Clinical and angiographic predictors of restenosis after percutaneous coronary intervention: insights from the Prevention of Restenosis With Tranilast and Its Outcomes (PRESTO) trial

Intrastent Restenosis: A Comprehensive Review

The primary objective of this paper is to delineate and elucidate the contemporary advancements, developments, and prevailing trajectories concerning intrastent restenosis (ISR). We aim to provide a thorough overview of the most recent developments in this area, covering various aspects such as pathophysiological insights, therapeutic approaches, and new strategies for tackling the complex challenges of ISR in modern clinical settings. The authors have undertaken a study to address a relatively new medical challenge, recognizing its significant impact on the morbidity and mortality of individuals with cardiovascular diseases. This effort is driven by the need to fully understand, analyze, and possibly improve the outcomes of this emerging medical issue within the cardiovascular disease field. We acknowledge its considerable clinical implications and the necessity for innovative methods to mitigate its effects on patient outcomes. Therefore, our emphasis was directed towards elucidating the principal facets of the condition's prevalence, expounding upon the foundational mechanisms underscoring conspicuous restenosis, and delineating the risk factors relevant in shaping the contemporary landscape of diagnostic and therapeutic modalities. This thorough examination aims to provide a comprehensive understanding of the various dimensions of the condition, including epidemiological data, pathophysiological complexities, and clinical considerations critical for evaluating and enhancing current diagnostic and treatment approaches.

Association of Endothelial Nitric Oxide Synthase and Angiotensin-Converting Enzyme Genes Polymorphism With In-Sent Restenosis of Bare Metal Stents vs Drug-Eluting Stents in Egyptians

Despite its unequivocal superiority compared with balloon angioplasty, coronary stenting did not abolish restenosis. We aimed to evaluate the associations between a common single nucleotide polymorphism occurring in endothelial nitric oxide synthase (eNOS) and angiotensin-converting enzyme (ACE) genes and the risk of in-stent restenosis (ISR) of bare metal stents vs drug-eluting stents (BMS vs DES) implanted in Egyptian patients. Two hundred patients who had coronary stenting were divided into group I (n = 98) who received a BMS and group II (n = 102) who received a DES. eNOS and ACE genes polymorphism were analyzed by polymerase chain reaction (PCR). We found that the GA and AA genotypes of the eNOS gene were associated with the ISR with both BMS and DES. However, the ACE gene was not associated with ISR. We concluded that eNOS gene polymorphism is associated with ISR. Hypertension, stent length, and AA genotype of the eNOS gene were found to be independent predictors of the occurrence of ISR after both BMS and DES use.

A systematic review of clinical and biomechanical engineering perspectives on the prediction of restenosis in coronary and peripheral arteries

Objective

Restenosis is a significant complication of revascularization treatments in coronary and peripheral arteries, sometimes necessitating repeated intervention. Establishing when restenosis will happen is extremely difficult due to the interplay of multiple variables and factors. Standard clinical and Doppler ultrasound scans surveillance follow-ups are the only tools clinicians can rely on to monitor intervention outcomes. However, implementing efficient surveillance programs is hindered by health care system limitations, patients' comorbidities, and compliance. Predictive models classifying patients according to their risk of developing restenosis over a specific period will allow the development of tailored surveillance, prevention programs, and efficient clinical workflows. This review aims to: (1) summarize the state-of-the-art in predictive models for restenosis in coronary and peripheral arteries; (2) compare their performance in terms of predictive power; and (3) provide an outlook for potentially improved predictive models.

Methods

We carried out a comprehensive literature review by accessing the PubMed/MEDLINE database according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search strategy consisted of a combination of keywords and included studies focusing on predictive models of restenosis published between January 1993 and April 2023. One author independently screened titles and abstracts and checked for eligibility. The rest of the authors independently confirmed and discussed in case of any disagreement. The search of published literature identified 22 studies providing two perspectives-clinical and biomechanical engineering-on restenosis and comprising distinct methodologies, predictors, and study designs. We compared predictive models' performance on discrimination and calibration aspects. We reported the performance of models simulating reocclusion progression, evaluated by comparison with clinical images.

Results

Clinical perspective studies consider only routinely collected patient information as restenosis predictors. Our review reveals that clinical models adopting traditional statistics (n = 14) exhibit only modest predictive power. The latter improves when machine learning algorithms (n = 4) are employed. The logistic regression models of the biomechanical engineering perspective (n = 2) show enhanced predictive power when hemodynamic descriptors linked to restenosis are fused with a limited set of clinical risk factors. Biomechanical engineering studies simulating restenosis progression (n = 2) are able to capture its evolution but are computationally expensive and lack risk scoring for individual patients at specific follow-ups.

Conclusions

Restenosis predictive models, based solely on routine clinical risk factors and using classical statistics, inadequately predict the occurrence of restenosis. Risk stratification models with increased predictive power can be potentially built by adopting machine learning techniques and incorporating critical information regarding vessel hemodynamics arising from biomechanical engineering analyses.

Association between lipoprotein(a) and long-term outcomes after percutaneous coronary intervention for lesions with in-stent restenosis

OBJECTIVES

This study aimed to evaluate the association between increased lipoprotein (a) [Lp(a)] and long-term outcomes in patients undergoing percutaneous coronary intervention (PCI) for in-stent restenosis (ISR).

BACKGROUND

Elevated Lp(a) is demonstrated to be associated with recurrent ischemic events after PCI. However, the impact of Lp(a) in patients with ISR remains undetermined.

METHODS

Between January 2017 and December 2018, a total of 2086 patients who underwent PCI for ISR were consecutively enrolled. Patients were categorized as elevated group (> 30 mg/dL, n=834) and non-elevated group (≤ 30 mg/dL, n=1252) according to baseline Lp(a) levels. The primary outcome was the rate of major adverse cardiac events (MACE), defined as a composite endpoint of all-cause death, spontaneous myocardial infarction (MI), or repeat revascularization.

RESULTS

During a median follow-up of 36 months, the primary outcome occurred in 202 of 1252 patients (26.7%) in the elevated Lp(a) group and 237 of 834 patients (21.8%) in the non-elevated Lp(a) group (adjusted hazard ratio: 1.31; 95% confidence interval: 1.08-1.58; P = 0.007), driven by higher rate of all-cause death (4.1% vs. 2.5%, P = 0.002 by Log-rank test; aHR: 1.77; 95% CI: 1.07-2.94; P = 0.03) and repeat revascularization (22.3% vs. 19.5%, P = 0.04 by Log-rank test; aHR: 1.18; 95% CI: 0.94-1.49; P = 0.16). Adding continuous or categorical Lp(a) to the Cox model led to a significant improvement in C-statistic, net reclassification, and integrated discrimination. The results were consistent across subgroups.

CONCLUSIONS

In the current cohort of patients who underwent PCI for ISR, elevated Lp(a) at baseline is associated with higher risk of long-term MACE.

Microchannel-embedded implantable device with fibrosis suppression for prolonged controlled drug delivery

For the prolonged, controlled delivery of systemic drugs, we propose an implantable drug-delivery chip (DDC) embedded with pairs of a microchannel and drug-reservoir serving as a drug diffusion barrier and depot, respectively. We pursued a DDC for dual drugs: a main-purpose drug, diclofenac (DF), for systemic exposure, and an antifibrotic drug, tranilast (TR), for local delivery. Thus, the problematic fibrotic tissue formation around the implanted device could be diminished, thereby less hindrance in systemic exposure of DF released from the DDC. First, we separately prepared DDCs for DF or TR delivery, and sought to find a proper microchannel length for a rapid onset and sustained pattern of drug release, as well as the required drug dose. Then, two distinct DDCs for DF and TR delivery, respectively, were assembled to produce a Dual_DDC for the concurrent delivery of DF and TR. When the Dual_DDC was implanted in living rats, the DF concentration in blood plasma did not drop significantly in the later periods after implantation relative to that in the early periods before fibrotic tissue formation. When the Dual_DDC was implanted without TR, there was a significant decrease in the blood plasma DF concentration as the time elapsed after implantation. Biopsied tissues around the Dual_DDC exhibited a significant decrease in the fibrotic capsule thickness and collagen density relative to the Dual_DDC without TR, owing to the effect of the local, sustained release of the TR.

Current and Future Applications of Artificial Intelligence in Coronary Artery Disease

Cardiovascular diseases (CVDs) carry significant morbidity and mortality and are associated with substantial economic burden on healthcare systems around the world. Coronary artery disease, as one disease entity under the CVDs umbrella, had a prevalence of 7.2% among adults in the United States and incurred a financial burden of 360 billion US dollars in the years 2016–2017. The introduction of artificial intelligence (AI) and machine learning over the last two decades has unlocked new dimensions in the field of cardiovascular medicine. From automatic interpretations of heart rhythm disorders via smartwatches, to assisting in complex decision-making, AI has quickly expanded its realms in medicine and has demonstrated itself as a promising tool in helping clinicians guide treatment decisions. Understanding complex genetic interactions and developing clinical risk prediction models, advanced cardiac imaging, and improving mortality outcomes are just a few areas where AI has been applied in the domain of coronary artery disease. Through this review, we sought to summarize the advances in AI relating to coronary artery disease, current limitations, and future perspectives.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

STRUCTURE

Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

Procedural Results and Long-Term Outcomes of Percutaneous Coronary Intervention for in-Stent Restenosis Chronic Total Occlusion Compared with de novo Chronic Total Occlusion

Background

In-stent restenosis (ISR) chronic total occlusion (CTO) represents a challenging subgroup for revascularization of CTO by percutaneous coronary intervention (PCI). There are limited data on the treatment and outcomes of PCI for ISR CTO.

Objective

We aimed to evaluate the procedural results and 2-year outcomes of PCI for ISR CTO compared with de novo CTO.

Methods

Patients undergoing attempted CTO PCI between January 2017 and December 2019 were prospectively enrolled. We analyzed the procedural results and 2-year major adverse cardiac events (MACE) in patients undergoing ISR CTO and those undergoing de novo CTO PCI.

Results

A total of 426 patients undergoing 484 consecutive CTO PCI (ISR CTO PCI, n=84; de novo CTO, n=400) were enrolled during the study period. Patients undergoing de novo CTO PCI had a significantly greater syntax score than those undergoing ISR CTO PCI [23.0 (17.5, 30.5) vs 21.5 (14.5, 27.0), p=0.039]. Technical (73.8% vs 79.0%, p=0.296) and procedural (73.8% vs 78.0, p=0.405) success rates, as well as the incidence of major procedural complications (1.2% vs 2.3%, p=0.842), were comparable between the two groups. After a median follow-up of 20 months, patients who underwent ISR CTO PCI had a significantly higher incidence of MACE (33.3% vs 10.3%, p<0.001), mainly attributed to the higher TVR rates (24.7% vs 7.6%, p<0.001). ISR CTO was the only independent predictor of MACE (hazard ratio, 4.124; 95% confidence interval, 1.951–8.717; p<0.001) during follow-up in patients who underwent CTO PCI.

Conclusion

ISR CTO PCI shows comparable technical and procedural success, as well as major procedural complications compared with de novo CTO PCI. However, patients who underwent ISR CTO PCI had a significantly worse prognosis than those who underwent de novo CTO PCI, in terms of MACE, driven by TVR. ISR CTO was the only independent predictor of MACE during the follow-up.

Coronary In-Stent Restenosis–Predictors and Treatment

BACKGROUND

Despite the use of modern drug-eluting stents (DES), in-stent restenosis (ISR) may still occur in as many as 2-10% of percutaneous coronary interventions (PCI) in certain lesion/patient subsets. ISR causes increased morbidity after stent implantation; acute myocardial infarction is a frequent correlate to a clinical ISR, arising in 5-10% of cases. Compared to de novo stenosis, patients with ISR also present more frequently with symptoms of unstable angina pectoris (45% versus 61%). In this article, we discuss the risk factors for ISR and the corresponding diagnostic measures and effective treatment strategies.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed, with special attention to current international guidelines and specialist society recommendations.

RESULTS

The type of implanted stent, the presence of diabetes mellitus, previous bypass surgery, and small vessel caliber are predictors for ISR. In their guidelines, the European specialist societies (ESC/EACTS) recommend repeated PCI with DES implantation or drug-coated balloon (DCB) angioplasty as the methods of choice for the treatment of ISR. This approach is supported by evidence from meta-analyses. The RIBS-IV trial showed that revascularization treatment of the target lesion is needed less often after everolimus-eluting stent (EES) implantation than after DCB dilatation (11 [7.1%] versus 24 [15.6%]; p = 0.015; hazard ratio: 0.43; 95% confidence interval: [0.21; 0.87]).

CONCLUSION

Because the pathogenesis of ISR is multifactorial, differentiated risk stratification is necessary. The identification of patient-, stent-, and lesion-related predictors is particularly important, as the most effective way to combat ISR is to prevent it.

Development and validation of a risk prediction nomogram for in-stent restenosis in patients undergoing percutaneous coronary intervention

Background

This study aimed to develop and validate a nomogram to predict probability of in-stent restenosis (ISR) in patients undergoing percutaneous coronary intervention (PCI).

Methods

Patients undergoing PCI with drug-eluting stents between July 2009 and August 2011 were retrieved from a cohort study in a high-volume PCI center, and further randomly assigned to training and validation sets. The least absolute shrinkage and selection operator (LASSO) regression model was used to screen out significant features for construction of nomogram. Multivariable logistic regression analysis was applied to build a nomogram-based predicting model incorporating the variables selected in the LASSO regression model. The area under the curve (AUC) of the receiver operating characteristics (ROC), calibration plot and decision curve analysis (DCA) were performed to estimate the discrimination, calibration and utility of the nomogram model respectively.

Results

A total of 463 patients with DES implantation were enrolled and randomized in the development and validation sets. The predication nomogram was constructed with five risk factors including prior PCI, hyperglycemia, stents in left anterior descending artery (LAD), stent type, and absence of clopidogrel, which proved reliable for quantifying risks of ISR for patients with stent implantation. The AUC of development and validation set were 0.706 and 0.662, respectively, indicating that the prediction model displayed moderate discrimination capacity to predict restenosis. The high quality of calibration plots in both datasets demonstrated strong concordance performance of the nomogram model. Moreover, DCA showed that the nomogram was clinically useful when intervention was decided at the possibility threshold of 9%, indicating good utility for clinical decision-making.

Conclusions

The individualized prediction nomogram incorporating 5 commonly clinical and angiographic characteristics for patients undergoing PCI can be conveniently used to facilitate early identification and improved screening of patients at higher risk of ISR.

Imaging Features of Complications after Coronary Interventions and Surgical Procedures

Coronary artery interventions and surgical procedures are used in the treatment of coronary artery disease and some congenital heart diseases. Cardiac and noncardiac complications can occur at variable times after these procedures, with the clinical presentation ranging from asymptomatic to devastating symptoms. Invasive coronary angiography is the reference standard modality used in the evaluation of coronary arteries, with intravascular US and optical coherence tomography providing high-resolution information regarding the vessel wall. CT is the mostly commonly used noninvasive imaging modality in the evaluation of coronary artery intervention complications and allows assessment of the stent, lumen of the stent, lumen of the coronary arteries, and extracoronary structures. MRI is limited to the evaluation of the proximal coronary arteries but allows comprehensive evaluation of the myocardium, including ischemia and infarction. The authors review the clinical symptoms and pathophysiologic and imaging features of various complications of coronary artery interventions and surgical procedures. Complications of percutaneous coronary interventions are discussed, including restenosis, thrombosis, dissection of coronary arteries or the aorta, coronary wall rupture or perforation, stent deployment failure, stent fracture, stent infection, stent migration or embolism, and reperfusion injury. Complications of several surgical procedures are reviewed, including coronary artery bypass grafting, coronary artery reimplantation procedure (for anomalous origin from opposite sinuses or the pulmonary artery or as part of surgical procedures such as arterial switching surgery and the Bentall and Cabrol procedures), coronary artery unroofing, and the Takeuchi procedure. Online supplemental material is available for this article. ^©RSNA, 2021.

Risk prediction of in-stent restenosis among patients with coronary drug-eluting stents: current clinical approaches and challenges

Introduction: In-stent restenosis (ISR) has been one of the biggest limitations to the success of percutaneous coronary intervention for the treatment of coronary artery disease (CAD). The introduction of drug-eluting stent (DES) was a revolution in the treatment of CAD because these devices drastically reduced ISR to very low levels (<5%). Subsequently, newer generation DES treatments have overcome the drawbacks of first-generation DES, i.e. delayed endothelialization, and late stent thrombosis. However, the issue of late ISR, including neoatherosclerosis after DES implantation especially in high-risk patients and complex lesions, still exists as a challenge to be overcome.Areas covered: We discuss the mechanisms of ISR development including neoatherosclerosis, past and current clinical status of ISR, and methods to predict and overcome this issue from pathological and clinical points of view.Expert opinion: The initial drawbacks of first-generation DES, such as delayed endothelial healing and subsequent risk of late stent thrombosis, have been improved upon by the current generation DES. To achieve better long-term clinical outcomes, further titration of drug-release and polymer degradation profile, strut thickness as well as material innovation are needed.

CYP2C19*2 genetic polymorphism and incidence of in-stent restenosis in patients on clopidogrel: a matched case-control study

OBJECTIVES

The cytochrome P450 2C19*2 (CYP2C19*2) genetic polymorphism is associated with reduced clopidogrel bioactivation, increasing the risk of atherothrombotic complications after percutaneous coronary intervention (PCI). In-stent restenosis (ISR) is a complication that limits the long-term prognosis of PCI. The aim was to investigate the association between presence of the CYP2C19*2 allele and ISR within one-year after PCI in patients prescribed dual antiplatelet therapy with aspirin and clopidogrel.

METHODS

Sixty patients with angiographically-confirmed drug eluting stent (DES)-ISR within 12 months post-PCI when on DAPT with aspirin and clopidogrel were retrospectively identified (Cases). Another 60 patients with no documented ISR post-PCI in the study period (Controls) were case-matched for age, gender, ethnicity, diabetes mellitus and estimated glomerular filtration rate value, and were invited for CYP2C19*2 genotyping. The association between presence of the CYP2C19*2 allele and ISR was analysed using the Fisher's Exact test and binary logistic regression.

RESULTS

Twenty-six (43.3%) cases and 5 (8.3%) controls were carriers of one or two CYP2C19*2 alleles. As to non-carrier status of the CYP2C19*2 allele, 34 (56.7%) cases and 55 (91.7%) controls were identified. The association between CYP2C19*2 carrier status and DES-ISR within one-year post-PCI was statistically significant (p<0.001) in both the univariate and multivariate analysis.

CONCLUSIONS

The proportion of patients who were carriers of one or two CYP2C19*2 alleles who presented with DES-ISR within one-year post-PCI while on clopidogrel was significantly higher compared to patients with no documented ISR.

Ten-year survival of patients undergoing coronary angioplasty with first-generation sirolimus-eluting stents and bare-metal stents

INTRODUCTION

Compared to bare-metal stents (BMS), drug-eluting stents reduce stent restenosis and improve subsequent revascularization rates. The impact on patients' survival has been the subject of debate.

OBJECTIVE

To assess the long-term (10-year) survival of patients undergoing percutaneous coronary intervention (PCI) with first-generation sirolimus-eluting stents (SES) in comparison with BMS.

METHODS

In a single-center registry, 600 consecutive patients who underwent successful PCI with SES between April 2002 and February 2003 were compared to 594 patients who underwent PCI with BMS between January 2002 and April 2002, just before the introduction of SES. Clinical and procedural data were collected at the time of intervention and 10-year survival status was assessed via the national life status database.

RESULTS

All baseline characteristics were similar between groups except for smaller stent diameter (2.84±0.38 vs. 3.19±0.49 mm; p<0.001), greater stent length (18.50±8.2 vs. 15.96±6.10 mm; p<0.001) and higher number of stents per patient (1.95 vs. 1.46, p<0.001) in the SES group. Overall five- and 10-year all-cause mortality was 9.6% (n=110) and 22.7% (n=272), respectively. The adjusted HR for 10-year mortality in patients undergoing PCI with SES was 0.74 (95% CI 0.58-0.94; p=0.013), corresponding to a relative risk reduction of 19.8%. Other than PCI with BMS, older age, chronic kidney disease, chronic obstructive pulmonary disease and lower ejection fraction were independent predictors of 10-year mortality.

CONCLUSION

To date, this is the longest follow-up study ever showing a potential survival benefit of first-generation sirolimus-eluting stents versus bare-metal stents, supporting prior observations on their sustained efficacy and safety relative to contemporary BMS.

Everolimus-eluting bioresorbable scaffolds and metallic stents in diabetic patients: a patient-level pooled analysis of the prospective ABSORB DM Benelux Study, TWENTE and DUTCH PEERS

Background

Several studies compared everolimus-eluting bioresorbable scaffolds (EE-BRS) with everolimus-eluting stents (EES), but only few assessed these devices in patients with diabetes mellitus.

Aim

To evaluate the safety and efficacy outcomes of all-comer patients with diabetes mellitus up to 2 years after treatment with EE-BRS or EES.

Methods

We performed a post hoc pooled analysis of patient-level data in diabetic patients who were treated with EE-BRS or EES in 3 prospective clinical trials: The ABSORB DM Benelux Study (NTR5447), TWENTE (NTR1256/NCT01066650) and DUTCH PEERS (NTR2413/NCT01331707). Primary endpoint of the analysis was target lesion failure (TLF): a composite of cardiac death, target vessel myocardial infarction or clinically driven target lesion revascularization. Secondary endpoints included major adverse cardiac events (MACE): a composite of all-cause death, any myocardial infarction or clinically driven target vessel revascularization, as well as definite or probable device thrombosis (ST).

Results

A total of 499 diabetic patients were assessed, of whom 150 received EE-BRS and 249 received EES. Total available follow-up was 222.6 patient years (PY) in the EE-BRS and 464.9 PY in the EES group. The adverse events rates were similar in both treatment groups for TLF (7.2 vs. 5.2 events per 100 PY, p = 0.39; adjusted hazard ratio (HR) = 1.48 (95% confidence interval (CI): 0.77–2.87), p = 0.24), MACE (9.1 vs. 8.3 per 100 PY, p = 0.83; adjusted HR = 1.23 (95% CI: 0.70–2.17), p = 0.47), and ST (0.9 vs. 0.6 per 100 PY, p > 0.99).

Conclusion

In this patient-level pooled analysis of patients with diabetes mellitus from 3 clinical trials, EE-BRS showed clinical outcomes that were quite similar to EES.

Cost-effectiveness of Drug-Eluting Stents in Percutaneous Coronary Intervention in Brazil's Unified Public Health System (SUS)

Fundamento

O uso do stent farmacológico (SF) comparado ao stent não farmacológico (SNF) na intervenção coronariana percutânea (ICP) reduziu o percentual de reestenose, porém sem impacto na mortalidade, com aumento no custo. A literatura carece de estudos randomizados que comparem economicamente esses dois grupos de stents na realidade do Sistema Único de Saúde (SUS).

Objetivo

Estimar a razão custo-efetividade incremental (RCEI) entre SF e SNF na coronariopatia uniarterial em pacientes do SUS

Métodos

Pacientes com coronariopatia uniarterial sintomática foram randomizados em 3 anos para uso de SF ou SNF durante a ICP, na proporção de 1:2, com seguimento clínico de 12 meses. Foram avaliados reestenose intrastent (RIS), revascularização da lesão-alvo (RLA), eventos adversos maiores e custo-efetividade (CE) de cada grupo. Os valores de p < 0,05 foram considerados significativos.

Resultados

No grupo SF, dos 74 pacientes (96,1%) que completaram o acompanhamento, ocorreu RIS em 1(1,4%), RLA em 1 (1,4%), óbito em 1 (1,4%), sem trombose. No grupo SNF, dos 141 pacientes (91,5%),ocorreu RIS em 14 (10,1%), RLA em 10 (7,3%), óbito em 3 (2,1%) e trombose em 1 (0,74%). Na análise econômica, o custo do procedimento foi de R$ 5.722,21 no grupo SF e de R$4.085,21 no grupo SNF. A diferença de efetividade a favor do grupo SF por RIS e RLA foi 8,7% e 5,9%, respectivamente, com RCEI de R$ 18.816,09 e R$ 27.745,76.

Conclusões

No SUS, o SF foi custo-efetivo, em concordância com o limiar de CE preconizado pela Organização Mundial da Saúde. (Arq Bras Cardiol. 2020; 115(1):80-89)

High low-density lipoprotein cholesterol as an independent risk factor for coronary restenosis in hemodialysis patients undergoing percutaneous coronary interventions

HD patients have been reported to have a higher risk of restenosis after percutaneous coronary intervention (PCI). The aim of this study was to investigate the risk factors of coronary restenosis in HD patients. We enrolled 54 HD patients (mean age: 66.5 ± 10.1 years; 72.2% men; mean HD duration: 3.7 years), who received PCI and follow-up coronary angiography. Of the patients, 22 (40.7%) had restenosis within 3 to 12 months of PCI. Univariate logistic analysis showed low-density lipoprotein cholesterol (LDL-C)/high-density lipoprotein cholesterol (HDL-C) ratio, LDL-C, non-HDL-C, and history of major adverse cardiovascular events were significantly associated with coronary restenosis (OR]: 1.89, 1.27, 1.22, and 5.79, respectively). Multivariate analysis showed that LDL-C was significantly associated with coronary restenosis (OR: 1.43). These data suggest that LDL-C is an independent risk factor for coronary restenosis in HD patients undergoing PCI, and strict lipid management may be required.

Incidence and predictors of target lesion failure in patients undergoing contemporary DES implantation-Individual patient data pooled analysis from 6 randomized controlled trials

BACKGROUND

Drug-eluting stents (DESs) have improved clinical outcomes of patients undergoing percutaneous coronary intervention (PCI). Nevertheless, adverse events related to previously treated lesion still occur. We sought to evaluate the incidence and predictors of target lesion failure (TLF) in patients undergoing contemporary DES implantation.

METHODS

Patient-level data from 6 prospective, randomized trials were pooled, and DES treatment outcomes were analyzed at up to 5 years. Primary outcome was TLF (cardiac death, target lesion revascularization, or target vessel myocardial infarction). Cox proportional-hazards model was used to identify predictors of TLF.

RESULTS

Overall, 10,072 patients were included in the analysis. TLF rate was 1.7%, 4.3%, and 11.9% at 30 days, 1 year, and 5 years, respectively. The only independent predictor of TLF at 30 days was stent length (hazard ratio [HR] 1.017, 95% CI 1.011-1.024, P < .0001). Moderate/severe calcification, stent length and post procedural diameter sthenosis were predictors between 30 days to 1 year but not at 1 to 5 years. Reference vessel diameter was the only lesion-related predictor at 5 years (P = .003). Clinical predictors of TLF between 30 days and 1 year were diabetes and hypertension (P < .01 for both), and between 1 and 5 years, diabetes (HR 1.40, 95% CI 1.13-1.73, P = .002), prior coronary artery bypass grafting (HR 2.52, 95% CI 1.92-3.30, P < .0001), and prior PCI (HR 1.29, 95% CI 1.02-1.64, P = .04) predicted TLF.

CONCLUSIONS

Predictors of TLF vary in the early, late, and very late postprocedural periods. Reference vessel diameter was the only lesion-related predictor of long-term TLF; clinical predictors were diabetes, prior coronary artery bypass grafting, and prior PCI.

Evaluation of relationship between common carotid artery intima-media thickness and coronary in-stent restenosis: A case-control study

Aim

The study was intended to evaluate relationship of common carotid artery intima-media thickness (CIMT) with coronary in-stent restenosis (ISR) and to assess clinical profile of patients to determine the predictors of coronary ISR.

Methods

This was a single-center, case-control study performed between December 2012 and February 2015 in India. The study population consisted of PCI-treated patients with ISR (n = 32) and those without any post-PCI symptoms at least 6 months prior to the study period (n = 40). Quantitative coronary angiography was performed in patients to determine ISR.

Results

Average CIMT for cases and controls was 0.96 ± 0.23 and 0.66 ± 0.09 mm (OR = 57, p < 0.001), respectively. CIMT was <0.8 mm in 25% of cases and 95% of controls. On multivariate analysis, presence of hypertension (OR = 10.79, p = 0.026) and higher stent diameter (OR = 14.87, p = 0.039) were independently associated with increased presence of ISR. CIMT <0.8 mm (OR = 0.03, p = 0.025), STEMI (OR = 0.03, p = 0.004), and estimated glomerular filtration rate >50 ml/min (OR = 0.005, p = 0.014) were independently associated with lower presence of ISR.

Conclusions

Elevated CIMT appears to be an independent risk indicator for increased ISR. As CIMT is a non-invasive parameter, post-PCI follow-up measurements of CIMT in routine clinical practice will provide potential benefits to predict the restenosis rates.

Current concepts on coronary revascularization using BRS in patients with diabetes and small vessels disease

Diabetes mellitus (DM) and small vessel (SV) disease are two major predictors of adverse outcome in patients treated by percutaneous coronary intervention (PCI), even when last generation metallic drug-eluting stents (DES) are used. Bioresorbable scaffold (BRS) technology has been recently developed to overcome the disadvantages of metallic DES due to their permanent struts. Through the resorption process, BRS may provide a vascular restoration that appears very attractive especially when distal or diffusely diseased coronary segments are involved, as in diabetic patients and SV disease. However, robust evidence on the use of BRS in diabetics is lacking, and recent data have raised concerns on the use of BRS in SVs, particularly when reference vessel diameter (RVD) is <2.25 mm. This review aims at summarizing current evidence related to the use of BRS in diabetics and SV disease.

Restenosis of the Coronary Arteries: Past, Present, Future Directions

Restenosis is a pathologic response to vascular injury, characterized by neointimal hyperplasia and progressive narrowing of a stented vessel segment. Although advances in stent design have led to a dramatic reduction in the incidence of restenosis, it continues to represent the most common cause of target lesion failure following percutaneous coronary intervention. Efforts to maximize restenosis prevention, through careful consideration of modifiable risk factors and an individualized approach, are critical, as restenosis, once established, can be particularly difficult to treat. Novel approaches are on the horizon that have the potential to alter the natural history of this stubborn disease.

Is ischemia the only factor predicting cardiovascular outcomes in all diabetes mellitus patients?

Diabetes mellitus (DM) is associated with an excess in cardiovascular morbidity and mortality, and is characterized by increased rates of coronary artery disease. Furthermore, once atherosclerosis is established, this is associated with an increased extent, complexity and a more rapid progression than seen in non-DM patients. Ischemia is the single most important predictor of future hard cardiac events and ischemia correction remains the cornerstone of current revascularization strategies. However recent data suggests that, in DM patients, coronary atherosclerosis despite the absence of ischemia, detected by either invasive or non-invasive methods, may not be associated with the same low risk of future cardiac events as seen in non-DM patients. This review seeks to examine the current evidence supporting an ischemia driven revascularization strategy, and to challenge the notion that ischemia is the only clinically relevant factor in the prediction of cardiovascular outcomes in all-comer DM patients. Specifically, we examine whether in DM patients certain characteristics beyond ischemia, such as microvascular disease, coronary atherosclerosis burden, progression and plaque composition, may need to be considered for a more refined risk stratification in these high-risk patients.

Factors associated with deferred lesion failure following fractional flow reserve assessment in patients with diabetes mellitus

OBJECTIVE

To explore the predictors of deferred lesion failure (DLF) in patients with diabetes mellitus (DM) and lesions with a fractional flow reserve (FFR) >0.80 and to examine whether a predictive relationship between negative FFR values (>0.80-1.00) and DLF exists.

BACKGROUND

DM is associated with rapidly progressive atherosclerosis and predictors of DLF in FFR negative lesions in this high-risk group are unknown.

METHODS

All DM patients who underwent FFR-assessment between 1/01/2010 and 31/12/2013 were included, and followed until 1/7/2015. Patients carrying ≥1 FFR negative lesion(s) were assessed for DLF, and multivariate models used to identify independent factors associated with DLF.

RESULTS

A total of 205 patients with 252 FFR >0.80 lesions were identified. At a mean follow-up of 3.1 ± 1.4 years, DLF occurred in 29/205 (14.1%) patients, 31/252 (12.3%) lesions. Using marginal Cox regression multivariate analysis, insulin requiring DM [HR 2.24 (95%CI; 1.01-4.95), P = 0.046] and prior revascularization [HR 2.70 (95%CI 1.21-6.01), P = 0.015] were identified as being associated with a higher incidence of DLF. Absolute FFR values in FFR negative lesions in DM patients are not predictive of DLF (receiver operating characteristics curve analysis: area under the curve: 0.57 ± 0.06, 95%CI 0.46-0.69).

CONCLUSIONS

In DM patients with FFR negative lesions, insulin requiring DM and prior revascularization are predictors for DLF. In contrast to non-DM patients, no predictive relationship between absolute negative FFR values (ranging >0.80-1.00) and the risk of DLF exists in DM patients. © 2017 Wiley Periodicals, Inc.

Adenosine triphosphate stress 99mTc-methoxyisobutylisonitrile gated myocardial perfusion imaging efficacy in diagnosing stent restenosis following coronary stent implantation

Coronary stent restenosis rate following implantation is considerably high. The adenosine stress gated myocardial perfusion imaging (G-MPI) method has been widely used in the diagnosis, risk stratification and prognosis evaluation of coronary heart disease; however, the high cost of adenosine limits its clinical application. The aim of the present study was to investigate the efficacy of adenosine triphosphate (ATP) stress ^99mTc-methoxyisobutylisonitrile (^99mTc-MIBI) G-MPI for diagnosis in-stent restenosis following coronary stent implantation. Data from 66 patients with typical angina pectoris symptoms who had undergone percutaneous coronary stent implantation >3 months prior to participation in the study were analyzed. All the patients underwent ATP stress ^99mTc-MIBI G-MPI and coronary artery angiography as the criterion diagnostic standard within 1 month. The sensitivity, specificity, and accuracy of ATP stress ^99mTc-MIBI G-MPI in the assessment of in-stent restenosis were calculated. In addition, Fisher's exact probability methods were used to compare differences between experimental groups. Among 66 patients with a total of 99 implanted coronary arterial branches, 39 patients (59%) with 45 coronary arteries (45%) presented in-stent restenosis. The diagnostic sensitivity, specificity, accuracy, positive predictive and negative predictive value of ATP stress ^99mTc-MIBI G-MPI for assessing stent restenosis in all patients were 85, 89, 86, 92 and 80%, respectively. Similarly, these values in patients with myocardial infarction were 79, 88, 83, 88 and 78%, respectively, while in patients without myocardial infarction the values were 90, 91, 90, 95 and 83%, respectively. Therefore, the diagnostic efficacy of ATP stress ^99mTc-MIBI G-MPI in patients without myocardial infarction was higher compared with those with myocardial infarction; however, no significant difference was observed between the two groups. Furthermore, the sensitivity, specificity and accuracy for diagnosing LAD stent restenosis were higher compared with LCX and RCA stent restenosis, but with no significant differences observed (P>0.05). The present results indicated that ATP stress ^99mTc-MIBI G-MPI had a high clinical application value for diagnosing in-stent restenosis following coronary stent implantation as a non-invasive examination tool, with the advantages of safety and low cost.

Efficacy and Safety of the Absorb Everolimus-Eluting Bioresorbable Scaffold for Treatment of Patients With Diabetes Mellitus: Results of the Absorb Diabetic Substudy

OBJECTIVES

The study sought to evaluate the efficacy and safety of the Absorb everolimus-eluting bioresorbable vascular scaffold (BVS) (Abbott Vascular, Abbott Park, Illinois) in patients with diabetes mellitus.

BACKGROUND

Randomized, controlled trials have demonstrated comparable clinical outcomes following percutaneous coronary intervention with either Absorb BVS or metallic Xience everolimus-eluting stent. However, these trials lack power required to provide reliable treatment effect estimates in this high-risk population.

METHODS

In a pre-specified, powered analysis, patients with diabetes who received ≥1 Absorb were pooled from the ABSORB II, III, and JAPAN randomized trials and from the single arm ABSORB EXTEND registry. The study composite primary endpoint was target lesion failure (TLF) at 1 year following Absorb BVS compared with a performance goal of 12.7%.

RESULTS

Among 754 diabetic patients included in analysis (27.3% insulin treated), the 1-year TLF rate was 8.3% (upper 1-sided 95% confidence limit: 10.1%; p = 0.0001 vs. performance goal). Scaffold thrombosis (definite or probable) was observed in 2.3% of patients. Multivariable regression identified older age, insulin treatment, and smaller pre-procedure reference vessel diameter as significant independent predictors of 1-year TLF.

CONCLUSIONS

The Absorb diabetic substudy suggests efficacy and safety of the Absorb BVS for treatment of patients with diabetes mellitus.

Impact of free thyroxine levels and other clinical factors on bare metal stent restenosis

Objective

Thyroid hormones have both direct and indirect effects on thermogenesis such as modulating vascular smooth muscle cell proliferation. However, the influence of more subtle changes in thyroid hormones on coronary atherosclerosis remains a matter of speculation. Smooth muscle cells play a crucial role in the pathogenesis of in-stent restenosis (ISR). However, the relationship between free thyroxine (fT4) and ISR has not been studied. In the present study, we aimed to assess the role of preprocedural serum fT4 level on the development of ISR in patients undergoing coronary bare metal stent (BMS) implantation.

Materials and methods

We enrolled and analyzed clinical, biochemical, and angiographic data from 705 consecutive patients without a history of primary thyroid disease [mean age 60.3 ± 9.3 years, 505 (72%) male]; all patients had undergone BMS implantation and further control coronary angiography owing to stable or unstable angina pectoris. Patients were divided into 3 tertiles based on preprocedural serum fT4 levels.

Results

ISR was observed in 53 (23%) patients in the lowest tertile, 82 (35%) patients in the second tertile, and 107 (46%) patients in the highest fT4 tertile (p < 0.001). Using multiple logistic regression analysis, five characteristics emerged as independent predictors of ISR: diabetes mellitus, smoking, HDL-cholesterol, stent length, and preprocedural serum fT4 level. In receiver operating characteristics curve analysis, fT4 level > 1.23 mg/dL had 70% sensitivity and 73% specificity (AUC: 0.75, p < 0.001) in predicting ISR.

Conclusion

Higher preprocedural serum fT4 is a powerful and independent predictor of BMS restenosis in patients with stable and unstable angina pectoris.

Coronary CT angiography-derived quantitative markers for predicting in-stent restenosis

OBJECTIVE

To evaluate quantitative markers derived from coronary CT angiography (coronary CTA) performed prior to percutaneous coronary intervention (PCI) with stent placement for predicting in-stent restenosis (ISR) as defined by quantitative coronary angiography (QCA).

MATERIALS AND METHODS

We retrospectively analyzed the data of 74 patients (60 ± 12 years, 72% male) who had undergone dual-source coronary CTA within 3 months prior to a PCI procedure that included stent placement. Quantitative markers of the target vessel were derived from coronary CTA: Total plaque volume (TPV), calcified and non-calcified plaque volumes (CPV and NCPV), plaque burden (PB in %), remodeling index (RI), and lesion length (LL). Marker performance for predicting ISR, as defined by QCA at follow-up, was assessed.

RESULTS

Twenty-one of 74 stented lesions showed ISR on follow-up (mean 616 ± 447 days). When comparing stent length and LL in patients with ISR, a trend towards less complete stent coverage of the target lesion was observed in cases with ISR (17/21 vs. 4/53 cases, p = 0.07). In multivariate analysis (corrected for dyslipidemia), the following markers showed predictive value for ISR (odds ratio [OR]): NCPV (OR 1.08, p = 0.045), LL (OR 1.38, p = 0.0024), and RI (OR 1.13, p = 0.0019). Sensitivity and specificity for ISR were: NCPV 65% and 80%, LL 74% and 74%, and RI 71% and 78%. At receiver-operating characteristics analysis, NCPV (0.72, p = 0.001), LL (0.77, p < 0.0001), and RI (0.79, p < 0.0001) showed discriminatory power for predicting ISR. A combination of these markers showed incremental predictive value (AUC 0.89, p < 0.0001) with sensitivity and specificity of 90% and 84%, respectively.

CONCLUSION

Coronary CTA-derived NCPV, LL, and RI portend predictive value for ISR with incremental predictive value when combining these parameters.

On the Design of Passive Resonant Circuits to Measure Local Pulse Wave Velocity in a Stent

In-stent restenosis is a frequent complication after stent implantation. This article investigates the design of a passive sensor system to be integrated into a stent for the detection of an in-stent restenosis by measuring the local pulse wave velocity (PWV). The proposed system uses two resonant circuits consisting of a capacitive pressure sensor and a coil as transponders. The pressure sensors are located at the proximal and distal end of the stent. An alternating external magnetic field with a constant frequency is applied such that the resonance frequencies of the transponders cross the excitation frequency when the pulse wave passes. The time delay between the resonances at the transponders can be captured to obtain the PWV. A model for the measurement system and a correlation between transponder design parameters and minimal resolvable time delay are derived. This correlation is based on the criterion that the 3 dB bandwidth of the transponder resonances may not overlap in the measurement time interval. This correlation can be used to design and analyze a transponder system for the proposed measurement system. In an experiment, in which the pressure sensors have been emulated by varactor diodes, it could be shown that the model is valid and that the criterion is suitable. Finally, the relevant design parameters of the transponders have been identified and their limitations investigated.

A journey from CABG to drug-eluting balloon

A middle aged male underwent series of percutaneous coronary intervention (PCI) of left main stenosis for Canadian cardiovascular society (CCS) IV angina. He developed recurrent severe proliferative in-stent restenosis which was treated with different available options including drug-eluting stents and finally with drug-eluting balloons. During his treatment, challenges of PCI including left main chronic total occlusion PCI, complications like coronary perforation were encountered and treated successfully.

Predicting target vessel revascularization in older patients undergoing percutaneous coronary intervention in the drug-eluting stent era

BACKGROUND

The contemporary need for repeat revascularization in older patients after percutaneous coronary intervention (PCI) has not been well studied. Understanding repeat revascularization risk in this population may inform treatment decisions.

METHODS

We analyzed patients ≥65 years old undergoing native-vessel PCI of de novo lesions from 2005 to 2009 discharged alive using linked CathPCI Registry and Medicare data. Repeat PCIs within 1 year of index procedure were identified by claims data and linked back to CathPCI Registry to identify target vessel revascularization (TVR). Surgical revascularization and PCIs not back linked to CathPCI Registry were excluded from main analyses but included in sensitivity analyses. Independent predictors of TVR after drug-eluting stent (DES) or bare-metal stent (BMS) implantation were identified by multivariable logistic regression.

RESULTS

Among 343,173 PCI procedures, DES was used in 76.5% (n = 262,496). One-year TVR ranged from 3.3% (overall) to 7.1% (sensitivity analysis). Precatheterization and additional procedure-related TVR risk models were developed in BMS (c-indices 0.54, 0.60) and DES (c-indices 0.57, 0.60) populations. Models were well calibrated and performed similarly in important patient subgroups (female, diabetic, and older [≥75 years]). The use of DES reduced predicted TVR rates in high-risk older patients by 35.5% relative to BMS (from 6.2% to 4.0%). Among low-risk patients, the number needed to treat with DES to prevent 1 TVR was 63-112; among high-risk patients, this dropped to 28-46.

CONCLUSIONS

In contemporary clinical practice, native-vessel TVR among older patients occurs infrequently. Our prediction model identifies patients at low versus high TVR risk and may inform clinical decision making.

Identification of independent risk factors for restenosis following bare-metal stent implantation: Role of bare-metal stents in the era of drug-eluting stents

In the era of drug-eluting stents (DESs), the ability of clinicians to predict which patients have a low risk of coronary restenosis following bare-metal stent (BMS) implantion is likely to be of benefit. The study population consisted of 2,711 patients who underwent BMS implantation in 3,770 lesions between 1995 and 2004. With clinical and 6 month follow-up angiographic data, we retrospectively sought to identify the independent risk predictors of restenosis, applied a previously proposed prediction model and assessed the characteristics of patients with a low likelihood of coronary restenosis within 6 months of BMS implantation. A 6-month follow-up coronary angiography was performed in 65.0% of the patients who had undergone the BMS implantation and the rate of restenosis was 26.6%. Using multivariate analysis, diabetes [odds ratio (OR), 1.294; 95% confidence interval (CI), 1.094–1.483; P=0.005], current smoking (OR, 1.294; 95% CI, 1.094–1.483; P=0.002), a reference vessel diameter of <3.25 mm (OR, 1.238; 95% CI, 1.021–1.501; P<0.001), a lesion length of >30 mm (OR, 1.645; 95% CI, 1.336–2.026; P<0.001), ostial lesion (OR, 1.858; 95% CI, 1.437–2.402; P<0.001), post-stenting minimal luminal diameter (OR, 0.576; 95% CI, 0.484–0.685; P<0.001) and bifurcation lesion (OR, 1.353; 95% CI, 1.070–1.711; P=0.012) were identified as significant independent predictors of restenosis. However, the accuracy of the prediction obtained with the current model, which used the clinical and angiographic variables correlated with the risk of restenosis, was poor. Various clinical and angiographic independent risk variables were revealed to be correlated with the risk of restenosis following BMS implantation in the present large dataset. Certain groups of patients with a relatively low risk of restenosis may be considered for BMS implantation as an alternative to DESs. However, the prediction models used at present are incomplete and further studies are required.

Clinical presentation and predictors of target vessel revascularization after drug-eluting stent implantation

BACKGROUND

Drug eluting stent (DES) failure including restenosis and stent thrombosis, or disease progression may result in target vessel revascularization (TVR) but the relative contribution of these mechanisms in the DES era is not well described. We sought to examine the predictors and presentations of patients with clinically driven TVR after DES.

METHODS

Patients with all lesions treated with a DES in the Dynamic Registry from 2004 to 2006 were analyzed. Included were 2691 patients with 3401 lesions. Patients with and without incident clinically driven TVR at 2years were compared according to baseline clinical, procedural, and angiographic characteristics and independent predictors of TVR and target lesion revascularization (TLR) were determined by multivariate analysis.

RESULTS

By 2-years, TVR occurred in 7.2% of patients and TLR in 3.8%, with 71.6% and 82.5% of repeat revascularization events occurring in the first year, respectively. The indication for first TVR was myocardial infarction in 18.6% (n=34), unstable angina in 42.6% (n=78), stable coronary disease in 25.7% (n=47) and other/unknown in 13.1% (n=24). Disease progression was responsible for 47% of TVR. Among patients with TLR, restenosis was the mechanism in 86.6% and stent thrombosis in 13.4%. Independent predictors of TVR included younger age, diabetes, attempted graft lesion, lesion length >30mm and prior lesion intervention. Independent predictors of TVR and TLR were similar.

CONCLUSION

The incidence of clinically driven TVR is low in patients treated with DES and nearly half is attributable to disease progression, which along with the low rate of in-stent restenosis explains why the mode of presentation is often an acute coronary syndrome.

Postoperative care and follow-up after coronary stenting

BACKGROUND

The diagnosis and treatment of coronary heart disease have improved in recent years. Most patients can return to their everyday routine a few days after a successful percutaneous coronary intervention (PCI). How should patients be followed up after the successful implantation of a coronary stent?

METHOD

Selective review of the pertinent literature, including current practice guidelines and recommendations.

RESULTS

After a PCI, the patient should be followed up both by the primary care physician and by the cardiologist one week after the procedure, and then every three to six months for the first year. Clinical history taking and physical examination, including an assessment of cardiovascular risk factors and of potential evidence of myocardial ischemia, constitute the best way to detect possible progression of coronary heart disease. Diagnostic coronary angiography is not routinely indicated after coronary stent implantation. If progression of heart disease is suspected, a stress test should be performed; patients who develop symptoms or show evidence of ischemia in a stress test should undergo diagnostic cardiac catheterization.

CONCLUSION

Repeated history taking and physical examination play an important role after PCI. For patients at high risk of restenosis and those with complex coronary morphology, coronary angiography may be indicated regardless of the findings of non-invasive stress tests.

Outcome of percutaneous coronary intervention utilizing drug-eluting stents in patients with reduced left ventricular ejection fraction

Ischemic cardiomyopathy with depressed left ventricular ejection fraction (LVEF) is predictive of death after percutaneous coronary intervention (PCI), but its association with stent thrombosis (ST) and the need for repeat revascularization is less clearly defined. In total 5,377 patients undergoing PCI were retrospectively evaluated. Multivariable Cox proportional hazards regression and competitive outcome analysis were employed. The primary end point was 1-year major adverse cardiac events (all-cause death, Q-wave myocardial infarction, ST, and target lesion revascularization [TLR]). Individual end points of ST and of TLR were also evaluated. Patients with normal LVEF (>50%) were compared to those with mild (41% to 50%), moderate (25% to 40%), and severe (<25%) decreases in LVEF. Patients with abnormal LVEF were older and more commonly diabetic and had renal insufficiency and heart failure syndrome (p <0.001 for all variables). These patients demonstrated more angiographically complex lesions and less frequently received a drug-eluting stent. The primary end point was significantly increased in patients with lower LVEF (9.7% for normal LVEF vs 20.6% for severely decreased LVEF, p <0.001). ST occurred more frequently in these patients (1.4% for normal LVEF vs 6% for severely decreased LVEF, p <0.001), but clinically driven TLR did not significantly change across LVEF categories. After adjustment, only moderate and severe LVEF decreases (i.e., LVEF ≤40%) demonstrated an association with major adverse cardiac events and with the individual outcome of ST. Subgroup analysis of patients receiving only a drug-eluting stent or a bare-metal stent demonstrated no statistically significant differences for the probability of ST. In conclusion, decreased LVEF is not associated with clinically driven TLR but does increase the risk of ST. Patients with LVEF ≤40% appear to be at significantly higher risk for ST and therefore might benefit from interventional and pharmacologic strategies aimed at minimizing this risk.