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Mohamed MO, Kinnaird T, Rab ST, Zaman S, Banerjee A, Sirker A, Mintz G, Mamas MA. Intracoronary imaging guided percutaneous coronary intervention outcomes among individuals with cardiogenic shock. Catheter Cardiovasc Interv 2023; 102:1004-1011. [PMID: 37870106 DOI: 10.1002/ccd.30859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/30/2023] [Accepted: 10/05/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Limited data exist around the utility of intracoronary imaging (ICI) during percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) and cardiogenic shock (CS), who are inherently at a high risk of stent thrombosis (ST). METHODS All PCI procedures for ACS patients with CS in England and Wales between 2014 and 2020 were retrospectively analysed, stratified into two groups: ICI and angiography-guided groups. Multivariable logistic regression analyses were performed to examine odds ratios (OR) of in-hospital outcomes, including major adverse cardiovascular and cerebrovascular events (MACCE; composite of all-cause mortality, acute stroke/transient ischaemic attack (TIA), and reinfarction) and major bleeding, in the ICI-guided group compared with angiography-guided PCI. RESULTS Of 15,738 PCI procedures, 1240(7.9%) were ICI-guided. The rate of ICI use amongst those with CS more than doubled from 2014 (5.7%) to 2020 (13.3%). The ICI-guided group were predominantly younger, males, with a higher proportion of non-ST-elevation ACS and ST. MACCE was significantly lower in the ICI-guided group compared with the angiography-guided group (crude: 29.8% vs. 38.2%, adjusted odds ratio (OR) 0.65 95% confidence interval [CI] 0.56-0.76), driven by lower all-cause mortality (28.6% vs. 37.0%, OR 0.65 95% CI 0.55-0.75). There were no differences in other secondary outcomes between groups. CONCLUSION ICI use among CS patients has more than doubled over 6 years but remains significantly under-utilized, with less than 1-in-6 patients in receipt of ICI-guided PCI by 2020. ICI-guided PCI is associated with prognostic benefits in CS patients and should be more frequently utilized to increase their long-term survival.
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Affiliation(s)
- Mohamed O Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK
- Institute of Health Informatics, University College London, London, UK
| | - Tim Kinnaird
- Department of Cardiology, University Hospital Wales, Wales, UK
| | - Syed Tanveer Rab
- Department of Cardiology, Emory University, Atlanta, Georgia, USA
| | - Sarah Zaman
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK
- Department of Cardiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Alex Sirker
- Institute of Health Informatics, University College London, London, UK
- Department of Cardiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Gary Mintz
- Cardiovascular Research Foundation, New York, New York, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK
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Zhou J, Liew D, Duffy SJ, Shaw J, Walton A, Chan W, Gerber R, Stub D. Intravascular Ultrasound Versus Angiography-Guided Drug-Eluting Stent Implantation: A Health Economic Analysis. Circ Cardiovasc Qual Outcomes 2021; 14:e006789. [PMID: 34003686 DOI: 10.1161/circoutcomes.120.006789] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is increasing evidence that use of intravascular ultrasound (IVUS) guidance during percutaneous coronary intervention (PCI) is associated with improved clinical outcomes compared with angiography guidance alone. However, concern regarding the cost-effectiveness of IVUS has limited use of this technology worldwide. In this study, we aimed to evaluate the cost-effectiveness of IVUS-guided PCI compared with angiography-guided PCI in patients undergoing drug-eluting stent implantation. METHODS A decision-analytic Markov model was constructed to compare the cost-effectiveness of IVUS to angiography guidance from the Australian healthcare system perspective. Procedure-related morbidity and mortality were estimated from the literature. Costs were obtained from Australian sources. The population of interest was all-comers undergoing PCI with drug-eluting stent. Outcomes of interest included costs, life-expectancy, and quality-adjusted life years (QALYs) for both treatment groups. RESULTS In the base case, IVUS guidance was cost-effective compared with angiography guidance alone. With 5% annual discounting, IVUS was associated with increased lifetime costs of Australian dollars (AUD) $823 (USD $597) per person and benefits of 0.04 life years and 0.05 QALYs compared with angiography, yielding an incremental cost-effectiveness ratio of AUD $17 539 (USD $12 730) per QALY gained. Results were robust to sensitivity analyses, with IVUS being cost-effective in 99% of 10 000 Monte Carlo iterations assuming a willingness-to-pay threshold of AUD $50 000 per QALY gained. In a worst-case scenario analysis, IVUS remained the cost-effective option, with an ICER of AUD $36 651 (USD $26 601) per QALY gained. Exploratory subgroup analysis revealed that cost-effectiveness may be greatest among patients with left main and complex coronary lesions. CONCLUSIONS Use of IVUS guidance during PCI is likely to be cost-effective compared with angiography guidance alone among patients undergoing drug-eluting stent implantation.
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Affiliation(s)
- Jennifer Zhou
- The Alfred Hospital, Melbourne, Australia (J.Z., D.L., S.J.D., J.S., A.W., W.C., D.S.)
| | - Danny Liew
- The Alfred Hospital, Melbourne, Australia (J.Z., D.L., S.J.D., J.S., A.W., W.C., D.S.).,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (D.L., S.J.D., D.S.)
| | - Stephen J Duffy
- The Alfred Hospital, Melbourne, Australia (J.Z., D.L., S.J.D., J.S., A.W., W.C., D.S.).,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (D.L., S.J.D., D.S.)
| | - James Shaw
- The Alfred Hospital, Melbourne, Australia (J.Z., D.L., S.J.D., J.S., A.W., W.C., D.S.)
| | - Antony Walton
- The Alfred Hospital, Melbourne, Australia (J.Z., D.L., S.J.D., J.S., A.W., W.C., D.S.)
| | - William Chan
- The Alfred Hospital, Melbourne, Australia (J.Z., D.L., S.J.D., J.S., A.W., W.C., D.S.).,Western Health, Melbourne, Australia (W.C., D.S.)
| | | | - Dion Stub
- The Alfred Hospital, Melbourne, Australia (J.Z., D.L., S.J.D., J.S., A.W., W.C., D.S.).,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia (D.L., S.J.D., D.S.).,Western Health, Melbourne, Australia (W.C., D.S.)
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Bhat S, Yatsynovich Y, Sharma UC. Coronary revascularization in patients with stable coronary disease and diabetes mellitus. Diab Vasc Dis Res 2021; 18:14791641211002469. [PMID: 33926268 PMCID: PMC8482730 DOI: 10.1177/14791641211002469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE OF STUDY Diabetes mellitus accelerates the development of atherosclerosis. Patients with diabetes mellitus have higher incidence and mortality rates from cardiovascular disease and undergo a disproportionately higher number of coronary interventions compared to the general population. Proper selection of treatment modalities is thus paramount. Treatment strategies include medical management and interventional approaches including coronary artery bypass graft (CABG) surgery and percutaneous coronary interventions (PCI). The purpose of this review is to assimilate emerging evidence comparing CABG to PCI in patients with diabetes and present an outlook on the latest advances in percutaneous interventions, in addition to the optimal medical therapies in patients with diabetes. KEY METHODS A systematic search of PubMed, Web of Science and EMBASE was performed to identify prospective, randomized trials comparing outcomes of CABG and PCI, and also PCI with different generations of stents used in patients with diabetes. Additional review of bibliography of selected studies was also performed. MAIN CONCLUSIONS Most of the trials discussed above demonstrate a survival advantage of CABG over PCI in patients with diabetes. However, recent advances in PCI technology are starting to challenge this narrative. Superior stent designs, use of specific drug-eluting stents, image-guided stent deployment, and the use of contemporary antiplatelet and lipid-lowering therapies are continuing to improve the PCI outcomes. Prospective data for such emerging interventional technologies in diabetes is however lacking currently and is the need of the hour.
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Affiliation(s)
- Salman Bhat
- Department of Medicine, University at Buffalo, NY, USA
| | - Yan Yatsynovich
- Department of Medicine, University at Buffalo, NY, USA
- Division of Cardiovascular Diseases, University at Buffalo, NY, USA
| | - Umesh C Sharma
- Department of Medicine, University at Buffalo, NY, USA
- Division of Cardiovascular Diseases, University at Buffalo, NY, USA
- The Clinical and Translational Science Institute, University at Buffalo, NY, USA
- Umesh C Sharma, Division of Cardiovascular Medicine, Jacobs School of Medicine and Biomedical Sciences, Clinical Translational Research Center, University at Buffalo, Suite 7030, 875 Ellicott Street, Buffalo, NY 14203, USA.
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Cui K, Shi YQ, Zhang YZ, Li ZG, Li CL. Optimized strategy of rotational atherectomy of underexpanded coronary stents in patients with acute coronary syndrome. World J Emerg Med 2021; 12:198-201. [PMID: 34141034 DOI: 10.5847/wjem.j.1920-8642.2021.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Stent under-expansion is a main cause of acute coronary syndrome (ACS), which can lead to serious clinical outcomes. The rotational atherectomy of underexpanded coronary stents (academically called stent ablation, SA) by intravascular ultrasound (IVUS) may provide more visual reference in the intervention. We aim to analyze the procedural and long-term outcomes of the optimized strategy of SA in patients with ACS and to provide real-world data on this technique. METHODS A total of 11 patients with ACS who underwent SA between April 2017 and January 2019 were analyzed. Clinical follow-ups were obtained either by telephone call or by scheduled visit. Clinical end-points included periprocedural and postprocedural myocardial infarction, stent thrombosis, target lesion revascularization, and major adverse cardiac events. RESULTS The mean age of patients was 69.6±6.5 years, and five (45.5%) patients were males. All cases presented with unstable angina and were admitted with ACS. All patients required at least two burrs during the intervention and the size of the burr was selected based on the data of minimum lumen diameter (MLD), and the first and the second burr/stent MLD ratios were 0.93 (0.88-0.99) and 1.09 (1.02-1.14), respectively. Nine patients were treated with drug-eluting stents and two were treated with drug-coated balloons. There were no complications including no flow, perforation, or burr entrapment during the intervention. No in-hospital deaths or major adverse cardiac events were documented during the follow-up period. In our study, less contrast agent and a lower dose of radiation were used during the intervention. CONCLUSIONS SA guided by IVUS can reduce the risk of complications, assess the results of surgery, inform the selection of stent size, and decrease the required dose of radiation and contrast.
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Affiliation(s)
- Kun Cui
- Department of Cardiology, Chongqing General Hospital, Chongqing 400013, China
| | - You-Quan Shi
- Department of Cardiology, the Third People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi 830000, China
| | - Yuan-Zheng Zhang
- Department of Cardiology, the First People's Hospital of Tianshui, Tianshui 741000, China
| | - Zheng-Gong Li
- Department of Cardiology, Chongqing General Hospital, Chongqing 400013, China
| | - Chang-Ling Li
- Department of Cardiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
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