute CVD, well-established infrastructures and resources both in primary and secondary hospital for CVD should be improved to reduce the high rates of 30-day and 6-month mortality and adverse outcomes in this population.

Validity of inducible ischaemia as a surrogate for adverse outcomes in stable coronary artery disease

Regional myocardial ischaemia is commonly expressed as exertional angina in patients with stable coronary artery disease (CAD). It also associates with prognosis, risk tending to increase with the severity of ischaemia. The validity of myocardial ischaemia as a surrogate for adverse clinical outcomes, however, has not been well established. Thus, in cohort studies, ischaemia testing has failed to influence rates of myocardial infarction and coronary death. Moreover, in clinical studies, pharmacological and interventional treatments that are effective in correcting ischaemia have rarely been shown to reduce cardiovascular (CV) risk. This contrasts with statins and other anti-inflammatory drugs that have no direct effect on ischaemia but improve CV outcomes by modifying the atherothrombotic disease process. Despite this, and with little evidence of patient benefit, stress testing is commonly used during the follow-up of patients with stable CAD when the demonstration of ischaemic change may be seen as a target for treatment, independently of symptomatic status. Substitution of a symptom-driven management strategy has the potential to reduce rates of non-invasive stress testing, unnecessary downstream revascularisation procedures and use of valuable resources in patients with stable CAD without adverse consequences for CV risk.

National Institute for Health and Care Excellence updates the stable chest pain guideline with radical changes to the diagnostic paradigm

In the 2016 update of the stable chest pain guideline, the National Institute for Health and Care Excellence (NICE) has made radical changes to the diagnostic paradigm that it-like other international guidelines-had previously placed at the centre of its recommendations. No longer are quantitative assessments of the disease probability considered necessary to determine the need for diagnostic testing and the choice of test. Instead, the recommendation is for no diagnostic testing if chest pain is judged to be 'non-anginal' and CT coronary angiography (CTCA) in patients with 'typical' or 'atypical' chest pain with additional perfusion imaging only if there is uncertainty about the functional significance of coronary lesions. The new emphasis on anatomical-as opposed to functional-testing is driven in large part by cost-effectiveness analysis and despite inevitable resource implications NICE calculates that annual savings for the population of England will be significant. In making CTCA the default diagnostic testing strategy in its updated chest pain guideline, NICE has responded emphatically to calls from trialists for CTCA to have a greater role in the diagnostic pathway of patients with suspected angina.

Systems characterization of differential plasma metabolome perturbations following thrombotic and non-thrombotic myocardial infarction

Myocardial infarction (MI) is an acute event characterized by myocardial necrosis. Thrombotic MI is caused by spontaneous atherosclerotic plaque disruption that results in a coronary thrombus; non-thrombotic MI occurs secondary to oxygen supply-demand mismatch. We sought to characterize the differential metabolic perturbations associated with these subtypes utilizing a systems approach. Subjects presenting with thrombotic MI, non-thrombotic MI and stable coronary artery disease (CAD) were included. Whole blood was collected at two acute time-points and at a time-point representing the quiescent stable disease state. Plasma metabolites were analyzed by untargeted UPLC-MS/MS and GC-MS. A weighted network was constructed, and modules were determined from the resulting topology. To determine perturbed modules, an enrichment analysis for metabolites that demonstrated between-group differences in temporal change across the disease state transition was then conducted.

BIOLOGICAL SIGNIFICANCE

We report evidence of metabolic perturbations of acute MI and determine perturbations specific to thrombotic MI. Specifically, a module characterized by elevated glucocorticoid steroid metabolites following acute MI showed greatest perturbation following thrombotic MI. Modules characterized by elevated pregnenolone metabolites, monoacylglycerols, and acylcarnitines were perturbed following acute MI. A module characterized by a decrease in plasma amino acids following thrombotic MI was differentially perturbed between MI subtypes.